Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Bethel Manor during CMS and state inspections, most recent first.
Staff failed to protect resident privacy and dignity when CNAs repeatedly entered multiple resident rooms to deliver meal trays without knocking or announcing themselves. During an observed supper meal service, CNAs entered several rooms in succession without prior notice to the occupants. A CNA later acknowledged that staff are expected to knock, announce themselves, identify their department, and request permission before entering a room, and the facility’s dignity policy states that residents are to be treated with respect and their rights protected.
Improper food storage, labeling, and hand hygiene were observed in the Main and Cottage kitchens. Surveyors found expired and undated food items in refrigerators and dry storage, staff with hair restraints not fully covering the hair, and a dietary staff member using a bare finger to wipe gravy from a resident’s plate, placing the finger in her mouth, and then serving the plate without washing her hands.
Lack of care plan for recurrent UTIs: A resident with Alzheimer's disease and total dependence for ADLs had repeated positive urine cultures, an order for D-Mannose for UTI prevention, and a hospital transfer for UTI and encephalopathy. The clinical record lacked a care plan addressing the recurrent UTIs, monitoring, or the medication used for prevention, despite the IPN noting frequent UTIs and ongoing decline.
Care plans were not revised after falls for three residents with dementia or Alzheimer's disease. One resident had a witnessed fall and the record lacked IDT review and a new intervention; another had an unwitnessed fall with no IDT review or care plan update; and a third had two falls, but no new interventions were added to the plan of care. The Administrator stated staff did not always enter interventions into the care plan, even though it should be used as a tracking tool.
Improper Preparation of Pureed Diet Item: A dietary staff member was observed preparing a pureed meat loaf using milk instead of following the facility recipe. The approved recipe called for standardized ingredients, and the staff member acknowledged the recipe should have been followed.
Infection control practices were not followed during resident care. A CNA transferred a resident on EBP without wearing a gown despite an EBP sign on the door, and an LPN used the same blood pressure cuff on two residents without sanitizing it between uses. The resident on EBP had severe cognitive impairment, was dependent on staff for care, and had a PEG tube.
Surveyors found that kitchen equipment and floors were soiled with grease, food buildup, and debris, including under sinks, tables, and around the hot water heater. Despite having cleaning schedules and policies, staff interviews confirmed that required cleaning tasks were not consistently performed, resulting in unsanitary conditions that did not meet professional food service standards.
The facility failed to provide adequate assistance with showering and bathing for four residents who required substantial assistance. Multiple residents expressed concerns about not receiving routine showers or complete bed baths. Clinical records revealed that residents received significantly fewer showers than scheduled, with no documented refusals in most cases. The DON confirmed the expectation for residents to receive at least two showers weekly, but a shower policy was not provided.
The facility failed to provide consistent restorative nursing therapy to residents with limited mobility, as evidenced by insufficient therapy sessions for four residents. A resident with Alzheimer's and polyosteoarthritis received only five days of therapy over 12 weeks, despite needing regular exercises. Another resident with diabetes and chronic kidney disease also received minimal therapy. A resident with hemiplegia had only one documented walking session in 30 days, and a resident with diabetes and vascular disease had no recorded restorative care minutes. The lack of a dedicated restorative aide contributed to these deficiencies.
The facility's Cottage kitchen failed to maintain proper dishwasher temperatures and chemical levels, with incomplete logs for June and July. A dietary aide was unsure of the required temperatures, and attempts to reach the necessary 120°F were unsuccessful. Additionally, refrigerator and freezer temperature logs were frequently incomplete, contrary to facility policy.
The facility failed to implement Enhanced Barrier Precautions for three residents requiring transmission-based precautions, as PPE carts lacked signage and clinical records were incomplete. Additionally, a fan in the laundry room was improperly positioned, blowing air from soiled to clean linen areas, contrary to infection control policies.
The facility failed to assess two residents for their capability to self-administer medications. One resident, who was severely cognitively impaired, had Desitin at their bedside without an assessment or care plan. Another resident, who was cognitively intact, had a pill at their bedside without an order or assessment for self-administration. The facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted.
The facility failed to maintain resident privacy during medication administration when an LPN left a medication cart unattended with resident information visible on the computer screen. This occurred on two separate occasions, involving two residents, while the LPN was away from the cart. The facility's policy on confidentiality was not followed, as staff were expected to hide and/or lock computer screens to protect resident privacy.
