Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Castleton Health Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not have their physician-ordered medications consistently administered or documented on the MAR, and no explanations were recorded in the clinical record for the missed doses. A resident with ankylosing spondylitis missed a scheduled Humira injection despite the drug having been delivered and available. Another resident with necrotizing fasciitis and anxiety had a Buspar dose left undocumented, while a resident with diabetes and chronic pain had undocumented gabapentin doses and missing blood glucose and HumaLOG sliding-scale entries. A further resident with multiple chronic conditions had several psychotropic, anticoagulant, pain, and GI medications left blank on the MAR at scheduled times, with no corresponding notes. Although the facility had policies on medication error reporting and handling unavailable medications, surveyors did not receive requested policies on medication administration documentation.
The deficiency involves missing and improperly handled narcotic pain medications affecting three residents. A cognitively intact resident with chronic pain had 40 tablets of oxycodone/APAP 10/325 mg delivered per pharmacy records, but none were signed out on the controlled drug record and the tablets were missing from the locked cart, with conflicting staff statements about who removed them. A cognitively impaired resident with paraplegia and other conditions had PRN oxycodone/APAP 5/325 mg ordered, yet an LPN documented removing two tablets under one prescription number and two more under a second prescription number at the same time, despite being aware the order had been changed. Another resident with dementia and epilepsy had hydrocodone/APAP 5/325 mg ordered as one tablet QID, but the same LPN signed out two tablets at once, and the physician confirmed there was no one-time order for an extra dose. These events show failures to safeguard residents’ medications and to accurately document controlled substance administration.
The facility failed to timely and completely report two allegations of misappropriation of narcotic pain medications. In one case, a QMA discovered that a resident’s oxycodone 10 mg/325 mg supply was short when the pharmacy reported it was too early for a refill and that 40 tablets should still be on hand; the QMA reported that the DON had removed the medication from the cart earlier in the shift. In another case, a controlled drug reconciliation at shift start revealed a discrepancy that was reported to the ADON and Administrator. For both incidents, the reportable incident forms omitted the names of the resident and staff involved, and the Administrator later acknowledged that required information and time frames for reporting to the state health department were not met, despite a facility policy requiring prompt and thorough reporting and investigation of abuse allegations.
A resident with multiple diagnoses, including traumatic brain injury, acute respiratory failure, cannabis dependence, and alcohol dependence, was discharged with medications and belongings but without a comprehensive person-centered discharge care plan in the clinical record. An LPN acknowledged that a discharge care plan should have been in place and provided to the resident at discharge. Review of the facility’s current “Transfer and Discharge” policy showed it requires a comprehensive person-centered discharge care plan for residents, yet no such plan was documented for this resident, resulting in a cited deficiency.
The facility did not ensure complete reconciliation and documentation of controlled medications upon delivery for three residents. For one resident receiving oxycodone/acetaminophen 10/325 mg, both the pharmacy delivery slip and the controlled drug record were missing required entries such as who received the medication, the delivery date/time, starting balance, and check-in information. For another resident with paraplegia, diabetes, and anxiety, narcotic administration records for oxycodone/acetaminophen 5/325 mg lacked documentation of who checked in the medications, the date, and the starting balance. For a third resident with dementia, epilepsy, and cognitive communication deficit, the controlled drug record for hydrocodone/acetaminophen 5/325 mg was missing the "checked in by" and date fields. An LPN confirmed that nurses should fully complete these records in accordance with facility policy requiring verification of deliveries and signing with name, date, and time.
Residents experienced disrespectful treatment, delayed responses to call lights, and lack of privacy due to staff actions such as turning off call lights without providing care, speaking rudely, using earbuds or phones during care, and discussing personal care needs loudly in hallways. Some residents waited up to two hours for assistance, and one was left exposed without a privacy curtain. These issues were more frequent during evening, night, and weekend shifts, and persisted despite being reported to management.
Two residents did not receive timely assistance with ADLs, including shaving and toileting. One resident with hemiplegia was not shaved as required by his care plan, and another resident with cerebral palsy waited an extended period for toileting care despite using his call light and being able to communicate his needs. Staff were unaware of the care needed, and records did not document required hygiene tasks.
Incomplete skin assessment and heel wound documentation A resident with multiple comorbidities and documented heel redness on admission was identified as at risk for pressure ulcers, but the record did not show thorough skin assessments or clear follow-up of the heel finding. Staff documentation was inconsistent, with wound orders repeatedly referencing the wrong heel, no documented left heel concerns, and no clear preventive measures recorded. The resident later developed a stage 3 pressure ulcer to the right heel with necrotic tissue and cellulitis, and reported that he had complained of heel pain for days before the wound was identified.
Multiple residents reported that staff were rude, dismissive, and rough during care, often using cell phones while providing assistance, ignoring call lights for extended periods, and speaking in a demeaning manner. Some residents were left in soiled briefs, denied food or beverage requests, and felt treated like children, contrary to facility policies requiring respectful and dignified care.
The facility failed to follow ordered medication regimens for several residents. A resident with diabetes and anxiety had insulin given without documented blood sugar checks and PRN hydroxyzine use was not documented or evaluated for effectiveness. Another resident received the wrong narcotic pain med, a third resident missed ordered bupropion doses when the pharmacy could not supply the prescribed tablet strength, and a resident with eye conditions had concerns about whether ordered ophthalmic drops were being administered as scheduled.
Expired vacutainers, expired liquid meds, and an opened TB testing vial without an open date were found in a medication storage room. During med pass, an RN left the med cart unlocked and unattended near residents, and while preparing meds for a resident, handled a taped bubble-pack pill and left a medication cup unattended on the cart.
Infection control surveillance and tracking were not documented for several months, with the IP/ADON stating she only began tracking infections in April and no earlier logs could be located. A resident with a PICC was observed missing the needless connector after a blood draw, and a hallway clean linen cart was found open and mixed with personal care items such as a wash basin, urinal, tissues, gloves, and scattered briefs.
A resident with significant mobility and cognitive impairments was repeatedly found unable to reach her call light, which was tied to the bed rail and hanging near the floor. Despite staff being present in the room and delivering meals, the call light was not placed within her reach, forcing her to use a stick to attract attention. This failure to ensure the call device was accessible was contrary to the facility's policy and the resident's care plan.
Two residents did not receive timely assistance with nail care and facial hair grooming, despite care plans and facility policies requiring these services as part of ADLs. One resident had long, dirty nails that were not trimmed on multiple documented occasions, while another resident with a self-care deficit was left with unkempt facial hair for weeks despite repeated requests for shaving.
Two residents with chronic pain did not receive timely or properly documented pain management, including missing care plans, delayed administration of PRN pain medications, and lack of required documentation such as pain assessments, vital signs, and non-pharmacological interventions, as required by physician orders and facility policy.
Staff failed to stay at bedside while giving a resident crushed Percocet in applesauce. The resident was cognitively intact, had a hx of pocketing meds, and had orders to have staff observe swallowing. During observation, an RN handed the medication to the resident and left the room immediately, and the resident then spooned the medication into his mouth. The record did not include a self-medication assessment or care plan showing he could safely self-administer meds without staff present.
Resident Preferences Not Honored: The facility failed to honor the care preferences of two cognitively intact residents. One resident reported staff did not know her bathing, transfer, and linen-handling preferences, and her record lacked a completed activities/preference assessment. Another resident’s care plan did not reflect her bathing and sleep/wake preferences, and she reported receiving fewer showers than desired and being unable to follow her preferred get-up and bedtime schedule because staff would not accommodate it.
A cognitively intact resident with anxiety was unable to receive $50 from the Business Office when requested because the ED who signed resident trust fund checks had abruptly left and the new ED had not yet been approved as signer. The BOM confirmed there was a one- to two-week period when residents could not access their personal funds, despite policy stating petty cash must be available during regular office hours.
Homelike Environment Not Maintained: Two residents were affected by environmental issues in their rooms. One resident’s closet doors had brown splatter that remained present across multiple observations, and an ADON acknowledged it. Another resident reported his TV had no sound for several weeks; staff observed the TV could turn on but the volume would not work, and a Corporate Nurse was unable to restore the sound. The resident was cognitively intact, had lower-extremity impairment, and valued keeping up with the news.
