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Persimmon Ridge Rehabilitation Centre

200 N Park St, Portland, IN 47371 · Non profit - Corporation · 100 certified beds · (260) 726-9355 Medicare & Medicaid certified

Call the home — (260) 726-9355 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 2025Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (20) — 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)
  • about 18% 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) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
510 W Votaw St · (260) 726-2890 · Call to confirm hours
Pharmacy
950 W Votaw St · (260) 726-3782 · Call to confirm hours
Grocery
316 N Meridian St · (260) 726-2434 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 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 fell from 3 to 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 increased15.8%11.0%15.4%typical
Long-stay residents who lose too much weight4.2%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 infection1.4%1.1%2.0%better
Long-stay residents with depressive symptoms22.8%25.2%6.5%typical for the 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 injury3.3%3.9%3.3%typical
Long-stay residents whose ability to walk worsened15.8%11.9%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.1%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers2.8%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control22.8%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table18.4%13.6%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine95.5%79.0%79.4%better
Short-stay residents rehospitalized after admission21.5%22.2%22.6%typical
Short-stay residents with an outpatient ER visit5.6%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days2.761.611.67worse
Long-stay outpatient ER visits per 1,000 resident days2.181.441.80worse

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

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

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

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

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

58.9% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.9%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

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 42 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 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF58.9%CMS range 48.9–68.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.3–14.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge57.1%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 discharge40.5%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 discharge45.2%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 — 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 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 worsened1.9%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 hospitalization5.5%CMS range 3.1–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.081.02Oct 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

0.40
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.75
Aide hours/ resident / day
3.74
Total nurse hours/ resident / day
0.34
RN hoursweekends
26.3%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 83.2 residents a day — about 83% 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 3.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.75 is at or above 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 3.47 hrs/resident/day on weekends vs 3.86 on weekdays — 10% thinner on weekends. RN hours go from 0.43 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below 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

6
deficiencies at the latest standard inspection (2025-06-11)
2
at the previous standard inspection (2024-08-16)

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.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

  • Potential for harm · Dcited before2025-07-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by CNA 10 for 1 of 3 residents reviewed for abuse. (Resident C) This deficient practice was corrected on 7/19/25, prior to the start of survey, and was therefore past noncompliance. Findings include:Review of a facility reported incident, dated 7/19/25, indicated CNA 10 took a picture, using her personal cell phone, of Resident C's peri-area. The resident had marked herself with a bingo dauber. The CNA said she took the picture to show to the nurse on duty, but it was later discovered she had shown the picture to multiple staff members.Resident C's clinical record was reviewed on 7/30/25 at 10:03 a.m. Diagnoses included Down syndrome, muscle weakness, osteogenesis imperfecta (a condition where bones are fragile and easily broken), cardiac murmur, obstructive and reflux uropathy, and a cognitive communication deficit. An annual Minimum Data Set (MDS) assessment, dated 6/25/25, indicated Resident C was cognitively intact, did not experience hallucinations, delusions,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-07-31 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure staff immediately reported abuse allegations to the Administrator or designee for 1 of 3 residents reviewed for abuse. (Resident C). This deficient practice was corrected on 7/19/25, prior to the start of survey, and was therefore past noncompliance. Findings include:Review of a facility reported incident indicated CNA 10 took a picture using her cell phone of the resident's peri-area where the resident had marked herself with a bingo dauber. The CNA said she took the picture to show to the nurse on duty, but it was later discovered she had shown the picture to multiple staff members.Resident C's clinical record was reviewed on 7/30/25 at 10:03 a.m. Diagnoses included Down syndrome, muscle weakness, osteogenesis imperfecta (a condition where bones are fragile and easily broken), cardiac murmur, obstructive and reflux uropathy, and a cognitive communication deficit. An annual Minimum Data Set (MDS) assessment, dated 6/25/25, indicated the resident was cognitively intact, did not experience hallucinations, delusions,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-06-11 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ a qualified Dietary Manager. This deficiency had the potential to impact 77 of 77 residents who received meals from the facility kitchen. Findings include: During an interview, on 6/6/25 at 9:50 a.m., the Dietary Manager (DM) indicated she did not have a certification qualifying her to act as the Dietary Manager. She was hired in March 2025 and had not passed her certification test. During an interview, on 6/10/25 at 12:24 p.m., the Administrator indicated the former Dietary Manager (CNA 4), was currently employed as a CNA, and had a Manager's ServSafe certification. CNA 4 worked full-time, five days a week as a CNA, and also covered in the kitchen. During an interview, on 6/11/25 at 9:43 a.m., CNA 4 indicated she had a ServSafe certification. She estimated she worked 30% of her scheduled shift in the kitchen while the other 70% she was on the floor as a CNA. A current facility policy, titled Director of Food Service, provided by the Administrator on 6/11/25 at 12:08 p.m., indicated the following: .must possess 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-11 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 and interview, the facility failed to store and prepare food under safe and sanitary conditions related to kitchen equipment and cleanliness. This deficient practice had the potential to affect 77 of 77 residents who received food from the facility kitchen. Findings include: During a kitchen observation, on 6/5/25 at 11:01 a.m., accompanied by the Dietary Manager (DM), the following was observed: Pieces of lettuce were on the floor in front of the prep table. Numerous food particles were on the floor between the prep table and the stove. A serving tray, sitting on the shelf under the food prep table, across from the warming table, had what appeared to be ketchup smeared on the tray, along with a torn salt packet. There was a honey-colored food particle on the bottom handle of the warmer doors. A zip lock bag was on the floor, underneath the pots and pans storage rack, along with three white plastic storage lids. A trash can, positioned next to the storage pot and pan rack, had dried white and dark reddish/purple food crumbs on top of the lid. A dried brown ring…

