Vernon Health & Rehabilitation
1955 S Vernon St, Wabash, IN 46992 · Non profit - Corporation · 71 certified beds · (260) 563-8438 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (61%) runs well above the national median (45%)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 improved from 2 to 3 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 | 22.2% | 11.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.9% | 5.5% | 5.4% | typical |
| 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 | 0.0% | 1.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 25.2% | 6.5% | check this* — see note marked star 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 | 0.5% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 26.5% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 47.3% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.8% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.2% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 31.1% | 13.6% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.54 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.06 | 1.44 | 1.80 | worse |
* 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.
Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 71 beds and averages 44.2 residents a day — about 62% occupied, or roughly 27 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 4.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.11 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 3.70 hrs/resident/day on weekends vs 4.49 on weekdays — 18% thinner on weekends. RN hours go from 1.26 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Dcited before2025-12-19 · 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 record review and interview, the facility failed to consistently notify the nurse practitioner or physician of a resident's weight gain per order for 1 of 5 residents reviewed for unnecessary medications. (Resident 3) Finding includes: Resident 3's clinical record was reviewed on 12/17/25 at 10:48 a.m. Diagnoses included atherosclerotic heart disease of the native coronary artery with angina pectoris (buildup of plaque in the heart's arteries), chronic atrial fibrillation (irregular heartbeat), acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, cardiomegaly (enlarged heart), ischemic cardiomyopathy (weakened and enlarged heart caused by lack of blood flow), edema, and stage 3 chronic kidney disease. Current orders included bumetanide (diuretic) 2 mg twice a day (8/28/25), metolazone (diuretic) 2.5 mg every Monday (11/10/25), and daily weight in the morning - notify the Nurse Practitioner (NP) for 3-pound weight gain in 24-hour period or 5 pounds in 48 hours (7/22/25). A current care plan, initiated on 5/13/25, indicated the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medication error rate of less than 5%, related to medications not being administered via ordered route for 2 observed medication administration opportunities of 34, resulting in a medication error rate of 5.88%.Findings include:During a medication administration observation, on 12/19/25 at 8:08 a.m., the following was observed:LPN 7 prepared aspirin 81 milligrams (mg) and ferrous sulfate (iron) 325 mg for Resident 17. Both medications were removed from medication cards and placed into a plastic sleeve to be crushed. Both medications were crushed by a pill crusher then mixed with vanilla pudding before administering the mixture orally to Resident 17.Resident 17's current physician orders included aspirin 81 mg daily via gastrostomy tube ([g- tube], a tube placed directly into the stomach for feedings, medications, nutrients, etc) and ferrous sulfate 325 mg daily via g-tube.During an interview, on 12/19/25 at 8:13 a.m., LPN 7 indicated Resident 17 did not have an order to give medications orally. Both…
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 before2025-12-19 · 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, record review, and interview, the facility failed to remove discontinued medications from the Kalor Court medication cart for 2 of 15 residents' medications contained in the medication cart. (Resident 10 and Resident 26) Findings include: During an observation, on 12/16/25 at 10:51 a.m., of the Kalor Court medication cart with LPN 13, an undated and opened bottle of GenTeal Tears (eye drops) with a pharmacy sent date of 6/20/25 and instructions to instill two drops a day to both eyes four times a day for Resident 10 was in the top right-hand drawer of the medication cart. An undated opened bottle of Blink Tears (eye drops) with a pharmacy sent date of 10/22/25 and instructions to instill two drops into right eye every six hours for two days was in the top right-hand drawer of the medication cart for Resident 26. The bottle did not have a change of directions sticker or writing on it. At the same time as the observation, LPN 13 indicated when the last dose of the eye drops was given, they should have been discarded. 1. Resident 10's clinical record was reviewed…
