Cumberland Pointe Health Campus
1051 Cumberland Ave, West Lafayette, IN 47906 · Non profit - Corporation · 71 certified beds · (765) 463-2571 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 8.7% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.5% | 5.4% | check this* — see note marked star below the table |
| 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 | 15.7% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.3% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.4% | 11.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 12.8% | 23.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.1% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.2% | 13.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.0% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 18.6% | 22.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.5% | 10.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.86 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.51 | 1.44 | 1.80 | better |
* 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.
53.3% 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 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 76.1% 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 46 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 53.3%CMS range 43.9–62.1 | 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 | 12.7%CMS range 9.6–16.9 | 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 | 76.1% | 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 | 67.4% | 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 | 54.4% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 | 0.0% | 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 | 7.7%CMS range 4.5–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 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 71 beds and averages 58.7 residents a day — about 83% occupied, or roughly 12 beds typically open. It usually has some room. 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 2.91 hrs/resident/day on weekends vs 3.35 on weekdays — 13% thinner on weekends. RN hours go from 0.79 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2025-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident was kept safe during care and was evaluated for assistive devices to prevent an accident for 1 of 1 resident reviewed for accidents. (Resident 19) This deficient practice resulted in a right femoral neck fracture, a left scalp laceration, and a hematoma of the frontal scalp for Resident 19. Findings include: During an interview, on 6/12/25 at 3:40 p.m., Resident 19's daughter indicated she was the resident's Power of Attorney (POA) and was never called by the facility to inform her the resident had fallen. She heard about the fall from a Home Health Aide (HHA 6) she had hired for extra help to make sure the resident received all the care he needed. Resident 19's bed was up at waist level, and the resident was on his side when he fell off the bed and was found face down. This happened on a Sunday, and the facility did not call her. She found out from HHA 6. The resident was sent to the hospital and had surgery for his broken hip. He had a busted lip, hematoma on his forehead, multiple bruises and skin…
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 · D2025-06-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
2. The clinical record for Resident 29 was reviewed on 6/10/25 at 3:06 p.m. The diagnoses included, but were not limited to, diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility. A current physician's order, dated 12/22/21, indicated Resident 29 had a full code status. A care plan, dated 12/23/21, indicated advanced directives would be reviewed quarterly and honor Resident 29's medical POA's decisions. An Indiana Physicians Orders for Scope of Treatment (POST) form, dated 4/9/24, was signed by Resident 29's power of attorney (POA) and indicated the resident's code status was DNR (do not resuscitate). It was not signed by a physician. During an interview, on 6/11/25 at 10:00 a.m., Resident 29 indicated she wanted to be a DNR. During an interview, on 6/16/25 at 11:07 a.m., the Executive Director (ED) indicated the form should have been given to the physician to complete after it was filled out by the POA and the code status should have been updated to reflect Resident 29's wishes. A current facility policy, titled Guidelines for Advanced Directives,…
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 before2025-06-16 · 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
2. The clinical record for Resident 29 was reviewed on 6/10/25 at 3:06 p.m. The diagnoses included, but were not limited to, diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility. A quarterly MDS assessment was completed on 2/22/25. There was no documentation in the clinical record, a care plan meeting for the quarterly assessment was completed. An annual MDS assessment was completed on 5/22/25. There was no documentation in the clinical record, a care plan meeting for the annual assessment was completed. During an interview, on 6/16/25 at 11:06 a.m., the DON indicated care plan meetings should be completed on admission and quarterly. There should have been two care planning meetings completed. A current facility policy, titled Resident's First Meeting Guidelines, dated 3/7/19 and received from the DON on 6/16/25 at 11:57 a.m., indicated .Subsequent meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change .Subsequent meetings for Medicare residents should be conducted minimally quarterly and prior…
