Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peabody Retirement Community during CMS and state inspections, most recent first.
Failure to complete required PASRR Level I screenings after new MH diagnoses and mental status changes. Surveyors found that three residents had new psychiatric diagnoses and psychotropic medication changes, including antipsychotic, mood stabilizer, and anti-anxiety use, but the facility did not submit updated PASRR Level I screenings to determine whether Level II review was needed. Staff interviews confirmed the screenings were not completed despite prior PASRR outcomes stating that new information or changes required a new screen.
Failure to Document Behaviors Supporting Antipsychotic Use: The facility did not identify and track targeted behaviors or individualized interventions to clinically support antipsychotic use for two residents. One resident with dementia, anxiety, delusional disorder, and sexually inappropriate behaviors had repeated yelling out and PRN anxiolytic use, but the record often showed no delusions or hallucinations and lacked documentation of nonpharmacologic interventions before PRN doses. Another resident with bipolar disorder, depression, PTSD, and delusional disorder received Seroquel despite MDS and psych notes showing no hallucinations or delusions during multiple periods, and the record lacked behavior tracking to support the medication.
An LPN administered insulin glargine to a resident with diabetes mellitus without priming the insulin pen needle before the injection. The LPN stated she did not prime insulin pen needles before administration, and the DON later indicated staff should prime the insulin pen before use. Facility and manufacturer instructions both stated the pen must be primed before each injection.
A cognitively impaired resident with dementia, aphasia, weakness, and a history of subdural hemorrhage and fractures repeatedly attempted to stand and ambulate without help and sustained multiple falls despite 15-minute checks, standby assistance, and later one-on-one monitoring. The resident fell in his room and bathroom, resulting in facial lacerations, nasal bleeding, an abrasion, and imaging that showed a mildly increased subdural hematoma plus acute right maxillary sinus and orbital floor fractures. In a separate incident, a dependent resident with cerebral palsy and contractures was rolled too quickly during bedpan removal while the bed was against the wall, causing her to roll out of bed and hit her head on the floor.
Dietary staff were observed repeatedly using the same gloves to handle food, kitchen equipment, and packaging without changing gloves or washing hands between tasks. This included touching ready-to-eat foods, opening packaging, and checking food temperatures, with inconsistent use of utensils like tongs. Interviews revealed confusion about proper glove use, and facility policy on minimizing foodborne illness risk was not followed, potentially affecting all residents receiving meals from the affected kitchen areas.
Staff failed to consistently use required PPE, including eye protection, and did not perform hand hygiene when entering or exiting rooms of residents on droplet precautions for respiratory illnesses. During meal assistance, a CNA was observed touching her face, sharing utensils between residents, and blowing on food, all without performing hand hygiene, contrary to facility policy. These lapses were confirmed by staff interviews and had the potential to affect all residents on droplet precautions and those receiving dining assistance.
A resident with paraplegia, bowel incontinence, and recent C. difficile infection was left sitting in feces for about an hour after being removed from his room for pest control spraying. Staff were aware of the soiling but did not provide prompt incontinence care due to uncertainty about where to assist the resident, resulting in a delay until the resident could return to his room. Facility policy and staff interviews confirmed that immediate care was expected to maintain dignity.
Two residents with moderate cognitive impairment were allowed to self-administer medications without proper assessment, physician orders, or care plans in place. Staff left medications at the bedside for one resident to dissolve in applesauce, despite documentation indicating she was not safe to self-administer. Another resident was found with pills on the floor and no evidence of a safety assessment or care plan for self-administration, contrary to facility policy.
A resident with multiple chronic conditions, including constipation and dementia, experienced several periods without a bowel movement, but staff did not consistently monitor or implement the facility's bowel protocol as ordered. Despite physician orders and facility policy requiring regular documentation and intervention for constipation, there was no evidence that appropriate actions were taken during these episodes.
Staff failed to provide prompt incontinence care to a resident with a pressure injury, leaving the individual sitting in feces for over an hour due to confusion about where to provide care after the resident's room was sprayed for pests. In a separate incident, an RN did not follow infection control protocols during wound care for another resident, placing supplies on an unclean surface and neglecting hand hygiene. Both residents had significant risk factors for pressure injuries, and required interventions were not implemented as outlined in their care plans and facility policy.
The facility failed to implement and document effective QAPI processes, resulting in repeated deficiencies in pressure injury care and infection prevention. Audits and interventions to promote healing and prevent wound contamination were not consistently carried out or documented, leading to ongoing issues for residents with pressure injuries.
A CNA in an LTC facility verbally abused a resident with severe cognitive impairment and neglected another resident who required assistance for showering. The first resident was told to 'shut up' and that permission to talk would be given by the CNA. The second resident was denied a shower by the CNA, who claimed to be too tired, but was later assisted by another CNA. The incidents were reported to the facility's DON, and the CNA involved was reported to the appropriate agencies and barred from working in the facility.
