Below 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 Waters Of Batesville, The during CMS and state inspections, most recent first.
Unsanitary food storage and preparation practices were observed in the kitchen and resident snack refrigerator. Clean trays, dish racks, the steam table area, and the plate warmer had crumbs, splatters, gray streaks, and black grit; dry storage items were contaminated with grit; hot foods were found below required temps; the DM was unclear on dishwasher type and temperature standards; and the dishmachine log showed repeated low rinse temps with no out-of-range entries circled. The resident snack refrigerator also contained unlabeled outside food items without a resident name or room number.
Food was not consistently palatable or served at proper temperatures. Dietary staff were unaware of checking steam table temps before service, and meal observations found pureed and mechanical soft items below acceptable temps, with a test tray described as cold, bland, and difficult to chew. Multiple residents and a family member reported that food delivered to rooms was often cold and unappealing, and a later tray check found hot items at 110 to 113 degrees Fahrenheit, below the 135-degree threshold stated by the Regional Dietary Manager.
Failure to initiate a baseline dialysis care plan for a resident with ESRD. The resident was severely cognitively impaired and was receiving dialysis a few times a week, but the clinical record lacked a baseline care plan for dialysis within the required 48-hour admission window. The MDS Coordinator stated a dialysis care plan should have been completed, and facility policy required a Baseline Care Plan to be completed and implemented within 48 hours of admission.
Incontinence care for a resident with moderate cognitive impairment, Parkinson’s disease, and recent UTI treatment was observed to be performed inconsistently with the facility’s perineal care policy. A CNA kept the resident’s legs close together, used washcloths with feces on them, did not fully separate the labia or dry the area, and completed care without ensuring the periarea was thoroughly cleaned; an LPN, QMA, and ADON confirmed the resident had no contractures and described the expected female pericare process.
Improper Medication Storage and Labeling: Surveyors found an unattended medication cup with an unknown powder at the nurses' station, an unlocked treatment cart containing resident-labeled creams and cleansers, a medication cart with a half full Lantus insulin pen lacking an opened date and unlabeled pudding cups, and another medication cart containing loose pills and paper debris. An LPN stated the powder may have been nystatin, the pudding should have been dated, and loose pills should not have been in the cart.
An LPN failed to follow EBP during wound care and feeding tube care for a resident with a heel wound history, obstructive hydrocephalus, and an unhealed stage 2 pressure ulcer. During dressing change, the nurse handled supplies inconsistently, reentered the room with an opened ABD pad in her bare hand, and did not recognize the resident was on EBP despite the door sign requiring gown and gloves. During feeding tube medication and supplement administration, the LPN entered without a gown even though the EBP sign directed staff to wear gloves and a gown for device care.
Delayed Response to Resident Call Light: A resident reported staff did not always answer the call light promptly, sometimes taking up to an hour. During observation, the resident’s call light remained on for several minutes while an RN sat at the nurses’ station, assisted another CNA, and later left the station, before a CNA finally answered it. The resident stated he needed the restroom, urinated on himself, and almost did not make it to the bedpan.
A cognitively intact resident with cellulitis and lymphedema-related needs was unable to get to a specialist because the facility could not secure safe transportation. Staff documented repeated attempts to schedule the appointment, but the office had no openings and the resident’s bariatric weight prevented transport on the available stretcher, leaving no safe way to reach the clinic.
Failure to notify the MD of abnormal BP and BG readings for two residents. One resident with HTN had multiple systolic BP readings above the ordered notification threshold, and another resident with DM had repeated BG readings above the ordered limit. EMARs and progress notes lacked documentation that the MD was notified, although an LPN stated such notifications and any new orders would normally be documented in the chart.
Failure to Follow Medication Parameters and Daily Weight Orders: The facility did not follow a physician order for Midodrine with SBP hold parameters for one resident, administering the medication when SBP was above the ordered limit on multiple occasions. The facility also failed to obtain and document daily weights for another resident despite an open-ended order for daily weight monitoring; staff interviews confirmed that ordered weights should be taken and recorded.
Two cognitively intact residents with multiple comorbidities, including cerebral palsy, HF, diabetes, and bowel/bladder incontinence, reported that a CNA used profane, demeaning, and hostile language toward them, delayed or begrudged assistance with toileting, and displayed irritable, dramatic behavior during care that made them uncomfortable. Other staff and residents had previously observed and reported the CNA being verbally rude, impatient, and snappy with residents. These behaviors conflicted with facility policies prohibiting condescending or profane speech and any disparaging or derogatory verbal language that constitutes abuse.
A resident with traumatic and anoxic brain injury, anxiety, and depression, who was cognitively intact and exhibiting depressive symptoms, told an LPN they wanted to kill themself after being informed they could not receive additional Adderall. The LPN documented the resident as a danger to self or others for suicide potential and notified the physician, and the resident was placed on frequent checks. However, the comprehensive care plan was not updated to include suicidal ideation or related interventions until weeks after this documented suicidal statement, despite facility policy and the social services director’s acknowledgment that such a statement constitutes suicidal ideation requiring care planning.
Surveyors found that the facility failed to adequately supervise two residents, one with dementia and elopement risk and another on suicide-related 1:1 observation. A resident with a wander guard and a documented history of exit-seeking was able to learn a door code, leave the building unsupervised, and was later found outside minimally clothed, cold, and with minor scratches. At the same time, both this resident and another on 1:1 observation were monitored by a single staff member seated in a hallway between their rooms, often without continuous direct visual contact and with no staff stationed in the main hallway leading to exit doors. Staff and facility policy defined 1:1 as continuous direct visual surveillance, yet interviews confirmed that one staff was assigned to both residents and might have to let one resident walk away if the other could not be left, demonstrating a failure to provide the ordered level of supervision and to keep the environment free of accident hazards.
