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Maple Park Village

776 N Union St, Westfield, IN 46074 · Government - County · 106 certified beds · (317) 896-2515 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)
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
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • 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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (56%) 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.

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

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
17471 Wheeler Rd · (317) 275-6131 · Call to confirm hours
Pharmacy
211 Jersey St · (317) 896-9378 · Call to confirm hours
Grocery
3026 IN-32 E · (317) 804-2026 · Call to confirm hours
Park
205 W Hoover St · (317) 804-3150 · Typically dawn to dusk
Place of worship
624 N Union St · (317) 558-9266

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 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 rating2★
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 increased10.2%11.0%15.4%better
Long-stay residents who lose too much weight5.9%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.4%0.9%worse 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 symptoms36.6%25.2%6.5%worse 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 injury3.5%3.9%3.3%typical
Long-stay residents whose ability to walk worsened9.1%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.0%23.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers4.7%3.6%4.7%typical
Long-stay residents with worsening bladder/bowel control16.4%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.1%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.6%79.0%79.4%better
Short-stay residents rehospitalized after admission8.7%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 days2.111.611.67worse
Long-stay outpatient ER visits per 1,000 resident days0.451.441.80better

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.

54.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.1%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
17.2%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 17.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 29 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 SNF54.1%CMS range 39.9–66.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 5.8–13.510.7%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 discharge17.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge17.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge13.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 worsened2.9%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 hospitalization6.5%CMS range 3.9–12.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.61
RN hours/ resident / day
0.76
LPN hours/ resident / day
2.00
Aide hours/ resident / day
3.37
Total nurse hours/ resident / day
0.46
RN hoursweekends
56.3%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 106 beds and averages 86.2 residents a day — about 81% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.88 hrs/resident/day on weekends vs 3.57 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.67 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

3
deficiencies at the latest standard inspection (2025-09-16)
4
at the previous standard inspection (2024-10-11)

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.

21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · G2026-03-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a CNA for 2 of 3 residents reviewed for abuse. (Resident D and F) This deficient practice resulted in Resident D thinking a staff member was going to kill him and signs he was scared after the abuse. Resident F had a history of abuse as a child and had two loose teeth in her mouth. The deficient practice was corrected on 2/20/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:1. During an interview, on 3/3/26 at 2:21 p.m., the Executive Director, Director of Nursing and Regional Director of Operations were in attendance and indicated Resident D was blind, had became combative while he was being changed, and CNA 5 put his hands on the resident.The clinical record for Resident D was reviewed on 3/5/26 at 2:29 p.m. The diagnoses included, but were not limited to, dementia with mood disturbance, major depressive disorder, legal blindness, and pain.A care plan, dated 1/15/25, indicated Resident D was legally…

    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
  • Actual harm · Gcited before2023-09-20 · 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 interview and record review, the facility failed to protect a resident from injury when the resident was left unattended in a bed which was not in the lowest position, and without a fall mat on the floor. The resident fell out of bed, sustained a laceration to the left side of the forehead and an acute left femoral neck fracture (a type of hip fracture of the thigh bone, just below the ball of the ball-and-socket hip joint). (Resident B) The facility also failed to ensure staff providing care were using/following the care sheet or electronic record which provides information on safety precautions put in place, resulting in Resident C had to be lowered to the floor, for 2 of 3 residents reviewed for accidents. (Resident B and C) The deficient practice was corrected on 9/12/23, prior to the start of the survey, and was therefore past noncompliance. Findings include: 1. During a phone interview, on 9/19/23 at 10:04 a.m., the Power of Attorney (POA) for Resident B indicated Resident B was dressed and prepped for a full body mechanical lift, which should have had two people 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 · Past Non-Compliance
  • Potential for harm · Dcited before2025-09-16 · 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 medication was held according to the ordered parameters and the physician was notified of blood glucose readings as ordered for 2 of 5 residents reviewed for quality of care. (Resident 7 and 6)Findings include:1. The clinical record for Resident 7 was reviewed on 9/12/25 at 8:26 a.m. The diagnoses included, but were not limited to, chronic diastolic heart failure, hypertensive heart, and chronic kidney disease with heart failure.A physician's order, dated 4/15/25 and discontinued 8/18/25, indicated to administer Entresto (a medication used to treat chronic heart failure) 49-51milligrams (mg) twice a day, with special instructions to hold the medication for a systolic blood pressure of less than 120.The Medication Administration Record (MAR), dated 7/1/25 to 7/31/25, indicated Entresto had been administered 13 times when Resident 7's systolic blood pressure was less than 120.The MAR, dated 8/1/25 to 8/18/25, indicated Entresto had been administered 5 times when Resident 7's systolic blood pressure was less than…

