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Avalon Springs Health Campus

2400 Silhavy Road, Valparaiso, IN 46383 · Government - County · 61 certified beds · (219) 462-1778 Medicare & Medicaid certified

Call the home — (219) 462-1778 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 2026
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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (28) — 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

Urgent care / clinic
3800 Saint Mary Rd #201 · (219) 286-3775 · Call to confirm hours
Pharmacy
1001 Sturdy Rd · (219) 465-9505 · Call to confirm hours
Grocery
2800 Calumet Ave · (219) 464-3571 · Call to confirm hours
Park
2501 McCord Rd · (219) 263-6683 · Typically dawn to dusk
Place of worship
2702 Glendale Blvd · (219) 462-2751

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
Short-stay residentsrehab / post-hospital 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 held steady at 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 weight3.2%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.4%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.9%1.1%2.0%better
Long-stay residents with depressive symptoms0.9%25.2%6.5%better 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 injury5.0%3.9%3.3%worse
Long-stay residents whose ability to walk worsened19.7%11.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.0%23.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers4.6%3.6%4.7%typical
Long-stay residents with worsening bladder/bowel control26.0%23.3%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table0.0%13.6%17.1%check this — see note marked star below the table
Short-stay residents who newly got an antipsychotic medication1.6%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine95.7%79.0%79.4%better
Short-stay residents rehospitalized after admission23.5%22.2%22.6%typical
Short-stay residents with an outpatient ER visit9.0%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.691.611.67typical
Long-stay outpatient ER visits per 1,000 resident days0.581.441.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 396 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.0%U.S. median 51.5%
Got home and stayed home
12.4%U.S. median 10.7%
Went back to hospital
89.7%U.S. median 56.6%
Met the expected recovery
0.65U.S. median 0.31
Therapy hours / resident / day
0.33hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 89.7% 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 234 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 0.65 therapist hours per resident per day in 2026Q1 — more than 90% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF63.0%CMS range 58.6–67.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.4%CMS range 9.5–15.010.7%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 discharge89.7%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 discharge90.6%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 discharge90.6%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 identified100.0%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.8%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 worsened1.8%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 hospitalization6.4%CMS range 4.6–8.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 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

1.06
RN hours/ resident / day
0.64
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.52
Total nurse hours/ resident / day
0.77
RN hoursweekends
46.4%
Total nursing turnover
31.3%
RN turnover

How full it usually is: this home is certified for 61 beds and averages 57.0 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 3.03 hrs/resident/day on weekends vs 3.72 on weekdays — 18% thinner on weekends. RN hours go from 1.17 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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 (2026-01-14)
12
at the previous standard inspection (2024-11-26)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-14 · 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, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to appropriate signage posted during a respiratory outbreak, lack of monitoring for a resident that was COVID-19 positive and lack of COVID-19 testing for a symptomatic resident for 2 of 3 residents reviewed for infection control and random infection control observations. (Residents 19 and 44)Findings include:1.On 1/8/26 at 8:35 a.m., the entrance to the facility was observed. There was no signage posted that indicated there was currently a respiratory outbreak in the facility and listed current precautions such as masking was optional or available. During the initial tour of the facility, there were resident rooms observed to have droplet precautions signs and PPE (personal protective equipment) bins outside the rooms. The staff indicated the residents on precautions had tested positive for COVID-19. The positive residents resided on the 100 and 300 halls. There was no signage that indicated those halls had a respiratory outbreak. During…