The facility failed to complete a Significant Change of Status MDS for a resident after dialysis was discontinued. The resident had diabetes, anxiety disorder, CKD, and acute and chronic respiratory failure. Staff interviews confirmed dialysis had stopped, the resident was no longer receiving HD, and the MDS Coordinator stated a significant change assessment should have been completed after the change.
Failure to hold timely care plan meetings for a resident with CKD and HF. The resident had multiple MDS assessments completed, but the EHR contained no care plan meeting notes in the Miscellaneous or Assessments section. The resident said she was not having care plan meetings and was unsure what they were, and the ED said the facility only had verification for two meetings since admission, with the last one held in January.
Failure to provide ordered catheter care and record urine output every shift for two residents with indwelling catheters. One resident with acute kidney failure and sepsis reported staff only emptied the Foley bag and did not clean or assess the site daily. Another resident with urinary retention and obstructive/reflux uropathy had multiple shifts with no urine output documented; the resident reported staff only emptied the bag, did not routinely cleanse the catheter site, and staff were observed emptying the bag without providing cleansing.
Failure to provide ordered oxygen therapy and missing physician order for oxygen: One resident with respiratory failure and other chronic conditions had an order for oxygen via NC each shift, but was observed without oxygen and the TAR showed missed administrations. Another resident on hospice was observed receiving oxygen via NC with a concentrator running, but the chart had no physician order for oxygen. The RN consultant stated the oxygen had been placed by hospice staff and that an order would be obtained.
A resident with ESRD, CHF, epilepsy, and diabetes had orders for HD on a set schedule, with required pre/post assessments and dialysis communication documentation. The record showed missing or inconsistent VS on dialysis forms, several dates with no dialysis communication forms, and progress notes that did not document multiple dialysis refusals or confirm dialysis appointments, despite the resident’s ongoing refusal of HD and other care.
Failure to obtain consent and arrange timely dental and vision services for two residents. One cognitively intact resident requested an eye doctor and dentist but had no documented ancillary consent and had not yet been seen by either provider. Another cognitively intact resident with DM2 reported needing dental cleaning, but his chart had no dental consent, orders, or consult notes, and the dental provider had no record of him on its caseload.
Incomplete Narcotic Count Documentation: The facility failed to maintain complete narcotic log documentation for controlled medications on multiple med carts. During observation and record review, two carts had repeated instances where staff did not sign in or sign out to show whether narcotic cards were added, removed, or the total count in the narcotic box. A Medication - Administration policy was provided as the practice standard for safe med administration.
Physician Responses Lacked Rationale on Medication Regimen Reviews: A resident with diabetes, anxiety, CKD, and acute/chronic respiratory failure had multiple meds reviewed by pharmacy, including trazodone for insomnia, apixaban, hydrocodone-acetaminophen, atorvastatin, dicyclomine, and pantoprazole. The pharmacist made several recommendations for dose reduction, discontinuation, or tapering, but the physician marked disagreement without providing any clinical rationale, and part of the review form was left incomplete.
A resident with insomnia received melatonin in an excessive dose because duplicate orders remained active. The MAR showed the resident was given 3 mg at 8:00 p.m. and 3 mg at 9:00 p.m. daily, while psychiatry notes directed only 3 mg every evening. A pharmacy note identified the duplicate orders and an NP stated the facility did not discontinue one of them.
A resident with seizures had orders for Dilantin at 8:00 p.m. and Jevity tube feeding with instructions to hold the feeding 2 hours before and 2 hours after the medication. The MAR showed the feeding continued on the same days the Dilantin was given, with no documentation that the tube feeding was stopped as ordered, and the ED said she did not know why staff failed to hold it.
Inaccurate medication and treatment documentation was found for two residents. One resident with kidney disease had bupropion orders and MAR entries that did not match what staff said was actually administered, and another resident with diabetes, CKD, and respiratory failure had MAR documentation showing ongoing hemodialysis even though the ADON said dialysis had been discontinued and the resident said she no longer received it.
Failure to Administer Consented Flu and Pneumonia Vaccinations: The facility did not ensure that immunizations were offered and administered after consent was obtained for three residents. One resident with asthma had orders allowing both pneumonia and influenza vaccines, and two other residents had orders allowing annual flu or pneumonia vaccination, but the EHR showed only historical or prior-year immunizations despite signed consent forms. The ADON stated consent is obtained annually and the facility administers the immunizations residents consented to.
Surveyors observed dirty floors with unknown black substance spills in a unit, and all residents reviewed reported environmental concerns. Multiple interviews and Resident Council minutes documented ongoing housekeeping issues, especially on weekends, with unclear cleaning responsibilities between CNAs and housekeeping staff. The facility's policy requires a clean environment, but this standard was not met.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with moderate cognitive impairment had $80 reported missing after being given to a previous BOM for safekeeping. The current BOM was unaware of the funds' location, and the incident was not documented in grievance records. The allegation was raised in a meeting with the BOM, Ombudsman, and Social Services Director, but was not reported to the state agency within the required timeframe, as the ED was on vacation and unaware of the situation. This failure to promptly report the suspected misappropriation of resident property resulted in a deficiency.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain the services of a licensed pharmacist, as required.
The facility did not complete timely post-fall assessments for a resident with cognitive impairment and heart failure, failed to document or follow physician orders for wound care and insulin administration for two residents with diabetes, and did not consistently record blood sugar readings or notify physicians when insulin was withheld, as required by policy.
A resident with cognitive impairment and multiple diagnoses exhibited confusion and restlessness, prompting a STAT order for CBC and CMP from the on-call provider. Despite the order, the laboratory tests were never drawn, and no results were present in the clinical record, indicating a failure to provide timely laboratory services as required by facility policy.
A resident with dementia and a history of repeated falls experienced an unwitnessed fall from a wheelchair, which was documented in a risk management incident report but not in the clinical record. Required notifications to the physician and responsible party were also not documented in the medical record, contrary to facility policy. The DON confirmed that best practice was not followed in this instance.
A resident with multiple medical conditions was prescribed oxycodone-acetaminophen for pain, and a shipment of 60 tablets was delivered by pharmacy. The medication was received by an RN and handed to another RN to be placed in the medication cart, but there was no documentation or record of it being added. Subsequent counts and searches revealed the medication and its record sheet were missing, and video footage confirmed the handoff but not the final disposition. The resident did not miss any doses, but the facility failed to follow required procedures for handling and securing controlled substances.
The facility's kitchen was found to have several deficiencies, including cracked flooring, improper dishwasher temperatures, and unlabeled food items. Personal drinks were also stored inappropriately. The dietary aide did not monitor dishwasher temperatures, and the Registered Dietitian confirmed issues with labeling and storage practices.
The facility did not effectively implement an antibiotic stewardship program, failing to track and monitor antibiotic usage among residents. The DON provided a binder missing monthly tracking data from January to May 2024, and subsequent months lacked details on infection types and resident locations. A change in corporate ownership in March 2024 led to documentation gaps, and the DON's tracking from June 2024 was incomplete.
A resident with type 1 diabetes mellitus did not receive properly administered insulin due to an LPN's failure to prime the insulin flex pen before injection. The LPN admitted to forgetting this crucial step, which is necessary to ensure the pen functions correctly and delivers the accurate dosage. Manufacturer instructions emphasize the importance of priming to avoid incorrect insulin delivery.
A resident with dementia, stroke, and major depressive disorder was admitted to a facility without a timely individualized behavior plan. Despite physician orders to monitor behaviors, the facility failed to document and address the resident's behavioral needs, including verbal aggression and mood swings. Delays in psychiatric evaluation and inconsistent documentation contributed to the deficiency.
A facility failed to monitor a resident's blood pressure before administering midodrine, a medication for low blood pressure, despite a physician's order to withhold the drug if systolic blood pressure was above 110. The medication was given without recording necessary blood pressure readings, as confirmed by the Regional Nurse Consultant, contrary to the facility's medication administration policy.
A facility failed to implement enhanced barrier precautions during a wound dressing change for a resident with a diabetic ulcer. The DON and an LPN did not use gowns, which are part of the required PPE, during the procedure. A misunderstanding about the duration of enhanced barrier precautions contributed to this deficiency.
