Willows Of Shelbyville
2309 S Miller St, Shelbyville, IN 46176 · Government - City/county · 121 certified beds · (317) 398-9781 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 28% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 4 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 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 13.5% | 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 | 0.3% | 0.4% | 0.9% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.4% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 62.5% | 25.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 12.0% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.5% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 34.8% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.7% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.3% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.0% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 9.2% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.2% | 10.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.13 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.74 | 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.
55.5% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 11.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.5%CMS range 40.3–73.3 | 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 | 9.9%CMS range 6.0–14.1 | 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 | 11.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 11.1% | 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 | 14.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.6% | 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 | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.5–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 121 beds and averages 84.4 residents a day — about 70% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 3.98 on weekdays — 11% thinner on weekends. RN hours go from 0.41 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as 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
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2024-05-02 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 resident's plan of care for behavioral health was implemented and evaluated after having physical behavioral symptoms directed towards staff and other residents, document a resident's behaviors in the clinical record, document interventions in response to such behaviors, document the reasoning for administration of an intramuscular (IM) injection of antianxiety and antipsychotic medications, and ensure other residents' safety was maintained during behavioral episodes to where a resident (Resident E) was found to have their hands around another resident (Resident F's) neck that resulted in redness. Resident F had felt fearful, anxious, and the need to relocate to another nursing facility. Findings include: 1a. The clinical record for Resident E was reviewed on 5/1/24 at 11:00 a.m. The diagnoses included, but were not limited to, Huntington's disease, extrapyramidal and movement disorder, psychosis, anxiety disorder, major depressive disorder, schizophrenia, and insomnia. A significant change minimum…
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 before2025-12-23 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 residents' fall interventions were in place for 3 of 4 residents reviewed for care plan implementation. (Residents 7, 19, and 44)Findings include:1. The clinical record for Resident 7 was reviewed on 12/19/25 at 11:14 a.m. The resident's diagnoses included, but were not limited to: osteoporosis, Alzheimer's disease, anxiety, chronic obstructive pulmonary disease, and chronic pain. The Interdisciplinary Team (IDT) note, dated 11/13/25, indicated the resident had an unwitnessed fall on 11/12/25 in the common area. She was found on the floor beside a recliner. The resident complained of pain to her left hip. An x-ray was completed and returned positive for left hip fracture.The IDT note, dated 12/16/25, indicated the resident had an unwitnessed fall on 12/15/25. The resident was found laying on the floor next to her bed.The at risk for falls care plan, revised 11/28/25, indicated an intervention was to ensure appropriate footwear was worn, initiated 6/12/25.An observation of Resident 7 was made 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 · Dcited before2025-12-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a resident's nutritional supplement, as ordered, and have their family member complete weekly menus, as care planned. (Resident 9)Findings include:The clinical record for Resident 9 was reviewed on 12/19/25 at 11:45 a.m. The resident's diagnoses included, but were not limited to: dysphagia, dementia, depression, malnutrition, and anxiety. The Skin, Wound, Assessment, Treatment (SWAT) note, dated 11/6/25, indicated the resident was reviewed due to a new 180-day significant weight loss. Her current weight was 87.9 pounds, a 16-pound loss in 180 days. She was admitted to the facility for long-term care and on hospice services. She ate meals in the dining room and required total assistance with feeding. The physician's orders indicated the resident was to be provided with a regular diet, thin consistency, finger foods with meals, as needed, and a magic cup at lunch, starting on 1/29/25. An observation of Resident 9 was made in the dining room during the lunch meal on 12/22/25 at 12:36 p.m. The resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-23 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 plan of care to address her behavior of picking/scratching herself and adequately monitor this behavior for 1 of 5 residents reviewed for dementia care. (Resident 53)Findings include:The clinical record for Resident 53 was reviewed on 12/23/25 at 1:00 p.