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Ashford Place Health Campus

2200 N Riley Hwy, Shelbyville, IN 46176 · Non profit - Other · 68 certified beds · (317) 398-8422 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jan 20231 immediate-jeopardy citation
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (26) — 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

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 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

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2158 Intelliplex Drive, Suite 200
Pharmacy
2123 Intelliplex Dr · (317) 421-2020 · Call to confirm hours
Grocery
310 E Broadway St · (317) 398-6977 · 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 5 of 5
Long-stay residentspeople who live here 5 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 improved from 1 to 4 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 rating4★
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 increased7.4%11.0%15.4%better
Long-stay residents who lose too much weight0.0%5.5%5.4%check this — see note marked star below the table
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 infection1.3%1.1%2.0%better
Long-stay residents with depressive symptoms27.5%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 injury0.6%3.9%3.3%better
Long-stay residents whose ability to walk worsened11.9%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.3%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers0.6%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control21.1%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table1.7%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine74.2%79.0%79.4%typical
Short-stay residents rehospitalized after admission19.8%22.2%22.6%better
Short-stay residents with an outpatient ER visit15.3%10.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.301.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.341.441.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

62.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 181 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.3%U.S. median 51.5%
Got home and stayed home
12.8%U.S. median 10.7%
Went back to hospital
85.9%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 85.9% 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 92 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 0.53 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF62.3%CMS range 55.0–67.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.8%CMS range 9.8–16.210.7%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 discharge85.9%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 discharge80.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge70.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.2%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 worsened2.4%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 hospitalization6.0%CMS range 3.8–9.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.56
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.04
Aide hours/ resident / day
3.72
Total nurse hours/ resident / day
0.38
RN hoursweekends
22.4%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 55.8 residents a day — about 82% occupied, or roughly 12 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 3.45 hrs/resident/day on weekends vs 3.83 on weekdays — 10% thinner on weekends. RN hours go from 0.64 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% 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

5
deficiencies at the latest standard inspection (2025-08-13)
7
at the previous standard inspection (2024-05-01)

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.

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.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · J2023-01-11 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents' right to be free from sexual abuse by not appropriately determining their capacity to consent to sexual interactions and implementing an effective plan to address the sexual activity between 2 residents for 2 of 2 resident's reviewed for abuse. (Resident 14 and Resident 28). The Immediate Jeopardy started on 5/5/22 when two cognitively impaired residents engaged in a sexual activity. Resident 14 and 28 continued to have sexual encounters after the 5/5/22 incident; resulting in increased falls, initiation of a prophylactic antibiotic, increase in antidepressant medication, initiation of a medication used to suppress sexual desire and emotional distress. The facility was unable to provide evidence an effective plan was in place to address the residents' sexual interactions and determining if Residents 28 and 14 had the mental capacity to consent to sexual activities. The Executive Director (ED), Director of Nursing Services (DNS),…

