Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Greencastle, The during CMS and state inspections, most recent first.
A resident with vascular dementia and anxiety disorder, identified as a wandering and elopement risk, exited a locked memory care courtyard after a contractor left the courtyard gate open and the glass doors did not latch. Surveillance video showed her walking rapidly across the parking lot and grassy area, then falling into a ditch near the road and remaining on the ground for minutes before help arrived. Staff later found her with a scratch on her nose and assisted her back inside.
Administrator and DON gave conflicting and inaccurate accounts of a resident’s elopement from the locked memory care unit and pressured staff to give vague or false statements about where she was found and whether she was supervised. The resident, who had vascular dementia, anxiety, and was assessed as a wandering/elopement risk, was seen on video leaving the courtyard gate, crossing the parking lot and grassy area, and falling in a ditch far from the facility before staff and hospital personnel reached her.
Improper Beard Restraints and Hand Hygiene in Food Service: Staff were observed preparing and serving food with beard restraints that did not fully cover beards and mustaches, including an aide whose mustache remained exposed and another whose beard growth extended outside the cover. One staff member also touched his face and nose while gloved, then continued food handling and meal service without washing hands or changing gloves. The RD confirmed beards and mustaches needed to be completely covered and that hand hygiene was required after touching the face or nose.
Failure to Obtain Consent for Psychotropic Medications: The facility did not obtain or document informed consent for psychotropic meds for multiple residents. Records showed residents with dementia, depression, anxiety, psychotic disorders, and bipolar disorder receiving meds such as Zoloft, Seroquel, divalproex sodium, and trazodone, but the chart lacked evidence that consent was obtained from the resident or responsible party before initiation or dose changes. The DON stated she could not find consent for a new Zoloft order and acknowledged the consent process should occur with new psychotropic meds and dose increases.
Resident Council food grievances were not addressed or explained to residents. Multiple residents reported cold meals, menus that did not match what was served, and repeated shortages of items such as coffee, peanut butter, jelly, creamer, and orange juice. Some residents said they had to buy their own food or rely on family to bring meals. Leadership acknowledged the concerns, but the ADM did not attend council meetings to discuss them directly, and the food council had stopped meeting after the dietary manager no longer attended.
Delayed AIMS Assessments for Residents on Psychotropic Medications: The facility failed to ensure timely AIMS assessments for two residents receiving psychotropic meds. One resident with dementia, depression, and HTN had an AIMS completed but no evidence of the required 6-month follow-up, and another resident with bipolar disorder receiving Zyprexa had an AIMS documented but no subsequent assessment since the prior one. Staff stated floor nurses were responsible for completing AIMS assessments every 6 months.
MDS assessments were not coded accurately for two residents. One resident had hospice documentation and a physician prognosis of less than 6 months, but the quarterly MDS was marked No for terminal prognosis. Another resident had a CPAP order for sleep apnea, used CPAP nightly per the MAR, and the quarterly MDS was marked No for use of a non-invasive mechanical ventilator; the DON and MDS Coordinator acknowledged the coding was incorrect.
Incomplete Care Plans and Missing Care Conference Documentation: The facility failed to keep complete, team-developed care plans for residents with significant changes in condition. One resident had documented weight loss despite a care plan focused on weight gain, another had an open lesion on the nose with treatment orders but no care plan for the skin issue, and a third resident had no documentation that a care plan conference was held. The DON and SSD acknowledged gaps in the care plan and meeting documentation.
Medication Error Rate Exceeded During Medication Pass: An RN administered inhalers to a resident without prompting a rinse-and-spit after fluticasone-salmeterol, gave the inhalers back-to-back without the required wait time, and administered only 1 puff of tiotropium bromide when 2 puffs were ordered. The RN also did not administer aspirin and cetirizine because they were out of stock, and the record lacked documentation that the meds were obtained from the EDK or that a provider order was obtained to hold them or give them later.
Failure to Document Held Insulin and Physician Notification: A resident with type 2 DM and cognitive impairment had ordered bedtime Lantus insulin that was not administered on several occasions. The MAR lacked documentation of resident refusal, justification for holding the insulin, or notification to the MD, despite staff stating they would document and report insulin refusals or holds.
Failure to perform hand hygiene during a medication pass was observed for 3 residents. An RN administered a nasal spray, inhalers, lidocaine patches, and eye drops while wearing gloves but did not cleanse hands before or after giving the medications, and also gave medication to another resident without hand hygiene between residents. The RN, DON, and IP all acknowledged hand hygiene should have been performed, and facility policies required cleansing hands before and after medication administration.