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease, chronic pain, depression, and dementia. An observation of Resident 53 in her wheelchair was made on 12/18/25 at 12:40 p.m. in the common area of the unit she resided. The resident had a quarter sized, reddish area with a partially scabbed center on her right cheek. There were no progress notes or assessments in the clinical record referencing the area on the resident's right cheek. An observation of Resident 53 and interview with Qualified Medication Aide (QMA) 6 were conducted on 12/23/25 at 11:52 a.m. QMA 6 indicated she hadn't noticed any areas on Resident 53's right cheek, so she went to Resident 53's room for an observation. Resident 53 was observed in…
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 before2025-12-23 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to ensure indwelling urological devices were maintained in accordance with infection control measures for 3 of 3 residents reviewed for indwelling urological devices. (Resident 96, Resident 11, and Resident 6)Findings include:1. The clinical record for Resident 96 was reviewed on 12/19/2025 at 2:15 p.m. The resident's diagnoses included, but were not limited to, bladder cancer and urinary retention.An admission Nursing Assessment, dated 12/17/2025, indicated Resident 96 had a urostomy and was alert and oriented to person only.A care plan, dated 12/17/2025, indicated Resident 96 had a urostomy with the goal of no infections related to urostomy. The interventions indicated for staff to monitor the resident for signs and symptoms of infection, as well as to use enhanced barrier precautions.A physician's order, dated 12/17/2025, indicated for Resident 96 to have urostomy care daily.During an observation, on 12/18/2025 at 12:59 PM, Resident 96's drainage bag and tubing for urostomy were on the floor.During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean manner and ensure a sanitizing bucket was at proper sanitization levels. This had the potential to affect 71 of 71 residents who reside in the facility. Findings include: A tour of the kitchen was conducted with the Dietary Manager (DM) on [DATE] at 10:35 a.m. Interviews were conducted with the DM at that time. During the tour, the DM indicated they did not have any test strips to test the stationary sanitization buckets used for wiping cloths. The DM indicated they could not test the solution for proper chemical levels. The DM indicated the facility used Cleanslate Disinfectant and Sanitizer with active ingredients including, dimethyl benzyl ammonium chlorides and ethylbenzyl ammonium chlorides in their sanitization buckets. During an interview with the DM, she indicated the test strips were noted to have been expired the week prior and at that time she notified the Executive Director (ED) that more…
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 · Fcited before2024-10-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store food and silverware properly and wear hair restraints in the kitchen. This had the potential to affect 57 of 57 residents in the facility. Findings include: A tour of the kitchen was conducted with the DS (Dietary Supervisor) on 9/25/24 at 11:15 a.m. Interviews were conducted with the DS at that time. During the tour, an observation of the clean dish racks was made. The silverware was stored in a cylindrical container with the handles facing downward, instead of upward. During the tour, an observation of the dry storage room was made. Masking tape was used to keep an opened package of vanilla wafers, an opened package of vanilla milk shake thickener, and opened package of graham cracker crumbs sealed, but the tape was no longer sticking. There were three bottles of syrup on a rack with opened tops and no lids, exposing the syrup to air. The DS indicated the opened packages of vanilla wafers, graham cracker crumbs, vanilla milk shake thickener, and bottles of syrup with no lids could have saran wrap used…
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 · F2024-10-01 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain the kitchen in a cleanly manner and in good repair for the potential to affect 57 of 57 residents in the facility. Findings include: A tour of the kitchen was conducted with the DS (Dietary Supervisor) on 9/25/24 at 11:15 a.m. Interviews were conducted with the DS at that time. The wall behind the ice chest was missing baseboard. There was a cracked wall corner cover by the handwashing sink. The dishwasher counter area had four missing tiles underneath it. There was one missing tile underneath the three-compartment sink. The dry storage room had a significant amount of dirt and debris, including macaroni, on the floor against the baseboards underneath the food storage racks. The baseboard under the racks was peeling away from the wall in the corner. There was a solidified brown liquid substance on the floor underneath one of the racks. The DS indicated the brown substance may have been from previous banana boxes. The walk-in cooler had spills all over the floor. The DS indicated one area on the floor…
