Sellersburg Healthcare Center
7823 Old State Road 60, Sellersburg, IN 47172 · For profit - Corporation · 110 certified beds · (812) 246-4272 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 8.1% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.8% | 5.5% | 5.4% | better |
| 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 | 0.6% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 14.1% | 25.2% | 6.5% | better 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 | 3.8% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.8% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.5% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.6% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 80.2% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.2% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.9% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.50 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.79 | 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.
50.4% 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 100 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.7% 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 52 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 50.4%CMS range 40.4–60.5 | 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 | 12.8%CMS range 8.8–16.5 | 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 | 57.7% | 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 | 57.7% | 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 | 38.5% | 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 | 100.0% | 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 | 98.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 0.9% | 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 | 0.9% | 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 | 8.4%CMS range 4.5–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.39 | 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 110 beds and averages 101.4 residents a day — about 92% occupied, or roughly 9 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 3.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 4.11 on weekdays — 18% thinner on weekends. RN hours go from 0.79 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. 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.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · E2026-04-20 · 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 interview and record review, the facility failed to ensure a resident's admission evaluation assessment accurately reflected wounds present on admission (Resident C); failed to ensure documentation of wound care was completed (Resident C); and failed to ensure the administration of a resident's (Resident C) narcotic pain medication was documented on the medication administration record for 1 of 4 residents reviewed for medical records. Findings include:1.a. The clinical record for Resident C was reviewed on 4/16/26 at 10:03 a.m. The resident's diagnoses included, but were not limited to, morbid obesity, anxiety and depression.The hospital discharge records indicated Resident C had an area to the coccyx, left buttock and excoriation to the abdominal folds.The facility admission evaluation assessment, dated 2/17/26 at 11:40 p.m., indicated Resident C had no skin areas noted. The assessment was completed and signed by Registered Nurse (RN) 5.The progress note, dated 2/18/26 at 11:54 a.m., indicated the Interdisciplinary Team (IDR) skin assessment indicated the resident had…
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 before2026-04-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and record review, the facility failed to ensure medication carts were locked, while unattended, for 2 of 6 medication carts. Findings include:During an observation, on 4/17/26 between 1:14 p.m. and 1:18 p.m., the medication cart for the 100 Hall was observed to be unlocked and unattended. During an observation, on 4/17/26 at 1:20 p.m., the medication cart on the 300 Hall was observed to be unlocked and unattended. During an interview, on 4/17/26 at 1:22 p.m., Licensed Practical Nurse (LPN) 4 indicated the medication carts should be locked while unattended. On 4/17/26 at 2:07 p.m., the Director of Nursing provided a current copy of the document titled Storage of Medications dated 9/2025. It included, but was not limited to, Policy.Medications.are stored safely, securely, and properly.Medication.carts.are locked when not attended. 410 IAC (Indiana Authorization Code) 16.2-3.1-25(m)
- Potential for harm · Ecited before2025-12-16 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure insulin flexpens were monitored for expiration dates for 4 of 33 insulin pens reviewed. (Residents 21, 24, 112, and 94), failed to ensure the pharmacy label and open date were on eye drops for 1 of 1 resident reviewed. (Resident 56) and failed to ensure documentation on the Controlled Substance Administration Record of administered narcotics for 2 of 33 residents reviewed for medication storage. (Residents 9 and 96) Findings include:1. During an observation on 12/10/25 at 1:32 p.m., Resident 21's Glargine flexpen had an open date of 11/4/25. The handwritten expiration date indicated 12/3/25. The record for Resident 21 was reviewed on 12/10/25 at 2:15 p.m. The resident's diagnoses included, but was not limited to, type 2 diabetes mellitus and dementia. The care plan, dated 8/15/23 and revised 7/16/25, indicated the resident had diabetes. The interventions, dated 8/15/23, included, but were not limited to, administer insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-16 · 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
