Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Persimmon Ridge Rehabilitation Centre during CMS and state inspections, most recent first.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment and behavioral symptoms was subjected to verbal and physical abuse by a CNA who attempted a transfer alone, contrary to the care plan requiring two staff. The CNA used forceful methods, ignored the resident's refusal, and made threatening statements, resulting in a skin tear and bruising. Multiple staff witnessed the incident and reported the abuse, which was not immediately communicated to facility leadership as required by policy.
A resident sustained a skin tear during a transfer by a CNA, and although the incident was reported internally and the CNA was suspended, the facility failed to notify law enforcement and APS as required by policy. Delays in communication among staff contributed to the failure to promptly report the alleged abuse to the appropriate agencies.
Two residents in the facility received PRN lorazepam without documented non-pharmacological interventions, despite care plans and facility policy requiring such measures. Resident 39, with multiple psychiatric diagnoses, and Resident 59, with depression and anxiety, were both administered the medication without prior interventions being documented. Interviews with staff confirmed the expectation for non-pharmacological attempts, but the facility failed to provide evidence of these actions.
The facility failed to label over-the-counter medications with resident and physician names and did not dispose of expired medications on a medication cart. Observations revealed improperly labeled melatonin and doxylamine succinate, and an expired psyllium fiber supplement. Interviews confirmed the labeling requirements and the need for disposal of expired medications.
A facility failed to report an abuse allegation involving a cognitively impaired resident in a timely manner. The resident was verbally abused by an RN, witnessed by two employees. The incident was reported to the Indiana Department of Health later than the required two-hour window due to a misunderstanding of the reporting policy by the administrator.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Staff-to-Resident Verbal and Physical Abuse During Improper Transfer
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, anxiety, depression, muscle weakness, and impaired mobility was subjected to staff-to-resident verbal and physical abuse during a transfer. The resident required maximum assistance for activities of daily living and had a care plan specifying the need for two staff members for transfers, as well as interventions to address behavioral symptoms such as agitation and combativeness. Despite these documented needs, a CNA attempted to transfer the resident alone, disregarding both the care plan and the resident's expressed refusal to go to bed. During the incident, the CNA used a bear hug technique to forcibly transfer the resident, despite objections from both the resident and other staff present. The resident became agitated, resisted the transfer, and bit the CNA. The CNA responded with threatening and inappropriate language, stating, "Bite me again, I will bite you back, I'll go to jail I don't care," and continued to attempt the transfer alone. The transfer was performed forcefully, resulting in the resident being thrown onto the bed and sustaining a skin tear on the left wrist. Witnesses reported that the CNA ignored suggestions to leave the resident in his chair and did not follow the recommended approach for managing the resident's behaviors. Multiple staff members witnessed the incident and reported that the CNA's actions were abusive, both verbally and physically. The resident was left with a skin tear and bruising, and the incident was subsequently reported to facility leadership. The CNA was not assigned to the resident's unit and was not requested to assist with the transfer. The facility's abuse policy required immediate reporting and removal of implicated staff, but there was a delay in notification to the Director of Nursing and Administrator.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who sustained a skin tear during a transfer by a CNA. The incident was identified late in the evening, and although the CNA involved was suspended promptly after administration was notified, local law enforcement and Adult Protective Services (APS) were not notified as required. The administrator indicated that law enforcement was not contacted because the resident did not have a serious bodily injury. The facility's policy requires immediate reporting of all alleged violations, including abuse, to the appropriate authorities, but this was not followed in this case. Interviews revealed that the aides initially reported the incident to a QMA, who then informed the RN, DON, and administrator, but there was a delay in communication due to the staff's shock over the event. The administrator and DON confirmed that the process for reporting abuse was not followed as outlined in facility policy, which mandates immediate protection of the resident, removal of the involved employee, and notification of the appropriate agencies. The deficiency was identified during a review of the facility's incident reporting and staff interviews.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to implement non-pharmacological interventions before administering PRN psychotropic medications to two residents, leading to a deficiency in medication management. Resident 39, diagnosed with Alzheimer's disease, psychotic disorder, and anxiety, among other conditions, was observed in various states of rest and activity. Despite having a care plan that included non-pharmacological interventions for anxiety, the resident received PRN lorazepam multiple times without documentation of attempted non-pharmacological interventions. The facility's records, including the MAR and behavior memos, lacked evidence of these interventions on several occasions when the medication was administered. Similarly, Resident 59, who had diagnoses including depression and generalized anxiety disorder, was also administered PRN lorazepam without documented non-pharmacological interventions. The resident's care plan required monitoring for adverse effects and changes in mood or behavior, yet the MAR showed multiple administrations of lorazepam without prior non-pharmacological attempts. The facility's documentation, including nurses' notes and behavior memos, did not reflect any interventions before the medication was given. Interviews with facility staff, including RNs and the DON, revealed an expectation for non-pharmacological interventions to be attempted and documented before administering PRN psychotropic medications. However, the facility was unable to provide documentation of such interventions for both residents. The facility's policy on PRN medications, which mandates non-pharmacological interventions before medication administration, was not adhered to, resulting in the identified deficiency.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to properly label over-the-counter medications with the resident's name and physician's name, and also failed to dispose of expired medications on one of the six medication carts observed. During an observation of the medication cart on the 300 Hall, it was noted that a container of melatonin and doxylamine succinate had only initials on the lid instead of full labeling. Additionally, an opened container of antifriction body powder lacked a resident name, physician name, directions, and an expiration date. A container of psyllium fiber supplement was found with a last name on the lid, missing a physician's name, and had expired in August 2020. Interviews conducted during the observation revealed that the Qualified Medication Aide (QMA) and the Unit Manager acknowledged the requirement for over-the-counter medications to be labeled with the resident's name, prescriber's name, and date opened. The Director of Nursing (DON) confirmed that expired medications should be disposed of and that medications should have resident and prescriber names. The facility's policy, dated April 2021, mandates compliance with federal and state laws for drug labeling and requires the removal and destruction of outdated or deteriorated drugs.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation to the Indiana Department of Health in a timely manner. The incident involved a resident who was severely cognitively impaired and was verbally abused by a registered nurse (RN 6). The abuse occurred when the resident was wheeling himself around the nurse's medication cart and talking to himself, at which point RN 6 told the resident to go to his room using inappropriate language. The incident was witnessed by two employees and occurred on May 22, 2024, at 11:01 p.m. However, the facility did not report the incident until May 23, 2024, at 3:35 p.m., which was not within the required two-hour reporting window for abuse allegations. The facility's policy mandates immediate reporting, but the administrator misunderstood the requirement, believing the two-hour rule only applied to incidents involving serious bodily injury or unknown sources of injury.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Dunkirk Skilled Nursing Facility, The | 11.2 mi | ★★★★★ | 3 | 1 |
| Envive Of Berne | 14.9 mi | ★★★★★ | 15 | 0 |
| Swiss Village | 15.5 mi | ★★★★★ | 8 | 0 |
| Albany Health Care & Rehabilitation Center | 16.3 mi | ★★★★★ | 13 | 0 |
| Briarwood Village | 17.8 mi | ★★★★★ | 4 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.