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Paoli Health And Living Community

559 W Longest St, Paoli, IN 47454 · Government - County · 109 certified beds · (812) 723-2595 Medicare & Medicaid certified

Call the home — (812) 723-2595 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 2025Behavioral-health or dementia-care citation — no harm found (F0740)2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$28,138 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $28,138 in federal fines (most recent 2025-01-24)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)
  • about 44% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
420 W Longest St · (812) 723-3944 · Call to confirm hours
Pharmacy
889 N Gospel St · (812) 723-3907 · Call to confirm hours
Grocery
735 N Gospel St · (812) 723-4444 · Call to confirm hours
Park
798 W Main St · (812) 653-9886 · Typically dawn to dusk
Place of worship
1199 N Daniel Ln · (812) 865-6171

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.4%11.0%15.4%better
Long-stay residents who lose too much weight7.7%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection4.1%1.1%2.0%worse
Long-stay residents with depressive symptoms13.2%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.1%3.9%3.3%worse
Long-stay residents whose ability to walk worsened11.0%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.9%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine94.4%95.4%95.3%typical
Long-stay residents with pressure ulcers3.4%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control16.8%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine81.8%79.0%79.4%typical
Short-stay residents rehospitalized after admission24.9%22.2%22.6%typical
Short-stay residents with an outpatient ER visit8.7%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.081.611.67better
Long-stay outpatient ER visits per 1,000 resident days2.471.441.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 101 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.3%U.S. median 51.5%
Got home and stayed home
13.7%U.S. median 10.7%
Went back to hospital
65.8%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.25hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 65.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 79 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.3%CMS range 35.9–54.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.7%CMS range 10.6–18.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge49.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified93.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge96.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization11.7%CMS range 6.6–17.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.56
RN hours/ resident / day
0.79
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.26
Total nurse hours/ resident / day
0.35
RN hoursweekends
58.0%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 109 beds and averages 81.1 residents a day — about 74% occupied, or roughly 28 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.68 hrs/resident/day on weekends vs 3.49 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2025-04-11)
8
at the previous standard inspection (2024-02-13)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · J2025-01-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by staff for 1 of 3 residents reviewed for abuse allegations. (Resident C) This deficient practice resulted in an alert and oriented female resident alleging staff to resident sexual abuse on 12/28/24 when Resident C indicated that Certified Nurse Aide (CNA) 13 lifted her gown during care and licked or sucked on her breast a week prior. CNA 13 indicated to a police detective on 12/21/24 that, she asked me to do it, so I done it, to shut her up. This Immediate Jeopardy began on 12/18/24 at approximately 4:00 P.M. when Resident C alleged that CNA 13 had lifted her gown and placed his mouth on her breasts. Resident C was tearful during staff interviews and indicated that she did not want the staff member to place his mouth on her breasts. On 12/21/24 local law enforcement placed CNA 13 under arrest after admitting the allegation. CNA 13 indicated to the police detective that he was assisting Resident C and she was flirting with him so he did it for like two…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · J2025-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from accidents for 1 of 3 residents reviewed for the use of a mechanical lift. A resident was in the process of transferring in a mechanical lift while the lift pad was wrapped under the resident's legs rather than through the resident's legs. The resident did not possess the required stability to transfer safely with the lift pad wrapped under her legs. The resident slid feet first out of the lift pad which resulted in multiple lower extremity fractures and a laceration to the back of her head. The resident was transferred to a local Emergency Department (ED) where she expired. (Resident D) This Immediate Jeopardy began on [DATE] at approximately 7:50 A.M., when Resident D fell 3.5 to 4 feet from a mechanical lift while being transferred by Certified Nurse Aide (CNA) 6 and CNA 7. Resident D's fall resulted in a left femur