Briarcliff Health & Rehabilitation Center

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

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.

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.

Therapy staffing: this home’s payroll records show 0.04 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% 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.

Staffing

How full it usually is: this home is certified for 131 beds and averages 92.5 residents a day — about 71% occupied, or roughly 38 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 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 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 3.63 hrs/resident/day on weekends vs 4.52 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.47 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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.

20 citations, most serious first. The 13 most serious are shown; the remaining 7 are one tap away and print in full.

• Actual harm · G2025-08-08 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure 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 record review and interview, the facility failed to implement effective, ongoing interventions to prevent behaviors for a resident with a history of behaviors. This deficient practice resulted in a hospitalization due to injuries incurred due to behaviors for 1 of 1 residents reviewed for behavior management. (Resident 1)Finding includes: Resident 1's record review was completed on 8/4/2025 at 2:10 P.M. Diagnoses included, but were not limited to: bipolar type schizoaffective disorder, mild intellectual disability, anxiety disorder and dementia.A Nursing Progress Note dated, 9/19/2025 at 12:15 P.M., and signed by the Director of Nursing (DON), indicated Resident 1 continued to insert foreign objects into his rectum. An Incident Note, dated 11/23/2024 at 6:35 P.M., indicated facility staff had found Resident 1 in his room with blood on his sheets. After staff had assessed the resident, he was found to have had a small pumpkin in his brief with the stem pointed up, toward the rectum with blood noted to the pumpkin stem. Resident 1's rectum was assessed and a butter knife 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
• Actual harm · G2024-08-12 · tag F0697 — failed to manage pain — isolated
  Provide 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 observation, interview and record review, the facility failed to administer medication as needed prior to a dressing change. This deficient practice resulted in severe pain during a treatment for 1 of 1 residents observed for wound care. (Resident 35) Finding includes: During an observation of wound care for Resident 35, on 8/08/2024 at 3:13 P.M. with the ADON and the Unit Manager, the ADON indicated the resident's treatment was to cleanse the resident's wound with wound wash, apply calcium alginate and medi- honey ointment, sprinkle Flagyl (an antibiotic) n the wound bed, and cover the wound with a dry dressing. First, CNA 2 wiped away some zinc barrier cream from around Resident 35's wound with a wet rag. Next, the ADON removed the soiled dressing from the resident's wound. After she washed her hands and donned clean gloves and a clean gown, she cleansed the wound and applied the medi honey ointment and packed the wound. The Resident began yelling Ouch, it hurts! and Please, it hurts! numerous times, during the removal of soiled dressing and packing, cleansing 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-11-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure a cognitively impaired resident was not videoed with derogatory captions on a social media network. This deficient practice had the potential/likelihood of a negative psychosocial outcome, resulting from the facility's noncompliance to protect the resident from humiliation related to the derogatory video and captions. (Resident E) Finding includes: A facility self-report incident #444, dated 11/4/23 at 5:41 P.M., indicated Resident E had been posted on a social media network, titled (name), in a 15 second video, sleeping in bed and CNA 3 speaking in garbled slang speech with an inappropriate text below the video. It was requested CNA 3 immediately delete the video, which she stated she did. A typed statement, undated, indicated the Administrator and the Director of Nursing (DON) had spoken to CNA 4, . the individual/employee who allegedly posted the video of resident [name of resident] on (social Media application) .We became aware of the video via nurse manager on call, [name of Nurse Manager] who had seen the…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff used a sling in good working order to transfer 1 of 3 residents reviewed with a mechanical sit to stand lift (Resident K). Findings include:A confidential report, dated December 2025, alleged Resident K had a fall when being transferred from bed to his wheelchair. The fall occurred when the sling strap broke, causing the resident to fall to his knees, striking the back of his neck against the bed frame. Initially, the resident had no injuries but later in the day, had increased pain in his knees and neck and was sent to the ER for evaluation and returned the same day.On 3/18/26 at 1:05 P.M., Resident K's record was reviewed. Diagnoses included surgically repaired cervical stenosis (caused pressure on the spinal cord and nerves) with rod and screws in the neck and spinal cord dysfunction with weakness of extremities.A quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated Resident K had no cognitive impairment.…