    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
  • Actual harm · Gcited before2024-08-14 · 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 interview and record review, the facility failed to ensure interventions to prevent falls were effectively implemented when Resident C exhibited signs and symptoms of lethargy, drowsiness, and sedation and failed to ensure staff used a gait belt during the transfer of a Resident D who required more than limited assistance with transfers for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident C falling in the shower and sustaining fractures to the left shoulder blade, the left second rib, and the endplate of the third lumbar spinal disc. (Resident C and Resident D) Findings include: 1. The clinical record for Resident C was reviewed on 8/14/24 at 8:30 a.m. The diagnoses included, but were not limited to, dementia, osteoporosis, and insomnia. A quarterly Minimum Data Set (MDS) assessment, dated 5/2/24, indicated Resident C was cognitively impaired. The resident's functional status was dependent of the staff person to provide all the effort for the resident to bathe. The staff was to provide more than half of the effort to assist with transferring…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for alarm use for 2 of 2 residents reviewed for falls. (Resident 17 and Resident 25)Findings include: 1. The clinical record for Resident 17 was reviewed on 8/11/25 at 11:30 a.m. The diagnoses included, but were not limited to, dementia. A fall care plan, dated 1/16/24, indicated Resident (17) is at risk for falling r/t [related to] decreased mobility, medication regimen, weakness, incontinent status and other comorbidities. The interventions included but were not limited to: the resident's usage of a clip alarm when in wc/chair [wheelchair] with a start date of 3/6/25, and usage of a floor mat alarm when in recliner with a start date of 11/14/24. A physician's order, dated 3/5/25, indicated Resident 17 was to wear a personal pull tab alarm while in the wheelchair every shift. A physician's order, dated 5/21/25, indicated Resident 17 was to have a floor mat alarm in place every shift. The 7/7/25 Quarterly MDS assessment for Resident 17 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-13 · 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 timely refer a resident for a level II evaluation for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (PASRR). (Resident 19)Findings include: The clinical record for Resident 19 was reviewed on 8/8/25 at 3:17 p.m. The diagnoses included, but were not limited to, diabetes and psychotic disorder with delusions. A PASRR Level I evaluation, dated 8/10/23, indicated Resident 19 was approved with no Level II required. On 6/1/24, Resident 19 received a new diagnosis of psychotic disorder with delusions. During an interview on 8/8/25 at 2:59 p.m., the Executive Director (ED) indicated Resident 19 did not have a Level II. During an interview on 8/11/25 at 2:35 p.m., the Social Services Director (SSD) indicated Resident 19 should have been referred for a Level II with the new diagnosis of psychosis. On 8/11/25 at 11:29 a.m., the Nurse Consultant (NC) provided the current Indiana PASRR Standard Operating Procedure, which indicated .Overview Preadmission Screening and Resident Review [PASRR] is a federal…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure an insulin flex pen was primed prior to dialing up the dosage to be given when administering insulin per the manufacture directions for 1 of 2 residents observed during insulin administration. (Resident 8)Findings include: The clinical record for Resident 8 was reviewed on 8/8/25 at 2:00 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus.A diabetic care plan, dated 7/1/25, indicated the staff was to administer the medication as ordered. A physician's order, dated 6/16/25, indicated Resident 8 was to receive 10 units of lispro insulin (fast acting insulin) with a flex pen before meals. An observation was conducted of an insulin administration for Resident 8 with Licensed Practical Nurse (LPN) 3 on 8/8/25 at 11:03 a.m. LPN 3 was observed obtaining the resident's blood sugar reading of 273. After, she prepared to administer 10 units of lispro insulin using an insulin flex pen. During that time, LPN 3 wiped the flex pen with an alcohol wipe and placed the needle on the pen. She…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-13 · 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 ensure a gait belt was used during the manual transfer of a resident and to ensure an evaluation was conducted timely for the usage of personal alarms for 2 of 2 residents reviewed for accidents. (Resident 17 and Resident 25) Findings include: 1a. The clinical record for Resident 25 was reviewed on 8/8/25 at 10:40 a.m. The diagnoses included, but were not limited to, Parkinson's disease and traumatic brain injury. A physician's order, dated 3/23/25, indicated he was to have a pressure alarm in his wheelchair at all times. This order was discontinued on 5/23/25. A physician's order, dated 5/23/25, indicated he was to have a pressure alarm to his wheelchair and recliner when he was present. This order was discontinued on 6/10/25. A physician's order, dated 6/10/25, indicated that he was to have a pressure alarm at all times, ensure pressure alarm was moved from