fracture, left tibial fracture, right femur fracture, right ankle fracture, and a 3-centimeter (cm)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-01-15 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 4 resident halls observed. Resident rooms contained used towels/washcloths on the floors, resident bed pans were stored uncovered in shared restrooms, resident toothbrushes were stored uncovered and unlabeled in shared restrooms, and odors were present 2 of 2 days during the survey. (100 hall, 200 hall, 300 hall, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])Findings include:1. During a review of the facility grievance log on 1/14/26 at 11:00 A.M., a grievance was filed on 12/18/25 that dirty laundry was left in a resident's room. 2. On 1/14/26 at 11:15, Hall 300 contained a urine odor. On 1/15/26 at 2:16 P.M., Hall 300 contained a urine odor. 3. During an observation on 1/14/26 at 2:30 P.M., the shared restroom in room [ROOM NUMBER] contained two resident toothbrushes, uncovered and unlabeled. On 1/14/26 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents reviewed for pharmaceutical services. A resident received an incorrect dose of an ordered medication for three days for a total of four doses due to incorrectly transcribed physician's order. (Resident B)Finding includes:During review on 1/14/26 at 11:00 A.M., a facility reported incident, dated 1/2/26, indicated Resident B had admitted to the facility following a hospitalization and with an order for the medication metoprolol 25 milligrams (mg), give 1/2 tablet twice a day. During transcription from the hospital discharge orders to the facility medication administration record, the order was entered as metoprolol 25 mg one tablet twice a day. As a result, the resident received three doses of the metoprolol 25 mg tablet. During therapy, the resident became weak and short of breath. The hospital did keep the resident for observation. Record review on 1/14/26 at 2:00 P.M., Resident B's diagnoses included but were not limited to heart disease,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 3 of 4 observations of resident care. Staff failed to change gloves when completing a dirty task and prior to starting a clean task, failed to perform hand hygiene between glove uses, and failed to implement enhanced barrier precautions for a resident per the physician's order. (Resident C, Resident D, Resident F)Findings include:1. During an observation on 1/15/26 at 1:23 A.M., CNA 2 and CNA 4 provided incontinence care for Resident C. CNA 2 and CNA 4 removed a wet brief and provided perineal care while wearing gloves. CNA 4 then applied a new brief wearing the same gloves, then opened the top drawer of a bedside table and retrieved a tube of cream and applied the resident's peri-area. CNA 4 placed the tube back in the drawer, removed gloves, pulled new gloves from a pants pocket and put on new gloves without performing hand hygiene. CNA 2 and CNA 4 then pulled the resident up in bed and adjusted the resident's pillow before removing gloves and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-11 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 3 of 5 residents reviewed for hospitalizations, and the ombudsman was not notified for 5 of 5 residents reviewed for hospitalizations. The transfer discharge form was not completed. There was no documentation of a resident, representative, and the ombudsman receiving a notice of transfer or discharge at the time of hospitalization. (Resident 15, Resident 56, Resident 48, Resident 41, Resident 231) Findings include: 1. On 4/9/25 at 9:03 A.M., Resident 15's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 8/9/24 and returned back to the facility from the hospital on 8/13/24. Resident 15's clinical record lacked documentation of ombudsman notification for Resident 15's transfer. 2. On 4/8/25 at 1:29 P.M., Resident 231's clinical record was reviewed. Diagnoses included, but were not limited to, stroke (cerebral…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-11 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 2 of 5 residents reviewed for unnecessary medications, 1 of 2 residents reviewed for skin conditions, and 1 of 4 residents reviewed for accidents. Residents were taking an anticoagulant, antiplatelet, and anticonvulsant medications and a resident had falls that were not listed on the MDS assessments. (Resident 231, Resident 57, Resident 15, Resident 56) Findings include: 1. On 4/8/25 at 1:29 P.M., Resident 231's clinical record was reviewed. Diagnoses included, but were not limited to, stroke (cerebral infarction), hypertension (HTN), and congestive heart failure (CHF). The most recent Annual MDS assessment, dated 3/27/25, indicated Resident 231 was cognitively intact and did not take an antiplatelet or anticoagulant medication. Current Physician's Orders included, but were not limited to, the following medications: Aspirin (antiplatelet) 81 milligram (mg) tablet, give one tablet orally…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-11 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain medical records on residents that are complete and accurate for 2 of 2 residents reviewed for self administration of medications, and 2 of 4 residents