    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 · D2026-01-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure complete and accurate information was included in Indiana Department of Health (IDOH) Reportable Incidents related to abuse allegations for 2 of 3 IDOH Reportable Incidents reviewed. (Residents 11 and 42)Findings include:1.During an interview on 1/9/26 at 11:07 a.m., Resident 11 indicated a staff member had been rude and mean to her. She indicated she did not recall who the staff member was but that she had reported it to another staff member. The resident's record was reviewed on 1/9/26 at 1:20 p.m. Diagnoses included, but were not limited to, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a cerebral infarction and dysphagia. The Significant Change Minimum Data Set assessment, dated 1/3/26, indicated the resident had moderate cognitive impairment. An IDOH Reportable Incident, dated 9/26/25, indicated the resident's family had reported a concern with care. The resident was assessed and no injury was noted. An investigation was initiated. Other residents who resided on the same hall…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 1 residents reviewed for accidents. (Resident 6)Finding includes:On 1/9//26 at 9:40 a.m., Resident 6's room was observed. There was a standard size bed placed in the middle of the room with the headboard against the wall. On the right side of the bed, there was an oxygen concentrator between the bed and the wall. The resident was seated in a Broda chair near the nurse's station.The resident's record was reviewed on 1/9/26 at 9:26 a.m. Diagnoses included, but were not limited to, traumatic subdural hematoma, acute and chronic respiratory failure and Alzheimer's dementia.The Significant Change Minimum Data Set assessment, dated 12/15/25, indicated the resident had severe cognitive deficits and was dependent for transfers and toileting.An Indiana Department of Health Reportable Incident, dated 11/3/25, indicated the resident had sustained a fall on 10/31/25 and had been sent to the hospital for evaluation. He sustained 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-14 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 peripherally inserted central catheter (PICC) intravenous (IV) access site was assessed and monitored accurately as ordered for 1 of 3 residents reviewed for parenteral/IV fluids. (Resident 41)Finding includes: Resident 41's record was reviewed on 1/14/26 at 12:36 a.m. Diagnoses included, but were not limited to, osteomyelitis (infection of the bone) and cellulitis of the right and left lower limbs (skin infection). The admission Minimum Data Set (MDS) assessment, dated 12/17/25, indicated the resident was moderately cognitively impaired. He required intermittent oxygen therapy, received intravenous (IV) antibiotic medications, and had a central IV access site. A Care Plan, dated 12/15/25, indicated the resident required IV medications related to osteomyelitis. Interventions included, but were not limited to, assess for complications of the IV every shift such as infection or dislodgment, and IV site care as ordered. A Physician's Order, dated 12/12/25, indicated PICC line dressing change every 5 days; measure…

    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 before2026-01-14 · 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, record review, and interview, the facility failed to document care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 2 of 3 residents reviewed for intravenous care. (Residents 14 and 59)Findings include:1. On 1/9/26 at 10:16 a.m. Resident 14 was observed with a PICC line to her right upper arm. She indicated she was receiving IV (intravenous) antibiotics.Resident 14's record was reviewed on 1/12/26 at 3:44 p.m. Diagnoses included, but were not limited to, bacteremia and type two diabetes mellitus.The admission Minimum Data Set (MDS) assessment, dated 12/22/25, indicated the resident was cognitively intact.A Physician's Order, dated 12/16/25, indicated piperacillin-tazobactam (an antibiotic medication) 4.5 grams intravenous every eight hours at 8:00 a.m., 4:00 p.m., and 12:00 a.m.A Physician's Order, dated 1/7/26, indicated daptomycin (an antibiotic medication) 350 mg intravenous every 48…

