Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Allisonville Meadows during CMS and state inspections, most recent first.
Resident council concerns were not reviewed back with members at the next meeting as required. Minutes showed repeated complaints about early bedtimes, missed bingo, meds left in rooms, late food service, and CNA staff using cell phones during care, but there was no documentation that prior concerns and resolutions were discussed with the council. During the council meeting, members said they had filed grievances but never heard back with resolutions, and the Resident Council President confirmed there had been no communication from staff about how concerns were addressed.
Anonymous Grievance Filing Not Available to Residents: Residents reported they could not file grievances anonymously and were unaware of any anonymous submission location. Grievance forms were kept at the nurse's station and had to be requested from staff, with an LPN stating residents would receive the forms from the desk and return completed forms to staff. An Activities Assistant said residents with concerns were directed to social services, while the facility grievance policy stated residents have the right to file grievances anonymously.
A resident with dementia and deafness was reportedly mocked by a CNA during toileting care, with an interpreter stating the CNA used the sign for poop and repeated, “it’s always poop, poop, poop.” Another cognitively intact resident reported CNA attitudes and anger during care, and a family member found a resident with lung cancer in an unkempt room with urine containers and an unemptied BSC. Resident council members also reported staff were disrespectful, put them to bed too early, and used cell phones or spoke in another language while providing care.
Meal service was not provided at scheduled times for multiple residents, with several residents on the 500 Hall reporting breakfast, lunch, and dinner were routinely late. A resident council also stated meals were often delayed, especially dinner, and the Dietary Mgr acknowledged staffing concerns on 3rd shift had caused some late dinner service.
A resident with dementia and a history of intrusive wandering and agitation was found lying in another resident’s bed despite care plans directing staff to redirect her to her own room or a quiet area. A laundry aide identified the room but did not redirect the resident or notify nursing staff, and an MCSS initially looked into the room and left before being informed the resident was still there. The other resident became visibly upset and stated the resident did not belong in the room.
A resident scheduled for a colonoscopy received bisacodyl as part of the prep, but colyte was not available because it was out of stock/backordered at the pharmacy. The prep was not completed, the colonoscopy had to be rescheduled, and the resident stated the facility did not ensure all needed meds were available.
A resident with CKD, nausea, vomiting, and diarrhea had STAT CBC and BMP orders, but the labs were not completed the same day and were not resulted until later. Nursing notes stated the lab failed to draw the ordered tests, while interviews indicated a new lab system integration caused the STAT orders not to go through. The resident later had critical BUN and creatinine results and was assessed with no acute distress.
Failure to document meal consumption for a resident with dementia, seizure disorder, poor appetite, diabetes, and weight loss. The resident required supervision with eating and monitoring of nutrition and hydration, but breakfast, lunch, and dinner intake were missing on multiple occasions over several weeks. Her weight declined from 172 lbs to 161 lbs and later to 154 lbs, and the RD stated staff should document consumption of all meals.
A facility failed to notify a physician promptly after a resident's fall, resulting in delayed treatment for a humerus fracture. Additionally, another resident's abnormal lab results indicating acute kidney injury were not communicated in a timely manner, delaying necessary treatment. These deficiencies highlight lapses in communication and adherence to protocols.
A resident with a history of falls and severe cognitive impairment fell and was not assessed by a licensed nurse, leading to a delay in treatment for a fractured humerus. Facility staff failed to document the fall or notify the physician, resulting in the resident self-reporting the incident the following day. The lack of communication and adherence to the fall management policy contributed to the deficiency.
The facility failed to provide adequate ADL care for several residents, including improper hair washing, positioning, and incontinence management. A resident with a traumatic brain injury reported unwashed hair and improper bed positioning. Another resident with Alzheimer's was left in urine for extended periods, and a resident with COPD experienced delays in care and double briefing. Additionally, a resident with dementia was not checked for incontinence as required.
