Waters Of Wabash Skilled Nursing Facility East The
1900 N Alber St, Wabash, IN 46992 · For profit - Limited Liability company · 84 certified beds · (260) 563-7427 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
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 14.3% | 11.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.1% | 5.5% | 5.4% | worse |
| 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 | 2.3% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 28.2% | 25.2% | 6.5% | worse 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 | 4.6% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.9% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.7% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 95.5% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.9% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.4% | 23.3% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.8% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 5.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 78.3% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 14.1% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.9% | 10.8% | 12.0% | 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.
54.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 54.8%CMS range 41.9–66.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 8.7–18.4 | 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 | 47.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 52.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 39.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.88 | 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 84 beds and averages 45.6 residents a day — about 54% occupied, or roughly 38 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 3.32 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 2.97 hrs/resident/day on weekends vs 3.47 on weekdays — 14% thinner on weekends. RN hours go from 0.35 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2026-03-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident's wound prevention interventions were implemented and the care plan was updated for 1 of 3 residents reviewed for wounds. (Resident C)Findings include: The following was observed on 3/16/26: At 9:50 a.m., Resident C laid on his back on an air mattress with his head elevated, a foot cradle (to keep the weight of the bed covering off a resident's feet and legs) was positioned at the end of the bed. His feet were directly on the mattress. His blankets covered his left foot, and he had a nonskid sock on his right foot. At 12:16 p.m., he was lying on his back on an air mattress with his head elevated. The foot cradle was positioned at the end of the bed. His feet were directly on the mattress. His blankets covered his left foot, and he had a nonskid sock on his right foot.At 3:23 p.m., he was lying on his back on an air mattress with his head elevated. The foot cradle was positioned at the end of the bed. His feet were directly on the mattress. His blankets covered both feet.Resident C's clinical…
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 · D2026-03-17 · tag F0659 — isolatedProvide care by qualified persons according to each resident's written plan of care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure Qualified Medication Aides (QMA) were completing wound treatments within their scope of practice for 1 of 3 residents reviewed for wounds. (QMA 5, 7, 9 and Resident D)Findings include:Resident D's clinical record was reviewed on 3/16/26 at12:09 p.m. Diagnoses included chronic systolic (congestive) heart failure, chronic pain syndrome, personal history of other venous thrombosis and embolism (blood clots), unspecified protein-calorie malnutrition, unspecified atherosclerosis of native arteries of extremities, bilateral legs, and restless legs syndrome. A Nurse Practitioner (NP) wound note, dated 12/30/25 at 10:08 a.m., indicated an original wound to the left second toe noted on 8/19/25 was resolved, but a new wound developed on the left great toe, initially presenting with purple discoloration concerning for an evolving arterial ulcer. Although vascular studies later showed adequate perfusion, the great toe wound progressed with intermittent redness, dryness, fluctuating exudate, and periods of 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 · D2026-02-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview and record review, the facility failed to protect a resident's right to be free from staff abuse during care for 1 of 3 residents reviewed for abuse. (Resident C)Findings include:Resident C's clinical record was reviewed on 2/13/26 at 12:50 p.m. Diagnoses included dementia and osteoporosis without fracture.A quarterly, 12/17/25, Minimum Data Set (MDS) assessment indicated Resident C's cognition could not be assessed. Resident C was dependent on staff members for toileting hygiene, maximum assistance for upper and lower body dressing, moderate assistance for changing from lying to a sitting position and maximum assistance.Resident C's current care plans included the following: I have a self-care deficit and require assistance with ADLs (activities of daily living) to maintain the highest possible level of functioning as evidenced by the following limitations and potential contributing factors: weakness, unsteady gait, and dementia. Interventions included: provide assistance with all ADLs as required per my dependence on needs: eating, transferring, bed mobility,…