    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 · D2025-10-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a resident who required maximum to dependent care received incontinence care in a timely manner, for 1 of 3 residents reviewed for incontinence care. (Resident B) Finding includes:During an observation on 10/27/25 at 10:27 a.m., Resident B was awake and lying in bed with the head of the bed elevated. The over the bed table was over the bed and the breakfast tray was on the table. The food on the tray had all been eaten. The resident indicated she was waiting on the staff to come and assist out of bed into the chair. She indicated when they brought the breakfast tray to her, they said they would be back to help her get out of bed.During an observation on 10/27/25 at 11:12 a.m., CNA 1 and CNA 2 entered the room. CNA 1 indicated the resident had incontinence care last completed at 7:30 a.m. and the resident was incontinent of large amounts of urine. The CNA's started morning care. The resident's incontinent brief was saturated, the lift sheet underneath her was soaked through to the bottom sheet on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-17 · 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 correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents who were in EBP and failed to ensure a staff member (CNA 2) completed hand hygiene after the removal of soiled gloves for 2 of 3 residents reviewed for infection control. (Residents F and D)Findings include:1. During an observation on 9/16/25 at 9:24 a.m., CNA 1 entered Resident F's room and assisted the resident into the bathroom. There was a sign on the door of the room that indicated EBP was required. CNA 1 had gloves on and no gown. The Director of Nursing (DON) entered and exited the bathroom and observed CNA 1 providing care without the use of a protective gown. She indicated a protective gown should have been worn. CNA 1 exited the bathroom with a soiled brief in a clear garbage bag for disposal.During an observation on 9/17/25 at 8:23 a.m., Resident F was lying in bed. There was a mid-line IV catheter inserted and dressed on the upper left arm and a urinary catheter 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 · Dcited before2025-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: On 2/27/25 at 10:06 a.m., Resident C was observed in bed asleep. The resident's bed was against the wall, he had bed rails, and there was a trapeze bar above the bed. The room was clean and clutter free and the call light was within reach. There were no bolsters observed on the resident's bed. On 2/27/25 at 10:25 a.m., and 1:10 p.m., the resident was observed sitting on the side of the bed. There were no bolsters on the bed. Record review for Resident C was completed on 2/27/25 at 10:36 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), stroke, chronic obstructive pulmonary disease (COPD), depression, and diabetes. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident was cognitively impaired. The resident required substantial/maximum assistance with…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-26 · 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

    Based on observation, record review, and interview, the facility failed to ensure a resident had Physician's Order to self-administer their own medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 38) Finding includes: During random observations on 11/21/24 at 10:20 a.m. and 2:04 p.m., and on 11/22/24 at 8:30 a.m., 10:21 a.m., and 1:24 p.m., Resident 38 was observed in bed. At those times, there was a bottle of nasal saline spray on her overbed table. On 11/22/24 at 2:45 p.m., LPN 1 was observed in the resident's room. At that time, she was made aware of the nasal saline spray on the overbed table. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had an unplanned significant weight loss and received 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    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 a physician was notified of abnormal vital signs for 1 of 5 residents reviewed for unnecessary medications. (Resident 5) Finding includes: The record for Resident 5 was reviewed on 11/22/24 at 2:17 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, hypertensive heart disease and diabetes mellitus. The admission MDS assessment, dated 10/11/24, indicated the resident was cognitively intact and was dependent on staff for toileting and transfers. A Physician's Order, dated 10/8/24, indicated to give carvedilol (medication used to treat hypertension) 25 milligrams (mg) twice daily for hypertension. There were no blood pressure or heart rate parameters in place indicating when to hold the medication. The October 2024 Medication Administration Record (MAR) indicated the medication had been given twice daily from 10/8/24 through 10/15/24. The resident was sent to the hospital on [DATE],…

    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 18 citations
  • Potential for harm · D2024-11-26 · tag F0583 — failed to protect personal privacy — isolated
    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 and interview, the facility failed to ensure a resident's privacy was maintained related to the electronic medication record (EMR) left open and unlocked in the hallway during medication pass for 1 of 8 residents observed during medication pass. (Resident 363) Finding includes: On 11/21/24 at 12:21 p.m., RN 1 was observed disconnecting an intravenous medication for Resident 363. She had the electronic medication record open on the computer as she gathered her supplies from the 300 Hall cart and then walked towards the resident's room to disconnect the medication and flush the line. The computer screen was left open and on, leaving the residents medications and personal information available to view. At 12:28 p.m., RN 1 was observed returning to the 300 Unit Nurses' Station where she sat down. The 300 Hall cart computer was still open and could be viewed in the hallway. During an interview on 11/21/24 at 12:28 p.m., RN 1 indicated she did not realize she had left the screen open, but the screen should always be locked when not in use. She proceeded to close 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 · D2024-11-26 · 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 record review and interview, the facility failed to ensure residents were involved in decisions about their care related to new medications and ensuring a resident attended and participated in care planning conferences for 2 of 2 residents reviewed for participation in care planning. (Residents 38 and 49) Findings include: 1. During an interview on 11/21/24 at 10:18 a.m., Resident 38 indicated she was not always informed of new medications, laboratory tests or treatments. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 11/14/24, indicated Remeron (an antidepressant medication) 15 milligrams (mg), give 1/2 tablet at bedtime. A Nurse's Note, dated 8/26/24 at 10:09 a.m., indicated the resident's daughter was made aware of…