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 before2024-10-01 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 redirect residents with wandering behaviors from other residents' rooms resulting in a lack of privacy for other residents for 5 of 8 residents reviewed for dementia care. (Residents 4, 22, 24, 27, 41, 157, 159) Findings include: 1. The clinical record for Resident 22 was reviewed on 10/1/24 at 1:10 p.m. The diagnoses included, but were not limited to, dementia. She resided on the memory care unit of the facility. The 6/16/24 care plan indicated she had alteration in mood and/or behavioral status related to depression, elopement risk, wanders, and history of hallucinations. Three of the five goals were for her to exhibit fewer episodes of physical/verbal behaviors toward others; to be accepting of redirection from triggered episodes of behavioral disturbances; and to be easily redirected and free from injury/adverse outcome related to wandering. Two of the interventions were to assist her with developing coping techniques that diminish/alleviate physical/verbal behaviors toward others and to redirect her from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-01 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately document a resident's code status in the clinical record for 1 of 1 resident reviewed for advanced directives (Resident 40). Findings include: The clinical record for Resident 40 was reviewed on [DATE] at 12:02 p.m. The resident's Indiana physician orders for scope of treatment (POST) form, dated [DATE], indicated the resident was to receive Cardiopulmonary Resuscitation (CPR) in the event the resident had no pulse and was not breathing. The form was signed by Resident 40 and the physician. The physician recapitulation (recap) orders for Resident 40, dated 9/2024, indicated the resident was not to be resuscitated in the event the resident had no pulse and was not breathing. Review of the record of Resident 40, on [DATE] at 1:44 p.m., indicated the diagnoses included, but were not limited to, cerebral palsy, hypertension, anxiety, anemia, atrial fibrillation, and major depressive disorder. During an interview with the Director of Nursing (DON)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-01 · tag F0641 — isolatedEnsure 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 encode minimum data set (MDS) assessments accurately for 2 of 2 residents reviewed for MDS accuracy. (Resident 44 and Resident 53) Findings include: 1. The clinical record for Resident 44 was reviewed on 10/1/2024 at 11:00 a.m. The medical diagnoses included benign neoplasm of cerebral meninges (layers of membranous connective tissue that cover and protect the brain and spinal cord). A Quarterly MDS assessment, dated 9/4/2024, indicated Resident 44 had a six month or less life expectancy, but did not receive hospice services. A hospice plan of care, dated 6/20/2024, indicated Resident 44 was admitted to hospice on 7/31/2023. During an interview, on 10/1/2024 at 12:00 p.m., the MDS Coordinator indicated Resident 44 was admitted on hospice care, had received hospice services continuously since admission, and the, 9/4/2024, MDS assessment was coded inaccurately. 2. The clinical record for Resident 53 was reviewed on 9/30/2024 at 1:03 p.m. The medical diagnoses included dementia. An admission MDS assessment, dated 8/13/2024,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2024-10-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to conduct care plan meetings for 1 of 4 residents reviewed for care plans. (Resident 10) Findings include: The clinical record for Resident 10 was reviewed on 9/30/24 at 11:02 a.m. The diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease, and major depressive disorder. During an interview with Resident 10 on 9/26/24 at 12:17 p.m., indicated they did not recall having care plan meetings. The Quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident 10 was cognitively intact. The EHR (electronic health record) indicated Resident 10 had a comprehensive care plan meeting, on 12/14/23, with no further care plan meetings held until 7/1/24. During an interview with the Social Service Director (SSD) on 10/1/24 at 12:30 p.m., indicated he was unable to find where Resident 10 had a care plan meeting. The SSD indicated social services were responsible to set up care plan meetings and meetings were conducted quarterly and as needed. A Comprehensive Care Plan policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-01 · 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 neurological checks, that included vital signs, were fully conducted for a resident who experienced an unwitnessed fall for 1 of 4 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/27/24 at 10:00 