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 · D2025-12-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure an allegation of staff to resident physical and verbal abuse was reported to the State Agency (Indiana Department of Health) for 1 of 3 residents reviewed for abuse. (Resident E)Findings include:Resident E's clinical record was reviewed on 12/10/25 at 9:50 a.m. Diagnoses included dementia and major depressive disorder.Current physician's orders included behavior monitoring every shift for restlessness, nervousness, mood disturbances (8/7/25), memantine 10 mg give one tablet by mouth every morning and at bedtime for dementia (11/2/23), and sertraline 100 mg give one table in the morning for depression (3/7/25).A quarterly Minimum Data Set (MDS) assessment, dated 9/17/25, indicated Resident E was severely cognitively impaired, did not experience hallucinations or delusions, and displayed no physical or verbal symptoms towards others during the assessment period.A care plan, initiated 11/17/25, indicated Resident E displayed behavioral symptoms related to dementia which included restlessness, nervousness, and mood…
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 · D2025-12-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to investigate an allegation of staff to resident abuse and failed to implement the facility policy to protect residents following an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident E)Findings include:An anonymous allegation of staff to resident verbal abuse involving Resident E was received by the Indiana Department of Health on 11/14/25. During an interview with the Dietary Manager (DM), on 12/8/25 at 12:59 p.m., she indicated, on 11/3/25, she observed CNA 2 become aggressive with Resident E during lunch. Resident E was sitting at her dining table when CNA 2 placed a drink for another resident on the table. When Resident E and CNA 2 reached for the drink at the same time, Resident E scratched the CNA's hand. CNA 2 grabbed both Resident E's wrists and in a very loud voice said, Don't scratch me!. The DM indicated she went to the DON's office to report the incident. She was later told, by the Administrator, there were no findings regarding the incident. The DM asked the Administrator if he needed 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.
- Potential for harm · F2025-05-22 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 the Dietary Manager completed the required education to meet the qualifications for a Dietary Manager. This deficiency had the potential to impact 56 of 56 residents who received meals from the facility kitchen. Findings include: During an interview on 5/18/25 at 9:49 a.m., the Dietary Manager indicated she did not have a certification qualifying her to act as Dietary Manager. She was hired in December of 2024 and had received no training at that time, or since. During an interview with the Administrator on 5/20/25 at 11:48 a.m., he indicated he was aware the Dietary Manager was not certified to act as Dietary Manager. During an interview with the Regional Director of Operations on 5/20/25 at 12:07 p.m., he indicated he was aware the Dietary Manager was not certified to act as Dietary Manager. He planned to enroll her in an appropriate training program to get her certification. He was aware she had been employed as the Dietary Manager since December of 2024. A current facility policy, dated 11/3/17, titled Food &…
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 · F2025-05-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions related to kitchen equipment, utensil storage, food storage, and chemical storage. This deficient practice had the potential to affect 56 of 56 residents who received food from the facility kitchen. Findings include: During a kitchen observation on 5/18/25 at 9:49 a.m., accompanied by the Dietary Manager, the following was observed: Next to the front service window, an open container of brown sugar was on the countertop with a scoop (including the handle) laying inside the brown sugar. The microwave had splatters of eggs and other unidentifiable foods on the bottom, three inside walls, and inside the door. The many food splatters varied in size and were dry and thick in appearance. The upper cabinets to the left of the service window contained different colored splatters on the outsides of the doors. Splatter sizes ranged from the size of a dime to the size of a quarter. Under the cabinets, a pair of discarded kitchen gloves lay on the countertop along…
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 before2025-05-22 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure meals were palatable for 17 of 31 residents reviewed for palatable meals. (Residents 3, 4, 5, 9, 17, 19, 23, 25, 33, 34, 36, 40, 49, 50, 51, 108, and 109) Finding includes: During an interview, on 5/18/25 at 11:04 a.m., the Resident 109's representative indicated the food at the facility was terrible. The resident's representative had talked with the Administrator and sent a letter to the vice president of the company. The food was worse than terrible. The roll yesterday was as hard as a rock. He could bounce it off the floor. The residents were served some kind of soup yesterday and were unable to tell what it was supposed to be. The food was cold, did not look good, and tasted terrible. He sent back the resident's breakfast three days in a row because it was cold and looked terrible. Sometimes, there was very little on the plate. One time, there was just a hot dog on the plate. He kept hearing everyone's hands were tied when trying to make the food more pleasing During an interview, on 5/18/25 at…
