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Westridge Health Care Center

125 W Margaret Ave, Terre Haute, IN 47802 · Non profit - Corporation · 66 certified beds · (812) 232-3311 Medicare & Medicaid certified

Call the home — (812) 232-3311 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Mar 20261 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 25% of its spending goes to commonly-owned related companies

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3401 S US Highway 41 · (812) 231-5734 · Call to confirm hours
Pharmacy
15 Southland Shopping Ctr · (812) 232-6655 · Call to confirm hours
Grocery
2501 S 3rd St · (812) 237-0007 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating 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.

Overall rating1★
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 increased25.5%11.0%15.4%worse
Long-stay residents who lose too much weight6.4%5.5%5.4%worse
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 infection6.0%1.1%2.0%worse
Long-stay residents with depressive symptoms60.5%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 injury1.7%3.9%3.3%better
Long-stay residents whose ability to walk worsened31.8%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication35.2%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers2.6%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control22.3%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.0%13.6%17.1%better
Short-stay residents rehospitalized after admission25.7%22.2%22.6%worse
Short-stay residents with an outpatient ER visit7.6%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days2.351.611.67worse
Long-stay outpatient ER visits per 1,000 resident days1.831.441.80typical

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.

10.2%U.S. median 10.7%
Went back to hospital
30.4%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.02hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 30.4% 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 23 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.7–14.910.7%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 discharge30.4%56.6%Oct 2024–Sep 2025CMS 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 discharge30.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge34.8%50.0%Oct 2024–Sep 2025CMS 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 identified93.8%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 worsened3.1%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.341.02Oct 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

0.60
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.40
Aide hours/ resident / day
3.58
Total nurse hours/ resident / day
0.31
RN hoursweekends
48.8%
Total nursing turnover
75.0%
RN turnover

How full it usually is: this home is certified for 66 beds and averages 42.6 residents a day — about 65% occupied, or roughly 23 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.09 hrs/resident/day on weekends vs 3.78 on weekdays — 18% thinner on weekends. RN hours go from 0.71 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-03-19)
5
at the previous standard inspection (2025-03-20)

Deficiencies are more than at the previous inspection — worsening. 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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2026-03-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, observation, and record review, the facility failed to ensure a resident's change in condition after a fall was assessed and treated which resulted in harm of a resident who had delayed treatment for a fractured right femur (thigh bone) that required surgery for 1 of 4 residents reviewed for accidents (Resident 8). Findings include:During an interview, on 3/15/26 at 1:33 p.m., Resident 8 indicated she had constant pain and recently had a fall and was hurt. Resident 8's record was reviewed on 3/17/26 at 11:56 a.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia, moderate, with mood disorder (fixed, false beliefs strongly held despite clear evidence to the contrary, often stemming from mental health, neurological, or substance-related conditions), major depressive disorder (serious mental health condition characterized by persistent sadness, hopelessness, and a loss of interest in activities lasting at least two weeks), right femur fracture (severe…

    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 before2026-03-19 · tag F0657 — failed to keep the care plan current — pattern
    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 ensure residents and their representatives participated in care plan meetings (a documented meeting where a resident, their family, and a team of health professionals meet to discuss the resident's goals, preferences, and necessary care services), for 4 of 16 residents reviewed for care plan meetings (Residents 41, 40, 1, and 8). Findings include:1. During an interview, on 3/15/26 at 12:53 p.m., Resident 41's brother indicated he was the resident Power of Attorney (POA-a legal document that allows someone else to act on another individual's behalf) and responsible party. He indicated he attended a care plan meeting right after the resident was admitted but had not known about or attended a meeting since that time. At the same time, the resident indicated she could not remember having a meeting since that time as well. Resident 41's record was reviewed on 3/18/26 at 8:43 a.m. The census indicated that the resident had been admitted to the facility on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 psychotropic medication consents were obtained for the initiation of or increase of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications (Residents 1 and 30). Findings include: 1. Resident 1's record was reviewed on 3/16/26 at 10:18 a.m. The profile indicated the resident's diagnoses included, but were not limited to, depression, schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia with a mood disorder such as depression or bipolar disorder), and fibromyalgia (a chronic multi system disorder characterized by widespread musculoskeletal pain, profound fatigue, and cognitive difficulties). Facility census information indicated the resident admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 12/19/26, indicated the resident had moderate cognitive impairment and received anti-psychotic and anti-depressant medications during the look back…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 observation, record review, and interview, the facility failed to ensure Registered Dietitian (RD) recommendations were addressed by the physician and ordered interventions were implemented to prevent weight loss for 1 of 2 residents reviewed for weight loss (Resident 11). Findings include:On 3/15/26 at 10:30 a.m., during an initial observation, observed Resident 11 sitting up in bed drinking water from a two handle cup. The resident was alert with slow verbal response. Noted while drinking she was coughing frequently. Liquid was noted to be thin consistency. On 3/15/26 at 1:44 p.m., the medical record of Resident 11 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and anorexia (a serious, potentially fatal eating disorder characterized by an intense…

