Lodge Of The Wabash
723 E Ramsey Rd, Vincennes, IN 47591 · Government - City/county · 70 certified beds · (812) 882-8787 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited May 2025
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 29% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 |
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 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 23.9% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.4% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.6% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.6% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.4% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.7% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 3.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.1% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.8% | 13.6% | 17.1% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.90 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.71 | 1.44 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not 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 SNF | 10.5%CMS range 6.8–17.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not 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 stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 0.68 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 70 beds and averages 42.0 residents a day — about 60% occupied, or roughly 28 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 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 2.89 hrs/resident/day on weekends vs 3.13 on weekdays — 8% thinner on weekends. RN hours go from 0.86 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2026-03-04 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist (IP) working at least part-time at that facility. The Director of Nursing (DON) acted as the IP, but lacked documentation of hours worked as the IP. Finding includes:During an interview on 3/3/26 at 7:04 A.M., Regional Support indicated the DON was the current IP, and the Clinical Nurse Manager was the backup IP, but lacked certification.During an interview on 3/4/26 at 12:20 P.M., the DON indicated she acted as the current IP, DON, and minimum data set (MDS) nurse. At that time, she indicated she lacked documentation of hours spent on IP duties.On 3/4/26 at 1:31 P.M., the Administrator provided an Infection prevention and Control Officer job description, revised 2/24, that indicated, At least a part time clinical who is responsible for supporting the facilities systems for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents and others in the facility .will have specialized training and education in infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 observation, interview, and record review, the facility failed to notify the Medical Doctor/Nurse Practitioner (MD/NP) about significant changes in a resident's physical and functional ability for 1 of 1 resident reviewed for positioning. (Resident 26) Finding includes:On 2/26/26 at 11:10 A.M., Resident 26 was observed propelling herself in her wheelchair to the dining room. She was leaning so far to the right side, that her right axilla was over the right arm rest, the resident's arm was hanging off the wheelchair over the side, and she was slouched over and down with her head toward her knees. The resident ran into chairs at the nurse's station and then ran her head into the wall and handrail going down the hallway. On 3/3/26 at 7:20 A.M., Resident 26's clinical record was reviewed. Diagnoses included, but were not limited to bipolar disorder, anxiety, and dementia. The resident's active diagnoses did not include any diseases of the spine. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/11/25, indicated the resident did not use any mobility devices…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was discharged with sufficient preparation for 1 of 3 closed records reviewed. A discharged resident failed to receive appropriate paperwork and assessments prior to being sent to the hospital. (Resident 44)Finding includes:On 3/3/26 at 9:14 A.M., Resident 44's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus.Resident 44 was admitted to the facility on [DATE] and discharged to the hospital on [DATE].An admission minimum data set (MDS), dated [DATE], indicated a moderate cognitive impairment.Progress notes lacked information related to Resident 44's discharge on [DATE].Resident 44's clinical record lacked any discharge assessments prior to or on 12/14/25.Resident 44's clinical record lacked any respiratory assessments prior to the 12/14/25 discharge.Resident 44's clinical record lacked a transfer/discharge and bed-hold form for the 12/14/25 discharge.During an interview on 3/3/26 at 9:35 A.M.