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 · D2025-12-19 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure food was served under safe sanitary conditions during meal service regarding food handling for 1 of 35 residents who received meals orally. (Resident 37) Findings include:During a lunch service observation, on 12/15/25 at 12:31 p.m., the following was observed. CNA 14 touched a piece of bread inside a storage bag. With her bare hands, she reached into the storage bag and pulled the bread out with her bare hands before placing it on Resident 37's plate. She then proceeded to butter the bread before she picked the bread up with her bare hands, folded it in half, and handed it to Resident 37. Resident 37 took a bite out of the bread before placing it down on his plate.During an interview, on 12/15/25 at 12:48 p.m., CNA 14 indicated she did not recall pulling the bread from the plastic bag with her bare hands. She probably touched the bread with her bare hands when she folded it in half and handed it to the resident.On 12/19/25 at 9:05 a.m., the Corporate Consultant indicated the facility had already started in-servicing…
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 · D2025-12-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 offer eligible residents and/or the residents' representatives the current pneumococcal immunization according to the Centers for Disease Control and Prevention (CDC) guidelines for 2 of 5 residents reviewed for immunizations. (Resident 2 and Resident 7). Findings include: 1. Resident 2's clinical record was reviewed on 12/17/25 at 9:12 a.m. Diagnoses included tracheostomy status, heart failure, obstructive sleep apnea, chronic pulmonary edema, and emphysema. Current orders included Vaccines - May receive vaccines as scheduled as recommended per CDC, per responsible part consent unless contraindicated (4/30/25); Change Trach Shiley 8 cuffless and as needed once a day on the first day of the month (5/1/25); Albuterol nebulizer 0.083% inhale orally twice a day (5/11/25); and Ipratropium solution 0.02% inhale orally via nebulizer twice a day (5/11/25). Resident 2's immunization record was reviewed. A pneumococcal vaccination, Prevnar 13 (PCV13), was given…
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 before2025-08-25 · 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 interview and record review, the facility failed to administer medications according to physician order for 1 of 3 residents reviewed for medication administration. (Resident B) Findings include:Resident B's closed clinical record was reviewed on 8/25/25 at 10:44 a.m. Diagnoses included spastic quadriplegic cerebral palsy, dysphagia, and scoliosis. Current orders during the resident's stay included diazepam 2.5 milligram (mg) four times a day. A June 2025 Medication Administration Record (MAR) indicated he received four doses of diazepam on 6/7/25.A June 2025 narcotic count sheet indicated the medication was not removed for his 6/7/25 morning and noon doses. During an interview, on 8/25/25 at 4:25 p.m., the ADON indicated it showed the medication was documented as administered on the MAR but was not signed out on the controlled medication log. Staff should double check the medication, dispense the medication from the medication card, mark that the medication was prepped on the MAR, give the medication, and then mark that the medication administered on the MAR. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-14 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 the resident's representative was notified in writing of the transfer/discharge appeal rights for 1 of 3 hospitalizations. (Resident D) Findings include: Resident D's clinical record was reviewed on 5/12/25 at 3:24 p.m. Diagnoses included cerebral palsy, fracture of left lower leg, adult failure to thrive, Cauda Equina syndrome, severe intellectual disabilities, osteoarthritis, congenital deformities of feet, and diabetes. Review of a progress note, dated 3/18/25 at 10:24 a.m., indicated the resident yelled out upon being rolled onto his left side during care. The resident's left hip had non-pitting edema, was warm to the touch, and slight green discoloration was noted. An order was received for a left hip x-ray. The resident's representative was notified. A progress note, dated 3/19/25 at 12:45 a.m., indicated x-ray results showed resident had a left hip fracture. The resident's representative was notified. A progress note, dated 3/19/25 at 2:04 a.m., indicated an order was received to send the resident to the ER…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-14 · 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 