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 before2025-06-16 · 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 a blood pressure medication was administered according to the physician's orders for 1 of 1 resident reviewed for quality of care. (Resident 19) Findings include: The clinical record for Resident 19 was reviewed on 6/8/25 at 11:07 a.m. The diagnoses included, but were not limited to, congestive heart failure, dementia, diabetes mellitus, and hypertension. A care plan, dated 4/24/25, indicated Resident 19 had a potential for cardiovascular distress related to congestive heart failure. The approaches included, but were not limited to, medications as ordered, observe and report side effects, and observe for signs and symptoms of cardiovascular distress. A physician's order, dated 5/20/25, indicated to give furosemide (a diuretic medication which could lower blood pressure) 20 milligrams (mg) daily and to hold the medication for a systolic blood pressure less than 120. The Medication Administration Record (MAR), dated 5/1/25 through 6/4/25, indicated furosemide 20 mg was given out of the physician ordered parameters…
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 · D2025-06-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure physician's orders for the care and monitoring of a catheter were obtained upon admission for 1 of 1 resident reviewed for catheter. (Resident 104) Findings include: The clinical record for Resident 104 was reviewed on 6/12/25 at 1:55 p.m. The diagnoses included, but were not limited to, chronic kidney disease, diabetes mellitus, urinary tract infection, myoglobinuria, and urogenital implants. A facility admission observation and data collection form, dated 5/25/25 at 7:45 a.m., indicated the resident was admitted with an indwelling catheter. A care plan, dated 5/26/25, indicated the resident had a catheter. The approaches included, but were not limited to, record urinary output and provide care and change catheter per the physician's orders. Physician's orders related to the catheter, the catheter care, and catheter monitoring were not ordered until 5 days after the resident was admitted to the facility. During an interview, on 6/16/25 at 10:25 a.m., the Director of Nursing (DON) indicated standing orders should…
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 · D2025-06-16 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 staff followed the physician's orders related to a gastrostomy tube (g-tube) for 1 of 1 resident reviewed for gastrostomy tubes. (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 6/11/25 at 1:45 p.m. The diagnoses included, but were not limited to, gastrostomy status, type 2 diabetes mellitus with diabetic chronic kidney disease, and diverticulosis of the large intestine. A physician's order, dated 2/13/25, indicated to flush the g-tube with 30 ml (milliliters) of water three times a day. A nursing progress note, dated 2/14/25 at 4:02 p.m., indicated Resident 43 and family were in agreement they did not want to proceed with supplementation through the g-tube. A physician's order, dated 3/20/25, indicated to administer 120 ml of the dietary supplement Med Pass 2.0 three times a day. There was no administration route indicated in the physician's order for the Med Pass. A nursing progress note, dated 6/7/25 at 8:47 p.m., written by Registered Nurse (RN) 2 indicated .Writer administered…
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 · D2025-06-16 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based interview and record review, the facility failed to implement physician's orders based upon current professional standards of practice for the maintenance and prevention of infection of an Intravenous (IV) line for 1 of 1 resident reviewed for IV therapy. (Resident 101) Findings include: The clinical record for Resident 101 was reviewed on 6/11/25 at 9:59 a.m. The diagnoses included, but were not limited to, immunodeficiency, benign neoplasm of meninges (non-cancerous tumor) and osteonecrosis (the death of bone tissue due to a lack of blood supply). A physician's order, dated 6/6/25 and discontinued 6/10/25, indicated to give ceftriaxone (an antibiotic) reconstitute solution 2 grams via IV daily. The only physician's order related to the IV was for the antibiotic. There were no physician's orders for the care and use of the pumps, tubing, syringes, or flushes. The Electronic Health Record did not have documentation of IV site assessments, normal saline flushes, Heparin lock flushes, monitoring for side effects, or PICC dressing changes until 6/9/25. A care plan, dated 6/8/25,…