wheelchair to recliner and bed with him. A Quarterly Minimum Data Set (MDS) assessment, completed 7/9/25, indicated he was dependent on staff for chair…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control was maintained by not disinfecting a glucometer (a device used to obtain blood sugar readings) per the manufacturer's instructions for 1 of 2 residents observed during medication administrations of blood sugar readings. (Resident 43)Findings include: The clinical record for Resident 43 was reviewed on 8/8/25 at 2:30 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus.A physician's order, dated 7/22/25, indicated Resident 43 was to receive nine units of Novolog (fast acting) insulin before meals. If the resident's blood sugar reading was less than 100; hold the insulin. An observation was conducted of obtaining Resident 43's blood sugar reading with Licensed Practical Nurse (LPN) 3 on 8/8/25 at 11:17 a.m. LPN 3 was observed removing the glucometer from the medication cart. She then wiped the glucometer utilizing an alcohol wipe. She then went to the resident's room. LPN 3 was observed pricking the resident's finger, placing a drop of blood from the resident's…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide bathing, as scheduled, to 1 of 3 residents reviewed for bathing. (Resident D) Findings include: The clinical record for Resident D was reviewed on 4/4/25 at 10:49 a.m. Her diagnoses included, but were not limited to, depression and diabetes. She was admitted to the facility on [DATE] and discharged on 3/29/25. The 3/21/25 admission MDS (Minimum Data Set) assessment indicated she required substantial, maximal assistance for bathing and was cognitively intact. The 3/18/25 ADL (activities of daily living) care plan indicated she required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was for her to have her functional needs met safely by staff. An approach was for showers on Wednesdays and Saturdays on the evening shift. A telephone interview was conducted with Resident D on 4/4/25 at 12:38 p.m. She indicated she did not receive baths or showers in the facility twice a week. The first time she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 address a grievance for 1 of 1 resident reviewed for dignity (Resident B). Findings include: The clinical record for Resident B was reviewed on 4/25/24 at 12:03 p.m. The Resident's diagnosis included, but were not limited to, hypertension. A Quarterly MDS (Minimum Data Set) Assessment, completed 2/5/24, indicated she was cognitively intact, frequently incontinent of bowel and bladder, and needed maximal assistance of staff for toileting. During an interview on 4/25/24 at 12:03 p.m., FM (Family Member) 20 indicated that approximately a week and a half ago, they had filed a grievance because Resident B had been brought to an appointment on the facility bus after being incontinent of bowel. The facility bus driver had gone back to the facility to get new clothing so that FM 20 could clean Resident B before the appointment. FM 20 was concerned that Resident B had not been toileted prior to leaving the facility. During an interview on 4/30/24 at 2:39 p.m., AS (Activity Assistant) 12 indicated that she had been the bus…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the required medical and contact information was sent to the hospital for 1 of 1 resident reviewed for discharge. (Resident 54) Findings include: The clinical record for Resident 54 was reviewed on 4/29/24 at 10:28 a.m. Her diagnoses included, but were not limited to, stage 4 chronic kidney disease and stage 4 pressure ulcer of the sacral region. She was discharged from the facility to the hospital on 1/27/24. The 1/27/24, 10:06 p.m. nurse's note read, Res [Resident] has no output in catheter and was flushed x [times] 2. IV [Intravenous] 1L [liter] finished this morning and has drank fluids this shift. Per [name of physician] and spouse send to ed [emergency department] for eval [evaluation.] The 1/28/24 Clinical Discharge Observation, recorded and completed on 2/2/24, indicated a paper-based reconciled medication list was sent to the hospital with Resident 54. There was no information in the clinical record to indicate the contact information of the practitioner responsible for the care of Resident 54, Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to timely revise a resident's care plans for refusal of showers and depression with individualized interventions for 1 of 5 residents reviewed for unnecessary medications (Resident 20). Findings include: The clinical record for Resident 20 was reviewed on 4/26/24 at 9:18 a.m. The Resident's diagnosis included, but were not limited to, depression and anxiety. A care plan, with a start date of 5/5/22 and last reviewed 4/17/24, indicated Resident 20 demonstrates symptoms of depression as evidenced by a score of on the PHQ-9 (depression assessment) sadness and tearfulness. The goal was that the resident will not demonstrate an increase in depressive symptoms. The approaches were GDR (Gradual Dose Reduction) of anti-depressant 4/3/24. Inform psych of an adverse effects noted or any changes in mood/ behavior, initiated 4/8/24, anti-depressant increased 2/5/24 due to failed GDR. Inform psych of any changes in mood/ behavior, initiated 2/5/24, anti-depressant decreased per GDR on 10/20/23 per psych, initiated 