A resident with Alzheimer's and severe cognitive impairment was physically abused by a CNA during care, resulting in a laceration above the left eye. The resident became combative, and the CNA, who had a history of PTSD, reacted by striking the resident. The incident was witnessed by a QMA, who reported it to the nurse on call. The facility's abuse policy was reviewed, and the CNA expressed remorse, with the incident considered isolated.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in their care. One resident, with Alzheimer's and anxiety, lacked care plans for monitoring multiple medications. Another resident, also with Alzheimer's, had a care plan for managing behavior and communication needs, but staff failed to follow it during incontinence care, causing distress. The DON confirmed care plans should be updated with new issues.
A resident with anxiety, depression, and psychotic disorder was given the wrong nasal spray medication, leading to rebound congestion. The NP intended for the resident to receive saline nasal spray, but Oxymetazoline HCl was administered instead. The error was discovered after the resident experienced symptoms following the discontinuation of the medication. The facility's policy on medication orders was not adhered to, resulting in this significant medication error.
The facility failed to prevent and properly care for pressure ulcers in two residents. One resident had a sacral pressure ulcer that was not covered as ordered, with inconsistent wound assessments and care. Another resident with diabetes and peripheral vascular disease had an unstageable heel ulcer, but weekly assessments were not conducted. The facility did not adhere to its policies on pressure injury prevention and management, leading to deficiencies in care.
Three residents experienced multiple falls due to inadequate supervision and failure to update care plans. Despite being deemed unsafe for independent mobility, a resident continued to fall without new interventions. Another resident's fall interventions were not properly documented or implemented, and a third resident fell due to insufficient assistance during transfers.
A facility failed to manage oxygen equipment properly and adhere to physician orders for a resident with COPD and diabetes. The resident's oxygen tubing was not labeled correctly, and there was no oxygen warning sign on the door. The resident's care plan required weekly changes of oxygen supplies, which were not followed, as confirmed by an LPN. The facility's policy also required an oxygen warning sign, which was missing.
The facility failed to implement care plans for two residents with dementia, leading to inadequate monitoring of symptoms and behaviors. One resident, significantly cognitively impaired, lacked a dementia care plan despite being on multiple medications. Another resident with Alzheimer's exhibited exit-seeking and agitation, yet had no care plans addressing these behaviors, resulting in a fall. The facility's policies on dementia care and elopement were not followed.
A resident with severe cognitive impairment did not receive their prescribed Pravachol medication on three occasions due to it being on order, despite facility policies requiring timely reordering. The pharmacy confirmed the medication was not dispensed, and the DON was unsure how it was marked as given on certain days. Facility policies for medication reordering and documentation were not adhered to, leading to this deficiency.
A resident with Alzheimer's and Anxiety Disorder, receiving hospice care, was prescribed lorazepam PRN without an end date, contrary to the facility's policy requiring evaluation every 14 days. The DON confirmed the oversight in medication management.
The facility failed to administer medications according to professional standards, resulting in a 7.69% medication error rate. Two LPNs administered insulin using Humalog Kwikpens without priming them, as required. The DON confirmed the need for priming but was unsure of the procedure. The user manual and facility policy both indicated the necessity of priming to ensure correct insulin dosage.
The facility failed to obtain consent before administering influenza vaccines to two residents. One resident received the vaccine without a current signed consent, and another was vaccinated despite a prior refusal by the resident's wife. An LPN admitted to not seeking annual consent due to time constraints. The facility's policy required education and documentation for immunizations, which was not followed.
The facility failed to post accurate nurse staffing information daily, with discrepancies in the actual hours worked by staff. Observations showed fractional staffing numbers without specifying shift details, and interviews confirmed the inaccuracy. The Scheduler pre-filled weekend sheets and updated them later, contrary to the facility's policy.