The facility failed to ensure proper hand hygiene and infection control practices, as observed in the care of several residents. A CNA did not perform hand hygiene during incontinent care for a resident with a history of traumatic brain injury and diabetes. Another CNA failed to perform hand hygiene during catheter care for a cognitively impaired resident at risk of MDRO transmission. Additionally, staff did not perform hand hygiene during coffee service, and medication carts were not cleaned after being touched by residents, indicating non-compliance with the facility's hand hygiene policy.
A facility failed to honor a resident's choice regarding her bedtime. The resident, who is cognitively intact, preferred to be put to bed between 7:15 p.m. and 7:30 p.m., but reported being put to bed much later on some days. The Unit Manager confirmed that the resident's care plan did not include her bedtime preferences, despite documentation indicating its importance. A CNA acknowledged the resident's preference but noted it was not always followed due to other situations.
A facility failed to document urinary output for a resident with an indwelling catheter as ordered. The resident, who was severely cognitively impaired, had a care plan requiring documentation of urinary output every shift, but records were incomplete or missing on several occasions. The facility's policy required documentation in milliliters, but output was recorded qualitatively instead.
The facility failed to provide timely medications for two residents. One resident, admitted with pneumonia, did not receive several prescribed medications due to pharmacy order issues and lack of follow-up by staff. Another resident with chronic pain did not receive a buprenorphine patch as ordered, as it was not re-ordered in time and was unavailable in the emergency drug kit.
A resident in an LTC facility experienced a significant medication error when nursing staff failed to administer fentanyl patches according to the physician's order and professional standards. The resident, who was cognitively impaired, had two patches applied simultaneously, leading to an overdose and hospitalization. The facility's failure to remove old patches and adhere to the prescribed schedule resulted in the resident's adverse reaction.
A resident with Alzheimer's and hypertension fell and sustained a hip fracture, but the family was not notified until the next day. The fall was not documented immediately, and the resident was found in pain the following day, leading to a hospital transfer.
A resident with Alzheimer's and other conditions was not provided with hipsters as part of their fall prevention plan, despite a physician's order and facility policy. Observations showed the resident without hipsters, and an LPN was unaware of their requirement or location.
A facility failed to document and manage a resident's behavioral health needs, who exhibited problematic behaviors such as yelling and inappropriate comments. Despite care plans including interventions like providing care in pairs and mental health services, these were not consistently implemented or evaluated. The facility's lack of documentation and evaluation led to ongoing issues with the resident's adjustment to LTC.
A resident with a urinary catheter experienced frequent leakage, resulting in a strong urine odor in the hallway. Despite the resident's care plan to manage catheter care, the staff reportedly did not lock the tubing correctly, causing leakage. Housekeeping staff mopped urine from the floor multiple times a week, but the DON and ED were unaware of the issue.
A facility failed to maintain accurate records for controlled medications for a hospice resident with multiple diagnoses, including hypertension and respiratory failure. The resident was prescribed lorazepam with specific administration instructions, but records showed incorrect dosages were administered. An interview with the DON revealed discrepancies in medication documentation, indicating a failure in the facility's medication administration and record-keeping processes.
The facility failed to ensure proper nail trimming and hand hygiene for three residents requiring upper extremity devices. Observations revealed long nails and unclean hands, with the FDNS confirming the need for better adherence to care plans and procedures.
Resident Council Concerns Not Reported Back
Penalty
Summary
The facility failed to ensure that follow-up resolutions to concerns raised in resident council meetings were reported back to resident council members. The January 2026, February 2026, and March 2026 resident council minutes showed concerns about residents being put to bed too early and missing evening bingo, medications being left in resident rooms without waiting for residents to take them, late food service, and CNA staff talking on cell phones while providing care. In each set of minutes, the Resident Council President signed that she had received follow-up with resolutions to the concerns reported that day, but the minutes did not document any discussion with the resident council members about resolutions to concerns from the prior month. During the 4/13/26 resident council meeting, attended by Residents G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z, the council stated they had filed grievances during resident council meetings but never heard back with resolutions to their concerns. The Resident Council President stated there were no discussions or communication from staff about how the facility had addressed concerns reported in resident council meetings. The Executive Director stated the Resident Council President was informed of the resolutions on the day the concerns were reported and signed off that she had been informed. The facility’s resident council policy stated that facility responses to concerns and suggestions would be reviewed by the Resident Council President and the resident council at their next meeting.