10/23/23,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · 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 observation, interview, and record review, the facility failed to administer a resident's medication, as ordered, and to timely address an issue with a physician's order for a new eye medication for a resident whose insurance did not cover the costs of the medication for 2 of 3 residents reviewed for pharmacy services and medication administration. (Resident E and Resident 16) Findings include: 1. The clinical record for Resident E was reviewed on 4/25/24 at 11:55 a.m. Her diagnoses included but were not limited to, type 2 diabetes mellitus and metastatic bone cancer. She was admitted to the facility from the hospital on 4/19/24. An interview was conducted with Resident E on 4/25/24 at 12:00 p.m. She indicated she was discharged from the hospital on a whole list of medications. Because she was admitted to the facility on a Friday, she did not start getting some of the medications until the following Monday. The 4/19/24 hospital discharge medication list indicated to administer one 75 mg capsule of Glucofunction twice daily and one 950 mg Nutrient capsule twice daily. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-05-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure: an ophthalmic (eye) medication was labeled with the date it was opened (Resident 24); the timely destruction of medications for an expired resident (Resident 272); and the controlled medication lock box was permanently affixed within the medication refrigerator (Facility) when reviewed for medication storage and labeling. Findings include: A medication storage observation was conducted on 4/30/24 starting at 4:02 p.m. and ending at 4:37 p.m. During the observation, the following was witnessed: 1. In the medication cart on [NAME] hallway with RN (Registered Nurse) 8, inside a drawer was an opened bottle of Timolol eye drops for Resident 24 with an opened date of 3/21. 2. An observation of the medication room on the healthcare side made with RN 9 found inside a cabinet, an opened bottle of Tylenol contained 10 tablets. The Tylenol bottle was labeled for Resident 272 and according to RN 9, Resident 272 was no longer a resident at 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to timely obtain a urinalysis, as ordered by the physician, for 1 of 5 residents reviewed for unnecessary medications (Resident 23). Findings include: The clinical record for Resident 23 was reviewed on 4/29/24 at 10:30 a.m. The Residents diagnosis included, but did were not limited to, diabetes and kidney failure. A Quarterly MDS (Minimum Data Set) Assessment, completed 3/6/24, indicated that she was cognitively intact. A Nurse Practitioner Nursing Home Visit note, dated 4/25/24, indicated that Resident 23 reported urinary frequency, dysuria, and urgency. The plan was to complete a STAT (right away) urinalysis with culture and sensitivity. A physician's order, dated 4/25/24, indicated to obtain a STAT UA with C and S. During an interview on 4/29/24 at 12:44 p.m., the DNS (Director of Nursing Services) indicated that the UA had not been sent to the lab on 4/25/24. It should have been obtained on 4/25/24. On 4/29/24 at 4:01 p.m., the Regional Nurse Consultant provided the current Ordering Lab Test Policy which read . Once the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control policy by not performing hand hygiene prior to glove use and after dropping a pill onto a medication cart, picking up the pill with bare hands and administering it to the resident for 1 of 3 residents reviewed during the medication administration observation. (Residents 9 and 16) Findings include: 1. A medication administration observation with RN (Registered Nurse) 4 was conducted on 4/30/24 at 8:43 a.m. RN 4 was observed while she prepped and administered Resident 16's oral medications. After administering the oral medications, she turned around back to her medication cart; touched the medication cart and her keys to unlock the cart; opened a drawer and retrieved a pill bottle which contained Resident 16's eye drops bottle. RN 4 had, without performing hand hygiene, donned (put on) gloves and administered the eye drops to Resident 16. An interview with RNC (regional Nurse Consultant) conducted on 4/30/24 at 11:53 a.m. indicated, yes, RN 4 should have performed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have the interdisciplinary team (IDT) determine and document that self administration of medications and treatments were clinically appropriate for 1 of 5 residents observed during medication administration. (Resident 40) Findings include: The clinical record for Resident 40 was reviewed on 1/10/23 at 2:23 p.m. The diagnoses for Resident 40 included, but was not limited to, chronic obstructive pulmonary disease. A Quarterly MDS assessment dated [DATE], indicated Resident 40 was cognitive intact. A physician order dated 1/27/22 indicated Resident 40 was to receive 50 micrograms (mcg) of flonase nasal spray. A physician order dated 8/25/22 indicated Resident 40 was to receive 100-25 mcg breo inhaler. An observation was made of a medication administration with License Practical Nurse LPN 15 on 1/10/23 at 9:40 a.m. During the preparing of a medication administration to Resident 40; LPN 15 indicated she had previously provided Resident 40 with his breo…

