Holy Cross Rehabilitation And Wellness
17475 Dugdale Dr, South Bend, IN 46635 · Non profit - Other · 168 certified beds · (574) 247-7500 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 held steady at 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 | 29.7% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.2% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.5% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 7.3% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 25.2% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.9% | 3.3% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 25.5% | 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 | 6.7% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.1% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.0% | 79.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.9% | 22.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.4% | 10.8% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
68.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 288 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.0% 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 135 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% 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 | 68.7%CMS range 63.4–74.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 7.4–11.9 | 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 | 43.0% | 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 | 40.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.8% | 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 | 98.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 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 | 3.5% | 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 | 5.8%CMS range 3.6–9.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.84 | 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 168 beds and averages 69.9 residents a day — about 42% occupied, or roughly 98 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 4.07 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.61 hrs/resident/day on weekends vs 4.26 on weekdays — 15% thinner on weekends. RN hours go from 0.98 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-15 · 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 assess a resident who had fallen for 1 of 3 residents who were reviewed. (Resident G)Finding includes:During an interview on 5/15/2026 at 10:00 A.M., Resident G indicated she had fallen about a month prior when a staff member had moved her with the Hoyer lift by themselves. Resident G indicated she had not been injured during the fall. Resident G denied have been assessed by a staff member before she was lifted off the floor and back into her bed. She also denied having been assessed by staff after she was put back into her bed. Resident G's record review was complete on 5/15/2026 at 11:00 A.M. Diagnoses included, but were not limited to: type two diabetes mellitus, chronic kidney disease, obesity and major depressive disorder. An Annual Minimum Data Set assessment, dated 3/9/2026, indicated Resident G had moderate cognitive impairment and had been dependent on staff for transfers.A Rehabilitation Evaluation assessment, completed on 3/8/2026, indicated it was appropriate for Resident G to be transferred with a Hoyer lift.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-15 · 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 interview and record review, the facility failed to transfer a resident appropriately resulting in the resident falling for 1 of 3 residents reviewed for falls. (Resident G)Finding includes:During an interview on 5/15/2026 at 9:30 A.M., the Director of Nursing (DON) indicated there had been an incident when Resident G had been in the process of being transferred with a lift by CNA 2 on 4/13/2026. The resident had been assisted to the floor during the transfer because the resident had been falling out of the mechanical lift transfer sling. CNA 2 had been sent home on 4/13/2026. An investigation into the incident had been started. During the facility's investigation it was determined that CNA 2 had moved Resident G with a mechanical lift, but had not had the assistance of another staff member. The DON indicated all mechanical lifts required the assistance of two staff members. CNA 2 was terminated on 4/15/2026 for not following the facility's policy related to transferring residents with a mechanical lift. During an interview on 5/15/2026 at 10:00 A.M., Resident G 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 before2026-03-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure wound treatment orders were obtained timely and wound treatments were completed and signed out as ordered for 2 of 2 residents reviewed for non-pressure related skin conditions. (Residents B and C)Findings Include:1.Resident B's record was reviewed on 3/12/26 at 10:00 a.m. The diagnoses included, but were not limited to, diabetes, atrial fibrillation, high blood pressure, and GERD.