    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 · D2026-03-19 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a physician's order for an assessment of a resident's dialysis access site ( surgically prepared area on the body that allows easy, high-volume access to the bloodstream for filtering blood during hemodialysis [a medical treatment that acts as an artificial kidney for people with kidney failure] was accurate, for 1 of 1 resident reviewed for dialysis (resident 2). Findings include:Resident 2's record was reviewed on 3/16/26 at 11:17 a.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (the final stage of kidney failure, where kidneys lose roughly 90% of their function, or are no longer able to work well enough to sustain life) and dependence on renal dialysis. A quarterly Minimum Data Set (MDS) assessment, dated 1/22/26, indicated the resident had no cognitive deficit. A care plan, dated 2/11/25, indicated the resident had diagnoses of end stage renal disease and required hemodialysis. Interventions included, but were not limited to, monitor shunt for bruit…

    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 · Dcited before2026-03-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure insulins stored in the medication carts were labeled with the open date for 1 of 2 medication carts reviewed and 3 of 3 residents with insulins stored in the medication cart (Residents 37, 12, and 34). Findings include:On 3/17/26 at 1:25 p.m., observed the North hall medication cart with RN 6. The following insulin pens (a portable, easy-to-use medical device for injecting insulin to manage diabetes) were observed: Resident 37, Novolog - Insulin Pen. The medication label indicated the prescription had been filled on 2/13/26. No date opened was recorded on the label or the pen. Resident 37, Basaglar insulin pen. The medication label indicated the prescription had been filled on 7/2/25. No date opened was recorded on the label or the pen. Resident 37, Novolog insulin pen. The medication label indicated the prescription had been filled on 12/10/25. No date opened was recorded on the label or the pen. Resident 12, Glargine insulin pen. The medication label indicated the prescription had been filled on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-19 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 lab services were completed as ordered, for 2 of 5 residents reviewed for unnecessary medications (Residents 30 and 3). Findings include: 1. Resident 30's record was reviewed on 3/16/26 at 10:28 a.m. The profile indicated the resident's diagnoses included, but were not limited to, other seizures (seizure types beyond common convulsions, characterized by temporary, abnormal brain activity causing sudden changes in movement, sensation, behavior, or awareness). A significant change Minimum Data Set (MDS) assessment, dated 2/10/26, indicated the resident had no cognitive deficit and received anticonvulsant medications (medications used to control seizures). A physician's order, dated 11/21/25, indicated to administer 1-500 milligram (mg) tablet of Keppra (anticonvulsant medication) two times a day. A Pharmacy recommendation, dated 2/3/26, indicated to consider checking the resident's Keppra level, if it had not been done lately. The physician agreed…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-30 · tag F0802 — failed to prepare enough nourishing food — widespread
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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 sufficient dietary support personnel was implemented per their facility assessment. This deficiency had the potential to affect 44 of 44 residents who receive food from the kitchen.Findings include:Review of a confidential statement, on 1/29/26 at 9:47 a.m., indicated the food was disgusting from the kitchen and the kitchen didn't have enough workers. During an observation during lunch meal service, on 1/29/26 at 12:07 p.m., there were two dietary staff members in the kitchen. There were a Dietary Manager (cook) and a Dietary Aide. The Dietary Manager was the only staff member plating the food for both the dining room and hall trays. The Dietary Manager was unable to provide an additional food item per a resident's request because she stated, I don't have time right now, I have to get all the hall trays ready to go. During an interview, on 1/29/26 at 12:25 p.m., Resident C indicated the food had really gone down hill lately and she refused to eat most of it. She indicated the facility served the same…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-19 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 assure staff provided safe and accurate administration of medication for 4 of 4 residents reviewed for pharmaceutical services (Residents D, E, F, and G). Findings include:1. During a random observation on 9/18/25 at 3:32 p.m., LPN 4 was observed seated at the 100 hall nurses' station. The desk had multiple cards of medications and plastic medication cups, with initials marked on the outer surface. LPN 4 was dispensing pills from the medication cards into her bare hands and placing the pills in the medication cups. She dropped a pill onto the desk surface, picked it up with her bare hands, and placed it into the medication cup. During the observation, LPN 4 indicated she was setting up her medications for administration later in her shift. There were nine filled medication cups, stacked one on top of the other, on the desk. She indicated these were for the east hall. The cups were labeled with initials in marker. The following was observed, with the Director of Nursing (DON), Nurse Consultant, and LPN 4…