    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 · D2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement fall interventions and provide supervision to prevent falls for residents with cognitive impairment for 2 of 3 residents reviewed for accidents. (Residents 59 and 72) Findings include: 1. During an observation on 6/5/25 at 10:14 a.m., Resident 59 was sitting on a loveseat in the dining/activity area, a bedside table in front of her and a blanket over her lap. Resident 59's clinical record was reviewed on 6/10/25 at 12:00 p.m. Diagnoses included Parkinson's disease with dyskinesia (involuntary movements), dementia, unsteadiness on feet, and a need for assistance with personal care. Current physician's orders included donepezil (used to treat dementia) 5 mg once daily at bedtime, buspirone (antianxiety) 5 mg three times a day, carbidopa-levodopa (to treat Parkinson's) 25-100 mg three times a day, lorazepam (antianxiety) 0.5 mg once daily, sertraline (antidepressant) 25 mg once daily, and trazodone (sedative) 50 mg daily at bedtime. A quarterly Minimum Data Set (MDS) assessment, dated 3/19/25,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · 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 change out, label, and date oxygen supplies for 3 of 17 residents reviewed. (Residents 42, 61, and 75) Findings include: 1. During an observation, on 6/5/25 at 12:35 p.m., Resident 61's oxygen bag and tubing were dated 5/4. On 6/6/25 at 10:38 a.m., Resident 61's oxygen bag and tubing were dated 5/4. Resident 61's clinical record was reviewed on 6/11/25 at 11:56 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia (low blood oxygen levels). Current orders included supplemental oxygen, 2 liters per minute via nasal cannula, at bedtime for hypoxia (4/16/25). 2. During an observation, on 6/5/25 at 10:22 a.m., Resident 75's oxygen bag and tubing were dated 5/17. On 6/6/25 at 10:30 a.m., Resident 75's oxygen bag and tubing were dated 5/17. Resident 75's clinical record was reviewed on 6/11/25 at 11:14 a.m. Diagnoses included restrictive lung disease. Current orders included supplemental oxygen, 2 liters per minute via nasal cannula, at bedtime for hypoxia…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · 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

