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Heritage Healthcare

3401 Soldiers Home Rd, West Lafayette, IN 47906 · Government - County · 127 certified beds · (765) 463-1541 Medicare & Medicaid certified

Call the home — (765) 463-1541 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Feb 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Feb 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 70% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
152 Sagamore Pkwy W · (765) 423-6556 · Call to confirm hours
Pharmacy
512 Sagamore Pkwy W · (765) 497-3551 · Call to confirm hours
Grocery
Aldi1.0 mi
210 Sagamore Pkwy W · (855) 955-2534 · Call to confirm hours
Park
Hamilton St · (765) 775-5110 · Typically dawn to dusk

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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.8%11.0%15.4%better
Long-stay residents who lose too much weight4.5%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms3.8%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.6%3.9%3.3%worse
Long-stay residents whose ability to walk worsened14.5%11.9%16.1%typical
Long-stay residents on antianxiety or hypnotic medication23.9%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine95.9%95.4%95.3%typical
Long-stay residents with pressure ulcers3.6%3.6%4.7%better
Long-stay residents with worsening bladder/bowel control22.9%23.3%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table15.3%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine90.4%79.0%79.4%better
Short-stay residents rehospitalized after admission14.5%22.2%22.6%better
Short-stay residents with an outpatient ER visit11.5%10.8%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.451.611.67better
Long-stay outpatient ER visits per 1,000 resident days0.591.441.80better

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.

13.5%U.S. median 10.7%
Went back to hospital
0.33U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.5%CMS range 9.1–18.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs1.441.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.24
RN hours/ resident / day
0.35
LPN hours/ resident / day
1.84
Aide hours/ resident / day
3.42
Total nurse hours/ resident / day
0.86
RN hoursweekends
45.5%
Total nursing turnover
31.6%
RN turnover

How full it usually is: this home is certified for 127 beds and averages 79.2 residents a day — about 62% occupied, or roughly 48 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.57 on weekdays — 14% thinner on weekends. RN hours go from 1.40 to 0.86 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-08-05)
9
at the previous standard inspection (2024-07-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · D2026-02-18 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on 2/10/2026, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 2/26/26 at 1:10 p.m., the Director of Nursing (DON) indicated, on the morning of 2/3/26, RN 2 informed her Resident B was missing a narcotic medication. RN 2 had completed a narcotic count with RN 3, on 2/2/26 at 10:00 p.m., and Resident B had two (2) narcotic cards for oxycodone (a medication used for pain). The next morning at 6:00 a.m., RN 2 returned to the facility for another shift and realized Resident B no longer had two (2) medication cards. RN 3 had indicated to RN 2 that Resident B had been given pain medication during the night, but RN 3 was not aware of a missing narcotic card. RN 3 then left the facility. The DON then reviewed the medication card with RN 2 and found the medication card and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2025-08-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 food items were labeled with the date received, the reach-in refrigerator was maintained at a safe temperature, and temperature logs were up to date. This deficient practice had the potential to affect 68 of 69 residents who received food from the kitchen.Findings include:1. During the initial kitchen tour with [NAME] 2, on 7/30/25 at 10:21 a.m., the following pre-packaged food items were found to be not labeled with the date received:a. six (6) packages of gravy mixb. three (3) containers of cream of wheatc. eight (8) bags of brown sugard. four (4) packages of brownie mixe. one can of sauerkrautf. one can of peasg. one can of marinara sauceh. one can of cheddar cheese sauce During an interview, on 7/30/25 at 10:43 a.m., [NAME] 2 indicated he dated items with the date received when he put away new food items and then labeled them with the date opened when the item was opened.During an interview, on 7/31/25 at 9:58 a.m., the Dietary Manager indicated the pre-packaged food items should have been labeled…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-05 