interview and record review, the facility failed to follow physician orders regarding continuation of care for residents transported to day programs with medications for 2 of 3 residents reviewed for day services (Resident B and C). Findings include: During an interview, on 5/12/25 at 9:14 a.m., LPN 6 indicated the Social Services Director informed her of Resident B and Resident C's school schedules. LPN 6 was unsure if the school had received their medications, but sent Resident C to school anyway without checking on 5/6/25. The school immediately called the facility to have Resident C picked up, as he was not approved to attend at that time. During an interview, on 5/12/25 at 10:36 a.m., the DON indicated all documents were sent to the school before the residents could attend. She ordered the school their own medication supply, but it wasn't delivered at this time. Staff sent Resident C to school one day before his care plan was approved or medications were delivered. During an interview, on 5/12/25 at 11:05 a.m., the Administrator indicated Resident B was sent to school…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-22 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 provide adequate supervision and intervention to prevent physical resident-to-resident abuse for 4 of 4 residents reviewed for resident-to-resident abuse (Resident 19, Resident 21, Resident 43, and Resident 44). Findings include: 1. During an observation, on 10/15/24 at 9:15 a.m., Resident 43 stood up from her wheelchair, grabbed the nurses' desk to steady herself, her foot caught behind the wheelchair pedal, and she continued to lean forward to attempt to ambulate toward facility visitors. CNA 10 attempted to assist the resident to sit down in the wheelchair. Resident 43 declined and continued to ambulate toward the visitors with the assistance of CNA 10. Resident 43 reached out and attempted to grab a visitor's drink. CNA 10 redirected the resident by offering her a soda if she would sit down in the wheelchair. The resident agreed. During an observation, on 10/16/24 at 9:03 a.m., Resident 43 sat in her wheelchair beside the nurses' station near the administrator's office and facility's front entrance doors.…
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 before2024-10-22 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to provide an arbitration agreement that granted the resident or their representative the right to rescind the agreement within 30 days of signing it for 3 of 3 current residents reviewed who were admitted after 2/1/24 (Resident 26, Resident 44, and Resident 97). Findings include: During an interview conducted in conjunction with the entrance conference on 10/15/24 at 9:37 a.m., the Administrator indicated the facility offered arbitration agreements in the admission agreement packet. The sample admission agreement packet, provided as indicated above, was reviewed on 10/21/24 at 2:39 p.m. The admission/arbitration agreement packet lacked mention of the resident's or resident's representative's right to rescind the arbitration agreement within 30 days of signing the agreement. 1. Resident 44's 2/25/24, admission Agreement document indicated section 8.7 addressed an agreement not to elect a trial by jury of any fact trialable by a jury. The resident initialed agree. The form lacked mention of the resident's or resident's…
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 17 citations
- Potential for harm · D2024-10-22 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure privacy was provided during incontinence care for 2 of 3 residents reviewed for dignity (Resident 38 and Resident 39). Findings include. 1. During a random observation, on 10/17/24 at 1:29 p.m., Resident 39 was visible from the room door window as a new brief was applied by CNA 6. The resident's privacy curtain had not been pulled. During an interview, on 10/17/24 at 1:46 p.m., Certified Nurse Assistent (CNA) 6 indicated she would typically pull the curtain around the resident for privacy during care. She was in a hurry and had not done so for Resident 39. Resident 39's clinical record was reviewed on 10/21/24 at 4:48 p.m. Diagnoses included need for personal assistance with care. A quarterly Minimum Data Set (MDS) assessment, completed on 9/18/24, indicated Resident 39 was dependent on the staff for upper and lower body dressing, toileting hygiene, personal hygiene, and for rolling left to right. 