    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 · D2023-01-11 · 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 report to the Indiana Department of Health (IDOH) resident to resident sexual activity without the competency to consent for 2 of 2 residents reviewed for abuse. (Resident 14 and Resident 28) Findings include: 1a. The clinical record for Resident 14 was reviewed on 1/5/23 at 9:32 a.m. The Resident's diagnosis included, but were not limited to, Parkinson's disease, dementia, cognitive impairment, and depression. A Psychiatric Evaluation/ Follow-up note, dated 1/6/22, indicated Resident 14 was being seen for depression, dementia, and Parkinson's disease. He is alert and oriented to person only. His cognition is fairly declined, with long term memory fair to poor, short term memory and concentration poor. His executive functioning and abstract thinking are very impaired. His MOCA (Montreal Cognitive Assessment Test for Dementia) was 13/30 (10 to 17 points indicate moderate cognitive impairment). A care plan, initiated 1/7/22, indicated Resident 14 had impaired cognition with associated short term memory impairment and risk…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately complete an admission Minimum Data Set Assessment for 1 of 2 residents reviewed for dental services (Resident 21). Findings include: The clinical record for Resident 21 was reviewed on 1/4/22 at 2:24 p.m. The Resident's diagnosis included, but were not limited to, diabetes. An admission MDS (Minimum Data Set) Assessment, completed 4/28/22, indicated Resident 21 was cognitively intact and had no dental concerns. On 1/04/23 at 2:21 p.m., Resident 21 was observed sitting in her wheelchair in her room. She had no natural teeth. She indicated she had recently seen a dentist who had referred her for new dentures. On 1/10/23 at 10:13 a.m., LPN (Licensed Practical Nurse) 20 provided the dental provider Patient Note History, dated 12/12/22, which indicated Resident 21 was seen by the dentist due to being edentulous. The dentures she currently had were [AGE] years old. During an interview on 1/11/23 at 12:15 p.m., the MDSC (Minimum Data…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to revise a resident's hearing loss care plan to include the use of an amplifier device for 1 of 16 residents whose care plans were reviewed. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 1/4/23 at 2:00 p.m. Her diagnoses included, but were not limited to, dementia without behavioral disturbance. The 10/1/22 Quarterly MDS (Minimum Data Set Assessment) indicated she had a BIMS (brief interview for mental status) score of 14, indicating she was cognitively intact. It indicated she had minimal hearing difficulty with the use of a hearing aide or appliance. The 2/3/21 social services note, written by the SSD (Social Services Director) read, Resident is having increased difficulty with hearing and SS provided resident with a Superear-Personal Sound Amplifier today. SS tested this with resident and resident was able to understand everything that SS said to her and SS was talking in a normal tone. SS showed resident how to use the device and also showed CNA (Certified Nursing…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths for 1 of 1 residents reviewed for activities of daily living (ADLs). Resident 20 Findings include: The clinical record for Resident 20 was reviewed on 1/10/23 at 9:32 a.m. Resident 20's diagnoses included, but not limited to, COVID-19 infection, atrial fibrillation, major depressive disorder, and acute embolism and thrombosis of unspecified deep veins. Resident 20 tested positive for COVID-19 on 12/26/22 and was subsequently placed into droplet isolation precautions. Resident 20's annual MDS (minimum data set) dated 12/30/22 indicated, Resident 20 was cognitively intact and required extensive assistance of one person for bed mobility, toileting and personal hygiene; physical help in part of one person for bathing; and considered choosing between a tub bath, shower, bed bath or sponge bath very important. An interview with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to inform the physician of blood sugar results below 150, as ordered by the physician, for 1 of 1 resident reviewed for insulin (Resident 21). Findings include: The clinical record for Resident 21 was reviewed on 1/4/22 at 2:24 p.m. The Resident's diagnosis included, but were not limited to, diabetes. A care plan, initiated 4/29/22, indicated Resident 21 was at risk for hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar) related to having diabetes. The goal was for her to be free of symptoms of hypoglycemia and hyperglycemia. The interventions included, but were not limited to, administering medication as ordered, monitor blood sugars per physician's orders. The interventions were initiated on 4/29/22. A physician's order, dated 10/14/22, indicated to perform accuchecks (blood sugar checks) at bedtime and call if results were greater than 400 or less than 150. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/22, indicated she was cognitively intact and received insulin (medication for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely address a dental referral for 1 of 2 residents reviewed for dental services (Resident 21). Findings include: The clinical record for Resident 21 was reviewed on 1/4/22 at 2:24 p.m. The Resident's diagnosis included, but were not limited to, diabetes. An admission MDS (Minimum Data Set) Assessment, completed 4/28/22, indicated Resident 21 was cognitively intact and had no dental concerns. On 1/04/23 at 2:21 p.m., Resident 21 was observed sitting in her wheelchair in her room. She had no natural teeth. She indicated she had recently seen a dentist who had referred her for new dentures. She had been told by the facility that they could not transport her to the dental office she had been referred to because they did not go to that town. She was unsure how she was going to obtain her new dentures. On 1/10/23 at 10:13 a.m., LPN (Licensed Practical Nurse) 20 provided the dental provider Patient Note History, dated 12/12/22, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to identify and implement an effective corrective plan of action to address two residents that were having sexual interactions. This affected 2 of 2 residents reviewed for abuse. (Resident 14 and Resident 28) Findings include: A quality deficiency was identified during a recertification, complaint and residential survey on 1/4/23 to 1/11/23. It was determined the deficiency was an Immediate Jeopardy at F600. Two residents that did not have capacity to consent were having sexual interactions in public and in private settings that occurred in May 2022 through September 2022. The facility did not provide evidence the facility's Quality Assurance & Performance Improvement (QAPI) committee had identified, developed or implemented an appropriate action plan with measures to address the sexual interactions between Resident 14 and Resident 28. Cross reference F600 An interview was conducted with the Executive Director (ED) on 1/11/23 at 12:19 p.m. He indicated QAPI had not reviewed and/or had a plan in place for anything regarding…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain contact isolation precautions for 1 of 6 resident reviewed for infections (Resident 13). Findings include: The clinical record for Resident 13 was reviewed on 1/4/22 at 1:37 p.m. The Resident's diagnosis included, but were not limited to, enterocolitis (infection of colon) due to recurrent Clostridium difficile (C-diff). A Quarterly MDS (Minimum Data Set) Assessment, completed 12/2/22, indicated that Resident 13 was cognitively intact. She was frequently incontinent of bowel. An IDT progress note, dated 12/4/22 at 10:36 a.m., indicated that Resident 13 had been sent to the hospital due to abdominal pain and increased temperature. A nursing progress noted, dated 12/7/22 at 3:58 p.m., indicated Resident 13 had been readmitted from the acute care hospital with diagnosis of pancolitis (inflammation of the entire colon) due to persistent C-diff infection. An Infection Event Report, dated 12/7/22 indicated Resident 13 had returned from the acute care hospital with colitis verses C-diff. She was placed in contact…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 had a true infection with the usage of an antibiotic prophylactically for the prevention of Urinary Tract infections (UTI) for 1 of 5 residents reviewed for unnecessary medications. (Resident 28) Findings include: The clinical record for Resident 28 was reviewed on 1/5/23 at 2:30 p.m. The diagnoses for Resident 28 included, but were not limited to, stroke, major depressive disorder, mild cognitive impairment, and dementia with behavioral disturbance. The resident had previously been living in an assisted living and was transferred to long term care on 11/22/21 in the same facility. A medical NP 2 note for Resident 28 dated 7/29/22 indicated .Details: Patient has the right to a consensual sexual relationship and appears appropriate with her decision making regarding the subject. Facility notes indicate family is aware of the relationship. she is at risk for UTI, spoke with DON [Director of Nursing] about possibly starting a ppx [prophylaxis] atb [antibiotic] and she was in agreement with this plan .1. 100…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-11 · tag F0886 — failed to test for COVID-19 as required — isolated
    Perform COVID19 testing on residents and staff.
    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 test a resident who had symptoms of Covid-19 for Covid-19 for 1 of 1 resident reviewed for respiratory care. (Resident 4) Findings include: The clinical record for Resident 4 was reviewed on 1/4/23 at 1:56 p.m. Her diagnoses included, but were not limited to, Alzheimer's disease. On 1/4/23 at 1:22 p.m., the ED (Executive Director) provided a list of residents who were considered Covid positive on 1/4/23. The list included 7 of the 49 residents in the facility. The 12/31/22, 8:49 a.m. nurse's note, recorded as a late entry on 1/1/23 at 8:51 a.m., read, Call to hospice re [regarding] yellow green thick nasal drainage throughout shift, decreased alertness and appearance of increased discomfort, vitals wnl [within normal limits,] awaiting call back. There was no information in the clinical record to indicate Resident 4 was tested for Covid-19 due to her symptoms. An interview was conducted with the IP (Infection Preventionist) on 1/4/23 at 3:20 p.m. She…