Failure to Knock or Announce Before Entering Resident Rooms During Meal Delivery
Penalty
Summary
The facility failed to ensure resident privacy and dignity when staff entered resident rooms without knocking or announcing themselves during meal tray delivery. During supper meal service on 3/12/26, a surveyor observed multiple instances in which CNAs entered specific resident rooms while delivering trays without first knocking or identifying themselves: at 5:06 p.m. CNA 3 entered one room, at 5:07 p.m. CNA 2 entered another room, at 5:10 p.m. CNA 2 entered a third room, at 5:11 p.m. CNA 3 entered a fourth room, at 5:12 p.m. CNA 2 entered a fifth room, and at 5:13 p.m. CNA 3 entered a sixth room, all without knocking or announcing their presence. On 3/16/26 at 11:37 a.m., CNA 4 stated that staff are expected to knock, announce themselves, state their department, and ask permission before entering a resident’s room. On 3/16/26 at 11:44 a.m., the Assistant Administrator provided the facility’s current dignity policy, revised in 2025, which states it is the practice of the facility to protect and promote resident rights and to treat each resident with respect and dignity. This deficiency was cited under 410 IAC 16.2-3.1-3(a) and relates to Intake 2738912.
Improper Food Storage, Labeling, and Hand Hygiene in Dietary Areas
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions during 3 of 3 kitchen observations. In the Main Kitchen, surveyors observed a gallon jug of coleslaw in a reach-in refrigerator that was dated 7/2 with a best-by date of 6/5/25, along with multiple spices and dry goods on the prep table and in dry storage that had no open dates, no lids, or expired best-by dates, including white vinegar best by 11/3/22 and salsa best by 1/25/25. In the Cottage Kitchen, surveyors observed stuffing with no open date, garlic with a best-by date of 6/2022 and an open date of 3/25, pepper with no open date, and turkey bacon with no open date in the reach-in refrigerator. During the Main Kitchen observation, Dietary Aide 13 had hair at the base of the neck uncovered, Dietary Aide 7 had hair by the ears uncovered, and the Dietary Manager had bangs on the forehead uncovered. During a random dining observation in the Cottage Kitchen, Dietary [NAME] 9 wiped gravy off a resident’s plate with her finger, put the finger in her mouth, and then served the resident the plate without washing her hands. The Dietary Manager stated that items should be dated when opened and that hair nets should completely cover the hair, and also stated that no one should use bare fingers to wipe food drizzles from resident plates. The Administrator provided policies dated 3/26/25 for date marking food safety and dietary employee personal hygiene.
Lack of Care Plan for Recurrent UTIs
Penalty
Summary
Facility failed to develop a care plan related to recurrent urinary tract infections (UTIs) and the medication used to treat recurrent UTIs for Resident 3. Resident 3 was admitted with diagnoses including Alzheimer's disease, and the most recent Significant Change MDS assessment indicated the resident's cognition was too low to be assessed and that the resident was dependent on staff for eating, toileting, bathing, and transfers. The clinical record showed physician orders for D-Mannose oral capsule 500 mg once daily for UTI prevention, starting 8/9/25, and laboratory results showed positive urine cultures on 10/17/24, 7/24/25, and 8/7/25. A nursing progress note dated 8/20/25 documented that Resident 3 was admitted to the hospital for a UTI and encephalopathy. Review of the clinical record, including the care plan, progress notes, and assessments, found no plan of care related to the resident's recurrent UTIs, monitoring, or the medication used to treat recurrent UTIs. The Infection Preventionist Nurse stated the resident had frequent UTIs causing an ongoing decline in condition, and the Administrator provided the facility policy stating the care plan must include services to maintain the resident's highest practicable well-being and individualized interventions.
Care plans not revised after resident falls
Penalty
Summary
The facility failed to revise care plans after falls for 3 residents reviewed for falls. Resident 7 had diagnoses including dementia, was rarely or never understood on the most current Annual MDS assessment, was independent for transfers, required supervision for toileting, and had no falls since the prior assessment. A care plan conference noted to continue the current plan of care, and the resident had a current fall risk care plan identifying a history of falls with multiple risk factors. After a witnessed fall on 4/14/25, the clinical record lacked documentation that the IDT met to review the fall, and the care plan was not updated with a new intervention. The Administrator later stated the root cause was anxiety, that mental health provider visits were increased, and that this was not put into the plan of care. Resident 54 had diagnoses including Alzheimer's disease, was rarely or never understood on the most current Annual MDS assessment, was dependent on staff for transfers and toileting, and had no falls since the prior assessment. The resident had a fall risk care plan dated 7/8/22 noting a history of falls with multiple risk factors. After an unwitnessed fall in the resident's room on 1/27/25, the resident was unable to voice why the fall occurred, but the record lacked documentation that the IDT met to review the fall and the care plan was not updated with a new intervention. Resident 3, who had Alzheimer's disease and was dependent on staff for eating, toileting, bathing, and transfers, had a fall risk care plan revised on 6/2/25 that identified multiple fall risk factors. The clinical record showed falls on 1/28/25 and 7/3/25, but the plan of care lacked new interventions for either fall. The Administrator stated staff did not always put interventions in the plan of care, although they should because it could be used as a tracking tool to find previously tried interventions.
