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Aperion Care Peru

1850 West Matador St, Peru, IN 46970 · For profit - Corporation · 92 certified beds · (765) 689-5000 Medicare & Medicaid certified

Call the home — (765) 689-5000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • 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
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (58%) runs well above the national median (45%)
  • about 21% 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 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
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1496 West Hoosier Boulevard
Pharmacy
2 S Broadway Ave · (765) 472-4367 · Call to confirm hours
Grocery
100 W Broadway St · (765) 689-0977 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2051 W Matador St

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 5 of 5
Long-stay residentspeople who live here 5 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 held steady at 2 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 rating2★
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 increased3.1%11.0%15.4%better
Long-stay residents who lose too much weight4.4%5.5%5.4%better
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 infection0.3%1.1%2.0%better
Long-stay residents with depressive symptoms74.8%25.2%6.5%worse 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 injury2.9%3.9%3.3%better
Long-stay residents whose ability to walk worsened9.7%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.1%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine97.7%95.4%95.3%typical
Long-stay residents with pressure ulcers2.5%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control20.0%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table52.8%13.6%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Long-stay hospitalizations per 1,000 resident days1.361.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.591.441.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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.

11.1%U.S. median 10.7%
Went back to hospital
10.0%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 10.0% 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 20 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 0.17 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 6.8–14.810.7%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 discharge10.0%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 discharge20.0%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 discharge20.0%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 identified100.0%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 settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.261.02Oct 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

0.43
RN hours/ resident / day
0.97
LPN hours/ resident / day
2.26
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.38
RN hoursweekends
57.9%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 92 beds and averages 75.2 residents a day — about 82% occupied, or roughly 17 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 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 3.23 hrs/resident/day on weekends vs 3.84 on weekdays — 16% thinner on weekends. RN hours go from 0.45 to 0.38 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%.

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 (2026-01-30)
7
at the previous standard inspection (2024-10-25)

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 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · F2026-01-30 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    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 maintain a safe and sanitary environment in resident rooms and resident areas for three of four halls. (100 Hall, 200 Hall and 400 Hall)Finding includes:During the initial observations of residents, conducted between 1/25/2025 at 11:04 A.M. through /27/2025 at 2:30 P.M, the following observations were made:-In room [ROOM NUMBER], the inside of the door was missing paint in numerous areas.-In room [ROOM NUMBER], the inside of door had paint scraped off in several places.-In room [ROOM NUMBER], the door had multiple scrapes without paint and the wall next to the resident's bed was dirty. -In room [ROOM NUMBER], the bathroom ceiling vent above the shower had a heavy build-up of dust and there was blue masking tape wrapped around the smoke alarm.-In room [ROOM NUMBER], the wall surrounding the window was buckled and cracked. -In room [ROOM NUMBER], there were three holes behind the bed.-In room [ROOM NUMBER], the window well above the window…

    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 · Ecited before2026-01-30 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 medications were secure on 2 of 4 carts observed and in 1 of 16 resident rooms) (Wound Cart, South Treatment Cart and Resident 14's room) Findings include: 1. During an observation on 1/25/2026 at 10:55 P.M., the South Treatment Cart was unlocked and had medicated ointments, powders and sharp supplies, such as needles and scissors noted in the cart. During an interview on 1/25/2026 at 11:01 A.M., Licensed Practical Nurse (LPN) 2 indicated the Treatment Cart was unlocked. 2. During an observation 1/27/2025 at 9:45 A.M., the Wound Treatment Cart was unlocked and contained medicated ointments, powders and sharp supplies, such as needles and scissors in the cart. During an interview on 1/27/2025 at 9:50 A.M., Registered Nurse 3 indicated she had been responsible for the Wound Treatment Cart and the cart was not locked. 3. Upon entering the room of resident 14 on 1/25/2026 at 11:08 A.M , a medication cup with 10 pills was observed on the bedside tray. During an interview with the Director of Nursing on…

