Brickyard Healthcare - Portage Care Center
3175 Lancer St, Portage, IN 46368 · For profit - Corporation · 186 certified beds · (219) 762-9571 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (29) — 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)
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.
| 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
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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 |
| 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 improved from 2 to 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.0% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 39.8% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.3% | 3.9% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.1% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.6% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 78.0% | 95.4% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.1% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.0% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.5% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.2% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.7% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.57 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.95 | 1.44 | 1.80 | better |
‡ 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.
56.8% 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 141 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.1% 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 77 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.8%CMS range 48.1–66.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 7.9%CMS range 5.9–11.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 57.1% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 48.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 95.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.5–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 186 beds and averages 161.0 residents a day — about 87% occupied, or roughly 25 beds typically open. It runs fairly full. 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 3.38 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 2.93 hrs/resident/day on weekends vs 3.57 on weekdays — 18% thinner on weekends. RN hours go from 0.59 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%. 2 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
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.
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.
29 citations, most serious first. The 10 most serious are shown; the remaining 19 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 record review and interview, the facility failed to ensure assessments of a resident's vascular wound were timely and accurate for 1 of 3 residents reviewed for wounds. (Resident H) The facility also failed to ensure Physician's Orders were followed related to insulin administration and blood sugar monitoring, for 3 of 3 residents reviewed for insulin administration and blood sugars. (Residents H, F, and J)Findings include:1. Resident H's closed record was reviewed on 6/25/26 at 11:13 a.m. The diagnoses included, but were not limited to, severe peripheral arterial occlusive disease with right common iliac artery and right common femoral artery occlusions (major blood vessels supplying the right leg), diabetes mellitus, and dementia.A Care Plan, dated 5/22/26, indicated a diagnosis of diabetes mellitus. The interventions included, the body would be assessed for breaks in the skin and treated promptly as ordered by a Physician, diabetes medication would be administered and blood sugars would be obtained as ordered by the Physician.A Care Plan, dated 5/22/26, indicated a risk…
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.
- Potential for harm · F2026-01-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 a sanitary kitchen related to the dishwasher not reaching the required temperature for a high temperature dish machine. This had the potential to affect 149 residents who received meals from the Main Kitchen. Finding includes: The initial kitchen tour was completed on 1/5/26 at 9:09 a.m. with the Dietary Manager (DM). The DM indicated the dishwasher was a high temperature dish machine. Dietary Server 1 was observed putting trays of dishes through the dishwasher. A wash cycle was observed with Dietary Server 1. There were three gauges on top of the dishwasher. During the wash cycle, the wash temperature gauge and the rinse temperature gauge did not move from 150 degrees F (Fahrenheit). The final rinse sanitation gauge did not move from 130 degrees F. The DM asked the Dietary Server to run a few more cycles. Each time the gauges did not move. The DM then put a digital thermometer on a tray and ran it through a cycle. The reading on the thermometer was 153.6 F.During an interview at the time of 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.
- Potential for harm · Ecited before2026-01-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 ensure blood pressure medications and insulin were held according to parameters for 3 of 7 residents reviewed for unnecessary medications. The facility also failed to ensure TED hose (compression stockings) were applied as ordered for 1 of 1 resident reviewed for TED hose and areas of bruising were assessed and monitored for 3 of 4 residents reviewed for non-pressure related skin conditions. (Residents 10, 64, 75, 126, 17, 4, and 114)Findings include: 1. The record for Resident 10 was reviewed on 1/8/26 at 11:32 a.m. Diagnoses included, but were not limited to, hypertension and congestive heart failure The Quarterly Minimum Date Set (MDS) assessment, dated 12/2/25, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 11/26/25, indicated the resident was to receive Norvasc (a blood pressure medication) 5 milligrams (mg) in the morning. Hold if the resident's systolic (top number) blood pressure was less than 120 or pulse less than 60. The November 2025 Medication…
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.
