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Brickyard Healthcare - Lincoln Hills Care Center

402 19th Street, Tell City, IN 47586 · For profit - Corporation · 86 certified beds · (812) 547-3427 Medicare & Medicaid certified

Call the home — (812) 547-3427 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 26 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
421 7th St · (812) 547-9663 · Call to confirm hours
Pharmacy
225 12th St · (800) 746-7287 · Call to confirm hours
Grocery
213 East Highway 66 · (812) 547-5601 · Call to confirm hours
Park
Franklin St · (812) 547-8802 · Typically dawn to dusk
Place of worship
16th and Franklin · (812) 827-0074

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.1%11.0%15.4%better
Long-stay residents who lose too much weight3.4%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%1.1%2.0%better
Long-stay residents with depressive symptoms31.6%25.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.9%3.9%3.3%better
Long-stay residents whose ability to walk worsened12.6%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication54.4%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers1.0%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control27.5%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.0%13.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine88.5%79.0%79.4%better
Long-stay hospitalizations per 1,000 resident days1.531.611.67typical
Long-stay outpatient ER visits per 1,000 resident days1.811.441.80typical

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.

36.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.7%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
0.77U.S. median 0.31
Therapy hours / resident / day
0.43hours / resident / day
Physical therapy
0.33hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.77 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.7%CMS range 24.3–55.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 7.8–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified56.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 3.7–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.88
RN hours/ resident / day
0.94
LPN hours/ resident / day
1.70
Aide hours/ resident / day
3.51
Total nurse hours/ resident / day
0.53
RN hoursweekends
37.9%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 61.3 residents a day — about 71% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 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 3.00 hrs/resident/day on weekends vs 3.72 on weekdays — 19% thinner on weekends. RN hours go from 1.02 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% 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

