Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Bertha D Garten Ketcham Memorial Center during CMS and state inspections, most recent first.
Excessive Hot Water Temperatures in Resident Bathrooms: Surveyors found hot water temperatures above 120 degrees in 9 of 9 rooms tested, including multiple private and shared bathrooms measuring as high as 126.8 degrees. Several affected rooms were occupied by cognitively impaired residents. The Maintenance Supervisor stated that temperatures over 120 degrees meant the building mixing valve needed adjustment, but he reported no complaints of water being too hot and said there was no written water temperature policy, only guidelines that hot water in showers and sinks should be between 100 and 120 degrees.
A resident with TBI and severe cognitive and functional impairment had a court-appointed guardian listed in the record, but the facility repeatedly contacted the guardian’s wife instead of the father named in the guardianship order. The resident’s profile, progress notes, and staff interviews showed the wife was treated as the primary responsible party for care conferences, medication changes, room changes, and other updates, even though the care plan identified the father as the decision-maker.
Dusty oxygen concentrator filters were observed for two residents receiving O2 via NC. One resident had hypoxia and impaired cognition, and the other had chronic respiratory failure with hypoxia. Their records included orders for oxygen therapy and tubing/humidifier changes, but lacked orders or care plan interventions related to oxygen concentrator filters. Staff interviews showed inconsistent understanding of who cleaned the filters, and the oxygen provider contract did not specify filter-cleaning details.
A resident with a newly acquired colostomy was admitted and had physician orders for specific ostomy care, but the baseline care plan did not include any mention of the colostomy or related care needs. The omission occurred because the initial admission assessment failed to document the colostomy, leading to a care plan that did not address the resident's immediate health care requirements.
The facility failed to prevent falls for two residents, leading to significant injuries and inadequate care plan updates. A resident fell due to a catheter bag leak that was not properly cleaned, resulting in a fractured leg. Another resident with a history of falls frequently fell near his recliner, but care plans were not updated with new interventions. The facility's fall prevention policy was not followed, as care plans were not revised after falls.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in care. A resident on diuretic medication lacked a care plan for its use. Another resident's care plan was not updated after a fall, despite existing fall prevention strategies. A third resident with complex medical needs did not have care plans for antiplatelet medication or necessary precautions due to a positive wound culture. These oversights highlight lapses in updating care plans to reflect changes in residents' conditions.
The facility failed to label medications according to professional principles, with multiple instances of missing open dates on medications like eye drops and inhalers. Additionally, medications were improperly pre-set in cups for residents, contrary to policy. Staff interviews confirmed these practices, highlighting a lack of adherence to the facility's medication expiration and storage policies.
The facility failed to store and prepare food safely, with observations of undated and unlabeled food items, and incomplete temperature and dishwasher logs. The Dietary Manager confirmed that food should be labeled and temperature logs filled out daily, but these practices were not followed.
The facility failed to notify the physician and family about significant changes in two residents' conditions. One resident experienced a notable weight loss without notification to the medical team, while another missed a dose of antipsychotic medication without physician notification. The DON acknowledged the lapses in communication and documentation.
A resident with severe cognitive impairment and a history of falls experienced two falls due to inadequate supervision and failure to update the care plan with necessary interventions. Despite the facility's fall prevention policy, the care plan and physician's orders were not updated after the first fall, leading to a second fall where the resident sustained a head injury.
A resident with dementia and severe cognitive impairment was not properly assessed for continued use of psychotropic medication. Despite a pharmacy recommendation to reduce the dosage of Zyprexa, the change was delayed, and the dosage was later increased without documented rationale. Behavior monitoring records were incomplete, and a missed medication dose occurred due to a computer error.
The facility failed to ensure proper infection control practices, as staff did not change gloves or perform hand hygiene during resident care and medication administration. A QMA and CNA did not change gloves or sanitize hands while providing incontinence care to a resident, and an LPN handled medication with bare hands without sanitizing before or after administration. The DON confirmed the need for hand hygiene and glove use according to facility policies.
