Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare At Parkwood during CMS and state inspections, most recent first.
Two residents with CHF, edema, and lymphedema did not receive ordered weekly weight monitoring as required by physician orders and care plans. For one resident, staff repeatedly documented temperatures instead of weekly weights in the MAR after an order was incorrectly entered in the EHR with a temperature task, and no weights appeared in the vitals section despite ongoing edema and diuretic use. For the other resident, whose plan of care and physician note called for weekly weights and who later had IV furosemide and fluid restriction for worsening edema and shortness of breath, there were no corresponding weight orders or documented weekly or daily weights in the EHR, even though a progress note stated the resident was placed on daily weights. Interviews with nursing, clinical support, and leadership staff confirmed that weight orders were either entered incorrectly or not entered at all, and that monitoring relied on incomplete EHR documentation rather than the actual physician orders.
The facility failed to conduct required quarterly care plan meetings for four residents, as mandated by their policies and federal and state laws. Residents with various medical conditions, including major depressive disorder, dementia, and COPD, did not have care plan meetings within the required timeframe. The Social Service Director confirmed the absence of these meetings, and there was no documentation to support that they occurred.
A resident in a memory care unit was not provided with cognitively stimulating activities as per her care plan. Despite her interest in group activities and crafts, she was observed multiple times alone in her room without engagement. Staff interviews revealed missing resources like a TV remote and no available magazines or coloring books, contrary to her preferences. The facility's policy on activity scheduling was not followed, leading to the deficiency.
The facility failed to maintain sanitary wound care for a resident, with dressings not changed promptly and soiled sheets not replaced. Additionally, the facility did not notify the physician of another resident's blood glucose readings outside the ordered parameters, leading to a lack of documentation and communication. These actions were inconsistent with the facility's policies on physician orders, resident rights, and skin integrity.
The facility failed to obtain consent and offer Influenza and Pneumococcal vaccinations to three residents. Two residents were not documented as being offered these vaccinations, and one resident received an Influenza vaccine without a signed consent. The Administrator acknowledged a lapse in the process, despite existing policies requiring consent and education on vaccinations.
The facility failed to offer COVID-19 vaccinations to three residents as required by policy. One resident had received vaccinations in 2021 and 2022, another in 2021, and a third declined upon admission in 2024, with no further offers documented. The Administrator acknowledged a failure in the follow-through process for obtaining consents and administering vaccinations.
The facility failed to provide effective dementia care, resulting in residents wandering into the room of a resident with aggressive and inappropriate behaviors. Despite care plans addressing wandering and cognitive impairments, incidents continued due to inadequate monitoring and documentation. The facility's actions were insufficient to prevent these interactions, highlighting a deficiency in person-centered care.
The facility failed to re-admit a cognitively impaired resident after hospitalization, did not provide adequate documentation for his discharge, and did not assist in finding alternative placement, leaving the resident at risk of homelessness.
The facility failed to follow up with psychiatric services for a resident with a history of cognitive and behavioral issues, leading to the resident's elopement. Despite repeated exit-seeking behavior and aggressive actions, the facility did not secure psychiatric care or adequately document the incident. The lack of documentation and follow-up contributed to the deficiency cited in the report.
The facility failed to ensure a cognitively impaired resident was safe from an injury of unknown origin, allowed a resident to have vaping materials in their room, and did not prevent recurring falls for a high-risk resident. These deficiencies resulted in a resident sustaining a left arm fracture, another resident having unauthorized vaping materials, and a high-risk resident experiencing multiple falls.