    Based on record review and interview, the facility failed to ensure shift to shift narcotic count and reconciliation was completed for 3 of 5 medication carts reviewed for controlled medication reconciliation. (500 hall, 300 hall, and 200 hall) Findings include: During a medication storage observation of the 500 hall 1st half medication cart, on 6/10/25 at 9:20 a.m., accompanied by RN 4, the Shift To Shift Narcotic Sheet and Card Verification Log was reviewed. RN 4 signed the log during the observation. RN 4 indicated she should have signed the log at the start of her shift. During a record review, on 6/10/25 at 10:33 a.m., the 300 hall 2nd half, Shift To Shift Narcotic Sheet and Card Verification Log lacked shift to shift count and reconciliation signatures on controlled medications for the following dates: June 2025 - lacked shift-to- shift narcotic reconciliation signatures: 6/9 - 2:00 a.m. to 6:00 a.m. 6/9 - 6:00 a.m. to 10:00 a.m. During a record review, on 6/10/25 at 10:40 a.m., the 500 hall 2nd half, Shift To Shift Narcotic Sheet and Card Verification Log lacked shift 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-11 · 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 — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to dispose of unlabeled and unused medications for 1 of 6 medication carts reviewed for medication storage and labeling. (Medication Cart 300, 2nd half) Findings include: During a medication storage observation of the 300 hall 2nd half medication cart, on 6/10/25 at 5:13 p.m., accompanied by the DON, two loose pills were found at the bottom of the lowest drawer in the medication cart. The DON indicated that the pills needed to be disposed of. During an interview, on 6/11/25 at 8:25 a.m., the DON identified the two loose pills observed on 6/10/25 were ibuprofen (non-steroidal analgesic) and Ativan (anxiety medication). The DON indicated that the 300 hall 2nd half medication cart contained one resident who had an order for Ativan. During an interview, on 6/11/25 at 10:32 a.m., the DON indicated medication and treatment carts were deep cleaned weekly and the floor nurses were expected to address cart cleanliness daily during their shifts. A current facility policy, titled STORING DRUGS, provided by the DON 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 · Dcited before2025-04-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a cognitively impaired resident was free from staff-to-resident verbal abuse and physical abuse resulting in a skin tear for 1 of 3 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 2/24/25, prior to the start of survey, and was therefore past noncompliance. Finding includes: Review of a facility reported incident, dated 2/18/25 at 10:30 p.m., indicated the following: Brief Description of Incident: On 2/18/25 the DON and Administrator were notified of allegations of abuse to Resident B during a transfer. CNA 3 was suspended pending an investigation. Preventative measures taken included: a resident assessment per the abuse policy and all alert and oriented residents and all staff members were scheduled for interviews. A follow up on 2/24/25 included the following: During an abuse investigation it was noted that there were two witnesses present during the interaction between the resident and CNA 3. The two witness interviews indicated CNA 3 wanted the resident to go to bed when 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-04-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to timely report allegations of abuse to the appropriate agencies for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: Review of an Indiana State Department of Health facility reported incident, dated 2/18/25 at 11:34 p.m., indicated the facility initiated an investigation for alleged abuse against Resident B. The incident was identified on 2/18/25 at 10:30 p.m. CNA 3 was the staff member involved and suspended pending investigation. Local law enforcement and APS (Adult Protective Services) were not notified. The brief description indicated Resident B was allegedly abused during a transfer. During an interview with the Administrator on 4/15/25 at 3:18 p.m., she indicated she had not notified law enforcement because the resident did not have any serious bodily injury. During a phone interview with QMA 4 on 4/15/25 at 4:12 p.m., she indicated QMA 6 was right outside the room after the incident and she immediately reported it to her, who reported it to RN 8 and subsequently the DON and Administrator. During an…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · D2024-08-16 · 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 observation, record review, and interview, the facility failed to ensure non-pharmacological interventions were implemented prior to the PRN (as needed) administration of psychotropic medications for 2 of 6 residents reviewed for unnecessary medications. (Resident 39 and Resident 59) Findings include: 1. During an observation, on 8/14/24 at 10:16 a.m., Resident 39 sat quietly in a tilt-in-space positioning wheelchair in while watching a group activity. During an observation, on 8/15/24 at 8:57 a.m., the resident lay quietly in bed with her eyes closed in her darkened room. During an observation, on 8/16/24 at 8:32 a.m., the resident sat quietly in a tilt-in-space positioning wheelchair in the dining room at a table. Resident 39's clinical record was reviewed on 8/14/24 at 12:01 p.m. Diagnoses included Alzheimer's disease with early onset, psychotic disorder with hallucinations due to known physiological condition, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent, mild, generalized anxiety disorder,…

    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 before2024-08-16 · 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 — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to label over-the-counter medications with resident name and physician name and failed to dispose of expired medications for 1 of 6 medication carts observed. (Medication cart on 300 Hall) Findings include: During a medication storage observation of the 300 Hall medication cart for rooms 310 -317, on 8/16/24 at 2:07 p.m., accompanied by QMA 2, the following medications were observed and lacked a resident name and physician name: one container of melatonin 10 mg strength with initials written on the lid and one container of doxylamine succinate with initials written on the lid. An opened container of antifriction, body powder lacked a resident name, physician name, directions, and an expiration date. A container of psyllium fiber supplement with a last name on the lid lacked a physician name and had expired 8/2020. During an interview at the same time of the observation, QMA 2 indicated over-the-counter medications should have the resident's name, the prescriber's name, and the date opened on them. The expired…