    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 · D2025-09-16 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure physician ordered medications included an appropriate supporting diagnosis and a medication included a stop date for 3 of 5 residents reviewed for unnecessary medications. (Resident 11, 5 and 13)Findings include:1. The clinical record for Resident 11 was reviewed on 9/12/25 at 10:36 a.m. The diagnoses included, but were not limited to, dementia, muscle weakness, and encounter for other specified aftercare. A review of Resident 11's obsolete diagnoses indicated a diagnosis of herpes viral infection was placed on 5/20/24 and resolved on 7/23/24. A physician's visit note, dated 7/7/25, indicated Resident 11 had been experiencing painful blisters on her bilateral thighs and vaginal area, which was a chronic issue, and had been treated in the past. The treatment plan was to initiate a topical antiviral cream for 5 days, followed by valacyclovir (an antiviral medication used to treat infections) 500 milligrams (mg) every day. The physician's note did not include instructions regarding when the medication would be stopped…

    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 · Dcited before2025-09-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 ensure staff wore Personal Protective Equipment (PPE) properly, wore the appropriate PPE when entering an isolation room, preformed hand hygiene, and changed gloves during a dressing change for 3 of 7 residents reviewed for infection control. (Resident 57, 34 and 5)Findings include:1. During a random observation, on 9/10/25 at 9:53 a.m., CNA 4 was observed to put on a protective gown, mask, and gloves outside of Resident 57's room. The gown was not tied at the neck. She then entered the room which had a sign posted to indicate it was a droplet/contact isolation room. The sign indicated to put on a gown and to tie the gown.During an interview, on 9/10/25 at 10:11 a.m., CNA 4 indicated the sign did indicate she should have tied her gown.During a random observation, on 9/11/25 at 8:48 a.m., CNA 3 was observed to put on a gown, mask, and gloves and enter Resident 57's room. She was not observed to put on the eye protection required for droplet precautions.During an interview, on 9/11/25 at 8:52 a.m., CNA 3…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-18 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident with continuous feeding through a Jejunostomy tube (J-tube) received the ordered amount of nutrient formula at the correct rate in the ordered time frame for 1 of 2 residents reviewed for enteral feedings. (Resident B) The deficient practice was corrected on 10/15/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: During an interview, on 10/18/24 at 8:42 a.m., the Executive Director indicated Resident B had received a total of 1000 ml (milliliters) of enteral feeding over a four (4) hour period via her J-tube. During an observation, on 10/18/24 at 1:29 p.m., the feeding pump was assessed. The Director of Nursing, Executive Director, Corporate Support Nurse and Regional [NAME] President of Operations were present. The history was not assessable as the pump had been disconnected from a power source since 10/14/24. The Executive Director indicated they had attempted to access the pump memory but kept receiving an error message. It was noted when 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 · Past Non-Compliance
  • Potential for harm · D2024-10-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to conduct care plan meetings at least quarterly for 2 of 2 residents reviewed for care plan conferences/meetings. (Resident 5 and 59) Findings include: 1. The clinical record for Resident 5 was reviewed on 10/8/24 at 1:49 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, chronic systolic heart failure, and hypertension. The last documented care plan meeting for Resident 5 was in March 2024. During an interview, on 10/10/24 at 2:34 p.m., the Social Service Director indicated the resident had a care plan in March of this year (2024). The resident should have had one in May and another one in early August. The resident was missing 2 care plan meetings. 2. The clinical record for Resident 59 was reviewed on 10/10/24 at 2:29 p.m. The diagnoses included, but were not limited to, hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine), chronic atrial fibrillation, and acute chronic diastolic heart failure. The last documented care…