Failure to Implement and Document Ordered Weekly Weights for Residents with CHF and Edema
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights for two residents with CHF, edema, and lymphedema. For one resident, multiple observations over several days showed the resident asleep in a recliner with legs elevated, wearing pants that had been cut from the hem to the calf and appeared wet, with bilateral lower leg edema noted each time. The resident’s care plans, addressing CHF, edema, diuretic use, and nutritional risk, directed staff to obtain and document weights as ordered. A physician’s order dated 12/19/25 specified weekly weights on Tuesday mornings. However, review of the MAR showed that staff documented weekly temperatures instead of weights, and the vitals section of the EHR contained no documentation of the ordered weekly weights. Interviews revealed that the QMA/Scheduler responsible for obtaining weights acknowledged that temperatures were documented instead of weights and that she was responsible for ensuring weights were completed and re-weights obtained for significant changes. An LPN confirmed that the physician’s order was for weekly weights but that temperatures were entered and documented, indicating the order had been entered incorrectly into the EHR. The Clinical Support Nurse explained that the order had been placed in the EHR with a task incorrectly set to “temperature” rather than “weight,” and that the IDT reviewed only the compiled weight report, not the underlying orders, when monitoring residents. The Executive Director stated that a nurse should have caught the entry error when completing the task, and the NP indicated that weights were difficult to monitor because they were not always documented in the same EHR location and that she relied on nurses to notify her of changes. For the second resident, observations documented the presence of a midline IV in the right upper arm and bilateral lower extremity edema, with the resident reporting weight gain from swelling and uncertainty about how often he was weighed. An empty IV bag labeled Furosemide 80 mg IV was observed, and later the midline had been removed while edema persisted. The resident’s diagnoses included CHF, edema, and lymphedema, and a care plan directed that his weight be obtained and documented per order. A physician visit note dated 1/28/26 included a plan to monitor weekly weights, but no weekly weight documentation or corresponding physician order was found in the EHR. A change in condition note on 2/20/26 documented increased edema and shortness of breath and new orders for IV Furosemide and fluid restriction, but did not include weight monitoring. A progress note on 2/25/26 stated that the DON contacted the MD, confirmed IV Lasix 80 mg, and indicated the resident was placed on daily weights, yet no daily weight documentation or physician order for daily weights was found in the EHR. In a later text message, the MD clarified the resident was supposed to be on weekly weights, and the DON acknowledged she had not placed an order for weekly weights in the EHR, contrary to the facility’s policy requiring physician orders to be followed and reviewed.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care plan meetings, as required by their policies and federal and state laws. This deficiency was identified for four residents who were reviewed for care plan conferences. The facility's policy mandates that care plan meetings should be held quarterly, yet these meetings were not conducted for the residents in question during the specified periods. For instance, Resident 36, diagnosed with major depressive disorder, type 2 diabetes, and muscle weakness, had not had a care plan meeting since November 2023. Similarly, Resident 64, with diagnoses including dementia and anxiety disorder, had not had a care plan meeting since October 2023. Resident 75, who has anxiety, schizoaffective disorder, and a history of myocardial infarction, attended a care plan meeting in April 2024, but the subsequent meeting scheduled for July 2024 did not occur. Resident 58, diagnosed with chronic obstructive pulmonary disease, heart failure, and pain, had not had a care plan meeting since July 2024. The Social Service Director confirmed during interviews that the care plan meetings were not held as required, and there was no documentation to support that these meetings took place. The facility's policies emphasize the importance of developing and implementing comprehensive person-centered care plans and ensuring residents' rights to participate in care planning decisions.
Failure to Provide Activities for Resident in Memory Care Unit
Penalty
Summary
The facility failed to provide cognitively stimulating activities for a resident residing in the locked memory care unit, as per the plan of care. The resident, diagnosed with Alzheimer's disease, dementia, and major depressive disorder, was observed multiple times over several days either awake or asleep in her room without engaging in any activities. Despite activities occurring in the lounge, the resident was not invited or escorted to participate, as required by her care plan. The care plan indicated that the resident enjoyed group activities, crafts, painting, and spending time in common areas, yet she was left in her room with the TV off and no other activities available. Interviews with staff revealed that the resident was not a morning person and preferred watching TV, reading magazines, and coloring in her room. However, the TV remote was missing, and there were no magazines or coloring books available in her room. The facility's policy on activity programs stated that group and individual activities should be scheduled according to residents' preferences and schedules, but this was not adhered to for the resident in question. The lack of engagement and failure to follow the care plan led to the deficiency identified by the surveyors.
