Indiana Veterans Home
3851 N River Rd, West Lafayette, IN 47906 · Government - State · 212 certified beds · (765) 463-1502 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 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 | 15.0% | 11.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.9% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.8% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.8% | 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 | 1.6% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.4% | 11.9% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 10.5% | 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 | 4.2% | 3.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 17.2% | 23.3% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.1% | 13.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 79.0% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.78 | 1.61 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.50 | 1.44 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 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 212 beds and averages 103.6 residents a day — about 49% occupied, or roughly 108 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 5.61 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.20 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.87 is at or above 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 4.79 hrs/resident/day on weekends vs 5.95 on weekdays — 19% thinner on weekends. RN hours go from 1.29 to 0.98 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 12 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · Gcited before2025-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a resident was kept safe during a transfer for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B sustaining a 3 cm laceration to his posterior scalp. The deficient practice was corrected on 6/13/25, prior to the start of the survey and was therefore past noncompliance. Findings include: A facility reported incident (FRI), dated 6/8/25, indicated Resident B had a change of plane from a Hoyer lift. Resident B received a 3 cm laceration to the posterior scalp, was sent to the emergency room (ER) for evaluation and returned with 3 staples to his posterior head. The clinical record for Resident B was reviewed on 6/18/25 at 1:10 p.m. The diagnoses included, but were not limited to, obsessive compulsive disorder, anemia, restlessness and agitation, and abnormal posture. A hospital report, dated 6/8/25, indicated the resident was seen for a scalp laceration and a closed head injury from a fall at a nursing home at 1:07 p.m. The wound was closed with 3 staples,…
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.
- Actual harm · Gcited before2023-10-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident in a wheelchair was assisted to get off the facility vehicle safely for 1 of 5 residents reviewed for falls. (Resident O) Resident O sustained a subdural hematoma and was hospitalized for 2 days. The deficient practice was corrected on 8/27/23, prior to the start of the survey and was therefore past noncompliance. Findings include: A Facility Reported Incident (FRI), dated 8/25/23 at 8:33 a.m., indicated Facility Driver 7 reported an accident while he was transporting Resident O. The driver was getting Resident O off the van at the hospital when he lost control of the resident's wheelchair while moving it toward the back of the van. The lift was down, and the resident fell backwards off the van and hit his head. Driver 7 fell on top of the resident. The facility had maintenance assess the van and lift, reviewed their transportation policies, and provided education and skills checks to staff. The follow up included the resident had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 2 residents reviewed for resident rights. (Resident B and 73)Findings include:1. A facility witness statement, dated 9/22/25, indicated LPN 4 told CNA 6 she needed to give Resident B a suppository and advised CNA 6 when she provided resident care, LPN 4 would give it to him. When CNA 6 provided care, LPN 4 came into the room. As the resident was facing the wall, LPN 4 put on her gloves, gave the suppository, and the resident immediately yelled out. Resident B said the nurse was supposed to ask him before she gave him the suppository and Resident B did not want the suppository. LPN 4 told the resident he had not had a bowel movement in days and he needed it. Resident B again told the nurse he did not want it. LPN 4 told him he could push it out, like if he had a bowel movement, and left the room. A facility incident report, dated 9/23/25, indicated LPN 4 administered Resident B a suppository and did not inform or get permission from the resident first. 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 · Dcited before2025-12-08 · 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 physician's order to hold a medication was followed according to the parameters for 2 of 7 residents reviewed for quality of care. (Resident 60 and 87)Findings Include:1. The clinical record for Resident 60 was reviewed on 12/4/25 at 2:08 p.m. The diagnoses included, but were not limited to, combined systolic and diastolic heart failure, fistula of the intestine, and cellulitis of the left toe.A care plan, dated 9/11/25, indicated the resident had a diagnosis of congestive heart failure, nonrheumatic mitral valve insufficiency, nonrheumatic tricuspid valve insufficiency and A-Fib. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 9/4/25, indicated administer metoprolol extended release (a blood pressure medication) 25 milligrams (mg) once a day with instructions to hold for a heart rate less than 60 or a systolic blood pressure less than 105.A medication administration record (MAR), dated 10/1/25 through 10/31/25, indicated metoprolol was 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 · Dcited before2025-04-11 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident with a diagnosis of dementia was free from a physical restraint used to inhibit freedom of movement for 1 of 2 residents reviewed for restraints. (Resident B) The deficient practice was corrected on 3/31/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: A facility reported incident (FRI) indicated, on 3/29/25 at 9:25 a.m., Resident B was found to have the foot of his bed elevated to prevent him from getting out of his bed during the night. Resident B was on a locked memory care unit. It was discovered Resident B's bed was elevated and a pillow was placed under his mattress. The night shift indicated the resident was restless and had attempted to get out of his bed multiple times during the shift. The clinical record for Resident B was reviewed on 4/11/25 at 10:30 a.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, major depressive disorder, and unsteadiness on feet. A Brief Interview for Mental Status (BIMS) assessment indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the physician was notified when blood sugar readings were in the call parameter range and to hold medications per the physician ordered parameters for 3 of 3 residents reviewed for quality of care. (Resident 93, 35 and 108) Findings include: 1. The clinical record for Resident 93 was reviewed on 12/4/24 at 9:43 a.m. The diagnoses included, but were not limited to, diabetes mellitus, atrophy of the kidney, and hypothyroidism. A current care plan, with a start date of 8/1/24, indicated the resident was at risk of complications related to diabetes and to notify the physician or Nurse Practitioner (NP) as needed. A physician's order, with a start date of 10/2/24, indicated to check blood sugars in the morning and at night and to call the physician if the blood sugar was below 60 or above 350. The electronic medical record indicated, on 10/7/24, the morning blood sugar was 57. A progress note, dated 10/7/24 at 6:08 a.m., indicated the blood sugar this morning was 57. The resident was given chocolate milk 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 · Dcited before2024-12-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure staff did not leave a resident unsupervised in a multi-sensory room for longer than 30 minutes per the facility policy, to ensure the resident had a call light or a way to summon staff while in the multi-sensory room, and failed to ensure staff did not leave the resident lying on a fall mat on the floor for an extended period of time for 1 of 6 residents reviewed for supervision. (Resident J) Finding includes: The clinical record for Resident J was reviewed on 12/5/24 at 11:32 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, violent behavior, primary insomnia, Alzheimer's disease, anxiety disorder, malignant neoplasm of prostate, frequency of micturition, history of falling, pain, and dementia with psychotic disturbance, mood disturbance, anxiety, and agitation. A significant change Minimum Data Set (MDS) assessment, dated 10/21/24, indicated the resident required moderate assistance to move from lying to sitting on the side of his bed, to come to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-09 · 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 the correct amount of oxygen was administered to 1 of 2 residents reviewed for respiratory care. (Resident 64) Finding includes: During an observation, on 12/2/24 at 12:35 p.m., Resident 64 was sitting at a table in the common area in his reclining wheelchair. He was wearing oxygen administered via a portable oxygen tank hanging on the back of his wheelchair at a rate of 3 liters per minute (L). During an observation, on 12/3/24 at 4:19 p.m., the resident was sitting in his wheelchair with the portable oxygen tank turned off and hanging on the back of his wheelchair. There was no oxygen tubing present. The resident was not receiving any supplemental oxygen. During an observation, on 12/4/24 at 11:53 a.m., the resident was coloring with the staff in the common area with the portable oxygen tank on the back of his wheelchair delivering oxygen at 1.5 liters per minute. At 12:05 p.m., CNA 8 pushed Resident 64 in his wheelchair to another table for lunch with the portable tank hanging on the back of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to wear PPE (personal protective equipment) into an enhanced barrier precaution (EBP) room for 1 of 4 residents reviewed for transmission-based precautions. (Resident 39) Finding includes: During an observation, on 12/4/24 at 2:04 p.m., Register Nurse (RN) 13 entered Resident 39's room to administer medication. The resident had a gastrostomy tube (a tube surgically inserted into the stomach to provide medication and nutrition) and was in isolation for enhanced barrier precautions. RN 13 did not put on an isolation gown to give the medication via gastrostomy tube. The clinical record for Resident 39 was reviewed on 12/4/24 at 11:28 a.m. The diagnoses included, but were not limited to, Huntington's disease (a disorder which damages brain cells), dysphagia (difficulty swallowing) and abnormal weight loss. A physician's order, dated 12/1/24, indicated the resident was in Enhanced Barrier Precautions. During an interview, on 12/4/24 at 2:39 p.m., RN 13 indicated the resident was not in isolation. The nurse then read…