    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 before2024-11-26 · 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 observation, record review, and interview, the facility failed to ensure blood pressure medication was administered as ordered according to parameters for 1 of 1 resident reviewed for blood pressure parameters and for 1 of 5 residents reviewed for unnecessary medications. (Residents 38 and 5) Findings include: 1. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident received oxygen therapy while at the facility. Physician's Orders, dated 12/22/22, indicated Hydralazine (a medication used to lower the blood pressure) 25 milligrams (mg) twice a day and to hold if systolic blood pressure was less than 110 and the heart rate was less than 60. Metoprolol succinate (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure urinary output was documented as ordered and an indwelling Foley (urinary) catheter collection bag was off of the floor for a resident with a history of infection for 3 of 3 residents reviewed for urinary catheters. (Residents 6, 216, and 13) Findings include: 1. Record review for Resident 6 was completed on 11/25/24 at 9:57 a.m. Diagnoses included, but were not limited to, neurogenic bladder, end stage renal disease, Alzheimer's, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/22/24, indicated the resident was cognitively impaired. The resident required maximum assistance for toileting. The resident had an indwelling urinary catheter. A Care Plan, dated 10/10/22 and revised 11/11/24, indicated the resident used a Foley catheter. The resident was at risk for complications, including a urinary tract infection. An intervention included to record the resident's urinary output. The November 2024 Physician's Order Summary (POS) indicated an order to monitor urinary output every…

    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 before2024-11-26 · 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

    Based on record review and interview, the facility failed to monitor weekly weights and nutritional intake for meals and supplements as ordered for a resident with significant weight loss for 1 of 2 residents reviewed for nutrition. (Resident 38) Finding includes: The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and weighed 78 pounds. The resident had an unplanned significant weight loss and received a therapeutic diet. The revised Care Plan, dated 11/12/24, indicated the resident was malnourished/ at risk for malnutrition related to inadequate nutrient/ energy intakes, and/or metabolic demands. The approaches were to provide diet, supplements, medications, and adaptive equipment as ordered. A Physician's Order, dated 3/3/23 and on the current Physician…

    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 before2024-11-26 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a peripherally inserted central catheter (PICC) line was maintained related to bandage changes for 1 of 1 resident reviewed for infections. (Resident 363) Finding includes: During an interview on 11/21/24 at 11:15 a.m., Resident 363 indicated he had received intravenous (IV) antibiotics for a wound infection in his foot. The PICC line bandage had not been changed since he had been at the facility and one of the ports did not work. The white split gauze sponge under the clear tegaderm was observed with brown dried blood. There was no date on the bandage of the PICC line. On 11/21/24 at 3:20 p.m., the resident was sitting up in his wheelchair inside his room. The PICC line bandage remained the same as above. During an interview on 11/22/24 at 8:25 a.m., the resident indicated the nurse had changed his PICC line bandage that morning. The record for Resident 363 was reviewed on 11/22/24 at 10:27 a.m. Diagnoses included, but were not…