A facility failed to follow proper medication administration protocols, including incorrect priming of an insulin pen and not adhering to hold parameters for blood pressure medications. Residents received medications without appropriate monitoring of vital signs, contrary to physician orders.
The facility did not maintain the required RN coverage for eight consecutive hours a day on 16 out of 21 days reviewed. The nursing schedule showed a lack of RN presence on several weekends from July 2024 to February 2025. The DON admitted to staffing issues, and the facility's policy requires RN coverage for at least eight hours daily, which was not met.
The facility failed to store medications appropriately, with issues such as unlabeled insulin pens, loose pills in medication carts, and outdated Tuberculin serum in the medication room. An LPN identified an insulin pen without a resident's name and labeled it before administration. The facility's policy requires safe and secure storage, but observations showed non-compliance.
A facility failed to notify a physician when a resident's blood glucose levels exceeded the threshold set in medical orders. The resident, with multiple health conditions including diabetes, had orders for insulin administration and required physician notification if glucose levels were above 351. Despite several instances of elevated glucose levels, the physician was not informed. Interviews with staff confirmed the oversight, which was against the facility's policy.
A resident's health information was improperly displayed in a public area, revealing their contact isolation status and guidelines for Candida auris. Facility staff confirmed that such information should remain private, and the DON was unaware of the posting. The resident was moderately cognitively impaired and had a current order for contact isolation.
A facility failed to follow a physician's order for daily weight monitoring of a resident with multiple health conditions, missing numerous weight records over a period of time. An LPN confirmed that CNAs were responsible for obtaining weights, but the facility's policy on accurate weight measurement was not consistently followed, leading to a deficiency.
The facility failed to maintain vascular access sites for two residents, leading to missed IV medication doses. One resident with osteomyelitis had a Midline catheter that was not flushed regularly, while another with a stump infection experienced missed doses due to PICC line issues and lack of medication. The facility's policies on flushing were not followed, and there was inadequate documentation and follow-up on physician recommendations.
A facility failed to complete necessary assessments for a resident requiring dialysis, leading to a deficiency. The resident, with conditions including heart failure and diabetes, reported attending dialysis three times a week. However, the facility did not consistently complete the required assessments before and after treatments, as confirmed by the DON. Additionally, the resident experienced delays in receiving assistance upon returning from dialysis, highlighting a lack of adherence to the facility's Dialysis Guideline policy.
The facility failed to provide timely IV antibiotics to two residents, resulting in missed doses. One resident with osteomyelitis missed six doses due to a lack of IV tubing, while another with a UTI did not receive Merrem on multiple occasions due to unavailability. Additionally, a resident experienced a delay in receiving an increased dose of Vancomycin due to the medication not being available. The facility's pharmacy policies were not effectively followed, contributing to these deficiencies.
A facility failed to conduct timely A1C tests for a resident with diabetes, as ordered by the physician. The resident's A1C tests were missed in June and September, despite a policy to ensure timely lab work. The DON confirmed the absence of records for the missing tests.
The facility failed to maintain a kitchen exterior door in good working order, as observed during three inspections. The door was cracked open, with a broken draft stopper creating a gap at the bottom. The Maintenance Director was informed weeks prior but had no documentation for repair. The facility's policy required timely maintenance, but the door remained unfixed.
A facility failed to notify a physician when a resident's blood glucose levels exceeded the set threshold. The resident, with multiple diagnoses including diabetes, had orders for Humalog insulin and additional doses based on a sliding scale. Despite elevated glucose levels on several occasions, discrepancies in documentation and lack of physician notification were noted. Interviews confirmed the physician should have been informed, as per facility policy.
A facility failed to update a care plan for a resident who engaged in inappropriate sexual behavior. Despite a reported incident, the care plan interventions had not been revised since August. The resident was placed on 15-minute monitoring, which was discontinued the next day without further interventions. Staff were aware of the behavior, but no new measures were implemented after the incident.
The facility failed to follow a physician's orders for a resident's laboratory tests, resulting in the tests not being conducted. The resident, who was cognitively intact and had multiple diagnoses, was supposed to have a CBC, CMP, and BNP drawn. A QMA attempted to draw blood but was unsuccessful, and no follow-up was conducted. The Administrator found no lab report and believed the order was incorrectly transcribed and dropped. An LPN confirmed that blood work should be collected the same day, but this did not occur.
The facility failed to ensure accurate medication administration records for four residents, leading to discrepancies between the Controlled Drug Receipt/Record/Disposition Form and the EMAR for narcotic pain medications. An RN indicated that documentation should occur in both the EMAR and on paper count sheets, but reviews showed missing documentation on specified dates.
A resident sustained a burn on his back during a TENS therapy session when the pad folded over on his skin. The therapist was following the device's directions and had used it multiple times without issues. The resident's wound was treated by a Wound NP and was improving, but the facility lacked documentation of the device's inspection since 11/14/22.
