Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Centerville Specialty Care during CMS and state inspections, most recent first.
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents with multiple open wounds and MASD. In one case, an RN removed soiled dressings from both lower legs without changing gloves between legs, repeatedly changed gloves without performing hand hygiene, and handled wound products after dropping a medication cup on the floor, then continued treatment without hand hygiene. In another case, an RN cleansed two open abdominal-fold wounds with the same washcloth and changed gloves without hand hygiene before applying Triad paste to both wounds with the same fingers. Staff interviews, including with an RN, an LPN, the IP, and the DON, confirmed that facility expectations and policy required hand hygiene between glove changes and glove changes between separate wounds to prevent cross-contamination.
The facility did not obtain or document informed consent for antipsychotic medications for two residents with impaired cognition. Although staff reportedly discussed the medications with family members, there was no documentation of completed consent forms outlining the risks and benefits prior to starting the medications, as required by facility policy.
Staff did not notify the provider or perform follow-up assessments after a resident with diabetes had multiple blood sugar readings above 500 mg/dl, despite care plan directives and facility policy requiring such actions.
A resident with severe cognitive impairment and a history of falls was assisted to the bathroom by a staff member without the use of a gait belt, contrary to facility policy and the resident's care plan. During the transfer, the staff member used one hand to adjust a commode and the other to support the resident, who then stepped backward and fell, resulting in reported pain. Interviews confirmed that the gait belt, which was typically used for this resident, was not utilized during this incident.
Staff did not weigh or measure ham portions before preparing mechanical soft and pureed diets, instead estimating serving sizes and using a standard scoop that did not meet the required 5-ounce portion per the menu. Additionally, rolls were not pureed and served as required for three residents on pureed diets. These actions resulted in multiple residents not receiving correct portions or all menu items as specified.
A staff member failed to remove PPE after providing care to a resident and transported the resident in a wheelchair with indwelling catheter tubing in contact with the floor. The resident had multiple medical conditions and was dependent for all ADLs. Facility policy required PPE removal before exiting the room and keeping catheter tubing off the floor, but these protocols were not followed.
The facility failed to maintain proper kitchen sanitation and food handling practices. Observations included the Dietary Manager's hair not fully restrained, outdated turkey, and dust on fire suppression spigots. The manager handled food without washing hands after picking up refuse. Dust and food particles were found on various surfaces, and the ice machine and dishwasher had buildups. The manager acknowledged staffing struggles and cleanliness expectations.
A facility failed to provide a resident on a pureed diet with the correct portion and texture of food. The Dietary Manager served a fish filet in a pureed form but did not provide the full portion, and processed green beans to a liquid consistency instead of the required pudding consistency. The facility's policy mandates that pureed food should be of pudding consistency and that residents should receive the same amount as others.
A resident with severe cognitive impairments and a history of wandering was not treated with dignity and respect by an LPN. The LPN used raised arms and voice to redirect the resident, escalating the situation. On another occasion, the LPN physically grabbed and pushed the resident, causing him to stumble. Housekeeping staff intervened to de-escalate the situation. The facility's policy prohibits such actions and emphasizes a culture of compassion.
The facility failed to properly assess and intervene for two residents, leading to deficiencies in care. A resident with a catheter had it removed without adequate follow-up, resulting in discomfort and the need for reinsertion. Another resident experienced an unwitnessed fall, but required neurological assessments were not documented, indicating a lapse in monitoring and care protocols.
Improper Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene and glove use during wound care, resulting in potential cross-contamination between wounds. For one resident with congestive heart failure, diabetes, peripheral vascular disease, and multiple venous ulcers, staff did not change gloves appropriately between wounds or perform hand hygiene between glove changes. This resident was cognitively intact but dependent on staff for most ADLs and had open venous ulcer wounds on both lower legs, as well as a left heel condition and a skin tear on the left shin, all requiring specific wound care orders including cleansing with Vashe Wound Cleanser, application of Triad paste, silver dressings, and Betadine. During an observed wound care session for this resident, an RN and an LPN initially washed their hands, gowned, and gloved, and a clean field was set up. The RN removed dressings from the right and then the left leg without changing gloves between legs, despite the right leg dressing having a large amount of bloody drainage and both legs having open wounds. After removing dressings from both legs, the RN changed gloves without performing hand hygiene, while the LPN removed gloves, washed hands, and re-gloved. The RN then cleansed the right leg wounds and later removed gloves, obtained Triad paste, re-gloved without hand hygiene, and applied Triad paste with gloved fingers. After both nurses removed gloves, washed hands, and re-gloved, the RN applied dressings to the right leg. When the medication cup with Triad paste was dropped on the floor, the RN picked it up, removed one glove, obtained more Triad paste, re-gloved again without hand hygiene, and applied Triad paste to the left leg, followed by Betadine to the left heel and additional dressing applications, again changing gloves without performing hand hygiene. For a second resident with diabetes, morbid obesity, MASD, and open wounds under an abdominal fold, the RN also failed to perform hand hygiene between glove changes. This resident was cognitively intact, dependent for most ADLs, and had an open MASD wound on the right iliac crest with orders for Triad paste and Interdry to abdominal folds. During observation, the RN placed Triad paste in a medication cup, washed hands, and gloved, then exposed the abdominal area and used a wet washcloth with a small amount of hand soap to wipe two open wounds on both sides of the abdominal fold, followed by drying with a hand towel. The RN then removed gloves and donned a new pair without performing hand hygiene between glove changes and applied Triad cream to both open wounds with the same fingers. Interviews with the RN, another RN, an LPN, the Infection Preventionist, and the DON confirmed that facility expectations and policy required hand hygiene between glove changes and glove changes between wounds to prevent cross-contamination, and the hand hygiene policy specified hand hygiene before handling clean or soiled dressings, after contact with blood or body fluids, after handling used dressings, and after removing gloves.