The facility did not post the nurse staffing data sheet daily at the beginning of each shift for two out of five days reviewed. Observations on two separate days showed outdated staffing sheets in both the main building and [NAME] House. The DON confirmed that the night shift should post the data sheet by 6:00 A.M. daily, as per the facility's policy.
The facility failed to update care plans for two residents with dementia who exhibited wandering and exit-seeking behaviors. Despite documented instances of these behaviors, the care plans lacked necessary interventions. Staff interviews and facility policies highlighted the need for updates, which were not implemented, resulting in a deficiency.
Excessive Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors when surveyors found hot water temperatures above 120 degrees in 9 of 9 rooms tested. On 1/15/2026, water temperatures measured in multiple bathrooms were 126.8 degrees in the bathroom of a private room, 125.7 degrees in the bathroom shared by Rooms 37/38, 126 degrees in another private room, 122.4 degrees in the bathroom between Rooms 33/34, 122.5 degrees in the bathrooms between Rooms 23/24 and 25/26, and 122.7 degrees in the bathroom between Rooms 35/36. On 1/16/2026, the bathroom between Rooms 11/12 measured 123.6 degrees and the bathroom between Rooms 15/16 measured 120.6 degrees. On 1/21/2026, a bathroom in another room was observed at 124 degrees, and the Maintenance Supervisor checked additional room temperatures that were 123 degrees, 123 degrees, and 122.7 degrees. Several of the affected rooms were occupied by cognitively impaired residents, including the two residents in Room 37/38, the two residents in Room 33/34, the two residents in Room 23/24, and residents in Rooms 25/26, 35/36, 11/12, 15/16, and other rooms noted in the findings. During interview, the Maintenance Supervisor stated that when temperatures were over 120 degrees the mixing valve in the building would need to be adjusted, and he reported no complaints that the water was too hot and that no one had been burned. On 1/22/2026, when a policy for water temperatures was requested, he stated that he did not have a written water temperature policy and that he followed guidelines indicating hot water in showers and sinks must be between 100 and 120 degrees.
Failure to Notify the Correct Legal Guardian of Resident Changes
Penalty
Summary
The facility failed to notify the correct resident representative of changes for a resident who had been deemed incompetent by the court and had a guardian appointed by circuit court order. The resident’s clinical record showed diagnoses including rhabdomyolysis, traumatic brain injury, contracture of the right hand, and persistent vegetative state, and the most recent MDS indicated the resident’s cognitive status could not be assessed and he was totally dependent on staff for eating, toileting, transfers, showers, and bed mobility. The care plan stated the resident was totally dependent on his guardian for all decision making and that the guardian should be referred to for all decisions pertaining to the resident or his care. Despite the guardianship document naming the resident’s father as guardian, the facility’s profile tab listed the father’s wife as the first responsible party, care conference person, and emergency contact, with the father listed second as guardian and emergency contact. Progress notes showed the facility repeatedly contacted the stepmother about care conferences, medication changes, lab discontinuation, a permanent room change, and dietary concerns, and social services documented that the facility talked to the wife for its purposes. Staff interviews confirmed they used the profile tab to determine who to notify and called the responsible party listed there, while the notification policy stated staff were to notify contacts in the order listed on the form and call the first listed contact first.
Dusty Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure necessary respiratory care and services were provided in accordance with professional standards of practice for 2 of 5 residents reviewed for respiratory care. Resident 27 was observed on multiple occasions wearing oxygen at 2 LPM via nasal cannula, and the filter on the oxygen condenser was observed to be dusty each time. Resident 27’s record showed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and hypoxia, and the most recent MDS indicated moderately impaired cognition and oxygen therapy use. The physician’s orders included continuous humidified supplemental oxygen at 2-4 LPM to maintain O2 saturation above 90%, monitoring O2 saturation every shift, and wiping down the portable oxygen tank and room concentrator with tubing and humidifier changes every Sunday, but the record lacked a physician’s order related to oxygen concentrator filters. The care plan for hypoxia also lacked an intervention related to oxygen concentrator filters. Resident 9 was also observed wearing oxygen at 2 LPM via nasal cannula, and the filter on the back of the oxygen condenser was observed to be dusty on more than one occasion. Resident 9’s record showed chronic respiratory failure with hypoxia, and the most recent MDS indicated the resident was cognitively intact and receiving oxygen therapy. The physician’s orders included changing the O2 tubing and prefilled humidifier every Sunday, but the clinical record lacked a physician’s order related to oxygen concentrator filters, and the impaired gas exchange care plan lacked an intervention related to oxygen concentrator filters. During interviews, an LPN stated maintenance cleaned the oxygen filters on the oxygen condensers, while a maintenance assistant and central supply indicated the oxygen provider cleaned the filters twice a year per the provider’s policy. The administrator reviewed the contract with the oxygen provider, which stated supplies and services would meet industry standards, but specific information related to cleaning oxygen condenser filters was lacking, and a policy for cleaning oxygen condenser filters was requested and not received.