A resident who was cognitively intact and receiving hospice care was required by staff to eat all meals in the dining room, despite repeatedly expressing a preference to eat in his room. The resident, who had a history of anxiety and depression, was able to feed himself with some assistance and understood the risks associated with his diet. Staff cited facility policy and safety concerns as reasons for not honoring his choice, resulting in frequent meal refusals and distress for the resident. The facility's policy emphasized resident rights to self-determination, but this was not upheld in practice.
A resident with vascular dementia and chronic pain syndrome experienced significant weight changes, but the facility failed to perform a reweight as required by their policy. Despite documented weight loss and gain, and recommendations for nutritional interventions, the facility did not adhere to its policy of reweighing residents after significant weight changes.
A resident with Alzheimer's disease had two PRN orders for acetaminophen, risking overdose. A pharmacy recommendation to discontinue one order was initially ignored, leading to a deficiency. The issue was only addressed after a second recommendation, with the physician discontinuing the 500 mg tablets.
The facility failed to ensure proper sanitation of kitchen equipment and drinking glasses, with a white cloudy substance observed on pitchers and glasses. Residents reported the issue, and the Dietary Manager acknowledged lime deposits as the cause. Additionally, an Activity Aide was observed handling snacks with bare hands, contrary to the facility's food safety policy. A CNA confirmed that gloves should be used when serving food.
Elopement from locked memory care unit after unsecured courtyard access
Penalty
Summary
The facility failed to supervise and ensure the safety of a resident with vascular dementia and anxiety disorder who was living on the locked memory care unit. The resident was ambulatory, had poor short- and long-term memory, nonsensical/slurred speech, and was identified on admission as being at moderate risk for wandering and at risk for elopement. Her baseline care plan included monitoring doors when staff and visitors came and went and redirecting her if she wandered into potentially unsafe areas. On the day of the event, the resident exited through the glass double doors at the end of the hallway into the courtyard after the outside courtyard gate had been left open so a contractor could move between the building and an outside vehicle with supplies to repair the air conditioning unit. The administrator stated the glass double doors did not latch when the contractor last exited the building. Surveillance video showed the resident leaving the locked courtyard gate, walking across the parking lot and a grassy area at a rapid pace while carrying a blanket, then turning toward the road and falling face first into a ditch about 100 yards from the facility. The resident remained on the ground for 13 minutes before a hospital staff member reached her. Video showed her near the edge of the road while vehicles passed, and she was unable to stand when approached. Facility staff later arrived and assisted her back to the building. Staff interviews described the resident lying in a ditch near the road, holding her blanket and glasses, with a scratch on her nose and no obvious change in gait when she was helped to walk. The report states this event resulted in an Immediate Jeopardy related to failure to prevent the resident from eloping from the locked unit and falling outside the facility.
Administrator and DON gave inaccurate accounts and pressured staff about a resident elopement
Penalty
Summary
The facility Administrator and DON failed to communicate accurate information, complete accurate documentation, and pressured staff to provide false statements regarding an elopement event involving a resident with vascular dementia and anxiety disorder who had been admitted to the locked Memory Care unit and identified as a wandering and elopement risk. The resident’s baseline care plan included monitoring doors when staff and visitors came and went and redirecting her if she wandered into unsafe areas. According to the record and interviews, the resident exited the locked courtyard gate, crossed the parking lot, and continued into a grassy area beyond the parking lot. Facility documentation initially stated the Administrator told the spouse the resident had followed a contractor out of the memory care courtyard door, stumbled in the grass, and was brought back inside after a small scratch to her nose. During the care plan meeting, the spouse asked for details about the fall outside, and the Administrator stated the resident had followed a contractor outside and that staff had eyes on her the entire time and returned her within minutes. Multiple interviews and surveillance footage showed the resident was farther from the facility than initially described. The video showed her leaving the locked courtyard gate, walking across the parking lot and a grassy area, and falling in a ditch about 100 yards from the facility, where she remained until hospital staff and facility staff arrived. Staff statements varied about where she was found and whether she was supervised, and several staff members stated the Administrator and DON told them what to say or not say during interviews and asked them to be vague about the location and circumstances. The Administrator stated the event was not reported because the resident had not left the property and staff had eyes on her the entire time, while the DON later described the resident as being found in a grassy area across the parking lot and assisted into a vehicle before being returned to the facility.