Anonymous Grievance Filing Not Available to Residents
Penalty
Summary
The facility failed to ensure residents were able to file grievances anonymously for 16 of 134 residents reviewed during resident council, including Residents G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z. During a resident council meeting, the residents stated they were unable to file a grievance anonymously and were unaware of any location where a grievance could be submitted anonymously. They reported that grievance forms had to be requested from staff at the nurse's station, and that the forms were not available within reach for residents to take without anyone knowing. The residents also stated there was no privacy to report a grievance without staff knowing what was written on the form. An observation of the 500 Hall nurses' station showed orange grievance forms sitting in a tray in the corner of the station, not accessible to anyone standing outside the nurses' station. An LPN stated the forms were grievance forms that residents had to ask for if they wanted to report a grievance, and staff could assist with completing them if requested. The LPN said residents would return the completed forms to staff at the desk, who would then turn them in for the residents. The Activities Assistant stated activity staff did not have grievance forms available for residents to take, and directed residents with concerns to social services. The Executive Director/Grievance Official stated residents could address concerns to their care companion or go to the nurse's station for grievance forms. The facility's grievance policy stated residents have the right to file grievances orally or in writing, file a grievance anonymously, and that grievances may be submitted anonymously as preferred by the resident, representative, and/or family member.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents’ dignity was maintained and respected. For Resident B, who had dementia, no useful hearing, no speech, and communicated with American Sign Language, the record showed she required assistance with ADLs, toileting, and incontinent care. A family member reported that a CNA had an attitude toward Resident B, and an incident report documented a concern that the CNA made an inappropriate comment in Resident B’s presence. The family member stated the CNA mocked Resident B during care, while the interpreter present during the interaction reported that the CNA used the sign for poop and said, “it’s always poop, poop, poop,” and appeared to be mocking the resident. Resident E, who was cognitively intact and had diabetes, reported that some CNAs had attitudes when they came into work. The resident stated they appeared angry, complained about their shifts and coworkers, and that he would prefer not to have to deal with those attitudes. Resident F, who had lung cancer, was described by a family member as having a urinal full of urine on the bedside table, a styrofoam cup with urine in it, and an unemptied bedside commode from the prior day. The family member also reported that the room had a foul smell and that staff did not promptly come to empty the commode. Resident council minutes and a resident council meeting showed repeated concerns from multiple residents that staff were not respectful. Residents reported being put to bed too early, which caused them to miss evening bingo and other activities, despite their requests to be placed in bed after activities. Residents also reported that staff were talking on cell phones while providing care and speaking in a language other than English in their presence. When residents asked what was being said, staff responded that they were not talking about them. The residents stated these concerns had been reported before and continued without improvement.
Late Meal Service for Multiple Residents
Penalty
Summary
Meal services were not provided at times in accordance with residents’ needs, preferences, and requests for 19 of 134 residents who ate food served from the kitchen. The facility’s meal service schedule showed breakfast, lunch, and dinner were to be served at set times by hall and dining area, but multiple residents reported that meals on the 500 Hall were routinely late. Resident CC stated breakfast was served after 10:00 a.m., lunch around 2:00 p.m., and dinner at 7:00 p.m., while Resident N said dinner trays were delivered to her room at 7:00 p.m. and sometimes later. Resident BB was observed receiving breakfast at 10:30 a.m. and said it was always late, and Resident G reported receiving breakfast at 10:30 a.m. that morning. Resident DD stated all meals were served late all the time. During a resident council meeting, attendees including Residents G, H, J, K, L, M, N, O, P, Q, R, S, T, V, Y, and Z stated meals were often provided late, with evenings described as the worst and dinner sometimes served between 7:00 p.m. and 8:00 p.m. A kitchen tour with the Dietary Manager confirmed lunch normally would be served at 11:30 a.m., but dinner had recently been provided late at times, with the latest meals served at 6:30 p.m. The Dietary Manager stated staffing concerns on 3rd shift, including vacations and call-ins, had caused dinner meals to be served late at times.