    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 before2024-10-11 · 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 medications were held according to the physician's ordered hold parameters for 2 of 2 residents reviewed for quality of care. (Resident 36 and 55) Findings include: 1. The clinical record for Resident 36 was reviewed on 10/10/24 at 11:02 p.m. The diagnoses included, but were not limited to, essential hypertension, type 2 diabetes, and hyperlipidemia. A physician's order, with a start date of 1/23/24, indicated to give metoprolol succinate (a blood pressure medication) 100 milligrams (mg) extended-release tablet once a day. Hold for a systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60. A current care plan, with a start date of 1/30/24, indicated the resident was at risk for ineffective tissue perfusion related to hypertension and to administer medications as ordered. A review of the Medication Administration Record (MAR) indicated metoprolol succinate was administered on the following dates outside of the physician's ordered hold parameters: On 7/1/24, with a systolic blood pressure of 101…

    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 · Dcited before2024-10-11 · tag F0761 — failed to label and store drugs safely — isolated
    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

    Based on observation, interview and record review, the facility failed to ensure unlabeled food was not stored in a medication room refrigerator and medications were stored in the original containers in 1 of 2 medication rooms and 1 of 3 medication carts reviewed for medication storage. (200 hall refrigerator and 300 hall medication cart) Findings include: 1. During an observation and interview, on 10/11/24 at 11:49 a.m., the 200-hall medication room supplement refrigerator had 2 unlabeled cans of Canada Dry and a grocery sack with a to-go container of food in it which was unlabeled. Registered Nurse (RN) 3 indicated she was unsure who the 2 cans of Canada Dry and the food belonged to. They did not have labels on them, and they should have had labels. During an interview, on 10/11/24 at 12:05 p.m., the Director of Nursing (DON) indicated food put in the refrigerator should be labeled.2. During an observation of the Moving Forward South medication cart there were 20 white oval tablets with marking 4H2 (cetirizine) and one round white table found in the bottom drawer. There was no…

    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 · D2024-10-11 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 staff prepared pureed food in a sanitary manner for 1 of 1 staff member observed to puree food. (Cook 6) Finding includes: During an observation, on 10/8/24 at 10:36 a.m., [NAME] 6 was preparing pureed tuna casserole for lunch. During an observation, on 10/8/24 at 10:44 a.m., while preparing the pureed tuna casserole, [NAME] 6 licked the pureed tuna casserole off the first finger of her right hand. [NAME] 6 then attempted to take the food processor bowl off the base of the appliance to transfer the pureed food into a different container. During an interview, on 10/8/24 at 10:44 a.m., [NAME] 6 indicated she should not have licked the food off her finger and instead, she should have washed her hands. A current facility policy, titled Food Handling, dated 11/15 and received from the Director of Nursing on 10/10/24 at 8:49 a.m., indicated .To provide quality food that is handled in a safe and sanitary manner .All food preparation and serving areas shall be maintained in accordance with state and local…