- Potential for harm · Ecited before2026-01-12 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 observation, record review, and interview, the facility failed to maintain clinical records that were complete and accurately documented related to clarification of oxygen orders and incorrect documentation of obtaining blood pressure readings on a restricted arm for 4 of 34 records reviewed. (Residents 112, 161, 92, and 2)Findings include:1. On 1/6/26 at 11:00 a.m., Resident 112 was seated in her wheelchair in her room. She had no oxygen in use. On 1/7/26 at 9:33 a.m. and 2:00 p.m., the resident was observed in her room. She was not wearing oxygen per a nasal cannula at the time. On 1/8/26 at 2:05 p.m., the resident was seated in her wheelchair and being transported back to her room. A portable oxygen tank was hanging from the back of the wheelchair. The resident was not wearing oxygen at the time. The record for Resident 112 was reviewed on 1/7/26 at 2:38 p.m. Diagnoses included, but were not limited to, congestive heart failure and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment, dated 12/13/25, indicated the resident 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.
- Potential for harm · D2026-01-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 1 resident reviewed for dignity. (Resident 75)Finding includes:On 1/5/26 at 11:21 a.m., Resident 75 was observed in her room in bed. The resident was wearing a hospital gown. On 1/6/26 at 9:35 a.m. and 11:38 a.m., the resident was observed in her room in bed and wearing a hospital gown. On 1/7/26 at 9:15 a.m., 11:37 a.m., and 1:40 p.m., the resident was observed in her room in bed wearing a hospital gown. On 1/8/26 at 10:42 a.m. and 1:55 p.m., the resident was observed in her room in bed wearing a hospital gown. The record for Resident 75 was reviewed on 1/7/25 at 10:35 a.m. Diagnoses included, but were not limited to, stroke and dementia without behavior disturbance. The Annual Minimum Data Set (MDS) assessment, dated 11/26/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. It was important for the resident to choose what…
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.
- Potential for harm · D2026-01-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 referrals from the optometrist were carried out and appointments were made for 1 of 1 resident reviewed for hearing and vision. (Resident 9)Finding includes:During an interview on 1/5/26 at 2:28 p.m., Resident 9 indicated he had seen the eye doctor a couple of times this year and was still waiting for his glasses and possibly eye surgery. The record for Resident 9 was reviewed on 1/9/26 at 10:32 a.m. Diagnoses included, but not limited to, end stage renal disease, heart failure, stroke, major depressive disorder, vascular dementia, anxiety, and renal dialysis. The 11/4/25 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and his vision was adequate with no corrective lens. There was no care plan for vision. An Eye Exam Visit Note by the optometrist, dated 7/12/25, indicated the resident had a mild cataract in his left eye and it was recommended to have YAG laser posterior capsulotomy (an outpatient procedure to address scar tissue that forms behind 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.
- Potential for harm · Dcited before2026-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, record review, and interview, the facility failed to ensure a resident was transferred properly in a mechanical lift and a floor mat was in place for a resident with a history of falls for 2 of 8 residents reviewed for accidents. (Residents B and C)Findings include:1. The record for Resident B was reviewed on 1/7/26 at 10:12 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia without behaviors, high blood pressure, major depressive disorder, anxiety, and osteoarthritis. The 12/18/25 Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making and was dependent on staff for transfers from the bed to the chair. A Care Plan, revised on 6/16/25, indicated the resident had an activities of daily living (ADL) deficit. The approaches were to provide assistance with transfers and the resident required a mechanical lift. The 12/2025 Physician Order Summary indicated the resident received Hospice Services. A Change of Condition…
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.
- Potential for harm · Dcited before2026-01-12 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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 observation, record review, and interview, the facility failed to ensure bolus tube feeding administration as well as gastrostomy tube (a tube inserted directly into the stomach for nutrition) site care was completed as ordered for 2 of 2 residents reviewed for tube feeding. (Residents 75 and 13)Findings include:1. The record for Resident 75 was reviewed on 1/7/25 at 10:35 a.m. Diagnoses included, but were not limited to, stroke, dysphagia (difficulty swallowing) and dementia without behavior disturbance. The Annual Minimum Data Set (MDS) assessment, dated 11/26/25, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. The resident was also receiving a tube feeding (a tube inserted directly into the stomach for nutrition). A Care Plan, reviewed on 12/9/25, indicated the resident required a tube feeding related to the diagnosis of dysphagia. The resident was NPO (nothing by mouth) status. A Physician's Order, dated 7/31/25, indicated bolus feedings (a method of delivering liquid nutrition through a feeding tube as…
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.