Failure to Redirect Resident with Dementia from Another Resident’s Bed
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia who displayed intrusive wandering and agitation. Resident 4’s clinical record showed diagnoses including dementia and multiple behavior care plans directing staff to redirect her to her own room or a quiet area, offer calm reassurance, and have her lay down when she became verbally or physically aggressive or wandered into other residents’ rooms. Despite these care plan interventions, Resident 4 was observed lying in another resident’s bed in a shared room on the memory care unit, with her eyes closed, while the door remained open and the other resident entered and then shut the door with Resident 4 still in the bed. During the observation, a laundry aide who was in the adjacent room came to the doorway, identified whose room it was, and left without redirecting Resident 4 or notifying nursing staff that she was in another resident’s bed. The Memory Care Support Specialist later came to the room, looked inside, and left before being informed that Resident 4 was still there; after being told, the MCSS entered to address the situation while the other resident repeatedly stated, in a raised and irritated voice, that Resident 4 did not belong in the room. The Memory Care Unit Manager stated that when Resident 4 was found in another resident’s bed, staff would normally redirect her to her own room and indicated the laundry aide should have redirected her or informed nursing staff.
Medication Unavailable for Colonoscopy Prep
Penalty
Summary
The facility failed to ensure medication was available for administration for one resident who was scheduled for a colonoscopy. The resident had a diagnosis that included diabetes and was cognitively intact. A nursing progress note documented that the resident was scheduled for a colonoscopy, and the March MAR showed he received bisacodyl 20 mg as part of the bowel prep, but colyte was not given because it was unavailable. A nursing progress note stated the resident did not complete the colonoscopy preparation and the appointment needed to be rescheduled because the colyte was out of stock at the pharmacy. During interview, the resident stated the facility did not ensure all medication was available for his colonoscopy prep and that he had to deal with the results of receiving only one of the medications. The DON stated the colyte had been on backorder, the pharmacy did not normally inform the facility of medications on backorder, and the physician did not want an alternative treatment, so the procedure was rescheduled.
Delayed STAT Lab Draw for Resident With Nausea, Vomiting, and Diarrhea
Penalty
Summary
The facility failed to timely complete a physician-ordered STAT CBC and BMP for a resident with chronic kidney disease who had nausea, vomiting, and diarrhea. On 4/6/26, the resident had an extra large amount of liquid greenish stool, his ostomy bag was changed three times, and he had one episode of emesis with thick, clear vomit and undigested food. The NP documented the chief complaint as nausea, vomiting, and diarrhea and ordered STAT CBC and BMP labs, but the resident’s record did not contain results for 4/6/26 or 4/7/26; the first CBC and BMP results were dated 4/8/26. A nursing note entered later stated the laboratory failed to draw the resident’s labs ordered on 4/6/26 and that the provider was notified for new orders. Another note documented two more episodes of emesis and a verbal order for a KUB. Later that evening, critical lab results showed a BUN of 61 and creatinine of 10.7, and the resident was assessed with no acute distress. Interviews indicated the facility was integrating a new lab system on 4/6/26 and that the STAT orders were not going through, and the lab procedure stated STAT draws were to be dispatched and received by a phlebotomist within 15 to 30 minutes, with a STAT turnaround time of 5 hours.
