Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Asbury Towers Health Care Center during CMS and state inspections, most recent first.
An RN took an unauthorized photograph of a resident's anal area on a personal device during care and sent it to a friend who was not involved in the resident's care and had no connection to the facility. The resident, who had rectal prolapse and no documented cognitive deficits, had signed a general photo release that did not authorize photographing private body parts or sharing images with individuals outside the facility. The resident's record lacked documentation of any photos being taken, and the resident reported not recalling giving permission for such a picture. This conduct violated the facility's resident rights policy prohibiting unauthorized release or disclosure of resident information.
Late Death in Facility MDS Submission: The facility failed to timely submit a death in facility MDS for a resident with brain cancer and acute/chronic respiratory failure. Nursing notes showed the resident stopped breathing in the presence of the hospice nurse and was later transported to the funeral home, but the death MDS was not submitted until much later. The RCM said the MDS Coord had been intermittently out on FMLA and the missed assessment may have been overlooked despite weekly calls with an MDS consultant.
Dialysis access assessment orders were inaccurate and not consistently documented for a resident with ESRD on HD. The resident stated she no longer had a permacath and only had an AV fistula, yet the chart still contained a permacath assessment order. The MAR also lacked documentation for ordered AV fistula bruit/thrill checks and pre/post-dialysis evaluations on multiple shifts, and the DON stated the permacath order had been overlooked.
Expired TB Solution Vial Found in Medication Storage: Surveyors observed a multi-dose vial of TB solution in the medication storage room that had been opened on a prior date and remained stored past its viable period. RN 7 stated the vial was viable for 30 days, while the DON later confirmed it was expired but had not been used after expiration. The facility policy stated opened multi-dose vials are dated and discarded if expired after use.
Three residents, including one with severe cognitive impairment, received food that was reported and observed to be cold at the time of service. Observations showed that food temperatures fell below the facility's policy requirements, and a dietary aide confirmed that food was not always served at the appropriate temperature.
Staff and a contracted service provider entered the kitchen and food service areas without wearing required hair or beard nets during meal service. Some staff indicated they were unaware of the requirement to wear hairnets in these areas, despite facility policy mandating hair restraints in food production zones.
The facility did not obtain or document physician orders for hospital transfers for three residents who experienced acute medical events, including pain, altered mental status, coughing up blood, and sepsis. Although physicians and families were notified and emergency services were called, the required physician orders authorizing these transfers were not present in the clinical records, as confirmed by the DON and contrary to facility policy.
Unauthorized Photograph and Disclosure of Resident's Private Body Area
Penalty
Summary
Facility staff failed to maintain a resident's rights to dignity, privacy, and confidentiality when an RN took and shared an unauthorized photograph of the resident's anal area. The resident, who had a diagnosis including rectal prolapse and no documented cognitive deficits on an admission MDS, had previously signed a general Photo Release Form allowing use of his image for lawful purposes such as publication, advertising, web content, and social media. However, this form did not document permission for photographing private body parts or for providing photographs to individuals outside the facility. The resident's progress notes contained no documentation that any pictures had been taken, and during interview the resident stated he did not remember ever giving permission for a nurse to take a picture of his backside and believed he would remember if he had given such permission. The incident came to light through an intake document alleging that the resident's rights had been violated when an RN took a photograph of the resident's anal area on a personal electronic device and sent it to a friend who was not involved in the resident's care and had no connection to the facility. The facility's investigation, documented on an Indiana State Reportable Incident form, confirmed that the RN had taken the picture during resident care and transmitted it via the personal device to this outside individual. This conduct was inconsistent with the facility's Resident Rights policy, which prohibited unauthorized release, access, or disclosure of resident information and required that any such release comply with privacy laws.
Late Death in Facility MDS Submission
Penalty
Summary
The facility failed to submit a death in facility MDS assessment timely for one resident reviewed for MDS accuracy. The resident’s record showed diagnoses including malignant neoplasm of the brain and acute and chronic respiratory failure. A significant change in status MDS assessment dated 1/16/26 indicated the resident was cognitively intact and marked that the resident did have a condition or chronic disease that may result in a life expectancy of less than 6 months. Nursing documentation dated 1/21/26 at 5:40 p.m. stated the resident stopped breathing at 5:08 p.m. in the presence of the hospice nurse, and another note dated 1/21/26 at 7:00 p.m. stated the resident’s body was transported from the facility to the funeral home. The death in facility MDS assessment was not submitted until 3/25/26. During interview, the Regional Clinical Consultant stated she was not aware why the MDS Coordinator had not submitted the death in facility assessment timely and said the MDS Coordinator had been out on FMLA intermittently since January 2026, so the assessment could have been missed. She also stated the facility had an MDS consultant on weekly calls with the MDS Coordinator and she was not sure why the missed death in facility assessment had not been caught.