A cognitively impaired resident, identified as an elopement risk, was able to leave the facility unnoticed due to inadequate supervision. The resident was not checked on overnight and was found the next morning in a local park. Staff failed to communicate the resident's elopement risk, and the CNA responsible did not perform required checks.
A resident identified as an elopement risk left the facility without his walker and was later found in a local park. The facility's report inaccurately stated the family declined secured unit placement, which the family disputed. The DON reported the incident without complete information, and the Administrator acknowledged the report was not intended to be misleading.
The facility failed to follow physician orders for blood glucose monitoring, insulin administration, and elastic wraps for two residents. Resident 90 did not have blood sugar levels monitored or insulin administered as ordered, and Resident 82's legs were often not wrapped as required. Staff interviews confirmed lapses in following orders and documentation.
The facility failed to provide adequate monitoring and interventions for pressure injuries for two residents. One resident was observed wearing non-skid shoes despite a physician's order for no shoe on the left foot, and the clinical record lacked consistent documentation of wound care. Another resident frequently did not wear the required offloading boot, and the facility's documentation did not reflect the resident's refusal or staff's attempts to ensure its use. The facility's failure to adhere to physician's orders and provide consistent monitoring resulted in inadequate care.
The facility failed to develop and implement a system of individualized behavior monitoring and management for a resident with dementia. The clinical record lacked detailed documentation of behavioral episodes, and staff interviews revealed that behaviors were documented by exception, resulting in insufficient information for effective care planning.
The facility failed to label medications with resident identifiers and directions for two of five medication carts reviewed. Unlabeled bottles of morphine sulfate and various other medications were found, and staff acknowledged that all medications should have been labeled immediately upon receipt.
The facility failed to follow infection prevention and control strategies during wound care for two residents. LPNs did not adhere to proper hand hygiene and glove-changing protocols, increasing the risk of infection for residents with surgical wounds and other medical conditions.
The facility failed to make nursing staffing data readily available in a prominent, easily accessible location for residents and visitors. Surveyors observed that the required staffing information was either missing or incomplete in various units. Staff members, including the DON and the Administrator, were unaware of the exact location of the nurse staffing posting, indicating a lack of proper communication and procedure adherence within the facility.
The facility failed to ensure that an LPN had a valid Indiana nursing license or an active out-of-state license through an interstate compact agreement. The LPN, employed since February 2023, continued to work and provide wound care with a Texas single-state license, impacting all 164 residents.
A resident with dementia ingested a pencil sharpener blade due to inadequate supervision, requiring hospitalization for surgical removal. The resident was left unattended with a box of colored pencils, leading to the incident. Staff interviews and video footage revealed lapses in supervision, contrary to the facility's safety policy.
A cognitively impaired resident with a history of elopement managed to exit a secured unit through his bedroom window. Despite previous elopement attempts and documented exit-seeking behavior, the resident was able to remove the screen from his window and walk outside before being noticed by staff. The facility's policy on elopement risk assessment was not effectively implemented.
Failure to Complete Required PASRR Level I Screenings After New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete required PASRR Level I screening assessments when residents had new major mental health diagnoses or significant mental status changes. Surveyors found that for 3 of 3 residents reviewed for PASRR, the facility did not complete a new Level I screening to determine whether a Level II assessment was required after new psychiatric diagnoses or related treatment changes were documented. For one resident, the clinical record showed diagnoses of psychotic disorder with delusions due to a known physiological condition, depression, anxiety, and mood disorder due to a known physiological condition with depressive features. The record also showed use of lurasidone for psychotic disorder, divalproex for mood disorder, and hydroxyzine for anxiety, along with MDS assessments identifying psychotic disorder and psychotropic medication use. The record lacked additional Level I screenings after the original PASRR screening from 2019. Staff interviews indicated the resident had not received a follow-up PASRR screening after the mental health diagnosis was added and antipsychotic therapy was started. For another resident, the record included dementia, depression, anxiety disorder, delusional disorder, and other sexual disorders, with current orders for lorazepam and risperidone related to anxiety and delusional disorder. A significant change MDS triggered cognitive loss/dementia, psychotropic drug use, anxiety, depression, and psychotic disorder. The prior PASRR outcome stated that if changes occurred or new information refuted the findings, a new screen must be submitted. During interview, staff acknowledged that a new Level I PASRR should have been performed when the resident was diagnosed with a new mental health disorder, but none was submitted because the resident already had dementia. For a third resident, the record showed bipolar disorder and current risperidone use related to that diagnosis. The resident had a prior PASRR outcome from 2024 stating that if changes occurred or new information refuted the findings, a new screen must be submitted. Staff were unable to locate a more recent PASRR Level I after that screening, and the DON later confirmed that a new Level I had not been submitted since the earlier PASRR. The facility’s own provider manual stated that a new Level I must be submitted when a resident’s behavioral or mental status significantly changes, including when a new mental health diagnosis is added that was not listed on a previous Level I or Level II.