Improper Beard Restraints and Hand Hygiene in Food Service
Penalty
Summary
The facility failed to ensure beard restraints were worn appropriately and that hand hygiene was performed after staff touched their face during kitchen and meal service observations. On 12/1/25, [NAME] 7 was observed in the food preparation area stirring food and preparing other items while wearing a beard restraint that covered only a small area of his chin, leaving his mustache and sides of his face open. While wearing gloves, he touched his face and nose several times with his forearm and wrist area of the glove, did not wash his hands, and continued preparing food. Later that day during lunch service, [NAME] 7 served food from the steam table with the same incomplete beard restraint and wiped his nose on the back of his glove/hand three times without changing gloves or washing his hands. On 12/3/25, [NAME] 7 was again observed in the kitchen and dining areas with his mustache uncovered during food preparation, oven use, and temperature checks. Dietary Aide 10 was also observed with a full beard and mustache while wearing a beard restraint that left the mustache uncovered. Dietary Aide 8 wore a beard restraint that was pulled over the mustache, but significant beard growth remained outside the cover on the bottom of the chin and neck. [NAME] 9 was observed in the food preparation area with a small amount of unshaved beard/mustache growth and no beard cover. The Regional Dietary Director stated that employees' mustaches and beards needed to be completely covered and acknowledged that some employees had not covered them completely; she also stated hand hygiene should have been performed if employees touched their face or noses.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications for 4 of 5 residents reviewed for unnecessary medications. The deficiency involved Residents 7, 8, 27, and 22, whose records showed orders for psychotropic medications including sertraline (Zoloft), quetiapine (Seroquel), divalproex sodium, and trazodone. The report states that the records lacked evidence that consent to administer these medications had been obtained from the resident or responsible party before the medications were started or, in some cases, when doses were changed. Resident 7 had diagnoses including dementia, hypertension, and depression, and was cognitively impaired and dependent for extensive assistance with daily care. The record showed orders for sertraline, quetiapine, and divalproex sodium, but did not indicate that consent had been obtained from the responsible party. Resident 8 had diagnoses including dementia, hypertension, anxiety, and depression, and was also cognitively impaired and dependent for extensive assistance. The record showed orders for sertraline, quetiapine, and divalproex sodium, and the psychotropic consent documentation showed assessments were completed, but the record lacked evidence that the responsible party was notified to obtain consent. Resident 27 had diagnoses including major depressive disorder, psychotic disorder with delusions, and Parkinson’s psychosis, and was documented as having moderate cognitive deficit. The record showed orders for quetiapine, trazodone, and sertraline, but lacked documentation that psychotropic medication consent had been obtained before the medications were initiated. Resident 22 had diagnoses including primary progressive multiple sclerosis, COPD, and bipolar disorder, and was cognitively intact. The record showed a new order for sertraline with a progress note indicating the medication was started and the dose was to be increased over the next few months, but the record lacked documentation that psychotropic consent was obtained when the new medication was initiated. The DON stated she could not find a consent for the initiation of Zoloft and acknowledged that psychotropic medication consents should be completed with initiation of a new psychotropic medication and/or dose increase.
Resident Council Food Grievances Not Addressed
Penalty
Summary
The facility failed to ensure that grievances raised by residents through the Resident Council were addressed and that resolutions were explained to the residents regarding repeated food concerns for 6 of 24 residents reviewed. Residents reported that meals were often cold, menu items did not match what was posted, and the kitchen frequently ran out of items such as coffee, peanut butter, jelly, creamer, orange juice, and even alternative foods. One resident stated he had to buy his own peanut butter, jelly, and bread to have something to eat, and another reported that family brought salads because the kitchen did not have much available. During interviews, multiple residents described ongoing dissatisfaction with the food service. One resident said he did not like the food and was told there were no alternatives, including peanut butter and jelly. Another resident said the food was never what was posted on the menu and that the facility had gone without coffee for two days. A resident council member stated the council had brought several concerns to the facility, but the food issues had continued. Another council member said the council used to meet with kitchen staff to discuss concerns, but that stopped when the kitchen manager stopped attending, and she was unsure whether anyone was currently in charge of the kitchen. Facility leadership acknowledged the concerns had been brought forward through the Resident Council. The Administrator stated she had been given the food concerns and had made the contracted dietary company aware, but she had not attended any Resident Council meetings to address the concerns directly. The Regional Director of Dietary acknowledged that coffee and pink sweetener had run out because one truck did not come in, while the Activity Director stated the facility had a history of difficulty keeping a dietary manager and that the food council had stopped meeting after the dietary manager stopped attending. The facility provided a Resident Council policy stating the council should influence decisions affecting residents and that the facility must listen to resident grievances and recommendations, along with a form process intended to track and resolve resident concerns.