reviewed for activities of daily living. Two residents who self-administered medication did not have assessments documented. Ancillary services were not documented accurately for two residents. (Resident 10, Resident 66, Resident 44, Resident 64) Findings include: 1. On 4/8/25 at 10:54 A.M., Resident 10's clinical records were reviewed. Diagnosis included, but was not limited to, Type 2 diabetes mellitus without complications. The most recent Quarterly Minimum Data Set, dated [DATE], indicated Resident 10 was cognitively intact, was independent with eating and bed mobility, needed set up or clean up assistance with toilet use, and needed supervision with transfers. Physician's Orders included, but were not limited to, the following: Humalog KwikPen Insulin (insulin lispro) insulin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 2 of 3 residents reviewed for dignity concerns and one random observation. Staff leaned over a resident to provide care and remove a fitted sheet, a resident's hair was disheveled, food was observed on a resident's face, blood ran down a resident's neck and staff failed to wipe it off, a resident had a gauze dressing on her forehead that was not covered, water was observed on the bedside table of a (nothing by mouth) NPO resident, and staff indicated they would provide water with a mouth sponge to a resident and failed to provide it. (Resident 57, Resident 44, Resident 64) Findings include: 1. On 4/7/25 at 1:10 P.M., Resident 57's clinical record was reviewed. Diagnoses included, but was not limited to, anemia, hypertension, and anxiety disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated Resident 57 was cognitively intact and had a skin tear. During an observation on 4/6/25 at 10:44 A.M., Resident 57 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. The bed hold form was not completed. There was no documentation of a resident or representative receiving a bed hold at the time of hospitalization. (Resident 15, Resident 41) Findings include: 1. On 4/9/25 at 9:03 A.M., Resident 15's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 8/9/24 and returned back to the facility from the hospital on 8/13/24. Resident 15's clinical record lacked documentation of a bed hold policy given to the resident or a representative at the time of the transfer. 2. On 4/8/25 at 10:03 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of external lower lip and dysphasia. A progress note, dated 11/6/25 at 3:48 P.M., indicated Resident 41 was scheduled to leave the facility the following…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with bathing, nail care and oral care for 3 of 3 residents reviewed for ADL care. (Resident 44, Resident 64, Resident 14) Findings include: 1. During an interview on Monday 4/7/25 at 10:44 A.M., Resident 14 indicated she was supposed to get a bath on Monday and Thursday but didn't always get them. She indicated she couldn't remember the last bath she got but knew she didn't get one last Thursday. She indicated the aides would tell her they were too busy. On 4/8/25 at 10:32 A.M., Resident 14 was observed lying in bed. She indicated she did not get a bath the previous day (Monday). She indicated an aide had asked her if she would like a washcloth to wash her face and hands, but no one else had asked her that. On Thursday 4/10/25 at 11:00 A.M., Resident 14 was observed lying in bed. She indicated she had the same dress on since she had went to her doctor's appointment a week ago yesterday. She indicated she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure care and services were provided to a resident with an open skin area for 1 of 3 residents reviewed with skin conditions. Assessments including measurements and description of the area were not completed for an open skin area. (Resident 60) Finding includes: On 4/7/25 at 2:05 P.M., Resident 60's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/9/25, indicated cognition status could not be assessed, the resident required partial to moderate assistance (helper does less than half the effort) with toileting, bathing, and transfers, and no skin concerns were identified. Physician orders included, but were not limited to: Observe (to right hip/buttock) dressing to open area every shift for soil or dislodgement. Observe for signs and symptoms of pain or infection, dated 4/4/25. Observe (right upper thigh/buttock) every shift. Observe for signs and symptoms of pain or infection, dated 3/4/25.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2025-04-11 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 residents reviewed for behavioral health. A resident's clinical record lacked documentation of behavior monitoring. (Resident 64) Finding includes: On 4/8/25 at 1:44 P.M., Certified Nurse Aide (CNA) 34 and CNA 16 were observed performing incontinence care on Resident 64. During the care, the resident indicated Let her do it. At the conclusion of care, when CNA 34 was leaving the room, the resident yelled A--hole. On 4/7/25 at 3:00 P.