- Potential for harm · D2026-01-12 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to document PICC line (a long-term use IV line) measurements as ordered for 1 of 2 residents reviewed with a PICC line. (Resident 161)Finding includes:The record for Resident 161 was reviewed on 1/7/26 at 10:47 a.m Diagnoses included, but were not limited to, unspecified severe protein-calorie malnutrition, colostomy, and intestinal obstruction.The admission Skilled Evaluation, dated 12/22/25, indicated the resident was alert and oriented and had a PICC line (a long-term use IV line).A Physician's Order, dated 12/23/25, indicated to measure the PICC catheter length on admission and with each dressing change thereafter, every Sunday night. The Medication Administration Record (MAR) indicated the PICC line dressing was changed on 12/24/25, 12/28/24, 12/31/24, and 1/4/26. The record lacked measurements of the PICC catheter length.A Care Plan, dated 12/23/25, indicated the resident was at risk for infection related to having a PICC line. Interventions included dressing change as ordered with measurements of the length of 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.
- Potential for harm · Dcited before2026-01-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, record review, and interview, the facility failed to ensure oxygen was flowing at the correct rate per minute for 1 of 1 resident reviewed for oxygen. (Resident 14)Finding includes:During random observations on 1/5 at 10:46 a.m., 11:36 a.m., and 2:13 p.m., on 1/6 at 9:50 a.m., on 1/7 at 9:14 a.m. and 11:00 a.m., and on 1/8/26 at 7:56 a.m., Resident 14 was observed in bed. At those times he was wearing oxygen at 1.5 liters per nasal cannula on the room concentrator. On 1/8/26 at 2:25 p.m. RN 1 entered the resident's room and observed the oxygen at 1.5 liters. The RN indicated, she was unaware what his oxygen was to be set at. The record for Resident 14 was reviewed on 1/6/26 at 4:03 p.m. Diagnoses included, but were not limited to, COPD, paranoid schizophrenia, intellectual disabilities, asthma, psychotic disorder, and high blood pressure. The 12/5/26 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and wore oxygen while at the facility. The Care Plan, revised on 10/23/25, indicated the resident…
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.
Show the remaining 19 citations
- Potential for harm · D2026-01-12 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 record review and interview, the facility failed to ensure residents were provided with medically related social services, related to the lack of documentation and follow up of an abuse allegation, missing cell phone, and a referral sent to another facility for 2 of 2 residents reviewed for Social Services. (Residents E and D)Findings include: 1. Closed record review for Resident E was completed on [DATE] at 9:38 a.m. Diagnoses included, but were not limited to, cancer, heart failure, hypertension, end stage renal disease, diabetes mellitus, thyroid disorder, anxiety, depression, chronic obstructive pulmonary disease, and metabolic encephalopathy. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact.A Behavior Charting Progress Note, dated [DATE] at 8:42 p.m., indicated the resident contacted 911 multiple times stating, we are breaking into her house. Prior to the behavior the resident was lying in bed. Interventions attempted were redirection 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.
- Potential for harm · D2026-01-12 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 record review and interview, the facility failed to ensure insulin was administered as ordered and blood sugars were monitored for 1 of 5 residents reviewed for unnecessary medications. (Resident 4)Finding incudes:The record for Resident 4 was reviewed on 1/8/26 at 11:02 a.m. Diagnoses included, but were not limited to type 2 diabetes. The 11/12/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making and received insulin. The Care Plan, revised on 11/3/25, indicated the resident had diabetes mellitus. The approaches were to check the resident's blood sugar as ordered by the physician. A Physician's Order, dated 11/5/25, indicated Insulin Glargine (a long acting insulin) inject 15 units subcutaneously (sq) every morning and at bedtime and to hold if the blood sugar was less than 100. The Medication Administration Record (MAR) for the months of 11/2025 and 12/2025, indicated the Glargine Insulin was administered at bedtime and there was no documentation the resident's blood sugar was checked on 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.