    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 before2024-06-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an abuse allegation was reported to the Indiana Department of Health in a timely manner for 1 of 1 abuse allegation reviewed (Resident B). Findings include: A facility investigation for an abuse allegation was reviewed on 6/13/24 at 9:43 a.m. The facility reported incident indicated on 5/22/24 at 11:01 p.m., it was reported RN 6 was witnessed by two employees being verbally abusive when interacting with Resident B. Resident B was wheeling himself around the RN 6's medication cart and talking to himself. RN 6 stated to Resident B Go to your f--king room and stay there. Resident B was severely cognitively impaired. The submission confirmation to the Indiana Department of Health for the abuse allegation indicated the actual or identified date and time of the incident was 5/22/24 at 11:01 p.m. The submission date and time was 5/23/24 at 3:35 p.m. During an interview with the Administrator, on 6/13/24 at 1:28 p.m., she indicated she thought she was supposed to report within two hours if the report would have involved…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-10-30 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    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 the dietary manager completed the required education to meet the qualifications for a dietary manager. This deficiency had the potential to affect 57 of 57 residents who received meals from the facility kitchen. Finding includes: Employee records were reviewed on 10/26/23 at 1:36 p.m. The records lacked documentation of the required certification for the Dietary Manager. During an interview, on 10/26/23 at 2:05 p.m., the Human Resources Director indicated the Dietary Manager began functioning in her role as the Dietary Manager on 10/9/22. She did not have any certifications for the Dietary Manager. During an interview, on 10/26/23 at 2:16 p.m., the Regional Director of Operations indicated the Dietary Manager had enrolled in a dietary manager training course on 2/20/23 to become a certified dietary manager. He was uncertain when she planned to complete the course. During an interview, on 10/26/23 at 2:53 p.m., the Dietary Manager indicated the dietician was not at the facility full time; she visited the facility…

    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 · E2023-10-30 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    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 resolve continued Resident Council concerns regarding late mealtimes. Finding includes: Resident Council minutes were reviewed on 10/23/23 at 2:49 p.m., and indicated the following concerns: 6/21/23 Old Business - Dietary: The mealtimes have not improved on all meals. They get them late frequently. 6/21/23 New Business - Dietary: The Council feels the mealtimes have not improved. 6/26/23 Resident Council Feedback - Dietary Concerns - The Council feel the mealtimes have not improved. They feel they receive meals later than the scheduled times. Dietary department response - Dietary Supervisor continues to monitor service times and ensures they are on time. The feedback notes lacked evidence of formal monitoring of meal times. 7/24/23 Old Business - Dietary: The mealtimes have not improved. 7/24/23 New Business - Dietary: The mealtimes have not improved. 8/5/23 Resident Council Feedback - Dietary Concerns - The Council all feel the mealtimes…

    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 · E2023-10-30 · 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

    Based on observation and interview, the facility failed to maintain toilets in a clean and homelike manner for 3 of 4 residents reviewed for environment (Residents 4, 25, and 52) of the 15 residents who resided on the 500 Unit. Findings include: 1. During an observation of Resident 4's room, on 10/24/23 at 11:41 a.m., the toilet had a thick black and gray residue in the bottom of the toilet bowl. The residue surrounded the entire opening where contents flushed down the toilet, with black debris along the base of the toilet on the right side where the toilet rested against the floor. During an interview on 10/24/23 at 11:41 a.m., Resident 4 indicated the previous Maintenance Director was aware of the black residue on the right side of the toilet at the floor, before the current Maintenance Director started at the beginning of September. During an interview on 10/24/23 at 11:54 a.m., a visitor in Resident 4's room indicated the resident's toilet was not kept in a clean manner because the facility was short on housekeeping staff members. During a observation on 10/25/23 at 3:58 p.m.,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-30 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's advance directives were consistent in the clinical record, and changes were verified, for 1 of 3 residents reviewed for advance directives (Resident 3). Finding includes: Resident 3's record was review on [DATE] at 9:21 a.m. Her diagnoses included hypertension, hypothyroidism, and dementia. Her physician's orders included a code status for DNR (do not resuscitate). The resident's electronic continuity of care document and face sheet indicated do not resuscitate. Her current code status care plan, with the last revision date of [DATE], indicated the resident did not want cardiopulmonary resuscitation (CPR). The advance directives in the resident's paper chart indicated the resident did not want to have CPR performed as a lifesaving measure. The DNR was signed by the resident's representative on [DATE]. An advance directive in the resident's electronic chart (in the admission agreement) indicated the resident did want to have CPR…

