Cycle 1
Health 2026-01-09 · Fire 2026-01-09
24 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (9 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Muncie, IN
Cardinal Care Strategies
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with 24 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4600 E Jackson St, Muncie, IN
(765) 282-1416
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-08-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.36
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
98%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,758
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.73
Performance 60.71% · Measure score 0.73 · Achievement 0.73 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.80
Baseline 2.02 hours · Performance 3.64 hours · Measure score 3.80 · Achievement 1.97 · Improvement 3.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 15.56% · Lower 95% interval 7.47% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 88% |
95.27%
7.3 pts worse
|
Numerator 22 · Denominator 25 |
| Falls with major injury | 4% |
0.77%
3.2 pts worse
|
Numerator 1 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8% |
2.29%
5.7 pts worse
|
Numerator 2 · Denominator 25 · Adjusted rate 7.23% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.85% |
8.2%
4.3 pts worse
|
Numerator 4 · Denominator 104 |
| Staff flu vaccination coverage | 30.11% |
42%
11.9 pts worse
|
Numerator 28 · Denominator 93 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.6
1.2 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
93.6%
1.5 pts better
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 97.0% · Q3 94.4% · Q4 92.9% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
95.4%
2.1 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.8%
2.6 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 6.0% · Q3 4.2% · Q4 1.4% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
24.6%
21.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 0.0% · Q3 3.1% · Q4 1.5% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.6%
0.3 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.2% · Q3 7.5% · Q4 3.1% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.0% |
23.5%
12.5 pts worse
|
19.6%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 38.5% · Q3 35.3% · Q4 35.9% · 4Q avg 36.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.2% |
14.8%
25.4 pts worse
|
16.7%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 32.5% · Q3 46.5% · Q4 51.4% · 4Q avg 40.2% · 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 | 24.4% |
13.3%
11.1 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 35.5% · Q3 20.7% · Q4 23.7% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.9% |
11.7%
18.2 pts worse
|
14.9%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 33.9% · Q3 49.2% · Q4 21.7% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.4%
1.1 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.5% · Q4 2.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
1.2%
1.7 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.1% · Q3 2.9% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.6% |
24.2%
5.4 pts worse
|
19.8%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.1% · Q2 28.4% · Q3 29.1% · Q4 27.2% · 4Q avg 29.6% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.1%
1.6 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 7.0% · Q4 1.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.6% |
81.6%
17 pts worse
|
81.7%
17.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.0% · Q2 71.0% · Q3 62.5% · Q4 53.8% · 4Q avg 64.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
10.5%
3.1 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.3% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 11.1% |
1.3%
9.8 pts worse
|
1.6%
9.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.2% |
79.0%
22.8 pts worse
|
79.7%
23.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
22.4%
1.7 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.8% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-17 · Fire 2024-12-17
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2024-01-30 · Fire 2024-01-30
20 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-02-13
F · Potential for more than minimal harm
2026-01-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-06
F · Potential for more than minimal harm
2026-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-06
E · Potential for more than minimal harm
2026-01-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-11
E · Potential for more than minimal harm
2026-01-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-06
E · Potential for more than minimal harm
2026-01-09
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2026-02-19
D · Potential for more than minimal harm
2026-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-04
F · Potential for more than minimal harm
2024-12-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-17
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 2025-01-24
E · Potential for more than minimal harm
2024-12-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-27
F · Potential for more than minimal harm
2024-01-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-01-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-01-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-01-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-01-30
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-01-30
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 2024-03-19
E · Potential for more than minimal harm
2024-01-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-02-04
E · Potential for more than minimal harm
2026-01-09
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2026-02-04
E · Potential for more than minimal harm
2026-01-09
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 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
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 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-02-04
J · Immediate jeopardy
2025-12-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-15
J · Immediate jeopardy
2025-12-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-15
J · Immediate jeopardy
2025-12-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-08-25
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-05-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
E · Potential for more than minimal harm
2024-12-17
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-17
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 2025-01-15
D · Potential for more than minimal harm
2024-12-17
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-01-15
C · Minimal harm
2024-12-17
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 2025-01-15
E · Potential for more than minimal harm
2024-11-14
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-14
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-09-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-05-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-04-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-06
D · Potential for more than minimal harm
2024-03-14
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-06-06
E · Potential for more than minimal harm
2024-01-30
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-30
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-30
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 2024-02-14
D · Potential for more than minimal harm
2024-01-30
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 2024-02-14
D · Potential for more than minimal harm
2024-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-03
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-12-06
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-10-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-09-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-06
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 2023-09-29
E · Potential for more than minimal harm
2023-06-21
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 2023-07-21
D · Potential for more than minimal harm
2023-06-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-12
J · Immediate jeopardy
2023-04-14
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 2023-05-05
Penalties and ownership
What sits behind the stars
Ownership
Pulaski Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Barry, Thomas
Corporate Officer · Individual
Malott, Gregg
Corporate Officer · Individual
Young, Cathy
Contracted Managing Employee · Individual
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