    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 · D2024-08-29 · 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 a narcotic pain patch was administered at the correct time and new sites were used for the transdermal patch administration for 1 of 1 resident reviewed (Resident B) and failed to ensure staff were signing the narcotic count sheets for 4 of 6 medication cart narcotic logs reviewed. Findings include: 1. During an interview, on 8/28/24 at 9:55 a.m., Resident B indicated she was experiencing pain and had been provided medication for the pain. The resident allowed observation of her Fentanyl pain patch. It was located on her right upper arm and dated 8/27/24. She indicated the patch was changed every three days. She was not aware of any missed doses of medications, including the narcotic pain patch. The clinical record for Resident B was reviewed on 8/28/24 at 11:29 a.m. The diagnoses included, but were not limited to, fibromyalgia, chronic pain, and polyneuropathy. A physician's order, initiated on 12/30/23 and discontinued on 7/22/24, indicated to administer one Fentanyl patch 50 mcg per hour every 72…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-12 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure residents received non-disposable utensils to eat their meals with for 17 of 17 residents reviewed for dining on the locked dementia unit. Finding includes: During an observation, on 10/5/23 at 11:34 a.m., the residents were sitting in the dementia dining area. The residents' trays were served by taking food off the tray. Plastic utensils were provided for all residents. During an observation, on 10/5/23 at 12:01 p.m., the residents in the main dining room were being served with non-disposable utensils. During an observation, on 10/11/23 at 11:42 a.m., the residents in the dementia dining room were being served paper napkins and plastic silverware including a spoon, knife, and fork. The staff put the residents' drinks in non-disposable plastic cups. During an interview, on 10/11/23 at 11:52 a.m., CNA 8 indicated a resident owned a restaurant and would take the silverware. CNA 8 indicated the resident might have gone after someone with a fork and everyone got plastic. During an interview, on 10/12/23 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · Ecited before2023-10-12 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 give medications within the prescribed time for 6 of 6 residents reviewed for quality of care. (Residents B, C, D, E, F, G) Findings include: 1. The record for Resident B was reviewed on 10/12/23 at 4:28 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, congestive heart failure, hypertension, atrial fibrillation, dementia, unspecified severity with other behavioral disturbance, depressive disorder, and anxiety disorder. A physician's order, dated 11/3/21, indicated clonazepam (for anxiety) 0.5 mg tablet, to give 0.25 mg tablet twice a day related to anxiety. A physician's order, dated 12/2/22, indicated acetaminophen (a pain medication) 500 mg (milligram) tablet, to give 2 tablets three times a day related to chronic pain. A physician's order, dated 6/30/23, indicated simethicone (relieves painful symptoms of too much gas in the stomach) chewable 80 mg to give 2 tablets by mouth daily. The Medication Administration Record (MAR) indicated the following medications were 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-12 · 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 observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment included the resident had a wanderguard for 1 of 1 resident reviewed for elopement. (Resident E) Finding includes: During an observation, on 10/5/23 at 3:28 p.m., Resident E had a wanderguard on her right ankle. The record for Resident E was reviewed on 10/10/23 at 10:44 a.m. Diagnoses included, but were not limited to, depression, dementia with mood disturbance, cognitive communication deficit, difficulty in walking, and a history of a traumatic brain injury. An MDS assessment, dated 8/11/23, indicated the resident did not use a wanderguard. During an interview, on 10/10/23 at 2:33 p.m., the MDS Coordinator indicated the resident did not have a physician's order for the wanderguard which was placed on 8/7/23. The only way she found out if the resident had a wanderguard was by reviewing the physician's orders. Since there was no physician's order then she did not code the MDS assessment with the wanderguard. During exit, the facility indicated they used the RAI…

    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 before2023-10-12 · 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 observation, interview and record review, the facility failed to ensure a resident with a wanderguard (an alarm bracelet) had a physician's order, daily assessment for placement and a care plan for the alarm for 1 of 1 resident reviewed for elopement. (Resident E) Finding includes: During an observation, on 10/5/23 at 3:28 p.m., Resident E had a wanderguard on her right ankle. During an observation, on 10/10/23 at 2:21 p.m., the resident was in her room watching television and had the door to her room closed. During an observation, on 10/10/23 at 10:54 a.m., the resident was sitting up in a chair in the dining room and listening to music with other residents. The resident had not been observed wandering or trying to leave the locked unit. The record for Resident E was reviewed on 10/10/23 at 10:44 a.m. Diagnoses included, but were not limited to, depression, dementia with mood disturbance, cognitive communication deficit, difficulty in walking, and a history of a traumatic brain injury. A care plan, dated 5/1/23, indicated the resident was at risk for elopement as evidenced…

    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 · D2023-10-12 · 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

    Based on interview and record review, the facility failed to identify and implement resident specific preventative nursing measures for a resident with multiple repeat urinary tract infections (UTI) for 1 of 3 residents reviewed for UTIs. (Resident F) Finding includes: The record for Resident F was reviewed on 10/10/23 at 3:55 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, chronic kidney disease stage 3, need for assistance with personal care, urinary tract infection, and difficulty in walking. The Surveillance Log indicated the resident had the following UTIs and treatments: 1. October 6-13, 2022, ceftriaxone for a urine culture positive for E coli. 2. October 26-November 11, 2023, amoxicillin for a culture report positive for P. mirabilis (a bacteria which causes UTIs). 3. January 1-7, 2023, Macrobid (an antibiotic for UTIs). There was no culture report. 4. February 15- 20, 2023, cephalexin (an antibiotic) for a urine culture positive for proteus mirabilis. 5. March 24-29, 2023, Augmentin for a urine culture positive for E. Coli (a bacteria found in stool).…