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 before2024-02-12 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a moderately impaired resident was free from restraints for 1 of 6 residents reviewed for abuse. (Resident B) Finding includes: An incident report sent to the Indiana Department of Health indicated, on 1/26/24, Resident B was found during morning rounds to have the foot of his recliner elevated with a dining room chair to prevent him from lowering the legs of his recliner during the night. It was reported CNA 9 had elevated the resident's recliner legs during the night to prevent the resident from lowering his legs. Resident B was allowed out of his recliner after discovery and was monitored for any signs and symptoms of distress. The clinical record for Resident B was reviewed on 2/12/24 at 12:15 p.m. Diagnoses included, but were not limited to, hypertensive heart disease, major depressive disorder, dementia, osteoporosis, and hyperlipidemia. The resident had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident's cognition was moderately impaired. A nursing note, 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 · Dcited before2023-10-26 · 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 resident had a door to the bathroom in his room for 1 of 1 resident reviewed for dignity. (Resident J) Finding includes: During an observation, on 10/19/23 at 2:54 p.m., Resident J did not have a door for the bathroom in his room. The sink and toilet were visible when entering the resident's room. The record for Resident J was reviewed on 10/23/23 at 2:08 p.m. Diagnoses included, but were not limited to, dementia with mood disturbance, restlessness and agitation, type 2 diabetes mellitus, and history of a traumatic brain injury. During an interview, on 10/23/23 at 2:31 p.m., Social Services 9 indicated she did not know the reason the resident did not have a door to his bathroom. During an interview, on 10/23/23 at 2:52 p.m., CNA 8 indicated the resident was getting a sliding door for his bathroom. She thought the door might have been taken off since the resident would slam the door at times. During an observation and interview, on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a cognitively impaired resident who received hospice services was free from abuse for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: The record for Resident B was reviewed on 10/23/23 at 11:27 a.m. Diagnoses included, but were not limited to, encounter for palliative care, pain of the left hip, dementia with anxiety, hearing loss, and cognitive communication deficit. A physician's order, dated 7/14/23, indicated to discontinue weights and labs due to hospice and end stage dementia. A care plan, dated 7/12/23, indicated the resident was receiving hospice services due to Alzheimer's disease. The goal was for the resident to be kept comfortable, to have her pain managed throughout the progression of the disease, and to have psychosocial support through the end-of-life care. A facility reported incident (FRI), dated 8/8/23, indicated an incident occurred at 7:34 a.m., when QMA 2 was observed to pull Resident B's face towards her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2023-10-26 · tag F0641 — isolatedEnsure each resident receives an accurate 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 accurately complete a Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for PASARR (Preadmission Screening and Resident Review). (Resident 101) Finding includes: The record for Resident 101 was reviewed on 10/23/23 at 9:48 a.m. Diagnoses included, but were not limited to, unspecified mood disorder with paranoia and behaviors, vascular dementia with psychotic disturbance, cerebrovascular disease, and post-traumatic stress disorder (PTSD). A PASRR level 1 screening, dated 9/14/23, indicated the resident had a diagnosis of bipolar disorder added from a MDS assessment. The resident did not have a diagnosis of bipolar disorder. A MDS assessment, dated 8/16/23, indicated the resident was marked to have a diagnosis of bipolar disorder. During an interview, on 10/25/23 at 4:13 p.m., the Social Service Director indicated the MDS assessment was coded incorrectly by the previous MDS Coordinator by mistake. The resident did not have bipolar disorder. The MDS assessment incorrectly coded the resident had a diagnosis 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 before2023-10-26 · 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 notify the provider when blood sugars were out of call parameters for 1 of 1 resident reviewed for insulin. (Resident 62) Findings include: The record for Resident 62 was reviewed on 10/23/23 at 11:19 a.m. Diagnoses included, but were not limited to, dementia with mood disturbance, Alzheimer's disease, and type 2 diabetes. A physician's order, with a start date of 7/9/23 and an end date of 1/16/23, indicated to call the provider for a blood sugar above 351. A current physician's order, dated 1/30/2023, indicated if a blood sugar was greater than 351, call the NP (Nurse Practitioner) or PA (Pysician's Asistant). The following blood sugars were noted: a. On 10/20/22 at 4:54 p.m., the resident's blood sugar was 381. b. On 12/8/22 at 11:45 a.m., the resident's blood sugar was 375. c. On 4/26/23 at 8:00 p.m., the resident's blood sugar read high (above 400). d. On 5/17/23 at 8:00 p.m., the resident's blood sugar was 361. There were no notes indicating the facility notified the provider for these blood sugars. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-26 · 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