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain injury (TBI), post traumatic stress disorder, schizophrenia, and dysphagia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident 64's cognition was not able to be assessed, he had no behaviors, and was totally…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain proper infection control practices and provide a safe and sanitary environment for 1 of 2 residents observed for incontinence care and 1 of 1 residents reviewed for feeding tube care. Staff did not sanitize their hands between glove changes, wash cloths were laid on the side of the bathroom sink and then used for wiping the resident during incontinence care, clean linens and a resident's bare skin were touched with soiled gloves, and a bed sheet with blood on it was not changed. (Resident 64, Resident 281) Findings include: 1. On 4/8/25 at 1:44 P.M., Certified Nurse Aide (CNA) 34 and CNA 16 were observed performing incontinence care on Resident 64. CNA 34 rolled resident from left to right while pulling down the resident's pants and pulling out the lift pad that was underneath him. CNA 34 grabbed two wash cloths and went into the bathroom. CNA 34 laid the washcloths on the side of the sink while he washed his hands. After getting…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0949 — failed to train staff on dementia and abuse — isolated
    Provide behavior health training consistent with the requirements and as determined by a facility assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a sufficient and competent behavioral and mental health training program for all staff was implemented, as determined by staff needs and the facility assessment. Resident clinical records lacked documentation of behavior monitoring and staff were unaware of a resident's diagnosis. (Resident 64) Finding includes: 1. The current facility assessment, last reviewed 3/21/25, indicated the facility cared for an average of 80 long term care residents daily. Current diseases/conditions, physical, and cognitive disabilities of those residents included, but were not limited to, psychosis (hallucinations, delusions, etc), impaired cognition, mental disorder, depression, Bipolar disorder, Schizophrenia, PTSD, anxiety, TBI, Down Syndrome, autism, Alzheimer's disease, non-Alzheimer's dementia, and behaviors that need intervention. Eleven of those residents were indicated to have had behavioral health needs. It indicated the following mental health and behavior services were offered based on the resident's needs: manage the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to completely and accurately report an allegation of sexual abuse to the state agency for 1 of 3 allegations of abuse reviewed. (Resident C) Finding includes: During a review of facility reported incidents on 1/21/25 at 11:45 A.M., an Indiana Department of Health (IDOH) Reportable Incident form, dated 12/18/24 at 4:15 P.M., indicated, [Resident C] stated that a Certified Nurses Aide [CNA] made contact with her chest area during care last week. She stated she had not reported to staff until now, but that she had told her roommate. One should note that resident does not have a roommate. A follow up to the incident, dated 12/26/24, indicated, Resident [C] continues to receive psychosocial monitoring and support as necessary. (Psychiatrist name) continues to follow resident. The facility investigation did not conclude any witnesses to any type of inappropriate actions from the alleged employee or any other employee. The alleged employee remained suspended during the investigation then was terminated. A police report was made by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for resident abuse. A resident was not assisted by two staff members during a transfer according to the resident's plan of care. (Resident C) Finding includes: During a review of facility reported incidents on 6/10/24 at 12:30 P.M., a reported incident dated, 6/6/24 included that Resident C state that QMA was rough with her when positioning leg during a transfer. During record review on 6/11/24 at 10:30 A.M., Resident C's diagnoses included, but were not limited to, age-related physical debility, contracture of left knee, infection and inflammatory reaction due to internal left hip prosthesis, and unspecified displaced fracture of fourth cervical vertebra. Resident C's most recent admission MDS (Minimal Data Set) assessment, dated 4/21/24, included that Resident C had no cognitive impairment, had one-sided impairment to upper and lower extremities, and was dependent for transfers. Resident C's physician orders included, but were not limited…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-16 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident's right to privacy was protected for 1 of 3 residents reviewed for privacy. Two photographs of a resident, taken by facility staff, were shared to the facility's social media website without the resident's consent. (Resident F) Finding includes: During an interview and observation on 4/15/24 at 10:50 A.M., Resident F indicated that staff had shared photographs of her on the facility's social media website after she had refused consent to do so. Resident F indicated that a friend had contacted her after seeing the photographs on the facility's social media website. Resident F indicated that one of the photographs was taken during the solar eclipse (4/8/24) and the other was taken around Easter (2024). Resident F had saved the