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 · D2025-06-16 · 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 physician's order for oxygen was in place and oxygen equipment was stored properly when not in use for 1 of 3 residents reviewed for respiratory care. (Resident 1) Findings include: During an observation, on 6/9/25 at 11:09 a.m., Resident 1 was in bed with an oxygen concentrator next to the bed. The concentrator was set on 3 liters (L) and was connected to a nasal cannula. Resident 1 was not wearing the nasal cannula, and it was laying on the floor. During an observation, on 6/10/25 at 9:57 a.m., Resident 1 was lying in bed. The oxygen concentrator was set on 3L. Resident 1 was not wearing the nasal cannula, and it was laying on the floor. During an observation, on 6/11/25 at 11:34 a.m., Resident 1 was lying in bed. The resident was wearing the nasal cannula and was receiving oxygen at 3L. The clinical record for Resident 1 was reviewed on 6/9/25 at 1:05 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia, acute diastolic heart failure, chronic…
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 · D2025-04-25 · 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 to ensure pharmaceutical services were provided to meet the needs of the residents for 1 of 3 residents reviewed for pharmacy services. This deficient practice was corrected on 1/24/25, prior to the start of the survey, and therefore was past noncompliance. (Resident D) Findings include: During an interview, on 4/23/25 at 12:49 p.m., Resident D indicated she did not receive all the medications she was supposed to receive while she was at the facility. Some of her medications were given very late. The staff told her the medications were not given because they were not received from the pharmacy. The clinical record for Resident D was reviewed on 4/24/25 at 2:02 p.m. The diagnoses included, but were not limited to, pneumonia, chronic obstructive pulmonary disease, pulmonary fibrosis, congestive heart failure and chronic atrial fibrillation. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The Medication Administration Record (MAR) indicated the following: 1. Alprazolam (an anti-anxiety…
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 before2024-06-10 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a bowel stimulant according to the bowel protocol, failed to ensure residents were wearing compression hose as ordered by the physician, failed to hold a medication per the physician's hold orders, and failed to ensure a preventive cushion was in place for 4 of 4 residents reviewed for quality of care. (Residents 43, 44, 15 and 25) Findings include: 1. The record for Resident 43 was reviewed on 6/4/24 at 3:44 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood) and constipation. a. The bowel record was reviewed and did not include documentation of a bowel movement between 2/11/24 to 2/14/24 (4 days). The Medication Administration Record, for February 2024, did not have documentation to show the resident received the PRN (as needed) bowel stimulants to promote bowel movements. The bowel protocol was not initiated. A physician's order, initiated on 2/7/24, indicated if there was no bowel movement within 72…
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 · D2024-06-10 · tag F0642 — isolatedEnsure a qualified health professional conducts resident assessments.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to ensure a PASARR (Preadmission Screening and Resident Review) level 2 was accurately documented on the comprehensive/annual MDS (Minimum Data Set) assessment submitted for 1 of 3 residents reviewed for PASRR level 2. (Resident 34) Finding includes: The clinical record for Resident 34 was reviewed on 6/5/24 at 10:00 a.m. The diagnoses included, but were not limited to, cerebral palsy, major depressive disorder, bipolar disorder, anxiety disorder, and insomnia. A PASARR level 2 was completed on 9/12/23. An annual MDS assessment, dated 12/25/23, indicated a PASARR level 2 had not been completed. During an interview, on 6/7/24 at 11:12 a.m., the MDS Clinical Support nurse indicated the MDS assessment should have been marked to indicate the level 2 had been completed During an interview, on 6/7/24 at 11:30 a.m., the MDS Clinical Support nurse indicated the facility followed the RAI manual as a policy. 3.1-31(f)
Show the remaining 17 citations
- Potential for harm · D2024-06-10 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) after a resident was started on an antipsychotic medication for 1 of 3 residents reviewed for PASARR. (Resident 18) Finding includes: The clinical record for Resident 18 was reviewed on 6/6/24 at 10:08 a.m. The diagnoses included, but were not limited to bipolar disorder, insomnia, and depression. A physician's order, with a start date of 11/4/22 and an end date of 11/21/22, indicated to give Seroquel (an antipsychotic medication) 25 milligrams (mg) at bedtime. A current physician's order, with a start date of 11/21/22, indicated to give the resident Seroquel 50 milligrams (mg) at bedtime. A notice of PASARR level 2 outcome, dated 9/9/22, indicated the resident was approved for long term approval without specialized services. The resident's mental health medications did not include Seroquel. There had not been another PASARR assessment completed after the resident was placed on Seroquel. During an interview, on 6/7/24 at 11:14 a.m., the Assessment 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 · D2024-06-10 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to administer pain medication as ordered by the physician and failed to notify the physician when the medication was not administered for 1 of 1 resident reviewed for pain. (Resident 9) Finding includes: During an interview, on 6/4/24 at 11:23 a.m., the resident indicated she had pain due to not getting her medications on time. The clinical record for Resident 9 was reviewed on 6/4/24 at 3:38 p.m. The diagnoses included, but were not limited to, chronic pain, chronic respiratory failure, and type 2 diabetes mellitus. A care plan, dated 4/18/24 and last updated on 5/17/24, indicated the resident was at risk for pain related to the diagnosis of chronic pain and decreased mobility. The interventions included, but were not limited to, administering medications as ordered. A physician's order, dated 2/14/24, indicated to give hydrocodone-acetaminophen (an opioid pain medication) every 6 hours for pain. A Medication Administration Record (MAR), dated 5/1/24 through 5/31/24, indicated the resident did not receive the 6:00 a.m. dose…
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 · D2024-06-10 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a full meal in a timely manner, as noted on the dietary menu slip, to a resident on a gluten free diet for 1 of 1 resident reviewed for an alternate diet. (Resident 43) Finding includes: During a dining observation, on 6/3/24 beginning at 12:13 p.m., Resident 43 was observed at the dining table with her meal consisting of chicken, brussels sprouts, and a dessert. The menu, for Resident 43, indicated she was to have a gluten free diet of caprese chicken with gluten free pasta, roasted brussels sprouts, gluten free garlic bread, and lemon mousse. During an interview, on 6/3/24 at 12:23 p.m., [NAME] 12 indicated the resident did not receive her gluten free items because it was not prepared. She indicated the meal should have been served all at once and not in parts. She would call the kitchen to have the remainder of the meal prepared. During an observation, on 6/3/24 at 12:37 p.m., Resident 43 did not have her gluten free garlic bread or gluten free pasta. During an observation, on 6/3/24 at 12:44 p.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 · D2024-06-10 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 adaptive dining equipment for 1 of 3 residents reviewed for dining. (Resident 43) Finding includes: During a dining observation, on 6/3/24 at 12:13 p.m., Resident 43 was observed to have chicken, brussels sprouts and a dessert. Her meal was served on a regular plate. During a dining observation, on 6/7/24 at 12:08 p.m., the resident was served grilled cheese, applesauce, and tomato soup on regular dishes. CNA 1 indicated the resident should have had a divided plate. The record for Resident 43 was reviewed on 6/4/24 at 3:44 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood) and constipation. A care plan, initiated on 2/8/24, indicated a divided plate at meals. A facility document, titled Profile Care Guide, included an intervention which was initiated, on 3/1/24, which indicated .Resident should have divided Plates with all meals A physician's order, initiated on 5/14/24, indicated a divided plate at meals.…
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 before2024-06-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff were wearing hair and facial covers while in the kitchen for 3 of 3 randomly observed staff members. (Staff Member 52, [NAME] 6 and Kitchen Employee 13) Finding includes: During a random observation, on 6/6/24 at 9:35 a.m., Staff Member 52 and [NAME] 6 were observed in the kitchen. Staff Member 52 was in the kitchen past the line by the door, and did not have a hairnet over her hair. [NAME] 6 who was standing between the grill and the prep table did not have a facial covering over his mustache. During a random observation, on 6/7/24 at 8:50 a.m., Kitchen Employee 13 was observed at the prep table to the left of the door wearing a facial hair covering under his chin. At that time, he indicated he forgot to put it back on. He was noted to have hair on his chin, jaw line and under his nose. During an interview, on 6/6/24 at 9:38 a.m., Staff Member 52 indicated [NAME] 6 did have facial hair which should have been covered. 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 · D2024-06-10 · tag F0882 — isolatedDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) was professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field and was also able to dedicate at least part-time to the roll for 1 of 1 Infection Preventionist reviewed. Findings include: During an interview, on 6/10/24 at 3:00 p.m., the Executive Director indicated she was the Infection Preventionist. She had taken CEU (continuing education unit) classes for the Infection Preventionist. The Assistant Director of Nursing (ADON) was the acting Infection Preventionist. The ADON had not passed the testing and was not certified. The Executive Director did not have a nursing degree and could not dedicate part-time to the role of the Infection Preventionist while overseeing the day-to-day operations of the facility. The State Operations