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact for daily decision making. The resident had a surgical wound prior to admission.A Care Plan, dated 2/5/26, indicated the resident had alteration in skin integrity related to an incision of the scrotal and perineal area. Approaches were to provide treatments as ordered, monitor for pain, and observe for signs/symptoms of infection and notify physician of any abnormal findings.A Physician's Order, dated 2/5/26, indicated to apply vacuum assisted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-13 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were implemented regarding glove change and hand hygiene during a dressing change. In addition, the facility failed to ensure nursing staff understood the required protective equipment needed to care for a resident requiring Enhanced Barrier Precautions for 1 of 2 resident's reviewed for non-pressure skin conditions. (Resident C)Findings include:On 3/13/26 at 10:38 a.m., a wound treatment was observed on Resident C. Wound treatment began at 10:41 a.m. with RN 1 removing the previous foam dressing that was dated 3/12/26. RN1 removed his gloves and left the room to clarify treatment orders. At 10:45 a.m., RN 1 returned with the Nurse Practitioner (NP) and she assessed the wound and agreed that the wound did not require packing and that it was healing great. She gave new verbal orders to RN 1 to clean with a gauze pad soaked with betadine, apply a 4x4 to the wound bed and wrap with kerlix.RN 1, donned…
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 before2025-09-17 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to adequately address resident grievances regarding call light wait times for 18 of 18 residents reviewed for call-light wait times, (Residents B, C, D, E, F, G, H, K, L, M, N, P, Q, R, S, T, and U).Findings include:During an interview, on 9/17/25 at 9:10 A.M., the Director of Nursing indicated the facility call light system was in working order and had not been out of working order at any time that she was aware of. The Director of Nursing indicated that each resident had a staff member, called a Guardian Angel, who checked on their assigned residents addressing concerns including concerns regarding call ight wait times. The Director of Nursing indicated when residents had concerns, the Guardian Angel was to address the concern and/or file a grievance or complete a Call Light Response Survey form. The Director of Nursing provided a call light audit form that had been created following the previous annual survey on 4/28/25, and indicated call light wait time audits were ongoing but there was no audit documentation completed…
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 before2025-04-28 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively act and resolve Resident Council's concerns related to long call light response times. This failure affected 2 of 7 residents attending the Resident/Surveyor group meeting. Findings Include: During a Resident/surveyor meeting on 4/22/25 at 12:59 P.M., seven of seven residents indicated the Resident Council had complained about long wait times for their call lights to be answered. Two of seven residents reported they were experiencing continued delays, and Resident B stated he had waited as long as an hour within the past couple of weeks. A review of Resident Council meeting minutes revealed repeated concerns over the past year about delayed call light responses on the following months: - 1/27/2025 - 10/16/2024 - 7/8/2024 During an interview on 4/24/2025 at 10:00 A.M., the Executive Director (ED) acknowledged he had been made aware of the Resident Council concerns regarding long call light response times. He indicated he had identified two…
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 · D2025-04-28 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 the Discharge Minimum Data Set (MDS) assessment was completed and submitted in a timely manner for 1 of 4 residents who were reviewed for discharge assessments. (Resident 29) Findings include: Resident 29's record review was completed on 04/23/2025 at 10:47 AM. Diagnoses included, but were not limited to: hypertension, atrial fibrillation, and arthritis. Resident 29 was discharged on 12/22/2024. Resident 29's Discharge MDS assessment was completed and submitted on 4/23/2025, 122 days after discharge. During an interview on 04/28/25 at 11:15 AM, the Director of Nursing (DON) indicated the MDS assessment had not been completed or submitted timely. The DON also indicated the facility did not have a policy related to MDS assessment completion and followed the Resident Assessment Instrument (RAI) manual as their guidance. According to the RAI User's Manual, Chapter 2, Page 2-17, a Discharge assessment must be completed (i.e., signed and dated as complete) within 14 days after the resident had been discharged from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-28 · 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 develop a comprehensive care plan for 2 of 17 residents reviewed for care planning ( Resident 22-bowel issues) and (Resident 27-skin issues). Findings include: 1. A record review was completed on 4/23/2025 at 9:01 A.M. for Resident 22. Diagnoses included, but were not limited to, Parkinson's disease and chronic kidney disease. A Significant Change Minimum Data Set (MDS) assessment, dated 1/29/2025, indicated Resident 22's cognition was moderately impaired and he was occasionally incontinent of bowels. Physician Orders included, but were not limited to: -3/20/2025 Linzess 145 micrograms (mcg) by mouth daily for constipation. -3/13/2025 polyethylene glycol 17 grams by mouth daily mixed with 4-8 ounces of water for constipation. -12/10/2024 docusate sodium 100 milligrams (mg) by mouth twice a day for constipation. The record lacked a care plan that addressed bowel issues, including constipation, and the use of bowel medications. During an interview on 4/25/2025 at 1:40 P.M., the ADON confirmed although 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 before2025-04-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the skin of a resident with a Gastronomy tube (G-tube) did not develop blisters caused by the friction