- Potential for harm · D2025-10-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Based on record review and interview, the facility failed to ensure anti-seizure medications were available and dispensed according to physician's orders for 1 of 3 residents reviewed for seizure medication administration. (Resident B)Finding includes:The record for Resident B was reviewed on 10/30/25 at 9:40 a.m. Diagnoses included, but were not limited to, seizures.A Physician's Order, dated 8/15/25 indicated lacosamide (an anti-seizure medication) oral tablet, 50 mg (milligrams) every morning and bedtime.The October 2025 medication administration record (MAR) lacked documentation that the 10/24/25 bedtime and 10/25/25 morning doses were administered. A Progress Note, dated 10/25/25 at 9:08 a.m., indicated the lacosamide medication was unavailable, and the pharmacy indicated a new prescription was needed. During an interview on 10/30/25 at 2:21 p.m., the Corporate Nurse Consultant indicated the medication came from the pharmacy on a card, and the nurse could visualize when a refill would be needed. She indicated the pharmacy had a prescription with refills available for 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.
- Potential for harm · Dcited before2024-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical appointments were completed in a timely manner for 1 of 1 resident reviewed for a medical referral. (Resident B) Finding includes: The record for Resident B was reviewed on 8/20/24 at 3:40 p.m. Diagnoses included, but were not limited to, stroke, aphasia (a language disorder) following a stroke, hemiplegia and hemiparesis (muscle weakness and paralysis) following a stroke affecting the left non-dominant side, seizures, and altered mental status. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 7/26/24, indicated the resident was cognitively impaired for daily decision making. A Physician's Order, dated 3/8/24, indicated an appointment with the resident's Neurologist was to be scheduled in one month. An appointment was scheduled for 4/16/24 at 9:30 a.m. Nurses' Notes, dated 4/16/24 at 10:41 a.m., indicated the resident's appointment was rescheduled for 5/8/24 at 10:45 a.m. due to…
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.
- Potential for harm · D2024-08-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 residents with pressure ulcers received the necessary treatment and services to promote healing related to offloading heels when in bed for 1 of 5 residents reviewed for pressure ulcers. (Resident D) Finding includes: During random observations on 8/19/24 at 3:00 p.m. and 3:45 p.m., on 8/20/24 at 10:10 a.m., 3:07 p.m., and 3:55 p.m., and on 8/21/24 at 1:39 p.m. and 2:45 p.m., Resident D was observed lying in bed. At those times, the resident's heels were not offloaded while in the bed. The heels were lying directly on the mattress. On 8/22/24 at 2:55 p.m., the Wound Nurse removed the resident's sock so his pressure ulcer could be observed. The wound was located on the left heel and had black and dark maroon intact tissue to the wound bed. The surrounding skin was starting to flake off. There was no drainage noted. The record for Resident D was reviewed on 8/20/24 at 3:15 p.m. Diagnoses included, but were not limited to, urine retention, anemia, high blood pressure, obstructive uropathy (a disorder of the urinary…
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.
- Potential for harm · Dcited before2024-08-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based on observation, record review, and interview, the facility failed to ensure a call light was in reach and preventative fall measures were in use for residents who were identified as a fall risk for 2 of 5 residents reviewed for falls. (Residents C and D) Findings include: 1. During a random observation on 8/20/24 at 11:40 a.m., Resident C was in her room in bed. The resident's eyes were closed and her call light was observed on the floor underneath her bed. On 8/20/24 at 3:05 p.m., the resident remained in her bed and was watching television. The call light remained on the floor underneath the bed. At 3:12 p.m., a CNA entered the resident's room. The CNA exited the room after providing care. At 3:25 p.m., the resident was observed in bed and the call light was in reach. The record for Resident C was reviewed on 8/21/24 at 3:32 p.m. Diagnoses included, but were not limited to, repeated falls, anxiety, and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 5/17/24, indicated the resident was cognitively intact. The resident 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.