Failure to Document Meal Consumption
Penalty
Summary
The facility failed to timely document meal consumption for one resident who was reviewed for nutrition. The resident had diagnoses including seizure disorder and dementia, and her care plan indicated she required assistance and/or monitoring with nutrition and hydration. Her admission MDS showed she had no useful hearing, no speech, and required supervision with eating. A care plan also identified her as being at risk for altered nutritional status related to impaired skin integrity, dementia, diabetes, poor appetite, family-provided food, change in environment, decreased social interaction, weight loss, and poor oral intake. Meal consumption amounts were not documented for multiple meals across numerous dates, including missed documentation for breakfast, lunch, and dinner entries on several occasions from late January through mid-April. The resident’s weight decreased from 172 pounds on admission to 161 pounds, then to 154 pounds, with a later weight of 157 pounds. During interview, the RD stated the resident had a poor appetite when she first admitted, several interventions were attempted, her appetite was improving, and staff should document consumption of all meals.
Failure to Notify Physician of Fall and Lab Results
Penalty
Summary
The facility failed to ensure timely notification of a fall and subsequent injury for Resident D, who was moderately cognitively impaired and diagnosed with Alzheimer's disease. On the morning following the fall, Resident D reported shoulder pain to a nurse, who observed bruising and swelling but was not aware of the fall until later. The resident had self-reported the fall to staff the previous evening, but the nurse on duty was not informed, resulting in a delay in treatment for a left humerus fracture. The resident was eventually transferred to the emergency room for evaluation and treatment after experiencing significant pain and a fainting spell. Additionally, the facility did not promptly inform a physician of a significant change in laboratory values for Resident B, who had a history of urinary tract infection, diarrhea, and dementia. Despite a physician's order for a basic metabolic panel (BMP) to be conducted, the results indicating elevated creatinine and BUN levels were not communicated to the physician until two days later. This delay in communication resulted in a delay in the initiation of intravenous fluids, which were necessary to address Resident B's acute kidney injury. The facility's failure to adhere to its policies regarding the notification of physicians and timely intervention following significant changes in resident conditions contributed to the deficiencies identified in the report. The lack of immediate communication and assessment following Resident D's fall and the delay in addressing Resident B's abnormal lab results highlight the need for improved staff training and adherence to established protocols.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident who had fallen was properly assessed and monitored by a licensed nurse. On the night of the incident, the resident fell and was assisted back to bed by facility staff, including a Qualified Medication Aide and a Certified Nurse Aide, without notifying a licensed nurse. The resident, who was severely cognitively impaired and required substantial assistance with mobility, later reported pain and was found to have a fractured humerus, which required hospitalization. The resident's clinical record indicated a history of falls and a care plan that included various interventions to prevent falls. Despite these measures, the resident fell and was not immediately assessed by a nurse. The following day, the resident self-reported the fall and exhibited signs of pain and injury, including bruising and swelling on the left shoulder and a skin tear on the left elbow. The facility staff failed to document the fall or notify the physician immediately, as required by the facility's fall management policy. Interviews with staff revealed a lack of communication and documentation regarding the fall. Several staff members, including a Licensed Practical Nurse and a Registered Nurse, were unaware of the fall until the resident self-reported it the next day. The resident's representative was also not informed of the fall until they arrived at the facility. The facility's failure to follow its fall management policy and ensure timely assessment and documentation of the fall led to a delay in the resident receiving appropriate medical care.