Improper Preparation of Pureed Diet Item
Penalty
Summary
The facility failed to ensure food was correctly prepared during an observation of puree altered diet preparation. On 8/19/25 at 12:07 P.M., Dietary [NAME] 9 was observed preparing one serving of pureed meat loaf and added one slice of meat loaf and an unknown amount of milk to the blender. The reviewed recipe for Meatloaf Pureed Thick specified ingredients for 20 servings as 5 pounds and 12 ounces of meatloaf, 2 and 5/8 teaspoon beef base, 2 3/4 cup hot water, and 1/3 cup and 2/3 teaspoon food thickener. During an interview on 8/19/25 at 12:10 P.M., Dietary [NAME] 9 stated she should follow the recipe instead of using milk. The Administrator later provided a current Puree Recipe policy dated 3/26/25 stating that all pureed items will be prepared using facility-approved, standardized recipes.
Infection Control Practices Not Followed During Resident Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during care for a resident on Enhanced Barrier Precautions. During a random observation of care for Resident 2, a CNA transferred the resident from bed to a Broda chair without wearing a gown, even though an EBP sign was posted on the resident’s door. Resident 2’s record showed diagnoses including Parkinson’s disease and unspecified protein-calorie malnutrition, and the most current Significant Change MDS indicated the resident was severely cognitively impaired, dependent on staff for eating, transferring, hygiene, and dressing, and had a PEG tube for nutrition. Current physician orders included Enhanced Barrier Precautions due to the PEG tube, and the care plan included EBP in high-contact activities. The facility also failed to clean shared blood pressure equipment between residents. During an observation, an LPN used a blood pressure cuff on Resident 63, went to the medication room to gather medications, and then used the same cuff on Resident 64 without sanitizing it. The Infection Preventionist stated that shared medical equipment should be cleaned after each use. The Administrator provided the facility policy for cleaning and disinfection of resident-care equipment, which stated that multi-resident use items are cleaned and disinfected between each use, and also provided the EBP policy stating that gloves should be used during high-contact activities with residents.
Unsanitary Kitchen Conditions and Inadequate Cleaning Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen during two separate inspections. Specifically, there was grease and food buildup on the stove burners, and debris was found on the floor under the two and three compartment sinks, under racks holding pots and pans, under stainless steel prep tables, in the dishwasher area, around the hot water heater, and under the stove and steam table. The hot water heater itself had visible dirt and dust on its top and pipes. Additionally, five food carts and the side of the steamer unit were noted to have debris on their surfaces. Interviews with dietary staff revealed that night staff are responsible for sweeping and mopping the floors, including under equipment, and that all staff follow a cleaning schedule. The Dietary Manager provided both the facility's food safety policy and the kitchen cleaning schedules, which included cleaning the areas and equipment that were found to be soiled. Despite these policies and schedules, the observed conditions did not meet professional standards for food service safety, as required by facility policy and regulatory guidelines.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically showering and bathing, for four residents who required substantial assistance. During a Resident Council meeting, multiple residents expressed concerns about not receiving routine showers or complete bed baths as scheduled. The clinical records of four residents were reviewed, revealing significant deficiencies in the provision of scheduled showers. Resident 28, diagnosed with Alzheimer's Disease and polyosteoarthritis, was scheduled to receive showers twice weekly but only received 3 out of 25 scheduled showers over a nearly three-month period, with no documented refusals. Similarly, Resident 37, who also has Alzheimer's Disease and anxiety, was scheduled for twice-weekly showers but only received 8 out of 25 scheduled showers, with one documented refusal. Resident 57, with dysphagia and muscle weakness, was completely dependent on staff for showers and received only 3 showers in seven weeks. Resident 6, diagnosed with diabetes and chronic kidney disease, was scheduled for twice-weekly showers but only received them consistently for 5 out of 12 weeks. The Director of Nursing confirmed that residents should receive at least two showers weekly or a complete bed bath if preferred, and that staff should document showers given or refused. However, a shower policy was requested but not provided.