Based on record review and interview, the facility failed to ensure residents received a minimum of a shower or bed bath twice weekly. This deficient practice affected 2 of 99 residents reviewed for Activities of Daily Living (ADLs). (Residents 2 and 14).Findings include During the Resident Council meeting, on 12/11/25 at 2:30 p.m.,. with 8 residents, which the Activities Director indicated were alert and oriented, several residents indicated they were not getting their showers twice weekly according to the shower schedules. No explanations were given by the Certified Nurse Aides (CNAs) or they were told the residents the next shift or the next day, a shower would be given. The residents indicated this was not happening.1.The record for Resident 2 was reviewed on 12/11/25 at 11:00 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), paranoid schizophrenia, major depressive disorder, anxiety disorder, drug induced subacute dyskinesia, chronic pain, and mild neurocognitive disorder due to known…
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 before2025-12-16 · 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 a resident with a history of Urinary Tract Infection (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 2 of 4 residents reviewed for bowel and bladder. (Residents 106 and 7)Findings include:1. During an observation, on 12/9/25 at 9:15 a.m., Resident 106 was lying in her bed. Resident 106's urinary catheter bag was 2/3 full of urine which was sitting on the floor. The tubing was also lying on the floor with yellow urine and sediment in the tubing. There was no barrier between the catheter and the floor.During an observation, 12/15/25 at 12:52 p.m., Resident 106 was lying in her bed on her back. The urinary catheter drainage system was sitting on the floor with 1/3 full of dark yellow urine. The tubing was also lying on the floor with dark yellow urine. The resident's bed had been lowered down as far as it could go. There was no barrier between 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 before2025-06-24 · 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 interview and record review, the facility failed to ensure a blood pressure medication was held for a resident (Resident E) with blood pressure readings in the physician's ordered hold parameters for 1 of 4 residents reviewed for quality of care. Findings include: The clinical record for Resident E was reviewed on 6/24/25 at 2:40 p.m. The resident's diagnosis included, but was not limited to, hypotension. The physician's order, dated 5/27/25, indicated the resident was to receive Midodrine HCl (hydrochloride) 15 mg (milligrams) three times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. for hypotension. The medication was to be held if the resident's systolic blood pressure (SBP) was greater than 120. The June 2025 medication administration record indicated the resident's medication was administered when the resident's SBP was greater than 120 on the following dates and times: - On 6/24/25 at 2:00 p.m., the resident's Midodrine was administered with a SBP of 139. - On 6/15/25 at 2:00 p.m., the resident's Midodrine was administered with a SBP of 132. - On 6/20/25 at 2:00 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.
- Potential for harm · Ecited before2024-10-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 insulin was administered as ordered by the physician on multiple days for 3 of 7 residents reviewed for pharmacy services. (Residents 207, 83, and 204) Findings include: 1. The record for Resident 207 was reviewed on 10/15/24 at 8:27 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy and foot ulcer, sepsis, and elevated white blood cell count. The physician's order, dated 9/20/24, indicated staff were to administer Humalog per sliding scale subcutaneously per before meals. Give 4 units for blood sugar readings of 151 - 200 mg/dL (milligrams per deciliter), 6 units for blood sugar readings of 201 - 250 mg/dL, 8 units for blood sugar readings of 251 - 300 mg/dL, 10 units for blood sugar readings of 301 - 350 mg/dL, and give 12 units for blood sugar readings greater than 350 mg/dL and call the physician or nurse practitioner. The physician's order, dated 9/20/24, indicated staff were to administer the resident's 35 units of Lantus SoloStar pen-injector,…
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 before2024-10-15 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to make a reasonable effort to meet the preferences of the residents' meal choices in that scheduled menu items were being substituted due to unavailability with the same food items being served almost daily during 4 of 4 observations. This deficient practice affected 83 of 100 residents who received meals from the kitchen. Findings include: During confidential interviews with residents, between 10/7/24 and 10/15/24, the following concerns were voiced: - Resident D indicated hamburgers were served 4 days in a row and the wanted the ravioli instead. The broccoli was not completely cooked; the same food was served multiple times a week; and the hot foods were not hot and the cold foods were not cold. - Resident E indicated voiced multiple concerns of never getting the correct meal and the same food was served multiple times per week. -Resident F indicated the food was just not good. - Resident G indicated ice cream was not on the lunch tray; the broccoli was not completely cooked; there was no sauce or butter 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.