    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 · Dcited before2025-09-19 · 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 and interview, the facility failed to assure nursing staff were using proper hygiene and infection control when preparing to administer medications for 1 of 2 observations for medication pass. Findings include:During a random observation on 9/18/25 at 3:32 p.m., LPN 4 was observed seated at the 100 hall nurses' station. The desk had multiple cards of medications and plastic medication cups, with initials marked on the outer surface. LPN 4 was dispensing pills from the medication cards into her bare hands and placing the pills in the medication cups. She dropped a pill onto the desk surface, picked it up with her bare hands, and placed it into the medication cup. She indicated she had not realized it was an issue after washing her hands. During an interview on 9/19/25 at 3:48 p.m. the Nurse Consultant indicated at no time should medications be handled with bare hands. A current facility policy, revised 4/2017, titled, Medication Administration, provided by the DON on 9/18/25 at 3:35 p.m., included the following: Purpose: To safely administer medications as per…

    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 · D2025-03-20 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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

    Based on interview and record review, the facility failed to ensure residents were provided showers/bed baths as preferred for 2 of 3 reviewed for choices (Residents 41 and 40). Findings include: 1. During an interview, on 3/17/25 at 9:29 a.m., Resident 41 indicated he had requested to receive two complete bed baths twice a week, but it was a challenge to receive the bed baths because of the facility not having enough staff. He indicated the bed baths were scheduled to occur on Monday and Thursday evening, but they were not getting done twice a week as requested. Resident 41 would sometimes only receive a washcloth from staff to wash his face and armpits and that was all he would get washed because he was unable to complete the task himself. Resident 41's record was reviewed on 3/18/25 at 10:50 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 12/3/24, indicated the resident was cognitively intact and required 1 to 2 staff assistance with activities of daily living (basic tasks that individuals perform to maintain their health and well-being). Review of daily preference…

    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
Show the remaining 10 citations
  • Potential for harm · Dcited before2025-03-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure expired medications were disposed of for 1 of 2 medication carts and 1 of 2 medication storage rooms reviewed (Residents 36 and 26). Findings include: 1. On 3/19/25 at 09:35 a.m., the south hall medication cart contained two expired insulin (medication used to lower blood sugar) vials with an open date of 2/6/25. The insulin vials contained labels that indicated they were for Resident 36. During an interview, on 3/19/25 at 09:37 a.m., Qualified Medication Aide (QMA) 7 indicated insulin was good for 30 days once opened. The insulin vials in the cart should have been discarded. Resident 36's record was reviewed on 3/19/25 at 10:06 a.m. The profile indicated the resident diagnosis included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (occurs when the body either doesn't produce enough insulin or its cells don't respond properly to insulin, leading to a buildup of glucose [simple sugar] in the blood stream). A physician order, dated 2/5/25, indicated to administer Humalog…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to label and date refrigerated and frozen food items, so it is used by its use-by date, frozen, or discarded, and the facility failed to prevent possible contamination of food in the refrigerator from water dripping onto food items for 2 of 2 kitchen observations. Findings include: On 3/16/25 at 10:05 a.m., during initial kitchen observation of refrigerated foods with Employee 11. The main refrigerator was observed with tomatoes in a clear plastic container date labeled with an opened date of 2/24. Two clear containers with lettuce inside with an opened date of 2/24. The tops of both containers were covered in water which was dripping down onto covered container of chicken noodle soup on the second shelf. The bottom of the refrigerator also had water on it and boxed food items were wet. On 3/16/25 at 10:10 a.m., an observation of freezer found an undated bag of frozen tater tots, two packages of undated frozen pie shells, two undated cakes, and four undated frozen pies. On 3/16/25 at 10:15 a.m., during interview employee 11…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure documentation of the facility contact with the hospital prior to a resident transfer was completed timely for 1 of 4 residents reviewed for hospitalization (Resident 31). Findings include: Resident 31's record was reviewed on 3/17/25 at 2:31 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs), cerebral infarction (a condition where brain tissue dies due to a lack of blood flow caused by a blockage in a blood vessel), and late-onset Alzheimer's disease (a common form of dementia that starts after the age of 65. It can cause memory and cognition issues, impaired judgment, and other symptoms as it progresses). A 5-day Minimum Data Set (MDS) assessment, dated 2/4/25, indicated the resident had moderate cognitive deficit, was totally dependent with all 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · 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, record review, and interview, the facility failed to ensure proper handling of the glucometer (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) meter during 2 of 2 blood glucose monitoring opportunities (Residents 42 and 35). Findings include: 1. During a blood glucose monitoring observation, on 3/19/25 at 11:11 a.m., the Qualified Medication Aide (QMA) 7 entered Resident 42's room and placed the glucometer onto her side table, no barrier placed under the meter. The QMA returned the glucometer to a resident specific black case and placed it back in the medication cart. Resident 42's record was reviewed on 3/19/25 at 1:10 p.m. The profile indicated the resident diagnosis included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (occurs when the body either doesn't produce enough insulin or its cells don't respond properly to insulin, leading to a buildup of glucose [simple sugar] in the blood stream). 2. During a blood glucose monitoring observation, on 3/19/25 at 11:17 a.m., QMA 7 entered…