Delayed AIMS Assessments for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were completed timely for residents receiving psychotropic medications. Resident 7 had diagnoses including dementia, hypertension, and depression, and an admission MDS dated 4/2/25 indicated the resident was cognitively impaired and required extensive assistance with daily care needs. The record showed an AIMS assessment completed on 4/2/25, but there was no evidence that another assessment was completed every 6 months as required. Resident 22 had diagnoses including active primary progressive multiple sclerosis, COPD, and bipolar disorder, and a quarterly MDS dated 9/23/25 indicated the resident was cognitively intact and received antipsychotic and antidepressant medications. The record showed an AIMS assessment completed on 3/25/25, but there was no documentation of another AIMS assessment since that date. The resident had physician orders for Zyprexa for bipolar disorder, and staff interviews indicated nurses on the floor were responsible for completing AIMS assessments every 6 months for residents on antipsychotic medications. The DON stated she would have to check the policy for AIMS assessments.
MDS Assessments Were Coded Incorrectly for Hospice Status and CPAP Use
Penalty
Summary
Ensure each resident receives an accurate assessment was not maintained when the facility failed to code two residents’ MDS assessments correctly. For Resident 22, the quarterly MDS dated 9/23/25 indicated the resident was cognitively intact and marked that the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. However, the record included a physician order dated 6/12/24 documenting verbal certification that the resident had a prognosis of less than 6 months if the disease ran its normal course, and a physician order dated 6/13/24 admitting the resident to hospice services for MS. The care plan also documented hospice services. During interview, the MDS Coordinator stated the resident was on hospice and the assessment should have been marked Yes for prognosis, but it had not been coded correctly. For Resident 65, the quarterly MDS dated 9/27/25 indicated the resident had moderate cognitive impairment and did not use a non-invasive mechanical ventilator. The record included a physician order dated 3/19/24 for CPAP at bedtime for sleep apnea, and the September MAR showed the resident used CPAP every night with no documentation of refusal. The care plan identified obstructive sleep apnea and included CPAP at night per order. During interview, the DON was not aware how the MDS should be coded for a resident using CPAP, and the MDS Coordinator stated the assessment was not coded correctly and should have been marked Yes for use of a non-invasive mechanical ventilation device.
Incomplete Care Plans and Missing Care Conference Documentation
Penalty
Summary
The facility failed to develop and maintain complete care plans within 7 days of comprehensive assessment and failed to ensure care plans were prepared, reviewed, and revised by a team of health professionals for 3 of 24 residents reviewed. For Resident 7, who had dementia, hypertension, depression, and required extensive assistance with eating, the record showed a care plan focused on being above ideal body weight and preventing further weight gain. However, the weight record from 4/2/25 to 12/2/25 showed a 10.66% weight loss since admission, and the care plan did not include documentation addressing the resident’s weight loss. A physician order dated 10/28/25 directed health shakes twice daily, but the care plan was not updated to reflect the change in condition. The DON stated the MDS nurse typically wrote and revised care plans and was unsure why the care plan had not been updated to reflect the weight loss. For Resident 71, who had type 2 diabetes, bipolar disorder, dementia, and limited cognition, staff observed an open and scabbed area on the top of the nose that the resident said was cancer. The record included a physician order for mupirocin to the nose for an open area until healed, with instructions to leave it open to air during the day and cover with a band-aid at bedtime. The existing care plan addressed risk for skin breakdown due to weakness and incontinence, with interventions such as Braden scale monitoring, keeping the resident clean and dry, pressure-relieving mattress use, preventative treatment as ordered, and skin assessment per facility policy. The care plan did not include documentation addressing the skin lesion on the resident’s nose. The DON stated the resident had a cancerous lesion being treated by a dermatologist and later said she did not know if the lesion was cancerous or whether a care plan was in place. For Resident 19, who had a traumatic amputation of the right lower leg and diabetes mellitus and no cognitive deficit on the admission MDS, the resident stated he did not remember having a care plan meeting. The record lacked documentation that any care plan meeting had been held. The SSD stated she had documentation of the scheduled care plan meeting on her cell phone and understood the meeting should have been documented in the medical record, but she could not determine why it had not been recorded. The facility policy stated the resident should be notified of the scheduled care plan conference and that an IDT note should document who attended, significant changes addressed, and the date and time of the meeting.