    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 · D2026-01-30 · 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 and interview, the facility failed to ensure a resident's right to communicate with staff providing services was protected for 1 of 3 residents reviewed for Resident's rights. (Resident 36)Finding includes:During an interview and observation on 1/27/2026 at 11:01 A.M., Resident 36 indicated, There he is ., and further stated he is a great guy when Employee 6 arrived to deliver the resident's clean laundry. However, Employee 6 did not acknowledge Resident 36 after the resident made the statements nor did the employee attempt to communicate with the resident. When Employee 6 was putting the Resident 36's clothes in his closet, the resident again indicated, There is my guy and attempted to engage the employee with conversation, but Employee 6 never acknowledged the resident before he put away the resident's clean laundry and left the room. During an interview on 1/27/2026 at 11:03 A.M., Employee 6 was asked if he could answer a few questions but he walked away without responding. Employee 6 was wearing a pink colored earbud in both of his ears. During an interview…

    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 · Dcited before2026-01-30 · 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 observation, record review, and interview, the facility failed to notify the physician of a significant weight loss for 1 of 1 resident reviewed for nutrition. Findings include:The clinical record for Resident 52 was reviewed on 1/28/2026 at 10:34 A.M. Diagnoses included but were not limited to: Alzheimer's disease, chronic obstructive pulmonary disease, asthma, anxiety and dementia. The most recent Minimum Data Set (MDS) assessment, completed as a quarterly review, on 12/1/2025 indicated the resident was severely cognitively impaired and required supervision for eating needs. Nursing Progress notes indicated on 12/3/2025, the resident weighed 108.5 pounds. On 1/6/2026, the resident weighed 104.5 pounds a -3.69% loss in one month.On 1/6/2026, the resident weighed 104.5 pounds, on 1/30/2026, the resident weighed 99 pounds a -5.26% loss in less than a month. There was no documentation the physician had been notified of the significant weight loss.On 8/5/2025, the resident weighed 117 pounds, on 1/30/2026, the resident weighed 99 pounds a -15.38% loss in less than 6 months.…

    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 · Dcited before2026-01-30 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 person-centered comprehensive care plan was updated for a resident with a significant weight loss for 1 of 1 residents reviewed for nutrition. (Resident 52)Findings include:The record for Resident 52 was reviewed on 1/28/2026 at 10:34 A.m. Diagnoses included, but were not limited to: Alzheimer's disease, chronic obstructive pulmonary disease, asthma, anxiety and dementia. The most recent Minimum Data Set (MDS) assessment, completed as a quarterly review on 12/1/2025, indicated Resident 52 had severe cognitive impairment, required supervision for eating needs and was a smoker. Resident 52 was observed, on 01/25/2026 at 10:40 AM, walking around the unit. She was thin, her skin was dry and flaky and her clothes did not fit and were loose and baggy.A current care plan, initiated on 12/10/2024, indicated the following problem: I have an unplanned/unexpected weight gain related to improved intake.(sic) The goal for the plan was . The interventions included. The plan indicated it had been reviewed on 12/9/2025 but there…

    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 before2026-01-30 · 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 provide showers or bed baths for a dependent resident for 1 of 4 residents who were reviewed for Activities of Daily Living needs. (Resident 3)Finding includes: During an observation on 1/25/2026 at 12:08 P.M., Resident 3's hair was sticking up and was unbrushed. During an interview on 1/25/2026 at 1:59 P.M., Resident 3's right hand was sticky and she was unable to recall the last time she had had a shower. Resident 3's record review was completed on 1/28/2025 at 10:30 A.M. Diagnoses included but were not limited to: schizophrenia, epilepsy, major depressive disorder, dementia with moderate behavioral disturbances and generalized anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 1/9/2025, indicated Resident 3 had clear speech, usually made herself understood and had been able to understand others, had severe cognitive impairment, had had no behaviors and had not rejected care and was dependent on staff for all transfers and for showering or bed baths needs. Resident 3's January showers…

