Cycle 1
Health 2025-06-09 · Fire 2025-06-09
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
24 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Granger, IN
Belltower Health & Rehabilitation Center
3-star overall rating with 3-star inspections with $6,293 in total fines with 4 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
5805 North Fir Road, Granger, IN
(574) 406-6600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2016-07-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,785
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.53
Baseline 20.83% · Performance 19.80% · Measure score 3.53 · Achievement 3.53 · Improvement 2.21
Healthcare-associated infections
0.49
Baseline 8.41% · Performance 8.07% · Measure score 0.49 · Achievement 0 · Improvement 0.49
Total nurse turnover
9.37
Baseline 51.56% · Performance 25.37% · Measure score 9.37 · Achievement 9.37 · Improvement 9
Adjusted total nurse staffing
0.62
Baseline 3.46 hours · Performance 3.25 hours · Measure score 0.62 · Achievement 0.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 139 · Observed rate 10.07% · Lower 95% interval 7.25% |
| Discharge to community | 56.64% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 53.66% · Lower 95% interval 46.76% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 50 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 76.74% |
53.69%
23 pts better
|
Numerator 33 · Denominator 43 |
| Discharge mobility score | 79.07% |
50.94%
28.1 pts better
|
Numerator 34 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 50 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.07% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 9.46% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 75 |
| Staff flu vaccination coverage | 94.12% |
42%
52.1 pts better
|
Numerator 80 · Denominator 85 |
| Discharge function score | 79.07% |
56.45%
22.6 pts better
|
Numerator 34 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 23.81% |
25.2%
1.4 pts worse
|
Numerator 5 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.8%
2 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.3% · Q3 8.1% · Q4 5.6% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
24.6%
16.9 pts better
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 1.6% · Q3 7.9% · Q4 14.1% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.6%
3.3 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 7.9% · Q3 8.6% · Q4 5.7% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
23.5%
12.1 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.8% · Q3 8.2% · Q4 13.0% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
14.8%
7.8 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.6% · Q3 10.6% · Q4 6.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.8% |
13.3%
13.5 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 34.8% · Q4 23.9% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
11.7%
1.9 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.9% · Q3 11.7% · Q4 20.0% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
24.2%
3.2 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 24.3% · Q3 23.3% · Q4 29.4% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.1%
2.9 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.5% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
81.6%
17.8 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 98.8% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
10.5%
2.9 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 13.3% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
79.0%
19.8 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
22.4%
3.6 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 18.3% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-29 · Fire 2024-07-29
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-08-14 · Fire 2023-08-14
19 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-01
F · Potential for more than minimal harm
2025-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
F · Potential for more than minimal harm
2025-06-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-10-01
F · Potential for more than minimal harm
2025-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-06-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-06-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-06-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-06-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-06-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-06-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-06-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-06-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-06-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-06-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-12
C · Minimal harm
2025-06-09
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-09-12
C · Minimal harm
2025-06-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-09-12
F · Potential for more than minimal harm
2024-07-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-09
F · Potential for more than minimal harm
2024-07-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-09
F · Potential for more than minimal harm
2024-07-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-09
F · Potential for more than minimal harm
2024-07-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-29
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-07-29
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-09-09
F · Potential for more than minimal harm
2023-08-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-05
F · Potential for more than minimal harm
2023-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-08-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-05
F · Potential for more than minimal harm
2023-08-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-08-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-08-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-08-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-08-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-12-05
E · Potential for more than minimal harm
2023-08-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-12-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-30
F · Potential for more than minimal harm
2025-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-04
F · Potential for more than minimal harm
2024-07-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-12
E · Potential for more than minimal harm
2023-08-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-08-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-18
G · Actual harm
2023-03-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-23
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-04-19
Penalties and ownership
What sits behind the stars
$6,293
2023-07-24
Fine
Fine · fine $6,293
Fine
Ownership
Beaty, Jeff
Operational/Managerial Control · Individual
Beaty, Jeff
Corporate Director · Individual
Caldwell, Dana
Operational/Managerial Control · Individual
Caldwell, Dana
Corporate Director · Individual
Carter, Douglas
Operational/Managerial Control · Individual
Carter, Douglas
Corporate Director · Individual
Coffin, John
Operational/Managerial Control · Individual
Coffin, John
Corporate Director · Individual
Horner, John
Operational/Managerial Control · Individual
Horner, John
Corporate Director · Individual
Horner, John
Corporate Officer · Individual
Jones, Curtis
Operational/Managerial Control · Individual
Jones, Curtis
Corporate Director · Individual
Knisley, Joanne
W-2 Managing Employee · Individual
Major Hospital
Operational/Managerial Control · Organization
Maples, Lorri
W-2 Managing Employee · Individual
Mercuri, Ralph
Operational/Managerial Control · Individual
Mercuri, Ralph
Corporate Director · Individual
Mercuri, Ralph
Corporate Officer · Individual
Sandman, Jan
Operational/Managerial Control · Individual
Sandman, Jan
Corporate Director · Individual
Shippensburg Health Care LLC
Operational/Managerial Control · Organization
Tandy, Sherri
Operational/Managerial Control · Individual
Tandy, Sherri
Corporate Director · Individual
Wessic, Linda
Operational/Managerial Control · Individual
Wessic, Linda
Corporate Director · Individual
Wessic, Linda
Corporate Officer · Individual
Nearby options
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Creekside Village
Mishawaka, IN
4-star overall rating with 3-star inspections with 7 recent health deficiencies
#2
Brickyard Healthcare - Fountainview Care Center
Mishawaka, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Holy Cross Rehabilitation And Wellness
South Bend, IN
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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