Baseline Care Plan Lacked Ostomy Care for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan for a newly admitted resident included pertinent information regarding the resident's colostomy care needs. Upon review, it was found that the resident had diagnoses including diverticulitis of the large intestine with perforation and abscess, and had a newly acquired colostomy. Physician orders specified detailed ostomy care requirements, including changing the stoma wafer and bag on specific days, daily observation of the stoma for skin breakdown and circulation, and monitoring colostomy output for abnormalities. Despite these orders and the resident's condition, the baseline care plan did not mention the presence of a colostomy or include any focus on ostomy care. Interviews with the DON revealed that the initial admission assessment did not document the presence of a colostomy, and the baseline care plan was created based on this incomplete assessment. The facility's policy on colostomy/ileostomy care requires review of the care plan to assess for special needs, but this was not followed in this case. As a result, the resident's immediate health care needs related to the colostomy were not addressed in the baseline care plan within 48 hours of admission.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to prevent falls for two residents, Resident C and Resident D, leading to significant injuries and a lack of updated care plans. Resident C, who had multiple diagnoses including a fracture of the lower end right femur and type II diabetes, experienced a fall due to a catheter bag leak that was not properly cleaned up by a CNA. The CNA used towels instead of a mop to dry the urine, and despite Resident C's warning that the floor was still wet, the CNA insisted it was dry, leading to Resident C slipping and fracturing his right leg. The care plan for Resident C was not updated with new interventions following this incident. Resident D, who had a history of falls and diagnoses such as vascular dementia and cerebral palsy, frequently fell near his recliner. Despite multiple falls, the care plan was not updated with new interventions to prevent further incidents. The resident often attempted to transfer himself without assistance, even after being reminded to call for help. Staff were aware of the resident's tendency to fall but did not implement new strategies to mitigate the risk. The facility's policy on fall prevention was not adhered to, as it required new interventions to be put in place and care plans to be revised following a fall. The Facility Administrator acknowledged that not all care plans were updated after falls, indicating a systemic issue in addressing fall risks and updating care plans accordingly. This deficiency was identified during a complaint investigation.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for several residents, leading to deficiencies in care. Resident 16, who had diagnoses including atrial fibrillation, hypertension, and coronary artery disease, was receiving a diuretic medication as per physician orders. However, the clinical record for Resident 16 lacked a care plan addressing the use of the diuretic medication, indicating a failure to incorporate this aspect of care into the resident's overall plan. Resident 36, diagnosed with diabetes mellitus, anxiety disorder, and depression, experienced a fall on July 14, 2024, after tripping over sandals. Although the resident's care plan included various fall prevention strategies, it was not updated following the incident, as confirmed by the Director of Nursing. This oversight highlights a lapse in revising care plans to reflect changes in the resident's condition or incidents that occur, which is crucial for ongoing risk management and resident safety. Resident 20, with a complex medical history including stroke, hemiplegia, and multiple infections, was observed with a catheter and bandages. The resident's clinical record did not include a care plan for the antiplatelet medication Cilostazol, nor for the Enhanced Barrier Precautions and contact isolation required due to a positive wound culture. The MDS Coordinator acknowledged the oversight, noting that new orders should trigger care plan updates, which did not occur in this case. This deficiency underscores the importance of timely and accurate care planning to address all aspects of a resident's medical needs and precautions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled in accordance with currently accepted professional principles, as observed in multiple medication carts. Specifically, medications such as eye drops, inhalers, and nasal sprays for several residents did not have open dates, which is a requirement for tracking expiration and ensuring safety. For instance, Resident 38's eye drops and inhaler, Resident 14's inhaler, and Resident 40's inhaler and nasal spray were among those without open dates. Additionally, some medications had open dates that were past the recommended usage period, such as Resident 14's Genteal Eye Drops with an open date of 12/15/23 and Resident 40's Flutisone Nasal Spray with an open date of 8/10/24. Furthermore, during a medication pass, it was observed that medications were pre-set in cups with resident names on them, which is against the facility's policy that medications should not be pre-poured or pre-set. This was confirmed during interviews with nursing staff, including an RN who admitted to preparing medications at the start of her shift. The Director of Nursing also acknowledged that medications should not be pre-set and should be labeled when opened, although she was unsure of the exact duration for which they remain usable. The facility's policies on medication expiration and storage were provided, indicating specific time frames for medication usage after opening, which were not adhered to in these instances.