    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 · D2026-01-30 · 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 observation, record review and interview, the facility failed to implement physician recommendations in a timely manner after a fall with injury for 1 of 1 resident reviewed for falls. (Resident 5)Finding includes:During an interview, on 1/27/2026 at 2:23 P.M., Resident 5 indicated he had a recent fall and had elbow pain.During an interview and observation, on 1/29/2026 at 8:51 A.M., Resident 5 indicated his elbow painful and there was obvious swelling around the elbow. In addition he wore a compression stocking on his right arm.During an observation, on 1/30/2026 at 9:15 A.M., Resident 5 was observed to have purple and red bruising below and above the left elbow.A record review for Resident 5 was completed on 1/28/2026 at 9:15 A.M. Diagnoses included, but were not limited to: neuropathy, gout, peripheral vascular disease, diabetes mellitus type 2 and schizoaffective disorder.A Quarterly Minimum Data Set (MDS) assessment, dated 12/3/2025, indicated Resident 5 had moderate cognitive impairment and required supervision for transfers. A Nursing Progress Note, on 1/25/2026 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 complete a timely nutritional assessment and initiate interventions to prevent weight loss for 1 of 1 residents reviewed for nutrition. (Resident 52) This resulted in continued significant weight loss of 15.38% over the previous 5 months. Findings include:The clinical record for Resident 52 was reviewed on 1/28/2026 at 10:34 A.M. Diagnoses included but were not limited to: Alzheimer's disease, chronic obstructive pulmonary disease, asthma, anxiety and dementia. The most recent Minimum Data Set (MDS) assessment, completed for a quarterly review, on 12/1/2025, indicated the resident was severely cognitively impaired, required supervision for eating needs and was a smoker. Resident 52 was observed, on 01/25/2026 at 10:40 AM walking around the nursing unit. She was thin, her skin was dry and flaky, her clothes were loose, baggy and did not fit her. A care plan dated 12/10/2024, indicated I have a nutritional problem or potential nutritional problems related to Alzheimer's disease, anxiety, chronic obstructive…

    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 · D2026-01-30 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to obtain ordered laboratory orders for 1 of 5 residents reviewed for unnecessary medications. (Resident 1)Finding includes:A record review for resident 1 was completed on 1/28/2026 at 10:00 A.M. Diagnoses included, but were not limited to: bipolar disorder, hepatitis C, diabetes mellitus and history of alcohol use. A Quarterly Minimum Data Set (MDs) assessment, dated 12/18/2025, indicated Resident 1 had severe cognitive impairment and was administered medication of an antipsychotic, antidepressant, opioid and anticonvulsant.A Physician's Order, dated 11/18/2024, indicated laboratory orders for a prealbumin, vitamin D, vitamin B12 and folate level annually in October. However, these laboratory values, due in October 2025, could not be located in the medical record, nor provided by the laboratory facility.During an interview, on 1/30/2026 at 9:02 A.M., LPN 3 indicted the ordered laboratory values could not be located and the laboratory orders should have been drawn.A current policy was provided by the Executive Director, on…

    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 · D2026-01-30 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to complete dental recommendations from the in-house dentist for 1 of 1 resident reviewed for dental care. (Resident 77) Finding includes:During an interview, on 1/25/2026 at 1:59 P.M. Resident 77 indicated he had mouth pain due to something messing with his teeth. He indicated, I have some cavities.A record review for Resident 77 was completed on 1/28/2026 at 1:05 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, dementia and obstructive sleep apnea.A Quarterly Minimum Data Set (MDS) assessment, dated 12/3/2025, indicated Resident 77 had severe cognitive impairment and had no dental issues.A Physician's Order, dated 1/2/2025, indicated dental care as needed.A Dental Consult Note, dated 12/8/2025, indicated Resident 77 had upper right mouth pain sometimes and lower left nerve pain if his tongue touched his teeth. Resident 77 also had a draining fistula between teeth number 20 and 21 (lower left bicuspids). An outside referral for full mouth extraction was made.A Dental Hygienist Encounter Form, dated…