Failure to Document Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of antipsychotic medications for two residents. For one resident with diagnoses including anxiety, depression, and non-Alzheimer's dementia, and a severely impaired cognition score, the clinical record showed an order for Abilify was initiated. Although a nurse's note indicated that the resident's representative was spoken to about the medication's reason and benefits, there was no documentation of a completed medication consent form outlining the risks and benefits prior to starting the medication, as required by facility policy. Similarly, another resident with moderately impaired cognition and diagnoses including diabetes, heart failure, and coronary artery disease was started on Rexulti. The care plan noted the use of antidepressant medications, but again, there was no documentation of a completed medication consent form prior to the initiation of the medication. The DON confirmed that while staff had conversations with the residents' families regarding the medications, these discussions were not documented in the clinical notes.
Failure to Notify Provider and Assess After Critically High Blood Sugar Readings
Penalty
Summary
Facility staff failed to carry out required assessments and interventions after a resident experienced multiple episodes of significantly elevated blood sugar levels. The resident, who had diagnoses including diabetes, heart failure, and coronary artery disease, had care plan directives and physician orders specifying that staff should notify the provider if blood sugar readings exceeded 500 mg/dl. Despite this, clinical records showed that on several occasions, the resident's blood sugar readings were well above this threshold. Documentation revealed blood sugar readings of 547 mg/dl and 600 mg/dl on one day, and 538 mg/dl on another, without any evidence that the provider was notified or that follow-up assessments or monitoring were conducted. The facility's policy required staff to follow physician-ordered parameters for reporting high blood sugars, but there was no documentation to show these protocols were followed. Interviews with the DON confirmed that no additional documentation or provider notification could be found regarding these incidents.
Failure to Use Gait Belt During Resident Transfer Results in Fall
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions, specifically the use of a gait belt, for a resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and restless leg syndrome. The resident was assessed as dependent on staff for toilet transfers and required partial to moderate assistance for walking. According to the care plan, the resident was at risk for falls and required assistance from one to two staff members for walking and transfers. Despite these documented needs and facility policy requiring the use of gait belts for safe lifting and movement, a staff member assisted the resident without a gait belt during a transfer to the bathroom. During the incident, the staff member, who was a traveling nurse, asked other staff about the resident's assistance needs and was told the resident was an assist of one. While attempting to help the resident use a commode, the staff member used one hand to adjust the commode and the other to support the resident, who then stepped backward and fell. The resident later reported pain following the fall. Interviews confirmed that the gait belt was not used during this transfer, although it was typically used for this resident. The DON confirmed that staff should use a gait belt for residents requiring assistance of one or two for transfers.
Failure to Provide Correct Portions and Follow Menu for Modified Diets
Penalty
Summary
The facility failed to ensure that residents on mechanical soft and pureed diets received the correct portions and that the menu was followed as required. Observations revealed that staff did not weigh or measure the ham portions before processing them to mechanical soft and pureed consistencies. Instead, staff estimated the portion sizes and used a standard scoop size, which did not align with the menu requirement of a 5-ounce serving of ham for each resident. Additionally, staff did not provide rolls to residents on pureed diets as required by the menu, as they forgot to puree the rolls with the ham. Interviews with staff confirmed that the correct procedures for measuring and serving portions were not followed. The dietary manager stated that the process should involve measuring meat portions before processing and using a chart to determine serving size, but this was not done. The facility's policy also directed staff to ensure correct portions and to include all menu items, such as bread, in pureed diets. These failures resulted in five residents not receiving the correct portions and three residents not receiving all menu items as specified.
