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Williamsport Nursing And Rehabilitation

200 Short St, Williamsport, IN 47993 · Government - County · 80 certified beds · (765) 762-6111 Medicare & Medicaid certified

Call the home — (765) 762-6111 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citations — no harm found (F0740, F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
200 W Jackson St · (765) 762-3390 · Call to confirm hours
Grocery
500 State Road 28 E · (765) 762-2023 · Call to confirm hours
Park
Park Ave · Typically dawn to dusk
Place of worship

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 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased12.7%11.0%15.4%better
Long-stay residents who lose too much weight1.0%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%1.1%2.0%better
Long-stay residents with depressive symptoms12.2%25.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.0%3.9%3.3%better
Long-stay residents whose ability to walk worsened12.0%11.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication18.0%23.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.4%95.3%typical
Long-stay residents with pressure ulcers4.5%3.6%4.7%typical
Long-stay residents with worsening bladder/bowel control17.1%23.3%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.4%13.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.0%79.0%79.4%better
Short-stay residents rehospitalized after admission17.0%22.2%22.6%better
Short-stay residents with an outpatient ER visit10.2%10.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.961.611.67better
Long-stay outpatient ER visits per 1,000 resident days1.721.441.80typical

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.

47.2% 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 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.2%U.S. median 51.5%
Got home and stayed home
13.4%U.S. median 10.7%
Went back to hospital
23.5%U.S. median 56.6%
Met the expected recovery
0.17U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 23.5% 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 34 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 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% 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 SNF47.2%CMS range 35.6–59.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.4%CMS range 10.2–18.410.7%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 discharge23.5%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 discharge20.6%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 discharge38.2%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 stay2.3%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 worsened0.0%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 hospitalization7.0%CMS range 3.9–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

0.49
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.25
Aide hours/ resident / day
3.48
Total nurse hours/ resident / day
0.27
RN hoursweekends
31.4%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 62.1 residents a day — about 78% occupied, or roughly 18 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 3.483 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.04 hrs/resident/day on weekends vs 3.66 on weekdays — 17% thinner on weekends. RN hours go from 0.57 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-06-13)
8
at the previous standard inspection (2024-05-15)

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

Inspection deficiencies

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

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Fcited before2025-06-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the kitchen was in a sanitary condition and the facility failed to ensure cleaning logs were completed and kept up to date for 1 of 1 initial kitchen observations. This had the potential to affect 64 out of 64 people who consumed food out of the kitchen. Findings include: During the initial kitchen tour on 6/9/25 at 10:00 a.m., the Dietary Cooperate Consultant was present during the initial tour. The convention oven burners were noted to have dark/chard particles caked on them. The grill next to the convention oven had food particles all around the outside rim of the grill. There was no food currently being cooked on the grill or oven at the time. The piping and wall behind the convention oven appeared dirty with old grease. The kitchen floor was dirty with food crumbs and pieces of paper towel throughout. Walk-in freezer contained food crumb/particles on the floor and shelving. During an interview, on 6/9/25 at 10:10 a.m., the Dietary Cooperate Consultant indicated the kitchen had a new dietary…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-13 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that was palatable and failed to serve food at the proper temperature for 1 of 1 test tray. This had the potential to affect all residents who received food from the kitchen. Findings include: 1. During an observation of the lunch service, on 6/9/25 at 11:50 a.m., The residents in the dining room were served a chicken salad sandwich, slice of lettuce, slice of tomato, beets, and sliced pears. This menu differed from what was to be served that day. The residents were to be served a bowl of tomato basil soup, hot tuna and cheese sandwich, pickled beets and sliced pears. During a dining room observation, on 6/9/24 at 12:27 p.m., Resident 31 was served her lunch tray, and she indicated she was tired of chicken salad, and they just had a chicken salad sandwich a couple of days ago. The resident also questioned the staff why they were also having chicken again for dinner. During an interview, on 6/10/25 at 2:44 p.m., the Dietary…