Deficiencies in Wound Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain a sanitary dressing for a non-pressure wound and did not change soiled bed sheets for Resident 139. Observations revealed that the resident's wound dressing was not changed promptly despite being soaked through with drainage, and the bed sheets were not replaced after being soiled. The resident was not educated on the risks of infection from not keeping the wound dressing clean and dry. The physician's order required daily dressing changes and as needed for soilage, but these were not adhered to consistently. Additionally, the facility did not notify the physician of blood glucose readings outside the ordered parameters for Resident 50. The resident's blood glucose levels were below the threshold set by the physician multiple times, yet there was no documentation of physician notification. The facility's messaging system and call orders were not aligned with the physician's order, leading to a failure in communication and documentation. The facility's policies on physician orders, resident rights, and skin integrity were not followed, resulting in deficiencies in the care provided to the residents. The lack of adherence to these policies contributed to the issues observed with wound care and blood glucose monitoring, impacting the quality of care for the residents involved.
Failure to Obtain Consent and Offer Vaccinations
Penalty
Summary
The facility failed to ensure proper consent and offering of Influenza and Pneumococcal vaccinations for three residents. Specifically, there was no documentation indicating that two residents were offered these vaccinations in 2024 or 2025. Additionally, one resident received an Influenza vaccination without a documented signed consent, and there was no record of a Pneumococcal vaccination being offered. Interviews with the Administrator revealed that obtaining vaccine consents was part of the admission process, but there was a lapse in ensuring that each resident signed or declined the vaccination consent forms. The facility's policies, which were last revised in late 2024 and early 2025, stated that all residents should be offered vaccines unless medically contraindicated, and that residents or their legal representatives should be informed about the benefits and potential side effects of the vaccinations. However, these policies were not effectively implemented, leading to the deficiencies noted.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered to three residents, as required by their policy. Resident 53 had received the COVID-19 vaccination in 2021 and 2022, but there was no documentation indicating they were offered the vaccine after 2022. Similarly, Resident 139 had received the vaccine in 2021, with no subsequent offer documented. Resident 23 declined the vaccine upon admission in 2024, but there was no documentation of any further offer after admission. Interviews with the Administrator revealed that the process of obtaining vaccine consents and ensuring vaccination administration was part of the admission process, but there was a failure in follow-through. The facility's policy required that all residents be offered vaccines unless contraindicated or already vaccinated, and that residents or their legal representatives be informed about the benefits and potential side effects of vaccinations. However, the facility did not adhere to this policy, resulting in the deficiency.
Inadequate Dementia Care Leads to Wandering and Inappropriate Interactions
Penalty
Summary
The facility failed to provide effective person-centered dementia care, resulting in residents on the locked dementia unit wandering into the room of a resident with known aggressive, impulsive, and sexually inappropriate behaviors. This deficiency was observed in four residents who were reviewed on the dementia care unit. The incidents involved residents wandering into the room of a resident who did not have a diagnosis of dementia but had a history of inappropriate sexual behaviors and aggression. The facility's actions to prevent such occurrences were inadequate, as evidenced by multiple incidents where residents entered the room of the aggressive resident, leading to situations where residents were found disrobed and inappropriately interacting. Resident D, who was involved in these incidents, had a history of inappropriate sexual behaviors, delusional disorders, and substance abuse. His care plan included interventions to manage his impaired cognition and behavior episodes, but these measures were insufficient to prevent other residents from entering his room. Despite being moved to the end of the hallway to reduce interactions, Resident D continued to experience incidents where other residents entered his room, leading to aggressive responses. The facility's documentation did not adequately record these interactions, indicating a lack of proper monitoring and intervention. Residents B and C, who wandered into Resident D's room, had their own care plans addressing their wandering behaviors and cognitive impairments. However, the facility's failure to effectively monitor and redirect these residents resulted in repeated incidents of inappropriate interactions. The lack of documentation in the residents' records further highlights the facility's inadequate response to these incidents, as staff were instructed to write statements but did not document the events in the residents' records. This deficiency in care and documentation contributed to the ongoing issues within the dementia care unit.