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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 pureed foods were prepared according to the recipe to ensure the nutritive value, flavor, and appearance were conserved for 5 of 5 residents reviewed for a pureed diet.Findings include:During an observation, on 7/30/25 at 10:48 a.m., [NAME] 2 was observed to add 5 cooked and seasoned hamburger patties to a food processor. He added an unmeasured amount of water, turned on the processor, and mixed until a pudding consistency was obtained. He did not refer to a recipe during the observation.During an interview, on 7/30/25 at 10:48 a.m., [NAME] 2 indicated he was unsure if there was a recipe for purees. He did not know where it was and thought it may have been in with the regular recipes. He usually thinned things with broth or water. He indicated he had already prepared the peas by adding 5 servings of peas to the blender and used milk to thin the peas to get the desired consistency.During an interview, on 7/31/25 at 9:30 a.m., the Dietary Manager indicated the puree recipes were stored in the regular…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-05 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the facility and resident rooms were maintained for 8 of 33 rooms reviewed for environment. (room [ROOM NUMBER], 16, 23, 18, 21, 32, 36, 103).Findings include: During an observation, on 7/30/25 beginning at 12:21 p.m., the following were observed.1. In room [ROOM NUMBER], the wall under the window had a large area with no paint. 2. In room [ROOM NUMBER], the wall had paint peeled off under the window and on the right side by the bathroom door.3. In room [ROOM NUMBER], the wall had black scuff marks and missing paint on the lower portion of the wall.4. In room [ROOM NUMBER], the bottom of the door had black scuff marks.5. In room [ROOM NUMBER], the lower part of the door had scuff marks and chipped paint on the door trim.6. The eye washing station door trim had peeling paint.7. The soiled utility room door trim had peeling paint.8. In room [ROOM NUMBER], the door had chipped paint and scuff marks on the trim.9. In room [ROOM NUMBER],…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-05 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the resident and resident's representative received notification in writing of the facility's bed hold policy and the reason for the resident's transfer and discharge to the hospital for 1 of 2 residents reviewed for hospitalization. (Resident 3) Findings include:The clinical record for Resident 3 was reviewed on 8/1/25 at 11:45 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, chronic kidney disease, diabetes mellitus, cerebral infarction, cognitive communication deficit and gastrostomy. A nursing progress note, dated 7/28/25 at 10:20 a.m., indicated the hospital called and informed the facility Resident 3 was admitted to the Intensive Care Unit with aspiration pneumonia.There was no documentation in the electronic medical record to indicate the resident and resident's representative was provided information in writing regarding the reason for the resident's transfer to the hospital and the facility's bed hold policy. During an interview, on 8/1/25 at 2:27 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-05 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level I was completed on or prior to admission for 1 of 3 residents reviewed for PASARR. (Resident 10)Findings include:The clinical record for Resident 10 was reviewed on 8/1/25 at 2:56 p.m. The diagnoses included, but were not limited to, mild intellectual disabilities, dementia, depression, post-traumatic stress disorder (PTSD), anxiety, and bipolar disorder. Resident 10 was admitted to the facility on [DATE].A physician's order, dated 1/15/25, indicated to administer duloxetine (an antidepressant medication) 30 milligrams (mg) once a day. An initial PASARR Level I was not completed until 6/26/25.During an interview, on 8/5/25 at 11:30 a.m., the Executive Director (ED) indicated the PASARR was not completed in the correct time frame. A current facility policy, titled Pre-admission Screening and Resident Review (PASARR), dated 10/2022 and received by the ED on 8/5/25 at 1:03 p.m., indicated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure physician's orders were followed related to medications hold parameters for 1 of 5 residents reviewed for quality of care. (Resident 5)Findings include:The clinical record for Resident 5 was reviewed on 8/1/25 at 9:52 a.m. The diagnoses included, but were not limited to, atrial fibrillation, atherosclerotic heart disease, presence of a coronary angioplasty implant and graft, and occlusion and stenosis of the carotid artery.A care plan, dated 6/6/19, indicated Resident 5 had altered cardiovascular status related to coronary artery disease, atrial fibrillation, hypertension, and a history of myocardial infarction. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 4/15/25, indicated to administer carvedilol (a medication used to treat high blood pressure and heart failure) 6.25 milligram (mg) by mouth twice a day and to hold the medication for a systolic blood pressure less than 100 or a heart rate less than 60.A physician's order, dated 5/23/25, indicated to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure smoking evaluations were completed quarterly to evaluate the resident's capabilities and deficits for 1 of 6 residents reviewed for accident hazards. (Resident 23) Findings include:The clinical record for Resident 23 was reviewed on 8/1/25 at 2:05 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, atrial fibrillation, anxiety disorder, major depressive disorder, right above the knee amputation, hypertension, and vascular dementia.A care plan, dated 4/13/23, indicated the resident was non-compliant with the smoking policy, smoked in his room and/or pocketed his cigarette butts. Interventions included, but were not limited to, instruct Resident 23 of the smoking risks and the facility policy on smoking and to make certain cigarette butts were disposed of properly in cigarette butt receptacle.The electronic medical record did not contain smoking safety evaluations for 2024. The last documented smoking evaluation was 1/2023.A quarterly smoking safety evaluation was completed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-11 · tag F0560 — isolated
    Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
    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 resident who did not experience a change in payor source was given the choice/opportunity to remain in his room for 1 of 1 resident reviewed for room transfers. (Resident C) Findings includes: The clinical record for Resident C was reviewed on 9/10/24 at 2:10 p.m. The diagnoses included, but were not limited to, traumatic brain injury, muscle weakness, abnormalities of gait and mobility and spastic hemiplegia affecting the left nondominant side. The resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated he was cognitively intact. The resident was admitted to the facility in room [ROOM NUMBER] during his rehabilitation therapy timeframe. When the resident's therapy was competed, the resident was moved to another room without giving him the option to remain in his current room. The new room the resident was provided, did not provide the resident with an adequate bathroom and space for living.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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 medications administered orally were separated from topical medications and eye drops, to store cleaning supplies separately from medications, correctly label OTC (over the counter) medications, date opened medications, and routinely dispose of medications after the date of expiration for 4 of 4 medication carts reviewed. (medication cart 1, medication cart 2, medication cart 3, and medication cart 4) Findings include: During a medication cart observation with Qualified Medical Assistant (QMA) 6, on [DATE] at 11:06 a.m., medication cart 1 was observed to have the following: a. The top right drawer had two medication cups containing one pill in each cup not labeled with the resident's names or with the medication name. b. The bottom right drawer had an unlabeled nebulizer machine (a device which turned liquid medication into a mist to be inhaled into the lungs through a mask or mouthpiece) c. The top left drawer had Smooth Nighttime…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-07-12 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to submit a discharge MDS (Minimum Data Set) assessment upon discharge, making the assessment greater than 120 days since the last submitted assessment for 1 of 2 residents reviewed for resident assessments. (Resident 67) Finding includes: The clinical record for Resident 67 was reviewed on 7/12/24 at 3:10 p.m. The diagnoses included, but were not limited to, hypo-osmolality (nutrient levels in the blood are lower than normal), hyponatremia (low sodium level in the blood), alcohol abuse, pneumonia, cystitis (infection in the bladder), dysphagia (difficulty swallowing), and protein calorie nutrition. An admission MDS assessment, dated 2/9/24, indicated it was submitted 2/9/24 and was approved. A discharge MDS assessment, dated 5/1/24, indicated the assessment was pending and was not submitted. During an interview, on 7/12/24, the MDS Coordinator indicated the discharge assessment should have been completed and submitted. During an interview, on 7/12/24 at 3:28 pm, the Administrator indicated the facility used the RAI manual,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0644 — isolated