Unsanitary food storage and preparation practices with unlabeled resident food items
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions during multiple kitchen observations. On 03/15/2026, the staff member in charge did not know whether the dishwasher was a high-temperature or chemical sanitizing dishwasher, and a Dietary Aide who had worked at the facility since October was observed in the kitchen with multiple sanitation concerns, including a silver cart of clean meal trays littered with crumbs and splatters, crumbs around the steam table reservoirs, a plate warmer with crumbs and gray streaks inside, a clean dish rack with brown crumbs and dark grit, and dry storage items including flour and sugar contaminated with black grit. The kitchen cleaning schedules were posted and initialed as completed for that day, and both kitchen staff indicated they were unaware of the need to check steam table food temperatures before serving lunch. On 03/16/2026, the Dietary Manager obtained steam table temperatures for lunch and found the pureed broccoli and mechanical soft chicken did not reach an acceptable temperature, leading staff to place the metal steam table containers on the gas stove to heat them. During that observation, the Dietary Manager was wearing gloves but pulled up his pants several times while using and cleaning the thermometer. The kitchen also contained two sheet cake pans of covered bowls labeled for lunch dessert with black residue caked around the pan edges, another clean tray cart with crumbs and white/gray splatters, and a plate warmer with crumbs and gray streaks inside. The Regional Dietary Manager later stated the kitchen staff worked every other weekend and that she did not think staff performed chemical testing on the dishwasher because the chemical supplier managed the dishwasher chemicals. On 03/19/2026, the dishwasher was observed running with wash and rinse cycles at 160 degrees, and the Dietary Manager first identified it as a chemical dishwasher, then changed his mind and said it was a high-temperature dishwasher. He later stated the rinse temperature should reach 180 degrees Fahrenheit or higher, and that disposable dishware would be used until the dishwasher reached appropriate temperatures. Review of the Dishmachine Temperature Log showed multiple February entries where the final rinse temperature failed to reach the required range of 180 to 195 degrees Fahrenheit, and no temperatures were circled as out of range. The Resident Snack Refrigerator also contained an opened bag of salad mix and two bottles of salad dressing in a brown grocery bag dated 03/18/2026, with no resident name or room number on the items, despite the policy requiring outside food to be labeled with the resident's name, dated, sealed properly, and stored appropriately.
Food Served Cold and Unpalatable
Penalty
Summary
The facility failed to ensure residents' food was palatable, attractive, and served at the proper temperature during meal service observations. During an interview with kitchen staff, the dietary staff indicated lunch was to be served starting at 10:50 A.M., but they were unaware they needed to check steam table temperatures before serving and stated they were the only staff working on the weekend. During a kitchen tour, the lunch meal of chicken ala king over toast, broccoli, and mashed potatoes was observed for residents on a pureed diet, and the pureed broccoli and mechanical soft chicken did not reach an acceptable temperature, leading staff to place the metal steam table containers on the gas stove to heat them up. A test tray sampled during observation was described as cold to taste, bland, with no flavor, and with carrots that were hard and difficult to chew. Resident interviews also described repeated concerns with cold and unappealing food. One resident stated the food was not appealing and was usually cold when received in the room, while another said the food was bad, always cold, and had to be warmed up by staff even though the resident felt she should not have to ask. Additional residents and a family member reported that food delivered to rooms was sometimes cold and not always good, and one resident said there were a lot of concerns about the food all the time. A later test tray from the hall cart showed regular spinach at 113 degrees Fahrenheit, pureed spinach at 110 degrees Fahrenheit, and pureed ham and beans at 110 degrees Fahrenheit, and the Regional Dietary Manager stated food on the steam table should not be served below 135 degrees Fahrenheit. The facility policy stated food should be prepared, held, and served to preserve nutritive value and palatability, with hot foods served hot and cold foods served cold.
Failure to Initiate Baseline Dialysis Care Plan
Penalty
Summary
The facility failed to initiate a resident's baseline care plan related to dialysis within 48 hours of admission for Resident 58. The resident stated during interview that he had been admitted to the facility about three weeks earlier and was going to dialysis a few times a week. The clinical record showed an admission MDS dated 03/08/2026 indicating the resident was severely cognitively impaired, and his diagnoses included end stage renal disease. Hospital records provided by the Regional Nurse Consultant showed the resident had received dialysis while in the hospital. Review of the clinical record found no baseline care plan for dialysis. During interview, the MDS Coordinator stated baseline care plans were to be developed within the first 48 hours of admission and that a dialysis care plan should have been completed for this resident. The facility policy stated every resident must have a Baseline Care Plan completed and implemented within 48 hours of admission and addressing areas of imminent concern.
Incontinence Care Not Performed According to Perineal Care Guidelines
Penalty
Summary
The facility failed to follow appropriate infection control guidelines during incontinence care for one resident who had recently completed IV antibiotics for a UTI. During observed care, staff gathered supplies, washed hands, donned gloves, and explained the procedure, but the CNA placed wet washcloths on the bed rail, kept the resident’s legs close together, and wiped the front periarea with washcloths that had feces on them. The resident’s pajama pants were only pulled to the tops of her knees and the brief was pulled away from the front while care was provided. The resident was then rolled to her side, the brief was removed, and the backside was wiped. The resident was not dried, and the folds of the private area were not parted to ensure thorough cleaning. The CNA removed gloves, used hand sanitizer, donned clean gloves, applied a fresh brief, and completed the care. Interviews with an LPN, QMA, and ADON confirmed the resident had recently been treated for UTIs, did not have contractures, and that female pericare should include separating the legs, opening the labia, cleaning in sequence, and patting the area dry. The resident’s record showed moderate cognitive impairment, Parkinson’s disease, and physician orders for Bactrim and Meropenem for UTIs.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when surveyors found multiple unsecured and improperly maintained medication areas. During the initial tour on 03/15/2026, a medication cup containing an unknown powder substance was left unattended on the counter above the nurses' station desk, and LPN 10 stated she was unsure what the substance was or who placed it there, though it may have been nystatin powder. The 77 Front Treatment Cart was also observed unlocked and unattended while it contained physician-prescribed creams, cleansers labeled with resident names, and bandages. At 9:13 A.M., the 77 Front Medication Cart was observed with LPN 10 and contained a half full Lantus insulin pen for Resident 45 that did not have an opened date. Three plastic cups with lids, each containing 2 ounces of a dark brown substance, were sitting on top of the cart without dates or labels; LPN 10 identified the substance as chocolate pudding used during medication pass and stated it should have been dated. Later, the 39 Front Medication Cart was observed with LPN 5 and contained loose pills, including one small round orange tablet, one small round white tablet, and one large oval white tablet, along with a moderate amount of paper debris. LPN 5 stated there should not be any loose pills in the medication cart.