2. During a random observation, on 10/17/24 at 1:36 p.m., CNA 6 assisted Resident 38 in his wheelchair to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-22 · 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 interview and record review, the facility failed to ensure interventions were implemented as ordered for a resident experiencing an acute medical decline for 1 of 2 residents reviewed for hospitalizations (Resident 18) Findings include: Resident 18's clinical record was reviewed on 10/17/24 at 3:44 p.m. Diagnoses included spastic quadriplegic cerebral palsy, severe intellectual disabilities, idiopathic epilepsy and epileptic syndromes, hyperglycemia (elevated blood sugar), and chronic kidney disease. A care plan, revised on 10/15/24 at 4:01 p.m., indicated the resident was unable to independently change positions, feed self, toilet self, or transfer self. He was dependent on staff for all needs to be met with routine, anticipatory care. A revision of his care plan, dated 9/17/24 at 12:47, included the addition of enhanced barrier precautions (EBP) because he had an indwelling device (suprapubic catheter) which placed him at higher risk for infection. Lab results, dated 10/10/24, indicated the resident's blood glucose level was 456 mg/dL (milligrams per deciliter). (Normal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-22 · 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 staff were qualified to perform GJ-tube care for 1 of 1 residents reviewed for feeding tubes. (Resident 42) Findings include: A clinical record review for Resident 42 was performed on 10/16/24 at 11:06 a.m. Diagnoses included anoxic brain damage, gastrostomy malfunction, lack of expected normal physiological development in childhood, artificial openings of the gastrointestinal tract, and a disorder of the autonomic nervous system which caused sympathetic storming (a condition which can occur with patients with severe brain injuries). Physician orders, dated 7/22/24, indicated the resident was to receive Pedia-Sure Enteral Formula through his gastrojejunostomy (GJ-tube). (A GJ-tube is a means of delivering food to someone who cannot eat by mouth.) The order specified 620 mils (milliliters)of Pedia-Sure combined with 340 mils of Pedialyte. The pump was to run at 42 ml/hour for 23 hours per day. The bag of formula was to be changed every 24 hours. A care plan, revised on 9/12/24 at 1:36 p.m., indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 shift to shift narcotic count and reconciliation was completed for 2 of 5 carts reviewed for medication reconciliation. (Kalor Hall and [NAME] Hall) Findings include: 1. During a medication storage observation of the Kalor Hall medication cart, on 10/21/24 at 1:21 p.m., accompanied by LPN 4, the Narcotic Sheet Log/ Tracking Form was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card, liquid, and/or bottle count: 10/8 on day shift and night shift 10/9 on day shift and night shift 10/10 on day shift 10/11 on day shift October 2024- lacked a shift-to-shift narcotic reconciliation signatures: 10/12 on day shift and night shift 10/15 on day shift 10/18 on day shift During an interview, at the time of the observation, LPN 4 indicated the narcotic count was completed by the oncoming nurse and offgoing nurse during shift change. 2. During a medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-22 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure monitoring of vital signs parameters as ordered for 1 of 1 residents randomly reviewed for parameters during medication administration. (Resident 27) Findings include: Resident 27's clinical record was reviewed on 10/21/24 at 8:35 a.m. Diagnoses included autistic disorder, essential hypertension (high blood pressure), hypothyroidism due to medicaments and other exogenous substances, and iron deficiency anemia. Current orders included atenolol (antihypertensive) 25 milligram (mg) tablet once daily with parameters of holding the medication if systolic blood pressure (top number) was less than 110 millimeters of mercury (mmHg) and/or heart rate was less than 55. A Medication Administration Report (MAR) for October 2024 indicated the resident received atenolol without obtaining blood pressure or pulse as follows: on 10/1, 10/2, 10/3, 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16. 10/17, 10/18, 10/19, 10/20, and 10/21. During a medication administration observation, on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 medication error rate of less than 5% related to medications not being administered according to orders for 2 of 36 opportunities of medication administration, resulting in a medication error rate of 5.56%. Findings include: During a medication administration observation, on 10/21/24 at 8:17 a.m., Licensed Practical Nurse (LPN) 4 was observed preparing mediations for Resident 27. The following was observed: LPN 4 prepared atenolol (high blood pressure) 25 milligram (mg) daily with parameters of holding the medication if systolic blood pressure was less than 110 millimeters of mercury (mmHg) and/or heart rate less than 55. Blood pressure and pulse were not obtained before administering the medication. LPN 4 prepared levothyroxine (hypothyroidism) 