5
deficiencies at the latest standard inspection (2026-04-16)
5
at the previous standard inspection (2025-02-21)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · E2026-04-16 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 privacy was provided for the residents for 6 of 6 random observations on 2 of 3 halls. Resident information was visible on the computer screens in Hall A and Hall B and staff did not knock prior to entering a resident room. (Hall A, Hall B, Resident D)Findings include:1. On 4/9/26 at 8:37 A.M., Hall A's Medication Cart was observed in the hallway with resident information (resident name, picture, and room number) visible on the computer screen without staff present at the computer.2. On 4/13/26 from 6:13 A.M. to 6:19 A.M., Hall A's Medication Cart was observed in the hallway with resident information (resident name, picture, and room number) visible on the computer screen without staff present at the computer.3. On 4/13/26 from 6:24 A.M. to 6:29 A.M., Hall B's Medication Cart was observed in the hallway with resident information (resident name, picture, and room number) visible on the computer screen without staff present at the computer.4. On 4/13/26 at 6:49 A.M., Licensed Practical Nurse (LPN) 22 did…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-16 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 physician orders were followed for 2 of 5 residents reviewed for unnecessary medications, and an insulin pen was not primed for 2 of 2 insulin administration observations. A blood pressure medication was not held as indicated in the order parameters, and a resident's blood sugar was not re-checked as ordered. (Resident 5, Resident 4, Resident D)Findings include:1. On 4/14/26 at 9:46 A.M., Resident 5's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent quarterly Minimum Data Set (MDS) assessment, dated 2/15/26, indicated no cognitive impairment and 7 of 7 days of insulin injections. Current physician orders included, but was not limited to: Insulin Aspart FlexPen 100 unit/ml (milliliter), Inject as per sliding scale: if 100 - 150 = 4 units <100 eat small snack and recheck blood sugar in 15 mins then administer insulin; 151 - 175 = 5 units; 176 - 200 = 6 units; 201 - 225 = 7 units; 226 - 250 = 8 units; 251 - 300 = 9 units; 301 - 325 = 10 units;…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-16 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents were provided activities to meet the interests of and well-being of each resident for 1 of 1 weekends reviewed for activities.Findings include:During the resident council meeting on 4/13/26 at 11:20 A.M., residents indicated they don't have activities on the weekends. One resident indicated he can't get around to host them or even tell people there are any. On 4/14/26 at 9:55 A.M., an activity calendar hanging in Hall 2 was reviewed and indicated the following dates and activities to be held:Saturday, 4/11/26 at 10:00 A.M. magnet game, 11:00 A.M. mealtime memories, 1:00 P.M. daily chronicles, 1:30 P.M. music and conversationsSunday, 4/12/26 at 10:00 A.M. tv time, 11:00 A.M. mealtime music, 1:00 P.M. daily chronicles, 1:30 P.M. friendly conversations, 3:00 P.M. church servicesTuesday, 4/14/26 at 10:00 A.M. nails on station 4. On 4/14/26 at 10:00 A.M., the Activity Manager was in the dining room sitting at a table with three male residents talking.During an interview on 4/14/26 at 9:45 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 2 ofv4 observations of medication administration. Gloves were not changed and hand hygiene was not performed between dirty and clean tasks during perineal care. The nurses dropped medications onto the medication cart, picked them up with their bare hand, and administered it to the residents. (Resident C, Resident B, Resident D, Resident G). Findings include:1. On 4/13/26 at 6:13 A.M., Licensed Practical Nurse (LPN) 5 was observed preparing medications for Resident G. When she poured the prepackaged medications into the medication cup, one pill fell onto the medication cart. LPN 5 picked it up with her bare hand and put it into the medication cup. LPN 5 took the medications into Resident G's room and administered them to the resident. 2. On 4/13/2026 at 6:49 A.M., LPN 22 was observed preparing medications for Resident D. When she poured the prepackaged medications into the medication cup, one pill…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-16 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were properly assessed for self administering medications for 2 of 2 random observations. A resident had a medication cup containing medications sitting on her bedside table and a resident was left alone with his medications. (Resident 14, Resident G)Findings include:1. On 04/13/26 at 6:40 A.M., Licensed Practical Nurse (LPN) 22 went to check a blood sugar on Resident 14's roommate. Resident 14 was laying in the dark, in her bed, with her eyes closed. A medication cup containing medications was on her