    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 · D2025-06-13 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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's shower preferences were upheld for 1 of 24 residents reviewed for choices (Resident 54). Findings include: During an interview, on 6/9/25 at 11:16 a.m., Resident 54 indicated she wanted a shower every day but had never been asked how often she wanted one. Resident 54's record was reviewed on 6/12/25 at 11:08 a.m. Census information indicated the resident was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 4/1/25, indicated the resident had a moderate cognitive impairment, it was very important for her to choose the type of bath she received, and she required partial/moderate staff assistance with bathing. A preferences for customary routines and activities observation, dated 4/8/25, indicated the resident was interviewed to obtain the information in the document. The resident indicated it was very important for her to choose the type of bath she received, and she preferred to be bathed more…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for 1 of 22 residents reviewed for MDS assessment accuracy (Resident 55). Findings include: Resident 55's record was reviewed on 6/11/25 at 11:58 a.m. A quarterly MDS assessment, dated 4/15/25, indicated the resident received an anticoagulant (blood thinner) medication during the look-back period. A Medication Administration Record (MAR), dated April 2025, lacked documentation the resident received an anticoagulant medication. During an interview, on 6/13/25 at 10:17 a.m., the Director of Nursing Services (DNS) indicated she reviewed the MDS assessment, dated 4/15/25, and the resident's record. At the time of the MDS assessment, the resident was not on an anticoagulant medication. He was on an anticoagulant previously, but it was discontinued prior to the MDS assessment's look-back period. The assessment was coded in error. On 6/13/25 at 10:16 a.m., the DNS provided the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (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 before2025-06-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During an interview, on 6/9/25 at 2:15 p.m., Resident 31 indicated she did not remember being invited to or attending a care plan meeting regularly. She did not recall when the last one was. Resident 31's record was reviewed on 6/11/25 at 11:29 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 4/30/25, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A Care Plan Summary note, dated 12/12/24, indicated a care plan meeting was conducted on this day for Resident 31. A Care Plan Summary note, dated 6/13/24, indicated a care plan meeting was conducted on this day for Resident 31. Resident 31's record lacked documentation of a quarterly care plan meeting being conducted for the last year from June 2024 to June 2025. The resident had two care plan meetings for the entire year. During an interview, on 6/11/25 at 1:28 p.m., the Social Service Director (SSD) indicated she would document a care plan summary note in the residents'…

    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 · D2025-06-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure residents were administered showers and shaved per resident preference for 2 of 24 residents reviewed for Activities of Daily Living (ADL), (Resident 50), (Resident 29). Findings include: 1. On 6/10/25 at 10:32 a.m., during initial observation and interview, Resident 50 observed to have extensive facial hair. The resident indicated he preferred to be shaved but the staff does not shave him, and due to poor vision he is unable to shave himself. The resident indicated he was scheduled to receive a shower on Monday and Friday, but he was not being administered regular showers. On 6/10/25 at 10:45 a.m., during an interview the Assistant Director of Nursing (ADON) indicated she was unsure how often the residents were shaved. On 6/10/25 at 10:46 a.m., during interview Certified Nurse Aide (CNA) 5, indicated residents were shaved on the days they received a shower. She indicated they record administered showers on a shower sheet. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to prevent potential accidents by ensuring medications were administered and disposed of according to medication professional standards for 2 of 5 residents reviewed (Residents 8 and 20). Findings include: 1. On 6/9/25 at 11:15 a.m., during an initial observation and resident interview, Resident 8 sat on side of bed. Two plastic medication cups containing several pills were observed. The resident indicated she had a rough night, and the nurse did not want to wake her up and left her medications on her overbed table. On 6/10/25 at 2:33 p.m., the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnoses included but not limited to chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), alcoholic cirrhosis (a severe liver condition where healthy liver tissue is replaced by scar tissue due to long-term, excessive…

    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 · D2025-06-13 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a resident had received a requested medication for muscle spasms (sudden involuntary powerful contraction of a muscle or muscle group) for 1 of 1 resident reviewed for pain management (Resident 112). Findings include: During the initial pool interview, on 6/9/25 at 2:22 p.m., Resident 112 indicated she had requested an as needed (PRN) dose of her tizanidine (medication to treat muscle spasms) earlier in the morning when she had been given her pain medication. The nurse asked if she would consider waiting until after lunch due to the high risk of falling as the medication was known to lower blood pressure. The resident was confused as to why the nurse was concerned about her falling as she was in a wheelchair and was non-weight bearing (when no weight should be placed on an affected limb, usually after a surgical procedure). She indicated she reluctantly agreed, and requested, and was given, a Xanax (anti-anxiety medication). The nurse had not returned, after lunch, to check on her and offer the tizanidine, and now…

    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 before2025-06-13 · 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 — the official record, unedited, may be distressing