Failure to Document Targeted Behaviors Supporting Antipsychotic Use
Penalty
Summary
The facility failed to identify targeted behaviors and individualized interventions to clinically support the use of an antipsychotic medication for 2 residents reviewed for chemical restraints. For one resident, diagnoses included dementia, depression, anxiety disorder, delusional disorder, and other sexual disorders. The resident was prescribed risperidone 0.5 mg twice daily for delusional disorder and lorazepam 0.5 mg as needed for anxiety/restlessness. Although the record contained multiple references to yelling out, repetitive verbalizations, wandering into other residents’ rooms, and sexually inappropriate comments, the annual and quarterly MDS assessments repeatedly documented no delusions, hallucinations, or behaviors during several assessment periods. The care plan listed broad behavioral concerns and psychotropic medication use, but the record also showed that the resident was often calm, quiet, and easily redirected during observations and interviews. For the same resident, the clinical record included several behavior notes and psychiatric follow-ups describing yelling out, repeating phrases, and occasional sexually inappropriate comments, along with staff attempts at redirection, reassurance, snacks, television, quiet space, and 1:1 interaction. A psychiatric note stated the resident denied delusions, hallucinations, paranoia, anxiety, and depression, and staff did not report hallucinations or delusions. The record also showed a GDR request for risperidone that was denied because a dose reduction was expected to worsen symptoms. However, the record lacked documentation of non-pharmacological interventions attempted before several PRN lorazepam administrations, and the facility did not clearly identify targeted behaviors and individualized interventions to clinically support the antipsychotic use. For the second resident, diagnoses included delusional disorders, major depressive disorder, bipolar disorder, and PTSD. The resident received Seroquel 25 mg at bedtime, along with antidepressants and trazodone. Quarterly MDS assessments and psychiatric notes documented no hallucinations or delusions during multiple assessment periods, and one note stated the resident was not having hallucinations or delusions at that time. The record lacked documentation of identification and tracking of behaviors, hallucinations, delusions, or paranoia, even though an email from Social Services referenced face picking, excessive itching, and the representative’s concern that the resident had lice and a mental issue. Later psychiatric notes described reported visual hallucinations, paranoid delusions, seeing bugs in the room, and increased psychosis, but the facility record still lacked documented behavior tracking to support the antipsychotic use. Interviews with nursing staff and the DON reflected limited recall of behaviors, while the psychiatric NP stated the resident had a history of paranoid delusions and intermittent psychosis and had been stable on Seroquel.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure insulin pen needles were primed before administration according to the manufacturer's instructions and professional standards for 1 of 14 residents reviewed for medication administration. During an observation on 5/13/26 at 6:58 p.m., an LPN administered 32 units of insulin glargine to Resident 17 and did not prime the pen needle before giving the injection. After the administration was completed, the LPN stated she did not prime insulin pen needles before administration. Resident 17's record showed diagnoses of diabetes mellitus and a physician order for insulin glargine, 32 units at bedtime. Facility documentation titled "Insulin Injections" stated that if using a pen, the needle should be kept in the skin for 10 seconds. Additional guidance from insulin pen instructions stated that the pen must be primed before each injection, and that priming removes air from the needle and cartridge so the pen will work correctly. The DON later indicated staff should prime the insulin pen before administration.
Inadequate supervision and unsafe bed mobility assistance led to resident falls
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident with a history of traumatic subdural hemorrhage, orbital and maxillary fractures, dementia, aphasia, unsteadiness, weakness, and multiple prior falls. The resident was moderately cognitively impaired, required supervision or touching assistance for transfers and walking, and had a care plan identifying him as at risk for falls due to impaired mobility, impaired cognition, pain, and multiple medications. Despite interventions such as nonskid strips, a relocated bedside table, 15-minute checks, standby assistance, and later one-on-one monitoring, he continued to attempt to stand and ambulate without assistance and experienced repeated falls in the facility. The resident fell in his room after getting up to use the restroom without asking for help, and later was found seated on the bathroom floor with facial lacerations, nasal bleeding, and an abrasion to his right elbow. Imaging showed a right frontal subdural hematoma that was mildly increased from a prior scan, along with acute fractures of the right maxillary sinus and a nondepressed right orbital floor fracture. After returning from the hospital, he remained confused and unsteady and continued to fall in the dining room, common area, and room, including episodes where he stood, lost balance, sat on the floor, or was found on the floor during safety checks. Staff interviews described efforts to keep him in the common area, provide toileting, and monitor him closely, but the resident still repeatedly attempted to rise when staff were not in view. The facility also failed to provide safe bed mobility assistance for a dependent resident with cerebral palsy, contractures, muscle wasting, stiffness, and impaired range of motion. The resident was dependent for all care except eating and used a motorized wheelchair. During bedpan removal, one staff member rolled her quickly while the bed was positioned with the left side against the wall and without assist rails present. The resident stated she was rolled too fast, fell out of the bed, and hit her head on the floor. Staff interviews confirmed that the resident was on the floor after being rolled out of bed during bedpan care, and one staff member acknowledged that the resident should have been rolled toward the wall to ensure safety and easier removal of the bedpan. A prior event in the record also showed the resident had been rolled out of bed during assisted care, and the interdisciplinary team had previously determined that two-person assistance was needed for bed mobility.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