Food Storage and Temperature Logging Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared safely in accordance with professional standards during two kitchen observations. In the [NAME] House kitchen, various food items in the refrigerators and freezers were found undated, unlabeled, and in some cases, open to air. These included tomatoes, a can of milk chocolate pudding, chicken patties, diced chicken, and several other items. Additionally, a used cooking utensil was dropped into the food to be served, further compromising food safety. Temperature and dishwasher logs were not consistently filled out, with numerous dates missing entries for the refrigerator/freezers, stock fridge, stock freezer, and dish machine from August through October. The Dietary Manager acknowledged that food should be labeled and not stored open to air, and that temperature logs should be completed daily. The facility's policies on food storage and temperature logging were not adhered to, as evidenced by the lack of proper labeling and incomplete temperature records.
Failure to Notify Physician and Family of Resident Changes
Penalty
Summary
The facility failed to notify and consult the physician, resident, and/or resident's representative of changes that may require an alteration in the resident's care for two residents. For Resident 4, who had a history of stroke, hemiplegia, and anxiety, the facility did not inform the medical doctor, registered dietitian, or family about a significant weight loss of 5.7 pounds over 31 days. The resident's care plan required such notifications for weight changes of 5 pounds or more within 30 days. The Director of Nursing acknowledged that the notification should have been made immediately and documented in a progress note. For Resident 15, who had severe cognitive impairment and was on antipsychotic medication, the facility failed to notify the physician about a missed dose of Zyprexa on a specific day. The resident's medication administration record showed that the new order for an increased dose was not administered on the day of the change. The Director of Nursing indicated that staff should clarify medication changes and new orders, and acknowledged uncertainty about why the dose was missed and whether the physician should have been notified. The facility did not provide a current notification policy when requested.
Failure to Update Care Plan and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents for a resident with a history of falls. The resident, who had severe cognitive impairment and required extensive assistance for mobility, experienced two falls. After the first fall, a pull tab alarm was placed on the resident as an intervention, but the care plan and physician's orders were not updated to reflect this change. Consequently, the resident fell again, sustaining a significant head injury, as the alarm was not attached at the time of the second fall. The facility's fall prevention policy required immediate intervention and care plan updates following a fall, but these procedures were not followed. The MDS Coordinator and DON acknowledged that the care plan should have been revised promptly after the falls, but it was not updated until months later. The CNA assignment sheet also lacked fall prevention measures for the resident, indicating a failure in communication and implementation of necessary interventions to prevent further accidents.