Failure to Administer and Document Physician-Ordered Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents routinely received their physician-ordered medications and that medication administration was accurately documented in the clinical record. For one resident with ankylosing spondylitis treated with Humira 40 mg subcutaneously every 14 days, the MAR for March 2026 showed the dose due on 3-24-26 was blank, with no documentation in the MAR or progress notes explaining why it was not administered. A friend of this resident reported the resident had missed at least two Humira doses, and although she notified the DON and one dose was later given a few days late, the facility’s review confirmed the 3-24-26 dose had been delivered by the pharmacy on 3-13-26 and was available but not administered as ordered. Another resident with necrotizing fasciitis and anxiety had a February 2026 MAR entry for Buspar 5 mg three times daily by mouth that was left blank for the 1:00 p.m. dose on 2-2-26, with no corresponding documentation in the MAR or progress notes to explain the omission. A third resident with type 2 diabetes and chronic pain had multiple undocumented medications on the April 2026 MAR. Gabapentin 600 mg three times daily for neuropathy was not documented as administered on 4-1-26 and 4-4-26 at 10:00 p.m., and the MAR also lacked documentation that blood glucose levels were obtained and that HumaLOG insulin was administered per sliding scale on 4-16-26 and 4-18-26 at 8:00 a.m. and 12:00 p.m., and on 4-19-26 at 8:00 a.m. A fourth resident with unspecified psychoses, anxiety, depression, type 2 diabetes, polyosteoarthritis, and polyneuropathy had multiple physician-ordered medications on the April 2026 MAR that were not documented as administered, with the administration blocks left blank and no explanatory notes in the MAR or progress notes. These undocumented medications included Buspar 15 mg three times daily for anxiety (missing at 5:00 p.m.), Eliquis 2.5 mg twice daily for anticoagulation (missing at 6:00 p.m.), Lyrica 75 mg twice daily for pain (missing at 6:00 p.m.), Ropinirole 1 mg twice daily for restless leg syndrome (missing at 6:00 p.m.), Quetiapine Fumarate 50 mg at bedtime for depression (missing at 9:00 p.m.), and Famotidine 10 mg at bedtime for stomach discomfort (missing at 9:00 p.m.). The facility had policies on medication error reporting and on actions to take when medications are not available in the cart, but surveyors noted that requested policies and procedures for medication and treatment administration documentation were not provided by the time of survey exit.
Misappropriation and Improper Handling of Controlled Pain Medications
Penalty
Summary
The deficiency involves failure to protect residents from misappropriation of controlled pain medications and improper handling and documentation of narcotics. Resident B, who had diagnoses including ankylosing spondylitis and muscle weakness and was documented as cognitively intact, reported that staff told him his pain medication was missing. His physician’s order authorized oxycodone/acetaminophen 10/325 mg, one tablet orally every six hours for pain. Pharmacy records showed that 40 tablets of this medication were delivered for him, and the controlled drug record reflected a starting balance of 40 tablets with no doses signed out as administered. A facility investigation included conflicting staff statements: one QMA stated the DON removed Resident B’s oxycodone/acetaminophen from the locked cart, while the DON stated she removed several medications from carts but none for Resident B and did not know what happened to his medication. The pharmacy indicated Resident B should have had 40 tablets available in the locked cart, but they were missing. The deficiency also includes improper documentation and handling of controlled substances for Resident C. Resident C had diagnoses including paraplegia, diabetes, and anxiety and was documented as cognitively impaired. A physician’s order authorized oxycodone/acetaminophen 5/325 mg, two tablets every eight hours as needed for pain. On a narcotic administration record, an LPN initialed that she removed two oxycodone/acetaminophen 5/325 mg tablets for Resident C under one prescription number at a specific time, and also documented removal of two additional oxycodone/acetaminophen 5/325 mg tablets for Resident C under a different prescription number at the same time. A handwritten statement indicated the LPN had been made aware that Resident C’s physician’s order for oxycodone/acetaminophen 5/325 mg had been changed, yet the records still showed these removals and administrations. For Resident D, who had diagnoses including dementia, epilepsy, and cognitive communication deficit, a physician’s order authorized hydrocodone/acetaminophen 5/325 mg, one tablet orally four times daily for pain. The controlled drug record showed that the same LPN signed out two hydrocodone/acetaminophen 5/325 mg tablets for Resident D at a specific time, exceeding the ordered single-tablet dose. An undated written statement from the attending physician confirmed that no one-time order had been given to administer an extra tablet of hydrocodone/acetaminophen 5/325 mg on that date. The facility’s abuse prevention policy stated that each resident has the right to be free from misappropriation, yet the documented missing narcotics and unexplained extra doses for multiple residents demonstrate failures in protecting residents’ property and in accurate narcotic documentation and handling.
Failure to Timely and Completely Report Alleged Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to timely and completely report two separate allegations of misappropriation of residents' narcotic pain medications. In the first incident, a facility reportable incident form dated 1/23/26 at 1:15 p.m. was provided, but the sections for the resident involved and the staff involved were left blank. Eight days after the initial allegation was reported to the Administrator, the brief description was completed, documenting that on 1/23/26 at 1:25 p.m. a QMA reported calling the pharmacy for a refill of a resident's oxycodone 10 mg/325 mg, and the pharmacy indicated it was too early to refill and that the resident should have had 40 tablets at the facility. The QMA reported that the DON had removed the medication from the medication cart earlier in the shift. The type of injury was documented as not applicable, and the immediate action taken section indicated the DON was suspended pending investigation. The follow-up section, dated 2/5/26, stated the facility was unable to substantiate the allegation of misappropriation. In the second incident, a facility reportable incident form dated 2/17/26 at 10:45 p.m. was also missing the names of the resident involved and the staff involved. The brief description, dated 2/18/26, indicated that during routine controlled drug reconciliation at the beginning of a shift, a discrepancy was identified and immediately reported to the ADON and the Administrator. The follow-up section, dated 3/5/26, indicated that the investigation had been completed and referenced personnel action, a complete audit of the medication cart, staff education, and ongoing audits. During an interview, the Administrator acknowledged that the staff and residents' names should have been included in each initial report, that misappropriation incidents should have been reported to the state health department within 24 hours, and that follow-ups should have been reported within five days of the incident. The facility’s Abuse Prevention and Prohibition Program policy stated that the facility promptly and thoroughly reports and investigates allegations of abuse.
Failure to Provide Person-Centered Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered discharge care plan for one resident. Resident F, whose diagnoses included traumatic brain injury, acute respiratory failure, cannabis dependence, and alcohol dependence, was reviewed on 3/4/26, and the clinical record showed a progress note dated 2/10/26 documenting that the resident was discharged with medications and belongings. However, the clinical record lacked any person-centered discharge care plan, and there was no evidence that such a plan had been created or provided to the resident at discharge. During an interview, an LPN confirmed that the resident should have had a person-centered discharge care plan in place and that a copy should have been given to the resident upon discharge. The Administrator provided the facility’s current “Transfer and Discharge” policy, dated 6/2020, which stated that residents will have a comprehensive person-centered discharge care plan. The absence of such a plan in Resident F’s record, despite the documented discharge and the facility’s policy requirement, formed the basis of the deficiency cited under 410 IAC 16.2-3.1-35(a) related to Intake 2743057.
Incomplete Reconciliation and Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure controlled medications were accurately reconciled during delivery and properly documented on pharmacy delivery slips and controlled drug records for three residents. For one resident, a pharmacy delivery slip dated 1/8/26 showed that 40 tablets of oxycodone/acetaminophen 10/325 mg were delivered, but the spaces for "Received By," "Delivery Date/Time," and "Print Name" were left blank. The corresponding Controlled Drug Record for the same prescription and date also lacked entries for the starting balance, the nurse who checked in the medication, and the date, and no tablets were signed out as administered on that record. For a second resident with diagnoses including paraplegia, diabetes, and anxiety, a Narcotic Administration Record covering a period from late January to mid-February for oxycodone/acetaminophen 5/325 mg showed that the spaces for "Checked in By" and "Date" were left blank. A subsequent Narcotic Administration Record for a new prescription of the same medication also had the "Starting Balance" field left blank. For a third resident with dementia, epilepsy, and cognitive communication deficit, a Controlled Drug Record for hydrocodone/acetaminophen 5/325 mg similarly lacked entries for "Checked in By" and "Date." During interview, an LPN stated that the pharmacy delivery slips and controlled drug records for these residents should have been completed in full by the nurse receiving the medications, and the facility’s policy required checking the delivery manifest at the time of delivery and signing with name, date, and time if correct.