The facility failed to prepare and distribute food in a safe and sanitary manner, as observed during multiple meal service periods. Dietary staff were seen repeatedly using the same pair of gloves to handle various food items, kitchen equipment, and packaging, without changing gloves or washing hands between tasks. For example, a dietary staff member donned gloves and used utensils to serve food, but then touched condiment containers, opened freezers, handled frozen chicken tenders, and placed them in the fryer, all without changing gloves. The same staff member also handled ready-to-eat foods, opened packaging, checked food temperatures, and manipulated kitchen equipment with the same gloves, only occasionally removing gloves and washing hands before donning new gloves. The use of gloves was inconsistent with safe food handling practices, as gloves were not changed between handling different items and surfaces, and tongs were not consistently used for serving food until prompted by the Dietary Manager. Interviews with the dietary staff and manager revealed a lack of consistent understanding and implementation of proper glove use and food handling protocols. The dietary staff member indicated he would change gloves if he touched something not food safe, but also believed it was acceptable to touch ready-to-eat items and clean kitchen handles with the same gloves. The Dietary Manager clarified that staff were not supposed to touch food items with gloved hands unless the gloves were clean and that gloves should be changed when touching other items. Facility policy required food to be stored, prepared, handled, and served to minimize the risk of foodborne illness, but these procedures were not followed during the observed meal services. This deficient practice had the potential to affect all 46 residents receiving meals from the Transitional Care Unit and Tulip Place kitchenette.
Failure to Adhere to Infection Control Practices for Droplet Precautions and Dining Services
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices related to droplet precautions for six residents. Staff members, including CNAs, QMAs, and dietary aides, entered rooms with droplet precaution signage without donning required personal protective equipment (PPE) such as eye protection, and in several instances, did not perform hand hygiene upon exiting the rooms. Some staff members were observed entering rooms without first ensuring PPE was available, and others misunderstood or disregarded the requirements for face shields or goggles, despite clear signage and facility policy. These lapses occurred even though residents had active physician orders and care plans for droplet precautions due to diagnoses such as Influenza A, bronchitis, pneumonia, and other respiratory illnesses. The residents involved had varying degrees of cognitive and physical impairment, with some being dependent on staff for mobility and care. Additionally, during dining services, staff failed to follow infection control protocols while assisting residents with meals. One CNA was observed touching her face, handling multiple residents' utensils and cups without performing hand hygiene, and blowing on food before serving it to residents. The CNA also used the same utensils between residents and touched the tops of cups and bowls, contrary to facility policy and infection control standards. Interviews with staff and the Infection Preventionist confirmed that these actions were not in line with expected practices, which require frequent hand hygiene, avoidance of bare-hand contact with food, and not sharing utensils among residents. Facility policies reviewed by surveyors indicated clear requirements for transmission-based precautions, including the use of appropriate PPE and hand hygiene. The observed failures to adhere to these policies and CDC guidelines were confirmed through staff interviews, which revealed gaps in understanding and inconsistent application of infection control measures. These deficiencies had the potential to affect all residents on droplet precautions and those receiving dining assistance.
Failure to Provide Prompt Incontinence Care and Maintain Resident Dignity
Penalty
Summary
Staff failed to provide prompt incontinence care to a resident who was dependent on staff for all toileting needs and was always incontinent of bowel. The resident, who had a history of depression, bipolar disorder, paraplegia, and recent Clostridioides difficile infection, experienced a bowel movement as he was assisted out of his room, which was then closed for pest control spraying. Staff were aware the resident was soiled but did not know how to proceed since his room was unavailable and there were no empty rooms on the unit. The resident remained in the common area, sitting in feces for approximately an hour, while staff expressed uncertainty about where to provide care and did not immediately seek guidance from supervisors. Observations confirmed the resident remained soiled in the common area until staff were eventually directed to return him to his room after it was deemed safe. Upon being assisted to his room and transferred to bed, the resident was found to have feces on and between his buttocks, extending from his scrotum to a bandage on his sacral/coccyx area. Interviews with staff and management indicated that incontinence care should have been provided immediately and that alternative arrangements, such as using an empty room or therapy room, were expected when the resident's room was unavailable. Facility policy also required prompt response to toileting needs to maintain resident dignity.
Failure to Assess and Document Safety for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for safety, as required. For one resident, a medication cup containing applesauce and several pills was observed on the bedside table. The resident explained that she needed her medications to dissolve in applesauce before swallowing, and staff would leave the cup with her for this purpose. However, her clinical record did not contain a physician's order for self-administration, and her Medication Self-Administration Safety Screen indicated she was not safe to self-administer medications, requiring staff presence during administration. There was also no care plan addressing medication self-administration for this resident. Another resident was found with medication pills on the floor and a medication cup on the bedside table. Staff removed the pills and cup, stating that medications should not be left in resident rooms and expressing uncertainty about how the pills ended up on the floor. This resident's clinical record also lacked a care plan for medication self-administration and did not include a Medication Self-Administration Safety Screen. Both residents were assessed as moderately cognitively impaired and had multiple medical diagnoses requiring complex medication regimens. Facility policy requires that only licensed or permitted staff administer medications unless the attending physician and interdisciplinary team determine a resident can safely self-administer. In both cases, there was no documentation of such determinations, and the required assessments and care planning for self-administration were missing, leading to the deficiency.