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 · D2025-05-22 · 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 provide a dignified dining experience for 2 of 20 residents observed during meal service in the main dining room. (Residents 22, 45) Findings include: 1. During an observation, on 5/19/25 at 11:54 a.m., Resident 22 sat in a wheelchair at the dining table. Her chair was low in comparison to the table height and put the resident's chin roughly four inches from the top of the table. On 5/19/25 at 12:30 p.m., Resident 22 was sitting very low in a wheelchair. The resident's chin was level with the tabletop. Resident 22 indicated it was difficult for her to eat. On 5/19/25 at 6:06 p.m., Resident 22 sat in a wheelchair at the dining table. She was eating while hunched over and leaning to the right. On 5/21/25 at 8:09 a.m., Resident 22 sat in her wheelchair at the dining table. Her chin was level with the tabletop. Resident 22's clinical record was reviewed on 5/21/25 at 8:55 a.m. Diagnoses included dementia, osteoarthritis, and heart failure. Current orders included a regular diet and may use her personal cup during…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-22 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide notification of Medicare non-coverage for 2 of 3 residents reviewed for Beneficiary Protection Notifications. (Residents 49, 14) Findings include: On 5/19/25 at 2:00 p.m., the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Forms were reviewed and indicated the following: 1. Resident 49 admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day for Part A services was 2/19/25. The resident remained in the facility. The clinical record lacked Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). 2. Resident 14 admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day for Part A services was 4/25/25. The resident remained in the facility. The clinical record lacked Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). During an interview, on 5/19/25 at 2:31 p.m., the Business Office Manager…
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 16 citations
- Potential for harm · D2025-05-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide clean equipment for 2 of 19 residents reviewed for wheelchair cleanliness. (Residents 22 and 34) Findings include: 1. During an observation, on 5/19/25 at 12:30 p.m., Resident 22's outer left panel of her wheelchair was smeared with a dark substance. During an interview, on 5/19/25 at 6:38 p.m., CNA 11 and CNA 12 indicated third shift CNAs deep cleaned the resident wheelchairs, but it was really every staff member's responsibility. During an observation, on 5/21/25 at 8:16 a.m., Resident 22's wheelchair had honey colored streak marks down the outside panels of her wheelchair. A dark reddish colored substance was smeared over the outer panels of her wheelchair. During an interview, on 5/21/25 at 10:04 a.m., LPN 4 indicated third shift CNAs were responsible for cleaning resident wheelchairs. There was a CNA book at the nurse's station that had the cleaning schedule for resident wheelchairs. Resident 22's wheelchair was scheduled for deep cleanings every Wednesday night. During an observation, on 5/21/25 at 10:13 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 · D2025-05-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to implement fall precautions and update care plan interventions following falls for 1 of 2 residents reviewed for accidents. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 5/20/25 at 9:57 a.m. Diagnoses included syncope (fainting) and collapse, repeated falls, chronic kidney disease, and protein-calorie malnutrition. An annual Minimum Data Set (MDS) assessment, dated 2/19/25, indicated Resident 41 was severely cognitively impaired, used a walker and/or wheelchair to ambulate, required supervision when eating, maximum assistance for toileting and showering, was frequently incontinent of both bladder and bowel, had repeated falls, and a history of syncope and collapse. Current orders included padded side rails related to seizure precautions (5/19/25), check wander alert bracelet placement (8/21/24), check bed/chair alarm placement every shift for frequent falls (8/15/24), and acetaminophen 650 mg by mouth every four hours as needed for pain/discomfort (11/2/23). A current care plan,…
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 · D2025-05-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 implement interventions to prevent and promote the healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 109) Finding includes: During an observation, on 5/19/25 at 9:12 a.m., Resident 109 rested in his bed on his back. During a continuous observation, beginning on 5/20/25 at 2:26 p.m., the resident was lying in his bed on his back. Moon boots (designed to prevent or reduce the risk of pressure injuries) set in a chair beside his bed. At 2:33 p.m., the resident turned on his call light. LPN 4 immediately entered the resident's room, talked with him, then exited his room. At 2:37 p.m., the resident's moon boots remained set on the bedside chair. At 2:42 p.m., the resident turned on his call light. At 2:46 p.m., CNA 5 entered the resident's room. She indicated the resident was asleep. The moon boots remained set on the bedside chair. At 3:26 p.m., the resident was lying in his bed on his back, and the moon boots remained set on the bedside chair. During an 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 before2025-05-22 · 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 observation, record review, and interview, the facility failed to implement seizure precautions for 1 of 2 residents reviewed for accidents. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 5/20/25 at 9:57 a.m. Diagnoses included syncope (fainting) and collapse, repeated falls, chronic kidney disease, and protein-calorie malnutrition. An annual Minimum Data Set (MDS) assessment, dated 2/19/25, indicated Resident 41 was severely cognitively impaired, used a walker and/or wheelchair to ambulate, required supervision when eating, maximum assistance for toileting and showering, was frequently incontinent of both bladder and bowel, had a history of repeated falls, and a history of syncope and collapse. An Interdisciplinary Team (IDT) progress note, dated 5/19/25 at 1:35 p.m., indicated Resident 41 had an unwitnessed fall that morning around 5:10 a.m. She was found on the floor by her bed, laying on her left side, with her blankets wrapped around her body. She was able to move all her extremities. Neurological checks were initiated, no injuries were…