    Based on observation and interviews, the facility failed to ensure medication was labeled properly for 1 of 2 medication storage rooms reviewed for medication storage. Findings include: On 6/11/25 at 9:15 a.m., observed the North Hall medication storage room with Licensed Practical Nurse (LPN) 17. The refrigerator observed with an opened, undated vial of tuberculin solution. On 6/11/25 at 9:20 a.m., during an interview LPN 17 indicated medications must be dated when opened. On 6/11/25 at 11:30 a.m., during an interview the Director of Nurses (DON) indicated tuberculin solution must be dated when opened. On 6/11/2025 at 10:12 a.m., the DON provided a document, titled, Medication Storage and Expiration policy, dated 11/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .9. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened 3.1-25(j) 3.1-25(m) 3.1-25(n)

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · 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 record review and interview, the facility failed to ensure a wound vacuum-assisted closure (vac) was placed properly for 1 of 3 residents reviewed for wound treatment (Resident B). Findings include: Resident B's closed record was reviewed on 11/21/24 at 11:53 a.m. The profile indicated the resident's diagnoses included, but were not limited to, acute osteomyelitis (a serious bone infection that occurs when bacteria or other infectious agents spread to the bone) of the left ankle and foot, type 2 diabetes (a chronic disease that causes high levels of blood sugar, because the body doesn't produce enough insulin or doesn't use it properly) and diabetic foot ulcer (an open sore or wound that develops on the foot of a person with diabetes). An admission Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the resident had no cognitive deficit and required extensive assistance with daily living skills (the routine tasks that people perform to care for themselves and their surroundings). A care plan, dated 10/13/24, indicated the resident required implementation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2024-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 and interview, the facility failed to ensure hot water temperatures were maintained within safe range for 5 of 7 residents reviewed for accidents (Resident 49, 36, 5, 29, and 208). Findings include: During random observation on 5/9/24 at 9:30 a.m., the public bathroom sink water was too hot to hold hands under for more than a few seconds without burning the skin. During random observation on 5/9/24 at 11:01 a.m., Residents 49's and 36's sink water was too hot to hold hands under for more than a few seconds without burning the skin. The water temperature after running at one and two minutes read 130.1 degrees Fahrenheit (F). During an interview on 5/9/24 at 11:19 a.m., Resident 5 indicated the water was too hot when she washed her hands. Residents 5's and 29's sink water was too hot to hold hands under for more than a few seconds without burning the skin. The water temperature after running one minute read 132.3 degrees F, and after running two minutes read 134.2 degrees F. During random observation on 5/9/24 at 11:31 a.m., Resident 208's sink water was too hot…

    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 · Ecited before2024-05-15 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure proper food handling for 1 of 2 dining observations and the facility failed to ensure proper hand sanitization was performed during meal service for of 1 of 2 dining observations. This had the potential to affect 50 out of 50 residents who ate meals from the kitchen. Findings include: 1a. During a dining observation, on 5/8/24 at 11:36 a.m., Certified Nurse's Aide (CNA) 12 was preparing drinks for the residents. She scooped the ice into 2 glasses and returned the ice scoop into the ice bucket. At 11:37 a.m., the Housekeeping Supervisor prepared a glass of fruit punch for a resident and placed the ice scoop back into the ice bucket that contained ice. At 11:56 a.m., the ice scoop remained in the ice bucket. At 11:57 a.m., another staff member approached the ice bucket and placed the ice scoop into an empty behind the ice bucket. 1b. During an observation of hall trays being served on 5/8/24 at 12:17 a.m., CNA 3 grabbed two empty…