Manual (SOM) indicated .The intent of this regulation is to ensure that the facility designates a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent 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 · Fcited before2023-03-07 · 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 ensure frozen food was securely covered, the refrigerator did not contain employee drinks and the thermometer used to temp food was cleaned between testing temperatures. The deficient practice had the potential to affect 62 of 62 residents who received food from the kitchen. Findings include: 1. During the kitchen observation, on 2/27/23 at 12:37 p.m., with the Dietary Manager (DM), the following were observed: a. The walk-in freezer had a large silver pan containing pulled pork and the plastic wrap over the top was not pulled tightly over the meat. The meat had ice formed over the top of the meat and the whole length of the pan. b. The refrigerator door had a large approximately 32 oz blue cup with a lid. The sticker on the cup indicated it was a staff member's cup. c. The thermometer to temp the food on the steam table was wiped off with a dirty rag from the Sani solution (a cleaning, sanitizing, and disinfecting solution) bucket. During an interview, 2/27/23 at 12:37 p.m., the DM indicated the frozen meat…
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 · E2023-03-07 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
9. The record for Resident B was reviewed on 03/01/23 at 10:25 a.m. Diagnoses included, but were not limited to, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, end stage renal disease, acute embolism and thrombosis of right femoral vein, acute embolism and thrombosis of deep veins of right upper extremity, saddle embolus of pulmonary artery without acute cor pulmonale, severe protein calorie malnutrition, mitral valve insufficiency, left bundle branch block, thrombocytopenia, hypotension, and a pacemaker. During the record review, the resident received the following medications late: a. levothyroxine (a hormone supplement) was administered late on 10/2/23. b. cholecalciferol (a supplement), colchicine (an anti-inflammatory) and omeprazole (to treat heartburn) were administered late on 10/23/22. c. Cholecalciferol, omeprazole, potassium (a supplement) and colchicine were administered late on 12/12/22. d. warfarin (a blood thinning medication) 3 milligrams was administered late 12/15/22. e. Cholecalciferol, omeprazole, potassium, 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 · D2023-03-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident had the same bed as other residents to prevent the bed frame from being on the floor for 1 of 1 resident reviewed for dignity. (Resident 59) Finding includes: During an observation, on 2/27/23 at 3:48 p.m., Resident 59 was lying in bed. His bed was in such a low position the bed frame was almost touching the floor and the resident appeared to be lying on a mattress on the floor. The record for Resident 59 was reviewed on 3/1/23 at 5:17 p.m. Diagnoses included, but were not limited to, chronic kidney disease stage 3, Alzheimer's disease, age related physical debility and a history of pulmonary embolism. A care plan, dated 2/8/23 and last revised on 2/21/23, indicated the resident was at a risk for falling related to weakness and confusion. The approaches included, but were not limited to, the bed in the lowest position with a mat on the floor. During an observation, on 3/2/23 at 11:28 a.m., 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 · D2023-03-07 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
2. The record for Resident 51 was reviewed on 03/01/23 at 11:50 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, delirium due to known physiological condition, hallucinations, and cerebellar stroke syndrome. A physician's order, dated 12/1/22, indicated lorazepam (an antianxiety) 0.5 milligrams at bedtime. A physician's order, dated 1/23/23, indicated Depakote sprinkles (a mood stabilizer) 250 milligrams three times daily. A physician's order, dated 1/23/23, indicated Seroquel (an antipsychotic) 25 milligrams three times daily. A physician's order, dated 2/27/23, indicated lorazepam 0.5 milligrams every four hours as needed. There was no documentation in the electronic medical record regarding education of the risks of psychoactive medications with the resident or representative. A recent publication of PDR.net' indicated .Seroquel was used in adults for the treatment of schizophrenia, mania associated with bipolar 1 disorder, bipolar depression, maintenance of bipolar one disorder .antipsychotics were not approved for treatment of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-07 · 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, interview and record review, the facility failed to update the care plan to include the resident's preferred activities for 1 of 4 residents reviewed for activities (Resident 42). Finding includes: During an observation, on 2/27/23 at 3:22 p.m., Resident 42 was sitting up on the edge of his bed. Other residents had been in the common area playing bingo. There was no music and no television on in the room and no books. During an observation, on 3/2/23 at 11:27 a.m., the resident was lying in bed, in his room, with his eyes closed. Other residents were in the dining room working on a craft of stringing beads. During an observation, on 3/3/23 at 3:21 p.m., residents were listening to live music outside of the dining area. Resident 42 was not attending the live music event. The record for Resident 42 was reviewed on 3/1/23 at 3:12 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, psychotic disorder with delusions due to a known physiological condition, depression, and anxiety disorder. A care plan, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