Dialysis Access Assessment Orders Were Inaccurate and Not Documented
Penalty
Summary
The facility failed to ensure accurate physician orders and documented assessments for a resident receiving hemodialysis. The resident’s record showed diagnoses including end stage renal disease and dependence on renal dialysis, and the care plan directed nursing staff to assess the AV fistula for bruit and thrill. However, a physician’s order dated 12/18/25 directed staff to check the resident’s permacath site daily and upon return from dialysis every shift, including caps in place and dressing dry and intact, even though the resident stated she no longer had a permacath and only had the AV fistula site. The DON also stated the permacath order was not accurate and had been overlooked. The resident’s January, February, and March 2026 MARs lacked documentation that the permacath site order was completed on multiple shifts, including day and night shifts on several dates. A separate physician’s order dated 12/30/25 directed staff to check the left upper extremity antecubital access site for bruit and thrill every shift, but the MAR also lacked documentation on multiple shifts. In addition, another order dated 12/30/25 required pre- and post-dialysis evaluations prior to leaving and upon return two times a day on dialysis days, and the MAR lacked documentation for several pre- and post-dialysis checks. The DON stated it was the expectation that nurses document in the MAR when an order was completed as ordered.
Expired TB Solution Vial Found in Medication Storage
Penalty
Summary
The facility failed to ensure medications were discarded according to facility policy and manufacturer guidelines in the medication storage room. During observation with RN 7, surveyors found one multi-dose vial of Tuberculin (TB) solution that had been opened on a prior date and was still present in storage. RN 7 stated the vial was viable for 30 days, while the DON initially said she needed to check the policy regarding the TB solution expiration date and later confirmed the vial was expired but had not been used after the expiration date. The DON then provided the facility’s Medication Storage and Medication Labeling policy, which stated that multi-dose vials that have been opened or accessed are dated and discarded if expired after use.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature for three residents. One resident, who was cognitively intact, reported that the food was cold when served. Another resident's family member also reported that the food was cold, and this resident had a severe cognitive impairment. A third resident indicated that food was often cold when served in her room, requiring staff to reheat it. These concerns were corroborated by interviews and review of resident records. Observation of meal service revealed that food was left unattended on a steam table before being transported to another dining area, where temperatures were checked prior to service. Recorded food temperatures at the time of service showed that some items, such as mashed potatoes and vegetables, were below the facility's policy requirement of 135°F for hot food. A dietary aide confirmed that food should have been at least 130°F or above when served, but test tray temperatures after service showed some items were below this threshold.
Failure to Enforce Hair Restraint Use in Food Service Area
Penalty
Summary
During a dining observation, a staff member with facial hair served lunch in the first floor dining room without wearing a beard net, as required by facility policy. Additionally, a contracted service provider entered the kitchen area to obtain water for a fish tank without wearing a hairnet, and both a registered nurse and a certified nurse aide entered the kitchen area to obtain drinks without hairnets. The staff members involved indicated they were not aware that hairnets were required to enter the kitchen area. The facility's policy on food safety and sanitation specifies that hair restraints must be worn at all times in or around food production areas.
Failure to Document Physician Orders for Hospital Transfers
Penalty
Summary
The facility failed to ensure that a physician's order was obtained and documented for hospital transfers for three residents who were reviewed for hospitalization. In multiple instances, residents were transferred to the hospital due to acute medical concerns such as pain, lethargy, severe back pain, vomiting, coughing up blood, and symptoms of sepsis. Despite these transfers, the clinical records for each event lacked documentation that a physician's order was obtained, written, or signed for the hospital transfer, as required by facility policy and professional standards. For one resident with medically complex conditions, there were several documented hospital transfers following episodes of pain, altered mental status, and gastrointestinal symptoms. In each case, while the physician and family were notified and emergency services were called, there was no evidence in the clinical record of a physician's order authorizing the transfer. Similar deficiencies were found for another resident with a history of atrial flutter and pulmonary embolism, who was sent to the emergency room after coughing up blood, and for a third resident with acute pyelonephritis and hydronephrosis, who was transferred due to fever, hallucinations, and sepsis. In all cases, the required physician's order for transfer was not documented. Interviews with the Director of Nursing confirmed the absence of documentation for physician's orders related to these hospital transfers. The facility's own policy, which was provided during the survey, specifies that a physician's order must be obtained for emergency transfers or discharges and that the transfer must be documented in the medical record. The lack of such documentation for these residents' hospital transfers constitutes a failure to maintain medical records in accordance with accepted professional standards.
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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) |
|---|---|---|---|---|
| Hickory Creek At Sunset | 0.7 mi | ★★★★★ | 7 | 0 |
| Mill Pond Health Campus | 1.3 mi | ★★★★★ | 10 | 0 |
| Waters Of Greencastle, The | 1.8 mi | ★★★★★ | 12 | 0 |
| Aperion Care Summerfield | 9.9 mi | ★★★★★ | 0 | 0 |
| Cloverleaf Of Knightsville | 14.3 mi | ★★★★★ | 6 | 0 |
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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.