    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 · D2024-05-15 · tag F0550 — failed to protect resident dignity and rights — isolated
    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, record review, and interview, the facility failed to ensure residents were treated with dignity for 1 of 1 resident reviewed for dignity (Resident 4). Findings include: During a dining observation on 5/8/24 at 11:50 a.m., the Speech Language Pathologist (SLP) was observed to be standing at Resident 4's left side, assisting him with eating and drinking. She was not observed to sit down while assisting him. Resident 4's record was reviewed on 4/15/24 at 11:21 a.m. His diagnoses included, but were not limited to, paraplegia (loss of muscle function in the lower body), lack of coordination (poor muscle control), contracture of muscles (permanent shortening of a muscle causing deformity), abnormal posture (involuntary abnormal position of the body), and mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). A comprehensive care plan, last reviewed 5/13/24, indicated resident had a problem with activities of daily living (ADL) that started 1/19/23 and needed assistance with ADL's, including eating,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 1 of 3 residents reviewed for care plan meetings (Resident 7), and the facility failed to ensure an oxygen care plan was implemented for 1 of 3 residents reviewed for care plans (Resident 15). Findings include: 1. During an interview, on 5/10/24 at 10:22 a.m., Resident 7 indicated he did not remember being invited to or attending a care plan meeting. He did not recall when the last one was. Resident 7's record was reviewed on 5/14/24 at 9:45 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 2/22/24, indicated the resident had moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A Social Service Director (SSD) note, dated 8/29/23, indicated a care plan meeting was conducted on this day for Resident 7. A SSD note, dated 2/22/24, indicated a care plan meeting was conducted on this day for Resident 7. Resident 7's record lacked…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure catheter care and placement of catheter equipment for 1 of 1 residents reviewed for catheter care. (Resident 15) Findings include: On 5/8/24 at 11:07 a.m., during main dining room meal observation, Resident 15 sat in his wheelchair. The catheter bag was completely in contact with floor touching wheel of wheelchair dignity bag (a cloth bag covering the urinary drainage bag) was not completely covering bag and urine was visible. On 5/08/24 at 11:21 a.m., during routine observation, observed catheter bag had continued to be in contact with the floor coming out of the dignity bag resident continues to pull on tubing causing bag to go up and down. touching the floor, his shoes, and wheel of wheelchair. On 5/08/24 at 11:28 a.m., during routine observation, observed Resident 15 pick up catheter bag and placed it in his lap. The resident continued to touch the drainage bag tubing with hands while in the drainage bag continued to be in his…

    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 before2024-05-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided to 2 of 2 residents reviewed for respiratory services (Residents 15 and 8). Findings include: A. On 5/09/24 at 10:52 a.m., during an observation and interview, Resident 15 was sitting in a wheel chair in his room. The portable oxygen tank meter flow gauge was set on 2 L (Liters) and being administered to the resident by a nasal canula (NC). The resident indicated it should have been on 3 L. The resident indicated he was not getting any air. CNA 7 remove portable oxygen tank from the resident and failed to place resident on an oxygen concentrator (a device that converts ambient room air to a higher concentration of level of oxygen) that was in his room. Certified Nurse Aide (CNA) 7 spoke to Licensed Practical Nurse (LPN) 9. The CNA failed to inform the nurse the residents oxygen concentrator was not on. On 5/09/24 at 10:56 a.m., during an interview with CNA 7, she indicated she would normally not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-15 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure 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

    Based on observations, interview, and record review, the facility failed to provide mental health services to 1 of 4 residents reviewed (Resident 48). Findings include: On 5/09/24 at 2:30 p.m., during an observation and interview with Resident 48, the resident was very confused, crying indicated she was not supposed to be married to her husband and she wanted to leave the facility. The staff indicated she was an elopement risk and had been trying to leave the facility. She often went to the front but did not attempt to leave the exit next to her room. The resident became more agitated while interviewing and distressed about wanting to leave. Ended the interview due to evident distress of the resident. On 5/14/24 at 1:45 a.m., the medical record for Resident 48 was reviewed. Diagnoses included but were not limited to: Essential (primary) hypertension (high blood pressure) dated 9/19/2023, dementia, severe, with other behavioral disturbance (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5%, related to not administering medications in a safe and sanitary manner and failed to follow manufacturer's guidelines for 2 of 9 residents observed for medication administration (Residents 31 and 159), 2 errors were observed during 31 opportunities resulting in an error rate of 6.45%. Findings include: 1. On 5/13/24 at 12:50 p.m., Licensed Practical Nurse (LPN) 16 was observed administering medications to Resident 31. While dispensing the resident's Creon (a medication to assist with pancreatic enzyme [protein that help speed up metabolism, or the chemical reactions in the body] ) from the medication bottle, the LPN touched the capsule with her ungloved finger, and continued to administer the medication to the resident. On 5/14/24 at 1:13 p.m., Resident 31's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, other chronic pancreatitis (a condition where the pancreas becomes permanently damaged from…