    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 · Ecited before2024-06-06 · tag F0657 — failed to keep the care plan current — pattern
    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 observation, record review, and interview, the facility failed to update care plans with post fall interventions for 4 of 6 residents reviewed for falls (Residents B, C, H, and K). Findings include: 1. On 6/6/24 at 2:30 p.m., observed Resident A sitting up in wheel chair she was propelling herself in the hall. She had both shoes and socks on. She had difficulty communicating related to aphasia. Bed alarm was on the bed under an incontinent pad. Chair alarm was not visible on the wheelchair. On 6/7/24 at 11:57 a.m., observed Resident A, sitting in wheelchair in the main dining room. A call alarm was on the wheelchair with the alarm device on the back of the chair. On 6/6/24 at 10:49 a.m., the medical record for Resident A was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, hemiplegia, unspecified affecting right dominant side (a loss of strength in the arm, leg, and sometimes face on one side of the body), unsteadiness on feet, muscle weakness…

    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 · Ecited before2024-03-01 · 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 and interview, the facility failed to ensure clean linen was carried away from the body and failed to ensure soiled linen was in a container while transporting in the hallway during 5 of 5 random observations for linen handling. Findings include: During a random observation on 2/28/24 at 10:01 a.m., Certified Nursing Assistant (CNA) 21 retrieved a stack of linens from the clean linen closet located in the 100 hall, she then held the linens against her body while transporting them to a resident's room. During a random observation on 2/28/24 at 11:00 a.m., CNA 21 retrieved a stack of linens from the clean linen closet located in the 100 hall, she held the linens against her body while transporting. During a random observation on 2/29/24 at 9:50 a.m., Employee 3 was observed coming out of a resident's room on the 200 hallway wearing gloves and holding soiled linens that were unbagged against her body. She left the resident's room and indicated she needed to take the linens to the hopper. During a random observation on 2/29/24 at 2:48 p.m., CNA 20 retrieved a stack…