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 · D2025-05-22 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program activities to prevent repeat deficiencies identified during a revisit to the annual survey. Finding includes: Review of the Summary Statement of Deficiencies (2567), for the facility's last annual Recertification and Licensure Survey completed on 5/22/25, indicated the facility had deficiencies related sanitary conditions related to kitchen equipment and food storage (F812). During an observation, on 6/24/25 at 9:02 a.m., accompanied by the Dietary Manager, the facility kitchen was found to be maintained in an unsanitary condition related to food storage and equipment maintenance. During an interview, the Dietary Manager indicated she was unable to provide audit tools for cleaning or cleaning schedules for the kitchen. Review the facility's plan of correction (2567), signed by the Administrator on 6/12/25, indicated the facility's F812 Food Safety Audit Tool will be completed five times per week for four weeks, then 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 · Dcited before2025-05-22 · 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 consistently implement facility policy for enhanced barrier precautions for staff to identify those residents requiring enhanced barrier precautions for 1 of 3 residents reviewed for enhanced barrier precautions. (Resident 21) Finding includes: During an observation, on 5/19/25 at 9:15 a.m., Resident 21 lay on his bed on top of the blankets looking at a phone. A heel boot was lying on the floor beside the bed. No signage for transmission-based precautions was on his door During an observation, on 5/20/25 at 9:49 a.m., Resident 21 sat in his wheelchair in his room with a heel boot on his right foot. No signage for transmission-based precautions was on his door. During an observation, on 5/21/25 at 9:19 a.m., Resident 21 sat in his wheelchair in his room. He had a heel boot on his right foot. No signage for transmission-based precautions was on his door. Resident 21's clinical record was reviewed on 5/20/25 at 3:26 p.m. Diagnoses included chronic diastolic (congestive) heart failure, peripheral vascular…
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 before2025-03-12 · 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 and interview, the facility failed to maintain appropriate infection control practices during urinary catheter care for 1 of 1 residents reviewed for Enhanced Barrier Precautions. (Resident D) Findings include: Resident D's clinical record was reviewed on 3/11/25 at 2:10 p.m. Diagnoses included aftercare following joint replacement surgery, weakness, congestive heart failure, and chronic kidney disease. Current physician orders included, but were not limited to, catheter care every shift and ensure catheter drainage bag is below the waist and covered, change catheter as needed for leakage or dislodgement. Change catheter drainage bag at the time of catheter change. During a catheter care observation for Resident D, on 3/12/25 at 9:25 a.m., CNA 2 performed hand hygiene with soap and water before donning gloves. CNA 2 failed to don a gown before starting Resident D's catheter care. Resident D had EBP signage displayed on the door. During an interview, at the time of observation, CNA 2 indicated she failed to put on a gown before providing Resident D's catheter…
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 before2024-03-21 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide palatable food to 23 residents in the main dining room during meal service. Findings include: During an interview, on 3/20/24 at 10:34 a.m., Resident 19 indicated the meat was dry and it took a while for everyone to be served. During an interview, on 3/20/24 at 10:48 a.m., Resident 12 indicated the meat was hard at times and the food was usually cold when she ate in her room. During a meal observation, on 3/20/24 at 12:18 p.m., CNA 6 was unable to cut a resident's brisket with a butter knife. She retrieved a different knife from the kitchen to cut the meat. During a meal observation, on 3/20/24 at 12:19 p.m., CNA 6 had difficulty cutting a piece of brisket for another resident. During an observation, on 3/20/24 at 12:21 p.m., Resident 16 carried her plate to the kitchen window and requested a salad as she indicated her food was inedible. During an interview, on 3/20/24 at 12:33 p.m., Resident 16 indicated the food was always terrible and usually inedible. She was unable to eat the meat, so she…
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 before2024-03-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to maintain infection control practices while serving food to 23 residents in the main dining room, in accordance with facility policy for meal service. Findings include: During a meal observation, on 3/20/24 at 12:18 p.m., CNA 5 pulled bread from the plastic wrapper with her bare hands on two separate occasions. Both residents had eaten the bread that was touched during the meal observation. During an interview, on 3/20/24 at 12:35 p.m., CNA 5 indicated she removed bread from the wrapper with her bare hands when she should have used a glove. A current undated facility policy titled Policy and Procedure Meal Service, provided by the Administrator on 3/21/24 at 1:45 p.m., indicated the following.there is no bare hand contact with ready to eat foods 3.1-21(i)(3) This citation relates to Complaint IN00427042.