    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 18 citations
  • Potential for harm · E2024-12-20 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 room temperatures were at the appropriate temperatures on the Behavior Unit (BHU). This deficient practice had the potential to affect 27 of 27 residents residing on the BHU. Finding includes: During an observation on the Behavior Unit on 12/20/2024 at 9:40 A.M., with the Maintenance Director the following ambient air temperature readings were obtained utilizing the facility's laser thermometer inside resident room, pointed at the following walls: Rm. 400--the inside wall temperature was 63 degrees Fahrenheit, and the outside wall temperature was 64 degrees Fahrenheit. Rm. 401--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 402--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 403--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees…

    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 · Dcited before2024-10-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 care plans related to respiratory status were revised for 1 of 25 residents reviewed. (Resident 7) Finding includes: During an observation, on 10/21/2024 at 10:54 A.M., Resident 7 was receiving 2 liters (L) of oxygen via a nasal cannula (NC). During an observation, on 10/22/24 at 9:54 A.M., Resident 7 was receiving 2L of oxygen via a NC. During an observation, on 10/23/2024 at 1:57 P.M., Resident 7 was receiving 2L of oxygen via a NC. The medical record for Resident 7 was reviewed on 10/23/2024 at 11:55 A.M. Diagnoses included, but were not limited to: delusional disorder, diabetes mellitus, peripheral vascular disease, obstructive sleep apnea, heart failure, acquired absence of left leg below knee, hypertension, depression, anxiety, chronic obstructive pulmonary disease and history of transient ischemic accident and cerebrovascular accident. There was no physician's order for the use of oxygen for Resident 7. During an interview, on 10/24/2024 at 9:51 A.M. with the Director of Nursing, she indicated a…

    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 before2024-10-25 · 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, record review and interview, the facility failed to provide showering, shaving and nail care services related to ADL's (activities of daily living) for 2 of 8 residents reviewed for ADL's. (Resident D and 4) Findings include: 1. During an observation, on 10/21/2024 at 9:58 A.M., Resident D was observed to have facial hair. During an observation, on 10/22/2024 at 9:11 A.M., Resident D was observed to have facial hair and disheveled hair. At 1:30 P.M., Resident C was observed to have a baseball hat on and continued have facial hair. During an observation, on 10/23/2024 at 9:13 A.M., Resident D was observed with more than a days growth of facial hair and his hair was disheveled. At 1:29 P.M., Resident D's face continued to be unshaven and his hair disheveled. During an observation, on 10/24/2024 at 10:03 A.M., Resident D was observed to be wearing a baseball hat on top of unbrushed, greasy hai. His facial hair continued to be unshaven. During an observation, on 10/25/2024 at 10:22 A.M., Resident D was observed with an unshaven beard and wearing a baseball cap over…

    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 · D2024-10-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 provide splinting to prevent further contractures of a resident's upper extremity for 1 of 3 residents reviewed for mobility. (Resident 18) Finding includes: During an observation, on 10/21/2024 at 11:06 A.M., Resident 18 was unable to move her right hand, which was partially closed with contractures (shortening of muscles, tendons, skin and nearby soft tissues that causes the joints to shorten and become very stiff preventing normal movement). During an interview, on 10/21/2024 at 11:07 A.M., Resident 18 indicated the staff were supposed to stretch her hand, but they did not do it. A record review for Resident 18 was completed on 10/23/2024 at 10:23 A.M. Diagnoses include but were not limited to: Hemiplegia and hemiparesis, Lung and Brain Cancer, depression and anxiety. An admission Restorative Observation Form, dated 7/30/2023, indicated Resident 18 had no existing contractures or limited Range of Motion (ROM). A Care Plan, initiated 7/31/2023 and revised on 6/28/2024, indicated Resident 18 had an ADL…