bedside table. On 4/13/26 at 8:07 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, chronic heart failure, stroke, diabetes mellitus type II, atrial fibrillation, and bipolar disorder.The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/5/26, indicated Resident 14's cognition was intact.The clinical record lacked an order, care plan, and assessment of the resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-21 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 qualified Infection Preventionist (IP) was working at least part-time at that facility. Documentation was not available to show how many hours were dedicated to the infection control program by the Director of Nursing (DON) who was certified and Registered Nurse (RN) 7 who had not completed training. Finding includes: During an interview on 2/21/25 at 11:34 A.M., the DON indicated she was the Infection Preventionist (IP) covering the DON position and the IP position for the last two months. She indicated RN 7 was assisting and would be the IP after completing training but was not certified at that time. The DON indicated she was the full time DON and did not have documentation of the hours she and RN 7 spent on IP duties. On 2/21/25 at 1:50 P.M., the DON provided an undated Infection Preventionist policy that indicated 1. The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-21 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 an Registered Nurse (RN) for 8 consecutive hours, seven days a week, for 4 of 26 days reviewed. Finding includes: On 2/20/25 at 2:30 P.M., review of weekend staffing from 7/1/24 thru 9/30/24 due to Payroll Based Journal (PBJ) triggering for low weekend staffing indicated there was no RN coverage for 8 consecutive hours on Sunday, 7/21/24, Sunday, 8/4/24, Saturday, 8/31/24, and Saturday, 9/28/24. On Sunday, 7/21/24, there was RN coverage for 4.03 hours. On Saturday, 9/28/24, there was RN coverage for 4 hours. On Sunday, 8/4/24 and Saturday, 8/31/24 there was no RN coverage. During an interview on 2/21/25 at 12:12 P.M., Director of Nursing (DON) indicated they tried their best to have RN coverage every day. They had the wound nurse and Unit Manager help cover on the weekends. On 1/21/25 at 1:50 P.M., the DON provided an undated nursing Services and Sufficient Staff policy which indicated .8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-21 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 respect and dignity was provided to a totally dependent resident. The resident's call light was not within reach for 1 of 16 residents reviewed for call lights. A resident's call light was not within his reach, staff did not respond promptly when he yelled for help and he was not able to use his call light to alert staff when he needed help. (Resident 47) Finding includes: On 2/17/25 at 11:59 A.M., Certified Nurse Aide (CNA) 9 brought Resident 47 his lunch, set it up, and left the room with call light pad on left side of pillow at head of bed. Resident 47 could not find it and was not able to reach it. At that time, he indicated the call light pad was not always where he could reach it, especially on the night shift. On 2/18/25 at 1:27 P.M., Resident 47 was observed hollering, Nurse's aide, I need your help finding something please multiple times. The nurse was at medication cart by the nurse's station. Two CNAs were observed to walk down the hall past his room without stopping to check on him. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure physician orders and care plan interventions were followed for 2 of 5 residents reviewed for unnecessary medications. A resident's oxygen concentration was set incorrectly, the bedside table was not locked, and medications were given for blood pressure without checking the blood pressure prior to administration of the medication to ensure resident was within the perimeters to give the medication. (Resident 38, Resident 56) Findings include: 1. During an observation on 2/17/25 10:09 A.M., Resident 38 was sitting on the side of her bed coloring and wearing oxygen per nasal cannula. The oxygen concentrator was set at 2 liters per minute (LPM). During an observation on 2/18/25 8:55 A.M., Resident 38 was sitting on the side of her bed and the bedside table was not locked. She was wearing oxygen per nasal cannula at 2 liters per minute (LPM). During an observation on 2/20/25 8:25 A.M., Resident 38 was laying in a lowered bed and the bedside table was not locked. During an observation on 2/21/25 at 10:00…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-21 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident's care plan was revised for 1 of 5 residents reviewed for unnecessary medications. A resident's care plan was not reviewed or revised to remove areas of concern that were no longer relevant to the resident's care, i.e. antibiotic use, fluid restriction, and daily weights. (Resident 38) Finding includes: On 2/19/25 at 9:10 A.