- Potential for harm · Dcited before2024-08-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 Foley catheter bags and tubing were kept off of the floor for 1 of 1 resident reviewed for catheters. (Resident D) Finding includes: During random observations on 8/19/24 at 9:56 a.m. and 11:40 a.m., Resident D was observed sitting in a high back wheelchair. The bottom of the catheter bag was observed on the floor under the wheelchair. During a random observation on 8/21/24 at 1:39 p.m., the resident was observed in bed. The bed was very low to the ground and the catheter bag and tubing was observed laying on the floor mat. On 8/22/24 at 10:00 a.m., the resident was observed sitting in the high back wheelchair. At that time, the catheter bag was hanging right below the arm rest of the wheelchair and not below his waist. The record for Resident D was reviewed on 8/20/24 at 3:15 p.m. Diagnoses included, but were not limited to, urine retention, anemia, high blood pressure, obstructive uropathy (a disorder of the urinary tract that occurred due to obstructed urinary flow), anxiety, schizophrenia, mood…
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.
- Potential for harm · Dcited before2024-08-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 90) Finding includes: During random observations on 8/19/24 at 10:36 a.m. and 3:35 p.m., Resident 90 was observed wearing oxygen per nasal cannula at just under 3 liters per minute. During random observations on 8/22/24 at 9:56 a.m. and 11:12 a.m., the resident was observed wearing oxygen per nasal cannula. The oxygen flow rate was set right under 3 liters. During a random observation on 8/23/24 at 8:46 a.m., the resident was observed awake in bed. The resident was wearing oxygen per nasal cannula. The oxygen flow rate was set directly below 3 liters. The record for Resident 90 was reviewed on 8/19/24 at 10:45 a.m. Diagnoses included, but were not limited to, insomnia (difficulty sleeping), chronic obstructive pulmonary disease (COPD), and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 7/22/24, indicated the resident was cognitively intact for daily decision making and 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.
- Potential for harm · Dcited before2024-08-23 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to not sanitizing and disinfecting multiple resident use equipment for a random observation during medication pass. (Residents 71 and 53) Finding includes: During medication administration pass on 8/22/24 at 8:10 a.m., LPN 1 was observed checking Resident 71's blood pressure, pulse, and temperature with reusable instruments. After she had finished, she brought all of the items back to the medication cart and placed them to the side. The LPN did not sanitize the blood pressure machine and cuff, thermometer, or the pulse oximetry device. LPN 1 prepared, poured, and administered the resident's medication and left the room. She moved the medication cart across the hall to Resident 53's room. At 8:27 a.m., she took the blood pressure machine, thermometer, and pulse oximetry device into his room and checked his vital signs. The items had not been sanitized after they were previously used. After checking his vital signs, she brought all of 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.
- Potential for harm · Dcited before2024-01-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interview, the facility failed to ensure resident records were complete and accurate related to a lack of documentation regarding edema and laboratory testing for 1 of 3 residents reviewed for edema. (Resident D) Findings include: Resident D's record was reviewed on 1/17/24 at 10:00 a.m. Diagnoses included, but were not limited to, muscle wasting and atrophy, schizophrenia, bipolar disorder, autistic disorder and deaf non speaking. The admission Minimum Data Set assessment, dated 9/6/23, indicated the resident required substantial/ maximum assistance for bed mobility and transfers, and was dependent on staff for toileting. A General Note, dated 10/4/23, indicated the resident had completed the Brief Interview for Mental Screening and was cognitively intact. A General Note, dated 10/4/23, indicated a verbal order had been received from the Physician's nurse for Lasix (a diuretic) 40 milligrams daily for 5 days for lower extremity swelling and to obtain a uric acid lab test to rule out the medical diagnosis of gout. The record lacked results of the uric acid…
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.
- Potential for harm · Dcited before2024-01-18 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those specific to properly prevent and/or contain COVID-19, related to not having current outbreak status information visibly posted or passive screening completed for visitors during an outbreak. This had the potential to affect all 134 residents in the facility. Findings include: On 1/17/24 at 8:45 a.m., the facility entrance was observed. There were no visible postings in the entrance way that indicated the facility was in COVID-19 outbreak status. There was a reception desk with an employee present. There was a sign-in book that required name, date, time of visit and reason for visit, there were no health screening questions, nor did the receptionist ask any. There was a stand with hand sanitizer and face masks with a sign that indicated to cover your cough, and clean your hands. During tour of the facility on 1/17/24, there were rooms noted to have isolation bins and contact/ droplet isolation signs on the door. A staff member…
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.