    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 · D2024-10-25 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to check gastric residual volumes (GRV) and contact the resident's physician as ordered for 1 of 1 resident reviewed for tube feedings. (Resident 3) Finding includes: A record review for Resident 3 was completed on 10/22/2024 at 1:30 P.M. Diagnoses included, but were not limited to: Schizoaffective disorder, non-Alzheimer dementia, malnutrition, Bi-polar, autism, and dysphagia. A Quarterly Minimum Data Set (MDS) assessment, dated 9/19/2024, indicated Resident 3 received a mechanically altered diet and had a feeding tube. Resident 3's Physician Order's regarding the feeding tube included: Jevity1.5 of 300 ml (milliliter) bolus (single large dose given at once) four times a day, and a 240 ml bolus at bedtime with 175 mls of water before and after each bolus. Check residuals before beginning the feedings and before medication administration. If the residuals amounts are greater than 100 ml, hold the feedings and recheck in 1 hour. If not resolved, call the physician. A Care Plan, initiated on 8/22/2024, indicated Resident 3…

    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 · D2024-10-25 · 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 proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for 2 of 2 residents reviewed for respiratory care. (Residents 7 and 238) Findings included: 1. During an observation, on 10/21/2024 at 10:54 A.M., Resident 7 was receiving 2 liters (L) of oxygen via nasal cannula (NC) and the resident's oxygen tubing was undated and without a bag. During an observation, on 10/22/24 at 9:54 A.M., Resident 7 was receiving 2L oxygen via NC and oxygen tubing was undated and without a bag. During an observation, on 10/23/2024 at 1:57 P.M., Resident 7 was receiving 2L oxygen via NC and oxygen tubing was undated and without a bag. The medical record for Resident 7 was reviewed on 10/23/2024 at 11:55 A.M. Diagnoses included but were not limited to: delusional disorder, diabetes mellitus, peripheral vascular disease, obstructive sleep apnea, heart failure, acquired absence of left leg below knee, hypertension, depression, anxiety, chronic obstructive…

    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 · D2024-10-25 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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, record review and interview, the facility failed to transcribe and administer ordered comfort medications for 1 of 1 resident reviewed for hospice services. (Resident B) and failed to ensure controlled narcotics were reconciled, counted and documented every shift for 2 of 3 narcotic count log books reviewed. ([NAME] Terrace & Behavioral Unit) Findings include: 1. A record review for Resident B was completed, on 10/22/2024 at 1:44 P.M. Diagnoses included, but were not limited to: pneumonia, chronic obstructive pulmonary disease (COPD), acute respiratory failure and generalized anxiety. A Nursing Progress Note, dated 10/10/2024 at 3:50 P.M., indicated Resident B was admitted to Hospice services with a diagnosis of senile degeneration of the brain. He was prescribed hydrocodone (pain medication) 5-325 milligrams every six hours as needed and lorazepam (antianxiety medication) 0.5 milligrams every six hours as needed for anxiety/agitation. A Nursing Progress Note, dated 10/12/2024 at 4:11 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and observation, the facility failed to ensure the use of an appetite stimulant medication was necessary for 1 of 5 residents reviewed for unnecessary medications. (Resident C) Finding includes: During an observation, on 10/21/2024 at 12:10 P.M., Resident C was observed to be feeding herself a meal of a quesadilla, corn and refried beans. A record review for Resident C was completed on 10/23/2024 at 8:44 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, chronic kidney disease and heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 9/4/2024, indicated Resident C had severe cognitive impairment and had not experienced a significant weight loss (weight loss of five percent in one month or 10 percent in 6 months). A Dietary Quarterly Review note, dated 9/6/2024, indicated the resident's fluid intake were good, their appetite was good and staff were to continue the plan of care. A Dietary Assessment for the MDS assessment, dated 9/6/2024, indicated there had been no significant weight loss of five…

    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 · D2024-10-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to limit an as needed (PRN) antianxiety medication to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident B) Finding includes: A record review for Resident B was completed, on 10/22/2024 at 1:44 P.M. Diagnoses included, but were not limited to: psychosis, adult failure to thrive, alcoholic dementia and generalized anxiety. An Annual Minimum Data Set (MDS) assessment, dated 9/26/2024, indicated Resident B had severe cognitive impairment. The assessment indicated Resident B was on an antipsychotic, antianxiety and opioid medications. He had behaviors including, but not limited to: -Delusions. -Verbal behavioral symptoms directed towards others as threatening others, screaming at others and cursing at others. -Other behavioral symptoms not directed towards others as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. A Physician's Order,…