Failure to Follow Enhanced Barrier Precautions During Wound and Feeding Tube Care
Penalty
Summary
The facility failed to follow infection control guidelines related to Enhanced Barrier Precautions for Resident 6 during wound care and feeding tube care. During an observed wound dressing change, the LPN entered the room, placed supplies on the over-bed table that also held the resident’s squishy gel toys, left and reentered the room with an opened ABD pad in her bare hand, and handled wound care supplies and the resident’s foot while her hair touched the resident’s foot at times. The nurse also dropped rolled gauze on the floor, left the room to get a new roll, and continued the dressing change. Immediately after the observation, the LPN was shown the EBP sign on the resident’s door and stated she was not aware the resident was on EBP; the sign indicated staff were to wear a gown and gloves when providing care. Resident 6 had obstructive hydrocephalus, was rarely/never understood per the quarterly MDS, and had a history of a heel wound infection. The resident also had one unhealed stage 2 pressure ulcer that was not present on admission. During a separate observation of medication administration through the feeding tube, the LPN entered the room and administered a liquid medication and a nutritional supplement through the feeding tube without donning a gown, despite the EBP sign on the door stating that everyone must wear gloves and a gown when providing care, including device care or use of a feeding tube. The ADON stated staff were to wear a gown and gloves when providing care for a resident on EBP, including wound treatment, catheter care, or dealing with a feeding tube.
Delayed Response to Resident Call Light
Penalty
Summary
The facility failed to answer a resident’s call light in a dignified and timely manner. During an anonymous resident interview, Resident D stated that staff did not always answer the call light promptly and that it sometimes took an hour for staff to come. During continuous observation on 03/17/2026, Resident D’s call light was visible from the hallway and remained on for an extended period while staff were present in the area but did not respond to it. At 2:27 P.M., RN 9 left a nearby resident’s room and went to the nurses’ station, where the RN sat at the computer and typed while Resident D’s call light stayed on. At 2:30 P.M., the light was still unanswered while RN 9 left to assist a CNA with a mechanical lift. The call light remained on at 2:34 P.M., 2:38 P.M., and 2:41 P.M., including while RN 9 returned to the nurses’ station and another nurse worked at the medication cart. At 2:43 P.M., RN 9 left the nurses’ station and went to the Assistant DON’s office, and the call light was then answered by a CNA. During interview, Resident D said he had the light on because he needed the restroom, did not make it, and urinated on himself; he also needed a bowel movement and almost did not make it to the bedpan.
Failure to Accommodate Transportation Needs for Specialist Appointment
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs related to transportation for a lymphedema specialist appointment. Resident D was cognitively intact and had diagnoses that included cellulitis of the lower limb. A physician ordered staff to schedule an appointment with a lymphedema specialist on multiple occasions, and social services documented repeated attempts to secure an appointment. The specialist office reported a wait list and later no openings for facility visit appointments. Social services also documented that transportation was being pursued for the resident to attend a lymphedema clinic in another town, but the resident’s bariatric weight prevented safe transport on the current stretcher used by the local fire department. The fire department reported a bariatric stretcher had been ordered and was still pending delivery. The clinical record lacked documentation that the physician had been notified that the resident was unable to make it to the lymphedema specialist.
Failure to Notify MD of Abnormal Blood Pressure and Blood Glucose Readings
Penalty
Summary
The facility failed to notify the physician of changes in residents’ conditions related to blood pressure and blood glucose levels for 2 of 14 residents reviewed. Resident B had a diagnosis of hypertension and an order to receive hydralazine 100 mg three times daily, with nursing staff instructed to notify the MD if systolic blood pressure was over 180 mmHg. The resident’s EMAR showed multiple systolic blood pressure readings above that threshold, including 210, 186, 188, 189, and 189 mmHg, but the EMAR and progress notes did not document that the MD was notified of those readings. Resident C had a diagnosis of diabetes and an order to check blood glucose four times daily, with instructions to call the MD if blood glucose was less than 60 or above 350. The resident’s EMAR showed numerous blood glucose readings above 350, including values of 376, 425, 436, 442, 360, 364, 376, 400, 383, 400, 479, 385, 363, 399, 395, 381, 396, 376, 398, 400, 398, 392, and 444, but the EMAR and progress notes lacked documentation that the MD was notified. During interview, an LPN stated that when a resident had an order to notify the MD for blood pressure or blood glucose outside a set range, the notification and any new orders would be documented in the computer and appear in progress notes and on the EMAR.
Failure to Follow Medication Parameters and Daily Weight Orders
Penalty
Summary
The facility failed to follow physician orders for a resident with renal insufficiency and diabetes who had an open-ended order for Midodrine 10 mg three times daily only if systolic blood pressure was below 100 mmHg. The March 2026 EMAR showed the medication was administered on multiple occasions when the resident’s systolic blood pressure was above the ordered parameter, including readings of 143 mmHg, 130 mmHg, 138 mmHg, 127 mmHg, 132 mmHg, 126 mmHg, and 134 mmHg. During interview, an LPN stated that when a resident had medication parameters, blood pressure and/or heart rate would be checked before administration and the medication would not be given if anything was out of range. The facility also failed to document daily weights for another resident who had an open-ended physician order for daily weight monitoring. The January, February, and March 2026 EMAR and clinical record did not show weights obtained on multiple dates, including 01/24/2026, 01/25/2026, 01/29/2026, 02/08/2026, 02/12/2026, 02/26/2026, 03/02/2026, 03/07/2026, 03/08/2026, and 03/12/2026. Interviews with a CNA and an RN indicated that daily weights should be obtained by CNAs and documented in the EMAR or clinical record.