    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 · D2024-03-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 a call light device was in reach for 1 of 16 residents reviewed for call light placement (Resident 34). Findings include: On 2/26/24 at 2:52 p.m., Resident 34's call light was observed to be draped on the outlet against the wall and out of reach. The resident indicated that staff stopped giving one to her recently, so she needed to ask for things when they came in. The resident indicated that she could not move her arms or legs very much and could not turn herself in bed without assistance. The resident was observed to be laying on her left side and the bed was positioned diagonally away from the call light device. On 2/27/24 at 11:57 a.m., Resident 34's call light was observed to be draped on the outlet against the wall and out of reach from the resident. On 2/28/24 at 11:04 a.m., Resident 34 requested help getting assistance from staff, her call light was observed to be draped on the outlet against the wall and out of reach from the resident. Resident 34's record was reviewed on 2/27/24 at 11:49 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-01 · tag F0659 — isolated
    Provide care by qualified persons according to each resident's written plan of care.
    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 pressure ulcer treatments were completed by qualified staff and staff followed proper standards of practice for 1 of 1 residents reviewed for pressure ulcer care (Resident 29). Findings include: During an interview, on 2/26/24 at 10:54 a.m., Resident 29 indicated he had an open area to his bottom, and it had been there for a few months. He indicated it was a facility acquired pressure ulcer. During an interview, on 2/28/24 at 10:20 a.m., the Qualified Medication Aide (QMA) 6 indicated she had already completed Resident 29's dressing change to his open area in the morning and it was a dayshift dressing change daily. During an interview, on 2/29/24 at 9:11 a.m., Registered Nurse (RN) 14 indicated a QMA would need to let the nurse know that a dressing change needed to be completed because QMAs were not licensed to perform a pressure ulcer dressing change. During an interview, on 2/29/24 at 10:13 a.m., Resident 29 indicated there were two QMAs who normally completed the pressure ulcer dressing change to his bottom, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-01 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide treatment to prevent further decrease in range of motion for 1 of 2 sampled residents reviewed for range of motion (Resident 32). Findings include: On 2/26/24 at 11:10 a.m., during a routine observation, Resident 32 was sitting in a wheelchair. The left hand was contracted in a fist position, nails were long and touching the inside of the palm of the hand. No anti-contractual device was in Resident 32's hand. During an observation on 2/28/24 at 11:00 a.m., Resident 32 was sitting in a wheelchair in the activity lounge area. The left hand was contracted in a fist position, no anti-contracture device was in the left hand. During an interview, on 2/27/24 at 2:44 p.m., the Director of Nursing (DON) indicated if a resident had a contracture of the limbs, therapy evaluated the resident, and the therapist would decide if the resident needed an anti-contracture device. During an interview on 2/28/24 at 11:13 a.m., the Certified…

    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 · Dcited before2024-03-01 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the wash temperature of the chemical sanitizing dish machine (a dishwashing machine that applies potable water and a chemical sanitizing solution to the surfaces of wares to achieve sanitization), met the required temperature for 1 of 2 kitchen observations. Findings include: During the initial kitchen tour, on 2/26/24 at 9:59 a.m., the dish machine temperature dial indicated a top temperature of 80 degrees Fahrenheit (a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees), during the wash cycle. Four separate wash cycles were attempted. None reached a wash temperature higher than 80 degrees Fahrenheit. On 2/26/24 at 10:01 a.m., the Dietary Manager used a manual thermometer to measure the dish machine wash temperature. The thermometer registered a top temperature of 80 degrees Fahrenheit. At the same time, the Dietary Manager indicated he believed the minimum temperature should be between 100 and 120 degrees Fahrenheit. On 2/28/24 at 8:50 a.m., the Dietary…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
WITHAM MEMORIAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2011
BAYSTON, BRETTIndividualCORPORATE DIRECTORsince 01/01/2023
BRAND, JOHNIndividualCORPORATE DIRECTORsince 11/01/2016
CASTETTER, ANDREAIndividualCORPORATE DIRECTORsince 01/01/2023
HAWKINS, CLAUDEIndividualCORPORATE DIRECTORsince 11/01/2016
HORNBECKER, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2024
REAGAN, JULIEIndividualCORPORATE DIRECTORsince 09/25/2024
BRAVERMAN, KELLYIndividualCORPORATE OFFICERsince 12/01/2021
SELLERS, DANIELIndividualCORPORATE OFFICERsince 06/20/2024
MAGNOLIA HEALTH MANAGEMENT X LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
BLOESING, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2025
HASHMI, SYEDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2025
REED, STUARTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2011
REED, MICHAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 12/10/2025
MAGNOLIA HEALTH SYSTEMS 63, LLCOrganizationADP OF THE SNFsince 11/14/2025
MAGNOLIA HEALTH SYSTEMS INCOrganizationADP OF THE SNFsince 11/01/2011
SABRA HEALTH CARE LIMITED PARTNERSHIPOrganizationADP OF THE SNFsince 11/01/2011
WARD, JONATHANIndividualADP OF THE SNFsince 11/01/2011

CMS files one row per role, so the 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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.

$6.2M
Net patient revenuemost recent cost report
+8.7%
Operating marginrevenue minus expenses
$1.4M
Related-party expense25% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 7%Other / private 9%

About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 25% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$345per resident / day
operating cost
$10,497per month
≈ monthly operating cost
$378per 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 155234. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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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