    Coordinate 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 resubmit a PASARR (Preadmission Screening and Record Review) for a resident after a new mental health diagnosis and medication were added for 1 of 3 residents reviewed for PASARR. (Resident 70) Finding includes: The clinical record for Resident 70 was reviewed on 7/10/24 at 9:52 a.m. The diagnoses included, but were not limited to, major depressive disorder, moderate vascular dementia, psychotic disorder with delusions, and sleep disorder. A medical diagnosis list indicated the resident was added a diagnosis of mild major depressive disorder on 2/2/24 A physician's order, with a start date of 2/3/24, indicated the resident was prescribed sertraline (an antidepressant medication) 25 mg (milligram). A PASARR, with a notice date of 4/24/23, indicated Resident 70 was evaluated and had no mental health diagnosis or mental health medications There was no record of another PASARR being completed after the major depressive disorder diagnosis or antidepressant medication were added. During an interview, on 7/12/24 at 10:37 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to notify the physician of blood glucose levels out of the physician's parameters and to follow-up on a hospice order for a Broda chair (chair which helps accommodate residents with impaired mobility) for 3 of 3 residents reviewed for quality of care. (Resident L, C and 136) Findings include: 1. During an interview, on 7/10/24 at 10:00 a.m., Resident L indicated he had high blood sugar readings while being at the facility. The clinical record for Resident L was reviewed on 7/10/24 at 3:16 p.m. The diagnoses included, but were not limited to, mild chronic stage 2 kidney disease, hypertensive heart disease with heart failure, and type 2 diabetes with diabetic neuropathy. A current physician's order, with a start date of 7/26/23, indicated to notify the physician for blood sugars greater than 400. A facility vital log indicated Resident L had the following blood sugars: On 3/26/24, his blood sugar was 433. On 3/27/24, his blood sugar was 452. On 3/27/24, his blood sugar was 432. On 3/28/24, his blood sugar was 426.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, interview and record review, the facility failed to turn and reposition a resident every 2 hours as ordered to promote healing and to prevent future pressure injuries for 1 of 4 residents reviewed for pressure ulcers. (Resident 50) Finding includes: During an observation, on 7/8/24 at 1:26 p.m., Resident 50 was sitting up in bed waiting for her lunch tray. She was paralyzed from the waist down with her right arm severely limited in range of motion and function with severe muscle wasting. The clinical record for Resident 50 was reviewed on 7/11/24 at 3:36 p.m. The diagnoses included, but were not limited to, paraplegia, type 2 diabetes mellitus, neuromuscular dysfunction of bladder, abnormal posture, depression, colostomy, indwelling urethral catheter, seizures, stage 3 and 4 pressure ulcers of sacral region, right and left buttock stage 3 pressure ulcers, recurrent moderate major depressive disorder, generalized anxiety disorder, and chronic obstructive pulmonary disease. A physician's order, dated 11/15/22, indicated to turn the resident every two hours for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. During an observation, on 7/08/24, Resident H was in the hallway in her wheelchair with her foley catheter in a dignity bag. The clinical record for Resident H was reviewed on 7/10/24 at 9:50 a.m. The diagnoses included, but were not limited to, peripheral vascular disease, retention of urine, polyneuropathy, acquired absence of left leg above the knee, restless legs syndrome, cerebral infarction without residual deficits, and obstructive and reflux uropathy. A physician's order, dated 2/2/24, indicated indwelling catheter to straight drainage. Size: 18 Fr Bulb: 30 cc. Change for infection, obstruction, or when the closed system was compromised as needed. A progress note, dated 4/3/24 at 4:47 p.m., indicated the resident complained the Foley catheter was leaking. The nurse deflated the balloon, advanced the catheter and re-inflated the balloon. The electronic medical record did not include a physician's order for the procedure of deflating the balloon, advancing the catheter, and re-inflating the balloon of the catheter. A progress note, dated 4/4/24 at 11:24 a.m., 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 ensure transportation was available for dialysis for 1 of 1 resident reviewed for dialysis. (Resident 