photographs to her personal phone. An observation of the images showed Resident F sitting in a wheelchair in what appeared to be the facility parking lot, and another image showed Resident F posing with an Easter bunny. During record review on 4/15/24 at 1:30 P.M.,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-13 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to meet medical needs that were identified in the comprehensive assessment. Staff did not follow orders and implement care plan interventions for 6 of 8 residents reviewed for falls and nutrition. (Resident 38, Resident 53, Resident 68, Resident 2, Resident 64, Resident 80) Findings include: 1. On 2/5/24 at 10:00 A.M., Resident 38 was observed sitting in a wheelchair beside the bed. She was leaning over with her arms and head resting on the bed, her butt still in the wheelchair, and wearing socks that were not non-skid. On 2/7/24 at 1:57 P.M., Resident 38 was observed sitting in a wheelchair in her room with a bedside table in front of her. Resident 38 was wearing socks that were not non-skid. On 2/8/24 at 8:01 A.M., Resident 38's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, and right femur fracture. The most…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-13 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 1 of 27 days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 4 of 2023 (weekends from July 1, 2023 through September 30, 2023). Finding includes: On 2/13/24 at 9:30 A.M., the Time Card Report from 7/1/23 through 9/30/23 was reviewed. Review of the Time Card Report indicated there was not any RN coverage on 9/29/23. During an interview on 2/7/24 at 1:46 P.M., the Administrator indicated the facility utilized Qualified Medication Aides (QMA) which may make their staffing ratio low. Corporate submits their staffing to the PBJ. On 2/14/24 at 12:33 P.M., a policy was requested, but not received during the survey period. 3.1-17(b)(3)

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-13 · tag F0728 — failed to protect against nurse-aide misconduct — pattern
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff were completed with the CNA training program and evaluation within 4 months of their hire date for 4 of 4 staff that completed the CNA training program at the facility. Findings include: A list of staff that had completed the CNA training program at the facility was provided by the Assistant Director of Nursing (ADON) on 2/13/24 at 2:25 P.M., and indicated the following: On 2/12/24 at 9:47 A.M., employee records were reviewed. Hospitality Aide/Nurse Aide 25 had a start date of 8/25/23 and was not certified. Hospitality Aide/Nurse Aide 21 had a start date of 8/17/23 and was not certified. Hospitality Aide/Nurse Aide 29 had a start date of 6/29/23 and was not certified. Hospitality Aide/Nurse Aide 30 had a start date 6/30/23 and was not certified. During an interview on 2/13/24 at 11:10 A.M., Licensed Practical Nurse (LPN) 24 indicated as a Nurse Aide (NA) they have been checked off on everything but had not become certified. During an interview on 2/13/24 at 11:15 A.M., the ADON indicated they had completed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-13 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure safe and sanitary infection control practices to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents observed for incontinence care, wound care, glucometer use. Gloves were not changed between dirty and clean tasks and the glucometer was cleaned with an alcohol wipe. (Resident 80, Resident 65, Resident 26, Resident 40) Findings include: 1. On 2/8/24 at 5:29 A.M., Nurse Aide (NA) 21 was observed performing incontinence care for Resident 80. NA washed her hands and put on gloves upon entering the room. She moved the bedside table, grabbed a clean brief, pulled down the sheets, removed the pillow between her legs and behind the resident, assisted resident onto her back, unfastened her brief, wiped creases of legs in front, grabbed a new wipe, and wiped the resident's peri area. Then she pulled out the wet brief. The resident indicated she had to urinate so NA placed the new brief under her and held it there. (A bedpan was not offered to the resident at the time.)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 1 of 2 residents reviewed for dignity and 1 random interview during the resident council meeting. A resident was not given oral care after vomiting and a resident's stained linens were not changed. (Resident 66, Resident 96) Findings include: 1. On 2/6/24 at 10:18 A.M., Resident 66 was observed laying in bed wearing a hospital gown that was falling off both shoulders and she was holding it up with her contracted hands. Her hair was greasy and disheveled and was not wearing non skid socks. On 2/9/24 at 1:23 P.M., Resident 66's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral infarction, dysphagia, aphasia The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 12/22/23, indicated her cognition was not able to be assessed, and was an extensive assist of 2 staff for bed mobility, transfers, and toileting. On 2/8/24 at 6:03 A.M., Resident 66 was observed laying in her bed with a dark brown substance smeared…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 4 residents observed during a medication pass. (Resident 58) Finding includes: On 2/8/24 at 7:11 A.M., Licensed Practical Nurse (LPN) 3 was observed during a medication pass to administer medications to Resident 58. The medications were obtained from the medication cart, placed in a medication cup, and taken into Resident 58's room. LPN 3 handed the medication cup to the resident, and the resident requested a pain medication. LPN 3 left the room prior to the resident taking the medications, closed the door, and obtained a pain medication from the cart. LPN 3 took that medication to Resident 58, and left the room prior to the resident taking that medication. On 2/9/24 at 1:30 P.M., Resident 58's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and emphysema. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/28/24, indicated no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure the residents received the necessary respiratory care and services in accordance with the professional standards of practice for 2 of 2 residents reviewed for respiratory care. The facility failed to have a physician's order for oxygen and follow physician's order for oxygen. (Resident 15, Resident 88) Findings include: 1. During an observation on 2/7/24 at 1:50 P.M., Resident 15 was sitting in a wheelchair in the common area with portable oxygen (O2) on at 2 liters per minute per nasal cannula with her eyes closed and her chin resting on her chest. During an observation on 2/8/24 at 10:01 A.M., Resident 15 was sitting in a wheelchair in the hallway outside of her room holding her oxygen tubing in her hand. The portable tank was hanging on the back of her wheelchair set at 2 liters. During an observation on 2/9/24 at 9:45 A.M., Resident 15 was sitting up in a wheelchair in the common area with oxygen on per nasal cannula at 2.5 liters per minute with her eyes closed and chin on chest. During an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-13 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure complete and accurate documentation of resident records for 1 of 4 residents reviewed for hospitalizations. A resident's allergy list was not updated. (Resident 2) Finding includes: On 2/7/24 at 12:14 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, traumatic brain dysfunction, seizures, persistent vegetative state. The most current MDS (Minimum Data Set) Assessment, dated 12/5/23, indicated the resident's cognition was not able to be assessed and he was totally dependent on 2 staff for bed mobility, transfers, and toileting. The resident's clinical record did not list Bactrim (antibiotic) as an allergy. A current Allergy Care Plan, revised 11/27/23, included an allergy to Zosyn (antibiotic). Progress notes included, but were not limited to, the following: On 5/22/23 at 12:50 P.M., This nurse reviewed systems and symptoms with [Nurse Practitioner's name]. New order received and noted for Bactrim DS BID [twice daily] x [for] 1 week. [mother's name] aware. ATB [antibiotic]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify the physician when a resident experienced changes in a level of consciousness, swallowing ability, wound condition, and the need to continue antibiotics for 1 of 19 residents reviewed for physician notification. (Resident 71) Findings include: The clinical record for Resident 71 was reviewed on 3/28/22 at 9:21 a.m. The diagnoses included, but were not limited to, cerebral palsy, pressure ulcer of sacral region, stage 4 pressure ulcer, sepsis, unspecified protein-calorie malnutrition, dysphagia, pharyngoesophageal phase; and type 2 diabetes mellitus with diabetic neuropathy. The nurse's note, dated 10/5/21 at 11:36 a.m., indicated the resident's dressing to the coccyx was saturated with foul-smelling fluid. Nursing was going to turn and reposition the resident. The nurse's note, dated 10/24/21 at 1:03 p.m., indicated the resident's dressing to the coccyx area was saturated with yellow foul smelling drainage with scant red streaks. Nursing staff were going to continue to monitor. The nurse's note, dated 10/26/21 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure proper catheter care was provided for 2 of 3 residents reviewed related to indwelling urinary catheters. (Residents 35 and 40) Findings included: 1. During an observation of catheter care, on 3/30/22 at 10:40 a.m., CNA (Certified Nurse Aide) 4 provided catheter care for Resident 35. Upon removing his disposable brief, she used a disposable wipe with the same side of the wipe, cleansing first the left side of his groin with 3 swipes, the right side of his groin with 3 swipes, and the scrotum with 3 swipes. She then obtained a new disposable wipe, and used multiple swipes, more than 30 with the same side of the cloth, to cleanse from the meatus down. She then took the same side of the same wipe and cleansed in a scrubbing motion around the catheter insertion site in the urethra. She then collected a new wipe and cleansed the length of the catheter in a scrubbing motion, going back and forth and made several passes over the length of the catheter from the insertion site to approximately 6 inches outwards.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$28,138 in federal fines across 2 penalties.