    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 · D2024-11-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure oxygen concentrators were set at the correct flow rate for 1 of 2 residents reviewed for oxygen therapy. (Resident 38) Finding includes: During random observations on 11/21/24 at 10:20 a.m. and 2:04 p.m., and on 11/22/24 at 8:30 a.m., 10:21 a.m., and 1:24 p.m., Resident 38 was observed in bed. At those times, she was wearing oxygen via nasal cannula and the oxygen concentrator was set at 2.5 liters per minute. On 11/22/24 at 2:45 p.m., LPN 1 was observed in the resident's room. At that time, she was made of the oxygen setting and immediately changed the rate to 3 liters. The record for Resident 38 was reviewed on 11/22/24 at 11:20 a.m. Diagnoses included, but were not limited to, heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The 9/17/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident received oxygen therapy while at the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-26 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure a resident's pain was managed and monitored for 1 of 2 residents reviewed for pain. (Resident 157) Finding includes: On 11/21/24 at 3:18 p.m., Resident 157 was observed sitting in his wheelchair in his room. He was grimacing, shifting in his chair, and complaining of back pain rated 7 out of 10 for severity. The resident indicated his back pain was not well controlled and he felt like he needed new or changed pain medications. On 11/25/24 at 9:26 a.m., the resident was observed fidgeting and attempting to reposition himself in bed. He indicated he was having back pain and the Fentanyl (an opioid pain medication) patch and Norco (an opioid pain pill) he had received were not controlling his pain. The resident's record was reviewed on 11/25/24 at 10:32 a.m. Medical diagnoses included, but were not limited to, cellulitis of the legs, heart failure, chronic kidney disease, atrial fibrillation, depression, spinal stenosis, and opioid use. The admission Observation and Data Collection, dated 11/17/24,…

    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 before2024-11-26 · 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 record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to the correct medication administration route for 1 of 1 resident reviewed for tube feeding. (Resident 41) Finding includes: During an interview on 11/21/24 2:15 p.m., Resident 41's daughter indicated the resident received her medications sometimes through the tube and sometimes she got them by mouth. The record for Resident 41 was reviewed on 11/25/24 at 9:05 a.m. Diagnoses included, but were not limited to, colitis, dehydration, congestive heart failure, dementia, Alzheimer's disease, heart disease, Parkinson's disease, dysphagia (difficulty swallowing), peg tube (a tube inserted directly into the stomach for nutrition) The 10/21/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a peg tube through which she received 25% or less of nutrition. Physician's Orders, listed on the current Physician Order Summary dated 11/2024, indicated the medications of…

    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 before2024-11-26 · 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 infection control guidelines were in place and implemented, related to enhanced barrier precautions (EBP) not in use for a resident with pressure ulcers during a wound treatment and for a resident with a peripherally inserted central catheter (PICC) line during medication pass. The facility also failed to change gloves in between pressure ulcer treatments and perform hand hygiene after glove removal during medication pass for 1 of 2 residents observed during a pressure ulcer treatment and for 1 of 8 residents observed during medication administration. (Residents 41 and 363) (Hospice CNA 1, Hospice RN 1, and RN 1) Findings include: 1. During an observation on 11/25/24 at 10:33 a.m., Hospice CNA 1 and Hospice RN 1 were observed in Resident's 41 room. At that time, Hospice CNA 1 indicated she was going to give the resident a complete bed bath and Hospice RN 1 was going to change the resident's bandages for her pressure ulcers. The CNA and RN both had performed hand hygiene and donned a pair of clean…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to follow up on a notification of a change of condition with a resident's physician, for 1 of 4 residents reviewed for physician notification. (Resident F) Finding includes: Resident F's record was reviewed on 6/12/24 at 10:36 a.m. The diagnoses included, but were not limited to, stroke and cellulitis. A Nurse's Progress Note, dated 5/8/24 (Wednesday) at 3:57 p.m., indicated 2+ left lower leg edema and 1+ right lower leg edema. The resident had gained 2.5 pounds in two days. The resident stated he usually took an extra dose of Lasix (diuretic) when edema was present. The physician was faxed the assessment information and the resident and family were notified and would be updated when the physician responded to the notification. There was no documentation that indicated the physician had responded to the fax sent to him on 5/8/24 at 3:57 p.m. and there was no follow up phone call with the condition changes. A Nurse's Progress Note, dated 5/9/24 at 5:51 a.m., indicated the resident complained of wheezing. Wheezing was heard 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-13 · tag F0694 — isolated
    Provide for the safe, appropriate administration of IV fluids for a resident when needed.
    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 care for peripherally inserted central catheter (PICC line - long catheter inserted through a peripheral vein for intravenous treatments) in accordance with professional standards of practice, related to lack of measurement of the catheter length and arm circumference above the site, dressing changes to the sites, assessments of the site, and flushes of the catheters, for 3 of 3 residents with PICC lines. (Residents E, F, and C) Findings include: 1. During an observation on 6/12/24 at 10:55 a.m., LPN 1 prepared and administered Resident E's antibiotic of piperacillan tazobactam 3.3555mg in 50 cc's (cubic centimeters) of 0.9% normal saline (NS). LPN 1 indicated she would use a 0.9% NS flush for the right upper arm PICC line lumen prior to the administration of the antibiotic. LPN 1 cleaned the PICC line's needleless connector with an alcohol prep pad, unclamped the PICC line lumen, and flushed the lumen with 10 cc's of 0.9% NS. She indicated she used 10 cc's of the NS for the flush. The IV (intravenous)…

