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 St Mary Healthcare Center during CMS and state inspections, most recent first.
Surveyors found staff personal beverages stored on a food preparation counter next to food items and improperly stored frozen chicken in the walk-in freezer, including an opened bag containing a single chicken breast with ice buildup and a large box of chicken left in an untied bag with the lid wide open. The Dietary Manager and dietary staff acknowledged that staff drinks should not be kept in the kitchen and that opened chicken should be properly sealed, contrary to the facility’s Culinary Services policy requiring proper storage and moisture-proof wrapping of frozen foods.
The deficiency involves failure to follow physician orders for medication administration and to obtain required admission weights for three residents. A resident with hypotension and other conditions had midodrine ordered with specific systolic BP hold parameters, but MAR review showed the drug was both given when BP exceeded the hold threshold and withheld when BP was within the ordered range. Two other residents with multiple comorbidities did not have admission weights obtained as ordered or upon admission, with one resident’s first weight documented several days after arrival. Staff interviews revealed that medications should not be given or held outside parameters and that admission weights were expected at or near the time of admission, while facility policies required medications to be administered as prescribed and weights to be taken upon admission to establish a baseline.
A resident was discharged to a group home with paperwork indicating she required extensive assistance with daily activities, despite being independent in these areas. The DON later confirmed the discharge assessment was incorrect and was unaware that the inaccurate information had been sent.
Staff did not consistently serve meals to residents at the same table together, with plates distributed randomly rather than by table, and a staff member was observed eating while standing instead of sitting with residents. Additionally, a resident was removed from the dining room before finishing his meal to receive a shower, requiring his meal to be retrieved later. These actions did not align with facility policies on resident dignity and family-style dining.
A resident with multiple chronic conditions had a DNR form completed and signed, but the physician's order in the electronic chart was not promptly updated to reflect the new DNR status. Staff interviews confirmed that while the DNR form was uploaded, the order remained as full code for a period, resulting in a failure to ensure the resident's wishes were accurately documented.
Two residents were not provided with required SNF ABN and NOMNC forms when their Medicare Part A services were discontinued before benefit days were exhausted. The DON confirmed that beneficiary notices were not being completed as required prior to a recent policy change.
A resident with a history of schizophrenia, bipolar disorder, and cognitive communication deficit had conflicting information in their clinical record, with mental health diagnoses incorrectly entered into the MDS assessment. The DON and MDS Coordinator confirmed these diagnoses were inputted in error, and the facility lacked a specific MDS policy, relying instead on RAI guidelines.
A resident with multiple chronic conditions experienced unwitnessed falls, and staff failed to document the required 72-hour follow-up vital signs and neurological assessments as outlined in facility policy. Interviews confirmed that neurological checks were not initiated and documentation was not completed by a new nurse, resulting in incomplete post-fall monitoring records.
A resident's medical record contained incorrect diagnoses of schizophrenia and bipolar disorder, which were also reflected on the resident information sheet. The DON confirmed these diagnoses were inaccurate and should not have been listed, and the facility could not provide an accurate records policy.
The facility did not document the time when TB skin tests were read for four employees, as required by its infection control policy. Forms showed the dates of administration and reading, but the time was missing, despite policy and staff interview confirming this information should be recorded.
A resident with severe cognitive deficits and under hospice care did not receive prescribed Morphine concentrate due to unavailability, and there was no pain assessment documented. The facility staff failed to notify the physician, family, or hospice, and did not use the Emergency Drug Kit. Two staff members were terminated for not following facility policies.
The facility failed to ensure proper documentation and handling of medications, particularly narcotics, with missing signatures and discrepancies in records. The narcotic sign-in and sign-out record book lacked 66 nursing staff signatures, and the medication destruction logbook had 24 errors, including missing dates and resident names. Additionally, there were discrepancies between narcotic logbook entries and resident MARs for 14 residents, with 61 errors noted. The Regional Clinical Support nurse acknowledged staff errors, leading to the termination of two staff members for policy violations.
The facility failed to administer medications within the ordered time frame for multiple residents, did not accurately assess and document a resident's dental status, and did not provide appropriate positioning equipment for a resident, leading to inadequate care and support.
The facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for a resident with epilepsy. Despite a physician's order for lamotrigine, the care plan did not address the risk for seizures, monitoring seizure activity, or safety measures. Interviews confirmed the omission, which contradicted the facility's policy on comprehensive care plans.