    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 before2024-10-25 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to provide sanitary serving of food plates for 1 of 3 dining rooms observed during the lunch meal service. This had the potential to affect 14 residents on the dementia unit. Finding includes: During a continuous observation, on 10/21/2024 from 11:52 A.M. through 12:17 P.M., the activities assistant was observed to serve plates with her thumb over the rim of the plate to 5 of 12 residents in the dining room. During an interview, on 10/21/2024 at 12:02 P.M., the activity assistant indicated she had not been educated on how to properly serve dinnerware. She indicated her thumb should not have been on the top of the plate. A current policy titled, Resident Tray Delivery, was provided by the Regional Director of Nursing Services, on 10/25/2024 at 10:54 A.M. The policy did not address proper handling of dinnerware when serving the residents. 3.1-21(i)(3)

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-25 · 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 safe infection control practices were followed regarding obtaining a blood sugar sample and administering insulin for 1 of 2 residents observed administering insulin. (Residents 43) Finding includes: During a medication administration observation, on 10/25/2024 at 8:35 A.M., LPN 17 was observed to donn (apply) gloves and walk to the main dining area. He then placed the glucometer (device to monitor blood glucose levels) on a dirty dining room table. Next, LPN 17 wiped the finger of Resident 43 with an alcohol pad. and then obtained the blood sample from Resident 43's finger. Afterwards, he removed the test strip, placed it in his gloves and removed his gloves. During an interview, on 10/25/2024 at 8:37 A.M., LPN 17 indicated he should not have obtained the blood sugar sample in the dining room and should have used a barrier between the dining room table and the glucometer. On 10/25/2024 at 12:25 P.M., the Corporate Nurse provided the policy titled, Insulin Pen Procedure, dated 8/4/2020, and indicated…

    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 · Ecited before2023-09-29 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 expired liquids and spices were not in use, failed to ensure the pantry and activity refrigerators were clean and without undated, unnamed foods, in 1 of 1 kitchens and 2 of 2 pantries observed. (Main kitchen, nourishment and activity cafe' pantry) Findings include: 1. During the initial tour of the main kitchen on 9/25/2023 at 9:45 A.M., with the Dietary Manager, the following items were observed: - In the walk in cooler there was 2 containers with small cartons of milk that were expired. There were 8 cartons with the expiration date of 9/18/23, 10 cartons with the expiration date of 9/19/23 and 50 cartons with the expiration date of 9/23/2023. - In the walk in freezer, a large build of ice was observed hanging down on the right side of the condenser. During an interview, on 9/25/2023 at 9:50 A.M., the Dietary Manager indicated the milk should have been pulled and the ice build up should not be there. 2. During a followup observation of the kitchen, on 9/28/2023 at 1:06 P.M., the following 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-29 · 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 of significant weight losses, abnormal blood glucose levels and failed to notify the family of a hospitalization and change of condition in 3 of 3 residents reviewed for physician notification. (Resident 21, C & D) Findings include: 1. A record review was completed on, 9/28/2023 at 2:19 P.M. Resident 21's diagnoses included, but were not limited to obstructive uropathy, diabetes, dementia, arthritis, Parkinson's disease and malnutrition. An admission MDS (Minimum Data Set) assessment, dated 6/9/2023, indicated Resident 21 required total assistance of 2 staff for bed mobility, transfers, bathing, and personal hygiene. Resident 21's weight history indicated on 6/23/2023 the weight was documented as 150.0. On 8/14/2023 Resident 21 was admitted to the hospital to have a leg amputation and returned on 8/25/2023. Resident 21's weights are as follows: A readmission weight was not obtained. On 8/28/23 the resident's weight was documented as 128.5. On 9/1/23 the resident's weight was documented as 136.5 showing…