2. During an observation, on 2/28/23 at 10:20 a.m., Resident F was sitting in a wheelchair. The resident's hair was not brushed and appeared dirty. During an observation, on 3/2/23 at 10:30 a.m., the resident's hair appeared flat and dirty. The record for Resident F was reviewed on 3/2/23 at 10:32 a.m. Diagnoses included, but were not limited to, anxiety disorder, transient cerebral ischemic attack, and chronic kidney disease. A profile care guide, dated 8/24/22, indicated Resident F's showers were scheduled on Tuesday and Saturday during the evening shift. The MDS (Minimum Data Set) assessment, dated 1/9/23, indicated the resident needed one-person physical assist with showers and bathing. A point of care history indicated Resident F was missing 8 showers from 12/1/22 through 2/28/23. During an interview, on 3/6/23 at 11:45 a.m., RN 5 indicated Resident F did not refuse care. During an interview, on 3/6/23 at 12:01 p.m., CRCA 7 indicated the resident did not refuse care. During an interview, on 3/7/23 at 2:26 p.m., CRCA 6 indicated the residents were scheduled two showers a week.…
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 · D2023-03-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to obtain a weight on a resident who was identified as a risk for malnutrition for 1 of 3 residents reviewed for nutrition. (Resident 59) Finding includes: The record for Resident 59 was reviewed on 3/1//23 at 5:17 p.m. Diagnoses included, but were not limited to, chronic kidney disease stage 3, Alzheimer's disease, anxiety disorder, age related physical debility, hypocalcemia, and hypokalemia. A physician's order, dated 1/25/23, indicated to provide a regular diet with thin liquids. A care plan, dated 1/26/23, indicated the resident was malnourished/at a risk for malnutrition related to his diagnoses, inadequate nutrient and energy intakes and metabolic demands. The goal was for the resident to consume adequate intakes to improve nutritional status, achieve and/or maintain an optimal weight range for the resident and prevent any significant weight changes. The approaches included, but were not limited to, dietitian to re-evaluate as indicated and to obtain a weight as ordered/needed. A care plan, dated 2/20/23, indicated 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 · D2023-03-07 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the resident or representative had been instructed on the specific risks versus benefits of bed rails and to have a signed consent for 1 of 2 residents reviewed for accident hazards. (Resident 12) Finding includes: During an observation, on 2/27/23 at 2:43 p.m., the resident had two upper quarter side rails on the bed. The record for Resident 12 was reviewed on 3/1/23 at 4:27 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, anxiety disorder, age related macular degeneration, and difficulty in walking. A care plan, dated 7/6/2020, indicated the resident had an impairment in functional status related to transfers, bed mobility, toileting, and eating. The approaches included, but were not limited to, bed rail assessed as an enabler for safe transfers or increased mobility. A physician's order, dated 2/20/23, indicated the side rails had been assessed as an enabler for safe transfers or increased mobility. During an interview, on 3/3/23 at 3:33 p.m., 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 · D2023-03-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
2. During an observation, on 03/01/23 at 11:46 a.m., the resident was resting in the bed, on her right side, with the head of the bed elevated slightly. Her daughter was visiting in the room with an activity staff member. The resident had her eyes closed. The resident was not grimacing or restless. During an observation, on 03/01/23 at 4:05 p.m., the resident was resting in the bed, on her right side, with the head of the bed slightly elevated. The resident had her eyes closed. No restlessness or movement was observed. During an observation, on 03/02/23 at 11:01 a.m., the resident was resting comfortably in bed with a low air loss mattress in place. She was lying on her right side and her eyes were closed. The record for Resident 51 was reviewed on 03/01/23 at 11:50 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, delirium due to known physiological condition, hallucinations, and cerebellar stroke syndrome. A physician's order, dated 12/1/22, indicated lorazepam (an antianxiety medication) 0.5 milligrams at bedtime. A physician's order, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-07 · 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 ensure a medication was not left on the top of the medication cart and the medication cart was locked for 2 of 4 carts and the temperature log for the 300-hall medication room was completed for 1 of 2 medication storage rooms reviewed for medication storage. (100 and 300 halls carts and 300 hall medication room). Findings include: 1. During an observation, on 3/6/23 at 3:40 p.m., the medication cart on the 100-hall next to room [ROOM NUMBER] had a medication bottle left unattended on top of the cart. There were three residents sitting at the nurse's station across from the medication cart. 2. During an observation, on 3/6/23 at 4:04 p.m., the medication cart on the 100-hall close to room [ROOM NUMBER] was unlocked and unattended. 