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that a resident with a decline in positioning was offered an evaluation for adaptive devices or equipment to help her maintain the highest practicable physical and functional well-being for 1 of 1 resident reviewed for positioning. A resident with kyphosis was observed leaning so far to the right seated in her wheelchair that her right axilla (arm pit) rested on the arm rest of the wheelchair and her head was down towards her knees. (Resident 26)Finding includes:On 2/25/26 at 11:40 A.M., Resident 26 was observed sitting in her wheelchair in the dining room. She was leaning so far to the right side, that her right axilla was over the right arm rest, the resident's arm was hanging off the wheelchair over the side, and she was slouched over and down with her head toward her knees. On 2/26/26 at 11:10 A.M., Resident 26 was observed propelling herself in her wheelchair to the dining room. She was leaning so far to the right side, that her right axilla was over the right arm rest, the resident's arm was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure proper storage of medications in 1 of 1 medication storage room. The temperature log for the refrigerator and room temperature lacked several readings. (Medication Storage Room)Finding includes:On 2/25/26 at 9:49 A.M., the February 2026 temperature log posted on the refrigerator in the medication storage room was observed to be missing refrigerator and room temperatures.The missing temperatures included, but were not limited to the following:2/10/26 Refrigerator temperatures for evening and night shift.2/12/26 Refrigerator and room temperatures for evening and night shift.2/13/26 Refrigerator and room temperatures for evening and night shift.2/16/26 Refrigerator and room temperatures for day shift.2/18/26 Refrigerator and room temperatures for day, evening, and night shift.2/19/26 Refrigerator and room temperatures for evening shift.2/20/26 Refrigerator and room temperatures for night shift.2/21/26 Refrigerator and room temperatures for day shift.2/22/26 Refrigerator and room temperatures for day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure accurate information was documented in the clinical record for 1 of 4 residents reviewed for nutrition. Meal intake documentation was missing and meal and snack consumption was recorded in the clinical record before the resident was served. (Resident 26) Finding includes:On 2/26/26 at 12:05 P.M., Resident 26 was observed during lunch sitting in her wheelchair at a table in the dining room with her head resting on her right hand on the table. On 3/3/26 at 7:20 A.M., Resident 26's clinical record was reviewed. Diagnoses included, but were not limited to bipolar disorder, anxiety, and dementia. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 1/27/26, indicated Resident 26's cognition was not able to be assessed, needed partial to moderate assistance of staff (staff performs over half the effort) for eating, was 64 inches, 135 pounds (lbs), and had not had weight loss. Current Physician's Orders included, but were not limited to, the following:Regular diet, initiated 8/4/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff used proper hand hygiene to help prevent the development and transmission of communicable diseases and infections for 2 of 2 observations of incontinence care. Staff washed their hands with an 8, 10, 15 and 12 second lather. (Resident 26, Resident 22)Findings include: 1. On 3/3/26 at 9:26 A.M., Qualified Medication Aide (QMA) 6 and Certified Nurse Aide (CNA) 14 were observed toileting Resident 26 in the shower room. After the resident was seated on the toilet, QMA 6 washed her hands with an 8 second lather and put on gloves. QMA 6 removed Resident 26's soiled incontinence pad and discarded it into the trashcan. Then she washed her hands with a 10 second lather. QMA 6 applied the gait belt and QMA 6 and CNA 14 lifted Resident 26 from the toilet to stand. 2. On 3/2/26 at 2:02 P.M., QMA 6 and CNA 8 took Resident 22 into the shower room to void. QMA 6 washed her hands with a 15 second lather and CNA 8 washed his hands with a 12 second lather. After putting gloves on, QMA 6 placed the gait belt around…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-04 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow antibiotic use protocol for 1 of 1 resident reviewed for urinary tract infection. An antibiotic was ordered and given prior to culture results that was resistant to the bacteria. (Resident 22)Findings include:On 3/2/26 at 9:15 A.M., Resident 22's clinical records were reviewed. Diagnoses included, but were not limited to, dementia and depression. The most current quarterly Minimum Data Set (MDS) assessment, dated 2/10/26, indicated Resident 22 was unable to complete the Brief Interview for Mental Status (BIMS) assessment due to the resident being rarely/never understood. Resident 22 was dependent on staff for toileting and was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).Physician orders included, but were not limited to the following:Keflex (an antibiotic) 500 mg (milligrams) bid (two times a day) x 7 days for UTI (urinary tract infection), dated 1/7/26 and discontinued on 1/12/26Bactrim (an antibiotic) 800mg-160 mg 1 bid through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation for 2 of 3 residents reviewed pharmaceutical services. Resident's narcotic medications went missing after being delivered from the pharmacy which caused residents to miss physician ordered routine medications. (Resident D, Resident G) Findings include: 1. During record review on 5/29/25 at 10:30 A.M., Resident D's diagnoses included, but were not limited to; osteoarthritis, chronic kidney disease, and diabetes. Resident D's most recent annual Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment, had occasional pain rated two (2) on a scale of zero (0) - ten (10) (zero being no pain and ten being the most pain), and received opiod medication. Resident D's physician orders included, but were not limited to; oxycodone hydrochloride (HCL) 5 