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

    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 TRILOGY HEALTH SERVICES — 123 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 4 of 54.2-0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Avalon Springs Health CampusValparaiso, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH 4 of 5Meadows Of Ottawa TheOttawa, OH

Showing 40 of 122; 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 / managerTypeRoleShareSince
HANCOCK REGIONAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2015
LUMENT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2023
BOND, MARIAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 07/01/2021
CLARK, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 05/01/2015
DAUGHERTY, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2020
FELKER, DEANIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 05/01/2015
LONG, STEVENIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROLsince 06/13/2022
WILLARD, LACEYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 07/01/2022
WILSON, ROYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 05/01/2015
TRILOGY HEALTHCARE OPERATIONS OF SHELBYVILLE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2015
MILES, NANCYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
SIMPSON, ZACHARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/17/2017
BARNEY, LEIGHIndividualLIMITED PARTNERSHIP INTEREST; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/12/2025
DAVIS, DAVIDIndividualLIMITED PARTNERSHIP INTERESTsince 12/31/2019
JOYNER, SARAIndividualTRUSTEE OF THE SNFsince 01/01/2022
AMERICAN HEALTHCARE REIT INCOrganizationADP OF THE SNFsince 10/01/2018
CONTINENTAL MERGER SUB LLCOrganizationADP OF THE SNFsince 10/01/2021
GAHC3 TRILOGY JV LLCOrganizationADP OF THE SNFsince 12/01/2015
GAHC4 TRILOGY JV LLCOrganizationADP OF THE SNFsince 10/18/2018
PARAGON OUTPATIENT REHABILITATION SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY HEALTH SERVICES LLCOrganizationADP OF THE SNFsince 08/11/2025
TRILOGY HEALTHCARE MASTER TENANT LLCOrganizationADP OF THE SNFsince 08/12/2025
TRILOGY HEALTHCARE HOLDINGS INCOrganizationADP OF THE SNFsince 08/11/2025
TRILOGY HEALTHCARE OF SHELBYVILLE LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY INVESTORS LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY OPCO LLCOrganizationADP OF THE SNFsince 08/12/2025
TRILOGY PRO SERVICES LLCOrganizationADP OF THE SNFsince 08/11/2025
TRILOGY PROPCO FINANCE LLCOrganizationADP OF THE SNFsince 08/11/2025
TRILOGY PROPERTY HOLDINGS LLCOrganizationADP OF THE SNFsince 08/11/2025
TRILOGY REAL ESTATE INVESTMENT TRUSTOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REIT HOLDINGS LLCOrganizationADP OF THE SNFsince 12/01/2015

CMS files one row per role, so the 43 rows in the source record cover these 32 parties — each is shown once here with every role it holds. Nothing is omitted.

20 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.

$11.2M
Net patient revenuemost recent cost report
+15.8%
Operating marginrevenue minus expenses
$1.5M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 32%Medicare 15%Other / private 53%

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$330per resident / day
operating cost
$10,041per month
≈ monthly operating cost
$392per 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 155735. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-13, 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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