- Potential for harm · E2024-10-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure meals were at appropriate temperatures and palatable for residents during 2 of 2 temperature checks and 1 of 1 meal test trays. This had the potential to affect 83 of 100 residents who ate meals at the facility. Findings include: 1. During confidential interviews with residents while on the initial tour of the facility on 10/7/24 between 9:45 a.m. and 11:00 a.m., the following concerns were voiced: - Resident A indicated the food was cold when it reached them, it looked unappealing, and the taste was worse. If they asked for a substitute, it could be worse than the main meal. Their family member told them it looked like the food they got in prison. They were a diabetic and were not getting enough to eat. - Resident B indicated the food was often cold due to it sitting on the halls when brought from the kitchen. They indicated it was not worth it to ask the staff to heat it up. 2. During the lunch food temperature observation on 10/7/24 at 11:30 a.m., with [NAME] 32, the following food temperatures were obtained by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 ensure food was served and stored under sanitary conditions during 3 of 3 kitchen observations. This deficiency had the potential to affect 83 of 100 residents currently receiving meals from the kitchen. Findings include: 1. During the initial tour of the kitchen while accompanied by the Dietary Manager and the Regional Dietary Manager on 10/07/24 at 9:15 a.m. , the following concerns were observed: - The Dry storage room in the corner next to a shelving unit and the canned goods rack, was a white drain. The inside of this drain, the tiles surrounding the drain, the pipe above the drain, and the wall from the door to the pipe had greenish/gray in color substance. - The floor behind and under the steamer had a heavy accumulation of yellow food particles and a heavy buildup of dirt and food particles brownish/black in color. - The steamer had multiple white streaks which ran down all sides of the unit. The drain tray in front of the steamer had brown and tan food particles and pieces of foil in it. - A blue floor plate, which…
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 18 citations
- Potential for harm · E2024-10-15 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure appropriate infection control measures were followed during high contact care for 8 of 11 staff observations of infection control. (CNA 39, CNA 40, CNA 9, CNA 8, CNA 7, CNA 29, CNA 30 and CNA 4) Findings include, 1. During the initial tour of the facility on 10/7/24 at 9:15 a.m., observation of the 400 Unit indicated 11 of 15 residents were in enhanced barrier precautions (an infection control techniques to reduce the spread of multidrug resistant organisms) and 1 of 15 residents was in droplet precautions (set of infection control measures to prevent the spread of pathogens that are transmitted through respiratory droplets). During an observation on 10/7/24 between 10:00 a.m. and 10:15 a.m., CNA (Certified Nurse Aide) 39 was walking exited a resident's room with a bag of soiled linen in her right hand. She walked down the 400 Hallway towards the soiled linen room and the bag was transferred to her left hand. The CNA then as a staff…
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 before2024-10-15 · 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
Based on observation, record review and interview, the facility failed to ensure that care was provided related to mobility and mouth care for 2 of 11 residents reviewed for Activities of Daily Living. (Residents 46 and 250) Findings include, 1. During an observation on 10/8/24 at 11:30 a.m., Resident 46 was observed in the bed. He had a below the knee amputation on the left leg. The resident indicated he did not get up out of the bed and he would like to get up. He wasn't sure why no one got him up. The record for Resident 46 was reviewed on 10/9/24 at 8:25 a.m. The resident's diagnoses included, but were not limited to, orthopedic aftercare following a surgical amputation, acquired absence of the left leg below the knee, and muscle weakness. The Annual Minimum Data Set (MDS) assessment, dated 9/6/24, indicated the resident was moderately cognitively intact. The resident required complete dependence of staff for transfers. The resident required a wheelchair for mobility. The physician's order, dated 5/30/24, indicated to encourage the resident to get out of bed daily, one time 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.