from the G-tube for of 1 of 6 residents who were reviewed for skin problems. (Resident 27) Finding includes: During an observation of a medication administration on 04/23/2025 at 8:51 A.M., Resident 27 had a dime-sized blister directly located below the G-tube site on his abdomen. LPN 4 indicated the blister was new and attributed it to friction caused by the G-tube tubing being too long. LPN 4 pointed to a band-aid located toward the center of Resident 27's abdomen and indicated the resident had developed a similar blister several days earlier due to friction from the tubing rubbing on the resident's skin. LPN 4 indicated the resident did not have an order for the treatment of the second blister and she did not know if the facility had created a Care Plan to address further blister formation from the G-tube. Resident 27's record review was completed on 04/23/2025 at 10:51 AM. Diagnoses included, but…
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 · D2025-04-28 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure there was adequate monitoring of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 25) Findings include: A record review for Resident 25 was completed on 4/23/2025 at 4:01 P.M. The resident's diagnoses included, but were no limited to: hypertension, diabetes mellitus, anxiety, depression, bipolar disorder and hereditary and idiopathic neuropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 4/15/2025, indicated Resident 25 was cognitively intact. The MDS assessment indicated the resident had no potential indicators of psychosis, no behavioral symptoms, had not demonstrated any rejection of care and had no wandering behaviors. In addition, the MDS assessment indicated the resident was receiving an antipsychotic, an antidepressant, an anticoagulant and a diuretic medication. A Physician Order, dated 2/20/2025, indicated the resident was to receive Aripiprazole (anti-psychotic) 2 mg (milligrams) tablet oral six times weekly for bipolar disorder. A Pharmacy…
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 16 citations
- Potential for harm · Dcited before2025-04-28 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the kitchen equipment was in working order for 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 66 of 66 residents who received meals from the kitchen. Finding includes: On 4/21/2025 at 9:26 A.M., an observation included the northernmost sink of the cooking area of the kitchen. This sink was leaking underneath into the drainage area from the drain pipe in addition to the faucet slowly running and unable to be turned off. During an interview, on 4/21/2025 at 10:15 A.M., the Dietary Manager indicated Maintenance was aware of the broken sink and she indicated maintenance was waiting for a part to fix the sink. During an interview, on 4/24/2025 at 1:44 P.M., the Maintenance Director indicated he had never received a work order for the kitchen sink and was unaware of any broken sink in the kitchen. During an interview, on 4/24/2025 at 1:51 P.M., Registered Dietician 1 indicated she was unaware of any leaking sink in the kitchen and stated, I usually just go through there and haven't noticed…
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 before2025-04-28 · 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, record review and interview, the facility failed to ensure enhanced barrier precautions were followed for 2 of 5 residents reviewed for isolation needs. (Resident 27 and 35) Findings include: 1. The clinical record of Resident 35 was reviewed on 4/24/2025 at 10:26 A.M. The resident's diagnoses included, but were no limited to: diabetes mellitus, septicemia, obstructive uropathy, hypertension, anxiety and depression. An Annual Minimum Data Set (MDS) assessment, dated 2/24/2025, indicated Resident 35 was moderately cognitively impaired, was taking an antibiotic and had an indwelling catheter. A Physician Order, dated 10/19/2024, indicated Resident 35 was to be in enhanced barrier precautions; with instructions noted to maintain enhanced barrier precautions during high-contact resident care activities. A current Care Plan, created 5/31/2024, indicated Resident 35 required enhanced barrier precaution isolation. During an observation and interview on 4/24/2025 at 11:08 A.M., CNA 3 entered Resident 35's room without any PPE (personal protective equipment or gear worn…
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 · D2025-04-28 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake 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 and interview the facility failed to ensure water faucets were functional in 4 of 30 rooms in the long term care unit. (Rooms W7, W12, W15 and W24) Findings include: 1. During an observation on 4/25/2025 at 2:00 P.M., the faucet in Room W7 was running and could not be turned off. During an interview on 4/25/2025 at 2:00 P.M., Resident 57 indicated it had been running for quite awhile but did not know how long. She had reported it to the facility but it had not been fixed yet. She indicated she turned her television volume up louder so she forgot about it and was able to sleep. 2. During an observation of Room W24 on 4/22/2025 at 11:12 A.M., the faucet was missing and water was continuously dripping down the back of the sink. 3. During an observation of W15 on 4/22/2025 at 9:44 A.M., the faucet was dripping continuously. 