    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 · Ecited before2023-03-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a scoop was not stored in the powdered thickener canister, expired food was not stored in the walk-in refrigerator, pureed food items were prepared in a sanitary manner, and staff sanitized their hands appropriately for 2 of 2 kitchen observations with the potential to effect 6 of 6 residents who received pureed food from the kitchen. Findings include: 1. During the initial kitchen tour with the Dietary Manager (DM), on 3/20/23 at 10:29 a.m., a scoop was observed in the powdered thickener canister and in the walk-in refrigerator a large bag of diced potatoes was observed with an expiration date of 3/19/23. On 3/20/23 at 10:56 a.m., the DM indicated, a scoop should not have been stored in the thickener canister and the bag of diced potatoes was expired and should have been discarded into the garbage. 2. During an observation of pureed foods with the DM in the kitchen, on 3/23/23 at 10:18 a.m., Dietary Aide (DA) 10 indicated the facility had 6 residents who received pureed diets from the kitchen, as she…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a care plan was developed for a resident who had no natural teeth for 1 of 17 residents' care plans reviewed (Resident 31). Finding includes: During an interview, on 3/21/23 at 10:49 a.m., Resident 31 indicated, he had all his teeth pulled in 2015 and was edentulous (having no teeth). Resident 31's record was reviewed on 3/24/23 at 9:49 a.m. The census information indicated the resident had been admitted to the facility, on 11/23/22, with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a mini stroke caused by a temporary disruption in the blood supply to part of the brain) and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). A significant change in status Minimum Data Set (MDS) assessment, dated 3/1/23, indicated the resident was cognitively intact, had no swallowing issues, received a mechanically altered diet, and was not edentulous. A care plan, started on 12/19/22, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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, record review, and interview the facility failed to ensure the proper labeling of the tube feeding bag and the flush bag for 1 of 1 resident reviewed for tube feeding (Resident 32). Findings include: On 3/20/2023 at 2:56 p.m., Resident 32 was observed resting in bed in her room. A clear bag of tube feeding was noted to be hanging from a pump and a red liquid substance was hanging in a clear bag on the opposite side of the tube feeding. Neither bag contained a date, time, or initials of when and who hung the bags. On 3/21/2023 at 10:41 a.m., Resident 32 was observed resting in her Broda chair (a type of chair that offers residents the ability to tilt and recline) in her room. A clear bag of tube feeding was noted to be hanging from a pump and a red liquid substance was hanging in a clear bag on the opposite side of the tube feeding. Neither bag contained a date, time, or initials of when and who hung the bags. On 3/22/2023 at 9:46 a.m., Resident 32 was observed resting in her Broda chair in her room. A clear bag of tube feeding was noted to be hanging from 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-24 · 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, record review, and interview, the facility failed to ensure the proper storage of nebulizer equipment and failed to assess the residents before, during, and after their nebulizer treatment for 2 of 2 residents reviewed for respiratory services (Resident 32 and 31). Findings Include: 1. Resident 32's record was reviewed on 3/22/2023 at 9:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, gastrostomy tube (a tube inserted through the bely that brings nutrition directly to the stomach), unspecified dementia (a condition characterized by progressive or persistent loss if intellectual functioning) without behavioral disturbance, chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and unspecified glaucoma (a group of eye conditions that can cause blindness). A change of condition Minimum Data Set (MDS) assessment, dated 3/07/2023, indicated the resident had severe cognitive impairment and indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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 timely re-order and provide a glaucoma eye drop for administration for 1 of 5 residents observed for unnecessary medication (Resident 32). Findings include: Resident 32's record was reviewed on 3/22/2023 at 9:45 a.m. The profile indicated the resident's diagnoses included, but were not limited to, gastrostomy tube (a tube inserted through the bely that brings nutrition directly to the stomach), unspecified dementia (a condition characterized by progressive or persistent loss if intellectual functioning) without behavioral disturbance, chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), unspecified glaucoma (a group of eye conditions that can cause blindness), and dysphagia (difficulty swallowing foods or liquids), oral phase. A change of condition Minimum Data Set (MDS) assessment, dated 3/07/2023, indicated the resident had severe impaired vision. A physician order dated 1/19/2023,…

    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 · D2023-03-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 40's record was reviewed on 3/21/23 at 2:15 p.m., diagnoses included, but were not limited to, hypertension (high blood pressure), chronic atrial fibrillation (longstanding chaotic and irregular heartbeat), hyperlipidemia (elevated concentrations of lipids or fats within the blood), unspecified dementia with behavioral disturbance (mental disorder with confusion and agitation including verbal and physical aggression, wandering, and hoarding), hypothyroidism (under active thyroid condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt heart rate, body temperature and aspects of metabolism), and gastro-esophageal reflux disease (GERD a digestive disease in which stomach acid or bile flows into the food pipe and irritates the food pipe lining). A quarterly Minimum Data Set (MDS) assessment, dated 2/2/23, indicated the resident had a moderate cognitive impairment and received an anticoagulant (blood thinner) on a routine daily basis. A physician's order, dated…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · 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 the documentation of medications administered for 3 of 5 residents reviewed for unnecessary medication (Residents 17, 40, and 26), and pharmacy recommendations lacked documentation of physician rationale for 2 of 5 residents reviewed for unnecessary medication (Residents 17 and 40). Findings include: 1. Resident 17's record was reviewed on 3/22/23 at 9:39 a.m. The profile indicated the resident's diagnoses included, but were not limited to psychotic disorder with delusions (a person has an unshakeable belief in something implausible, bizarre, or obviously untrue) and generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed). A significant change Minimum Data Set (MDS) assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 2/16/23, indicated the resident was never/rarely understood and received antipsychotic medication (used to treat symptoms of psychosis)…