Failure to Properly Assess and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was properly assessed for the continued use of the medication. Resident 15, who had a diagnosis of dementia with behaviors, anxiety, and depression, was observed to have severe cognitive impairment and required extensive assistance with daily activities. Despite a recommendation from a pharmacy consultant to decrease the dosage of the antipsychotic medication Zyprexa from 7.5mg to 5mg, the change was delayed by 18 days. Furthermore, the resident's medication was later increased to 10mg without a documented rationale for the increase. The facility's documentation practices were inadequate, as evidenced by the lack of proper behavior monitoring records. The Treatment Administration Record (TAR) for Resident 15 did not include the required 'Y' or 'N' indicators to show whether behaviors were observed during shifts, and some entries were left blank. Additionally, the clinical record lacked sufficient documentation to justify the increase in the medication dosage, and there was a missed dose of Zyprexa on one occasion, which was attributed to a computer error when the new order was entered. Interviews with facility staff revealed gaps in communication and follow-up regarding pharmacy recommendations and physician orders. The Director of Nursing (DON) acknowledged that pharmacy recommendations were reviewed in morning meetings, but there was a delay in implementing the recommended dosage reduction due to a lack of follow-up with the physician. The DON also noted that behavior monitoring should have been documented more thoroughly, and there was uncertainty about why the medication order was not entered correctly, resulting in a missed dose.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the transmission of infections. During an observation, a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA) did not change gloves or perform hand hygiene while providing incontinence care to a resident. The QMA wiped the resident's perineal area and buttocks, then failed to change gloves and perform hand hygiene before placing a clean brief under the resident. After removing gloves, the QMA and CNA continued to handle the resident's brief and lift pad without performing hand hygiene until later. The Infection Preventionist confirmed that staff should change gloves and perform hand hygiene between dirty and clean tasks. In another instance, a Licensed Practical Nurse (LPN) was observed preparing medications for a resident without sanitizing her hands before or after the process. The LPN handled a medication pill with bare hands, placing it back into the medication bottle after it was mistakenly dispensed. The Director of Nursing (DON) indicated that staff should sanitize hands between residents when passing medications and should not touch pills with bare hands. The facility's policies on hand hygiene and medication administration were provided, indicating the need for hand hygiene before and after medication preparation or administration and the use of gloves when touching tablets.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post the nurse staffing data sheet on a daily basis at the beginning of each shift for two out of five days reviewed. On October 3rd, 2024, at 11:30 A.M., the nurse staffing data sheet in the main building was observed with the date of October 2nd, 2024, and similarly, at 11:34 A.M., the sheet in the [NAME] House was also dated October 2nd, 2024. Again, on October 7th, 2024, at 8:30 A.M., the staffing data sheet in the main building was observed with the date of October 6th, 2024. During an interview on October 9th, 2024, the Director of Nursing (DON) indicated that the night shift is responsible for posting the nurse staffing data sheet daily by the beginning of the morning shift at 6:00 A.M. A current non-dated Posting Direct Care Daily Staffing Numbers Policy provided by the DON stated that within two hours of the beginning of each shift, the number of staff directly responsible for resident care should be posted.
Failure to Update Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to ensure proper assessments and updates to care plans for residents with dementia who exhibited wandering and exit-seeking behaviors. Resident B, who resides in a locked dementia unit, was observed to have severe cognitive impairment and was not initially assessed as at risk for elopement. Despite this, Resident B managed to exit the facility, and subsequent behaviors indicating exit-seeking were documented in the nurse's progress notes. However, these behaviors were not reflected in the resident's care plan, which lacked interventions for wandering or exit-seeking. Similarly, Resident C, who also has severe dementia, was documented to have wandering behaviors and was assessed as at risk for elopement. Despite this, Resident C's care plan did not include interventions for wandering or exit-seeking behaviors. The resident's progress notes detailed multiple instances of exit-seeking and wandering, yet the care plan remained unchanged to address these behaviors. Interviews with facility staff, including LPNs and Social Services, revealed that there was an expectation for care plans to be updated with new interventions when residents displayed new or increased exit-seeking behaviors. The facility's policies on elopement risk and behavioral assessment emphasized the need for safety interventions and care plan updates, but these were not implemented for Residents B and C, leading to the deficiency.
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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 Odon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sycamore Care Strategies | 5.3 mi | ★★★★★ | 2 | 1 |
| Poplar Care Strategies | 12.5 mi | ★★★★★ | 16 | 0 |
| Eastgate Manor Nursing And Rehabilitation | 15.7 mi | ★★★★★ | 0 | 0 |
| Prairie Village Nursing And Rehabilitation | 16.2 mi | ★★★★★ | 0 | 0 |
| Hillside Manor Nursing Home | 16.3 mi | ★★★★★ | 31 | 1 |
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