4. During an observation of Room W12 on 4/22/2025 at 9:45 A.M., the faucet was dripping continuously. During a tour and an interview on 4/25/2025 at 2:35 P.M., the Maintenance Director indicated he had tried to fix the faucets but they needed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-25 · 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 record review and interviews the facility failed to ensure a resident received the required transfer assistance for 1 of 2 residents reviewed for accident hazards. (Resident E) Finding includes: The record for Resident E was reviewed on 6/24/24 at 1:41 P.M. Resident E's diagnoses, included but were not limited to: cerebrovascular accident and osteoporosis. The admission Minimum Data Set (MDS) assessment, dated 5/29/24, indicated Resident E's cognition was moderately impaired and she was dependent on staff to complete all activities of daily living (ADLs) including transfers. A care plan for Resident E, dated 5/23/24, indicated the resident had a self care deficit related to right side hemiparesis and staff were to transfer the resident with the extensive assistance of 2 staff members. During an interview on 6/24/24 at 1:53 P.M., Resident E's family member indicated during her visit on 6/6/24, the resident told her she had fallen and her leg was injured. During an interview on 6/24/24 at 1:42 P.M., the DON indicated during the investigation of the incident regarding a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review, the facility failed to maintain appropriate food temperatures of the meal trays on St. Paul's Unit. This had the potential to affect the 21 Residents who eat on St. Paul's Unit. Finding includes: During an interview, on 4/15/2024 at 11:15 A.M., Resident 117 indicated he ate his meals in the dinning area on the unit and most of his meals were cold. Resident 117 was able to request to have his meals heated to a warmer temperature, but stopped asking because every meal was cold. An observation of food temperatures for the meal trays on St. Paul's Unit was completed, on 5/20/2024 at 12:13 P.M. The Dietary Project Manager pulled the first tray off the food cart and used her thermometer to take the temperature of the food. The cabbage had a temperature of 135 degrees Fahrenheit and the pot roast had a temperature of 141 degrees Fahrenheit. The Dietary Project Manger requested a dietary aide begin microwave each plate. There were 21 trays on the food cart. During an interview, on 5/20/2024 at 12:15 P.M., the Dietary Project Manager…
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 before2024-05-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner in 1 of 1 kitchens observed. The facility also failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety and used for food and beverages only for 4 of 4 panty rooms observed. This deficient practice had the potential to affect 76 of 77 residents who resided in the facility and consumed from from the kitchen or pantries Findings include: 1. Upon entering the kitchen on 5/14/2024 at 9:05 A.M., on top of the ice machine was 2 scoops lying uncovered, and the storage container was open but empty. During an interview on 5/14/2024 at 9:06 A.M., the Dietary Supervisor indicated that the scoop storage container was broken, and they had just been laying the scoops on top of the machine, another container had been ordered. On 5/15/2024 at 3:33 P.M., the Administrator provided…
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 · D2024-05-21 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the resident or representative, a notice of transfer/discharge or a copy of the bed hold policy for 1 of 1 resident reviewed for hospitalizations. (Resident 65) Finding includes: During an interview, on 5/14/24 at 10:29 A.M., Resident 65 indicated he was hospitalized a couple of weeks ago but could not recall why. A record review for Resident 65 was conducted on 5/16/24 at 9:31 A.M. Diagnoses included, but were no limited to, partial amputation of right foot and diabetes mellitus. A Five Day Minimum Data Set assessment, dated 4/19/24, indicated Resident 65 had an intact cognition Nursing Progress Notes, dated 5/1/24, indicated Resident 65 was sent to the emergency room for a change in condition and was admitted to the acute care center with a diagnosis of pneumonia. The record lacked documentation a notice of transfer/discharge or a bed hold policy was given to the resident when he was sent to the emergency room. During an interview, on 5/17/24 at 2:23 P.M., the DON indicated she was unable to find tdocumentation…
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 before2024-05-21 · 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 record review and interview, the facility failed to develop a person-centered care plan addressing depression for 1 of 21 residents whose care plans were reviewed. (Resident 53) Finding includes: A record review was completed on 5/15/2024 at 12:22 P.M. for Resident 53. Diagnoses included, but were not limited to major depressive disorder, chronic obstructive pulmonary disease, and heart failure. A Care Plan, dated 4/29/2024, indicated Resident 53 had mood and behavior concerns related to depression. Interventions included: administer medications as ordered; provide a calm and quiet environment; monitor for triggers of mood changes and provide appropriate interventions as needed. There were no specific interventions to address what specific triggers the resident exhibited or what appropropriate interventions were planned for Resident 53. During an interview, on 5/20/2024 at 10:08 A.M., the Assistant Director of Nursing indicated Resident 53 did not have person-centered interventions for her Care Plan. A policy for developing person-center care plans was requested from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-21 · 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 