Failure to Monitor and Manage Constipation per Bowel Protocol
Penalty
Summary
The facility failed to monitor and manage constipation for a resident as required by physician orders and facility policy. The resident, who had diagnoses including Parkinson's disease, constipation, dementia, and other chronic conditions, reported experiencing hard bowel movements and periods of up to three days without a bowel movement. Despite a physician's order for a bisacodyl suppository as needed for constipation, there was no documentation that the bowel protocol or prescribed interventions were implemented during periods of constipation. Review of the resident's clinical record and bowel elimination logs revealed gaps in monitoring and documentation. The bowel elimination record showed multiple periods where the resident did not have a bowel movement for more than 72 hours, specifically between 3/16/25 to 3/18/25 and 3/24/25 to 3/31/25. Staff interviews confirmed that concerns about constipation were reported to nursing, but there was no evidence in the clinical record that the bowel protocol was followed or that interventions were provided during these times. The last documented use of the bowel protocol for this resident was in December 2024, despite ongoing issues. Facility policy required that bowel movements be documented every shift, that a bowel movement report be run nightly, and that residents with no bowel movement in 72 hours receive assessment and intervention. Interviews with staff, including CNAs, RNs, and the unit manager, confirmed that these procedures were not consistently followed for this resident. The lack of monitoring and failure to implement the bowel protocol as ordered resulted in the deficiency.
Failure to Provide Timely Pressure Ulcer Care and Maintain Infection Control
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident with a known pressure injury. The resident, who was paraplegic, cognitively intact, and always incontinent of bowel, was left sitting in feces in a common area after his room was sprayed for pests. Staff were aware of the resident's soiled condition but did not know where to take him for care, as his room was unavailable and there were no empty rooms on the unit. The resident remained in this state for over an hour, and when finally assisted, was found to have feces on and between his buttocks, extending to the area of his pressure injury, with reddened skin observed. The care plan for this resident required incontinence care after each episode, and facility policy stated that skin should be cleaned promptly after incontinence, but these interventions were not implemented as required. Another deficiency was identified in the infection prevention and control practices during wound care for a resident with a pressure injury on the right heel. During wound care, an RN failed to clean the overbed table or use a barrier before placing wound care supplies on it. The RN also did not perform hand hygiene after removing the resident's shoe and before beginning wound care. These lapses in infection control created a potential for contamination of the wound site. The facility's policy required cleaning the bedside stand and establishing a clean field before placing supplies, as well as proper hand hygiene, but these steps were not followed. Both residents involved had significant risk factors for pressure injuries and required specific interventions as outlined in their care plans and physician orders. The first resident had a history of C. difficile infection, was dependent on staff for all mobility and toileting, and had a stage 3 pressure injury that worsened over the week. The second resident had a right heel pressure injury and a recent hip fracture, requiring pressure-relieving devices and careful wound care. In both cases, staff actions and inactions directly led to failures in pressure ulcer care and infection prevention.
Repeat Deficiencies in Pressure Injury Care and Infection Control Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to develop and implement effective approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies related to pressure injury care and infection prevention. During the last annual recertification and state licensure survey, the facility did not provide adequate monitoring of a pressure injury and did not implement interventions to promote healing. Additionally, the facility failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care. These deficiencies were again cited in a subsequent survey, where it was observed that interventions to promote healing and infection control strategies were not implemented for residents with pressure injuries. Interviews with facility leadership revealed that QAPI meetings were held at least quarterly, sometimes monthly, and covered previously identified areas of concern. However, the Director of Nursing (DON) was unable to provide documentation supporting the initiation of a Performance Improvement Plan (PIP) related to pressure ulcers after the previous survey. The facility's QAPI policy outlined a proactive approach to quality improvement, but the lack of implementation and documentation contributed to the recurrence of deficiencies in pressure injury management and infection control.