Medication Error Rate Exceeded During Medication Pass
Penalty
Summary
The facility failed to ensure it was free of a medication error rate greater than 5 percent for 1 of 4 residents observed during medication pass. During observation of Resident 19, RN 12 administered fluticasone-salmeterol inhaler 250-50 mcg and tiotropium bromide inhaler 2.5 mcg, but the resident was not prompted to rinse and spit after the fluticasone-salmeterol inhaler, and the two inhalers were given one after the other with no wait time between them. RN 12 also administered only 1 puff of the tiotropium bromide inhaler, although the resident’s order was for 2 puffs once daily. In addition, aspirin 81 mg and cetirizine 10 mg were not administered because RN 12 stated the medications were out of stock. Resident 19’s record showed orders for tiotropium bromide inhalation aerosol 2.5 mcg, 2 puffs inhaled once daily for shortness of breath; aspirin chewable 81 mg once daily; cetirizine 10 mg once daily for allergy symptoms; and fluticasone-salmeterol aerosol powder 250-50 mcg, 1 puff every 12 hours for shortness of breath. Medication administration notes documented that aspirin and cetirizine were out of stock and that the pharmacy was called, but there was no documentation that the medications were pulled from the EDK or that a physician’s order was obtained to hold them or give them when they arrived. The facility’s FDA drug information stated the resident should rinse his or her mouth with water without swallowing after inhalation, and the inhalation administration policy stated that if more than one inhalation is ordered, one minute should be waited between inhalations and that the mouth should be rinsed after the last inhalation if specified by the manufacturer.
Failure to Document Held Insulin and Physician Notification
Penalty
Summary
The facility failed to document resident refusal, justification for holding insulin, or notification to the physician for Resident 8, who was admitted with type 2 diabetes mellitus and was cognitively impaired. A quarterly MDS indicated the resident received daily insulin injections, and the care plan identified diabetes with risk for hypoglycemia or hyperglycemia, with interventions including antidiabetic medications per order and notifying the physician and family as needed. A physician order dated 7/24/25 directed Lantus SoloStar 10 units subcutaneously at bedtime for diabetes mellitus. Review of the MAR for October and November 2025 showed Lantus insulin was not administered on 10/30/25, 11/1/25, 11/2/25, and 11/27/25. The record did not contain documentation of resident refusal, a reason for holding the insulin, or notification to the physician. During interviews, the DON stated whether a nurse would notify the physician when insulin was held depended on the resident, and RN staff stated they would document the event and notify the physician if insulin was refused or held. The facility also provided a policy titled Physician Orders indicating it was the policy to follow physician orders.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure hand hygiene was performed during a medication pass for 3 of 4 residents reviewed. During a continuous observation on 12/3/25 from 9:31 a.m. to 9:52 a.m., RN 12 prepared and administered medications to Resident 19, including a nasal spray, two inhalers, and lidocaine patches, while wearing gloves but without performing hand hygiene before or after the administration. RN 12 then prepared and administered medications to Resident 26 without hand hygiene before or after the medication administration. RN 12 next prepared and administered eye drops to Resident 67 while wearing gloves, but again did not perform hand hygiene before or after the medication administration. During interviews, RN 12 stated she should have used hand sanitizer between residents. The DON stated staff should have used hand sanitizer between residents and was unsure when handwashing would be required instead of sanitizer. The IP stated hand sanitizer should have been used between residents on the medication pass and after procedures requiring gloves. The facility’s Medication Administration, Inhalation (Oral and Nasal) Administration, and Eye Drop Administration policies all indicated hands should be cleansed before and after medication administration.