Failure to Maintain Resident Dignity, Timely Care, and Privacy
Penalty
Summary
Multiple residents experienced a lack of dignity and respect due to staff actions and inactions, as evidenced by resident council meeting notes, direct observations, and interviews. Residents reported that staff would enter rooms, turn off call lights without providing the requested care, and leave without returning, resulting in residents waiting one to two hours for assistance. Staff were also described as speaking disrespectfully, being rude, and using earbuds or phones while providing care. Additionally, staff were overheard discussing residents' personal care needs loudly in hallways, including using residents' names and making derogatory comments about care tasks they did not want to perform. These issues were reported to occur more frequently during evening, night, and weekend shifts. Direct observations confirmed that call lights for two residents remained unanswered for extended periods, with one resident waiting approximately 30 minutes before staff entered the room and another waiting nearly two hours to be cleaned up. One resident was found with his pants down and without a privacy curtain available, indicating a lack of bodily privacy. Another resident reported waiting an hour and a half after her call light was answered before being assisted to bed, resulting in discomfort. Staff were observed engaging in personal conversations and not prioritizing resident care needs, while some staff were unaware of residents' care requirements during their assigned shifts. Resident council meeting minutes from several dates documented ongoing concerns about untimely call light responses, staff being distracted by phones and earbuds, and unkind or disrespectful behavior. Residents also reported that their concerns had been brought to management but remained unresolved. Facility policies reviewed by surveyors emphasized the importance of dignity, respect, privacy, and timely assistance, but these standards were not consistently upheld for the residents involved.
Failure to Provide Timely ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents. One resident with hemiplegia and a history of stroke required total staff assistance for self-care and preferred bed baths. The care plan specified that the resident should be shaved on shower days. However, observations on multiple occasions showed the resident with long facial hair, and the resident reported that staff did not offer to shave him. Bathing records confirmed that shaving was not documented on several bed bath days, and the Executive Director was unable to explain why shaving was not provided as required by the care plan and facility policy. Another resident with cerebral palsy and depression, who had moderately impaired cognitive ability but could communicate his needs, was observed with his call light on for an extended period. The resident was found lying in bed with his pants down, waiting to be cleaned up, and reported waiting for two hours for assistance. The assigned CNA was not aware of the resident's need for care until informed during the observation. The Executive Nurse Consultant confirmed that call lights should be answered promptly and care provided in a timely manner. These findings demonstrate a failure to provide timely and appropriate ADL care, including personal hygiene and toileting assistance.
Incomplete skin assessment and inconsistent heel wound documentation
Penalty
Summary
The facility failed to ensure a resident at risk for pressure ulcer development received thorough skin assessments and identification of risk factors after admission. The resident had multiple diagnoses including fracture of the right femur, peripheral vascular disease, congestive heart failure, atrial fibrillation, diabetes mellitus, and muscle weakness. On admission, the resident was documented with redness to the right heel, but the assessment did not include further description, measurements, or additional evaluation of that area. The Braden Scale identified the resident as mild risk for pressure ulcer development, and the admission MDS later indicated the resident was at risk for pressure ulcers and required substantial to maximal assistance with mobility and transfers. The record showed inconsistent and incomplete follow-up of the heel skin concern. A weekly skin assessment documented no skin concerns, and the MAR/TAR did not show preventative measures related to the heel redness or pressure ulcer risk. Later documentation noted ulcers to the right foot, but no further assessments were completed. When the resident complained of pain to the right heel, an open area was noted, yet the change-in-condition documentation did not include a further assessment of the area. Physician orders then repeatedly referenced the left heel even though the progress note and change-in-condition evaluation identified the wound on the right heel, and there were no skin assessments or progress notes showing any left heel skin concerns. The resident’s right heel wound was later identified by the wound provider as a stage 3 pressure ulcer measuring 3.5 cm by 4.5 cm by 0.1 cm with a large amount of necrotic tissue. The resident was also diagnosed with cellulitis of the right heel and treated with antibiotics. During interview, the resident stated he had complained of heel pain for several days before staff identified the wound, and he reported that his heel and feet had been pressed into the footboard when he was admitted. He also stated staff did not change the heel dressing daily as ordered and that he had issues with the air mattress staying inflated. Corporate nursing staff confirmed the resident was tall and had been resting his heel on the footboard when the area was assessed.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple reports from residents and observations during interviews and record reviews. Several cognitively intact residents reported that Certified Nurse Aides (CNAs) and other staff were rude, sarcastic, and dismissive, often using their cell phones during care and speaking to residents in a demeaning manner. One resident described being transferred with a mechanical lift while the CNA was on a speakerphone call, and another reported that staff would call him out of his name and refuse to assist with food requests. Residents also described staff as rough during care, particularly when moving residents with physical limitations, causing both physical and emotional discomfort. Residents further reported significant delays in response to call lights, with some stating that their calls for assistance went unanswered for extended periods, sometimes overnight. During a resident council meeting, multiple residents expressed that staff treated them like children, pushed them to their rooms, and ignored their needs. The council also noted that staff often spoke in a commanding tone and failed to address residents by their preferred names, contributing to a sense of being dismissed and forgotten. Additional concerns included staff limiting access to beverages such as coffee, ignoring residents' requests, and leaving residents in soiled briefs for prolonged periods. Interviews with both residents and staff confirmed that these practices were ongoing, with staff admitting that residents would not receive certain items during specific shifts. The facility's own policies require staff to treat residents with dignity, respect, and kindness, and prohibit demeaning practices, but these standards were not upheld in the care provided to the residents identified in the report.
Failure to Provide Ordered Medications and Monitoring
Penalty
Summary
The facility failed to provide ordered diabetes care for a resident with diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure. The resident had physician orders for Lantus 10 units twice daily with instructions to hold for blood sugar less than 150, Humalog 15 units three times daily with the same hold parameter, and blood sugar checks twice daily. The MARs showed multiple instances where Lantus was given when the recorded blood sugar was below 150, and multiple Humalog administrations were documented without blood sugar readings recorded on the MAR. During interview, the CNC stated the insulin should have been held as ordered and was unsure why blood sugar results were not documented for the Humalog doses. The facility also failed to monitor and document the effectiveness of an as-needed anxiety medication for the same resident. A physician ordered hydroxyzine 25 mg every 8 hours as needed for anxiety, and an observation of the medication cart showed six pills missing from the card. The September MAR did not show that hydroxyzine had been administered since it was ordered. The ADON stated the doses should have been documented on the MAR when given and the effectiveness of the dose should have been documented. For another resident with dysphasia and left shoulder pain, the facility failed to ensure an ordered narcotic pain medication was administered as prescribed. The resident had an order for oxycodone-acetaminophen 5-325 mg via gastric tube every 6 hours as needed for pain, but an incident report showed she received Norco 5-325 mg instead of the ordered oxycodone 5-325 mg. The resident was stable and had no adverse side effects noted, and the CNC stated the resident should have received her pain medication as ordered. The facility also failed to timely address an antidepressant dosage that was not available from the pharmacy for another resident with kidney disease. The resident’s bupropion order was increased from 150 mg to 225 mg daily, but the August MAR showed multiple days when the 1.5-tablet dose was not given. Facility leadership stated the pharmacy did not notify them until several days later that the medication could not be supplied as half tablets, and the provider was not notified until after the delay. The order was later changed to 300 mg daily. In addition, the facility failed to administer ordered eye medication for a resident with an infected ocular socket lesion, conjunctival injury, corneal abrasion, and impaired visual function with only left-eye vision. The resident had an order for Refresh Celluvisc Ophthalmic Gel 1% in both eyes four times daily, and the MARs showed it as administered as ordered. However, a family member who was present in the facility all day on two days stated he did not see nursing staff administer the drops. An inspection of the medication cart found two boxes of the eye medication with remaining doses, and the pharmacist stated there had been a long lapse in refilling the medication.