  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 · Fcited before2025-08-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store food in a sanitary manner related to labeling and dating leftovers and throwing away expired food in the refrigerator for 1 of 1 kitchen and 1 of 1 kitchenettes observed. This had the potential to affect 93 of 95 residents who consumed food from the kitchen and the Memory Care Kitchenette.Findings include:1. During the initial kitchen tour on 7/29/2025 at 9:45 A.M with the Director of Dietary (DD), the following was observed in the three-door refrigerator:-Two premade ham and cheese sandwiches had not been labeled with a made on or use by date. -A plate had sliced tomatoes, onion and shredded lettuce, wrapped in clear plastic but did not have made on or used by dates. -A bag of shredded cheese had been opened but had not been labeled with an opened or use by date. -A container of leftover green beans had not been labeled with a made on or use by date. -A bag of celery labeled with a use by date of 7/26/2025.-A container of diced tomatoes labeled with a use by date of 7/25/2025. -A container of cheese…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-08 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to report an unusual occurrence that resulted in resident injuries to the Indiana State Survey Agency for 1 of 1 residents reviewed for injuries. (Resident 1)Finding includes:Resident 1's record review was completed on 8/4/2025 at 2:10 P.M. Diagnoses included, but were not limited to: bipolar type schizoaffective disorder, mild intellectual disability, anxiety disorder and dementia. An Incident Note dated, 11/23/2024 at 6:35 P.M., indicated facility staff had found Resident 1 in his room with blood on his sheets. After staff had assessed the resident, he was found to have had a small pumpkin in his brief with the stem pointed up, toward the rectum with blood noted to the pumpkin stem. Resident 1's rectum was assessed and a butter knife with only the handle of the blade was observed outside of the rectum. The resident had indicated he had inserted a straw into his rectum as well. Staff had observed the resident's meal tray and all his utensils were accounted for but there was no straw. Emergency Services was called, as well as…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-12 · tag F0880 — failed to prevent and control infections — pattern
  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 2 of 2 laundry staff transported residents clothing appropriately when delivering them. Finding includes: During an observation on 8/5/2024 at 11:00 A.M., Laundry Aide 4 was pushing a cart with residents personal clothing partially covered with a draw sheet. The sheet only covered the top of the clothing to middle of the items and the lower portion of the clothing was exposed and uncovered. During an observation on 8/8/2024 at 12:55 P.M., Laundry Aide 5 was coming down the hall with a cart with residents' personal items covered with a draw sheet. The items were covered from the top of the clothing to middle of the items and the lower portion of the clothing was exposed and uncovered. During an interview on 8/8/2024 at 12:58 P.M., Laundry Aide 5 indicated they (the resident's clothing)probably should be covered up more. During an interview on 8/8/2024 at 1:03 P.M., the Housekeeping/Laundry Director indicated the draw sheet was what they had to cover the rack, they did not have a cover that covered 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-12 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to include the resident, or representative, in meetings to review the plan of care for 1 of 3 residents reviewed for care planning. (Resident 17) Finding includes: A record review for Resident 17 was completed on 8/9/2024 at 1:27 P.M. Diagnoses included, but were not limited to, stage 5 chronic kidney disease, unspecified osteoarthritis, and type 2 diabetes mellitus. An admission Minimum Data Set (MDS) assessment, dated 6/5/2024, indicated Resident 17's cognition was intact and she participated in goal setting. During an interview on 8/6/2024 at 9:28 A.M., the resident indicated she had not attended a care plan meeting since her admission on [DATE]. A Social Service Progress Note, dated 5/30/2024, included a brief medical history and her goal of returning to the community after therapy was completed. The record lacked any notes indicating a care plan meeting had been planned or had taken place since Resident 17 was admitted . During an interview 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-12 · 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, observation and record review, the facility failed to implement fall prevention interventions related to signage and an adaptive call light system for a resident with repetitive falls for 1 of 20 residents reviewed for falls. (Resident 10) Finding includes: During an interview on 8/7/2024 at 1:41 P.M., Resident 10 indicated she had fallen the previous day and her leg was sore. The staff had told her to call for help when she needed to use the bathroom. A record review was completed for Resident 10 on 8/7/2024 at 1:40 P.M. Diagnoses included, but were not limited to: glaucoma, dementia, type 2 diabetes mellitus, and syncope. A quarterly Minimum Data Set (MDS) assessment, dated 5/23/2024, indicated the resident had severe cognitive impairment and required extensive assistance for transfers. A quarterly Fall Risk Evaluation, dated 8/5/2024, indicated the resident was at high risk for falls. The clinical record indicated Resident 10 had fallen within the last year on the following dates: -8/14/2023 -8/16/2023 -9/6/2023 -9/23/2023 -10/28/2023 -12/6/2023 -5/15/2024…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-12 · 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 maintain a system for reconciliation of controlled substances for 1 of 3 medication carts reviewed. (800 hall medication cart) Finding includes: During an observation on 8/8/2024 at 9:41 A.M. of the Medication Cart on the 800 Hall, the Shift Change Accountability Record for Controlled Substances was missing signatures to indicate the controlled substances had been counted and reconciled by two staff members (the on coming an out going nursing staff member) on the following dates and shifts: -8/1/2024 fist shift did not contain two signatures. -8/4/2024 first shift did not contain two signatures. -8/4/2024 third shift did not contain two signatures. -8/5/2024 third shift did not contain two signatures. -8/6/2024 third shift did not contain two signatures. -8/7/2024 first shift did not contain two signatures. During an interview, on 8/8/2024 at 9:42 A.M., Qualified Medication Aide (QMA) 6 indicated there should not be any missing signatures and staff should always count the controlled substances with another…