    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 · D2023-09-29 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure accurate clinical information was provided to the hospital for a hospital transfer, failed to obtain an order to transfer a resident to the hospital causing an unnecessary emergency room visit, and failed to obtain a physicians order to discharge to the hospital for 3 of 3 residents reviewed for hospitalization. (Residents 21) Finding includes: 1. A record review was completed on 9/28/2023 at 2:19 P.M. Resident 21's diagnoses included, but were not limited to anemia, dysphagia (difficulty in swallowing), diabetes, dementia, arthritis, and Parkinson's disease. An admission MDS (Minimum Data Set) Assessment, dated 6/29/2023, indicated the resident required extensive assist of 2 staff for bed mobility, transfers, dressing, eating and toilet use, and did not ambulate. Had a surgical wound, and 1 stage 2, and 1 stage 3 pressure ulcers. Treatment orders included: clease the area to the right hip with wound wash. Pat dry, and pack wound with 1/2 strength Dakin's soaked gauze and cover with dry border dressing once daily…

    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 · Dcited before2023-09-29 · 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, record review, and interview the facility failed to provide personal hygiene to a resident unable to complete per self for 1 of 5 residents reviewed for activities of daily living. (Resident 21). Finding includes: During an observation, on 9/25/2023 at 1:55 P.M., Resident 21 was observed in his bed with contracted hands, dirty nails to both hands and unshaved with a large growth of whiskers. During an observation, on 9/26/2023 at 9:28 A.M., Resident 21 was observed unshaven with a large growth of whiskers. During an observation, on 9/27/2023 at 2:23 P.M., Resident 21 was observed unshaven with a large growth of whiskers. During an observation, on 9/28/2023 at 1:45 P.M., Resident 21 was observed unshaven with a large growth of whiskers. During an observation ,on 9/29/2023 at 9:30 A.M., Resident 21 was observed unshaven with a large growth of whiskers. A record review was completed on, 9/28/2023 at 2:19 P.M. Resident 21's diagnoses included, but were not limited to obstructive uropathy, diabetes, dementia, arthritis, Parkinson's disease and malnutrition. Required…

    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 · D2023-09-29 · 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 record review and interview, the facility failed to provide education to the nursing staff on care of nephrostomy tubes for 1 of 26 residents reviewed. (Resident C) Finding includes: A record Review of Resident C was completed on 9/25/2023 at 11:28 P.M. Diagnoses included, but were not limited to: traumatic brain injury, tracheostomy, PEG tube, aphasia, a stage 3 and 4 decubitus ulcer, and quadriplegia. A Nurse's Note, dated 7/22/2023 at 12:06 P.M., indicated Resident C had recently readmitted to the facility with bilateral nephrostomy tubes. The nephrostomy tubes were leaking approximately ninety percent of the urine excreted onto the bed and Resident C. On 7/22/2023 at 12:10 P.M. at 12:10 P.M., a Nurse's Note indicated a decision was made to send Resident C to the hospital based on barely any urine drained properly through the nephrostomy tubes. A Physician's Order could not be located in the medical record, nor documentation of the physician being updated on the resident's condition. An Emergency Documentation, dated 7/22/2023 at 6:55 P.M., indicated, .Bilat [Bilateral]…

    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 before2023-09-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 provide water at the bed side for 1 of 2 residents reviewed for hydration. (Resident 20) Findings include: During an observation, on 9/25/2023 at 2:03 P.M., no water container was noted on the bedside table. A record review was completed on, 9/27/2023 at 9:01 A.M. Resident 20's diagnoses included, but were not limited to: Cerebral palsy, dementia and osteoarthritis. A Quarterly MDS (Minimum Data Set) Assessment, dated 8/25/2023, indicated the resident had severe cognitive function. Required total assistance of 2 staff for bed mobility, transfers, and toilet use, and extensive assistance for dressing and 1 staff for eating. Resident 20's diet order was a regular texture and thin liquids and assist with all meals. A current care plan, dated 9/25/2023, indicated the resident was on a regular diet with thin liquids, ice cream at lunch and dinner, snacks four times a day. Interventions: encourage resident to be up for all meals. Monitor for signs/ symptoms of aspiration. Position for eating and drinking safely.…