- Potential for harm · D2023-09-22 · tag F0554 — isolatedAllow 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, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for a resident with medication at the bedside for 1 of 1 residents reviewed for self-administration of medication. (Resident 45) Finding includes: On 9/18/23 at 10:33 a.m., Resident 45 was observed lying in her bed. There was a bottle of Deep-Sea Nasal Spray on top of the bedside table. On 9/20/23 at 10:02 a.m., the bottle of nasal spray was still observed on the bedside table. The record for Resident 45 was reviewed on 9/19/23 at 2:09 p.m. Diagnoses included, but were not limited to, anemia, heart failure, diabetes, anxiety, depression, weakness and cellulitis. The Quarterly Minimum Data Set (MDS) assessment, dated 7/12/23, indicated the resident was cognitively intact and required extensive assistance with 2 staff physical assist for bed mobility, dressing, toileting, personal hygiene, and transfers. A Physician's Order, dated 7/5/23, indicated to give Ocean Nasal Spray (Saline spray), 1 spray in both nostrils every 8 hours as needed. 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.
- Potential for harm · D2023-09-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with ADL's (activities of daily living) related to nail care for 1 of 7 residents reviewed for ADL's. (Resident 118) Finding includes: On 9/18/23 at 11:30 a.m. and 1:52 p.m., on 9/19/23 at 10:30 a.m. and 3:17 p.m., and on 9/20/23 at 10:40 a.m. and 2:14 p.m., Resident 118 was observed with long fingernails to both hands. The record for Resident 118 was reviewed on 9/19/23 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, dysphagia, peg tube, high blood pressure, dementia, altered mental status and neuromuscular dysfunction of the bladder. The admission Minimum Data Set (MDS) assessment, dated 8/10/23, indicated the resident was severely impaired for decision making. The resident had no mood or behavior problems and was totally dependent on staff with a 2 person physical assist needed for personal hygiene. The resident had 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.
- Potential for harm · D2023-09-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure palm protectors were in place as ordered for 1 of 1 residents reviewed for limited range of motion (ROM). (Resident 231) Finding includes: On 9/18/23 at 11:15 a.m., 1:20 p.m., and 2:24 p.m., on 9/19/23 at 10:30 a.m., 1:52 p.m., and 3:15 p.m., and on 9/20/23 at 9:40 a.m., Resident 231 was observed in bed. At those times, there were no palm protectors to either one of his hands. The record for Resident 231 was reviewed on 9/19/23 at 2:15 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, traumatic subdural hemorrhage, stroke, hemiplegia, dysphagia, peg tube, repeated falls, dementia, depression, and anxiety. The admission Minimum Data Set (MDS) assessment was still in progress. There was no Care Plan for limited range of motion. Physician's Orders, dated 9/12/23, indicated palm protectors to both hands at all times. May remove for bathing and check the placement and skin every…
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.
- Potential for harm · Dcited before2023-09-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure an indwelling foley (urinary) catheter was placed below the level of the bladder and not on the floor for 3 of 3 residents reviewed for catheters. (Residents 118, 83, and 102) Findings include: 1. On 9/18/23 at 11:30 a.m., 1:35 p.m., and 2:55 p.m., Resident 118 was observed seated in a wheelchair. At those times, her indwelling foley catheter was wrapped around the arm of the wheelchair and above the level of her bladder. On 9/19/23 at 10:30 a.m., 1:52 p.m., and 3:17 p.m., and on 9/20/23 at 9:42 a.m., the resident was observed in bed. At those times, the bed was very low to the ground and the indwelling foley catheter bag was resting directly on the floor. The record for Resident 118 was reviewed on 9/19/23 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, dysphagia, peg tube, high blood pressure, dementia, altered mental status and neuromuscular dysfunction of…
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.
- Potential for harm · D2023-09-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 ensure residents received the correct diet for double portions and a fluid restriction was monitored for 2 of 3 residents reviewed for nutrition. (Residents 87 and 83) Findings include: 1. An interview with Resident 87's spouse on 9/18/23 at 2:01 p.m., indicated she visited her husband every day and was there during the lunch meal. He was supposed to receive double portions for all meals but had not been getting them. On 9/20/23 at 12:12 p.m. the resident was seated in a broda chair in the lounge next to his wife. At that time, lunch was served to him and he received 1 tuna fish sandwich, 1 can of tomato juice, 1 small piece of cake and 1 bowl of creamed soup. The meal ticket on his tray indicated double portions. On 9/21/23 at 12:00 p.m., the resident was seated in a broda chair in the lounge next to his wife. At that time, lunch was served to him and he received single portions of carrots, potato salad, cake and chopped meat. The record for Resident 87 was reviewed on 9/20/23 at 10:55 a.m. Diagnoses…
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.
