Providence Health Care Center
1 Sisters Of Providence, St Mary of the Woods, IN 47876 · Non profit - Church related · 70 certified beds · (812) 535-4001 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — 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)
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 | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 fell from 3 to 1 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 | 7.8% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.2% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.4% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.2% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.7% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.0% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.7% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.4% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.7% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.6% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 26.7% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.8% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.48 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.28 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.7% 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 255 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 29.5% 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 156 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 59.7%CMS range 53.2–63.6 | 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 | 13.2%CMS range 10.3–16.3 | 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 | 29.5% | 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 | 39.7% | 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 | 37.2% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 4.1–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 70 beds and averages 63.3 residents a day — about 90% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.53 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.35 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 4.27 hrs/resident/day on weekends vs 5.51 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 1.77 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 unchanged from the previous inspection. 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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2025-05-16 · 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, interview, and record review, the facility failed to ensure that staff assessed a resident with a pressure ulcer and implemented treatments which resulted in harm due to the pressure ulcer worsening from a stage 1 (non-blanchable red intact skin) to a stage 3 (full thickness skin loss where fat tissue may be visible) before pressure ulcer assessments and treatments were started for 1of 2 residents reviewed for pressure ulcers (Resident 16). Findings include: On 5/12/25 at 11:23 a.m., during an initial observation and interview Resident 16 indicated he had a sore area on his bottom. On 5/14/25 at 8:46 a.m., the medical record of Resident 16 was reviewed. The resident was admitted to the facility on [DATE], diagnosis included but were not limited to myocardial infarction type 2 (occurs when there's an imbalance between the heart's oxygen supply and demand, leading to injury or death of heart muscle tissue), chronic respiratory failure with hypoxia (the lungs are unable to adequately transfer…
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 before2026-01-16 · 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 record review and interview, the facility failed to ensure pressure ulcers (skin and tissue damage caused by prolonged pressure) were treated timely after admission for 3 of 3 residents reviewed for pressure ulcers (Residents B, C, and D). Findings include:1. Resident B's record was reviewed on 1/15/26 at 11:16 a.m. Census information indicated the resident was admitted to the facility on [DATE]. A pre-admission screening tool, dated 10/30/25, indicated the resident had a wound to the right buttock. An admission Minimum Data Set (MDS) assessment, dated 11/10/25, indicated the resident had an unhealed pressure ulcer. Hospital discharge instructions, signed 11/3/25, indicated, .Wound care-Mepilex [soft foam dressing] on coccyx [tailbone] wound, barrier cream. An admission skin assessment, dated 11/3/25, indicated the resident had a red, scabbed area on the upper mid back. The assessment lacked documentation there was a wound to the buttocks or coccyx. A wound Nurse Practitioner (NP) note, dated 11/5/25,…
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 before2025-05-16 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication was labeled properly and the facility failed to ensure expired medication was disposed of for 2 of 2 medication storage rooms reviewed for medication storage (Resident 49). Findings include: 1. On [DATE] at 10:00 a.m., the north hall medication storage room refrigerator contained an opened and undated multi use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution. During an interview, on [DATE] at 10:02 a.m., Registered Nurse (RN) 7 indicated she was not aware of how long the Aplisol was good for once opened, but she was aware it should be dated once opened. 2. On [DATE] at 10:11 a.m., the south hall medication storage room refrigerator contained an opened bottle of Mary's Magic Mouthwash (a compounded oral rinse used to treat mouth sores and pain, often associated with cancer treatment). The bottle contained a label that indicated it was for Resident 49 and was…