- Potential for harm · Dcited before2024-10-15 · 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 the prevention of Urinary Tract Infections and proper perineal care for 2 of 6 residents reviewed for bowel and bladder. (Residents 4 and 36) Findings include: 1. The record for Resident 4 was reviewed on 10/10/24 at 2:50 p.m. The resident's diagnoses included, but were not limited to, cerebral palsy, neuromuscular dysfunction of the bladder, muscle weakness, need for assistance with personal care, anemia, and candidiasis. The current care plan, start date 6/28/23, indicated the resident had an indwelling urinary catheter related to a neurogenic bladder. The interventions, dated 6/29/23, indicated to place the resident in Enhanced Barrier Precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting, and peri-care, providing care to the urinary catheter, and to provide catheter care every shift and PRN (as needed), and to notify the medical provider if the urine was abnormal in color, consistency, or odor. The current physician's order, dated 8/2/23, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-26 · 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 interview and record review, the facility failed to ensure an increase in free water flushes was implemented (Resident B) and failed to ensure staff followed parameters for blood pressure medication administration (Resident D) for 2 of 3 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident B was reviewed on 9/24/24 at 10:08 a.m. The resident's diagnosis included, but was not limited to, gastrostomy status. The physician's order, dated 7/9/24, indicated to flush the resident's feeding tube with 30 ml (milliliters) of free water every hour. The resident's laboratory report, dated 7/15/24, indicated the resident's BUN (blood urea nitrogen) test result was elevated at 31 mg/dl (normal 10 mg/dl to 20mg/dl). A higher than 20 mg/dl suggest that the kidneys may not be functioning at optimal capacity. The nurse practitioner note, dated 7/16/24, indicated to increase the resident's free water flushes to 40 cc's (cubic centimeters) every hour. The clinical record lacked documentation of an order to increase the resident's free water dosage or…
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 before2024-09-26 · 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 interview and record review, the facility failed to implement Indwelling catheter care for a resident (Resident B), upon readmission, for 1 of 3 residents reviewed for Indwelling catheters. Findings include: The clinical record for Resident B was reviewed on 9/24/24 at 10:08 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction, bacterial meningitis, gastrostomy status and urinary retention. The care plan, dated 7/5/24, indicated the resident had an indwelling catheter and staff were to provide catheter care every shift. The progress noted, dated 8/16/24 at 7:30 p.m., indicated Resident B was sent to the emergency room for evaluation. Resident B was readmitted to the facility on [DATE] at 5:00 p.m. The hospital history and physical, dated 8/16/24, indicated Resident B had chronic urinary retention, an indwelling catheter was in place which was changed. The resident's indwelling catheter was replaced during the resident's hospital stay. The clinical record lacked…
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 before2024-09-26 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement a laboratory order for a resident (Resident B) for 1 of 3 residents reviewed for laboratory services. Findings include: The clinical record for Resident B was reviewed on 9/24/24 at 10:08 a.m. The resident's diagnoses included, but were not limited to, cerebral infarction, respiratory failure and hypercalcemia. The nurse practitioner note, dated 7/16/24 at 8:00 a.m., indicated to obtain a BMP (basic metabolic panel) on 7/19/24 due to elevated calcium level of 10.9 (normal range was 8.5 to 10.2). The nurse practitioner note, dated 7/19/24 at 8:15 a.m., indicated the BMP needed to be obtained. The clinical record lacked documentation of the BMP requested by the nurse practitioner. During an interview on 9/26/24 at 1:55 p.m., the Director of Nursing indicated the nurse practitioner was responsible for putting the lab order in. The order should have been put in the system and the nurse practitioner did not enter them into the system. On 9/26/24 at 2:45 p.m., the Director of Nursing provided a current, undated copy 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 · Dcited before2023-11-21 · 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 observation, interview, and record review, the facility failed to ensure the treatment for a resident's venous wound was completed, as ordered by the physician, for 1 of 3 residents reviewed for wound care. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/20/23 at 10:49 a.m. The diagnosis included, but was not limited to, vascular wounds to the bilateral lower extremities. On 11/20/23 at 12:00 p.m., Resident B was observed sitting up in his wheelchair in his room with an unna boot (special bandage used for the treatment of venous wounds/ulcers) in place to his bilateral lower extremities. The care plan, dated 12/20/21, indicated the resident had impaired skin integrity and to complete treatments as ordered by the medical provider. The November 2023 Treatment Administration Record (TAR) indicated staff were to cleanse the resident's wounds to the right lower extremity with normal saline or wound cleanser, pat dry, apply hydrofera blue to the open areas and cover with an unna boot every day shift on Tuesday and Friday. The November 2023 TAR…