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, hypertension, anxiety, weakness, and repeated falls. An admission Minimum Data Set (MDS) assessment, dated 5/24/24, indicated moderate cognitive impairment, impairment to one side of the lower extremity, and substantial/maximal assistance with bathing, toileting, and personal hygiene. Resident B had a history of falls prior to admission to the facility and one fall since admission to the facility. A fall care plan, last revised on 8/5/24, indicated Resident B had a history of falls and required assistance from at least one staff member for safe transfers. The interventions included, but were not limited to, observe for and report changes in mobility and/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 before2024-05-02 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 with dementia had a care plan with resident-specific interventions in regards to making inappropriate comments towards staff, monitoring of behaviors and documentation of such behaviors in the clinical record; document interventions in response to such behaviors, and ensure the safety of other residents to where a resident (Resident H) was found to have touched another resident's (Resident G's) breast for 3 out of 5 residents reviewed for behavioral health. (Resident G and Resident H and Resident J) Findings include: 1. The clinical record for Resident G was reviewed on 4/30/24 at 3:00 p.m. The resident's diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and neurocognitive disorder with Lewy bodies. The 4/23/24 Quarterly MDS (Minimum Data Set) assessment indicated Resident G was severely cognitively impaired. 2. The clinical record for Resident H was reviewed on 4/30/24 at 2:45 p.m. The resident's diagnoses included, but were not limited to, disorientation,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure narcotic medication was administered per physician orders for 2 of 3 residents reviewed for medication administration. (Resident E and Resident D) Findings include: 1. The clinical record for Resident E was reviewed on 5/1/24 at 11:00 a.m. The diagnoses included, but were not limited to, Huntington's disease, extrapyramidal and movement disorder, psychosis, anxiety disorder, major depressive disorder, schizophrenia, and insomnia. A quarterly minimum data set (MDS) assessment, dated 3/19/24, indicated severe cognitive impairment and physical behavior directed towards others that occurred in 1-3 days. A physician order, dated 12/28/23, was noted for diazepam 10 milligrams (mg) twice daily for hyperkinesia due to Huntington's disease. The narcotic log sheets for Resident E's diazepam tablets was reviewed and indicated the following date(s)/time(s) were noted without documentation of the medication administration: 3/4/24 for both doses, 3/5/24 for both doses, 3/14/24 at 8:00 p.m., 3/15/24 at 8:00 p.m., 3/17/24 at 8:00…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 preference for frequency of bathing was honored on a regular basis for 1 of 4 residents reviewed for bathing. (Resident B) Findings include: The clinical record of Resident B was reviewed on 2-20-24 at 9:42 a.m. Her diagnoses included, but were not limited to chronic obstructive pulmonary (lung) disease (COPD), dementia, diabetes, chronic respiratory failure, unspecified heart failure, fibromyalgia, chronic atrial fibrillation, high blood pressure and glaucoma. Her most recent Minimum Data Set analysis, dated 1-8-24, indicated she is moderately cognitively impaired, requires a walker or wheelchair for mobility and requires substantial assistance with bathing. In an interview on 2-20-24 at 1:41 p.m., with Resident B, she indicated she prefers to receive bedbaths as opposed to a shower or tub bath and is scheduled for Tuesdays and Friday evenings. She indicated in recent weeks, this has only happened once a week with her last bedbath one week ago. A review of Resident B's bathing records for January 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 · D2024-02-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure oxygen therapy supplies were maintained in a clean and hygienic manner for 1 of 3 residents reviewed for oxygen therapy services. (Resident F) Findings include: During a care observation on 2-21-24 at 3:30 p.m., Resident F was observed receiving supplemental oxygen via a nasal cannula at 3 liters per minute. Her oxygen concentrator (machine delivering supplemental oxygen) was observed to have oxygen tubing without any identifier as to the date the tubing was replaced. Additionally, there was not a storage bag for oxygen tubing for the concentrator. Her portable oxygen tank tubing had an identifier to indicate it had been most recently changed on 2-18-24, and had a storage bag for the oxygen tubing. This was verified by CNA 4, who was present at that time, due to care provision to Resident F. A review of Resident F's physician orders, dated 1-28-24, indicated, Change O2 [oxygen] tubing and bag weekly and date every day shift every Sun [Sunday]. She was physician-ordered to receive supplemental oxygen at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 1 of 4 residents reviewed for pain medication received pain medications as ordered by their physician. (Resident B) Findings include: In an interview on 2-20-24 at 1:41 p.m., with Resident B, she indicated her primary concern is getting her pain medication as ordered. She indicated it is ordered routinely at 6:00 a.m., 2:00 p.m., and 10:00 p.m., and also has an as needed order for the same medication that she can receive one tablet every 12 hours as needed for pain. She indicated some staff give her pain medication too early and some administer it late, which can make it hard to keep her pain at bay. The clinical record of Resident B was reviewed on 2-20-24 at 9:42 a.