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), hypertension, pneumonia, unsteadiness on feet, and other fractures of cervical (neck)vertebra and left hand. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/24/25, indicated Resident 38's cognition was moderately impaired, was a substantial/maximum assist (staff performed over half the effort) for bed mobility, transfers, toileting, took a diuretic, and was not monitored for fluid intake. Current Physician's Orders included, but were not limited to, the following: monthly weight 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2025-01-28 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 a resident's code status was known during an emergency situation for 1 of 2 residents reviewed for death. During a change in condition and prior to starting Cardio-Pulmonary Resuscitation (CPR), a resident's physician was notified and informed of the resident's code status as Do Not Resuscitate (DNR) before staff realized the resident's full code status. (Resident D) Finding includes: The record review was started on, [DATE] at 11:40 A.M., indicated Resident D's diagnoses included but were not limited to, aortic valve disorder, pulmonary disease, type II diabetes, and heart failure. A signed Indiana Physician Orders for Scope of Treatment (Post) form, dated [DATE] indicated Resident D had chosen to receive resuscitation / CPR if the resident has no pulse and is not breathing. A physician's order included, Full Code (started [DATE]). Resident D's nurse's progress notes included, but were not limited to: [DATE] at 5:39 P.M. - Change of Condition -…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-22 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure MDS (Minimum Data Set) Assessments were accurate for 4 of 19 residents in the initial sample. The MDS Assessment failed to indicate residents had a PASRR (preadmission screening and resident review) II. The MDS failed to indicate a resident received hospice services. (Resident 1, Resident 31, Resident 39, Resident 51) Findings include: 1. On 4/17/24 at 8:43 A.M., Resident 39's clinical record was reviewed. Diagnosis included, but were not limited to, epilepsy, developmental disorder of speech and language, spastic quadriplegic cerebral palsy, and severe intellectual disabilities. The most recent Annual MDS, dated [DATE], indicated Resident 39 did not have the following: .currently considered by the state level II PASRR [preadmission screening and resident review] process to have serious mental illness and/or intellectual disability or a related condition. On 11/5/21 a PASRR level II was completed by [name of company] and indicated the PASRR 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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 observation, interview, and record review, the facility failed to ensure palatable food was served for 1 of 1 meal tray reviewed. Finding includes: During the course of the survey, the following anonymous resident interviews were obtained: The food is horrid and temperatures are not what they should be. Half of the food is not worth eating. On 4/16/24 at 11:03 A.M., during the resident council meeting, the following anonymous resident interviews were obtained: We (the residents) have complained about the food but were told it was because corporate did the menus and restricted what the facility could have a choice of. Everything is overcooked and dry. On 4/22/24 at 8:10 A.M., a meal tray was obtained that contained oatmeal, a sausage patty, and a piece of french toast. All food items were bland and tasteless. The french toast had hard edges. On 4/22/24 at 9:54 A.M., the Dietary Manager indicated there had been no complaints about the taste of the food to her knowledge. She indicated sometimes french fries and french toast were troublesome due to not being steam table…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident was treated with dignity for 2 of 2 residents reviewed for choices. One resident continued to receive styrofoam dishes after a suicide watch was discontinued. A CNA (Certified Nursing Aide) was standing up to feed a resident and asked the nurse What do you want me to do with her? when she was done. (Resident 37, Resident 26) Findings include: 1. On 4/17/24 at 8:38 A.M., Resident 37 was observed sitting on the side of her bed while staff were putting TED (Thrombo-Embolic Deterrent) hose on her legs. Her breakfast tray containing Styrofoam dishes was sitting on the bedside table. On 4/17/24 at 8:53 A.M., Resident 37's clinical records were reviewed. Diagnosis included, but were not limited to depression and anxiety. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 1/19/24 indicated Resident 37 was cognitively intact. Progress Notes: 4/16/2024 8:52 A.M. General Note Note Text: suicide watch over this…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 notify the ombudsman of transfer or discharge for 3 of 4 residents reviewed for hospitalizations. (Resident 23, Resident 25, Resident 35) Findings include: 1. On 4/16/24 at 11:02 A.M., Resident 23's clinical record was reviewed. Resident 23 was sent to the hospital on 4/9/24. Resident 23's clinical record lacked documentation that notification of the hospitalization was sent to the ombudsman. 