record review, and interview, the facility failed to ensure care plans were revised and care conferences were held quarterly for 2 of 3 residents reviewed for care planning. (Resident 37 & 58) Finding include: During an observation, on 5/14/2024 at 3:18 P.M., Resident 37's right hand was contracted and there was no splint on the resident's right hand. During an observation, on 5/15/2024 at 9:16 A.M., Resident 37 was wearing a soft splint to her right hand. During an observation, on 5/17/2024 at 9:11 A.M., Resident 37 was not wearing a soft splint to her right hand. A Physicians Order, dated 8/31/2019, indicated to apply a soft resting hand splint to the right hand daily, place on prior to bed and take off upon rising. A Care Plan, dated 5/22/2020, indicated the following: -I have right side hemiparesis related to cardiovascular accident. Interventions included: I wear a soft splint to my right hand, on in AM, off HS (hour of sleep). -I have self care deficits associated with need for assistance with activities of daily living (ADL's). Interventions included: right soft…
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 · D2024-05-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to bed baths, shaving, and turning and positioning per standards of care for 2 of 3 residents reviewed for ADL care. (Resident 37 & 46) Finding includes: 1. During an observation, on 5/14/24 at 3:18 P.M., Resident 37's fingernails were long and dirty. During an observation, on 5/15/2024 at 9:16 A.M., Resident 37's fingernails remained long and dirty. During an observation, on 5/16/2024 at 10:19 A.M., Resident 37's fingernails remained long and dirty. A record review was completed on 5/16/2024 at 9:56 A.M. for Resident 37. Diagnoses included, but were not limited to hemiplegia and hemiparesis, type 2 diabetes, major depressive disorder, dementia, and aphasia. A Quarterly Minimum Data Set (MDS) assessment, dated 3/6/2024, indicated that Resident 37 had severely impaired cognition and was dependent on staff with bed mobility, transfers, dressing, toileting, hygiene and bathing, and required a mechanical lift (hoyer) with two staff for transfers. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 with a limited range of motion received appropriate treatments and services to prevent further decrease in range of motion for 1 of 3 residents for range of motion. (Resident 46) Finding includes: During an interview and observation on 5/15/2024 at 9:35 A.M., Resident 46 indicated RN 4 is was the only nurse that put his left hand splint on him. There was no splint observed on the resident's left hand. During an observation and interview on 5/16/2024 at 10:42 A.M., the resident was awake and indicated he had not seen his nurse today. The resident did not have a splint on his left hand. During an observation on 5/17/2024 at 10:59 A.M. at 10:59 A.M., 1:18 A.M., and 2:09 P.M. Resident 46 did not have a left hand splint on. The splint was noted on the nightstand. During observations on 5/20/2024 at 9:25 A.M., 11:49 A.M., and 2:37 P.M., Resident 46's left hand splint was not on the resident's hand. The splint was observed on the top of his nightstand. During an observation on 5/21/2024 at 9:35…
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 before2024-05-21 · 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 and interview, the facility failed to ensure medications stored in the med cart were labeled according to accepted professional standards for 1 of 3 medication carts observed. (St. John's Way medication cart) Finding includes: During an observation of the medication cart on St. John's Way, on 5/20/24 at 10:16 A.M., with LPN 11, a half full bottle of milk of magnesia was found without a pharmacy label or any information to identify the resident to whom it belonged. During an interview, on 5/20/24 at 10:16 A.M., LPN 11 indicated she did not know to whom the milk of magnesia belonged. She did not know why it was there and it should not be kept in the cart. Resident medications were kept in their room in a locked cabinet. On 5/20/24 at 2:07 P.M., the Executive Director provided a policy titled, Storage and Expiration Dating of Medications, Biological's, dated 8/7/23, and indicated the policy was the one currently used by the facility. The policy included, but was not limited to, .Facility should destroy and reorder medications and biologicals with soiled, illegible,…
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 before2024-05-21 · 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 follow standards of practice for infection control to help prevent the development and transmission of communicable diseased and infections for 1 of 3 residents who received pressure ulcer care requiring enhanced barrier precautions (EBP) and 1 of 4 residents observed during medication administration. (Residents 181 and 16) Findings include: 1. During an observation, on 5/17/24 at 11:41 A.M., RN 10 was documenting on the computer immediately before donning gloves to perform a blood glucose check for Resident 181. He did not wash his hands prior to donning the gloves. He cleansed the resident's finger with an alcohol swab and fanned the area with his gloved hand. During an interview, on 5/17/24 at 11:45 A.M., RN 10 indicated he should have washed his hands before applying the gloves and did not know fanning the swabbed area was an infection control issue. 