Inadequate Restorative Nursing Therapy for Residents
Penalty
Summary
The facility failed to provide adequate restorative nursing therapy to residents with limited range of motion or mobility, as evidenced by the lack of consistent therapy sessions for four residents. Resident 28, diagnosed with Alzheimer's Disease and polyosteoarthritis, was supposed to receive bilateral lower and upper extremity exercises multiple times a week. However, documentation showed that the resident only received five days of therapy over a 12-week period. Similarly, Resident 6, with diagnoses including diabetes and chronic kidney disease, was also documented to have received only five days of therapy in the same timeframe, despite needing substantial assistance and having a care plan that included specific exercise routines. Resident 52, who had hemiplegia and hemiparesis following a cerebral infarction, was supposed to walk with staff assistance multiple times a week. However, the resident only participated in one documented session in the last 30 days, with another session refused and the rest not completed. The Director of Nursing acknowledged the lack of a dedicated Certified Nurse Aide for restorative nursing, indicating that the responsibility fell on whichever CNA was available. This lack of dedicated staff contributed to the inconsistency in providing the necessary restorative care. Resident 55, with diagnoses including Type 2 diabetes mellitus and peripheral vascular disease, was observed multiple times sitting in a wheelchair and had no recorded restorative care minutes during a seven-day look-back period. The resident's care plan included active range of motion exercises and walking with assistance, but the medical record lacked current physician orders for restorative care. Interviews with staff revealed that there was no restorative aide in the facility, and the existing policy on restorative nursing was not being followed, as indicated by the lack of documented restorative nursing activities.
Dishwasher and Temperature Log Deficiencies in Cottage Kitchen
Penalty
Summary
The facility failed to ensure proper dishwasher temperatures and chemical levels in one of its kitchens, known as the Cottage kitchen. During an initial kitchen tour, a dietary aide was unsure of the required dishwasher temperature and noted water on the floor, indicating potential malfunction. The temperature logs for June and July were incomplete, with numerous entries missing. Another dietary aide attempted to run the dishwasher to reach the required temperature of 120 degrees Fahrenheit but was unsuccessful, with the highest temperature recorded being 116 degrees Fahrenheit. The dishwasher's instruction manual indicated a recommended temperature of 140 degrees Fahrenheit and a minimum of 120 degrees Fahrenheit. Additionally, the chemical concentration was not logged, and a test strip showed 0 parts per million of hypochlorite, indicating a lack of proper sanitization. The report also highlighted issues with the temperature logs for the Cottage kitchen's refrigerators and freezers, which were frequently not filled out. The logs showed numerous missing entries for both the morning and evening shifts in June and July. The facility's policies required that temperatures be checked and logged at least twice per day, and that dishwasher temperatures and chemical concentrations be recorded at least once per shift. The dietary manager confirmed that the dishwasher was a low-temperature model and that staff had been instructed not to use it if the required temperatures and chemical levels were not met, but these instructions were not consistently followed.
Failure to Implement Enhanced Barrier Precautions and Prevent Cross-Contamination
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required transmission-based precautions. For Resident 57, a PPE cart was observed outside the room without any signage indicating specific PPE instructions or the need to consult a nurse before entering. The clinical record for Resident 57 lacked orders, care plans, and progress notes related to transmission-based precautions, despite the resident having a feeding tube. Similarly, Resident 60, who had an indwelling urinary catheter, did not have a PPE cart or signage outside the room. The clinical record also lacked necessary documentation for transmission-based precautions. Resident 17 had a PPE cart outside the room, but no signage was present. The facility used a bumblebee sticker on the nameplate to indicate precautions, but staff had to rely on reports or physician orders for specific instructions. Additionally, the facility failed to prevent cross-contamination in the laundry processing area. A fan was observed blowing air from the side of the room where soiled linen was stored to the side where clean linen was stored. The Environmental Services Manager acknowledged that the fan was supposed to remain on the clean side of the room. The facility's Enhanced Barrier Precautions Policy and Infection Prevention and Control Program required clear signage for precautions and proper handling of linens to prevent infection spread, but these protocols were not followed.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who were self-administering medications were assessed for their capability to do so. Resident 49 was observed with Desitin on their bedside table, despite being severely cognitively impaired and requiring substantial assistance with daily activities. The clinical record for Resident 49 lacked any assessment or care plan for self-administration of medication, and the QMA indicated that Desitin should not be kept at the bedside. This indicates a lack of adherence to the facility's policy regarding medication management and assessment for self-administration. Similarly, Resident 23 was observed with a medicine cup containing a pill on their bedside table. Although Resident 23 was cognitively intact, the clinical record did not include an order, care plan, or assessment for self-administration of medications. The Administrative Support confirmed that medications should not be left at the bedside and that Resident 23 did not have a self-administration assessment. The facility's policy requires an interdisciplinary team assessment to be recorded in the resident's medical record, which was not done in these cases.