- Potential for harm · D2024-01-25 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure residents were assessed to determine ability to self-administer medications prior to self-administering for 2 of 3 residents observed during random observations. (Resident E and Resident D) Findings include: 1. During an interview with Resident E, on 1/24/24 at 11:10 a.m., there was a clear bag with several boxes of medication in it and a medication bottle next to the bag located on his overbed table, next to his bed. He indicated the bag contained his eye drops that he administered to himself. He had one eye drop that he put in his eye four times a day, three eye drops twice a day, and one eye drop once a day. He identified the drops by the color of the lids on the bottles. There were drops that he had to wait 10 minutes before putting in the next drop and asking the nurses to run back and forth to administer them was ridiculous. Resident E's clinical record was reviewed on 1/24/24 at 11:49 a.m. Diagnoses included type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema 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 · D2024-01-25 · 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 was supervised per facility policy during a nebulizer treatment for 1 of 1 resident randomly observed for respiratory treatment during a medication administration observation. (Resident H) Findings include: During an observation of a medication administration with LPN 15, on 1/25/24 at 9:31 a.m., an alarm sounded from her phone in her pocket. She indicated it was an alarm to remember to get a resident off his breathing treatment. Upon entering resident H's room, his wife was standing at the bedside, and he was lying in bed, with a nebulizer mask on his face and the nebulizer machine was running. LPN 15 placed an oximeter on his index finger on his right hand and listened to his lung sounds with a stethoscope. After exiting his room, she indicated she was not aware that he could not administer is own breathing treatments, even with his wife in the room, or that she was to supervise him during the treatment. Resident H's clinical record was reviewed on 1/25/24 at 9:57 a.m. Diagnoses included,…
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 · D2024-01-25 · 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 record review and interview, the facility failed to administer medications per physician's order for 2 of 2 residents reviewed for following physicians' orders for narcotics. (Resident F and Resident J) Findings include: 1. Resident F's clinical record was reviewed on 1/24/24 at 1:56 p.m. Diagnoses included unilateral pulmonary emphysema (Macleod's syndrome), type 2 diabetes mellitus with foot ulcer, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and low back pain. Review of the resident's Medication Administration Record (MAR) for October 2023 indicated an order for oxycodone-acetaminophen (narcotic pain reliever) 10-325 mg (milligram) at bedtime for severe pain. The clinical record did not indicate a PRN (as needed) order for the oxycodone-acetaminophen. His narcotic count sheets indicated he was administered oxycodone-acetaminophen 10-325 mg in contradiction with his physician orders on 10/24/23 at 8:00 a.m. by LPN 15, on 11/20/23 at 8:30 a.m. by QMA 23, on 11/21/23 at 8:33 a.m. by QMA 23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · 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 and interview, the facility failed to ensure resident's topical medication was stored securely for 2 of 2 random observations. Findings include: During an initial tour of the facility, on 1/24/24 at 9:04 a.m., a medication cup containing a white cream and two medication cups containing a white powdery substance were observed on an entrance table in a common area on the 100 hall. The medication was sitting next to a drinking tumbler and a can of juice. During an interview with LPN 17, on 1/24/24 at 9:07 a.m., she indicated it looked like nystatin (anti-fungal medication) and cream for a resident's buttocks, and it should not had been there. During an interview with CNA 3, on 1/24/24 at 9:25 a.m., she indicated the medications were for specific residents and that she got them from the top of the treatment cart provided by the nurse. She normally got them from the treatment cart and placed them in the resident's room, so when she got the resident cleaned up, the nurse would apply the medication on the resident. During an interview with Housekeeper 31, on 1/24/24 at…