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 before2025-05-16 · 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 A. Based on interview and record review, the facility failed to prevent a delay in treatment after a fall with fracture for 1 of 3 residents reviewed for accidents (Resident 27). B. Based on record review and interview, the facility failed to ensure a treatment order was stopped or clarified after 60 days for 1 of 5 residents reviewed for unnecessary medications (Resident 30). Findings include: A. During an interview, on 5/12/25 at 9:40 a.m., Resident 27's Health Care Representative indicated the resident fell in December 2024 and fractured her hip. They thought the resident was not injured, so she was not sent to the hospital right away. The Health Care Representative indicated she normally placed the resident's walker next to her bed before she left in the evening, but the day the resident fell she had not ensured the walker was next to the resident's bed before she left. The Health Care Representative indicated since the resident's fall she always made sure the resident's walker was next to her bed before…
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 before2025-05-16 · 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 ensure a root cause analysis was completed and an intervention put in place after falls for 1 of 3 residents reviewed for accidents (Resident 27). Findings include: During an interview, on 5/12/25 at 9:40 a.m., Resident 27's Health Care Representative indicated the resident fell in December 2024 and fractured her hip. They thought the resident was not injured, so she was not sent to the hospital right away. The Health Care Representative indicated she normally placed the resident's walker next to her bed before she left in the evening, but the day the resident fell she had not ensured the walker was next to the resident's bed before she left. The Health Care Representative indicated since the resident's fall she always made sure the resident's walker was next to her bed before leaving for the evening. Resident 27's record was reviewed on 5/15/25 at 9:11 a.m. A significant change Minimum Data Set (MDS) Assessment, dated 3/14/25, indicated the resident had a severe cognitive impairment and had occasional urinary…
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 · D2025-05-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a semi-flexible plastic tube with one end inserted into the bladder) which is attached to a urinary drainage bag (a bag that collects urine) did not touch the floor for 1 of 1 residents reviewed for catheter care (Resident 52). Findings include: On 5/9/25 at 11:18 a.m., during an initial observation and interview Resident 52 indicated he was not sure why he had a catheter, but he thought it may be due to prostate cancer. Observed the resident sitting in a wheelchair in the main dining area. The catheter bag was attached to the bar under the wheelchair and was touching the floor. On 5/9/25 at 12:11 p.m., observed Resident 52 propelling self in wheelchair. Observed catheter bag dragging on the floor under the wheelchair. On 5/13/25 at 9:52 a.m., during interview with Registered Nurse (RN) 5 she indicated the catheter bag should never touch the floor and when she was positioning a drainage bag…
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 before2025-05-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure proper cleaning and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Residents 50 and 270). Findings include: 1. During an observation, on 5/15/25 at 8:53 a.m., Registered Nurse (RN) 8 administered a breathing treatment to Resident 50. The nurse removed the breathing treatment mask from the resident at 9:08 a.m., she opened the chamber (this holds the liquid medication) and dumbed out the remaining medication left in the chamber into the trash can and returned the respiratory mask and tubing to a clear plastic bag. Resident 50's record was reviewed on 5/15/25 at 11:07 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a lung disease characterized by airflow obstruction, making it difficult to breathe) with acute exacerbation (a period where COPD symptoms worsen significantly beyond the usual day-to-day experience)…
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 · E2024-03-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure beard restraints were worn in the kitchen serving area (on the skilled unit) and in the main kitchen food prep area for 2 of 2 kitchen observations. Findings include: 1. During an observation in the kitchen serving area (located on the skilled unit), on 3/11/24 at 11:40 a.m., the Dietary Director was placing whip cream on top of the vanilla and chocolate shakes. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. 2. During an observation in the kitchen serving area, on 3/11/24 at 11:43 a.m., the Dietary Director was placing cinnamon pita chips onto 16 dessert plates from a serving pan. The Dietary Director was not wearing a beard restraint and his facial hair was exposed. During an interview, on 3/11/24 at 11:50 a.m., Dietary Director indicated he should have worn a beard restraint while prepping food that was to be served to the residents. During an interview, on 3/11/24 at 11:54 a.m., Dietary aide 5 indicated when you have facial hair it was to be covered 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.