The facility failed to evaluate and document the effectiveness of post-fall interventions before removing them from the care plans of two residents. One resident experienced multiple falls, and interventions were not included in the care plan or documented for resolution. Another resident's intervention to offer activities after lunch was also not included in the care plan, with no documentation of its effectiveness.
The facility failed to monitor a resident on a fluid restriction related to dialysis, resulting in the resident exceeding the daily fluid limit on multiple occasions. Staff were unaware of the restriction, and the resident did not have a care plan for noncompliance with fluids.
The facility failed to monitor seizure medication side effects and seizure activity for a resident prescribed lamotrigine. The care plan lacked safety measures for seizures, and the facility did not confirm the seizure disorder diagnosis. Additionally, there was no attempt at a gradual dose reduction for the medication when given for mood disorder.
The facility failed to ensure timely AIMS assessments for a resident prescribed antipsychotic medications, with initial and subsequent assessments not completed according to policy. The resident had multiple diagnoses, including dementia and anxiety, and was at risk for adverse reactions.
The facility failed to maintain a clean and odor-free environment, with strong odors in hallways and rooms, damaged walls and doors, and wet carpets posing risks to residents. Ongoing sewage system issues contributed to the odors, and the facility's wall maintenance policy was not effectively implemented.
Improper Food Storage and Staff Beverages in Kitchen Preparation Area
Penalty
Summary
The deficiency involves improper food storage and the presence of employee beverages in the food preparation area, affecting the kitchen that serves all 65 residents. During a kitchen observation with the Dietary Manager, surveyors observed two unopened cans of energy drinks and a white cup with a lid and straw stored on a food preparation counter next to a jar of peanut butter and a loaf of bread. The Dietary Manager stated these drinks belonged to staff and acknowledged that staff were not supposed to store any personal food or drinks in the food preparation area. Dietary Staff later confirmed that staff should never leave their personal drinks or food in the kitchen. Additional observations in the walk-in freezer showed improper storage of frozen chicken. On the second shelf, there was a large opened plastic bag containing one skinless chicken breast with a small amount of ice buildup on the upper left corner, and a large cardboard box of skinless chicken breasts with the plastic bag left untied and the cardboard lid wide open. The Dietary Manager confirmed that the clear package containing the single chicken breast was open with ice on the edges and that the box of opened chicken should have been tied and not left open to air. These practices were inconsistent with the facility’s Culinary Services policy, which requires that food and supplies be properly stored and that all foods in the freezer be wrapped in moisture-proof wrapping or placed in suitable containers, labeled and dated, to keep foods safe and preserve quality.
Failure to Follow Medication Parameters and Obtain Timely Admission Weights
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medication administration and to obtain required admission weights for multiple residents. For one resident with hypotension, vitamin deficiency, acute kidney failure, and iron deficiency anemia, a care plan dated 3/19/26 identified potential for cardiovascular distress and included an intervention to administer medications as ordered. A physician’s order dated 3/11/26 directed administration of midodrine 5 mg four times daily, to be held for systolic blood pressure greater than 110. Review of the MAR from 3/11/26 through 3/25/26 showed midodrine was administered despite systolic blood pressures above the ordered hold parameter on several occasions, including readings of 167, 129, 112, 114, 111, and 127. The MAR also showed midodrine was held when it should have been given on multiple occasions when systolic blood pressure was at or below 110, with readings ranging from 100 to 110. The DON and an LPN confirmed during interviews that medications should not be administered or held outside of ordered parameters and that the MAR would reflect when medications were not given and the reason. The deficiency also includes failure to obtain admission weights as ordered or per facility guidelines for two residents. For one resident with diastolic congestive heart failure, dementia, type 2 diabetes mellitus, and anxiety disorder, a physician’s admission order dated 7/31/25 required a one-time weight, but no admission weight was found in the clinical record, and the DON stated the first weight was not obtained until 8/5/25. For another resident with cellulitis of the right lower limb, pulmonary fibrosis, dementia, diabetes mellitus, and hypertension, the resident was admitted on a specified date, but the admission weight was not obtained until three days later. Staff interviews revealed inconsistent understanding of when admission weights should be obtained: the Clinical Support Nurse stated the policy did not specify timing, while an LPN, another LPN, and a QMA each indicated admission weights should be obtained at admission, by the end of the admission shift, or within 24 hours. The facility’s Medication Administration General Guidelines policy stated medications are to be administered as prescribed, and the Guidelines for Weight Tracking policy stated residents will have their weight taken and recorded upon admission to establish a baseline.