Deficiencies in ADL Care and Incontinence Management
Penalty
Summary
The facility failed to provide adequate care for several residents, leading to deficiencies in activities of daily living (ADL) care. Resident L, who had a history of traumatic brain injury and diabetes, required assistance with ADLs due to weakness from a recent hospital stay. Despite being cognitively intact, Resident L reported that her hair had not been washed in two weeks, and she felt that incontinence care was lacking. Observations confirmed that her hair was unwashed, and she was improperly positioned in bed, increasing the risk of skin shearing. Resident D, diagnosed with Alzheimer's disease, was moderately cognitively impaired and required assistance with toileting due to various health issues. Despite a care plan indicating the need for incontinence checks every two hours, Resident D's family reported instances where he was left in urine for extended periods. Observations and interviews revealed that staff were not consistently performing the required checks, and documentation of urinary output was infrequent. Resident 20, with chronic obstructive pulmonary disease and moderate cognitive impairment, reported infrequent changes and was under the impression that double briefing was standard care. Observations confirmed delays in response to her requests for assistance, and staff were found to be using double briefs, which was not a standard practice. Similarly, Resident G, who required assistance due to dementia and incontinence, was not checked for incontinence every two hours as required. Family members reported and observations confirmed that staff did not perform regular checks, leading to prolonged periods without necessary care.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during the provision of care for several residents, leading to potential infection control issues. For Resident L, who has a history of traumatic brain injury and diabetes, a Certified Nurse Aide (CNA) did not perform hand hygiene when changing gloves during incontinent care. The CNA used double gloves, which was not in accordance with the facility's policy, and failed to perform hand hygiene between glove changes, despite Resident L's concerns about the quality of care and risk of urinary tract infection. In another instance, during catheter care for Resident E, who is severely cognitively impaired and at risk of MDRO transmission, a CNA failed to perform hand hygiene after touching high-contact surfaces before handling clean washcloths and providing care. The CNA touched various surfaces, including a doorknob and a bedside table, without changing gloves or performing hand hygiene, which compromised the infection control measures required for Resident E's care. Additionally, during a coffee service, staff members did not perform hand hygiene before and after interacting with residents, and medication carts were not cleaned after being touched by residents. A CNA and a Qualified Medication Aide (QMA) failed to sanitize the medication cart surfaces after residents placed items on them or touched them, which could lead to cross-contamination. These observations indicate a lack of adherence to the facility's hand hygiene policy, which outlines specific moments when hand hygiene should be performed to minimize infection transmission.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to honor and facilitate a resident's choice regarding her bedtime, as evidenced by the case of Resident 30. Resident 30, who is cognitively intact and has diagnoses including muscle weakness and obesity, expressed a preference to be put to bed between 7:15 p.m. and 7:30 p.m. However, she reported that there were days when she was not put to bed until 9:30 p.m. to 10:00 p.m. An interview with the Unit Manager revealed that Resident 30's care plan did not include her bedtime preferences, although a document titled 'Preferences for Customary Routine and Activities' indicated that choosing her own bedtime was very important to her. A Certified Nurse Aide confirmed that Resident 30 preferred to be put to bed after the evening meal but acknowledged that this did not always occur due to other situations.
Failure to Document Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to accurately document urinary output for a resident with an indwelling catheter, identified as Resident E. The resident, who was severely cognitively impaired, had a care plan requiring documentation of bowel and urinary output every shift. A physician order also specified that the nurse should record the output every shift. However, the urine output was not documented for two out of three shifts on specific dates and was entirely missing for other dates. When documented, the output was recorded in qualitative terms such as 'Large' or 'Medium' rather than in milliliters as required. During an interview, the facility's Nurse Consultant indicated that urinary output should be documented in milliliters for residents with indwelling catheters. The Director of Nursing provided a Bowel and Bladder Program Policy, which stated that urinary output from indwelling catheters should be documented. The failure to document urinary output as ordered represents a deficiency in the care provided to Resident E.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure the timely availability of medications for Resident 182, who was admitted with diagnoses including pneumonia. Upon admission, several physician orders were placed for medications such as finasteride, hydroxyurea, levofloxacin, metoprolol, tamsulosin, and a Trelegy inhaler. However, these medications were not available for administration on multiple occasions as documented in the Medication Administration Record (MAR). The Nurse Consultant indicated that the pharmacy had not received all medication orders upon the resident's admission, and the staff did not follow up promptly to obtain the medications. For Resident 47, who was moderately cognitively impaired and had a diagnosis of chronic pain, the facility failed to administer a buprenorphine patch as ordered on two occasions. The Unit Manager explained that the nurse was supposed to re-order the patch when the last one was placed, but it was not available in the facility's emergency drug kit. The facility's re-ordering policy required medications to be re-ordered when there was a 3-day supply remaining, but this procedure was not followed, resulting in the unavailability of the medication.