  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 · D2024-08-12 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and addressed timely by a physician for 2 of 5 residents reviewed for medications. (Residents 55 and 10) Findings include: 1. Resident 55's record review was completed on 8/7/2024 at 9:58 A.M. A Consult Pharmacist's Medication Regimen Review, dated 12/14/2023, indicated the Pharmacist recommended discontinuing 500 micrograms of Cyanocobalamin (Vitamin B12). The order for Cyanocobalamin was discontinued on 2/12/2024. A Pharmacy Medication Regimen Review form, from the Pharmacist to the Physician, dated 11/13/2023, indicated the Pharmacist recommended discontinuing Biofreeze Gel 4% topical analgesic. The Physician responded to the recommendation form to discontinue the Biofreeze on 12/12/2023 and the Biofreeze Gel 4% was discontinued on 1/11/2024. A Pharmacy Medication Regimen Review form, from the Pharmacist to the attending Physician, dated 2/19/2024, indicated the Pharmacist recommended weekly blood glucose monitoring and the Physician had agreed to the recommendation but 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store and prepare food in a sanitary manner in 1 of 1 kitchens. This had the potential to affect 88 out of 89 residents who ate food prepared in the kitchen. Finding includes: During an observation of the kitchen, with the Dietary Manager (DM), on 8/5/2024 at 9:07 A.M., the following was noted: -Vegetable burgers, strawberries, and 3 tubs of ice cream in the reach-in freezer were not dated. -Food processor bowls stacked together and stored as clean, were still wet on the inside. -The ductwork and ceiling in the food preparation area had a thick layer of dust. -The electrical outlet above the spices was dusty. -Two large and one small pans had missing and/or flaking Teflon coating on the cooking surface. During an interview on 8/5/2024 at 9:20 A.M., the DM indicated the food in the reach-in freezer should have been dated, the food processor bowls should have been dry before stacking them, the ceiling, ductwork, and electrical outlet should have been free of dust, and the Teflon pans should have been replaced.…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-12 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make 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 a sanitary environment related to clean air vents and dirty ceiling tiles on the 500 Hall. Finding includes: During an observation, on 8/8/2024 at 12:30 P.M., a food cart was sitting under an air vent on the 500 hall. The vent had a thick layer of dust and the dust was mixing with condensation, forming droplets of mud. The droplets were falling onto the food cart below it. During a environmental tour with the Director of Maintenance (DM) on 8/8/2024 at 12:30 P.M., the 500 hall had five vents on the ceiling and all 5 vents and the four ceiling tiles surrounding the vents and/or light covers had a thick build up of dust. One of the vents had condensation mixed with the dust and mud colored droplets were dripping down to the floor. During an interview with the DM on 8/9/2024 at 8:30 A.M., he indicated the reason there was condensation on the ceiling vents was due to residents opening their windows in their rooms and causing humidity in the facility. The vents and ceiling tiles should not be dirty 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.

  Environmental 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.

Fines & penalties

$10,839 in federal fines across 1 penalty.

• $10,839 — penalty dated 2024-08-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to STERLING HEALTHCARE — 5 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 →

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

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 81% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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