88 micrograms (mcg) daily. The medication was administered with eleven other medications, including but not limited to, famotidine (antacid) 20 mg twice daily, and ferrous sulfate (iron supplement) 325 mg daily. During an interview, on 10/21/24 at 8:34 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-10 · 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 interview and record review, the facility failed to ensure residents received medications per physician orders for 5 of 6 residents reviewed for medication administration. (Residents E, F, H, J, and K) Findings include: 1. The clinical record for Resident E was reviewed on 9/10/24 at 11:50 a.m. Diagnoses included spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, anemia, idiopathic epilepsy and epileptic syndromes with status epilepticus, neuromuscular dysfunction of bladder, aphasia, rheumatoid arthritis with rheumatoid factor of multiple sites, respiratory disorder, pain, and gastro-esophageal reflux disease. The clinical record indicated the following orders: baclofen (muscle relaxant) 10 mg three times daily (dated 6/3/24) and ferrous sulfate (iron supplement) 325 mg three times daily (dated 6/3/24). A care plan, dated 8/8/24, indicated Resident E was at risk for excessive tiredness, shortness of breath, and cold intolerance due to anemia. An intervention dated 8/8/24, indicated Supplement as ordered. A care plan, dated 2/3/17, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed ensure a resident's medication was available for administration for 1 of 6 residents reviewed for medication availability. (Resident G) Findings include: During an interview on 9/9/24 at 3:09 p.m., the DON indicated the facility had experienced two incidents of medication errors within the past 30 days. The DON provided a list of 6 residents who had medication errors within the past 30 days. Resident G (whose name was on the list) had not been administered a dose of diazepam 15 mg on 9/7/24 between 5:30 a.m. and 9:30 a.m. The facility had failed to secure a refill prescription, and the pharmacy could not refill the medication without a prescription from the provider. The DON indicated staff had attempted to call the Nurse Practitioner (NP) to get a renewed prescription for the medication with no response. The staff then called the alternate NP, with no response. After staff were unable to reach the NP, they called the DON. The DON instructed them to call the NP again and if no response inform her (DON). The staff were able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 ensure a resident's controlled substances were accounted for and were being reconciled during shift change for 1 of 3 residents reviewed for medication storage and availability. (Resident B) Findings include: Resident B's clinical record was reviewed on 7/17/24 at 1:41 p.m. Diagnoses include anoxic brain damage, cognitive communication deficit, history of disorder of muscle, unspecified-hypertonia, other muscle spasm, other seizures, and familial dysautonomia ([NAME]-Day). His medication orders included lorazepam (treat anxiety) 0.4 ml (milliliter) as needed with neurostorming episodes (4/12/24) and diazepam (treat muscle spasms) 1 ml as needed 30 minutes after Tylenol (pain reliever), if not effective (7/12/24). A quarterly Minimum Data Set (MDS) assessment, dated 6/5/24, indicated he was rarely/never understood. A pharmacy packing slip, with RN 6's signature and dated 3/21/24, indicated 60 mls of diazepam was delivered to the facility for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-18 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each 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 ensure residents were receiving dental services for 3 of 3 residents reviewed for mouth care. (Residents C, Resident E and Resident F) Findings include: 1. Resident C's clinical record was reviewed on 7/17/24 at 4:15 p.m. Diagnoses include spastic quadriplegic cerebral palsy, profound intellectual disabilities, dysphagia, oropharyngeal phase, aphasia, and posteruptive color changes of dental hard tissues. His orders included he may be seen by podiatrist, dentist, optometrist, psychiatrist, psychologist and an audiologist as needed (PRN). A significant change Minimum Data Set (MDS) assessment, dated 7/3/24, indicated he was severely cognitively impaired. He was dependent on staff for oral hygiene. He had obvious or likely cavity or broken teeth. His dental care plan indicated he was at risk for chewing complications related to posteruptive color changes of dental hard tissues, encounter for dental examination and cleaning without abnormal findings (2/2/22). His interventions included assist with oral care as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure changes in a resident's condition was reported immediately to the charge nurse for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: Resident B's clinical record was reviewed on 5/1/24 at 10:15 a.m. Diagnoses included, but were not limited to, anoxic brain damage, cognitive communication deficit, and tracheostomy status. The current physician's orders included, but were not limited to, baclofen (muscle relaxer) 12.5 mg (milligram) three times daily, clobazam (treat seizures) 5 mg twice daily, gabapentin (treat nerve pain) 1 ml (milliliter) twice daily, and levetiracetam (treat seizures) 1.5 ml twice daily. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident B was rarely, never understood. Resident B had an impairment to his bilateral upper and lower extremities, and was dependent on staff for showering, toilet hygiene, personal hygiene, upper and lower body dressing, putting on and taking off…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-24 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 was free from a physical restraint for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: On 4/23/24 at 4:03 a.m., Resident B was observed laying on a bed in his room. On 4/23/24 at 4:26 a.m., Resident B was observed scooting down the hallway on his buttocks. QMA 4 assisted Resident B off of the floor and sat Resident B in a chair in the dining room. QMA 4 walked down to Resident B's room, retrieved a helmet, and placed it on Resident B's head. On 4/23/24 at 4:57 a.m., Resident B was ambulating independently in the hallway with a soft helmet on. He wandered into an all-male resident room. On 4/23/24 at 11:23 a.m., Resident B was lying on a bare mattress in his room. On 4/24/24 at 7:15 a.m., Resident B was scooting on his buttocks in the hallway. On 4/24/24 at 7:42 a.m., Resident B was laying in a female resident's bed while she occupied it, in a room across from the nurse's station. On 4/24/24 at 8:12 a.m., Resident B was ambulating independently near the nurse's 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 · D2024-01-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 a resident with a brain injury was free from a significant medication error related to repeated missed doses of a muscle relaxer for 1 of 3 residents reviewed for medication availability. (Resident B) Findings include: Resident B's clinical record was reviewed on 1/11/24 at 8:32 a.m. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter, diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, spastic hemiplegic cerebral palsy, and other disorders of autonomic nervous system. His medications included dantrolene (treat muscle spasms) 50 milligrams (mg) three times daily (a.m., lunch and evening), amantadine (treat palsy like symptoms) 15 ml (milliliters) twice daily, Keppra (treat seizures) 5 ml twice daily, propranolol (treat blood pressure) 10 mg three times…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-15 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement individualized activities programming to meet individual resident needs for 6 of 7 residents with developmental disabilities reviewed for activities (Residents D, F, H, I, J, and C). Findings include: 1. Resident D's clinical record was reviewed 9/12/23 at 3:12 p.m. Current diagnoses included profound intellectual disabilities, personal history of traumatic brain injury, spastic quadriplegic cerebral palsy, cognitive communication deficit, and mixed receptive-expressive language disorder. The resident had a current physician's order which originated 8/25/16 and was continued as current in September 2023 for may participate in activities and recreations program. The resident did not have an order for bed rest or isolation. An 9/10/2014, OBRA Pre admission Screening indicated the resident could not make his wants and needs known and he depended on others to anticipate his needs. He had the social skills of a 6 (six) month old. He had the communication skills of an 8 (eight) month-old. 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 · Ecited before2023-09-15 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents and/or their representatives were not required to sign an agreement for binding arbitration as a requirement for admission to the facility for 6 of 7 current residents admitted after 8/1/22 (Residents 29, 46, 47, 48, 49, and 51). Findings include: During an interview conducted in conjunction with the entrance conference on 9/11/23 at 9:31 a.m., the Administrator indicated the facility offered arbitration agreements in the admission agreement packet. 1. Resident 29's 7/12/23, admission Agreement document indicated section 8.7 addressed an agreement not to elect a trial by jury of any fact trialable by a jury. The form did not indicate signing the binding arbitration agreement was voluntary. The admission Agreement did not have any section allowing the signer to decline the binding arbitration agreement. 2. Resident 46's, 8/8/23, admission Agreement document indicated section 8.7 addressed an agreement not to elect a trial by jury of any fact trialable by a jury. The form did not indicate signing the binding…