    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 · D2023-10-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to identify significant weight changes, implement timely interventions, and notify the provider and family in a timely manner for 2 of 4 residents reviewed for nutrition. (Resident 31 and E) Findings include: 1. The record for Resident 31 was reviewed on 10/12/23 at 12:10 p.m. Diagnoses included, but were not limited to, iron deficiency anemia, chronic obstructive pulmonary disease, dementia, feeding difficulties, and fracture of the right femur. A weight log indicated the following: a. On 9/7/23, the resident's weight was 144 pounds. b. On 10/4/23, the resident's weight was 131 pounds. c. On 10/6/23, the resident's weight was 131 pounds. The resident had a 9.03%- or 13-pound weight loss in 27 days. A progress note, dated 10/06/2023 at 3:15 p.m., indicated an MDS (Minimum Data Set) significant change assessment was initiated for a significant weight loss. The facility did not contact the provider or family after recognizing the significant weight loss. A progress note, dated 10/12/23 at 12:28 p.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 · D2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 residents oxygen tubing was dated and replaced for 2 of 3 residents reviewed for respiratory care. (Residents 38 and 76) Findings include: 1. During an observation, on 10/5/23 at 11:52 a.m., Resident 38's oxygen tubing did not have a date on it. The record for Resident 38 was reviewed on 10/10/23 at 10:45 a.m. Diagnoses included, but were not limited to, restrictive lung disease, dyspnea (difficulty breathing), chronic respiratory failure, and obstructive sleep apnea. A physician's order, dated 9/22/23, indicated the resident was on 3 liters of oxygen continuously. A physician's order, dated 9/22/23, indicated to change the oxygen tubing once a day on Sundays. During an interview, on 10/5/23 at 2:48 p.m., RN 9 indicated the oxygen tubing should have been dated. During an interview, on 10/10/23 at 3:53 p.m., the ED (Executive Director) indicated the oxygen tubing for residents should be dated. 2. During an observation, on 10/5/23 at 2:45 p.m., Resident 76's oxygen tubing was dated 8/6/23. The record 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 · D2023-10-12 · 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 record review and interview, the facility failed to ensure symptom monitoring was in place for the use of an antipsychotic medication prescribed and a gradual dose reduction (GDR) was considered for 1 of 5 residents reviewed for unnecessary medications. (Resident F) Finding includes: The record for Resident F was reviewed on 10/10/23 at 3:55 p.m. Diagnoses included, but were not limited to, dementia with other behavioral disturbance, delusional disorder, major depressive disorder, generalized anxiety disorder, and a cognitive communication deficit. A care plan, dated 2/23/23, indicated the resident was at a risk for adverse side effects related to the use of an antipsychotic. The interventions included, but were not limited to, administer the medication as ordered and observe for effectiveness, the interdisciplinary team (IDT) to review routinely, and to attempt a gradual dose reduction unless contraindicated by the physician. A physician's order, dated 4/10/23, indicated risperidone (an antipsychotic) 0.5 milligram (mg) twice a day for a delusional disorder. The resident…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-12 · tag F0761 — failed to label and store drugs safely — isolated
    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

    Based on observation, interview and record review, the facility failed to label medications with an open date on medications with a shortened expiration date once opened in 1 of 2 medication storage refrigerators and 2 of 3 medication carts (300 Unit, 100 Unit and 300 North Unit). Findings include: 1. During an observation, of 300-unit medication storage room and refrigerator, on 10/5/23 at 12:55 p.m., with LPN 2 in attendance, a bottle of Tuberculin (the testing solution for a Tuberculosis skin test) was found open in the medication storage refrigerator. It did not have an open date. During an interview, on 10/5/23 at 12:55 p.m., LPN 2 indicated it should have been labeled with the open date when it was opened. 2. During an observation, of the 100 Unit Medication Cart, on 10/10/23 at 9:21 a.m., with RN 3 in attendance, an Advair inhaler was found outside the original foil packaging. The inhaler had 56 of 60 doses left. The label on the packaging indicated the medication expired 30 days after opening. There was no open date on the packaging or inhaler. During an 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 ensure a catheter bag was not touching the ground for 1 of 1 resident reviewed for infection control related to catheters. (Resident 14) Finding includes: During an observation, on 10/11/23 at 10:21 a.m., Resident 14 was being seen for wound care. The resident's catheter bag was observed to be touching the ground. During an observation, on 10/11/23 at 10:33 a.m., the bed was lowered back down after wound care was completed and the catheter bag touched the ground again. The basin to protect the catheter bag from touching the floor was underneath the bed towards the head of the bed and not underneath the catheter bag. The record for Resident 14 was reviewed on 10/11/23 at 3:09 p.m. Diagnoses included, but were not limited to, obstructive and reflux uropathy, history of urinary tract infections, and dementia. During an interview, on 10/11/23 at 10:37 a.m., the ADON (Assistant Director of Nursing) indicated the catheter bag should have a basin which the catheter bag sat in to prevent it from touching the ground.…

    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.