Expired Medications and Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure medication storage rooms were free of expired medication and supplies and failed to ensure medication was stored appropriately during observation of one of two medication storage rooms and during medication administration for one resident. In the rehabilitation hallway medication storage room, two boxes of vacutainers were found expired, two bottles of liquid medication in the refrigerator were labeled as expired, and a vial of tuberculin solution for TB skin testing was opened without an open date written on either the vial or the box. An LPN confirmed the tuberculin solution did not have an open date. During medication administration, an RN prepared medications for a resident and left the medication cart unlocked while walking down the hallway to administer the medications, with the cart left in close proximity to residents in the dining room. The RN later prepared medications for Resident 80, including Lomotil, and encountered a bubble pack with tape covering a pill, which the RN indicated may have been taped back into the pack after a prior error on the narcotic log. The RN also accidentally popped a blood pressure medication twice into the medication cup and left one medication cup unattended on top of the cart while administering medications to Resident 80. A nurse consultant observed that the medication should not have been left unattended, and the DON later stated it was not proper practice to tape the medication back into the bubble pack.
Infection Control Program, PICC Line, and Linen Storage Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program with surveillance and tracking of infections for 6 of 12 months reviewed. The infection control binder showed monthly tracking logs only for April, May, June, July, and August 2025, with no logs available to show surveillance and monitoring of infection trends before April 2025. The ADON, identified as the Infection Preventionist, stated she began conducting infection surveillance and tracking in April 2025 and was unsure who had been monitoring infection control before that time. A nurse consultant later stated the facility was unable to locate any infection surveillance records prior to April 2025. The facility also failed to maintain infection control for a resident with a PICC line and failed to properly store clean linen on a hallway cart. Resident W, whose diagnoses included heart failure, was observed sitting in a wheelchair with a PICC missing the needless connector and a dressing dated 9/12/25. When observed with the ADON, the resident reported having blood drawn that morning, and the ADON stated the lab technician probably removed the connector and that she would replace it. In addition, the clean linen cart on the Shoreline hallway was observed open to air and contained mixed items including linens, a personal wash basin, open boxes of facial tissues, a urinal, an open box of gloves, alcohol hand gel, and scattered clean incontinent briefs. The ADON acknowledged the urinal was clean but stated it was not recommended that personal care items be mixed with clean linen.
Call Light Not Accessible to Resident with Mobility Impairments
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis, was found to have her call light out of reach on two separate occasions. The resident, who was moderately cognitively impaired and had significant mobility limitations, was observed lying in bed with her call light cord tied around the right side rail, hanging eight inches from the floor. She was unable to reach the call light and instead used a wooden stick to hit the bedside table or side rail to get staff attention. The resident reported that staff had been in her room earlier but did not adjust the call light to be within her reach, and she frequently could not access it when needed. Further observations confirmed that the call light remained out of reach even after her lunch was delivered, and staff did not ensure it was accessible. The facility's policy requires that call lights be within reach of residents and never placed on the floor or bedside stand. The deficiency was based on the failure of staff to ensure the call light was accessible to the resident, as required by both her care plan and facility policy.
Failure to Provide Timely Nail and Facial Hair Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of nail care and facial hair grooming. For one resident with heart failure and moderate cognitive impairment, observations revealed long nails with a black substance underneath, and the resident expressed a desire to have them trimmed. Review of bathing sheets showed multiple instances where nail care was not documented as provided, despite the care plan specifying that nail care should occur on bath days and as needed. The Assistant Director of Nursing confirmed that nail care should have been provided on those days. Another resident, diagnosed with Parkinson's disease and a history of fractures, also with moderate cognitive impairment, was observed with long, unkempt facial hair. The resident reported having requested to be shaved for several weeks without the request being fulfilled. Documentation indicated the last shave occurred several days prior to the observation, and the resident confirmed that shaving was only recently provided after repeated requests. Facility policies require that residents be cared for in a manner that promotes dignity and includes regular shaving as part of personal hygiene.
Failure to Ensure Timely and Documented Pain Management for Residents
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents with chronic pain and complex medical histories. For one resident with chronic pain, polyosteoarthritis, COPD, chronic kidney disease, and heart failure, there was no care plan in place to address her pain. Although physician orders specified the use of tramadol as needed, with requirements for pain assessment before and after administration, documentation of pain scale results, vital signs, and non-pharmacological interventions, these were not completed. Medication administration records showed tramadol was given on two occasions, but the corresponding treatment records and progress notes lacked required documentation, including vital signs and non-pharmacological interventions. The effect of the medication was also not documented in one instance. For another resident with diagnoses including cancer, right femur fracture, peripheral vascular disease, inguinal hernia, and spinal stenosis, the care plan included goals and interventions for pain management, such as anticipating pain needs and encouraging non-pharmacological methods. However, the resident reported significant delays in receiving as-needed pain medication, particularly at night, with one instance where he waited several hours after requesting medication. Physician orders required pain assessments, documentation of pain scale, vital signs, and non-pharmacological interventions before and after PRN medication administration, but these were not documented in the treatment records or progress notes for multiple administrations. Interviews with the DON confirmed that vital signs were supposed to be obtained and documented when residents complained of pain, but this was not consistently done. The facility's pain management policy required timely interventions and documentation of both pharmacological and non-pharmacological measures, but the records reviewed did not reflect compliance with these requirements for the residents involved.
Staff Did Not Remain Present During Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure staff remained at bedside while administering a narcotic medication to a resident who had a documented history of pocketing medications. Resident X was cognitively intact and had diagnoses including heart failure. His care plan, dated 4/5/24, stated that he had been witnessed holding pain medication in his hand after placing a pill in his mouth and drinking water, and the interventions directed staff to observe him swallowing medication and not pocketing it. A physician’s order dated 4/4/24 also directed staff to observe the resident swallowing medication due to pocketing. A physician’s order dated 5/19/25 directed that Resident X receive Percocet 10-325 mg every six hours, crushed and administered in applesauce. During an observation, RN 10 handed the resident a medication cup containing crushed medication in applesauce and immediately left the room. The resident stated the crushed medication was his Percocet and said he had been accused of selling his narcotic medication, but now received it crushed. He then spooned the medication from the cup into his mouth. The resident’s clinical record did not include a self-medication assessment or care plan showing he could safely administer his medications without staff present. The ADON stated that RN 10 should have remained in the room until the resident swallowed the medication.
Resident Preferences Not Honored
Penalty
Summary
The facility failed to ensure resident preferences were honored for 2 of 2 residents reviewed. Resident V, who had diagnoses including kidney disease and was cognitively intact, stated that staff had poor communication and did not know her care preferences. She reported that she had to tell staff how she preferred to be bathed and transferred in her wheelchair, and that she reminded staff to remove dirty clothes from her hamper because wet linen and trash were being placed there with her clothes, delaying laundry service. Her clinical record did not include a completed initial activities/preference assessment, and the Executive Director was unable to locate one. Resident T, who had diagnoses including obstructive and reflux uropathy and was cognitively intact, had preferences documented in an initial activities assessment for bathing type and bedtime, but the care plan did not include preferences for bathing type and frequency or getting up and going to bed timeframes. The resident stated she preferred showers twice a week, but she was receiving one shower weekly with the remaining bathing as bed baths. She also stated she preferred to get up at 11:30 a.m. and return to bed at 2:30 p.m., but staff told her she could not be put back to bed at that time and would have to wait until evening shift arrived. Shower sheets showed multiple dates when she received a bed bath instead of a shower, and an activities initial assessment in the record was blank.
Failure to Provide Resident Personal Funds on Request
Penalty
Summary
The facility failed to ensure a resident was able to receive personal funds when requested. Resident Z, whose diagnoses included anxiety and whose 8/4/25 MDS indicated he was cognitively intact, told the surveyor that he had been unable to get $50.00 from the Business Office when he requested it a couple of weeks earlier. He stated the BOM told him she was unable to give him any money. The BOM later confirmed there was a period of one to two weeks when residents were unable to receive their personal funds because the former ED had abruptly left employment and the new ED had not yet received home office approval to become the signer on the residents’ personal funds checks. The resident trust fund policy stated the Administrator is responsible for ensuring the Resident Trust Fund is maintained and that petty cash must be available to residents according to state and federal guidelines, but not less than Monday through Friday during regular office hours.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment for 2 of 4 residents reviewed. In Resident 44’s room, brown splatter was observed along both closet doors on 9/18/25 at 9:25 a.m., and the same splatter remained visible on 9/19/25 at 10:55 a.m. and again on 9/22/25 at 3:30 p.m. An ADON entered the room on 9/22/25 at 3:35 p.m. and acknowledged the splatter on the closet doors. Resident BB was observed and interviewed in his room on 9/22/25 at 10:50 a.m. He stated his television would turn on but had no volume, and he demonstrated that the remote could turn the TV on and off but could not restore sound. He said the volume had not worked for about four to five weeks and that he liked watching television and keeping up with the news. A later observation with a Corporate Nurse showed the TV still had no sound, and the Corporate Nurse was unable to get it to work. Resident BB’s record showed diagnoses including femur fracture, CHF, DM, and muscle weakness, and his admission MDS indicated he was cognitively intact, had impairment to one side of his lower extremities, and reported that keeping up with the news was very important to him.