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 before2023-11-21 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure laboratory services were obtained, as ordered by the physician, for 1 of 3 residents reviewed for laboratory services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/20/23 at 10:49 a.m. The diagnoses included, but were not limited to, chronic osteomylitis, diabetes and end stage renal disease. The physician's order, dated 10/25/23, indicated to obtain Resident B's weekly creatine level, in the evening, for six weeks. The creatine level was to be drawn once a week on Fridays for six weeks. Review of the November 2023 Treatment Administration Record indicated the resident's creatine level was not obtained on Friday, 11/10/23, as ordered by the physician. During an interview on 11/21/23, the Director of Nursing indicated the lab was not obtained on 11/10/23. On 11/21/23 at 12:40 p.m., the Director of Nursing provided a current, undated copy of the document titled Laboratory and Radiological Services and Results Reporting. It included, but was not limited to, Policy .It is 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 · E2023-08-17 · tag F0554 — patternAllow 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 appropriate oversight of medication administration during 5 of 6 random observations. (Residents 32, 37, 11, and 38) Findings include: 1. During an observation of Resident 32 on 8/13/23 at 9:03 a.m., there was a medication cup sitting on the resident's bedside table with two round, white tablets, in the cup. The resident indicated she did not know what the tablets were. During an interview on 8/13/23 at 10:11 a.m., RN 9 indicated she had given Resident 32 her medications with water a while ago. She told the resident they were on her left side. She had not stayed to observe the resident taking the medication. The clinical record for Resident 32 was reviewed on 8/13/23 at 10:00 a.m. The resident's diagnoses included, but were not limited to, blindness of the right eye and weakness. The Annual MDS (Minimum Data Set) Assessment, dated 7/4/23, indicated the resident was cognitively intact. The physician's order, dated 6/29/22, indicated the resident received Tylenol 325 mg (milligrams) every 6 hours 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 · E2023-08-17 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there were enough staff to assist residents with medication administration and activities of daily living in a timely manner. This deficient practice had the potential to affect for 92 of 101 resident reviewed for sufficient staffing. Findings include: Review of the Facility Assessment Tool, dated 11/1/22 through 10/31/23, indicated the purpose of the assessment was to determine what resources were necessary to care for the residents. The tool indicated the average daily census was 97. The facility had 21 residents on ventilators or respirators. The general staffing plan included, but was not limited to, 2 to 8 licensed nurses providing direct care per day, 4 to 14 nurse aides per day, and 1 to 2 respiratory care services staff per day. During a continuous observation on 8/13/23 from 9:40 a.m. until 9:51 a.m., indicated the call lights for rooms [ROOM NUMBERS] were alarming. Two CNAs were removing food trays from other rooms 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 · Ecited before2023-08-17 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 ensure appropriate storage and labeling of multiple medications for 2 of 4 medication carts observed for medication storage and labeling. (300 Hall Back and 300 Hall Back Medication Carts) Findings include: 1. During an observation of the 300 Hall Back Medication Cart with Unit Manager 15 on 8/15/23 at 10:15 a.m., the following concerns were observed: a. Resident 258's insulin glargine injector pen was opened and contained 140 units of insulin. The pen was not marked with an open date. The clinical record for Resident 258 was reviewed on 8/15/23 at 1:00 p.m. The diagnosis included, but was not limited to, Diabetes Mellitus type 2. The physician's order, dated 8/1/23, indicated the resident received Lantus 100 unit/mL (milliliters) 5 units subcutaneously at bedtime. b. Resident 67's Lantus injector pen had a sticker on the outside of it which indicated it had been opened on 7/8/23 and should have been discarded on 8/5/23. During an interview on 8/15/23 at 10:17 a.m., Unit Manager 15 indicated the resident did…