Failure to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to accept a cognitively impaired resident back after hospitalization and did not adequately document the reason for his discharge. The resident, who had a traumatic brain injury and seizure disorder, was transferred to the hospital after eloping from the facility. Despite the hospital and the guardian requesting the resident's return, the facility refused to accept him back, citing an inability to meet his needs. The facility did not provide a 30-day written notice of involuntary discharge to the guardian and did not assist in finding alternative placement, leaving the resident at risk of homelessness. The resident's record lacked documentation from a physician or the facility for a permissible reason for his permanent discharge. The facility's documentation indicated the resident was transferred for behavior problems but did not provide specific details. The hospital's records showed that the resident was brought in for a psychiatric evaluation and had no aggressive behavior en route or in the emergency room. The facility's Executive Director claimed the resident was a danger to himself and others, but there was no detailed documentation to support this claim. Interviews with facility staff revealed inconsistencies in their accounts of the events. The Executive Director stated that the hospital never made a referral for the resident's return, while the hospital's social worker documented multiple attempts to contact the facility. The facility's policy required written notice and documentation for transfers and discharges, which were not adequately followed in this case. The facility's failure to document the resident's needs and the reasons for discharge, along with the lack of proper communication and assistance in finding alternative placement, led to the deficiency.
Failure to Secure Psychiatric Services for Resident B
Penalty
Summary
The facility failed to follow up with psychiatric services for Resident B, who had a history of cognitive communication deficit, encephalopathy, epilepsy, traumatic brain injury, and other conditions. Despite the resident's repeated exit-seeking behavior and aggressive actions, the facility did not secure psychiatric care or adequately document the elopement incident. On 2/15/24, Resident B exhibited agitated behavior, threatening staff and attempting to leave the facility. Although a referral was made to an inpatient psychiatric hospital, the admission was declined, and no further psychiatric services were sought. On 2/16/24, Resident B continued to show signs of anxiety, and a new medication order was placed to manage his condition. Despite these measures, the resident's care plan, which included monitoring for exit-seeking behavior, did not result in effective intervention. On 3/2/24, Resident B again expressed a desire to leave the facility, and staff noted his ongoing exit-seeking behavior. However, there was no documentation of additional attempts to secure psychiatric services or hospital admission for the resident. The facility's Executive Director (ED) and Director of Nursing (DON) confirmed that no other psychiatric hospitals or services were contacted to evaluate Resident B. The DON indicated that due to the resident's age, no psychiatric service companies were willing to come to the facility. The lack of documentation regarding efforts to obtain psychiatric care and the failure to follow up with additional services contributed to the resident's elopement and the deficiency cited in the report.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a cognitively impaired and dependent resident was safe from an injury of unknown origin. Resident F, who had severe cognitive impairment and was totally dependent on staff for transfers and other activities of daily living, sustained a left arm fracture. The facility did not complete an investigation to identify the root cause of the injury, and there was no documentation to show how the injury occurred. The resident's care plan did not reflect the most recent assessment indicating total dependence on staff, and the facility did not provide sufficient documentation to corroborate the suspicion of a fall as the cause of the injury. The facility also failed to ensure that a resident did not have vaping materials in their room. Resident 72, who had a cognitive communication deficit and other diagnoses, was observed with two vapes in their room. The facility's policy prohibited any type of smoking or vaping materials in resident rooms. Despite this, Resident 72 admitted to occasionally using the vape in their room, and the facility staff were unaware of this violation. Additionally, the facility failed to prevent recurring falls for a resident identified as high risk for falls. Resident H, who had multiple diagnoses including hemiplegia, repeated falls, and altered mental status, experienced several falls, including one from a shower bed and another from her bed. The facility's interventions were not effective in preventing these falls, and there were lapses in staff adherence to safety protocols, such as leaving the resident unattended on an unlocked shower bed with the side rails down. The resident expressed fear of falling again, indicating ongoing concerns about her safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 678 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homewood Health Campus | 1.5 mi | ★★★★★ | 1 | 0 |
| Witham Extended Care | 1.7 mi | — | 0 | 0 |
| Waters Of Lebanon, The | 3 mi | ★★★★★ | 11 | 0 |
| Restoracy Of Whitestown, The | 7.7 mi | ★★★★★ | 5 | 0 |
| Zionsville Meadows | 12.1 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Signature Healthcare At Parkwood.
100% money-back within 48 hours.
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.