Failure to Complete Significant Change MDS After Dialysis Discontinued
Penalty
Summary
The facility failed to timely complete a Significant Change of Status MDS assessment for a resident whose dialysis services were discontinued. The resident had diagnoses including diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure. A quarterly MDS completed on 7/26/25 indicated the resident was cognitively intact and had received dialysis, and a physician order dated 7/28/25 directed hemodialysis on Monday, Wednesday, and Friday. During interviews, the resident stated she no longer received dialysis and that the doctor had stopped it a couple of months earlier. The Transportation Director stated she had not transported the resident to or from dialysis since starting work at the facility in July 2025. The ADON stated the resident's dialysis was officially discontinued on 7/3/25 and that she had not received dialysis for a week and a half before it was officially discontinued. The Corporate MDS Coordinator stated a Significant Change of Status MDS assessment should have been completed after dialysis was discontinued.
Failure to Hold Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure care plan meetings were held timely for 1 resident, Resident N, whose clinical record showed diagnoses including chronic kidney disease and heart failure. Resident N had MDS assessments completed on 9/19/24 for admission, 12/27/24, 3/14/25, 6/9/25, and 8/20/25, but there were no care plan meeting notes documented in the Miscellaneous or Assessments section of the electronic health record. During interview, Resident N stated she was not having care plan meetings at the facility and was unsure what they were. The Executive Director stated the facility only had verification for two care plan meetings since the resident’s 9/13/24 admission, with the last one held in January 2025, and provided two care plan meeting notes dated 10/25/24 and 1/10/25.
Failure to Provide Catheter Care and Document Urine Output
Penalty
Summary
The facility failed to ensure catheter care was provided and urine outputs were recorded every shift for 2 of 3 residents reviewed for catheter care. One resident had diagnoses including acute kidney failure and sepsis, was cognitively intact, and had an indwelling Foley catheter ordered due to neurogenic bladder with catheter care ordered every shift and as needed. Although the September MAR/TAR indicated catheter care was completed every shift, the resident stated staff did not clean or assess the Foley catheter site daily and only emptied the bag. A second resident had diagnoses including obstructive and reflux uropathy, was cognitively intact, and had an indwelling catheter ordered due to urinary retention and obstructive and reflux uropathy with catheter care and urinary output documentation ordered every shift as needed. The September TAR showed catheter care was being provided, but multiple shifts had no documented urinary output. The resident stated staff only emptied the catheter bag, did not clean the catheter site unless there was a bowel movement, and observed staff lifting the bag above her head. Observation showed staff emptying the catheter bag without cleansing the catheter site, and the ADON and Nurse Consultant stated staff should be cleansing the catheter site and documenting urinary outputs every shift.
Failure to Provide Ordered Oxygen Therapy and Missing Physician Order
Penalty
Summary
The facility failed to ensure oxygen therapy was delivered as ordered for one resident and failed to have a physician's order in place for another resident who was receiving oxygen therapy. One resident had diagnoses including diabetes, anxiety disorder, chronic kidney disease, and respiratory failure, and a physician's order dated 12/20/24 directed oxygen at one liter per minute via nasal cannula each shift. The resident was identified in the MDS as cognitively intact and receiving oxygen therapy, but during interview and observation she was not wearing oxygen, and the September 2025 TAR showed multiple shifts when oxygen was not administered as ordered. The Clinical Nurse Consultant stated the resident should have oxygen applied as ordered and was unsure why it was not being worn. The second resident had diagnoses including cirrhosis of the liver and was receiving hospice services. Observations showed the resident in bed with an oxygen concentrator running and receiving 3.5 liters of oxygen via nasal cannula on two separate occasions, yet the clinical record did not contain physician orders for oxygen therapy. The Nurse Consultant stated hospice staff had placed the oxygen on the resident and that physician orders would be obtained. The facility's oxygen administration policy stated that a physician's order is required to initiate oxygen therapy and that a physician is to be contacted as soon as possible after initiation in emergency situations for verification and documentation of the order.
Incomplete Dialysis Monitoring and Documentation
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who required dialysis. Resident P had diagnoses including end stage renal disease, type 1 diabetes mellitus, epilepsy, congestive heart failure, noncompliance with other medical treatment, and muscle weakness. The resident was cognitively intact on MDS assessments and had a care plan and physician orders for hemodialysis on Tuesday, Thursday, and Saturday, with staff to complete pre/post dialysis assessments and open and complete dialysis communication forms on those days. The facility’s dialysis care policy stated it would maintain communication with the dialysis provider and document all dialysis services and care in the resident’s medical record. Record review showed inconsistent dialysis documentation and missing entries for refusals and appointments. Dialysis communication forms were incomplete on multiple dates, with missing vital signs on pre- or post-dialysis documentation, and several scheduled dates had no dialysis communication forms completed at all. The progress notes did not indicate refusals on multiple dates when Resident P refused dialysis, and the record also lacked progress notes for several dates when dialysis was not documented. A document from the dialysis provider showed the resident’s most recent hemodialysis treatment at the dialysis facility was on 9/6/25, while there were no progress notes indicating refusals on 9/9/25, 9/11/25, and 9/13/25. NP 8 stated the resident refused dialysis on an ongoing basis and often refused medications and vital signs.
Failure to Obtain Consent and Arrange Timely Dental and Vision Services
Penalty
Summary
The facility failed to ensure ancillary services were consented to and provided timely for two residents reviewed for dental services and one resident reviewed for vision services. One resident was cognitively intact and told surveyors she wanted to see an eye doctor and a dentist, and that she had been asking to see the eye doctor but had not heard anything. The Executive Director later stated she could not locate any ancillary consents showing the resident declined or wanted ancillary services, so the resident completed an ancillary consent form in September indicating she wanted vision and dental services. At the time of the interview, she had not been seen by a dentist or eye doctor. Another resident, who was cognitively intact and had type 2 diabetes, told surveyors he had not seen a dentist in the facility and needed his teeth cleaned. His record contained no dental consents, orders, or consultation notes. The Executive Director stated the process was to obtain dental consent on admission and place the resident on the list for the dentist's next visit, and the Social Services Director stated dental consent forms should be in the electronic health record and a binder in her office. The Medical Records Coordinator stated the dental provider had not received a consent form for the resident and had no verification that he had consented to or declined dental services.
Incomplete Narcotic Count Documentation
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to maintain a system of records for staff sign-on and sign-off regarding controlled medications being accounted for. During observation and record review, three medication carts with narcotic logs/binders were reviewed on Sunset, Shoreline, and the rehabilitation hallway. One cart had a count sheet dated 9/16/25 to 9/22/25 with three instances where staff did not sign in or sign out from their shift to indicate whether narcotic cards were added, removed, or the total number of narcotic medication cards in the narcotic box. Another cart had a count sheet dated 9/1/25 to 9/22/25 with seven instances where staff did not sign in or sign out from their shift to indicate whether narcotic cards were added, removed, or the total number of narcotic medication cards in the narcotic box. A policy titled Medication - Administration, undated, was provided and stated it was intended to provide practice standards for safe administration of medications for residents in the facility.
Physician Responses Lacked Rationale on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the physician included clinical rationales when declining pharmacy recommendations during the monthly medication regimen review for one resident. Resident 2 had diagnoses including diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure, and her medication list included atorvastatin, dicyclomine, pantoprazole, trazodone for insomnia, hydrocodone-acetaminophen as needed for pain, and apixaban. A medication regimen review noted that trazodone had been given every evening since [DATE] and recommended considering a dose reduction to 25 mg at bedtime, but the physician response section marked disagreement without any clinical rationale. A later medication regimen review listed multiple recommendations, including renal-adjusted dosing or possible discontinuation of apixaban, re-evaluation of hydrocodone-acetaminophen because it had not been used since it was started, consideration of reducing atorvastatin, discontinuing dicyclomine because scheduled use beyond 2 weeks had not been studied, and tapering pantoprazole with possible discontinuation. For each of these recommendations, the physician response section again indicated disagreement without any clinical rationale. The third page of the review still needed handwritten notation, and the Clinical Nurse Consultant stated she was unsure what that meant. The DON stated the NP who completed the medication regimen review forms was new and unsure how to fill out the forms.