- Potential for harm · Dcited before2023-09-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 9/20/23 at 2:22 p.m., QMA 1 was observed preparing to administer a medication through Resident 57's peg tube. QMA 1 washed her hands with soap and water and donned clean gloves to both hands. She checked for placement of the peg tube and for any residual. She attached a piston syringe to the peg tube and administered 15 ml (milliliters) of water. She then opened a package of duloxetine (antidepressant medication) and emptied it with 5 ml of water into a medicine cup. She stirred the mixture with the piston syringe and administered the medication through the peg tub. After administering the medication, she flushed the tubing with 15 ml of water. Interview with LPN 1 on 9/20/23 at 3:30 p.m., indicated QMA 1 was busy remembering the policy and didn't read the flush order correctly. The record for Resident 57 was reviewed on 9/21/23 at 10:45 a.m. A Physician's Order, dated 12/21/22, indicated to flush the peg tube with 30 ml (milliliters) of water before and after medication administration. Interview with 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.
- Potential for harm · Dcited before2023-09-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, record review, and interview, the facility failed to provide proper respiratory care and services related to oxygen at the correct flow rate for 1 of 2 residents reviewed for oxygen. (Resident 69) Finding includes: On 9/18/23 at 11:15 a.m. and 2:25 p.m., on 9/19/23 at 10:35 a.m., 1:52 p.m., and 3:15 p.m., and on 9/20/23 at 9:40 a.m., Resident 69 was observed in bed. At those times he was wearing oxygen per nasal cannula. The flow rate on the concentrator was less than 2 liters per minute but greater than 1.5 liters per minute. The record for Resident 69 was reviewed on 9/20/23 at 10:00 a.m Diagnoses included, but were not limited to, peg tube, diabetes, acute kidney failure, stoke, major depressive disorder, and dementia. The resident had just returned from a hospital admission from 8/24/23 to 8/29/23 for sepsis. The 9/5/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact. The resident was not using oxygen while a resident. A 9/18/23 Significant Change MDS assessment was in progress due to a change in the resident's…
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.
- Potential for harm · D2023-09-22 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a sanitary and safe environment related to marred and gouged walls, rusted ceiling vents, and a broken heat register control on 1 of 3 units observed. (100 unit) Findings include: During the Environment Tour on 9/21/23 at 3:33 p.m. with the Maintenance Director, the following was observed: 100 Unit a. The ceiling vent in room [ROOM NUMBER] was rusted. The heat register was rusted, and pieces were broken. There was one resident who resided in the room. b. The floor tile was discolored in room [ROOM NUMBER] under the television. The wall near bed one was gouged and marred. The cover for the heat register was broken. There were two residents who resided in the room. Interview with the Maintenance Director on 9/21/23 at 3:33 p.m., indicated he wasn't aware of the issues and he will fix everything next week. 3.1-19(f)
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to BRICKYARD HEALTHCARE — 23 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.4 | -1.4 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 22 homes this chain runs (chain average 2.7★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| CARPENTER-HEARD, JACQUELINE | Individual | CONTRACTED MANAGING EMPLOYEE | since 10/31/2022 |
| ENGELS, ERIN | Individual | CORPORATE DIRECTOR | since 11/01/2014 |
| GENTRY, MARK | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| STARKEY, TYLER | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WAITE, JOHN | Individual | CORPORATE DIRECTOR | since 08/01/2020 |
| WHICKER, TIMOTHY | Individual | CORPORATE DIRECTOR | since 01/12/2022 |
| FENOUGHTY, DEANNA | Individual | CORPORATE OFFICER | since 07/10/2023 |
| FOUNTAINVIEW PORTAGE OPERATING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2012 |
The source lists no ownership percentage for any party here — 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.
About 73% 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 $857K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
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
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.
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 155187. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-12, 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.