Resident Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to ensure resident privacy during medication administration for two observed instances. On the first occasion, a Licensed Practical Nurse (LPN) left a medication cart unattended with a computer screen displaying Resident 13's personal information, including their picture, name, date of birth, and medication list. This occurred while the LPN walked away from the cart and entered a resident's room, during which time another resident walked by the cart. On the second occasion, the same LPN left the medication cart unattended between the nurses' station and elevator, with Resident 16's information visible on the computer screen. During this time, the LPN was in the Dining Room with a resident, and a Certified Nurse Aide (CNA) was observed pushing a resident past the cart. The facility's policy on confidentiality was not adhered to, as staff were expected to hide and/or lock computer screens to protect resident privacy.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nurse Aide (CNA). The incident involved a resident with Alzheimer's Disease and severe cognitive impairment, who was dependent on staff for daily care activities. During a care routine, the resident became combative, and the CNA, who had a history of post-traumatic stress from childhood abuse, reacted by striking the resident, resulting in a laceration above the left eye. The incident was witnessed by a Qualified Medicine Aide (QMA) who heard the resident yelling and intervened. The resident's care plan included specific interventions to manage behavioral disturbances, such as allowing time for the resident to respond and approaching them slowly. However, these interventions were not effectively implemented during the incident. The CNA reported that the resident was kicking and scratching during the care process, and despite attempts to calm the resident, the situation escalated. The CNA admitted to striking the resident once in response to the resident's aggressive behavior. Following the incident, the QMA reported the event to the nurse on call, who then informed the Director of Nursing (DON), Administrator, and the resident's family. The facility's policy on abuse, neglect, and exploitation was reviewed, which mandates the protection of residents from abuse and outlines procedures for identifying and reporting such incidents. Despite the CNA's popularity among staff and residents, the incident was considered an isolated event, and the CNA expressed remorse for their actions.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. Resident 37, who has Alzheimer's Disease and anxiety, was receiving multiple medications, including antianxiety, antidepressant, diuretic, and antiplatelet drugs. However, the clinical record lacked care plans related to the monitoring of these medications, which is essential given the resident's severe cognitive impairment and need for substantial assistance with daily activities. Resident 49, also diagnosed with Alzheimer's Disease, required significant assistance with daily activities and had specific care plan interventions to manage their behavior and communication needs. Despite these interventions, a CNA failed to implement the care plan during incontinence care, resulting in the resident resisting care and expressing distress. The staff did not follow the care plan's guidance to stop and reapproach the resident later, which was confirmed by a QMA and the DON, who acknowledged that care plans should be updated with new orders or issues.