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 before2023-06-30 · 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 provide physician-ordered enhanced barrier precautions (EBP) for 3 of 6 residents reviewed for transmissions-based precautions (Resident 3, Resident 37, and Resident 95). Findings include: 1. Resident 37's clinical record was reviewed on 6/28/23 at 9:23 a.m. Current physician orders included clean area to right coccyx with wound cleanser, pat dry, apply collagen to area, and apply foam dressing daily and as needed for dislodgement or soilage (6/15/22), enhanced barrier precautions every shift for open wound (5/11/23), and monitor area to right buttocks daily until resolved (4/29/23). A 6/21/23 significant change MDS (Minimum Data Set) assessment indicated the resident had a stage 2 pressure injury (a partial thickness of loss of skin with exposed dermis). A current care plan indicated the resident had an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to two open areas present on admission (initiated 6/15/23). During an interview, on 6/28/23 at…
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 before2023-06-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided and individualized interventions were implemented to prevent falls for 1 of 2 residents reviewed for falls (Resident 16). Findings include: During an observation, on 6/26/23 at 2:17 p.m., Resident 16 ambulated with a front-wheeled walker in his room without staff assistance. Non-skid strips were on the floor in front of his recliner. On 6/28/23 at 10:25 a.m., he was sitting in a recliner with his feet elevated. A front-wheeled walker and a wheelchair were along a wall across the room from him. On 6/28/23 at 10:41 a.m., he was ambulating in his room, unassisted and without a walker, towards the bathroom while holding onto his oxygen tubing. His clinical record was reviewed on 6/28/23 at 9:30 a.m. He was admitted to the facility on [DATE]. Diagnoses included, congestive heart failure, unsteadiness on feet, other abnormalities of gait and mobility, weakness, and repeated falls. Current physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-30 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the physician was notified of a significant weight loss for 2 of 3 residents reviewed for nutrition (Resident 30 and Resident 31). Findings include: 1 During an interview, on 6/27/23 at 11:16 a.m., Resident 31 indicated he had lost a lot of weight since he was admitted to the facility. Resident 31's clinical record was reviewed on 6/27/23 at 3:17 p.m. Diagnoses included type 2 diabetes mellitus, morbid obesity, gastroesophageal reflux disease, diarrhea, dysphagia, oropharyngeal phrases, major depressive disorder, chronic respiratory failure with hypoxia, acute pulmonary edema, and cardiomegaly. Current physician orders included mechanical soft diet with ground meat texture (2/13/23), fluoxetine (for depression) 20 mg daily (6/21/23), insulin glargine (for diabetes mellitus) 40 units daily at bedtime (1/10/23), Lasix (for swelling) 20 mg daily (10/19/22), metformin (for diabetes mellitus) 500 mg two times a day (4/20/23), and omeprazole delayed release (for gastrointestinal upset) 20 mg daily (6/3/23). A 6/7/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 INFINITY HEALTHCARE CONSULTING — 69 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 | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 1 of 5 | 2.1 | -1.1 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 3.7 | +0.3 vs chain |
The other 68 homes this chain runs (chain average 2.0★, per CMS)
Showing 40 of 68; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| JOHNSON MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2015 |
| WOLFE, MICHAEL | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 01/01/2020 |
| DECOLA, ROBERT | Individual | W-2 MANAGING EMPLOYEE | — | since 02/16/2019 |
| BERKHOUSE, STEVEN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 10/18/2021 |
| DUNKLE, DAVID | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2019 |
| MILLER'S HEALTH SYSTEMS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2015 |
| THE WATERS OF WABASH SKILLED NURSING FACILITY EAST LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2022 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
This home reported $405K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 155006. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-22, 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.