Inaccurate Discharge Paperwork Provided to Receiving Facility
Penalty
Summary
The facility failed to ensure that accurate discharge paperwork was provided to the receiving facility for a resident who was being transferred to a group home. The discharge assessment sent with the resident indicated that she required assistance with eating, hygiene, toileting, showers, lower body dressing, and putting on and taking off footwear. However, interviews and record review revealed that the resident was actually independent in these areas and did not require such assistance. The Director of Nursing confirmed that the discharge plan was incorrect and was not aware that the inaccurate assessment had been sent with the resident. The resident involved had diagnoses including asthma, tracheostomy status, and congenital malformation of the musculoskeletal system, but was cognitively intact and capable of making her own decisions. The clinical record and nursing progress notes documented the discharge planning process, including meetings with the resident and family, and the actual discharge to the group home. Despite this, the discharge narrative provided to the receiving facility did not accurately reflect the resident's functional status at the time of transfer.
Failure to Ensure Dignified Dining Experience and Resident Rights
Penalty
Summary
The facility failed to uphold residents' rights to dignity and a respectful dining experience in the legacy dining room. Staff did not serve meals to residents at the same table together, instead distributing plates randomly based on meal tickets, contrary to the usual practice of serving one table at a time. Interviews with staff confirmed confusion and inconsistency in meal service procedures, with some staff following instructions to serve by ticket order and others expressing that serving by table was the standard. Additionally, a staff member was observed eating while standing next to residents rather than sitting with them, which was acknowledged by both the staff member and the DON as inappropriate and not in line with facility policy, which encourages staff to sit and eat with residents to promote a dignified, family-style dining environment. A resident was also removed from the dining room by a hospice CNA before completing his meal to receive a shower, despite having only finished his soup and waiting for the main course. The resident was returned to the dining room after the shower, at which point his meal had to be retrieved from the kitchen as other residents had already been served. Staff interviews and facility policy indicated that showers should not be given during mealtimes except in extreme situations, such as incontinence. The facility's own policies emphasize serving residents together, respecting their dignity, and providing a fine dining experience, all of which were not consistently followed during the observed incidents.
Failure to Timely Update DNR Order in Resident Record
Penalty
Summary
The facility failed to ensure that a do not resuscitate (DNR) order was updated in a timely manner for a resident with multiple complex medical diagnoses, including heart failure, coronary artery disease, hypertension, Parkinson's disease, type 2 diabetes, obesity, schizophrenia, iron deficiency anemia, and hypothyroidism. The resident initially had a physician's order indicating full code status. Subsequently, a State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form was completed and signed by the resident's representative and a witness, and later by the physician. Despite the completion of the DNR form, there was a delay in updating the physician's order to reflect the resident's new DNR status. Interviews with staff revealed that while the signed DNR form was uploaded into the resident's electronic chart, the corresponding order was not immediately updated to match the form. The Director of Nursing acknowledged that there were instances where the form was uploaded but the orders were not updated accordingly, which led to the deficiency.
Failure to Issue Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents who were discharged from Medicare Part A services before exhausting their benefit days. For both residents, documentation showed that Medicare Part A services were discontinued, but there was no evidence that the appropriate beneficiary notices were issued at the time of discharge. The Director of Nursing confirmed during an interview that beneficiary notices were not being completed prior to February of the current year. Facility policy required that NOMNCs be issued prior to therapy discharge and, if Medicare days remained, that both SNF ABN and NOMNC forms be provided, but this was not followed for the residents in question.
Incorrect Coding of MDS Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a history of schizophrenia, bipolar disorder, and cognitive communication deficit. The resident's clinical record included conflicting information: a Preadmission Screening and Resident Review (PASARR) indicated no known mental health conditions, while a resident information sheet reviewed by a physician listed schizophrenia and bipolar disorder as diagnoses. The admission MDS assessment did not indicate a diagnosis of schizophrenia, but a subsequent significant change in status MDS assessment did. Physician's orders did not include any antipsychotic medications for these conditions. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the diagnoses of schizophrenia and bipolar disorder were incorrectly entered into the MDS assessment, and these errors were later identified and removed. The facility did not have a specific MDS policy and relied on RAI guidelines.