Medication Error Due to Incorrect Nasal Spray Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of the wrong medication. A resident, who had diagnoses including anxiety, depression, and psychotic disorder, was mistakenly given Oxymetazoline HCl nasal spray for allergies, which was not ordered by the Nurse Practitioner (NP). The NP had intended for the resident to receive saline nasal spray for nasal congestion. The error was discovered when the resident experienced rebound congestion after the Oxymetazoline HCl nasal spray was discontinued. The resident's clinical records indicated that the nasal spray was administered from 6/3/24 to 7/1/24, despite the NP's order for saline nasal spray. The Director of Nursing (DON) and the NP were unable to determine how the incorrect order was entered into the system. The facility's Medication Orders policy requires specific details when recording medication orders, but it appears this protocol was not followed, leading to the administration of the incorrect medication.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper prevention and care of pressure ulcers for two residents, leading to deficiencies in their treatment. Resident 54 was observed with a pressure ulcer on the sacrum that was not covered with a dressing as required by physician orders. The wound was slightly open, revealing subcutaneous tissue, and surrounded by dark pink skin, indicating a deeper wound. Despite the presence of granulation tissue, the Licensed Practical Nurse (LPN) did not address the missing dressing. The resident's clinical records showed a history of Alzheimer's disease, anxiety, and a Stage 3 pressure ulcer, with orders for specific wound care that were not consistently followed. Weekly wound assessments were not completed as scheduled, and there were gaps in skin assessments, contributing to the deterioration of the pressure ulcer. Resident 55, diagnosed with Type 2 diabetes mellitus, diabetic neuropathy, and peripheral vascular disease, had an unstageable pressure ulcer on the left heel. The resident's care plan included the use of heel lift boots and Betadine swabs for wound care, but the facility failed to conduct regular weekly skin and wound assessments as required. The Administrative Support Person confirmed that the wound assessments were not being performed, indicating a lapse in the facility's adherence to its own policies on pressure injury prevention and management. The facility's policies on pressure injury prevention and management, as well as wound dressing, were not followed, leading to inadequate care for the residents' pressure ulcers. The lack of consistent wound assessments and failure to adhere to physician orders for wound care contributed to the worsening of the residents' conditions. The facility's failure to implement its surveillance system for pressure injuries further exacerbated the issue, resulting in deficiencies in the care provided to the residents.
Inadequate Supervision and Care Plan Updates Lead to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for three residents reviewed for falls. Resident 52 experienced multiple falls, with interventions not consistently updated following each incident. Despite being deemed unsafe to be up independently by therapy, Resident 52 continued to attempt self-toileting and other activities without assistance, leading to several unwitnessed falls. The care plan was not updated with new interventions after some of these falls, indicating a lack of proactive measures to address the resident's fall risk. Resident 28, who is severely cognitively impaired and requires substantial assistance, also experienced multiple falls. The interventions put in place following these falls were not always effective or properly documented. For instance, staff education was listed as an intervention for several falls, but the Director of Nursing later admitted that this education did not exist. This lack of follow-through on planned interventions contributed to the resident's continued fall risk. Resident 11, with a history of falls and mild cognitive impairment, also experienced falls due to inadequate supervision and assistance. The resident's care plan indicated a need for two-person assistance for transfers, but falls occurred when this protocol was not followed. The facility's failure to consistently update care plans and implement effective interventions after falls highlights a systemic issue in managing fall risks for residents.
Failure to Properly Manage Oxygen Equipment and Adhere to Physician Orders
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically in the management of oxygen equipment and adherence to physician orders. During an observation, Resident 24 was found using an oxygen concentrator with tubing that was not labeled with the correct date, as it displayed a future date of 6/30/24. Additionally, there was no oxygen warning sign on the resident's door, which is a requirement according to the facility's policy. The resident, who has a history of COPD and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, was noted to be mildly cognitively impaired and required partial assistance with daily activities. The resident's clinical records indicated a physician's order to change oxygen tubing and supplies weekly, specifically on the night shift every Sunday, which was not followed. The care plan also highlighted the need for regular changes of oxygen tubing, water, and filter. An interview with an LPN confirmed that the oxygen tubing should be changed weekly and properly labeled. The facility's policy, provided by the Administrative Support Person, reiterated the need for oxygen to be administered under physician orders and for the placement of an oxygen warning sign on the resident's door, which was not adhered to in this case.