18) Finding includes: During an interview, on 7/9/24 at 10:06 a.m., Resident 18 indicated she had to be hospitalized about a month ago when the facility did not have transportation to dialysis on a Saturday. The facility did not tell the resident until the last minute there was no transportation. The clinical record for Resident 18 was reviewed on 7/11/24 at 11:44 a.m. The diagnoses included, but were not limited to, dependence on renal dialysis, type 2 diabetes mellitus, end stage renal disease, congestive heart failure, right lower leg amputation at level between knee and ankle and acquired absence of the left leg below the knee. A care plan, dated as last revised on 4/9/24, indicated the resident had chronic congestive heart failure. The interventions included, but were not limited to, observing and reporting signs of congestive heart failure including shortness of breath on exertion. A care plan, dated as last revised…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0700 — isolated
    Try 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 an order for side rails was obtained and an assessment for side rails was completed prior to the use of side rails for 1 of 3 residents reviewed for accident hazards. (Resident D) Finding includes: During an interview, on 7/9/24 at 9:02 a.m., Resident D indicated she used the side rails for mobility assistance while in bed. During an observation, on 7/9/24 at 10:25 a.m., Resident D was in bed with the side rails in the raised position. During an observation, on 7/11/24 at 9:37 a.m., Resident D was asleep in bed with both side rails in the raised position. The clinical record for Resident D was reviewed on 7/10/24 at 9:22 a.m. The diagnoses included, but were not limited to, generalized muscle weakness, unspecified protein-calorie malnutrition, attention and concentration deficit, and insomnia. The physician's orders did not include an order for the use of the side rails. The electronic health record did not include a side rail assessment. The electronic health record did not include a signed consent for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    Based on observation, interview, and record review, the facility failed to address an annual gradual dose reduction (GDR) for an anti-depressant and an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident J) Finding includes: During an observation, on 7/8/24 at 12:30 p.m., Resident J was smiling and engaged in conversation with the surveyor. The resident was sitting up in her wheelchair, waiting for her lunch tray. During an observation, on 7/9/24 at 10:15 a.m., the resident was up in her wheelchair. The resident was smiling and eager to engage in conversation. The resident was very talkative. During all other observations, between 7/10/24 and 7/12/24, Resident J was smiling, talkative, and readily engaged in conversation. The clinical record for Resident J was reviewed on 7/10/24 at 2:29 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia and polyneuropathy, schizoaffective disorder bipolar type, affective mood disorder, major depressive disorder, malignant neoplasm 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 thoroughly investigate allegations of a staff member working while impaired and the potential residents' physical or emotional suffering from the impaired staff member's interactions for 1 of 1 staff member reviewed for allegation of abuse. (CNA 12) Finding includes: A Facility Reported Incident (FRI), dated 5/24/24, indicated Resident B had voiced concerns by social media. The resident indicated a male employee refused drug testing when it was reported he was altered. The staff was terminated due to refusal of the testing and left the building. The facility completed resident interviews, staff interviews, skin assessments, and education as deemed necessary. The clinical record for Resident B was reviewed on 7/10/24 at 12:25 p.m. The diagnoses included, but were not limited to, fusion of the spine in the lumbar region, generalized anxiety disorder, depression, and chronic obstructive pulmonary disease. An undated note from social media was provided by…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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 expired food was discarded, the refrigerator did not contain employee lunches and the dishwasher was washing at the recommended temperature. The deficient practice had the potential to affect 67 of 68 residents who received food from the kitchen. Findings include: During an observation, on 4/20/23 at 11:36 a.m., the walk-in refrigerator had a container of creamed corn and a container of cottage cheese with expiration dates of 4/17/23. The 3-door refrigerator had a yellow sack which contained the Dietary Manager's