2. On 4/16/24 at 10:44 P.M., Resident 35's clinical record was reviewed. Resident 35 was sent to the hospital on [DATE]. Resident 35's clinical record lacked documentation that notification of the hospitalization was sent to the ombudsman. 3. On 4/17/24 at 10:30 A.M., Resident 25's clinical record was reviewed. Diagnoses included, but was not limited to, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and diabetes mellitus type II. Progress Notes indicated Resident 25 was hospitalized [DATE] through 7/10/23. A completed Notice of Transfer or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure care was provided in accordance with the written plan of care for 2 of 2 residents reviewed for smoking. A resident smoked in a non-designated smoking area. Staff failed to lock up residents smoking materials.(Anonymous Resident, Resident 1) Findings include: 1. During an interview on 4/17/24 7:37 A.M., an Anonymous Resident indicated cigarettes are kept in the resident's room and supervision is not needed to smoke. During an observation on 4/19/24 at 1:42 P.M., an Anonymous Resident was unsupervised on the front porch. At that time, the resident lit a cigarette. On 4/16/24 at 10:30 A.M., the Resident's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus, hypertension, seizure disorder, and chronic obstructive pulmonary disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 3/10/24, indicated the Anonymous Resident was cognitively intact and had shortness of breath. A current smoking and safety assessment, dated 3/6/24, indicated that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-22 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care plan conferences quarterly for 2 of 5 residents reviewed for unnecessary medications. (Resident 35, Resident 52) Findings include: 1. On 4/18/24 at 12:50 P.M., Resident 35's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and anxiety disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/11/24, indicated a severe cognitive impairment. Resident 35's most recent care plan meeting was held 12/13/23. Resident 35's clinical record lacked a care plan meeting since 12/13/23. On 4/15/24 at 12:39 P.M., the Administrator indicated there was no current Social Services Director (SSD) as the most recent one quit in January 2024. She indicated the Activities Director was assuming the role of care plan meeting coordinator until a new SSD could be found. 2. On 4/17/24 at 11:00 A.M., Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of existing pressure ulcers for 2 of 2 residents reviewed for pressure ulcers. Residents admitted with a deep tissue injury (DTI) and incontinence associated dermatitis (IAD) worsened and resident developed a stage IV pressure ulcer on the right heel. (Resident 64, Resident 23) Findings include: 1. On 4/16/24 at 10:52 A.M., Resident 64's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure, weakness, and atrial fibrillation. Resident 64 was admitted on [DATE]. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/25/24, indicated Resident 64 was cognitively intact and an extensive assist of 2 staff for bed mobility, transfers, and toileting. Resident 26 noted to have a foley catheter, colostomy, and 1 unstageable pressure ulcer. Current Physician Orders 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents for 1 of 3 residents reviewed for falls. Interventions put into place after falls were not evaluated and modified and interventions were not followed for a resident at risk for falls resulting in multiple falls. (Resident 26) Finding includes: On 4/15/24 at 9:47 A.M., Resident 26 was observed laying in her lowered (but not lowest position)bed. Her call light was wrapped around hook on the wall above the head of bed. Resident 26 indicated she wanted to get out of bed. On 4/15/24 at 9:50 A.M., Resident 26 told staff, I need to get up. I have a hair appointment at 10. Staff told the resident, Hang on, let me check. and left the room. Resident uncovered, sat bedside, was restless, and repeating, I need to get up. On 4/15/24 at 9:54 A.M., staff came back to the room and notified resident that her hair appointment wasn't until the next day and left the resident's room. On 4/15/24 2:14 P.