    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 · D2023-10-30 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 Preadmission Screening and Resident Review (PASARR) was submitted for a resident with a new mental health diagnosis (Resident 18). Finding includes: Resident 18's clinical record was reviewed on 10/26/23 at 3:14 p.m. Diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance (10/3/22), delusional disorders (4/12/22), other recurrent depressive disorders (12/1/20), and generalized anxiety disorder (7/19/22). Her current medication orders included sertraline (anti-depressant) 75 mg daily. A quarterly Minimum Data Set (MDS) assessment, dated 10/9/23, indicated the resident was moderately cognitively impaired. She had an indicator of psychosis with hallucinations. Her active diagnoses included anxiety disorder, depression, and psychotic disorder. A care plan, last updated 7/27/23, indicated the resident had hallucinations as evidenced by seeing men in her room and talking to people who were not there. A care plan, last updated 7/27/23, indicated the resident suffered from…

    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 · D2023-10-30 · tag F0728 — failed to protect against nurse-aide misconduct — isolated
    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a nurse aide became certified within four months of completing training for 1 of 4 CNA students reviewed. (CNA 7) Finding includes: During an interview on 10/26/23 at 10:06 a.m., CNA Student 7 exited a resident's room on the 300 unit after providing care. She indicated she was hired in late April 2023, and continued to work full time for the facility, approximately 36 hours a week. She continued independently with her CNA Student duties each shift, without a CNA certification. She needed to retake her skills test, but she did not have a date scheduled. Review of employee records on 10/26/23 at 1:36 p.m., indicated CNA Student 7 was hired on 4/25/23. During an interview on 10/30/23 at 5:20 p.m., the Human Resources Director indicated CNA Student 7 completed her CNA classroom and clinical training on 5/18/23. She was not currently certified, but should have been certified within 4 months from her training completion date. During an interview on 10/30/23 at 5:27 p.m., the DON indicated she sent an email…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 offer and/or provide updated pneumococcal immunizations based on current Center for Disease Control (CDC) guidelines for 2 of 5 residents reviewed for infection control. (Residents 4 and 8) Findings include: 1. The clinical record for Resident 4 was reviewed on 10/25/23 at 10:50 a.m. Diagnoses included chronic diastolic congestive heart failure, diabetes mellitus, hypertensive chronic kidney disease, and atherosclerosis of native arteries of extremities with intermittent claudication. The resident had a historical administration of Prevnar 13 (pneumococcal immunization) on 3/18/16 and lacked any additional pneumococcal doses. The resident was last offered and refused a pneumococcal immunization on 8/5/20, during admission. 2. The clinical record for Resident 8 was reviewed on 10/25/23 at 11:17 a.m. She admitted to the facility on [DATE]. Diagnoses included Type 2 diabetes mellitus with chronic kidney disease, unspecified dementia, hypertension,…

    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

“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 HCF MANAGEMENT INDIANA — 6 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 53.5-1.5 vs chain
Health inspection 2 of 53.7-1.7 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 4 of 53.5+0.5 vs chain
The other 5 homes this chain runs (chain average 3.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
WITHAM MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/01/2011
BAYSTON, BRETTIndividualCORPORATE DIRECTORsince 01/01/2023
BRAND, JOHNIndividualCORPORATE DIRECTORsince 01/01/2015
CASTETTER, ANDREAIndividualCORPORATE DIRECTORsince 01/01/2023
HAWKINS, CLAUDEIndividualCORPORATE DIRECTORsince 09/01/2013
HORNBECKER, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2024
REAGAN, JULIEIndividualCORPORATE DIRECTORsince 09/25/2024
BRAVERMAN, KELLYIndividualCORPORATE OFFICERsince 12/01/2021
SELLERS, DANIELIndividualCORPORATE OFFICERsince 06/20/2024
MAGNOLIA HEALTH MANAGEMENT XXIV LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
HODGSON, MELINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/28/2025
REED, STUARTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
VORMOHR, J. FRANKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
REED, MICHAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/09/2025
MAGNOLIA HEALTH SYSTEMS 55, LLCOrganizationADP OF THE SNFsince 12/09/2025
MAGNOLIA HEALTH SYSTEMS INCOrganizationADP OF THE SNFsince 11/01/2011
SABRA HEALTH CARE LIMITED PARTNERSHIPOrganizationADP OF THE SNFsince 11/01/2011
WARD, JONATHANIndividualADP OF THE SNFsince 11/01/2011

CMS files one row per role, so the 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$8.5M
Net patient revenuemost recent cost report
+13.7%
Operating marginrevenue minus expenses
$1.3M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 11%Other / private 28%

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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

$364per resident / day
operating cost
$11,067per month
≈ monthly operating cost
$422per 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 155526. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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