lunch. During an observation, on 4/20/23 at 11:45 a.m., the Dietary Manager (DM) started the dishwasher. She indicated the wash cycle temperature needed to be at least 160 degrees. The temperature dial on the dishwasher was stationary at 140 degrees during the wash cycle. She was given a thermometer by the [name of company] technician to place into the machine to get a temperature when the machine ran through a cycle. She placed the thermometer in the dishwasher and ran two cycles. She opened…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident hallways and a bathroom were clean and in good repair for 2 of 4 hallways and 1 of 10 bathrooms observed for the environment. ([NAME] and Ross Hall) Findings include: During an observation of the Ross Hall, on 4/20/23 at 1:49 p.m., the following was observed: 1. The beige carpet on the lower half of the wall below the handrails had several bubbled areas all throughout the hallway and appeared like the carpet was coming off the wall. 2. The carpet on the floor in the hallway was faded and worn. During an observation of the [NAME] hallway, on 4/21/23 at 11:08 a.m., the following was observed: 1. The carpet on the floor in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] had a hole larger than the size of a softball. 2. The carpet on the floor in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] had two very large dark stains. 3. The carpet on the wall between room [ROOM NUMBER] and room [ROOM…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a MDS (Minimum Data Set) assessment was accurate for 1 of 1 resident reviewed for resident assessments. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 4/24/23 at 3:29 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, acute kidney failure, and hemiplegia and hemiparesis following cerebral infarction. A quarterly MDS assessment, dated 3/28/23, indicated the resident received insulin 7 days out of the last 7 days. During a review of the physician orders, the resident's insulin had been discontinued 8/2022. During an interview, on 4/24/23 at 11:19 a.m., the MDS Coordinator indicated she marked the March 28, 2023, MDS assessment as the resident was receiving insulin. She indicated she was not aware Victoza (a non-insulin medication which lowers blood sugar) was not insulin. The resident was receiving Victoza and not insulin. The MDS should have only been coded for receiving injections and not insulin. A current policy, titled Resident Assessment Instrument & 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident with congestive heart failure received daily weights and the physician was notified of a weight gain as ordered for 1 of 3 residents reviewed for quality of care. (Resident 33) Findings include: During an interview, on 4/20/23 at 2:00 p.m., Resident 33 indicated she had lost weight. The resident had an order for daily weights and was not always weighed daily. The record for Resident 33 was reviewed on 04/24/23 at 10:32 a.m. Diagnosis included, but were not limited to, heart failure, hypertension, vascular dementia, atrial fibrillation (irregular, rapid heartbeat), Alzheimer's disease, and cognitive communication deficit. A physician's order, dated 5/11/22, indicated daily weights and to notify the physician if there was a plus or minus of 3 pounds a day or 5 pounds a week or if there was a 5% plus or minus change in 30 days. Notify the physician and Director of Nursing (DON) for all refusals as soon as possible. A physician's order, dated 6/26/22, indicated furosemide (a diuretic) tablet 20 mg…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 observation, interview and record review, the facility failed to ensure the controlled substance record used was provided by the pharmacy and not altered by facility staff for 1 of 3 medication carts observed for medication storage. (Ross Hall) Findings include: During an observation of Ross Hall medication cart, on 4/26/23 at 11:15 a.m., the following was observed for Resident 11: 1. Resident 11's controlled substance record from the pharmacy for lorazepam 0.5 mg indicated there were 27 tablets remaining. 2. The card for the lorazepam 0.5 mg contained 25 tablets. 3. The controlled substance record from the pharmacy for hydrocodone-acetaminophen 5-325 milligrams indicated 26 tablets remained. 4. The card for the hydrocodone-acetaminophen had 26 tablets. 5. The controlled substance records for the medications had been switched by the staff and the counts for the medication were off by one tablet. A controlled substance record, dated 4/24/23, indicated hydrocodone-acetaminophen 5-325 milligram tablets. The hydrocodone-acetaminophen had a line drawn through it with an arrow…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE CENTERS OF AMERICA — 194 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.4-0.4 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 53.3+0.7 vs chain