    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 before2024-06-13 · 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 staff were aware of which residents were in Enhanced Barrier Precautions (EBP), failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 3 and LPN 2) when providing care to a resident who was in EBP, and failed to ensure staff removed soiled gloves and washed hands after touching contaminated surfaces, for 1 of 3 residents observed for infection control and EBP (Resident F) This had the potential to affect 2 residents with PICC lines (peripherally inserted central catheter - long catheter inserted through a peripheral vein for intravenous treatments). (Residents E and F). Findings include: 1. During the initial tour of Hall 100 on 6/12/24 at 8:49 a.m., LPN 1 indicated Residents E and F had PICC lines in place. There were no signs on the entry doors to Resident E and F's rooms that indicated the residents were on EBP. There was no cart outside the rooms that indicated the resident's were on EBP. During an interview on 6/12/24 at 9 a.m., Resident Care Associate 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-11 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 medications were given as ordered to prevent significant medication errors for 1 of 3 residents reviewed for medication errors. (Resident B) The deficient practice was corrected by [DATE], prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the medication error. The facility's plan of action included staff education related to counseling and education on medication administration and dosage calculations. Medication administration competencies were completed for nurses and QMAs. Audits began for as needed (PRN) injectable medications. Finding includes: Resident B's record was reviewed on [DATE] at 9:35 a.m. Diagnoses included, but were not limited to, encephalopathy, diabetes mellitus, and congestive heart failure. The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was moderately cognitively impaired for daily decision making. A Progress Note, dated [DATE]…

    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 · Past Non-Compliance
  • Potential for harm · D2023-12-04 · 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

    Based on record review and interview, the facility failed to ensure a resident and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 1 residents reviewed for hospitalization. (Resident 45) The closed record for Resident 45 was reviewed on 11/30/23 at 10:40 a.m. Diagnoses included, but were not limited to, chronic kidney disease and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, indicated the resident was cognitively intact. A Progress Note, dated 10/10/23, indicated the resident was lethargic, her heart rate was 44, and her oxygen saturation was 60%. The resident's blood pressure was not able to be assessed. The resident was put on a rebreather mask. The Nurse Practitioner checked on the resident. The family and Physician were notified and the resident was sent to the hospital. There was a lack of documentation any hospital transfer form had been completed or the State transfer form had been provided in writing to the resident or her responsible party. Interview with the Director of Nursing…

    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 · D2023-12-04 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, 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 a baseline care plan was developed and implemented that included an assistive device within 48 hours of admission for 1 of 19 residents reviewed for care plans. (Resident 97) Finding includes: On 11/27/23 at 11:37 a.m. and 11/28/23 at 1:00 p.m., Resident 97 was observed wearing a back brace. Record review for Resident 97 was completed on 11/28/23 at 1:03 p.m. The resident was admitted to the facility on [DATE]. An admission Observation Form, dated 11/20/23, included the resident's Baseline Care Plans. The Assistive Device section indicated the resident did not have a brace or a splint. There was not a baseline care plan put into place related to the resident's back brace. Interview with LPN 1 on 11/28/23 at 1:16 p.m., indicated the resident was admitted to the facility with the back brace. She could not find any documentation to indicate a baseline care plan for the back brace was put into place. 3.1-30(a)