Failure to Prevent Verbal Abuse and Demeaning Conduct by CNA
Penalty
Summary
The facility failed to protect residents from verbal abuse by CNA 6, resulting in multiple incidents involving two cognitively intact residents. Resident D, who has cerebral palsy, diabetes, renal insufficiency, and is frequently incontinent of bowel and bladder, reported that after he requested bathroom assistance, CNA 6 told him she would come back later because she had other people to worry about. While he waited, he experienced a bowel accident and, after ringing the call light again, reported that CNA 6 told him to keep his mouth shut and not get into other people's business. Resident D also reported overhearing CNA 6 in the hallway saying she was sick and tired of taking care of him while she gathered supplies to clean him after the accident. In a separate incident on an unknown date, Resident D reported that CNA 6 told him that if he did not do what she wanted regarding use of the call light, he would need to find another nurse to help. A QMA later documented that Resident D stated CNA 6 told him to "shut his damn mouth" when he tried to explain what he wanted regarding a personal care item, repeated the directive, and then left the room. Resident F, who has heart failure, diabetes, and is occasionally incontinent of urine and frequently incontinent of bowel, reported that CNA 6 was hostile, overly dramatic, and made negative sound effects while assisting him, which made him feel uncomfortable. In a confidential witness statement, Resident F described CNA 6 as irritable, clumsy, and grumpy over several days, with an attitude suggesting he was upset and taking it out on the resident. The QMA’s statement indicated that Resident F told her CNA 6 seemed to be having a bad day, was not in a pleasant mood, and that this made him feel uncomfortable, a feeling he had not experienced before. Additional staff interviews indicated that, prior to these events, other residents had reported CNA 6 being more stressed, irritated when residents were not fast enough during care, verbally rude, impatient, and snappy, and that such concerns had been reported to the Administrator. These actions and behaviors conflicted with the facility’s DIGNITY and ABUSE PREVENTION PROGRAM policies, which prohibit condescending, critical, or argumentative speech, profanity or vulgar words in the presence of residents, and any disparaging or derogatory verbal language that meets criteria for abuse.
Failure to Timely Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and update a care plan addressing suicidal ideation for a resident with documented suicide risk. The resident, who was cognitively intact, had diagnoses including traumatic brain dysfunction, anoxic brain damage, anxiety, and depression, and was documented as having little interest or pleasure in activities nearly every day, feeling down or hopeless at least half the days, feeling tired nearly every day, and feeling bad about themself. On one afternoon, a progress note documented a change in condition when the resident requested Adderall and was informed it was not due; the resident then began crying, pointed to their neck, and mouthed words that the LPN eventually interpreted as the resident stating they wanted to kill themself. The progress note indicated the resident was considered a danger to self or others for suicide potential, and the physician was notified. Despite this documented suicidal statement and identification of suicide potential, the resident’s care plan did not include any care plan addressing suicidal ideation until several weeks later. The LPN confirmed in interview that the resident had asked for more Adderall, became visibly upset and tearful, and affirmed that they wanted to kill themself when asked directly. The Social Service Director stated that residents are care planned for suicidal ideation when a nurse asks if they want to kill themself and the resident says yes, and acknowledged that this would be considered suicidal ideation. The facility’s policy on Baseline and Comprehensive Care Plans requires that every resident have a care plan that expands on mental and psychosocial needs, but the care plan for this resident lacked an intervention for suicidal ideation during the period following the documented suicidal statement.
Failure to Prevent Elopement and Provide True One-to-One Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known exit-seeking behavior, and failure to provide true one-to-one (1:1) supervision for two residents ordered to be on 1:1 observation. Resident C had diagnoses including non-Alzheimer’s dementia and arthritis and a physician’s order for a wander guard on his ankle with daily checks for placement and function due to elopement risk. His care plan identified him as at risk for elopement based on a history of wandering and dementia, with interventions such as monitoring doors when staff and visitors come and go and redirecting him from unsafe areas. Social services documented that the day before the elopement incident he attempted to follow a visitor out of the facility, triggering his wander guard alarm, after which 15‑minute monitoring was initiated for 48 hours. On a cold night when outdoor temperatures ranged between 23 and 34 degrees Fahrenheit, Resident C reported that he told staff he did not want to be at the facility and had been told he could not go outside. He stated he then went to a facility door, used a code to exit, and remained outside until he became cold and returned by waving at staff through a side door window. Staff interviews established that around 8:30 p.m. an LPN responded to a wander guard alarm at the front door and saw Resident C in his powered scooter heading down the hallway, and around 9:00 p.m. she saw him sitting in front of the nurse’s station. An RN reported seeing him in the atrium with other residents at about 9:15 p.m. At approximately 9:45 p.m., staff could not locate him and initiated missing resident protocol; he was then found standing outside the doors at the end of a hallway, wearing only a cowboy hat and black underwear, cold, scared, and shivering, with small scratches on his arm and above his left ear. He was sent to the emergency room and later returned with no additional injuries identified. The maintenance director explained that most doors had alarms that would sound even when a code was used, and that two of three non‑alarmed doors had wander guard alarms; however, the back doors of the main dining room could be opened with a punch code without any additional alarm, and the administrator stated that cameras were not working, so the exit door used by Resident C could not be determined. The deficiency also includes the facility’s failure to provide actual 1:1 supervision as defined in its own policy and by staff and the physician for Residents B and C. Resident B, who was cognitively intact with diagnoses including traumatic brain dysfunction, anxiety, and depression, had recently been hospitalized for an attempted suicide and was readmitted on 1:1 observation, where she remained. Observations showed Resident B lying in bed with a staff member sitting in the hallway outside her room, and at one point there was no call light within her reach. Resident C’s room was directly across the hall, and both residents were on 1:1 observation. A staff member was observed sitting between their rooms in the hallway, with no staff present in the main hallway leading to the main entrance; from the residents’ rooms, approximately nine steps led to the main hallway and another