    Infection Control 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 AMERICAN SENIOR COMMUNITIES — 90 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 2 of 53.9-1.9 vs chain
Health inspection 2 of 53.4-1.4 vs chain
Staffing 2 of 52.3-0.3 vs chain
Quality measures 4 of 54.7-0.7 vs chain
The other 89 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Valparaiso Care & RehabilitationValparaiso, IN 2 of 5Arbor Grove VillageGreensburg, IN 2 of 5Bethany VillageIndianapolis, IN 2 of 5Columbia Healthcare CenterEvansville, IN 2 of 5Community Nursing And Rehabilitation CenterIndianapolis, IN 2 of 5Eagle Valley MeadowsIndianapolis, IN 2 of 5Harcourt Terrace Nursing And RehabilitationIndianapolis, IN 2 of 5Harrison TerraceIndianapolis, IN 2 of 5Hickory Creek At New CastleNew Castle, IN 2 of 5Park Terrace VillageEvansville, IN 2 of 5Riverside VillageElkhart, IN 2 of 5Trailpoint VillageSouth Bend, IN 2 of 5University Nursing CenterUpland, IN 2 of 5Williamsport Nursing And RehabilitationWilliamsport, IN 3 of 5Allisonville MeadowsFishers, IN 3 of 5American VillageIndianapolis, IN 3 of 5Brownsburg MeadowsBrownsburg, IN 3 of 5Countryside MeadowsAvon, IN 3 of 5East Lake Nursing & Rehabilitation CenterElkhart, IN 3 of 5Hickory Creek At CrawfordsvilleCrawfordsville, IN 3 of 5Hillcrest VillageJeffersonville, IN 3 of 5North Capitol Nursing & Rehabilitation CenterIndianapolis, IN 3 of 5Rosebud VillageRichmond, IN 3 of 5Rosewalk VillageIndianapolis, IN 3 of 5Rosewalk Village At LafayetteLafayette, IN 3 of 5Spring Mill MeadowsIndianapolis, IN 3 of 5Stonebrooke Rehabilitation CenterNew Castle, IN 4 of 5Autumn Ridge Rehabilitation CentreWabash, IN 4 of 5Beech Grove MeadowsBeech Grove, IN 4 of 5Clark Rehabilitation And Skilled Nursing CenterClarksville, IN 4 of 5Clinton GardensClinton, IN 4 of 5Creekside VillageMishawaka, IN 4 of 5Edgewater WoodsAnderson, IN 4 of 5Forest Creek VillageIndianapolis, IN 4 of 5Franklin MeadowsFranklin, IN 4 of 5Heritage House Rehabilitation & Health Care CenterConnersville, IN 4 of 5Hickory Creek At ColumbusColumbus, IN 4 of 5Hickory Creek At MadisonMadison, IN 4 of 5Hickory Creek At PeruPeru, IN 4 of 5Hickory Creek At RochesterRochester, IN

Showing 40 of 89; 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
HORN, BRENDAIndividualCORPORATE DIRECTORsince 12/01/2023
BABCOCK, PAULIndividualCORPORATE OFFICERsince 09/30/2020
AMERICAN SENIOR COMMUNITIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/05/2026
DICE, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
GARCIA, TRALENEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/11/2023
PATEL, KEESHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/13/2026
PIKE, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2019
VAN CAMP, STEVENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023

CMS files one row per role, so the 13 rows in the source record cover these 8 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.

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.

$10.1M
Net patient revenuemost recent cost report
-2.8%
Operating marginrevenue minus expenses
$923K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 5%Other / private 21%

About 74% 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 $923K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$341per resident / day
operating cost
$10,373per month
≈ monthly operating cost
$332per 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 155199. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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