Failure to Properly Administer Fentanyl Patches Leads to Resident Overdose
Penalty
Summary
The facility failed to administer a synthetic opioid pain patch in accordance with the physician's order, manufacturer's specifications, or accepted professional standards, resulting in a significant medication error for a resident. The resident, who was cognitively impaired and receiving pain management, was found to have two fentanyl patches applied simultaneously. This error led to a significant change in the resident's consciousness, requiring the emergent administration of an opioid overdose medication and subsequent hospitalization. The clinical record review revealed that the resident was to receive a 75 mcg fentanyl patch every three days for pain, but the patches were applied more frequently than ordered, and previous patches were not removed before new ones were applied. Specifically, the resident received fentanyl patches five times within an eight-day period, and there was no documentation of patch removal or monitoring for changes in the resident's condition. On one occasion, the resident was found unresponsive with two patches in place, necessitating the administration of Narcan and hospitalization. Interviews and documentation indicated that the medication errors were due to nursing staff not adhering to the prescribed schedule and failing to remove old patches. The errors were compounded by a lack of proper documentation and monitoring, which contributed to the resident's adverse reaction. The facility's medication administration procedure policy was not followed, leading to the resident's overdose and subsequent medical intervention.
Failure to Notify Family of Resident's Fall
Penalty
Summary
The facility failed to timely notify a resident's representative of a fall incident involving Resident B, who had a history of Alzheimer's disease and hypertension. On 12/11/24, Resident B was found on the floor in another resident's room, but no injuries were noted at that time. Despite being assessed and showing no immediate signs of pain, Resident B later exhibited pain in her left lower extremity, leading to a physician's order for a STAT X-Ray, which revealed a left femoral neck fracture. The resident was subsequently sent to an acute care hospital for treatment. The deficiency arose because the family member, FM 10, was not informed of the fall until the following day when she visited and noticed Resident B in distress. The facility's investigation revealed that the fall was not documented in the clinical record on the day it occurred, and the family was not notified promptly. Interviews with staff indicated a lack of communication and documentation regarding the fall, which contributed to the delay in notifying the family and addressing Resident B's injury.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement care-planned fall interventions for a resident identified as being at risk for falls. The resident, who has diagnoses including Alzheimer's disease, dementia, anxiety, fibromyalgia, and osteoarthritis, was observed multiple times without wearing hipsters, which were part of the prescribed fall prevention measures. A physician's order from July 2024 required the use of hipsters at all times, with nursing staff checking for their use every shift. However, observations on January 2nd and 3rd, 2025, revealed that the resident was not wearing hipsters while sitting in a wheelchair at the nurse's station. When questioned, an LPN was unsure if the resident was supposed to be wearing hipsters and confirmed that the resident was not wearing them upon inspection. The resident's room did not contain hipsters, and the LPN was unaware of their whereabouts, despite knowing the resident had worn them previously. The facility's Fall Management Policy, revised in March 2024, mandates the implementation of resident-centered fall prevention plans for those at risk, but this was not adhered to in the case of this resident.
Failure to Document and Manage Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately document and manage the behavioral health care needs of Resident H, who was admitted with diagnoses including stroke and dementia. Despite being cognitively intact upon admission, Resident H exhibited problematic behaviors such as yelling, cursing, and making inappropriate sexual comments. These behaviors were noted in various nursing and care plan notes, but the facility did not consistently document these incidents or evaluate the effectiveness of the interventions put in place to address them. Resident H's care plans included interventions such as providing care in pairs, encouraging expression of feelings, administering medications, and providing mental health services. However, these interventions were not consistently implemented or evaluated. For instance, there were instances where care was provided by a single staff member, contrary to the care plan's directive to provide care in pairs. Additionally, the facility did not document all behavioral incidents, such as inappropriate sexual comments, in the resident's clinical record. The facility's failure to document and evaluate Resident H's behaviors and the effectiveness of interventions led to ongoing issues with the resident's adjustment to long-term care. Despite discussions during care plan meetings and awareness of the resident's behaviors, the facility did not ensure that staff consistently followed the behavior management policy. This lack of documentation and evaluation contributed to the deficiency identified in the report.