Quality measures 5 of 54.5+0.5 vs chain
The other 193 homes this chain runs (chain average 3.4★, per CMS)
1 of 5Garden Terrace At Overland ParkOverland Park, KS 1 of 5Hammond-Whiting Care CenterWhiting, IN 1 of 5Life Care Center Of AndoverAndover, KS 1 of 5Life Care Center Of Cape GirardeauCape Girardeau, MO 1 of 5Life Care Center Of GrayGray, TN 1 of 5Life Care Center Of HixsonHixson, TN 1 of 5Life Care Center Of Mount VernonMount Vernon, WA 1 of 5Life Care Center Of RenoReno, NV 1 of 5Life Care Center Of Sierra VistaSierra Vista, AZ 1 of 5Life Care Center Of The WillowsValparaiso, IN 1 of 5Life Care Center Of TucsonTucson, AZ 1 of 5Life Care Center of Coeur d'AleneCoeur d'Alene, ID 1 of 5Life Care Center of ElkhornElkhorn, NE 1 of 5Life Care Center of Hilton HeadHilton Head Island, SC 1 of 5Life Care Center of OmahaOmaha, NE 1 of 5Life Care Center of PlainwellPlainwell, MI 1 of 5Life Care Ctr Of LawrencevilleLawrenceville, GA 1 of 5Rensselaer Care CenterRensselaer, IN 2 of 5Canon Lodge Care CenterCanon City, CO 2 of 5Darcy Hall Of Life CareWest Palm Beach, FL 2 of 5Desert Cove Nursing CenterChandler, AZ 2 of 5Evergreen Nursing HomeAlamosa, CO 2 of 5Garden Terrace Healthcare Center of HoustonHouston, TX 2 of 5Hallmark ManorFederal Way, WA 2 of 5Lane House, TheCrawfordsville, IN 2 of 5Life Care Center Of Altamonte SpringsAltamonte Springs, FL 2 of 5Life Care Center Of AthensAthens, TN 2 of 5Life Care Center Of BridgetonBridgeton, MO 2 of 5Life Care Center Of BrookfieldBrookfield, MO 2 of 5Life Care Center Of ClevelandCleveland, TN 2 of 5Life Care Center Of ColumbiaColumbia, SC 2 of 5Life Care Center Of Coos BayCoos Bay, OR 2 of 5Life Care Center Of Federal WayFederal Way, WA 2 of 5Life Care Center Of GrandviewGrandview, MO 2 of 5Life Care Center Of KirklandKirkland, WA 2 of 5Life Care Center Of Merrimack ValleyBillerica, MA 2 of 5Life Care Center Of Morgan CountyWartburg, TN 2 of 5Life Care Center Of PuyallupPuyallup, WA 2 of 5Life Care Center Of Red BankChattanooga, TN 2 of 5Life Care Center Of South Las VegasLas Vegas, NV

Showing 40 of 193; 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 / managerTypeRoleSince
ENGELS, ERINIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 09/01/2018
GENTRY, MARKIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
STARKEY, TYLERIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WAITE, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 08/01/2020
WHICKER, TIMOTHYIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/12/2022
FENOUGHTY, DEANNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/10/2023
LAFAYETTE MEDICAL INVESTORS LIMITED PARTNERSHIPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
LIFE CARE CENTERS OF AMERICA, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/17/2025
BENTINGANAN, VICTORIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2021
CROSS, CINDYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2018
DAVIS, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/24/2021
FLETCHER, TODDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
HENRY, TERRYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
LAY, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
PRESTON, AUBREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/06/2025
PRESTON, FORRESTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2018
SWANKER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
THURMOND, JOANIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
ZIEGLER, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2018
HENDRICKS COUNTY HOSPITALOrganizationADP OF THE SNFsince 02/26/2025

CMS files one row per role, so the 31 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$9.1M
Net patient revenuemost recent cost report
+2.5%
Operating marginrevenue minus expenses
$6.2M
Related-party expense70% of expenses
Who pays — share of resident-days
Medicaid 79%Medicare 7%Other / private 14%

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $6.2M paid to related parties — landlords or management companies under common ownership — equal to about 70% 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

$360per resident / day
operating cost
$10,934per month
≈ monthly operating cost
$369per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IN

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.

Typical monthly cost in Indiana
$8,943/mo
Nursing home (semi-private)
$10,326/mo
Nursing home (private)
$5,639/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155402. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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