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-04 · 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 observation, record review and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of Physician's Orders in place for a wound treatment for 1 of 2 residents reviewed for non-pressure skin conditions and for a back brace for 1 of 3 residents reviewed for positioning and limited range of motion. (Residents 102 and 97) Findings include: 1. On 11/27/23 at 11:41 a.m., Resident 102 was observed sitting in a wheelchair in the dining room. The resident had a bandage to his right elbow. There was writing on the bandage that was not legible. On 11/28/23 at 11:02 a.m., Resident 102 was observed sitting in a wheelchair in his room. The resident had a bandage to his right elbow that was dated 11/27/23. He indicated he had fallen a while ago and had been wearing a bandage to his elbow since then. The nurses changed the bandage once in a while. Record review for Resident 102 was completed on 11/28/23 at 11:03 a.m. An admission Observation Form, dated…

    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 before2023-12-04 · 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

    Based on record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 11/30/23 at 9:06 a.m. Diagnoses included, but were not limited to, congestive heart failure and atrial fibrillation. The admission Minimum Data Set (MDS) assessment, dated 9/23/23, indicated the resident was cognitively impaired and required supervision with eating. The resident weighed 200 pounds on 10/26/23 and 183 pounds on 11/26/23. A Registered Dietician Note, dated 11/21/23, indicated the resident had a significant weight loss of 10.9% weight loss in 30 days. The Meal Consumption Log for November 2023 lacked documentation of the following meals: - Breakfast on 11/2/23, 11/9/23, 11/11/23, and 11/20/23. - Lunch on 11/2/23, 11/9/23, 11/11/23, 11/20/23, and 11/24/23. - Dinner on 11/2/23, 11/5/23, 11/6/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/12/23, 11/18/23, 11/21/23, 11/24/23, 11/25/23, 11/26/23, and 11/27/23.…

    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

“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 TRILOGY HEALTH SERVICES — 123 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 54.2-0.2 vs chain
Health inspection 3 of 53.5-0.5 vs chain
Staffing 3 of 53.3-0.3 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 122 homes this chain runs (chain average 4.2★, per CMS)
1 of 5Heritage TheFindlay, OH 1 of 5The Oaks Rehabilitation and Healthcare CenterZanesville, OH 2 of 5Homewood Health CampusLebanon, IN 2 of 5Violet Springs Health CampusPickerington, OH 2 of 5Woodmont Health CampusBoonville, IN 3 of 5Cobblestone Crossings Health CampusTerre Haute, IN 3 of 5Creasy Springs Health CampusLafayette, IN 3 of 5Cumberland Pointe Health CampusWest Lafayette, IN 3 of 5Forest Park Health CampusRichmond, IN 3 of 5Franciscan Health Care CenterLouisville, KY 3 of 5Greenleaf Health CampusElkhart, IN 3 of 5River Terrace Health CampusMadison, IN 3 of 5Scenic Hills At The MonasteryFerdinand, IN 3 of 5Smiths Mill Health CampusNew Albany, OH 3 of 5Springhurst Health CampusGreenfield, IN 3 of 5Springs Of Richmond, TheRichmond, IN 3 of 5St Mary Healthcare CenterLafayette, IN 3 of 5Stonegate Health CampusLapeer, MI 3 of 5Sun Prairie Senior LivingSun Prairie, WI 3 of 5Taylor Springs Health CampusGahanna, OH 3 of 5The Willows at Fritz FarmLexington, KY 3 of 5The Willows at HamburgLexington, KY 3 of 5The Willows at HarrodsburgHarrodsburg, KY 3 of 5The Willows at SpringhurstLouisville, KY 3 of 5Villages At Oak Ridge, TheWashington, IN 3 of 5Waunakee Valley Senior LivingWaunakee, WI 3 of 5Wellbrooke Of CarmelCarmel, IN 4 of 5Arlington Place Health CampusIndianapolis, IN 4 of 5Ashford Place Health CampusShelbyville, IN 4 of 5Aspen Place Health CampusGreensburg, IN 4 of 5Bethany Pointe Health CampusAnderson, IN 4 of 5Blair Ridge Health CampusPeru, IN 4 of 5Bridgepointe Health CampusVincennes, IN 4 of 5Cedar Creek Health CampusLowell, IN 4 of 5Clearvista Lake Health CampusIndianapolis, IN 4 of 5Forest Springs Health CampusLouisville, KY 4 of 5Glen Oaks Health CampusNew Castle, IN 4 of 5Glen Ridge Health CampusLouisville, KY 4 of 5Meadows Of Delphos TheDelphos, OH 4 of 5Meadows Of Ottawa TheOttawa, OH