milligrams (mg), one tablet by mouth twice a day for pain (started 10/9/23), and Tylenol 325 mg, two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 7 of 16 observations of medication administration. Gloves were not changed and hand hygiene was not performed between dirty and clean tasks during peri care, hand hygiene was not performed prior to administering medications, and staff performed a 2 second hand lather. (Resident B, Resident F, Resident 37, Resident 12, Resident 14, Resident 39, Resident 46, Resident 2, Resident 41). Findings include: 1. On 1/13/25 at 11:04 A.M., Resident B transferred from the wheelchair to the toilet by Certified Nurse Aide (CNA) 37 and CNA 41. CNA 37 used both gloved hands to remove the foot pedals on Resident B's wheelchair. CNA 37 failed to change gloves and perform hand hygiene before she removed Resident B's incontinence pad. CNA 37 removed the soiled brief and failed to change gloves or perform hand hygiene before she put the clean incontinence pad on Resident B. CNA 37 then wrapped toilet paper around her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Ecited before2025-01-14 · tag F0882 — patternDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist (IP) worked at least part-time at that facility, and the interim IP lacked an infection control certification. Finding includes: During an interview on 1/13/25 at 1:47 P.M., the Clinical and Quality Consultant indicated the Director of Nursing (DON) is the IP, but she was currently out on leave, and the interim IP was the Assistant Director of Nursing (ADON) . At that time, she indicated the ADON lacked a certification related to infection control. During an interview on 1/14/25 at 9:24 A.M., the Clinical and Quality Consultant indicated the facility lacked documentation on how many hours were dedicated to IP. At that time, she indicated the DON had a weekly schedule that she followed. During an interview on 1/14/25 at 10:56 A.M., the ADON indicated the DON was the IP. At that time, she further indicated that she was the interim IP when the DON was not in the building, but she was not certified. On 1/14/25 at 1:40 P.M., the Director of Nursing weekly routine provided by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-14 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a sanitary and home-like environment for 3 of 3 halls, 1 of 1 shower rooms reviewed for environment, and 19 of 19 resident personal refrigerator temperature logs reviewed. Personal items and linens were not labeled and uncovered, vent fans were caked with dust, toilets were soiled, paint was missing, baseboards were falling off or missing, and a toilet seat riser was uncovered on the floor under the sink in the shower rooms. (200 Hall, 300 Hall, 400 Hall, Shower Room, room [ROOM NUMBER], room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]-1, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, room [ROOM NUMBER]-1, room [ROOM NUMBER]-2, room [ROOM NUMBER], room [ROOM NUMBER]-2, room [ROOM NUMBER]-2) Findings include: 1. On 1/2/25 at 10:49 A.M., the following was observed in the shower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 3 of 3 residents reviewed for hospitalizations. The transfer discharge form was not completed. (Resident 27, Resident 37, Resident 13) Findings include: 1. On 1/6/25 at 11:20 A.M., Resident 27's clinical records were reviewed. Diagnoses included, but were not limited to anemia, dementia, neurogenic bladder, and chronic kidney disease, stage 4. The most current Quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, indicated Resident 27 had moderate cognitive impairment, required set up or clean up for eating, bed mobility, toilet use and transfer, and had a suprapubic catheter. On 1/6/25 at 11:47 A.M., Resident 27's clinical records indicated he was hospitalized from [DATE] to 12/5/24. Clinical records lacked transfer/discharge paperwork. During an interview on 1/9/25 at 1:35 P.M., Licensed Practical Nurse (LPN) 9 indicated she was unable to find the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 3 of 3 residents reviewed for hospitalizations. The bed hold form was not completed. (Resident 27, Resident 37, Resident 13) Findings include: 1. On 1/6/25 at 11:20 A.M., Resident 27's clinical records were reviewed. Diagnoses included, but were not limited to anemia, dementia, neurogenic bladder, and chronic kidney disease, stage 4. The most current Quarterly Minimum Data Set (MDS) assessment, dated 11/14/24, indicated Resident 27 had moderate cognitive impairment, required set up or clean up for eating, bed mobility, toilet use and transfer, and had a suprapubic catheter. On 1/6/25 at 11:47 A.M., Resident 27's clinical records indicated he was hospitalized from [DATE] to 12/5/24 for sepsis and weakness with a one week history of nausea, vomiting, diarrhea and abdominal pain. Clinical records lacked bed hold paperwork. During an interview on 1/9/25 at 1:35 P.M., Licensed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to provide adequate supervision and prevent falls for 2 of 6 residents reviewed for accidents. Fall assessments and care plans were not updated in a timely manner and family was not notified a fall. (Resident 44, Resident 33) Findings include: 1. On 1/6/25 at 1:23 P.M., Resident 44's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus, hypertension, and dementia. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 11/5/24, indicated Resident 44 had a severe cognitive impairment, and he required substantial or maximal assistance on toileting and transferring. The MDS indicated Resident 44 had 2 or more falls since the last MDS assessment. Resident 44's care plans included, but were not limited to, a potential for falls, dated 11/8/24. Resident 44's fall history included, but was not limited to the following: Fall 1--1/12/24 Resident 44's clinical record lacked a care plan update and indicated the fall assessment for the 1/12/24 fall was completed on 2/5/24. Fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice for 3 of 3 residents reviewed for respiratory care. Oxygen tubing was not changed, portable oxygen tanks were not checked, and oxygen concentrator machine filters were not cleaned. (Resident C, Resident B, Resident D) Findings include: 1. On 1/2/25 at 1:57 P.M., Resident C was observed laying in bed wearing oxygen per nasal cannula at 2 liters per minute (LPM). The tubing was dated 12/8/24. The oxygen concentrator machine filter was soiled with dust and hair. On 1/8/25 at 9:57 A.M., Resident C was observed laying in bed wearing oxygen per nasal cannula at 2 LPM. The oxygen concentrator machine filter was soiled with dust and hair. During an observation of room [ROOM NUMBER] on 1/13/25 11:40 A.M., the Maintenance Supervisor came into the room, observed the oxygen concentrator machine filter was soiled with dust and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-14 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure 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 ensure competent nurse staffing necessary to provide services to meet resident rights and well-being for 1 of 3 residents reviewed for respiratory care and 1 random observation. A resident's order for an expectorant was not administered, a wound dressing was initiated without an order or notification to the physician, and a bandage was left on a resident for six days. (Resident 43, Resident 46) Findings include: 1. On 1/6/25 at 10:42 A.M., Resident 43's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and allergic rhinitis. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/24, indicated cognition status could not be assessed, and resident required substantial to maximal assistance with bed mobility and transfers, and was dependent on staff for toileting and bathing. Physician orders included, but were not limited to: guaifenesin ER (extended release) (an expectorant) 600 mg (milligrams) twice a day through 1/4/25, ordered 12/28/24.…
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.
- Potential for harm · D2025-01-14 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 person-centered dementia treatment and services were provided for 2 of 4 residents reviewed for dementia care. (Resident 46, Resident 47) Findings include: 1. On 1/2/25 at 11:14 A.M., Resident 46 was observed sitting in a wheelchair in front of the nurses station with her head drooped down and eyes closed. Staff were observed walking by the resident without engaging. On 1/8/25 at 9:12 A.M., Resident 46 was observed sitting in a wheelchair by the nurses station with her eyes closed. Staff were observed walking by the resident without engaging. On 1/8/25 at 9:34 A.M., Resident 46 was assisted to the activities room and transferred from a wheelchair to a recliner facing a television. On 1/8/25 at 1:32 P.M., Resident 46 was observed sitting in her room in a wheelchair with a family member. The family member indicated when he got to the facility that day, Resident 46 was sitting at the nurses station weeping. On 1/9/25 at 10:51 A.M., Resident 46 was observed sitting in a wheelchair at the nurses station.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure proper storage of medications in 2 of 3 medication carts. Narcotic boxes were not double locked in the medication carts. (200 Hall medication cart, 400 Hall medication cart) Findings include: 1. On 1/2/25 at 9:58 A.M., the narcotic box was observed unlocked in the 200 Hall medication cart. On 1/9/25 at 11:23 A.M., the narcotic box was observed unlocked in the 200 Hall medication cart. 2. On 1/2/25 at 10:00 A.M., the narcotic box was observed unlocked in the 400 Hall medication cart. During an interview on 1/2/25 at 10:03 A.M., Registered Nurse (RN) 21 indicated the narcotic boxes in the medication carts should be locked when not in use. On 1/14/25 at 11:20 A.M., a current Controlled Substances Policy, revised April 2021, was provided by the Clinical and Quality Consultant and indicated Purpose: To ensure appropriate and consistent procedures for safeguarding controlled substances are followed from deliver through the actual administration and/or destruction of the medications . all schedule 2 [two]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen. A resident's oxygen was not given as ordered and the oxygen concentrator and filter were not cleaned. (Resident 12) Findings include: On 12/6/23 at 2:09 P.M., Resident 12 was observed laying in bed watching TV with oxygen on per nasal cannula at 3 LPM (liters per minute). The oxygen tubing was not dated and the oxygen concentrator machine and filter were dusty. On 12/13/23 at 11:08 A.M., Resident 12 was observed laying in bed with the oxygen concentrator set at 3 LPM oxygen per nasal cannula. The oxygen concentrator machine and filter were dusty. On 12/11/23 at 12:49 P.