nineteen steps to two exit doors with push keypads and alarms, and if either resident walked nine steps down the hall, they would be out of the staff member’s sight. On another observation, the assigned staff member was looking at her phone while sitting outside their rooms, and at one point Resident C was in the bathroom with the door closed while the ADON sat in the hallway. Multiple staff interviews confirmed that both Residents B and C were on 1:1 observation and that documentation was done on paper. The primary care physician stated that 1:1 observation meant one staff to one resident. The ADON and administrator, along with the corporate clinical nurse, described 1:1 as having eyes on the resident at all times, with a staff member posted where they could visibly see the resident at all times, and the facility’s written policy on one‑on‑one supervision required a staff member to remain in direct supervision of the resident, with direct visual surveillance at all times. However, staff also reported that one staff member was assigned to both residents on 1:1, and that if Resident C was not redirectable and no additional staff were available, the assigned nurse would have to let him walk away because she could not leave Resident B. The social services director was unsure whether 1:1 meant one staff to one resident and stated that if Resident C walked up the main hallway, she would leave Resident B to follow him. These observations and statements show that the facility did not maintain continuous direct visual supervision of each resident on 1:1 observation and did not ensure adequate supervision to prevent elopement and other accidents for Residents B and C.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to properly prime an insulin pen before administering it to a resident. During a medication administration observation, an LPN was observed using a Fiasp insulin pen for a resident without holding the pen upwards as required to ensure no air was present. The LPN administered the insulin with the door open, which was not in accordance with the proper procedure. The package insert for the insulin pen clearly stated the need to hold the pen with the needle pointing up during priming, which was not followed. The facility also failed to monitor and document vital signs appropriately before administering medications with specific hold parameters. For one resident, Metoprolol was administered without documenting vital signs on multiple occasions, despite physician orders to hold the medication if the heart rate was below 60 or blood pressure was below 110/60. Similarly, another resident received Carvedilol even when their blood pressure or heart rate was below the specified parameters, as documented in the EMAR over several months. Additionally, a resident was administered Midodrine despite having a systolic blood pressure greater than the hold parameter of 120, as per physician orders. This occurred on numerous occasions, as evidenced by the EMAR records. Interviews with nursing staff and the DON confirmed that the facility's policy was to check vital signs and hold medications based on the parameters, which was not adhered to in these cases.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the required registered nurse (RN) coverage for eight consecutive hours a day for 16 out of the 21 days reviewed. The nursing schedule revealed that there was no RN on duty for the required hours on several weekends spanning from July 2024 to February 2025. During an interview, the Director of Nursing (DON) acknowledged staffing issues in the previous months. The facility's policy mandates RN coverage for at least eight consecutive hours per day, seven days a week, which was not adhered to during the specified dates.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to store medications appropriately, as observed during a survey. In one instance, an LPN removed a Fiasp insulin pen from a medication cart that was not stored in a plastic bag and lacked a resident's name or identifying information. The pen was labeled with an opened date but was not associated with a specific resident until the LPN identified it as belonging to a resident who was the only user of that insulin type. The LPN then labeled the pen with the resident's name before administering the insulin. Additionally, the Front Medication Cart contained several loose pills of various types and a drawer covered in a spilled substance, indicating a lack of proper medication storage and organization. Further observations revealed that the Rehab Medication Cart also contained loose pills, and an LPN acknowledged that insulin pens should be labeled with a resident's name. In the 39 Hall Medication Room, two opened vials of Tuberculin serum were found, one of which was outdated and should have been discarded after 30 days. The facility's policy on medication storage, dated February 2017, was provided, indicating that medications and biologicals should be stored safely and securely following manufacturer recommendations. However, the observations during the survey indicated non-compliance with these storage protocols.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were out of range for one of the residents reviewed. The resident, who was cognitively intact, had multiple diagnoses including diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident had medical orders to receive Humalog insulin three times a day and additional doses based on a sliding scale, with instructions to notify the physician if blood glucose levels exceeded 351. However, the facility did not notify the physician when the resident's blood glucose levels were documented as being above this threshold on multiple occasions. The discrepancy in blood glucose documentation was noted in the Electronic Medication Administration Record (EMAR) and Vitals Reports for several dates across November and December 2024, and January and February 2025. Despite the blood glucose levels being recorded as higher than 351, there was no indication that the physician was informed. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the physician should have been notified according to the facility's policy. The facility's policy mandates notifying the resident's attending physician and representative of changes in the resident's condition or status.
Resident's Health Information Inappropriately Posted Publicly
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records by posting personal health information in a public setting. Specifically, signage on the door of a resident's room indicated that the resident was in contact isolation and under enhanced barrier precautions. Additionally, a document titled 'Guidelines for addressing Candida auris' was posted on the wall next to the door, directly above the resident's name and room number. This public display of the resident's health information was observed on two separate occasions. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that resident information, such as diagnoses and medication lists, should remain private and not be publicly displayed. The DON and the Regional Nurse Consultant were unaware of the posted documentation and acknowledged that it should not have been there. A review of the resident's clinical record indicated that the resident was moderately cognitively impaired and had a current order for contact isolation due to a Candida auris infection. The facility's policy on protected health information, provided by the DON, emphasized the confidentiality of health information that identifies an individual.