Excess Melatonin Dosing Due to Duplicate Orders
Penalty
Summary
The facility failed to administer a resident's medication as ordered, resulting in the resident receiving an excessive dosage of melatonin. Resident 68 had diagnoses that included insomnia. Her physician's orders included melatonin 3 mg by mouth in the evening for insomnia, effective 1/6/25, and another order for melatonin 3 mg by mouth at bedtime for sleep, effective 7/28/24. The September 2025 MAR showed the resident received melatonin 3 mg at 8:00 p.m. and again at 9:00 p.m. each day, for a total of 6 mg daily. Psychiatry progress notes from 8/13/25 and 9/19/25 directed continuation of melatonin 3 mg every evening for sleep disorder. A pharmacy note dated 8/19/25 identified that there were two melatonin orders and requested that one be discontinued, and NP 8 stated in interview that he signed the pharmacy recommendation on 9/3/25, but the facility did not discontinue one of the orders.
Tube Feeding Not Held Around Dilantin Administration
Penalty
Summary
The facility failed to ensure tube feeding was held before and after administration of phenytoin sodium (Dilantin) for a resident with diagnoses that included seizures. The resident had physician orders for two 100 mg tablets of Dilantin at 8:00 p.m. and for Jevity enteral feeding to run daily with instructions to hold the feeding for two hours before and two hours after the Dilantin administration. The September 2025 MAR showed the resident received Dilantin at 8:00 p.m. on multiple days, and also received the Jevity tube feeding on those same days. The MAR did not indicate that the tube feeding was stopped for two hours before the Dilantin or two hours after the Dilantin as ordered. When interviewed, the Executive Director stated she did not know why staff did not hold the tube feeding as ordered.
Inaccurate Medication and Treatment Documentation
Penalty
Summary
The facility failed to ensure resident medical records were accurately documented for 2 of 5 residents reviewed for unnecessary medications. For Resident V, who had kidney disease, the record showed a physician order for bupropion 150 mg in the evening on 7/17/25, then an order on 8/6/25 for 1.5 tablets totaling 225 mg daily, and another order on 8/25/25 for 300 mg daily. The August 2025 MAR documented administration of 1.5 tablets, equal to 225 mg, on multiple days in August. During interview, the ED, NC, and DON stated the resident was taking 150 mg as of 7/17/25, the provider increased the dose to 225 mg daily on 8/6/25, and the pharmacy did not notify the facility until 8/11/25 that it could not supply half tablets; they stated the staff documenting 1.5 tablets must have actually administered 1 tablet of 150 mg because the ordered dosage could not be filled by the pharmacy. For Resident 2, whose diagnoses included diabetes, anxiety disorder, chronic kidney disease, and respiratory failure, the Quarterly MDS dated 7/26/25 indicated she was cognitively intact and receiving dialysis. A physician order dated 7/28/25 indicated hemodialysis on Monday, Wednesday, and Friday weekly. However, the resident stated she no longer received dialysis and that the doctor had stopped it a couple of months earlier. The ADON stated the dialysis had officially been discontinued on 7/3/25 and that Resident 2 had not received dialysis for a week and a half before it was officially discontinued. Despite this, the August 2025 MAR documented hemodialysis on several dates in August.
Failure to Administer Consented Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure influenza and pneumococcal immunizations were offered and administered after consent was obtained for 3 of 5 residents reviewed for immunizations. Resident 35 had a current physician order dated 6/25/24 allowing the pneumonia vaccination unless contraindicated, and an immunization informed consent dated 4/13/25 showing consent for the pneumococcal immunization, but the EHR immunization tab showed the last pneumococcal immunization was historical and last administered on 10/8/1999 as Pneumovax Dose 1. Resident 7 had diagnoses including asthma and had a current physician order dated 8/28/25 allowing both pneumonia and influenza vaccinations unless contraindicated. An immunization informed consent dated 4/14/25 showed consent for both pneumococcal and influenza immunizations, but the EHR immunization tab showed the last pneumococcal immunization was historical and last administered on 5/22/18 as Prevnar 13. Resident 9 had an immunization informed consent dated 11/24/24 for influenza and a current physician order dated 12/21/24 allowing annual influenza vaccination, but the EHR immunization tab showed the last influenza immunization was administered on 11/28/23. The ADON stated consent forms are obtained annually and the facility administers the immunizations residents consented to, and provided documents for Residents 7, 9, and 35 indicating consent for influenza and pneumococcal immunizations, though those documents had no dates.
Failure to Maintain Clean and Safe Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain clean floors in one of five units, affecting all 14 residents reviewed for environmental conditions. Observations on multiple occasions revealed dirt and spillage of an unknown black substance on the floors near the nurse's station and in the Shoreline hallway. Resident interviews and Resident Council meeting minutes documented ongoing concerns about inadequate housekeeping, particularly on weekends, with reports of rooms and bathrooms not being cleaned and food trays left in rooms. Residents and their representatives described the facility as dirty, and staff interviews confirmed that there had been recent problems with housekeeping coverage. Documentation from Resident Council meetings indicated that both residents and staff were unclear about cleaning responsibilities, with CNAs and housekeeping staff each indicating it was the other's duty. The facility's policy requires a safe, clean, and comfortable environment, but observations and interviews demonstrated that this standard was not met during the survey period. The deficiency was cited in relation to a specific complaint.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Allegation of Missing Resident Funds
Penalty
Summary
The facility failed to timely report an allegation of missing funds for a resident with a cognitive communication deficit and moderate cognitive impairment. The resident's representative reported bringing $80 into the facility and giving it to the previous Business Office Manager (BOM) to be placed in a safe. Later, when the representative inquired about the funds, the current BOM was unaware of the money's location, and the resident was not listed in the facility's grievance records for missing items or funds. During a meeting with the current BOM, the resident's representative, the Ombudsman, and the Social Services Director, the allegation of missing funds was raised, and the BOM indicated she notified the Executive Director (ED) afterward. However, the ED was on vacation at the time of the meeting and could not confirm being notified of the missing funds. The ED stated that if she had been made aware, she would have reported the incident to the Department of Health. The facility's policy requires reporting allegations of misappropriation of resident property within 24 hours of forming a suspicion, but the incident was not reported in a timely manner as required. The missing funds were later located, but the initial failure to report the allegation constituted a deficiency.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Perform Timely Post-Fall Assessments and Adhere to Physician Orders for Diabetic Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with encephalopathy and heart failure, there were two documented falls within a short period. Despite policy requiring a post-fall assessment and investigation within 24 hours, the clinical record did not contain evidence of such assessments after either fall. The Director of Nursing confirmed that the required fall risk evaluations were not completed, and there was a lack of documentation in the medical record regarding the falls and subsequent assessments. Another resident with diabetes, a foot ulcer, repeated falls, and dementia did not have updated or consistent physician orders for wound care, despite podiatry notes indicating changes in wound treatment. The Medication Administration Record (MAR) showed that wound care was provided inconsistently with the orders, and there was no documentation of a physician's order for weekly dressing changes at podiatry visits. Additionally, this resident did not receive insulin on several occasions due to blood sugar readings, but there was no documentation that the physician was notified as required. Blood sugar checks were also incompletely documented, with only one daily reading recorded despite orders for checks before meals and at bedtime. A third resident with diabetes had physician orders for blood sugar checks and insulin administration every six hours. However, the MAR lacked documentation of blood sugar readings and insulin administration on multiple occasions. The facility's policy required that vital signs and test results be recorded prior to medication administration and that any held medications be documented with reasons. The Director of Nursing confirmed that the required documentation was missing for these instances.
Failure to Obtain STAT Laboratory Tests for Resident with Altered Mental Status
Penalty
Summary
The facility failed to provide timely laboratory services for one resident who was reviewed following a fall. The resident, who had diagnoses including encephalopathy and heart failure and was noted to be cognitively impaired, exhibited confusion and restlessness. Nursing staff received new STAT orders from the on-call Nurse Practitioner/Physician for a complete blood count (CBC) and complete metabolic panel (CMP) due to altered mental status. Despite these orders, the laboratory tests were never drawn, and the clinical record did not contain results for the ordered tests. The facility's policy requires coordination and timely provision of laboratory services as ordered by a provider, but this was not followed in this instance.