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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 accurately document care planned interventions for a resident. Restorative walking nursing tasks were not completed as documented for 1 of 2 residents reviewed for Activities of Daily Living (ADLs). (Resident 18) Findings include: On 4/15/24 at 10:39 A.M., Resident 18 indicated the therapy department had told her she needed to use her walker and walk as much as possible, but would need a staff member to walk with her. She indicated she had asked staff to assist her in the past and was told they were too busy. She indicated she had not asked since, as she did not want to bother anyone. On 4/19/24 at 10:30 A.M., Resident 18's clinical record was reviewed. Diagnosis included, but were not limited to, renal failure, heart failure, and depression. The most recent Annual and State Optional MDS (Minimum Data Set) Assessment, dated 2/22/24, indicated no cognitive impairment, active range of motion (AROM) was completed 7 of 7 days during the look back period for at least 15 minutes a day, and walking was completed 6…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure for 1 of 2 residents reviewed for pressure ulcers and 1 of 1 residents observed for incontinence care. Staff did not use Enhanced Barrier Precautions (EBP) for a resident with an open wound. Staff did not use hand hygiene between dirty and clean tasks, did not lather before placing hands under water when washing their hands. (Resident 23, Resident 32) 1. On 4/16/24 at 11:02 A.M., Resident 23's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent Quarterly MDS Assessment, dated 3/24/24, indicated a severe cognitive impairment, and a stage 3 pressure ulcer. A current risk for pressure ulcer care plan included, but was not limited to, the following intervention: Enhanced Barrier Precautions (EBP): gown and glove use during high-contact resident care activities related to open wound, dated 3/26/24. On 4/22/24 at 10:25 A.M., a copy of Resident 23's current orders was provided and lacked an order for EBP. On 4/19/24 at 8:14 A.M., Certified Nurse Aide (CNA) 8 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0919 — failed to provide a working call system — isolated
    Make 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 4/15/24 at 9:34 A.M., Resident 17 was observed sitting up in a wheelchair, eyes closed, bedside table in front of her, and no call light within reach. On 4/16/24 at 11:35 A.M., Resident 17 was observed lying in bed, head of the bed elevated with call light lying on cabinet next to bed out of reach of resident. On 4/17/24 at 8:31 A.M., Resident 17 was observed sitting up in wheelchair eating breakfast with call light behind resident out of reach. On 4/17/24 at 10:49 A.M., Resident 17 was observed lying in bed with head of bed elevated watching television. Call light was observed lying on cabinet next to bed out of reach of resident. When the resident was asked if she had a call light close to her to use, she looked at the bed control and asked Is this it? On 4/16/24 at 10:30 A.M., Resident 17's clinical records were reviewed. Diagnosis included but were not limited to, displaced fracture of olecranon process of right ulna, dementia, and urinary tract infection. The current Quarterly, State Optional MDS…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-22 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and visitors for 4 of 4 rooms on A and B Halls and 2 of 2 shower rooms on A and B Halls tested for hot water. The water temperatures were above 120 degrees and a raised toilet seat was stored on the floor. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], A Hall shower room, and men's shower room) Findings include: 1. On 4/16/24 at 9:15 A.M., the water temperature in room [ROOM NUMBER]'s bathroom felt hot. The temperature was 121.4 degrees with the thermometer. On 4/19/24 at 8:25 A.M., the water temperature in room [ROOM NUMBER]'s bathroom felt hot. The temperature was 125.5 degrees with the thermometer then immediately dropped back down stopping at 105 degrees. On 4/19/24 at 10:53 A.M., the water temperature in room [ROOM NUMBER]'s bathroom was 132.5 degrees with the thermometer. Administrator was notified and indicated she would notify…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that infection control measures were implemented according to the plan of care for a resident with an active urinary tract infection (UTI). Staff failed to don appropriate personal protective equipment when providing care for a resident with an active UTI caused by an organism that required advanced barrier precautions. (Resident B) Finding includes: During record review on 3/5/24 at 10:00 A.M., Resident B's diagnoses included, but were not limited to muscle wasting and atrophy, type II diabetes, cognitive communication deficit, weakness, and unsteadiness on feet. Resident B's most recent Quarterly MDS (Minimum Data Set) Assessment, 2/8/24, included that the resident was frequently incontinent of bladder and always incontinent of bowel, and that Resident B required substantial assistance with toileting hygiene. Resident B's physician orders included, but were not limited to; trimethoprim / sulfamethoxazole (antibiotic) 800 - 160 mg (milligrams) 1 tablet by mouth two times a day for UTI from 3/3/25 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 during 2 of 3 observations of care. Staff failed to complete hand hygiene after removing their gloves and staff performed handwashing with a 4 second scrub time. (Resident D, Resident F) Findings include: 1. During an observation on 12/27/23 at 10:10 A.M., LPN 4 was assisting Resident D during incontinence care. After removing an old brief and providing perinial care, LPN 4 removed her gloves and donned new gloves without performing hand hygiene. LPN 4 then applied a barrier cream to Resident D's buttocks, removed the right hand glove, and donned a new glove to the right hand without performing hand hygiene. 