Failure to Monitor Resident's Daily Weight
Penalty
Summary
The facility failed to adhere to a physician's order for daily weight monitoring of a resident, identified as Resident 29, who was cognitively intact and had multiple diagnoses including diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The physician's order, initiated on 12/28/24, required daily weights and notification if the resident's weight increased by more than 3 pounds in a day or 5 pounds in a week. However, the clinical record showed missing daily weights on numerous dates between 12/30/24 and 02/04/25. During an interview, an LPN confirmed that CNAs were responsible for obtaining the resident's weight and informing the nurse, who would then document it and notify the physician if necessary. The facility's policy emphasized the importance of accurate weight measurement for assessing nutritional and health status, and the potential impact of inaccurate measurements on care plans. Despite this policy, the facility did not consistently record the resident's weight as required, leading to a deficiency in maintaining the resident's health through proper monitoring.
Deficiencies in IV Site Maintenance and Medication Administration
Penalty
Summary
The facility failed to provide proper maintenance for vascular access sites for two residents, leading to deficiencies in the administration of IV fluids and medications. Resident 4, who was admitted with an infected heel wound and osteomyelitis, had a Midline catheter that was not flushed regularly, resulting in missed IV antibiotic doses due to a lack of supplies and issues with the venous access site. The clinical records lacked documentation of regular flushing of the vascular access sites, and there were no physician's orders to maintain the patency of the sites. Resident 38, admitted with a right stump infection, also experienced deficiencies in IV medication administration. The resident had a PICC line for antibiotic administration, but the clinical record showed missed doses due to unavailability of medication and issues with the PICC line placement. Although there was a physician's order to flush the IV-midline, it lacked scheduling details, resulting in the absence of documentation for flushing from the clinical record. Additionally, there was a failure to follow up on a recommendation for a central line placement, with incomplete documentation related to the scheduling and completion of this procedure. The facility's policies required specific flush orders to be documented and followed to ensure catheter patency and prevent medication incompatibility. However, the lack of proper documentation and adherence to these policies contributed to the deficiencies observed. Interviews with staff revealed that orders for flushing were not properly inputted into the system, and there was a lack of follow-up on physician recommendations, further exacerbating the issues with vascular access site maintenance.
Failure to Complete Dialysis Assessments for Resident
Penalty
Summary
The facility failed to complete necessary assessments for a resident requiring dialysis, leading to a deficiency in care. Resident 24, who is cognitively intact and has diagnoses including heart failure, hypertension, renal insufficiency, and diabetes, reported attending dialysis treatments three times a week. However, the facility did not consistently complete the required assessments before and after these treatments. The Director of Nursing (DON) confirmed that staff were supposed to fill out the DIALYSIS/OBSERVATION COMMUNICATION FORM each time the resident went for dialysis, but the forms were incomplete, with only a few records available for December. Additionally, the resident expressed concerns about having to wait in her wheelchair with her coat on for extended periods after returning from dialysis, indicating a lack of timely assistance from staff. The facility's current Dialysis Guideline policy emphasizes the importance of communication between the dialysis provider and the facility staff, including the review of daily weights and changes in condition. Despite this, the facility failed to adhere to these guidelines, as evidenced by the incomplete documentation and the resident's reported experiences.
Failure to Provide Timely IV Antibiotics
Penalty
Summary
The facility failed to provide timely IV antibiotics to two residents, resulting in missed doses. Resident 4, who was admitted with acute osteomyelitis of the right ankle and foot, missed six doses of IV antibiotics due to a lack of IV tubing. The facility ran out of tubing for two days, and the pharmacy did not send tubing with the medications. Although the facility ordered tubing from a supplier, it was discovered that the supplier no longer carried it, leading to a delay in treatment until the pharmacy delivered the necessary supplies. Resident 29, diagnosed with a UTI, did not receive the prescribed IV antibiotic Merrem on multiple occasions due to the medication being unavailable. The pharmacy was expected to deliver the medication, but it was not received in a timely manner, resulting in missed doses over several days. Progress notes indicated repeated communication with the pharmacy, but the medication was not delivered as expected, leading to further delays in treatment. Additionally, Resident 38 experienced a delay in receiving an increased dose of Vancomycin due to the medication not being available in the emergency drug kit. The resident's trough level indicated a need for an increased dose, but the clinical record lacked an order for the increase, and the medication was on hold for several days. The facility's policies on pharmacy hours and delivery schedules were not effectively followed, contributing to the deficiencies in medication administration.
Failure to Conduct Timely A1C Tests for a Resident
Penalty
Summary
The facility failed to obtain required blood tests for a resident, identified as Resident 27, who was moderately cognitively impaired and had diagnoses including diabetes, anxiety, and hypertension. The resident's physician had ordered an A1C test every three months, starting from June 2023. However, the facility only conducted the A1C tests in March and December of 2024, missing the tests that should have been conducted in June and September of that year. During an interview, the Director of Nursing confirmed that the facility did not have records of the missing A1C tests. The facility's policy on lab scheduling and tracking was intended to ensure timely lab work, but it was not followed in this instance.