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 before2023-09-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to securely store medications during a random observation of 1 of 2 medication carts utilized for the east end of the 300 Hall. Finding includes: During a random observation, on 9/14/23 at 9:40 a.m., a medication cart outside of room [ROOM NUMBER] was unlocked and unattended. The drawers were easily opened and contained various liquid and tablet medications which included amlodipine (lowers blood pressure), baclofen (muscle relaxant), carbamazepine (for seizures), and potassium chloride liquid. No licensed staff members were in view of the medication cart. During an interview, on 9/14/23 at 9:46 a.m., LPN 5 locked the medication cart and indicated the medication cart should have been locked. During an interview, on 9/14/23 at 3:07 p.m., LPN 6 indicated the above-mentioned medication cart stored the medications for the four residents from room [ROOM NUMBER]. During an interview, on 9/15/23 at 10:44 a.m., the DON indicated the medication carts…
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 · D2023-09-15 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 provide recommended dental services to 1 of 2 residents reviewed for nutrition (Resident 43). Finding includes: During an interview, on 9/11/23 at 2:52 p.m., Resident 43 indicated she received ground up food and did not care for it. She had been told that the problem was taken care of, and she should be getting the regular diet. She had given up trying to find out when she could get regular food. Resident 43's record was reviewed on 9/13/23 at 9:09 a.m. Her current physician's orders included mechanical soft diet with thin liquids (12/17/21). The 12/14/22 annual Minimum Data Set (MDS) assessment indicated the resident had no natural teeth. The 8/22/23 quarterly MDS assessment indicated the resident was moderately cognitively impaired. She required supervision of one staff member for eating. No swallowing issues were identified. A Notification of Discharge from therapy, dated 12/1/22, indicated the resident's last day of speech therapy was 12/8/23. The reason for the discharge was the resident had plateaued…
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 STERLING HEALTHCARE — 5 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 | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 3.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 vs chain |
The other 4 homes this chain runs (chain average 3.2★, 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 |
|---|---|---|---|---|
| PUTNAM COUNTY HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2015 |
| BRAY, ARNOLD | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| FRY, JANICE | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| HEADLEY, MATTHEW | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2012 |
| LANDRY, KEITH | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 09/01/2020 |
| LEWIS, KATRINA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 12/21/2022 |
| SILLERY, DEBRA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 01/03/2026 |
| UNDERWOOD, WENDELL | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 05/20/2024 |
| WEATHERFORD, DENNIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/18/2012 |
| WOOD, MARK | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | — | since 08/05/2024 |
| STERLING HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| VERNON HEALTH OPERATIONS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| VERNON MANOR CHILDREN'S HOME, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2015 |
| MENORA, SHALOM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2025 |
| OFFERLE, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2022 |
| PATTON, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/16/2025 |
| HOOSIER CARE PROPERTIES INC | Organization | ADP OF THE SNF | — | since 05/01/2025 |
| MENORA FINACIAL CORP | Organization | ADP OF THE SNF | — | since 09/22/2025 |
| MFC INVESTMENT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 09/22/2025 |
| VERNON HEALTH PROPERTY LLC | Organization | ADP OF THE SNF | — | since 05/01/2025 |
CMS files one row per role, so the 34 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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 96% 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 $683K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155810. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
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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.