Verbal Abuse and Neglect by CNA in LTC Facility
Penalty
Summary
The facility failed to prevent staff-to-resident verbal abuse and neglect involving two residents. Resident D, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was verbally abused by CNA 1. According to a written statement and an interview, CNA 1 told Resident D to 'shut up' and that she would give her permission to talk. This incident was reported by another resident, Resident C, who witnessed the verbal abuse. The incident was not reported to the facility until a later date. Resident E, who was cognitively intact and required moderate assistance for showering and dressing due to an intertrochanteric fracture of the right femur, was neglected by CNA 1. Resident E requested a shower, but CNA 1 refused, stating they were too tired to provide the service. Another CNA, CNA 2, eventually provided the shower. The facility's Director of Nursing (DON) confirmed the incident and indicated that CNA 1 was reported to the appropriate agencies and was no longer allowed to work in the facility.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a cognitively impaired resident, identified as an elopement risk, leading to the resident's elopement. The resident, who had a history of dementia and was assessed as an elopement risk, was not observed overnight and was able to leave the facility unnoticed. The resident exited the facility without his walker and was found the next morning in a local park, approximately one-half mile away, after being unaccounted for overnight. The resident's care plan included interventions to prevent elopement, such as offering diversions and monitoring his whereabouts. However, these interventions were not effectively implemented. The CNA responsible for the resident did not check on him throughout the night, and the agency nurse on duty was not informed of the resident's elopement risk. The resident was last seen by staff around 9:30 p.m. and was not discovered missing until the following morning during routine rounds. Interviews with staff revealed a lack of communication and adherence to protocols. The CNA assigned to the resident did not perform the required checks, citing that the resident was independent and did not want her in his room. Additionally, the agency nurse was unaware of the resident's elopement risk, indicating a failure in communication during shift changes. The facility's policies on safety and supervision were not followed, contributing to the resident's ability to leave the facility undetected.
Removal Plan
- Inserviced all staff on care checks
- Systemic change of identifying residents who were an elopement risk
- Inserviced staff on the elopement and abuse/neglect policies
- Implemented colored background name plates for residents who are at risk for elopement
- Implemented ribbons on electronic health records noted for those residents who are an elopement risk
- Implemented documentation for safety checks for residents who were at risk for elopement and resided on an unsecured unit
- Conducted audits to ensure elopement assessments were completed with new admissions and appropriate interventions were in place
Inaccurate Reporting of Resident Elopement Incident
Penalty
Summary
The facility failed to report accurate information regarding an elopement incident involving a resident identified as moderately cognitively impaired and at risk for elopement. The resident was admitted for rehabilitation services, and although the family was informed of the elopement risk, they declined placement in a secured unit. On the night of the incident, the resident left his room and exited the facility without his walker. He was later found in a local park and returned to the facility without incident. The initial facility report inaccurately stated the family had declined secured unit placement, which the family later disputed. The facility's Director of Nursing (DON) admitted to reporting the incident without complete information, and the Administrator acknowledged the report was not intended to be misleading. Video footage confirmed the resident's exit from the facility, and interviews with staff and family highlighted discrepancies in the facility's account of events. The facility's policy for reporting incidents was not clearly followed, contributing to the inaccurate reporting of the elopement incident.
Failure to Follow Physician Orders for Blood Glucose Monitoring, Insulin Administration, and Elastic Wraps
Penalty
Summary
The facility failed to follow physician orders regarding blood glucose monitoring, insulin administration, and elastic wraps for two residents. Resident 90, diagnosed with type 2 diabetes mellitus and hypothyroidism, had specific physician orders for blood glucose monitoring and insulin administration. However, the facility did not obtain the resident's blood sugar as ordered on multiple occasions and failed to administer insulin according to the sliding scale. The clinical record lacked documentation indicating the resident refused the blood glucose monitoring or medication, and the resident was not on leave of absence during the mentioned dates and times. Interviews with staff confirmed the lapses in following physician orders and documentation. Resident 82, diagnosed with morbid obesity, diabetes mellitus, gout, and chronic peripheral venous insufficiency, had physician orders to apply elastic wraps to both legs daily. Observations revealed that the resident's legs were often not wrapped as ordered, and the resident expressed concern about his legs and pain relief from the wraps. The electronic treatment administration record lacked documentation for certain days, and interviews with staff indicated that the resident sometimes refused care, which should have been documented in the electronic medical record. The facility's policy on physician orders, revised recently, indicated that the facility is responsible for carrying out physician orders as written. However, the facility failed to adhere to this policy for both residents, leading to deficiencies in care. Staff interviews confirmed that the orders were not consistently followed, and documentation was incomplete or missing for the specified dates and times.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate monitoring and interventions for pressure injuries for two residents. Resident 5, who had multiple diagnoses including type 2 diabetes mellitus and chronic kidney disease, was observed multiple times wearing non-skid shoes on both feet despite having a physician's order for no shoe on the left foot due to a pressure injury. The clinical record lacked consistent documentation of wound descriptions, measurements, and treatment orders for the pressure injury on the left heel. The wound was initially identified upon readmission from the hospital, but the facility did not implement appropriate interventions or monitor the wound effectively, leading to its deterioration over time. Interviews with staff revealed a lack of awareness and adherence to the treatment orders, and the Kardex report did not include the necessary care interventions for the left heel pressure injury. Resident 120, who had diagnoses including adult failure to thrive and unspecified protein-calorie malnutrition, was observed multiple times without the required offloading boot on his left foot, despite a physician's order for the boot to be worn at all times except during showers and morning or night care. The resident's clinical record indicated a history of a stage 3 pressure ulcer on the left heel, but observations and interviews revealed that the resident frequently did not wear the offloading boot. The facility's documentation did not consistently reflect the resident's refusal to wear the boot or the staff's attempts to ensure its use. The Unit Manager acknowledged the lack of proper documentation and monitoring for the resident's pressure injury care. The facility's failure to adhere to physician's orders and provide consistent monitoring and interventions for pressure injuries resulted in inadequate care for both residents. The lack of proper documentation, staff awareness, and adherence to care plans contributed to the deficiencies observed during the survey. The facility's policies and procedures for pressure ulcer care were not effectively implemented, leading to the identified issues in pressure injury management for Residents 5 and 120.