3. During an observation, on 3/1/23 at 11:36 a.m., the medication refrigerator in the 300-hall medication storage room was missing five temperatures on the temperature log. During an interview, on 3/1/23 at 11:36…
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 · D2023-03-07 · 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 ensure the cook prepared pureed foods according to the recipes for 1 of 1 resident who was ordered a pureed diet. (Cook 1) Finding includes: During the observation of pureed foods, on 2/28/23 at 11:12 a.m., [NAME] 1 was observed to do the following: a. He put a 4-ounce scoop of green beans into the Robo coupe (a machine to puree foods), added 1 and 1/2 teaspoons of melted unsalted butter and 3/4 teaspoon of thickener to the green beans and mixed to a pureed consistency. b. He then added an unmeasured piece of ham into the clean Robo coupe, added 1 tablespoon of water. He placed an additional unmeasured amount of water to the ham and mixed. The recipe called for 1 and 1/3 tablespoon of pineapple juice. He placed an unmeasured amount of pineapple juice in the Robo coupe, he added eight more tablespoons of water, mixed the ham, and added 3/4 teaspoon of thickener. He scooped the ham on the plate using a three and one-fourth ounce scoop. During an interview, on 2/28/23 at 11:12 a.m., [NAME] 1 indicated they did…
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 TRILOGY HEALTH SERVICES — 123 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 3.5 | -1.5 vs chain |
| Staffing | 2 of 5 | 3.3 | -1.3 vs chain |
| Quality measures | 5 of 5 | 4.8 | +0.2 vs chain |
The other 122 homes this chain runs (chain average 4.2★, per CMS)
Showing 40 of 122; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WITHAM MEMORIAL HOSPITAL | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2015 |
| LUMENT REAL ESTATE CAPITAL LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 01/01/2023 |
| BARDOCZI, STEPHEN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/03/2013 |
| BAYSTON, BRETT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2023 |
| BRAND, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2015 |
| CASTETTER, ANDREA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2023 |
| HAWKINS, CLAUDE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/09/2013 |
| HORNBECKER, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2024 |
| REAGAN, JULIE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/25/2024 |
| TRILOGY HEALTHCARE OF TIPPECANOE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2015 |
| BRAVERMAN, KELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2021 |
| SELLERS, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/21/2024 |
| THOMAS, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| WARD, CAROL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/09/2018 |
| BARNEY, LEIGH | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| DAVIS, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 09/19/2025 |
| AMERICAN HEALTHCARE REIT HOLDINGS LP | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| AMERICAN HEALTHCARE REIT INC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| CONTINENTAL MERGER SUB LLC | Organization | ADP OF THE SNF | — | since 10/01/2021 |
| GAHC3 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| GAHC4 TRILOGY JV LLC | Organization | ADP OF THE SNF | — | since 10/01/2018 |
| PARAGON OUTPATIENT REHABILITATION SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY HEALTH SERVICES LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY HEALTHCARE MASTER TENANT LLC | Organization | ADP OF THE SNF | — | since 07/14/2025 |
| TRILOGY INVESTORS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY MANAGEMENT SERVICES LLC | Organization | ADP OF THE SNF | — | since 10/15/2025 |
| TRILOGY PROPCO FINANCE LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY PROPERTY HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE INVESTMENT TRUST | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REAL ESTATE OF WEST LAFAYETTE, LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
| TRILOGY REIT HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/01/2015 |
CMS files one row per role, so the 34 rows in the source record cover these 31 parties — each is shown once here with every role it holds. Nothing is omitted.
18 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155775. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-16, 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.