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 before2023-08-17 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to make a reasonable effort to meet the preferences of the residents' meal choices in that scheduled menu items were being substituted due to unavailability with the same food items being served almost daily. This deficient practice affected 93 of 101 residents who received meals in the facility. Findings include: During an interview on 8/13/23 at 9:36 a.m., Resident 8 indicated weekends were the worst and the food was the same thing over and over. During an interview on 8/13/23 at 10:08 a.m., Resident 11 indicated the facility served the same food multiple times in one week. During an interview on 8/13/23 at 10:11 a.m., Resident 56 indicated the food was bad. The facility kept running out and portions were small. They have rice and peas for several meals every week. During an interview on 8/13/23 at 11:14 a.m., Resident 58 indicated the food lacked seasoning and quality. Sometimes it tasted or smelled spoiled and they frequently served the same foods every day. On 8/13/23 at 11:50 a.m., the following items were…
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 before2023-08-17 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 ensure food was served and stored under sanitary conditions and served at the appropriate temperatures during 5 of 5 kitchen observations. Findings include: 1. During an observation of the kitchen on 8/13/23 at 9:15 a.m. while accompanied by [NAME] 20, the following concerns were observed: - The floor under the shelves in dry storage had a build-up of black grime; around the baseboards and corners in the dry storage, there was a heavy build-up of black grime. - The floor, corners and baseboards in the kitchen under all the preparation tables, convection oven, refrigerators and freezers, and ice machine had a heavy build up of black grime. - The floor under the stove had a heavy build up of black grime with a bottle of seasoning half way under the stove. - The ovens had a moderate amount of white and black spills on the bottom of both ovens. - The walk-in refrigerator floor had milk spills under the crates of milk sitting on a stool. - The walk in freezer had one box of chocolate and one box of strawberry shakes that were…
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 · D2023-08-17 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to notify the physician of a resident's blood sugar levels over 400 mg/dL (milligrams per milliliter) for 1 of 3 residents reviewed for Notification of Change. (Resident 1) Findings include: The record for Resident 1 was reviewed on 8/14/23 at 10:48 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes and acute kidney failure. The admission MDS (Minimum Data Set) assessment, dated 7/11/23, indicated the resident was rarely or never understood. The physician's order, dated 7/17/23, indicated staff were to administer the resident's Humalog 100 units per mL (milliliters) solution per sliding scale for a blood sugar of 151 to 200 mg/dL, administer 3 units; 201 to 250 mg/dL administer 6 units; 251 to 300 mg/dL administer 9 units; 301 to 350 mg/dL administer 12 units; 351 to 400 mg/dL administer 15 units. If the blood sugar is less than 70 mg/dL or greater than 400 mg/dL contact the physician or NP (Nurse Practitioner). The care plan, dated 7/5/23, indicated the resident had diabetes. The interventions…
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 · D2023-08-17 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interview, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals for 1 of 1 resident reviewed for discharge. (Resident 76) Findings Include: During an interview on 8/13/23 at 10:06 a.m., Resident 76 indicated he wanted to get out of the facility and go to his own place. No one was helping him to get out of the facility. The Annual MDS (Minimum Data Set) assessment, dated 7/4/22, indicated the resident's discharge plan was checked yes. The resident's diagnosis included, but were not limited to, hypertension and peripheral vascular disease. The resident required extensive assistance of one staff member for mobility and toileting assistance. He was cognitively alert and oriented and had no behaviors. The resident's expectation was to be discharged . A Quarterly MDS assessment, dated 5/14/23, indicated the resident's active discharge plan was blank and not documented. The resident's expectation goals for discharge were left blank. A Quarterly MDS assessment, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · 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