  • $14,069 — penalty dated 2025-01-24
  • $14,069 — penalty dated 2025-01-24

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CARDON & ASSOCIATES — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 53.7-2.7 vs chain
Health inspection 1 of 53.3-2.3 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 54.6-0.6 vs chain
The other 18 homes this chain runs (chain average 3.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
RIVERVIEW HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/01/2011
GERMAN AMERICAN BANKOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 07/21/2025
BALLA, MATTHEWIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/23/2022
CATTELL, ZACHARYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/25/2022
FAUTH, KENDRAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/26/2021
GORMAL, GREGGIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2016
HAUG, AMYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2022
LOPOSSA, LYNNIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/17/2023
MCCLELLAND, THOMASIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/26/2021
MCGRAW, LINDIEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2025
SPENCER, LEAANNIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 06/18/2018
TACKETT, TIFFANYIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 09/01/2011
FRIEND, JAYNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2021
HYATT, DAVIDIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 03/27/2023
CARDON AND ASSOCIATES INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/26/2025
CARDON MANAGEMENT COMPANY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/26/2025
MOORE OPERATING GROUP INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/18/2020
EMERSON, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2018
LOPEZ, JOSEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2017
MCINTOSH, ERICIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/31/2021
MILLER, SONYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/12/2024
ANKURA CONSULTING GROUP LLCOrganizationADP OF THE SNFsince 06/15/2022
BRADLEY & ASSOCIATES INCOrganizationADP OF THE SNFsince 01/01/2023
COLE MARKETING COMMUNICATIONS INCOrganizationADP OF THE SNFsince 04/01/2015
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/01/2021
HEALTHDRIVE PODIATRY GROUP PAOrganizationADP OF THE SNFsince 03/07/2019
HEART OF CARDON LLCOrganizationADP OF THE SNFsince 09/06/2007
JEFFREY L MORER OD PCOrganizationADP OF THE SNFsince 03/07/2019
LACY BEYL & COMPANY INCOrganizationADP OF THE SNFsince 07/15/2015
LIFESPAN THERAPY LLCOrganizationADP OF THE SNFsince 10/25/2007
MED-PASS INCORPORATEDOrganizationADP OF THE SNFsince 09/01/2020
MOBILE AUDIOLOGY ASSOCIATES PCOrganizationADP OF THE SNFsince 03/07/2019
MOSER CONSULTING INCORPORATEDOrganizationADP OF THE SNFsince 04/01/2020
PAOLI H&L PROPERTY LLCOrganizationADP OF THE SNFsince 09/11/2006
RESPIRATORY PARTNERS INCOrganizationADP OF THE SNFsince 11/01/2019
THIRD EYE HEALTH INCOrganizationADP OF THE SNFsince 02/04/2022
VOHRA WOUND PHYSICIANS OF THE WEST PCOrganizationADP OF THE SNFsince 09/01/2021
VOX GLOBAL LLCOrganizationADP OF THE SNFsince 02/28/2019

CMS files one row per role, so the 66 rows in the source record cover these 38 parties — each is shown once here with every role it holds. Nothing is omitted.

22 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.3M
Net patient revenuemost recent cost report
+4.7%
Operating marginrevenue minus expenses
$5.2M
Related-party expense44% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 14%Other / private 17%

This home reported $5.2M paid to related parties — landlords or management companies under common ownership — equal to about 44% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$343per resident / day
operating cost
$10,434per month
≈ monthly operating cost
$360per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155333. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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