2. During an observation on 12/27/23 at 11:28 A.M., CNA 2 and CNA 3 were assisting Resident F in the 400 unit shared bathroom. CNA 2 and CNA 3 donned gloves and transferred Resident F with a sit-to-stand lift. The lift controller was resting on the floor of the shared bathroom. CNA 3 picked up the controller with her…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-04-22 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 posted nurse staffing sheets contained the required information daily for 5 of 5 days reviewed during the survey. Findings include: On 4/15/24 at 8:30 A.M., a staffing sheet was observed posted in the front entrance of the facility on the wall. The posted nurse staffing sheet lacked the facility name and actual hours worked the nursing staff worked was not clear on the posting. On 4/16/24 at 9:30 A.M., a staffing sheet was observed posted in the front entrance of the facility on the wall. The posted nurse staffing sheet lacked the facility name and actual hours worked the nursing staff worked was not clear on the posting. On 4/17/24 at 9:31 A.M., a staffing sheet was observed posted in the front entrance of the facility on the wall. The posted nurse staffing sheet lacked the facility name and actual hours worked the nursing staff worked was not clear on the posting. On 4/18/24 at 3:00 P.M., a staffing sheet was observed posted in the front entrance of the facility on the wall. The posted nurse staffing…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to BRICKYARD HEALTHCARE — 23 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.7+1.3 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 3 of 52.4+0.6 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 22 homes this chain runs (chain average 2.7★, per CMS)
1 of 5Brickyard Healthcare - Bloomington Care CenterBloomington, IN 1 of 5Brickyard Healthcare - Elkhart Care CenterElkhart, IN 1 of 5Brickyard Healthcare - Golden Rule Care CenterRichmond, IN 1 of 5Brickyard Healthcare - Merrillville Care CenterMerrillville, IN 1 of 5Brickyard Healthcare - Richmond Care CenterRichmond, IN 2 of 5Brickyard Healthcare - Brandywine Care CenterGreenfield, IN 2 of 5Brickyard Healthcare - Fountainview Care CenterMishawaka, IN 2 of 5Brickyard Healthcare - Laporte Care CenterLa Porte, IN 2 of 5Brickyard Healthcare - Portage Care CenterPortage, IN 2 of 5Brickyard Healthcare - Terrace Care CenterLa Porte, IN 2 of 5Brickyard Healthcare - Twelfth Street Care CenterMishawaka, IN 2 of 5Brickyard Healthcare - Willow Springs Care CenterIndianapolis, IN 3 of 5Brickyard Healthcare - Brookview Care CenterIndianapolis, IN 3 of 5Brickyard Healthcare - Muncie Care CenterMuncie, IN 3 of 5Brickyard Healthcare - Woodbridge Care CenterEvansville, IN 3 of 5Brickyard Healthcare -Sycamore Village Care CenterKokomo, IN 4 of 5Brickyard Healthcare - Churchman Care CenterIndianapolis, IN 4 of 5Brickyard Healthcare - Petersburg Care CenterPetersburg, IN 4 of 5Brickyard Healthcare - Valparaiso Care CenterValparaiso, IN 4 of 5Brickyard Healthcare - Woodlands Care CenterNewburgh, IN 5 of 5Brickyard Healthcare - Brentwood Care CenterEvansville, IN 5 of 5Brickyard Healthcare - Knox Care CenterKnox, IN

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 / managerTypeRoleSince
PENNINGTON, JULIEIndividualCONTRACTED MANAGING EMPLOYEEsince 09/01/2012
ENGELS, ERINIndividualCORPORATE DIRECTORsince 10/25/2014
GENTRY, MARKIndividualCORPORATE DIRECTORsince 01/12/2022
STARKEY, TYLERIndividualCORPORATE DIRECTORsince 08/01/2020
WAITE, JOHNIndividualCORPORATE DIRECTORsince 08/01/2020
WHICKER, TIMOTHYIndividualCORPORATE DIRECTORsince 01/12/2022
FENOUGHTY, DEANNAIndividualCORPORATE OFFICERsince 07/10/2023
GGNSC TELL CITY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2012

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

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

Follow the money — this home’s finances

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

$9.4M
Net patient revenuemost recent cost report
+6.2%
Operating marginrevenue minus expenses
$430K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 8%Other / private 18%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $430K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$391per resident / day
operating cost
$11,876per month
≈ monthly operating cost
$417per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155384. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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.

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