Failure to Document Post-Fall Vital Signs and Neurological Assessments
Penalty
Summary
The facility failed to ensure that vital signs and neurological assessments were documented for a resident following unwitnessed falls. The resident, who had diagnoses including hypertension, chronic kidney disease, type 2 diabetes mellitus, and urinary retention, experienced unwitnessed falls on two separate occasions. In both instances, the clinical records and incident reports did not include documentation of the required 72-hour follow-up vital signs or neurological assessments. Interviews with the DON confirmed that neurological assessments were not initiated after one of the falls, and documentation was not started for the other. A nurse involved was new and did not initiate the required records. Facility policies required that nursing staff monitor and document the resident's response and effectiveness of interventions for 72 hours following a fall, including completing and documenting neurological assessments and vital signs. Staff interviews confirmed that the expected practice was to assess for injuries and complete vital signs and neurological checks every shift for 72 hours, with documentation in the electronic health record. However, these procedures were not followed or documented as required for the resident after the unwitnessed falls.
Inaccurate Resident Diagnoses Documented in Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record by listing incorrect diagnoses. Review of the clinical record for one resident showed diagnoses of schizophrenia and bipolar disorder, as well as a cognitive communication deficit. The resident information sheet, last reviewed by the physician, also included schizophrenia and bipolar disorder. However, physician's orders did not include any antipsychotic medications for these conditions. During interviews, the DON confirmed that the resident did not have schizophrenia or bipolar disorder and acknowledged that these diagnoses were incorrectly listed. Additionally, the facility was unable to provide an accurate records policy upon request.
Failure to Document Time of TB Test Readings for Employees
Penalty
Summary
The facility failed to follow its policy and procedure for administering and documenting two-step Mantoux skin tests for tuberculosis for four out of five employees reviewed. Specifically, for each of the employees, the facility's forms indicated the dates the TB tests were administered and read, but there was no documentation of the time the tests were read, as required by facility policy. The policy states that both the date and time of administration and reading must be recorded. During an interview, an LPN confirmed that all information, including lot number, date, time, and initials, should be documented when administering and reading TB tests, and that the tests should be read within 48-72 hours. The facility's current policy, reviewed and provided by the DON, also specifies that the administration and reading of the Mantoux test must include the date and time. The lack of time documentation for both steps of the TB test for these employees constitutes a failure to follow established infection control procedures.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received medications as per the physician's order, specifically for a resident with Alzheimer's disease, dementia, chronic kidney disease, and anxiety who was under hospice care. The Medication Administration Record (MAR) showed that the resident did not receive the prescribed Morphine concentrate every 6 hours on multiple occasions over a three-day period. The medication was reportedly unavailable for administration, and there was no documentation of pain assessment during this time. Additionally, the physician, family, and hospice were not notified of the missed doses, and the Emergency Drug Kit was not utilized. Interviews revealed that the errors were attributed to facility staff, leading to the termination of two staff members for not adhering to the facility's policies and procedures. The facility's policies required that medication administration be recorded immediately after administration and that controlled drugs have a corresponding count sheet. However, there was no documentation of pain assessment for the resident during the days in question, and the resident was only given routine Tylenol. The lack of adherence to these policies contributed to the deficiency in care provided to the resident.
Medication Documentation and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and handling of medications, particularly narcotics, as evidenced by missing signatures and discrepancies in medication records. The narcotic sign-in and sign-out record book was missing 66 nursing staff signatures over a period of more than a month. Additionally, the medication destruction logbook contained 24 errors, including missing dates, resident names, quantity amounts, and nursing signatures. Furthermore, there were significant discrepancies between the narcotic logbook entries and the resident Medication Administration Records (MAR) for 14 residents, with 61 errors noted over a two-month period. The narcotic book indicated that 32 medications were withdrawn, but the MAR did not reflect their administration, while the MAR showed 29 medications were administered without corresponding withdrawals in the narcotic record logs. During an interview, the Regional Clinical Support nurse acknowledged that documentation errors were made by the staff, and two staff members were terminated for not adhering to the facility's policies and procedures. The facility's policies, which were revised in 2018 and 2016, respectively, outlined the requirements for medication destruction and narcotic count documentation. These policies required detailed entries in the controlled substance accountability record/book and the MAR immediately after medication administration. The deficiencies were identified during a survey related to a specific complaint, highlighting lapses in the facility's medication management practices.