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary (lung) disease (COPD), dementia, diabetes, chronic respiratory failure, unspecified heart failure, fibromyalgia, chronic atrial fibrillation, high blood pressure and glaucoma. Her most recent Minimum Data Set analysis, dated 1-8-24, indicated she is moderately cognitively…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure an insulin pen was properly labeled for use for 1 of 4 residents observed during 1 of 2 medication pass observations with 3 staff members with 4 residents. (Resident H, LPN 3) Findings include: During a medication pass observation on 2-19-24 at 7:41 p.m., LPN 3 was observed to obtain a Lispro (type of insulin) Kwikpen from the medication cart. There were no directions for use on the pen and LPN 3 was unable to locate the pen's bag with the label directions for use. Additionally, there was not a date identified in which the insulin pen had been opened. LPN 3 indicated insulin pens should include the date it was opened and should be kept in the bag it was dispensed in as the bag contains the directions for use. LPN 3 attempted to locate another Lispro Kwikpen, but failed to find one, but she was able to obtain an equivalent insulin from the facility's emergency drug kit. At 8:07 p.m., LPN 3 administered 6 units of Humalog insulin subcutaneously (under the skin) for Resident H's blood glucose level of 266.…
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 before2024-02-22 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure facility staff appropriately sanitized a glucometer (testing machine for blood sugar levels) utilized for multiple residents. (Resident H and QMA 2) Findings include: During 1 of 2 medication pass observations with 3 staff members with 4 residents, QMA 2 was observed to obtain a blood sugar level for Resident H on 2-19-24 at 7:33 p.m. Upon completion of the procedure, QMA 2 was observed to use an alcohol wipe to cleanse the glucometer. She indicated this is how she normally cleans the glucometers after using them. LPN 3 intervened at this time and indicated the facility's policy does not utilize alcohol wipes to sanitize the glucometer, but utilizes a bleach solution product to clean and sanitize the glucometer and to leave it wrapped in the bleach solution product to keep it wet for a designated amount of time. LPN 3 was observed to obtain a bleach solution container from the medication cart and demonstrated to the QMA how to sanitize the glucometer. In interviews conducted on 2-22-24 with QMA 5, QMA 6…
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 · E2023-07-26 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure overhead light fixtures were free of dead insects for all 4 hallways in the facility. This had the potential to affect all 63 residents who resided in the facility. Findings include: On 7/21/23, at 2:02 p.m., numerous dead insects were observed in 7 of the 8 overhead light fixtures on the [NAME] hall. All 8 light fixtures on the [NAME] hall, and all 8 light fixtures on the [NAME] hall had numerous dead insects on the light covers. On 7/24/23 at 10:02 a.m., all the light fixtures on [NAME], [NAME], and [NAME], continued to have numerous dead insects on the light covers, On 7/25/23, at 10:03 a.m., all 3 halls continued to have numerous dead insects in the light fixtures. On 7/25/23 at 12:17 p.m., all the light fixtures on the memory care hallway had numerous bugs/pests located within each light. On 7/26/23, at 2:13 p.m., the Administrator indicated the light fixtures are typically cleaned when they see something in the light fixtures. On 7/26/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a dignified environment for 2 of 2 residents reviewed for dignity. (Resident C and Resident D) Findings include: 1. An observation conducted of the memory care unit, on 7/24/23 at 12:37 p.m., noted Licensed Practical Nurse (LPN) 8 standing in front of Resident C. Resident C was yelling out loud and LPN 8 commented to Resident C I'm gonna put you down. Resident C continued to yell, and LPN 8 then commented let's put you to bed. Resident C was then assisted to lay down in his bed. An interview conducted with Housekeeping Staff 6, on 7/24/23 at 12:42 p.m., indicated it's common for Resident C to yell. She was unsure if it was related to his dementia or the fact that he was hard of hearing, or both. An interview conducted with LPN 8, on 7/24/23 at 12:50 p.m., indicated she would remove herself and reapproach a resident if they were difficult to redirect and then reapproach. 2. An observation of meal service was conducted on the memory care unit, on 7/25/23 at 12:00 p.m. LPN 8 was observed feeding 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.