- Potential for harm · Dcited before2024-03-18 · 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 accurately assess and document impairments in skin for 1 of 1 residents reviewed for skin impairments (Resident 15). Finding includes: During an observation, on 3/12/24 at 10:21 a.m., Resident 15 was sitting in her wheelchair in her room. The resident indicated she had a sore area behind her right ear, and it had been there for a long time. The resident indicated she thought it was caused by her glasses. A couple of scabbed areas were noted behind her right ear underneath where her glasses touched her skin. Excoriated skin tissue was noted as well. The resident also had a scabbed area on her cheek and nose and indicated she was told they were skin cancer spots. Resident 15's record was reviewed on 3/15/24 at 1:36 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), disorder of the skin and subcutaneous tissue (medical condition that occurs in 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 · D2024-03-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to address a significant weight discrepancy for 1 of 2 residents reviewed for nutrition (Resident 57). Finding includes: Resident 57s record was reviewed on 3/15/24 at 9:08 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified protein-calorie malnutrition (a disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). An admission Minimum Data Set assessment, dated 2/21/24, indicated the resident required supervision or touching assist with eating, and had no swallowing or nutrition disorders noted. The assessment lacked documentation of weight gain or loss. A physician's order, dated 2/14/24, indicated weekly weights and to review weights and report significant changes to physician. A physician's order, dated 2/16/24, indicated the resident was…
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 before2024-03-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask was stored properly when not in use and an self administration assessment was completed for 1 of 2 residents reviewed for respiratory care (Resident 113), and failed to ensure oxygen orders were in place for 1 of 2 residents reviewed for respiratory care (Resident 39). Findings include: 1. During the initial pool observation, on 3/11/24 at 11:24 a.m., Resident 113's nebulizer mask was observed un-bagged and sitting on his bedside table. At the same time, the resident indicated he had used the nebulizer earlier that morning and that it should have been placed into a bag, but the nurse had not been in since he had used the nebulizer. During a random observation, on 3/14/24 at 10:09 a.m., the resident's nebulizer mask was observed un-bagged and sitting on his bedside table. During a random observation, on 3/14/24 at 1:42 p.m., the resident's nebulizer was sitting, un-bagged on his bedside table. At the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2024-03-18 · 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, observation, and interview, the facility failed to ensure physician orders were followed for 2 of 5 residents reviewed for unnecessary medication review (Residents 35 and 37). Findings include: 1. On 3/13/24 at 11:00 a.m., the medical record of Resident 35 was reviewed. Resident 35's diagnoses on the resident's profile included but were not limited to, type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), Atherosclerosis (a thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), Hyperlipidemia (high cholesterol) is an excess of lipids or fats in your blood), Atrial Fibrillation (Fibrillation an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart), Hypertension (HTN) (also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure). Physician Orders include but are not limited to: Lisinopril Tablet 40 mg (milligrams) give 1 tablet by mouth one time a day for HTN hold…
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 · D2024-03-18 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for the resident to call for staff assistance when needed for 1 of 24 residents rooms observed for call light availability (Resident 34). Findings include: On 3/12/24 at 9:36 a.m., observed the resident lying in bed. The call light was hanging on the wall several feet from the resident. On 3/13/24 at 10:51 a.m., observed the resident sleeping in her bed. The call light was not within reach of the resident. The call light was clipped to the wall several feet from the resident. On 3/13/24 at 10:58 a.m., during an interview with Certified Nurse Aide (CNA) 10, she indicated she did not know why the call light was not on the bed next to the resident. She acknowledged it should always be within reach for the resident to call for assistance. On 3/13/24 at 11:02 a.m., during an interview with Registered Nurse (RN) 8, she indicated the call light must be within reach. It was the last thing the staff check before they leave the resident's room. On 3/14/24 at 11:34 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-21 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor a resident's request to be transferred to the hospital related to increased pain of a right femur fracture and without her signing a document saying the transfer was against medical advice (AMA) and without being informed her AMA transfer may result in the facility not allowing her to return for 1 of 3 residents reviewed for transfer and discharge (Resident B). Findings include: During a confidential phone interview, on 8/17/23 at 8:55 a.m., Resident B's friend indicated she had visited the resident on 8/15/23 at the facility. The resident informed her friend that she had a fractured right femur. She was unable to explain how the fracture happened. The friend indicated the facility had always called her with any condition changes until this one. She was not notified of the fracture. She observed the resident's external rotation to her right leg during this visit. The friend indicated the rotation had never been noted before. The friend had just…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-21 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to accept a resident back from the hospital without a 30-day discharge notice for 1 of 3 residents reviewed for transfer and discharge (Resident B). Findings include: During an interview, on 8/17/23 at 2:45 p.m., Resident B indicated she had increased pain in her right leg related to a fracture and she wanted to be transferred to the hospital for further assistance. Cross reference F622 and F684. During an interview, on 8/17/23 