Medication Administration and Care Plan Deficiencies
Penalty
Summary
The facility failed to administer medications within the ordered time frame for multiple residents. Resident 40, diagnosed with type 2 diabetes mellitus, heart failure, edema, and chronic kidney disease, had a physician's order for buspirone to be administered three times a day within specific time frames. However, the medication was repeatedly given outside the ordered times, often in the early morning hours, without notifying the physician. Similar issues were observed with Resident 47, who was prescribed Eliquis, and Resident 1, who was prescribed baclofen. Both residents received their medications outside the ordered times, and there was no documentation indicating that the physician was informed of these deviations. The DON and QMA were unable to provide a clear explanation for these early administrations. The facility also failed to accurately assess and document Resident 46's dental status. The resident's clinical record contained conflicting information about her dental condition. While some records indicated she was edentulous, other notes suggested she had upper and lower dentures. Observations revealed that the resident had no upper teeth and several natural lower teeth, but there was no clear documentation or follow-up on her dental needs. Interviews with staff indicated a lack of awareness and inconsistency in the resident's dental care, with some staff unsure about the presence of dentures and others noting that the resident had lost her dentures at a previous facility. Additionally, the facility did not provide appropriate positioning equipment for Resident 27, who was observed sitting in a Broda chair without leg rests or foot supports, making it difficult for her to eat comfortably. The resident's care plan did not include the use of a Broda chair, and there was no physician's order for it. Hospice staff noted that the resident's wheelchair was being used for another resident, and the Broda chair provided by the facility was broken. The facility failed to communicate effectively with hospice about the resident's needs and did not update the care plan to reflect the current situation, leading to inadequate positioning and support for the resident.
Failure to Include Seizure Disorder in Care Plan
Penalty
Summary
The facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for a resident with epilepsy. The resident's clinical record indicated diagnoses including epilepsy, dementia with behavioral disturbance, delusional disorder, depression, anxiety disorder, and insomnia. A physician's order prescribed lamotrigine, an anticonvulsant, for epilepsy. However, the care plan did not address the risk for seizures, monitoring seizure activity, or safety measures for seizures. Additionally, the care plan did not include the resident's anticonvulsant medication or approaches for monitoring its side effects. Interviews with the Clinical Support Nurse and the Director of Nursing confirmed that the facility had not included monitoring for seizures in the care plan. The facility's policy on comprehensive care plans indicated that care plan interventions should reflect risk areas or disease processes impacting the resident and should be revised to reflect changes in the resident's condition. Despite this policy, the care plan for the resident remained incomplete and did not address the necessary monitoring and safety measures for the resident's seizure disorder and medication side effects.
Failure to Evaluate and Document Post-Fall Interventions
Penalty
Summary
The facility failed to ensure post-fall interventions were evaluated for effectiveness and documented before being removed from the care plans of two residents. Resident 23, diagnosed with malignant neoplasm of the pancreas, unspecified dementia with behavioral disturbance, and chronic kidney disease stage 3, experienced a fall while ambulating with a walker. An intervention for hospice to re-evaluate the use of the ambulatory device and weakness was noted but not included in the current care plan, nor was there documentation of its resolution. Another fall resulted in an acute metatarsal injury, and a new intervention for staff to toilet the resident in the morning was also not included in the current care plan. Resident 54, diagnosed with unspecified dementia with anxiety, heart failure, type 2 diabetes mellitus, chronic kidney disease stage 3, repeated falls, and difficulty in walking, was found on the floor in his room. An intervention to encourage and offer activities after lunch was noted but not included in the fall care plan. The Director of Nursing indicated that interventions would be removed if the root cause of the fall changed, but there was no documentation to indicate whether the interventions were effective or no longer applied. The facility's Fall Management Program Guidelines require thorough investigation, reassessment, and updating of care plans, which was not followed in these cases.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper monitoring of a resident on a fluid restriction related to dialysis. Resident 47, who had diagnoses including dependence on renal dialysis, diabetes mellitus, depression, and end-stage renal disease, had a care plan indicating a potential for weight fluctuations and alterations in labs due to dialysis treatments. The care plan included interventions such as limiting fluid intake if a fluid restriction was ordered. A physician's order dated 12/28/23 specified a daily fluid restriction of 1200 milliliters, with specific amounts to be given during meals and different shifts. However, a facility vitals report indicated that the resident exceeded the daily fluid restriction on 17 out of 25 days between 4/1/24 and 4/25/24. Interviews revealed that CNA 4 was unaware of the resident's fluid restriction and had not recently reviewed the care plan. The Director of Nursing (DON) confirmed the resident was on a fluid restriction and acknowledged that the resident did not have a care plan for being noncompliant with fluids. The resident herself indicated awareness of the need to limit fluid intake due to dialysis. The facility's policy on fluid restrictions, revised on 12/1/21, outlined procedures for monitoring and documenting fluid intake, but these were not effectively implemented for Resident 47.