Failure to Document Resident Fall and Required Notifications in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's fall, as well as the notifications to the physician and responsible party, were properly documented in the clinical record. The resident involved had diagnoses including diabetes with foot ulcer, repeated falls, and dementia, and was assessed as severely cognitively impaired, requiring substantial assistance with daily activities. Although a fall incident report was completed and maintained in risk management, this documentation was not included in the resident's clinical record. The incident report detailed that the resident fell forward out of a wheelchair while reaching for a dropped fork, with no injuries noted, and that the family and DON were notified. However, there was no documentation in the clinical record on the day of the fall regarding the incident or the notifications made. A subsequent health status note referenced the fall but was written the day after the event, based on information from the unit manager. The facility's policy required documentation of the fall, notification of the physician and responsible party, completion of an incident report, and detailed progress notes in the medical record, including the resident's condition every shift for 72 hours. The DON acknowledged that it was best practice to document falls in the clinical record and that risk management notes were sometimes copied into progress notes, but this was not done in this case.
Failure to Secure and Document Receipt of Controlled Medication
Penalty
Summary
The facility failed to ensure the secure handling and storage of a resident's controlled medication, specifically 60 tablets of oxycodone-acetaminophen, which were delivered by the pharmacy. The medication was received by a registered nurse (RN 2), who handed both the narcotic record sheet and the medication to another nurse (RN 1) to be placed in the medication cart. However, there was no documentation or record that the medication was added to the cart, and subsequent counts by staff revealed that the medication and its record sheet were missing. Multiple staff statements and interviews confirmed that the medication was not observed in the cart during shift changes, and a thorough search of all medication carts and the medication supply room failed to locate the missing narcotics. Video surveillance footage showed RN 2 handing the medication and record sheet to RN 1, who placed them in a folder or envelope on top of the medication cart, but the footage did not show what happened to the items afterward. RN 1 did not return to work the following day and was unresponsive to attempts to obtain a statement regarding the missing medication. The resident for whom the medication was intended had diagnoses including stroke, heart disease, and kidney disease, and was prescribed oxycodone-acetaminophen for pain management. Despite the missing medication, the resident did not report pain or missed doses, as there was still a supply available. The incident was reported to the appropriate authorities, and the facility's policy required controlled substances to be stored under double lock and properly documented upon receipt, which was not followed in this case.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and properly functioning kitchen environment, which had the potential to affect 52 of 53 residents consuming food from the kitchen. During an observation, the kitchen was found to have cracked and broken flooring tiles in the dishwasher and dry storage areas, and a yellow substance was observed dripping down the walls behind the dishwasher and oven. The dishwasher was not reaching the required rinse cycle temperature of 180 degrees Fahrenheit, as indicated by the manufacturer's guidelines, and the dishwasher log lacked recorded temperatures for several meal periods. Additionally, food items in the refrigerators were not labeled or dated, and personal drinks were improperly stored in the walk-in refrigerator. The dietary aide responsible for operating the dishwasher admitted to not monitoring the temperature gauges during its operation. The Registered Dietitian confirmed that the rinse cycle gauge was broken and acknowledged the need for all food items to be labeled and dated, as well as the prohibition of storing personal drinks in the walk-in refrigerators. The facility's policies on cleaning schedules, dish machine temperature recording, and food storage were not adhered to, contributing to the deficiencies observed during the survey.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which is crucial for tracking and monitoring antibiotic usage among residents. The deficiency was identified when the Director of Nursing (DON) provided an antibiotic stewardship binder that lacked monthly tracking data from January 2024 through May 2024. Additionally, the tracking sheets for June, July, and August 2024 did not include essential information such as the type of infection or the location of residents with infections within the facility. This oversight had the potential to affect all 53 residents residing in the facility. During an interview, the Regional Nurse Consultant (RNC) revealed that the facility had undergone a change in corporate ownership in March 2024, which resulted in a lack of documentation for the first three months of the year. The previous corporation's staff had been responsible for tracking and monitoring antibiotic usage, but this process was not continued effectively after the transition. The DON began tracking antibiotic usage in June 2024 but failed to document critical details such as the type of infection and the location of infected residents, which are necessary for a comprehensive antibiotic stewardship program.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure proper administration of insulin for a resident with type 1 diabetes mellitus. During an observation of medication administration, an LPN was seen preparing and administering 8 units of Humulin N insulin using an insulin flex pen without priming it first. The priming step is crucial as it removes air from the needle and cartridge, ensuring the pen functions correctly and delivers the accurate dosage of insulin. The LPN admitted to normally priming the pen with two units of insulin but forgot to do so on this occasion. The manufacturer's instructions for the Humulin N Pen, retrieved from the manufacturer's website, clearly state the necessity of priming the pen before each injection. The instructions detail the steps required to prime the pen, which include selecting 2 units, holding the pen with the needle pointing up, and ensuring insulin is visible at the needle tip. Failure to prime the pen can result in administering too much or too little insulin, which was not observed in this instance, as the LPN did not follow the priming procedure.
Failure to Implement Timely Behavior Plan for Resident
Penalty
Summary
The facility failed to timely develop and implement an individualized behavior plan of care for a resident, identified as Resident 15, who was reviewed for behaviors. Resident 15 was admitted to the facility from a psychiatric hospital with diagnoses including dementia, stroke, aphasia, and major depressive disorder with psychotic symptoms. Despite a physician's order to monitor and document targeted behaviors and interventions, the clinical record lacked a care plan addressing the resident's aphasia and specific interventions for behaviors. The resident exhibited various behaviors such as yelling, verbal aggression, and emotional lability, which were not adequately documented or addressed in the care plan. Throughout the resident's stay, there were multiple instances of behavioral episodes, including yelling at staff, becoming upset during interactions, and displaying mood swings. These behaviors were noted in progress and behavior notes, but the facility's documentation was inconsistent, and the Nurse Administration Record did not contain documentation of behaviors, interventions, or outcomes. The resident's care plan was not updated to reflect his behavioral needs until a month after admission, and there was a delay in psychiatric evaluation due to miscommunication and scheduling issues. Interviews with facility staff revealed that the resident's mood was labile, and there was a lack of timely psychiatric intervention. The Social Services Director and Regional Nurse Consultant acknowledged the resident's behavioral issues and the need for a psychiatric evaluation, which was delayed. The facility's Behavior Management policy emphasized the importance of identifying residents with behavioral risks and developing effective management programs, which was not adequately followed in this case.
Failure to Monitor Blood Pressure Before Administering Midodrine
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of midodrine for a resident with hypertension. The physician's order required that midodrine be withheld if the resident's systolic blood pressure exceeded 110. However, from the beginning of September until mid-September, the medication was administered without recording the necessary blood pressure readings prior to administration. This oversight was confirmed during an interview with the Regional Nurse Consultant, who acknowledged that staff should have been obtaining blood pressure readings before administering the medication. The facility's medication administration policy also emphasized the need to check vital signs before medication administration.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions during a wound dressing change for Resident 25, who was observed to have a diabetic ulcer on the right ankle. The care plan indicated that the resident was under enhanced barrier precautions due to a wound, and a physician's order specified the wound care procedure. During an observation of the wound dressing change, the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) performed hand hygiene and donned gloves but did not use any other personal protective equipment (PPE) such as gowns, which are part of the enhanced barrier precautions. An interview with the Regional Nurse Consultant revealed a misunderstanding among the facility staff regarding the duration for maintaining enhanced barrier precautions. The staff believed that once the infection in Resident 25's wound was resolved, the precautions could be discontinued. This misunderstanding led to the failure in implementing the necessary infection control measures as outlined in the facility's infection control policy, which aims to prevent the transmission of disease and infection.
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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 Indianapolis
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 | 0.3 mi | ★★★★★ | 24 | 0 |
| Clearvista Lake Health Campus | 0.3 mi | ★★★★★ | 4 | 0 |
| Allisonville Meadows | 2 mi | ★★★★★ | 25 | 0 |
| Allison Pointe Healthcare Center | 2.5 mi | ★★★★★ | 19 | 0 |
| Hamilton Trace Of Fishers | 3.9 mi | ★★★★★ | 2 | 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.