at 3:00 p.m., the Administrator indicated Resident B was going to be sent out to the hospital against medical advice (AMA) because it was her request to be sent out. The Medical Director did not feel her transfer was medically necessary. During an interview, on 8/17/23 at 4:05 p.m., Resident B's emergency contact individual indicated she was not made aware of the resident not being allowed to return to facility once discharged from the hospital by any facility personnel when the resident was sent to the hospital per the resident's request. During an interview, on 8/18/23 at 3:15 p.m., the Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and document a baseline for a new injury, failed to report an unknown injury for orders and treatment, and failed to follow up timely on an external rotation of the right leg resulting in the delay of care for 1 of 3 residents reviewed for quality of care (Resident B). Findings include: During a confidential phone interview, on 8/17/23 at 8:55 a.m., Resident B's friend indicated she had visited the resident on 8/15/23 at the facility. The resident informed her friend that she had a fractured right femur. She was unable to explain how the fracture happened. The friend indicated the facility had always called her with any condition changes until this one. She was not notified of the fracture. She observed the resident's external rotation to her right leg during this visit. The friend indicated the rotation had never been noted before. The friend had just been in the facility at the end of July 2023, and it was not seen at that time. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-02-01 · 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
A. Based on interview and record review, the facility failed to address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions of the Resident Council and the facility's grievance log. This potentially affected 63 of 63 residents who resided in the facility. B. Based on observation, interview, and record review, the facility failed to ensure a grievance provided during resident council was resolved for 1 of 1 resident reviewed for grievances (Resident 40). Findings include: A1. Resident Council minutes were provided by the Activity Director (AD) on 1/24/23 at 10:28 a.m. The minutes indicated the following concerns by the Resident Council: a. Cold food temperatures of the residents' meals b. Call lights taking too long to be answered by staff During the Resident Council meeting, on 1/26/23 at 9:30 a.m., the residents indicated the facility had not acted promptly upon the grievances of the cold food temperatures of the residents' meals and the call lights taking too long to be answered by staff. During an interview with the Activities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 an effective fall management program and failed to ensure fall interventions were personalized, implemented, and care planned for 4 of 4 residents reviewed for accidents (Residents 36, 31, 40, and 35). Findings include: 1. During an initial pool interview on 1/24/23 at 11:16 a.m., Resident 36 indicated she had multiple falls, but she was not sure when the last fall had occurred. Pointing to her head, she indicated she had pain in a bump on the back of her head and on her leg. The resident's private bathroom was observed to have pieces and strips of toilet paper on the floor around the toilet, and a clean brief on the sink with pieces torn out of it. Resident 36's record was reviewed on 1/27/23 at 1:24 p.m. Diagnoses on Resident 36's profile included, but were not limited to, history of falls, hemiplegia and hemiparesis (paralysis of one side) of left dominant side, anxiety disorder, age-related debility, difficulty walking, 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 · E2023-02-01 · 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 ensure the temperature and palatability of food served, for 1 of 1 test tray reviewed for temperature and palatability. This had the potential to effect 59 of 59 residents who received food from the kitchen. Findings include: During an interview, on 1/23/23 at 12:10 p.m., Resident 27 indicated she ate meals in her room and the food was often not hot enough. During an interview, on 1/24/23 at 10:50 a.m., Resident 111 indicated she ate meals in her room and the food was cold when she received the meal tray. During an interview, on 1/24/23 at 10:49 a.m., Resident 25 indicated he ate meals in his room and the food was not as warm as it could be. Resident Council minutes were provided by the Activity Director (AD) on 1/24/23 at 10:28 a.m. The minutes indicated the resident group had voiced multiple concerns of cold food temperatures of the residents' meals. During an interview with the Activities Director (AD), on 1/26/23 at 10:12 a.m., she indicated she took minutes for the Resident Council meetings and then…
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 · D2023-02-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 ensure resident shower choices were met for 1 of 24 residents reviewed for choices (Resident 25). Findings include: During the initial pool interview, on 1/24/23 at 10:50 a.m., Resident 25 indicated his preference was to receive at least 1 shower a week but had only been getting one every-other-week. Resident 25's record was reviewed on 1/30/23 at 2:42 p.m. The profile indicated the resident had been admitted to the facility on [DATE], for diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [a state in which oxygen is not available in sufficient amounts at the tissue level]) and acute kidney failure (when the kidneys suddenly become unable to filter waste products from your blood). A quarterly Minimum Data Set (MDS) assessment, dated 12/12/22, indicated the resident had no cognitive deficit and required physical help in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure nail care was provided to a dependent resident for 1 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Resident 50). Finding includes: On 1/23/23 at 11:57 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/24/23 at 10:11 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/25/23 at 1:31 p.m., Resident 50 was observed, with long, untrimmed fingernails with dark debris underneath the fingernails on bilateral (both) hands, while lying in bed, feeding himself from a bedside table. On 1/26/23 at 10:57 a.m., Resident 50 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/27/23 at 11:25 a.m., Resident 50 was observed 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.