Failure to Remove PPE and Maintain Catheter Hygiene During Resident Transport
Penalty
Summary
Staff failed to implement the Infection Prevention and Control Program (IPCP) by not properly removing personal protective equipment (PPE) after providing resident care and by allowing indwelling catheter tubing to contact the floor during resident transport. Specifically, a physical therapy assistant was observed wearing PPE while assisting a resident in his room and then transporting him in a wheelchair to the shower room without removing the gown. During this transport, the resident’s indwelling catheter tubing was observed in contact with the floor. The staff member admitted to keeping the gown on because she anticipated needing it again for further care in the bathroom and was unaware that the catheter tubing had touched the floor. The resident involved had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, thyroid disorder, arthritis, stroke, urinary tract infection, and acute cystitis with hematuria, and was dependent on staff for all activities of daily living and mobility. Facility policies required staff to remove PPE before exiting a resident’s room and to ensure catheter tubing and drainage bags were kept off the floor. Interviews with the infection preventionist and director of nursing confirmed that staff should have removed PPE before leaving the resident’s room, and policy review indicated that enhanced barrier precautions should be followed in certain situations outside the resident’s room, but not in hallways unless specific care activities were being performed.
Inadequate Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation and food handling practices during two separate visits to the kitchen. During the initial kitchen tour, it was observed that the Dietary Manager's hair was not fully restrained under a hair net, and an opened package of turkey breasts was dated two weeks prior. Dust particles were hanging from the fire suppression system spigots. On a subsequent visit, the same dust was observed on the spigots, and the Dietary Manager was seen picking up refuse from the floor and then touching food without washing her hands. Additionally, the plastic menu holder, steam table, and a shelf above the steam table were found to be dusty and sticky, with loose food particles hanging over the food. Further observations revealed that the Dietary Manager retrieved ice cream from the freezer without washing her hands before serving meals. The ceiling above the sink was covered with dust-like particles, and a fire suppression system spigot above the spices and clean plates was covered with a thick layer of dust. The dishwasher had a crusty white buildup, and a drawer contained crumbs and a black substance in the corners. The ice machine had a brown buildup on the interior wall and a white buildup on the exterior. The Dietary Manager acknowledged the staffing struggles and the expectation for cleanliness, stating that all hair should be restrained under a hair net.
Deficiency in Pureed Diet Consistency and Portioning
Penalty
Summary
The facility failed to ensure that a resident on a pureed diet received the correct portion and texture of food. During an observation, the Dietary Manager (DM) processed a fish filet to a pureed consistency and served it to the resident, leaving 1/4 of a cup remaining, indicating the resident did not receive the full portion. Additionally, the DM processed green beans to a liquid consistency, which was not in accordance with the facility's policy that required pureed food to be of pudding consistency. The DM acknowledged that the resident should have received the entire fish filet and that the pureed food should not be runny. The facility's undated policy on Puree Technique directed staff to follow the menu as planned, process the correct number of portions, and ensure pureed food is of pudding consistency.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by interactions between a Licensed Practical Nurse (LPN) and a resident with severe cognitive impairments and a history of wandering and aggression. The resident, who had diagnoses including Non-Alzheimer's dementia and aphasia, was observed by housekeeping staff to be wandering the halls, a behavior noted in his care plan. On one occasion, the LPN attempted to redirect the resident by standing in front of him with raised arms and a raised voice, which escalated the situation. Despite an offer from a housekeeper to intervene, the LPN continued to interact with the resident in a manner that was not calm or respectful. Further incidents were reported where the LPN physically grabbed the resident by the arms to redirect him away from the front door and later from a room, actions that were described as aggressive. During one of these interactions, the resident began hitting the LPN, who then pushed the resident hard enough that he stumbled and almost fell, although the LPN prevented the fall. Housekeeping staff intervened by engaging the resident in an activity, which helped to de-escalate the situation. The facility's policy strictly prohibits abuse and emphasizes the importance of staff education and a culture of compassion, which was not adhered to in these interactions.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to ensure appropriate assessment and intervention for two residents, leading to deficiencies in their care. Resident #5, who had an intact cognitive status and was dependent on maximal assistance for various needs, had a catheter removed on a trial basis. Despite the resident's preference to have it removed in the morning, there was a lack of documentation and follow-up by Staff E, an LPN, regarding the resident's voiding status. Although Staff E claimed the resident had voided a little, other staff and the resident's family reported no voiding occurred. This led to the reinsertion of the catheter by another nurse, which resulted in the return of 400 milliliters of urine, indicating a failure to monitor and address the resident's condition adequately. Resident #6, who was independent with some assistance and had a history of pneumonia, diabetes, and COPD, experienced an unwitnessed fall. The facility's protocol required frequent neurological assessments, including vital signs, which were not properly documented by Staff E and Staff F. Despite indications that vital signs were completed, there were no corresponding records in the PointClickCare system. This lack of documentation and adherence to protocol highlights a deficiency in the facility's monitoring and care practices for residents who have experienced falls.
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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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Nursing homes near Centerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercyone Centerville Medical Center | 0.9 mi | ★★★★★ | 15 | 0 |
| Golden Age Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Oakwood Specialty Care | 19.1 mi | ★★★★★ | 2 | 0 |
| Putnam County Care Center | 19.3 mi | ★★★★★ | 4 | 0 |
| Corydon Specialty Care | 23.3 mi | ★★★★★ | 4 | 0 |
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