- Potential for harm · D2023-07-26 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 beneficiary notices for 1 of 3 residents reviewed. (Resident 8) Findings include: Beneficiary notifications were reviewed on 7/24/23 at 1:30 p.m. Resident 8's documentation indicated his Medicare part A skilled services began on 4/20/23 and the last day covered, of his part A services was 6/22/23. There was no explanation of how the Medicare part A was terminated. There was no indication a Notice of Medicare Non-Coverage or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage had been provided, or that a two day notice had been given. On 7/24/23, at 2:06 p.m., the Bookkeeper indicated she had taken his letters of the Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary to him, to explain it, and he was asleep so she never went back to talk to him. He was his own responsible person and he didn't receive either the Notice of Medicare Non-Coverage or a Skilled Nursing Facility Advanced Beneficiary. On 7/24/23 at 3:40 p.m., the Director of Nursing indicated they don't have…
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 · D2023-07-26 · tag F0585 — failed to handle grievances — isolatedHonor 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 file a grievance for a resident voicing missing items for 1 of 2 residents reviewed for missing personal property. (Resident 5) Findings include: The clinical record for Resident 5 was reviewed on 7/24/2023 at 11:15 a.m. The medical diagnosis included glaucoma. A Quarterly Minimum Data Set Assessment, 7/8/2023, indicated that Resident 5 had a cognitive impairment and did not hallucinate or have delusions. An interview with Resident 5 on 7/20/2023 at 11:45 a.m. indicated she had multiple missing items that included three pairs of missing socks and a pair of pajama bottoms. She stated they have been missing for at least a few weeks. She stated she had reported them to the housekeeping staff and during the most recent resident council. Review of resident council minutes, dated 7/3/2023, indicated that multiple residents indicated they had missing clothing items, included Resident 5 reporting she had missing cheetah print pants. This was listed as found 7/6. An interview and observation on 7/24/2023 at 1:55 p.m. with CNA 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 care plan was initiated for the utilization of a splint for 1 of 1 resident reviewed for range of motion. (Resident 37) Findings include: An observation was conducted of Resident 37, on 7/20/23 at 12:26 p.m., to where no splint was in place to either hand. An observation, on 7/21/23 at 11:12 a.m., noted a splint to Resident 37's left hand. An observation, on 7/24/23 at 12:44 p.m., noted a splint to Resident 37's left hand. An observation, on 7/24/23 at 3:42 p.m., noted a splint to left hand. An interview conducted with Licensed Practical Nurse (LPN) 9, on 7/24/23 at 3:44 p.m., indicated Resident 37 has had the device on her left hand for a while. Resident 37 wears the device so her hand doesn't close up. The resident would not open her left hand. An observation, on 7/25/23 at 9:24 a.m., noted no splint device to either hand. An observation, on 7/25/23 at 10:10 a.m., noted no splint device to either hand. The clinical record for Resident 37 was reviewed on 7/24/23 at 2:32 p.m. The diagnoses included,…
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 · D2023-07-26 · 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 interview, observation, and record review, the facility failed to provide supervision and/or assistance for 3 of 3 residents observed for eating activities of daily living. (Resident 61, Resident 31, and Resident 33). Findings include: 1. The clinical record for Resident 61 was reviewed on 7/24/2023 at 1:55 p.m. The medical diagnoses included acute kidney failure and obstructive uropathy. An admission Minimum Data Set Assessment, dated 6/8/2023, indicated Resident 61 was cognitively impaired and was supervision for eating task. An activities of daily living care plan, dated for 6/2/2023, indicated that Resident 61 needed limited to extensive assistance of one staff member to eat. An observation on 7/21/2023 at 12:45 a.m. indicated Resident 61 was sitting in the main dining room with his meal tray in front of him. No staff were present in the dining room. He was attempting to eat his lunch, including a taco and ice cream. Resident 61 was trying to eat his taco with a spoon and dropped it on his shirt before attempting to eat his ice cream, which he also dropped upon his…