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to Chronic Obstructive Pulmonary Disease (COPD). The most recent MDS (Minimum Data Set) Assessment, dated 9/15/23, indicated Resident 12's cognition was moderately impaired and he required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to provide hot food for 1 of 1 lunch trays sampled on 1 of 2 halls. Food that was supposed to be served hot was served cold. (300 hall and 400 hall) Finding includes: During an interview on 12/12/23 at 10:08 A.M., two anonymous residents indicated the food that should be hot was served cold. During an observation on 12/13/23 at 11:15 A.M., the 300 hall and 400 hall trays were being distributed on an open cart. The individual trays were covered with an insulated dome without the use of a base. At 11:22 A.M., a hall tray was sampled. The Bar-B-Que Chicken temperature was 102.6 degrees Fahrenheit, felt cold, and tasted cold. During an interview on 12/14/23 at 9:43 A.M., the Dietary Manager indicated she would expect the chicken to be 160 degrees Fahrenheit when the residents received a tray. On 12/13/23 at 2:45 P.M., Corporate Consultant 1 provided a current Food Temperatures policy, reviewed 4/21, that indicated, .typical serving temperature standards: Solids (meats/vegetables): 160 degrees Fahrenheit . 3.1-21(a)(2)
- No harm found · C2026-03-04 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 past state survey results were readily available to visitors, residents, and other individuals without them having to ask to review them for 2 of 2 days reviewed for the survey period. Finding includes:On 3/3/26 at 12:34 P.M., during the resident council meeting, residents indicated there was a sign on the wall at the nurse's station and the state survey results should be in a binder under it. On 3/3/26 at 7:00 A.M., a sign was observed on the wall by the nurse's station that indicated the state survey results were in a slot below it, but the slot only contained a blue emergency preparedness binder. The survey results were not there. On 3/4/26 at 9:10 A.M., the same was observed. During an interview on 3/4/26 at 9:30 A.M., the Administrator indicated that the sign by the nurse's station should have been taken down because they no longer kept the past state survey results there. She went into the front business office and obtained a binder labeled survey history from the top of the filing cabinet…
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.
- No harm found · C2025-01-14 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets were posted and contained the correct information daily for 6 of 6 days reviewed. (January 2, 3, 8, 9, 13, 14, 2025) Findings include: On 1/2/25 at 10:24 A.M., Posted Nurse Staffing was observed hanging on the wall behind the nurse's desk dated correctly with the Day Shift section filled out. Under the column Shift and Schedule-Day- 6:00-2:00, 6:30-2:30, 7:00-3:00. Under the Registered Nurse (RN) Nursing Staff-Actual Hours Worked 8, Staffing Total 1. Under the Licensed Practical Nurse (LPN) Nursing Staff-Actual Hours Worked 8, Staffing Total 1. Under the Non Licensed Nursing Staff-Actual Hours worked 30, Staffing Total 4. It did not differentiate what hours the staff worked. On 1/3/25 at 1:06 P.M., Posted Nurse Staffing was observed hanging on the wall behind the nurse's desk dated correctly with the Day Shift section filled out. Under the column Shift and Schedule-Day- 6:00-2:00, 6:30-2:30, 7:00-3:00. Under the RN Nursing Staff-Actual Hours Worked 16, Staffing Total 2.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to REAL PROPERTY HEALTH FACILITIES — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.1 | -1.1 vs chain |
| Health inspection | 2 of 5 | 3.2 | -1.2 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 2.7 | -0.7 vs chain |
The other 8 homes this chain runs (chain average 3.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RUSH MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2012 |
| KINDER, ASHLEY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 05/01/2020 |
| MATHEIS, GREGORY | Individual | W-2 MANAGING EMPLOYEE | — | since 11/07/2016 |
| SMITH, BRADLEY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 08/01/2012 |
| BACON, MARK | Individual | CORPORATE DIRECTOR | — | since 06/29/2017 |
| BURKETT, KIPLAND | Individual | CORPORATE DIRECTOR | — | since 08/01/2012 |
| BYRNE, JOHN | Individual | CORPORATE DIRECTOR | — | since 08/01/2012 |
| JARMAN, RONALD | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| MOHR, GERALD | Individual | CORPORATE DIRECTOR | — | since 01/01/2020 |
| SPURLIN, MARK | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| WILKINSON, PAUL | Individual | CORPORATE DIRECTOR | — | since 06/29/2017 |
| HAWORTH, ALBERT | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2021 |
| MARSH, DAWN | Individual | CORPORATE OFFICER | — | since 04/15/1994 |
| REAL PROPERTY HEALTH FACILITIES CORP | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 08/01/1989 |
| PENN, CHRISTINA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2015 |
| SMYTH, CHAD | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/30/2015 |
CMS files one row per role, so the 19 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 79% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 29% 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155632. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, 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.