Showing 40 of 122; lowest-rated first.

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 / managerTypeRoleShareSince
HANCOCK REGIONAL HOSPITALOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2014
LUMENT REAL ESTATE CAPITAL LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2023
BOND, MARIAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 07/01/2021
CLARK, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 05/01/2015
DAUGHERTY, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2020
FELKER, DEANIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 05/01/2015
JOYNER, SARAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2022
LONG, STEVENIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/13/2022
WILLARD, LACEYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 07/01/2022
WILSON, ROYIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 05/01/2015
TRILOGY HEALTHCARE OF GREENFIELD, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2014
TRILOGY HEALTHCARE OF PORTER, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/01/2014
MIROCHNA, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
WRAY, CRYSTALIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/21/2016
BARNEY, LEIGHIndividualGENERAL PARTNERSHIP INTERESTsince 12/01/2015
DAVIS, DAVIDIndividualGENERAL PARTNERSHIP INTERESTsince 12/31/2019
AMERICAN HEALTHCARE REIT HOLDINGS LPOrganizationADP OF THE SNFsince 12/01/2015
AMERICAN HEALTHCARE REIT INCOrganizationADP OF THE SNFsince 10/01/2018
CONTINENTAL MERGER SUB LLCOrganizationADP OF THE SNFsince 10/21/2021
GAHC3 TRILOGY JV LLCOrganizationADP OF THE SNFsince 12/01/2015
GAHC4 TRILOGY JV LLCOrganizationADP OF THE SNFsince 10/01/2018
PARAGON OUTPATIENT REHABILITATION SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY HEALTH SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY HEALTHCARE HOLDINGS INCOrganizationADP OF THE SNFsince 07/21/2025
TRILOGY HEALTHCARE MASTER TENANT V, LLCOrganizationADP OF THE SNFsince 07/22/2025
TRILOGY HEALTHCARE OF HANCOCK II, LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY INVESTORS LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY MANAGEMENT SERVICES LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY OPCO LLCOrganizationADP OF THE SNFsince 07/22/2025
TRILOGY PRO SERVICES LLCOrganizationADP OF THE SNFsince 07/21/2025
TRILOGY PROPCO FINANCE LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REAL ESTATE INVESTMENT TRUSTOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REAL ESTATE OF PORTER, LLCOrganizationADP OF THE SNFsince 12/01/2015
TRILOGY REIT HOLDINGS LLCOrganizationADP OF THE SNFsince 12/01/2015

CMS files one row per role, so the 52 rows in the source record cover these 34 parties — each is shown once here with every role it holds. Nothing is omitted.

22 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.

$13.0M
Net patient revenuemost recent cost report
+7.7%
Operating marginrevenue minus expenses
$1.9M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 12%Medicare 16%Other / private 73%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$325per resident / day
operating cost
$9,894per month
≈ monthly operating cost
$352per 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 155795. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-14, 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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