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 · D2023-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the utilization of a gait belt during a transfer for 1 of 1 resident randomly observed. (Resident 30) Findings include: A random observation was conducted of dining service on 7/24/23 at 12:46 p.m. Licensed Practical Nurse (LPN) 8 and Certified Nursing Assistant (CNA) 10 were present in the dining room. Resident 30 was assisted in her wheelchair to the lounge area, off of the dining room, and was assisted to a standing position by LPN 8 and CNA 10. One staff person had their arm going underneath Resident 30's left arm while the other staff was holding onto the back of Resident 30's pants during the transfer to a recliner. There was no gait belt utilized during the transfer for Resident 30 from wheelchair to bed. The clinical record for Resident 30 was reviewed on 7/26/23 at 11:24 a.m. The diagnoses included, but was not limited to, hypertension, dementia, and diabetes mellitus. A quarterly minimum data set (MDS) assessment, dated 4/20/23, indicated severe cognitive impairment along with extensive…
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 · D2023-07-26 · 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
Based on interview and record review, the facility failed to document the outputs as careplanned for a resident with an indwelling urinary catheter for 1 of 1 residents reviewed for urinary catheters. (Resident 61) Findings include: The clinical record for Resident 61 was reviewed on 7/24/2023 at 1:55 p.m. The medical diagnoses included acute kidney failure and obstructive uropathy. An admission Minimum Data Set Assessment, dated 6/8/2023, indicated Resident 61 was cognitively impaired and had an indwelling urinary catheter. A catheter care plan, dated for 6/2/2023, indicated for Resident 61 to have his urinary catheter bag emptied every shift and as needed and to document the output. Review of the outputs for Resident 61 for 7/11/2023 through 7/15/2023, indicated outputs were only documented once on 7/11/2023 for a volume of 400 ml, twice on 7/12/2023 with a combined 900 ml, once on 7/13/2023 with a volume of 100 ml, documented three times for 7/14/2023 for a total of 900 ml, and twice on 7/15/2023 for a total of 2925 ml. An interview with CNA 5 on 7/21/2023 at 2:01 p.m. 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 before2023-07-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure water pitchers were available for resident utilization for 2 of 3 residents reviewed for hydration. (Resident 52 and Resident D) Findings include: 1. The following observations were conducted of Resident 52 not having a water pitcher available for use: 7/20/23 at 11:51 a.m., 7/21/23 at 11:16 a.m., 7/24/23 at 12:40 p.m., 7/24/23 at 3:38 p.m., & 7/25/23 at 10:11 a.m. The clinical record for Resident 52 was reviewed on 7/26/23 at 3:00 p.m. The diagnoses included, but were not limited to, dementia, schizophrenia, edema, major depressive disorder, and cerebrovascular disease. A significant change minimum data set (MDS) assessment, dated 5/17/23, noted Resident 52 with severe cognitive impairment along with the need for extensive assistance with one staff for eating. A constipation care plan, revised 6/5/23, indicated to offer and encourage fluids for an intervention. An activities of daily living (ADL) care plan, revised 6/5/23, indicated Resident 52 required extensive assistance with one staff for eating.…
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 before2023-07-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed between contact with multiple residents during dining service. (Resident D and Resident 11) Findings include: A dining observation was conducted on the memory care unit on 7/25/23 at 12:00 p.m. Licensed Practical Nurse (LPN) 8 was observed assisting Resident D with consuming his lunch. LPN 8 then went to encourage and assist Resident 11 with taking bites of food without performing hand hygiene before or after. LPN 8 then proceeded to return back to Resident D to continue to assist with his lunch by giving him bites of food. No hand hygiene was performed before returning to Resident D to assist with consuming lunch. An interview conducted with the Director of Nursing (DON), on 7/26/23 at 2:35 p.m., indicated the expectations are for nursing staff to perform hand hygiene between contact with other residents. A policy titled HANDWASHING POLICY, undated, was provided by the DON on 7/26/23 at 2:34 p.m. The policy indicated the employee should wash his/her hands routinely after…
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CLAXTON, RYAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/27/2025 |
| HORNER, JOHN | Individual | CORPORATE OFFICER | since 01/01/2012 |
| SHELBYVILLE IN OPCO LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2023 |
| FRANKEL, ISRAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2023 |
| PAUL, MANDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2024 |
| RADADIYA, PRAGNESHKUMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2023 |
CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 28% 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 155022. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-23, 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.