Based on observation, record review, and interview, the facility failed to ensure a dependent resident received assistance with hygiene and bathing for 1 of 3 residents reviewed for activities of daily living care. (Resident 91) Findings include: During an observation on 8/13/23 at 9:48 a.m., Resident 91 was lying in bed with his eyes wide open. The resident was non-verbal. There was a white crusty substance on his lips. During an observation on 8/13/23 at 2:01 p.m., Resident 91 was observed lying in bed with his eyes wide open. The resident was non-verbal. There was a crusty white substance on his lips. During an interview on 08/14/23 at 11:34 a.m., the resident's family member indicated the resident was often not bathed. He did not receive his planned baths. The family member would often have to wash him up herself. During an observation on 8/14/23, the resident was lying on a cot to be transferred. The resident's appearance was clean and well groomed. The SSD (Social Service Director) Note, dated 4/27/23, indicated the resident was not able to use the call light and was fully…
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 · D2023-08-17 · 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 emergency respiratory supplies were available for residents with a tracheostomy for 3 of 12 residents reviewed for Respiratory Care. (Residents 7, 79 and 54) Findings include: 1. During an observation on 8/13/23 starting at 11:00 a.m., Resident 7 did not have an AMBU (artificial manual breathing unit) bag at the bedside. The record for Resident 79 was reviewed on 8/15/23 at 11:43 a.m. The diagnoses included but were not limited to chronic respiratory failure with hypoxia, asthma, anxiety disorder, obstructive sleep apnea, malignant neoplasm of the esophagus, and tracheostomy (trach). The Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/23, indicated the resident was cognitively intact and required assistance with oxygen therapy, suctioning, tracheostomy care and ventilator. The care plan initiated on 8/26/22, indicated the resident was currently receiving ventilator care due to respiratory failure. The interventions included, but were not limited to, evaluate changes in the resident's mental…
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 before2023-08-17 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure a sputum culture was sent to the laboratory for testing as ordered by the physician for 1 of 6 resident's reviewed for laboratory testing. (Resident 48) Findings include: The clinical record for Resident 48 was reviewed on 8/16/23 02:18 PM. The diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, COPD (Chronic Obstructive Pulmonary Disease), acute on chronic congestive heart failure, streptococcus group B, pseudomonas aeruginosa, resistance to beta lactam antibiotics, and tracheostomy status. The Quarterly MDS (Minimum Data Set) assessment, dated 6/1/23, indicated the resident was cognitively intact and received oxygen therapy, suctioning, and tracheostomy care. The care plan, dated 9/9/21, indicted the resident received tracheostomy care related to her disease process. The interventions included, but were not limited to, obtain and monitor laboratory and diagnostic studies as ordered, report abnormal findings to medical provider, the resident, and her…
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.
“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 COMMUNICARE HEALTH — 110 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 | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.6 | -0.6 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
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 |
|---|---|---|---|
| BORNE-BAUMAN, CANDICE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| FLUECKIGER, RUSSELL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| LEHMAN, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| MACKLIN, LARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| MCINTIRE, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| ADAMS COUNTY MEMORIAL HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| OLD (IN) MGT CO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2017 |
| MASROOR, MUHAMMAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2026 |
| ODENTHAL, RICHARD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2017 |
| SMITH, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| SPRUNGER, KYLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| VOGT, JUSTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/10/2025 |
| WHEELER, DANE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2023 |
| BLUE MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | since 12/01/2023 |
| FIRST BANK OF BERNE | Organization | ADP OF THE SNF | since 12/01/2023 |
| OMEGA HEALTHCARE INVESTORS INC | Organization | ADP OF THE SNF | since 09/01/2017 |
| OMG IN MSTR LSCO LLC | Organization | ADP OF THE SNF | since 08/29/2025 |
CMS files one row per role, so the 25 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 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.
About 76% 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 $924K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 155659. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-16, 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.