    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 before2023-03-24 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, related to not administering medication in accordance with physician's orders and manufactures instructions for 2 of 3 residents observed for insulin administration, 2 errors were observed during 35 opportunities resulting in an error rate of 5.71% (Residents 19 and 27). Findings include: 1. During a random insulin administration observation for Resident 19 on 3/22/23 at 9:30 a.m., Licensed Practical Nurse (LPN) 7 was observed to check the blood glucose level with a result of 300 (normal 70 - 125). She then dialed up 8 units (U) of Novolog insulin, put the insulin needle into the abdomen, push in the plunger, and immediately pull the needle back out. She was observed to administer the insulin late, not prime the insulin pen and when she put the needle into the skin she pulled it back out in one fluid movement, not giving time for the insulin to administer. Resident 19's record was 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-24 · 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, and interview, the facility failed to ensure medications were stored properly for 1 of 2 medication refrigerators reviewed for medication storage (200 hallway). Findings include: On 3/24/23 at 10:45 a.m., the 200 hallway medication storage refrigerator was observed with Licensed Practical Nurse (LPN) 6. The refrigerator had 2 glass shelfs, the top shelf contained 3 clear plastic bags with insulin pens, one clear plastic bag containing suppositories and one clear plastic bag with narcotic medication. The second shelf was observed to have one clear plastic bag with an insulin pen. Both shelves and the outside of all the plastic bags were observed to have pooling water on the outside of the bags. LPN 6 indicated the refrigerator thermometer reading was currently 49 degrees F (Fahrenheit). She was not aware of what the medication refrigerator temperature should have been and was not aware of what the medication refrigerator temperature should have been for insulin storage, and she did not know why the refrigerator was dripping water on the medication bags. LPN 6…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 4 of 52.3+1.7 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 5Maple Park VillageWestfield, IN 2 of 5Park Terrace VillageEvansville, IN 2 of 5Riverside VillageElkhart, IN 2 of 5Trailpoint VillageSouth Bend, IN 2 of 5University Nursing CenterUpland, 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
KELSEY, DONNAIndividualCONTRACTED MANAGING EMPLOYEEsince 06/01/2016
VAN CAMP, STEVENIndividualCONTRACTED MANAGING EMPLOYEEsince 09/06/2019
DRUMMER, CARLIndividualCORPORATE DIRECTORsince 01/01/2017
FEHRIBACH, GREGORYIndividualCORPORATE DIRECTORsince 12/24/2004
HANIFY, THOMASIndividualCORPORATE DIRECTORsince 01/01/2022
LAZARD, ROBERTIndividualCORPORATE DIRECTORsince 01/29/2021
MANTRAVADI, GEETAIndividualCORPORATE DIRECTORsince 07/21/2021
MUKES-GAITHER, BEVERLYIndividualCORPORATE DIRECTORsince 01/01/2022
PAYNE, MONICAIndividualCORPORATE DIRECTORsince 08/09/2021
BABCOCK, PAULIndividualCORPORATE OFFICERsince 09/30/2020
CAINE, VIRGINIAIndividualCORPORATE OFFICERsince 01/10/1994
HARRIS, LISAIndividualCORPORATE OFFICERsince 12/23/2003
AMERICAN SENIOR COMMUNITIES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2011
CHAVEZ, BROOKEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/14/2018
HUSKEY, SHEILAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/14/2018

The source lists no ownership percentage for any party here — 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.

$5.7M
Net patient revenuemost recent cost report
-6.8%
Operating marginrevenue minus expenses
$599K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 67%Medicare 9%Other / private 24%

This home reported $599K paid to related parties (affiliated landlords or management companies) in its most recent 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 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

$331per resident / day
operating cost
$10,052per month
≈ monthly operating cost
$310per 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 155568. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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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