- Potential for harm · Dcited before2023-02-01 · 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 interview, the facility failed to ensure pharmacy recommendations were acted upon by the physician in a timely manner and that the physician provided rationale for decisions made on pharmacy recommendations, for 2 of 5 residents reviewed for unnecessary medications (Residents 21 and 35). Findings include: 1. Resident 21's record was reviewed on 1/26/23 at 11:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 5 chronic kidney disease (when the kidneys are getting very close to failure or have already failed) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). An annual Minimum Data Set (MDS) assessment, dated 12/6/22, indicated the resident had no cognitive deficit, received routine pain medications, and received dialysis services. A physician's order, dated 11/30/22, indicated atorvastatin calcium tablet (drug used to lower the amount of cholesterol in the blood), 20 milligrams (mg). Give 1 tablet, by mouth, at bedtime. 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 · D2023-02-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 record review and interview, the facility failed to ensure pharmacy recommendation were reviewed and addressed by the physician for 2 of 5 residents reviewed for unnecessary medications (Residents 2 and 21). Findings include: 1. Resident 2's record was reviewed on [DATE] at 1:59 p.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), and mood disorder due to a known physiological condition (when various physical diseases or conditions create some form of mental health issue). An annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had severe cognitive deficit and received antispychotic, antidepressant and antianxiety medications. On [DATE] at 9:50 a.m., the Director of Nursing (DON) provided pharmacy recommendations, for 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 before2023-02-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications, biologicals, and feeding tube formulas were labeled, stored, and destroyed according to policy for 1 of 4 medication carts observed, and 1 of 2 medication rooms observed for medication and biological storage. Findings include: 1a. On [DATE] at 10:50 a.m., observation of the rehabilitation unit medication room with Registered Nurse (RN) 19, the following was observed, a. A plastic bin containing 32 cartons of Perative 1.5 cal (enteral formula) with an expiration date of [DATE]. b. A plastic bin containing 10+ bags of Peptamen 1.5 (for tube feeding) with an expiration date of 12/2022. c. A plastic bin containing 20 + cartons of Peptide 1.5 (Kate's Farm plant based formula) with an expiration date of [DATE]. A medication cart was also observed to have an opened and unlabeled tube of Lidocaine with Prilocaine (topical antiseptic) 2.5%-2.5% cream laying on top a roll of Acetaminophen 325 mg tablet packets for Resident 107.…
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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-06-17 for 43 days
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PUTNAM COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2013 |
| BRAY, ARNOLD | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| FRY, JANICE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| HEADLEY, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| LANDRY, KEITH | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2020 |
| LEWIS, KATRINA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 12/21/2022 |
| UNDERWOOD, WENDELL | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 05/20/2024 |
| WOOD, MARK | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 08/05/2024 |
| MANN, ROBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2016 |
| O'HAIR, DENNIS | Individual | CORPORATE DIRECTOR | — | since 12/01/2013 |
| SILLERY, DEBRA | Individual | CORPORATE DIRECTOR; TRUSTEE OF THE SNF | — | since 01/03/2026 |
| PROVIDENCE HEALTH CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/01/2013 |
| HENMAN, BRANDON | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/29/2023 |
| HOLLOWELL, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/30/2022 |
| KIGORWE, KENNETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/02/2024 |
| KLINGEL, MARY BETH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/30/2022 |
| LYNCH, MANDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/25/2016 |
| MILLER, MARCIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/30/2016 |
| ORRINGTON-MYERS, JANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/29/2023 |
| PARKER, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/22/2017 |
| RODGERS, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/29/2023 |
| WEATHERFORD, DENNIS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/18/2012 |
| WELCH, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/21/2018 |
| WILKINSON, DENISE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/16/2024 |
| SISTERS OF PROVIDENCE | Organization | ADP OF THE SNF | — | since 09/01/2023 |
CMS files one row per role, so the 36 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 $1.1M 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155802. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.