    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 before2023-09-29 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview and record review, the facility failed to ensure an insulin cart and a treatment cart were kept locked when unattended during 2 of 2 random observations. (100 and 200 Halls) Findings include: 1. During a random observation, on 9/27/2023 at 10:59 A.M., the insulin cart on the long hall was unlocked. During an interview, on 9/27/2023 at 11:00 A.M., LPN 8 indicated the cart should not be unlocked. 2. During a random observation, on 9/28/2023 at 11:25 A.M., the treatment cart on 100 hall was unlocked. QMA 5 walked by the cart and locked it. During an interview, on 9/28/2023 at 11:26 A.M. QMA 5 indicated the cart should not be unlocked. On 9/28/2023 at 5:20 P.M., the Corporate Nurse provided the policy titled,Medication Storage, dated 7/2/2019 and indicated the policy was the one currently used by the facility. The policy indicated . 3. Facility should ensured that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 3.1-25(m)

    Pharmacy Service 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

No federal fines in the current CMS record.

Part of a chain

This home belongs to APERION CARE — 33 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 2 of 51.9+0.1 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 1 of 51.6-0.6 vs chain
Quality measures 5 of 53.3+1.7 vs chain
The other 32 homes this chain runs (chain average 1.9★, per CMS)
1 of 5Aperion Care Arbors Michigan CityMichigan City, IN 1 of 5Aperion Care DemotteDemotte, IN 1 of 5Aperion Care DoltonDolton, IL 1 of 5Aperion Care Forest ParkForest Park, IL 1 of 5Aperion Care HanoverHanover, IN 1 of 5Aperion Care InternationalChicago, IL 1 of 5Aperion Care KokomoKokomo, IN 1 of 5Aperion Care LakeshoreChicago, IL 1 of 5Aperion Care LincolnEvansville, IN 1 of 5Aperion Care MidlothianMidlothian, IL 1 of 5Aperion Care MonroeBloomington, IN 1 of 5Aperion Care Oak LawnOak Lawn, IL 1 of 5Aperion Care Tolleston ParkGary, IN 1 of 5Aperion Care VincennesVincennes, IN 1 of 5Aperion Care WesleyChicago, IL 1 of 5Aperion Care WilmingtonWilmington, IL 1 of 5Arcadia Care MortonMorton, IL 2 of 5Alta Rehab At FairmontChicago, IL 2 of 5Alta Rehab At Oak BrookOak Brook, IL 2 of 5Aperion Care Chicago HeightsChicago Heights, IL 2 of 5Aperion Care DekalbDekalb, IL 2 of 5Aperion Care GreenfieldGreenfield, IN 2 of 5Aperion Care Marion LLCMarion, IN 2 of 5Aperion Care West ChicagoWest Chicago, IL 2 of 5Park Ridge Healthcare CenterPark Ridge, IL 3 of 5Aperion Care BurbankBurbank, IL 3 of 5Aperion Care ElginElgin, IL 3 of 5Aperion Care WestchesterWestchester, IL 5 of 5Alta Rehab At WaucondaWauconda, IL 5 of 5Aperion Care Fox RiverElgin, IL 5 of 5Aperion Care NilesNiles, IL 5 of 5Aperion Care SummerfieldCloverdale, IN

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 / managerTypeRoleSince
HANDY, SHAYNEIndividualCONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 09/01/2014
HORNER, JOHNIndividualCORPORATE OFFICERsince 09/01/2014
APERION CARE PERU LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2014
BEATY, JEFFIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022
CALDWELL, DANAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022
CARTER, DOUGLASIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022
COFFIN, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022
JONES, CURTISIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022
SANDMAN, JANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022
TANDY, SHERRIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2022

CMS files one row per role, so the 11 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$10.8M
Net patient revenuemost recent cost report
-0.0%
Operating marginrevenue minus expenses
$2.2M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 5%Other / private 7%

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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

$359per resident / day
operating cost
$10,908per month
≈ monthly operating cost
$359per 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 155702. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-30, 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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