2. During an observation of wound dressing change for Resident 16 on 5/17/2024 at 1:53 P.M., LPN 9 applied alcohol based hand rub (ABHR), donned gloves 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 · Dcited before2023-05-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to assess and monitor a wound for 1 of 1 residents reviewed for skin conditions. (Resident 45) Finding includes: The record for Resident 45, reviewed on 5/22/2023 at 1:54 P.M., indicated the resident's diagnosis included, but were not limited to: hypertensive heart disorder, scoliosis, constipation, pain, hearing loss, cerospinal (sic) shunt, history of falling, unspecified severe protein, adjustment disorder and insomnia. The most recent MDS assessment, completed as a quarterly review on 4/13/2023, indicated the resident was moderately cognitively impaired and required extensive assistance of one person for dressing and personal hygiene needs. During an observation of Resident 46, on 5/18/2023 at 11:36 A.M., a moist, dark pink/red colored centered, pencil eraser sized open sore was observed on the right side of her face. The resident indicated the sore was taking a long time to heal and she tried not to pick at it. The resident was observed on 5/19/2023 to have an open, moist, pencil eraser sized wound on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the physician's order was followed regarding pressure ulcer treatment for 1 of 3 residents reviewed for pressure ulcer care. (Resident 42) Finding includes: 1. Resident 42 was admitted to the facility on [DATE] with diagnoses included, but not limited to: unspecified dementia, status post fracture of the left femur, anemia, diabetes and severe protein calorie malnutrition. A care plan, created on 3/3/2023, for Resident 42 indicated she was at risk for skin breakdown. The goal was to reduce her risks and keep her free from skin breakdown. The interventions included monitoring the skin, using lotions as needed and notifying the MD of any impairments. A change in condition nursing progress note, dated 3/8/2023 at 3:58 P.M., indicated a 3cm (centimeter) by 2.4 cm SDTI (superficial deep tissue injury) area purple and blanchable in color to the left heel. The resident complained of pain. The note indicated skin prep was ordered 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 · Dcited before2023-05-23 · 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, record review and interview, the facility failed to ensure narcotics were stored appropriately and failed to ensure liquid medications were dated when opened for 1 of 1 narcotic storage areas and 1 of 12 residents whose medications were observed. (Rehab Narcotic Drawer and Resident 202) Findings include: 1. During a random observation, on 5/22/2023 at 3:14 P.M., the narcotic storage cart was observed to be unlocked. During an interview, on 5/22/2023 at 3:20 P.M., LPN 2 indicated the cart should have been locked. 2. During a medication storage observation, on 5/22/2023 at 3:28 P.M., in Resident 202's medication storage area the following was noted: -An opened and undated bottle of Latanoprost eye drops. -An opened and undated bottle of Dorzolamide 2% eye drops. -An opened and undated bottle of Debrox Ear drops. During an interview, on 5/22/2023 at 3:30 P.M., LPN 2 indicated the opened bottles should have been dated. On 5/23/2023 at 11:46 P.M., the Director of Nursing provided the policy titled,Storage and Expiration Dating of Medications and Biological's, with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to TRINITY HEALTH — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.3 | -1.3 vs chain |
| Health inspection | 2 of 5 | 3.0 | -1.0 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 3.7 | -1.7 vs chain |
The other 18 homes this chain runs (chain average 3.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SMITH, SCOTT | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| SPRUNGER, KYLE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2018 |
| WHEELER, DANE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 08/01/2017 |
| TRINITY CONTINUING CARE SERVICES INDIANA INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2017 |
| ANDERSON, RAY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| BATTJES, ABIGAIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/26/2022 |
| BORNE-BAUMAN, CANDICE | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 01/01/2019 |
| BOWENS, MARCUS | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2022 |
| CARTER, BENJAMIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| DRAKE, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| FLUECKIGER, RUSSELL | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 08/01/2017 |
| ISACKSEN, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| LEHMAN, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 07/14/2020 |
| MACKLIN, LARRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 08/01/2017 |
| MCINTIRE, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | since 01/01/2019 |
| MOORE, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| ROTH, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| SEPPALA, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2025 |
| TRINITY CONTINUING CARE SERVICES | Organization | ADP OF THE SNF | since 08/01/2017 |
CMS files one row per role, so the 29 rows in the source record cover these 19 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.
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.
This home reported $873K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 2024. 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, FY2024). 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 155506. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-28, 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 →
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