Failure to Implement Individualized Behavior Monitoring for Dementia Resident
Penalty
Summary
The facility failed to develop and implement a system of individualized behavior monitoring and management for a resident diagnosed with dementia. Resident 85, who has diagnoses including unspecified dementia, Parkinson's disease, delusional disorder, and major depressive disorder, was observed multiple times in a calm state. However, the clinical record lacked detailed documentation of behavioral episodes, including the location, preceding events, staff present, and specific interventions attempted. The facility's documentation primarily consisted of check marks without narrative descriptions, failing to provide comprehensive information necessary for individualized care planning. The resident's care plan included monitoring and recording occurrences of target behaviors and documenting them per facility protocol. Despite this, the progress notes from February 2024 lacked detailed documentation of behavioral events, such as the environment, specific behaviors displayed, and the effectiveness of interventions. Interviews with staff indicated that behaviors were documented by exception and only dangerous behaviors required detailed documentation. This approach resulted in insufficient information to assess and manage the resident's behaviors effectively. The facility's policy on behavior management emphasized the importance of identifying and investigating mood and behavior symptoms to provide appropriate interventions. However, the lack of detailed documentation and individualized behavior monitoring for Resident 85 indicates a failure to adhere to this policy. The deficiency highlights the need for a more thorough and systematic approach to behavior management and documentation to ensure the resident's needs are adequately addressed.
Failure to Label Medications with Resident Identifiers and Directions
Penalty
Summary
The facility failed to ensure medications were labeled with resident identifiers and directions for two of five medication carts reviewed. During an observation, an opened and unlabeled bottle of morphine sulfate oral solution was found in the narcotic drawer of Rehabilitation Unit Medication Cart 2. The bottle lacked identifiers and directions, and the Qualified Medication Aide (QMA) present was uncertain why it was not labeled. The QMA acknowledged that all medications required labels, including resident identifiers, drug name, drug dose, route of administration, and directions for use. She admitted that she should have noticed the unlabeled morphine bottle during her controlled medication count at the beginning of her shift. Additionally, Rehabilitation Unit Medication Cart 1 contained several opened and unlabeled medication bottles, including aspirin, pain relievers, supplements, and other medications, all without resident identifiers or directions for use. The QMA and Licensed Practical Nurse (LPN) present during the observation confirmed that the bottles should have been labeled immediately upon receipt. The facility's policy, revised in April 2019, indicated that all medications maintained in the facility should be properly labeled in accordance with current state and federal guidelines and regulations.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility failed to utilize infection prevention and control strategies during wound care for two residents. For Resident 154, the LPN did not follow proper hand hygiene and glove-changing protocols during wound care. The LPN moved an uncleaned overbed table, handled a contaminated marker, and continued with wound care without changing gloves or performing hand hygiene. This included cleansing and treating abdominal wounds with the same gloves used to handle potentially contaminated items, increasing the risk of infection for the resident who had a history of necrotic pancreatitis, muscle weakness, and required assistance with personal care. The resident had surgical wounds that were worsening and showed signs of infection, as indicated by purulent drainage and dehiscence noted in wound assessments. For Resident 467, the LPNs also failed to follow proper infection control procedures during wound care. One LPN used gloved hands to touch the bed controller and then continued with wound care without changing gloves or performing hand hygiene. Additionally, the LPN used the same gauze to cleanse multiple surgical incisions on the resident's back, rather than using a new gauze for each incision. This resident had a history of spinal fractures and multiple surgical incisions, requiring substantial assistance from staff for daily activities. The improper handling of wound care supplies and failure to maintain hand hygiene protocols posed a risk of infection for the resident. Interviews with the LPNs and the Director of Nursing confirmed that the observed practices did not align with the facility's hand hygiene policy, which mandates hand hygiene before and after handling clean or soiled dressings and after contact with objects in the immediate vicinity of the resident. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of infections, which was not adhered to during the observed wound care procedures.