Failure to Implement Care Plans for Dementia and Behavioral Monitoring
Penalty
Summary
The facility failed to ensure proper interventions were in place for monitoring symptoms, side effects, and behaviors of medications for two residents diagnosed with dementia. Resident 46, who was significantly cognitively impaired and dependent on staff for daily activities, was prescribed multiple medications for mood disturbance and anxiety. However, there was no care plan designated for dementia care, despite the facility's policy requiring individualized care plans for residents with dementia. The Licensed Social Worker acknowledged the absence of a care plan related to dementia for Resident 46. Resident 37, diagnosed with Alzheimer's Disease and anxiety, exhibited behaviors such as exit-seeking and agitation, which were documented in progress notes. Despite these behaviors, the clinical record lacked care plans addressing anxiety or exit-seeking behaviors. An elopement evaluation indicated that Resident 37 had not expressed a desire to go home or wandered, yet the resident had a witnessed fall while attempting to exit. The facility's policy on elopement and wandering required a systematic approach to monitoring and managing residents at risk, which was not reflected in Resident 37's care plan.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for a resident with hyperlipidemia. The resident, who had severe cognitive impairment and required assistance with eating, was prescribed Pravachol to manage high cholesterol. However, the medication was not administered on three occasions because it was on order, despite being dispensed on two other days. The pharmacy confirmed that the medication had been reordered but not yet dispensed, and the Director of Nursing was uncertain how the medication was marked as given on the days it was unavailable. The facility's policies required medications to be reordered when a four-day supply remained, but the medication was not reordered in a timely manner, leading to the missed doses. The Licensed Practical Nurse indicated that medications should be reordered seven days before they run out, but this protocol was not followed. The facility's documentation policy emphasized the need for complete and accurate records, yet there was a discrepancy in the medication administration record, suggesting errors in documentation.
Failure to Evaluate PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications, specifically regarding the use of a PRN anti-anxiety medication. A resident, who was receiving hospice services and had a diagnosis of Alzheimer's Disease with late onset and Anxiety Disorder, was prescribed lorazepam 0.5 MG to be taken orally every 4 hours as needed for anxiety and agitation. This order, dated 6/28/24, did not include an end date and was not evaluated every 14 days as required by the facility's Use of Psychotropic Medication Policy. The Director of Nursing acknowledged that PRN antianxiety medications should have been evaluated every 14 days and that an end date should have been set when the order was initiated.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards, resulting in a medication administration error rate of 7.69%. This deficiency was observed in two instances involving insulin administration. In the first instance, an LPN prepared a Humalog Kwikpen for insulin administration for a resident with a blood glucose reading of 313. The LPN administered 3 units of insulin Lispro without priming the insulin pen, which is a necessary step to ensure the pen is working correctly and to avoid administering an incorrect dose. In the second instance, another LPN prepared a Humalog Kwikpen for a different resident who was to receive 5 units of insulin Lispro with her lunch meal. Similarly, the LPN administered the insulin without priming the pen. The Director of Nursing later confirmed that insulin pens should be primed before administration but was unsure of the exact procedure. The Humalog Kwikpen user manual and the facility's insulin pen policy both indicated the need to prime the pen by selecting 2 units and ensuring insulin appears at the needle tip before administration.
Failure to Obtain Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to obtain consent before administering influenza vaccines to two residents. Resident 37 received the influenza vaccine without a signed consent on record for the vaccination administered. The only consent form available was dated over two years prior. Similarly, Resident 36 was given the influenza vaccine without a signed consent, despite the resident's wife having declined all vaccines upon admission. An LPN admitted to not seeking annual consent due to the time it took to contact families each year. The facility's Infection Prevention and Control Program required education and documentation regarding immunizations, but this was not adhered to in these cases.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information for licensed and unlicensed nursing staff responsible for resident care per shift on a daily basis during the annual survey period. Observations revealed discrepancies in the posted nurse staffing data sheets, which did not reflect the actual hours worked by the staff. For instance, on 7/21/24 and 7/22/24, the sheets indicated fractional staffing numbers, such as 0.5 RNs and 2.5 LPNs, without specifying which part of the shift these staff members worked. This lack of specificity made it difficult to determine the actual staffing levels during each shift. Interviews with facility staff, including the MDS Coordinator and the Scheduler, confirmed that the posted staffing sheets did not accurately represent the actual hours worked. The Scheduler admitted to pre-filling the staffing sheets for the weekend and updating them with correct information only upon returning to work on Monday. The facility's policy required the Nurse Staffing Sheet to be posted at the beginning of each shift with accurate information, but this was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 307 citations issued within 25 miles in the last 12 months — including the 2 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 Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Center | 1.4 mi | ★★★★★ | 0 | 0 |
| North Park Nursing Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Parkview Care Center | 2.3 mi | ★★★★★ | 25 | 0 |
| Envive Of River City | 3.4 mi | ★★★★★ | 25 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 3.5 mi | ★★★★★ | 0 | 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.