Failure to Maintain Odor-Free Environment Due to Catheter Leakage
Penalty
Summary
The facility failed to maintain an environment free from strong urine odors, affecting one of the three residents reviewed for environmental conditions. Resident J, who has a medical history of neuromuscular dysfunction of the bladder and urinary retention, required an indwelling urinary catheter. The care plan for Resident J, initiated in December 2018, included interventions such as recording urinary output every shift and maintaining a closed catheter system. However, observations on multiple occasions revealed a strong urine odor in the 500 hallway, traced back to Resident J's room. Resident J reported that her urinary catheter frequently leaked onto the floor, suspecting that the staff did not lock the tubing on the bag correctly, leading to the leakage. Housekeeping staff confirmed that they mopped urine from the floor in Resident J's room 2-3 times a week due to leakage from the catheter bag. Despite these occurrences, the Director of Nursing Services and the Executive Director were unaware of the strong urine odor and had not received any concerns regarding the nursing staff's handling of the urinary bag. This deficiency was identified during a complaint investigation related to Complaint IN00446808.
Inaccurate Controlled Medication Records for Hospice Resident
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled medications for a resident receiving hospice services. The resident, who had diagnoses including hypertension, congestive heart failure, and respiratory failure, was prescribed lorazepam, an antianxiety medication, with specific administration instructions. A physician order indicated lorazepam was to be administered at a dosage of one milliliter every three hours, which was later adjusted to every two hours. However, the controlled substances record showed that the medication was administered at a significantly lower dosage of 0.1 milliliters at various times, contrary to the physician's orders. An interview with the Director of Nursing revealed that the lorazepam bottle should have been empty by a certain date, but a new bottle was received and not utilized according to the records. This discrepancy indicated that the documentation on the controlled substances record was inaccurate, as the nursing staff recorded administering a much lower dosage than prescribed. This issue was identified during a review related to a specific complaint, highlighting a failure in the facility's medication administration and record-keeping processes.
Failure to Ensure Proper Nail Trimming and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper nail trimming and hand hygiene for three residents who required upper extremity devices. Resident D, diagnosed with chronic kidney disease and hemiplegia following a stroke, was observed with long nails and a brown flaky substance on his hand, which was only cleaned on shower days. The Float Director of Nursing Services (FDNS) confirmed that the resident's nails needed trimming and that staff should wash the resident's hand before placing the palm protector on it. Resident C, diagnosed with diabetes mellitus, dementia, and chronic kidney disease, was found with long nails despite a care plan indicating the need for nail trimming twice a week. A hospice RN noted a foul smell from the resident's hands and observed maceration between the fingers due to long nails. The FDNS confirmed that the resident's nails needed trimming and that the nursing staff should be responsible for this task. Resident F, diagnosed with dementia and muscle weakness, was observed with long nails with uneven edges and a black substance underneath them. The FDNS confirmed that the resident's nails needed cleaning and trimming. The facility's procedures for splinting device application and fingernail care were not followed, leading to the deficiencies observed in the care of these residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 999 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fishers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Castleton Skilled Nursing Facility, The | 1.9 mi | ★★★★★ | 24 | 0 |
| Clearvista Lake Health Campus | 1.9 mi | ★★★★★ | 4 | 0 |
| Castleton Health Care Center | 2 mi | ★★★★★ | 36 | 0 |
| Allison Pointe Healthcare Center | 2.7 mi | ★★★★★ | 19 | 0 |
| Mcgivney Health Care Center | 3 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.