Kitchen Door Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a kitchen exterior door in good working order, which was observed during three separate kitchen inspections. The door was found to be cracked open about 1/2 to 1 inch, allowing visibility to the outside. Additionally, the door draft stopper at the bottom was broken on the right side, creating an approximately 2-inch gap. This issue was noted during observations on multiple occasions, and the Dietary Manager was seen closing the door during one of the inspections. The Maintenance Director was informed of the broken door a few weeks prior to the inspection, but there was no documentation indicating that the door needed to be fixed. The kitchen staff had been educated to ensure the door remained closed, despite its inability to shut properly. The facility's policy required maintenance requests to be addressed in a timely manner, with urgent issues being prioritized. However, the broken door had not been repaired, and the Maintenance Director indicated it would be fixed by the end of the day.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were out of range for one of the residents reviewed. Resident 29, who was cognitively intact, had multiple diagnoses including diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident had medical orders to receive Humalog insulin three times a day and additional doses based on a sliding scale, with instructions to notify the physician if blood glucose levels exceeded 351. However, the facility did not notify the physician when the resident's blood glucose levels were above this threshold on multiple occasions. The clinical records showed discrepancies in the documented blood glucose levels for the scheduled insulin and the sliding scale insulin, even though both doses were administered together. For instance, on several dates, the blood glucose levels documented for the scheduled insulin were significantly higher than those documented for the sliding scale insulin. Interviews with the LPN and the DON confirmed that the physician should have been notified when the blood glucose levels were outside the call parameters, as per the facility's policy. However, there was no indication that the physician was informed of these elevated levels, leading to a deficiency in the facility's notification process.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to update a resident's care plan related to behaviors, specifically for a resident who engaged in inappropriate sexual behavior. Resident E, who was cognitively intact and diagnosed with multiple sclerosis and depression, was involved in a reported incident where he engaged in sexual touching with another resident in a common area. Despite having a care plan that addressed inappropriate behavior, the interventions had not been updated since August, even after the incident in October. The care plan included interventions such as monitoring the resident in common areas and educating staff to redirect him from female residents' rooms, but these were not revised following the new incident. Interviews and record reviews revealed that Resident E was placed on 15-minute monitoring after the incident, but this was discontinued the next day without further interventions. Staff were aware of Resident E's behavior, and a stop sign was placed on Resident F's door to prevent inappropriate interactions. However, the Social Service Director was on leave, and the Administrator and DON did not implement new interventions after the incident. The facility's policy required care plans to be reviewed and updated based on changes in the resident's condition, but this was not adhered to in this case.
Failure to Follow Physician's Orders for Laboratory Services
Penalty
Summary
The facility failed to follow a physician's orders for obtaining laboratory services for Resident B, who was cognitively intact and had diagnoses including diabetes, GERD, and ESRD. A physician's order dated 09/11/24 required the staff to obtain a CBC, CMP, and BNP for the resident. However, during an interview, Resident B indicated that a QMA attempted to draw her blood but was unsuccessful, and although she was told another nurse would return, no one did. The Administrator confirmed that there was no laboratory report for Resident B for the specified date and believed the order was incorrectly transcribed and subsequently dropped from the system after 24 hours. An LPN stated that blood work should be collected the same day it is ordered, and there was no reason for the order not to have been collected. The facility's policies on following physician orders and lab scheduling/tracking were reviewed, indicating that the facility should ensure ordered lab work is obtained, but these policies were not followed in this instance.
Medication Administration Record Discrepancies
Penalty
Summary
The facility failed to ensure that the medication administration records accurately reflected the administration of narcotic pain medication for four residents. Resident B, who was cognitively intact and had diagnoses including diabetes and arthritis, had discrepancies between the Controlled Drug Receipt/Record/Disposition Form and the Electronic Medication Administration Record (EMAR) for Hydrocodone-Acetaminophen on multiple dates. Similarly, Resident D, also cognitively intact with diagnoses including heart failure and polyneuropathy, had discrepancies in the administration records for Hydrocodone-Acetaminophen on several dates. Resident G, with diagnoses including diabetes and kidney disease, had discrepancies in the administration records for Tramadol. Lastly, Resident H, who was moderately cognitively impaired with diagnoses including hip fracture and seizure disorder, had discrepancies in the administration records for Oxycodone on multiple dates. During an interview, RN 2 indicated that the facility's procedure required nurses to document the administration of controlled medications both in the computer EMAR and on the paper controlled medication count sheets. However, the review of the clinical records and the EMARs for the four residents showed a lack of documentation for the administration of the narcotic pain medications on the specified dates and times. The facility's policy on medication administration, dated February 2017, was provided by the Director of Nursing and indicated that all medications should be administered safely and appropriately, with documentation in the appropriate spaces on the Medication Administration Record (MAR).
Resident Sustains Burn During TENS Therapy
Penalty
Summary
The facility failed to ensure a resident did not sustain a skin injury during therapy. Resident B, who was in the facility for back issues and participated in physical therapy, sustained a burn on his back while using a TENS (Transcutaneous Electrical Nerve Stimulation) machine. The incident occurred when the pad of the TENS machine folded over on the resident's skin, causing a burn. The therapist was following the directions on the TENS unit and had used the device on the resident multiple times without issues. However, during this session, the pad moved and folded, leading to the injury. The resident did not report feeling any discomfort during the session, and the therapist turned off the machine when it indicated a problem with the pads. The wound was assessed and treated by a Wound NP, and the resident reported pain from the burn. The TENS device had been inspected annually, with the most recent inspection occurring on 11/14/22, which showed no concerns. The facility lacked documentation of any inspection since that date. The resident's clinical record indicated he was cognitively intact and had diagnoses including diabetes, arthritis, spinal stenosis, and intervertebral disc displacement. The wound was a second-degree burn, which was improving but still painful for the resident. The facility's policy on Low Voltage Electrical Stimulation indicated treatments should be administered by designated personnel under the supervision of a licensed therapist, but the therapist did not visually monitor the resident's skin throughout the session. The therapist acknowledged that he would likely monitor residents' skin more closely in the future.
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What surveyors actually found near you
We read the 179 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Batesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Andrews Health Campus | 1 mi | ★★★★★ | 7 | 0 |
| Ripley Crossing | 10.5 mi | ★★★★★ | 12 | 0 |
| Manderley Health Care Center | 13.1 mi | ★★★★★ | 11 | 0 |
| Arbor Grove Village | 13.8 mi | ★★★★★ | 18 | 0 |
| Aspen Place Health Campus | 14.1 mi | ★★★★★ | 0 | 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.