2. During an observation, on 10/19/23 at 1:50 p.m., Resident 23 was resting in bed and had oxygen on. The oxygen tubing was not dated. The record for Resident 23 was reviewed on 10/23/23 at 3:27 p.m. Diagnoses included, but were not limited to, dementia, insomnia, and hypertension. A physician's order, date 8/17/23, indicated the resident was to wear oxygen at 1 liter continuously. During an interview, on 10/19/23 at 2:57 p.m., the Respiratory Therapy Supervisor indicated the oxygen tubing was not dated. The oxygen tubing should be dated. During an interview, on 10/19/23 at 2:58 p.m., the Respiratory Therapy Supervisor indicated the facility did not have a policy for labeling or dating oxygen tubing. The oxygen tubing should be changed and dated once a week. 3.1-47(a)(6) Based on observation, interview and record review, the facility failed to ensure oxygen tubing was dated and initialed for 2 of 2 residents reviewed for oxygen. (Resident C and 23) Findings include: 1. During an observation, on 10/19/23 at 12:40 p.m., Resident C was wearing a nasal cannula with oxygen at 2 LPM…
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 · D2023-10-26 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 include a resident's family/healthcare representative (HCR) in decisions about a staff who made visits outside of work hours to a resident with dementia, delusions, and aggressive behaviors and to include the resident's negative interactions with male staff on his plan of care for 1 of 2 residents reviewed for dementia care. (Resident J) Finding includes: During a telephone interview, on 10/4/23, an anonymous complainant indicated RN 14 was causing emotional distress to Resident J and continued to visit the resident even though he was no longer on the unit RN 14 worked. The resident had pictures of RN 14's children and she was emotionally attached to the resident. During an interview, on 10/23/23 at 2:31 p.m., Social Services 9 indicated Resident J had early onset dementia and was agitated at times. He was moved to another building because he was struggling with the male staff and always wanted to oversee the staff and residents. The resident was young…
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 · D2023-10-26 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to schedule follow-up care on recommendations from the dentist for 1 of 1 resident reviewed for dental services. (Resident G) Finding includes: During an interview, dated 10/20/23 at 11:45 a.m., Resident G indicated he lost his uppers when he was here the last time and was trying to get new ones. The record for Resident G was reviewed on 10/23/23 at 10:06 a.m. Diagnoses included, but were not limited to, dysphagia, pain, type 2 diabetes, and cerebral infarction. A dental visit note, dated 1/17/23, indicated the resident needed a tooth extraction. The son was contacted and agreed with the extraction. A dental visit note, dated 10/2/23, indicated the dentist discussed with the resident the need to have his remaining teeth extracted and have dentures fabricated. No acute infections were noted, and he ate puree food well. During an interview, on 10/26/23 at 2:49 p.m., the Assistant Superintendent indicated the resident had not been scheduled for a dental extraction. A current policy, titled Dental Services, dated as reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-26 · 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 and interview, the facility failed to ensure an ice machine was clean and room tray drinks were covered for 1 of 5 units reviewed for dining. ([NAME] 2). Findings include: 1. During an observation, on 10/23/23 at 9:59 p.m., the ice machine on [NAME] 4 appeared dirty. The piece where the ice came out had a lot of crusted white hard water areas with unidentified brown areas stuck to both the inside and outside of the plastic piece. During an interview, on 10/24/23 at 3:10 p.m., the Maintenance Manager indicated the ice machines were cleaned once a month by maintenance. He was unsure what the brown areas around the plastic piece of the ice machine were. It might have been soda which had crusted over. 2. During an observation, on 10/23/23 at 12:14 p.m., Residents 1, 16, and 77 were observed to have trays delivered with drinks not covered. During an interview, on 10/23/23 at 12:15 p.m., CNA 17 indicated the drinks did not have covers. During an interview, on 10/23/23 at 12:16 p.m., RN 18…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| STATE OF INDIANA AUDITOR OF STATE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/21/2011 |
| BALZER, MANDY | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2017 |
| GROW, JOY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/01/2020 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 155787. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-08, 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.