Failure to Post Nursing Staffing Information
Penalty
Summary
The facility failed to make nursing staffing data readily available in a prominent, easily accessible location for residents and visitors. On multiple occasions, surveyors observed that the required staffing information was either missing or incomplete. For instance, a binder labeled Nursing Daily Schedules was found at the reception desk but lacked specific hours worked and nursing roles such as RN and LPN. Additionally, no staffing information was posted in various units including Evergreen Park, [NAME] Way, Magnolia Lane, Tulip Place, and TCU units during the survey dates. The receptionist and other staff members, including the DON and the Administrator, were unaware of the exact location of the nurse staffing posting, indicating a lack of proper communication and procedure adherence within the facility. During an interview, the DON eventually located the staffing posting behind the reception desk, where it was not visible or accessible to the public. The posting was positioned parallel to a wall, making it difficult to read. The facility's policy on Daily Nursing Staffing Data Posting was provided, which stated that the data should be posted in a visible area and include the number of hours worked by each type of staff. However, the facility failed to adhere to this policy, resulting in the deficiency noted by the surveyors.
Failure to Ensure Valid Nursing License
Penalty
Summary
The facility failed to ensure that an LPN employed in the nursing department had a valid Indiana nursing license or an active out-of-state license valid through an interstate compact agreement. The LPN, who had been employed since February 2023, was found to have a Texas single-state license, which was verified in January 2024. Despite this, the LPN continued to work as a nurse supervisor and provide wound care to residents without the proper licensure for Indiana. The Human Resources Director and Administrator acknowledged the issue but did not provide an explanation for why the compact status was not clarified earlier. The facility's policy required employees to notify the Director of Human Resources of any changes to the status of their licensure. However, this policy was not followed, leading to the LPN working without a valid license for Indiana. The LPN had applied for an Indiana license by endorsement as of the date of the survey, but the deficiency had the potential to impact all 164 residents in the facility. The facility did not offer an explanation as to why the clarification of the compact status had not been obtained following the January 2024 verification, which indicated the employee had a Texas single-state license.
Failure to Supervise Resident with Dementia Leads to Ingestion of Pencil Sharpener Blade
Penalty
Summary
The facility failed to ensure effective supervision for a cognitively impaired resident with dementia, resulting in the resident ingesting a pencil sharpener blade and requiring hospitalization for surgical removal. The resident, diagnosed with Alzheimer's disease and other cognitive impairments, was observed in a wheelchair in the common area and dining room without adequate supervision. The resident's clinical record indicated she required extensive assistance for various activities and was rarely/never understood, with no exhibited behaviors noted in the recent assessment. On the day of the incident, the resident was left unattended with a box of colored pencils, which contained a small pencil sharpener. The resident was found chewing on the sharpener by a CNA, who, along with a nurse, removed plastic fragments and a screw from the resident's mouth but could not locate the blade. The resident was sent to the ER, where an x-ray confirmed the presence of the blade in her stomach, and it was subsequently removed via endoscopy. The resident returned to the facility with minor cuts in her upper airway and throat but no new orders or limitations. Interviews with staff revealed that the pencil sharpener was not typically left out and was usually stored in a toolbox or the medication cart. Video footage showed the resident being left alone at the table multiple times, with staff intermittently checking on her. The facility's policy on safety and supervision emphasized the importance of resident supervision based on individual needs and environmental hazards, which was not adequately followed in this case.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to identify effective, individualized interventions to prevent the elopement of a cognitively impaired resident with a known elopement risk. Resident C, who had a history of elopement and was moderately cognitively impaired, managed to exit the secured unit through his bedroom window. Despite being on a secured unit and having an ankle monitor, Resident C was able to remove the screen from his window and climb outside, walking around the facility before being noticed by staff. This incident occurred after multiple previous elopement attempts and behaviors indicating a desire to leave the facility, which were documented in his clinical records and nurses' notes. Resident C's clinical record indicated multiple diagnoses, including unspecified dementia, depression, and anxiety, among others. He had a history of exit-seeking behavior and had previously eloped from the facility and other locations. Despite these behaviors, a quarterly elopement risk assessment dated 2/20/24 indicated that the resident was not at risk for elopement. However, on 3/25/24, Resident C was found outside the facility after removing the screen from his window and climbing out. He stated that he wanted to talk to someone about residents coming into his room and expressed a desire to have a lock on his door, which was not allowed due to safety concerns. Interviews with staff and observations of video footage confirmed that there was a lapse in supervision, allowing Resident C to exit the building. The CNA and LPN on duty were aware of his agitation and desire to leave but did not prevent his elopement. The resident was observed walking outside without his walker, and staff had to escort him back into the building. The facility's policy on elopement risk assessment was not effectively implemented, as evidenced by the resident's ability to elope despite being on a secured unit and having a history of exit-seeking behavior.
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What surveyors actually found near you
We read the 211 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timbercrest Church Of The Brethren Home | 1.4 mi | ★★★★★ | 12 | 0 |
| Wellbrooke Of Wabash | 13.1 mi | ★★★★★ | 12 | 0 |
| Waters Of Wabash Skilled Nursing Facility East The | 13.1 mi | ★★★★★ | 5 | 0 |
| Waters Of Wabash Skilled Nursing Facility West | 13.2 mi | ★★★★★ | 8 | 0 |
| Autumn Ridge Rehabilitation Centre | 14 mi | ★★★★★ | 4 | 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.