Failure to Honor Resident's Meal Location Preference
Penalty
Summary
The facility failed to honor a resident's expressed preference to eat meals in his room rather than in the dining room. During a wound care observation, the resident stated he would rather eat in his room, but staff required him to eat in the dining room for all meals. The Assistant Director of Nursing acknowledged the resident's preference but did not accommodate it. The resident was cognitively intact, able to feed himself with some assistance, and receiving hospice care. His care plan included interventions to offer him choices and assist with meal setup as needed. The clinical record and interviews revealed that the resident had a history of anxiety, depression, and physical limitations, but no upper extremity impairment. A speech therapy summary recommended close supervision during meals and upright posture, but did not specify a requirement for dining room meals. The resident's diet was changed from pureed to regular with thin liquids at his request, after being educated about aspiration risks. Despite understanding the risks, the resident consistently expressed his desire to eat in his room, which was supported by his spouse and documented by the hospice nurse case manager. Staff interviews indicated that it was facility policy for residents requiring assistance to eat in the dining room, citing safety concerns. The Director of Nursing and Administrator both stated that the resident was encouraged or required to eat in the dining room, and noted his resistance, especially when family was present. Meal intake records showed the resident frequently refused meals, particularly breakfast, due to not wanting to go to the dining room. The facility's own policy emphasized residents' rights to self-determination and choice, but these were not honored in this case.
Failure to Reweigh Resident After Significant Weight Change
Penalty
Summary
The facility failed to complete a reweight for a resident, identified as Resident 47, who experienced a significant weight change. Resident 47's medical history included vascular dementia, chronic pain syndrome, and a need for assistance with personal care. A physician's order from January 2022 indicated a general diet with regular texture and thin liquids. The resident's quarterly Minimum Data Set (MDS) assessment in August 2024 documented severe cognitive deficits and significant weight fluctuations, both loss and gain, over a period of months. Despite these documented changes, the facility did not perform a reweight after a notable weight loss from 122.5 pounds in June 2024 to 111.5 pounds in July 2024, which represented an 8.98% decrease. Progress notes from July 2024 indicated that the resident was monitored for significant weight loss, with recommendations for house shakes and weekly weights. However, these notes lacked documentation of any reweight being completed. Interviews with Registered Nurses (RN) 7 and 8 revealed that staff were expected to reweigh residents immediately upon discovering significant weight discrepancies. The Director of Nursing (DON) provided a policy document from April 2017, which stated that a reweight should be obtained and recorded for all significant weight changes. Despite these guidelines, the facility did not adhere to its policy, resulting in the deficiency.
Failure to Address Pharmacy Recommendation for PRN Medication
Penalty
Summary
The facility failed to address a pharmacy recommendation in a timely manner for a resident with Alzheimer's disease. The resident's record indicated two PRN orders for acetaminophen, which posed a risk of overdose. The pharmacy initially recommended discontinuing one of the orders on 2/12/24, but this recommendation was not addressed by the Director of Nursing or the physician at that time. The lack of action was confirmed during an interview with the Administrator, who acknowledged that the recommendation should have been addressed promptly. A second pharmacy recommendation was issued on 6/9/24, reiterating the need to discontinue one of the acetaminophen orders. This time, the physician agreed with the recommendation and ordered the discontinuation of the 500 mg acetaminophen tablets on 6/18/24. The facility's policy required that each recommendation be acted upon, with the Director of Nursing and the attending physician responsible for documenting their review and response. However, the initial failure to address the recommendation led to a deficiency in the resident's drug regimen management.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain adequate sanitation standards in the kitchen and during snack distribution. During a kitchen tour, a thick white cloudy substance was observed on the inside surface of a 2-gallon pitcher used for making beverages for residents. This substance was also noted on the sink and faucet base in the kitchen. Multiple residents reported noticing a white cloudy substance on the drinking glasses, which was attributed to lime deposits. The Dietary Manager acknowledged the issue and mentioned attempts to address it, including checking salt levels, using bleach, and a de-liming solution. However, the problem persisted due to insufficient staff to scrub each cup by hand. The Administrator confirmed that a service man inspected the dishwasher, but no equipment concerns were identified. Additionally, during a random snack distribution observation, an Activity Aide was seen removing oatmeal cream pies from their packaging with bare hands and handing them to residents without using gloves or hand sanitizer. This practice was contrary to the facility's policy on food safety and sanitation, which requires the use of gloves to avoid bare-hand contact with ready-to-eat food. A CNA confirmed that staff should not touch food with bare hands, highlighting a lapse in adherence to the facility's food handling protocols.
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 61 citations issued within 25 miles in the last 12 months — 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 Greencastle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Sunset | 1.3 mi | ★★★★★ | 8 | 0 |
| Mill Pond Health Campus | 1.4 mi | ★★★★★ | 8 | 0 |
| Asbury Towers Health Care Center | 1.8 mi | ★★★★★ | 10 | 0 |
| Aperion Care Summerfield | 8.1 mi | ★★★★★ | 0 | 0 |
| Cloverleaf Of Knightsville | 14.4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Waters Of Greencastle, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.