Failure to Monitor Seizure Medication and Activity
Penalty
Summary
The facility failed to include monitoring for seizure medication side effects and seizure activity for Resident 29, who was prescribed lamotrigine. The resident's clinical record did not include a care plan for monitoring seizure activity or side effects of the anticonvulsant medication. The care plan also lacked safety measures for seizures, despite the resident having a diagnosis of epilepsy. Interviews with the Clinical Support Nurse and the DON revealed that the facility did not have a clear reason for the lamotrigine prescription and had not confirmed the seizure disorder diagnosis. The DON later concluded that Resident 29 did not have a seizure disorder after reviewing all records and attempting to contact the family for confirmation. Additionally, the facility did not attempt a gradual dose reduction for the lamotrigine when it was given for mood disorder rather than seizure disorder. The facility's policy on psychotropic medication usage and gradual dose reductions emphasized the need for appropriate use, evaluation, and monitoring by the interdisciplinary team. However, the facility failed to adhere to this policy, as there was no regular monthly review of the antipsychotic medication for continued need, appropriate dosage, side effects, risks, and benefits for Resident 29.
Failure to Conduct Timely AIMS Assessments for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure timely assessments for side effects of antipsychotic medications for one resident. Resident 54, who had diagnoses including unspecified dementia with anxiety, major depressive disorder, anxiety disorder, and a cognitive communication deficit, was prescribed olanzapine and Risperdal without timely completion of the Abnormal Involuntary Movement Scale (AIMS) assessments. The initial AIMS assessment for olanzapine was completed 27 days after the medication was ordered, and the subsequent AIMS assessment was completed 7 months and 4 days after the initial assessment. Additionally, there was no diagnosis provided with the physician's orders for these medications. The facility's policy required AIMS assessments to be completed prior to or at the earliest possible time after the medication was prescribed and every six months thereafter. However, the Director of Nursing (DON) confirmed that the AIMS assessments were not completed according to the facility's policy. The failure to conduct timely AIMS assessments for Resident 54, who was at risk for adverse reactions related to antipsychotic medications, was a significant oversight in monitoring and managing the resident's medication regimen.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for residents, staff, and the public. Observations revealed strong odors in various hallways and rooms, with the back hallway near the riser room and the chapel being particularly affected. The dementia unit dining room had walls with gouges and black marks on the doors, while the carpet in the hallways was faded and stained. Additionally, a urine-soaked brief was found in the trash can of a bathroom, contributing to a strong urine odor. Another room had very wet and slick carpet, posing a risk to residents walking on it with non-skid socks that became wet. The front hallway also had a foul, unidentifiable odor that was neither urine nor bowel movement-related. The Maintenance Director confirmed ongoing issues with the sewage system, which contributed to the odors, and noted that repairs were needed but had not yet been completed. The Executive Director acknowledged the wet carpet issue and the sewer smells, especially in the back hall, which were exacerbated by rain. The facility's current policy on wall maintenance was not effectively implemented, as evidenced by the damaged and poorly maintained walls and doors in several rooms and common areas.
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 122 citations issued within 25 miles in the last 12 months — including the 1 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 Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs At Lafayette, The | 0.3 mi | ★★★★★ | 9 | 0 |
| Rosewalk Village At Lafayette | 0.3 mi | ★★★★★ | 2 | 0 |
| Saint Anthony Rehab And Nursing Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Majestic Care Of Lafayette | 2.3 mi | ★★★★★ | 16 | 0 |
| Creasy Springs Health Campus | 2.6 mi | ★★★★★ | 13 | 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.