Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Celina Manor during CMS and state inspections, most recent first.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident receiving Medicare Part A skilled services was discharged from coverage when skilled services were ending, but the facility did not document issuance of the required NOMNC or SNF ABN. The resident had diagnoses including aftercare following circulatory surgery, DM, and dementia, and the MDS indicated the resident was cognitively intact. The DON confirmed the record lacked evidence that the notices were provided before Part A services ended.
Failure to timely address a resident’s dignity concern. A resident with anoxic brain damage, DM2, and depression reported that a CNA told him he was too old to be wearing a diaper, which he felt was disrespectful. The DON was not initially aware of the concern, did not speak directly with the resident right away, and the concern was not promptly escalated; the Administrator stated staff were expected to follow up within 24 hours.
Missing Discharge Documentation for Planned Transfer: The facility failed to complete a discharge recapitulation of stay or discharge summary for a cognitively intact resident with pneumonia, pulmonary fibrosis, emphysema, and COPD who was planned for transfer to an ALF. The medical record contained a discharge planning note, but no documentation of the required discharge summary, and the DON confirmed the record was incomplete. The facility policy required discharge documentation and written notification including the reason for transfer, effective date, appeal rights, and Ombudsman contact information.
Fall Care Plan Interventions Not in Place: A resident at risk for falls with impaired cognition, COPD, lymphedema, anxiety, weakness, and a history of falls did not have the chair alarm intervention in place while sitting in a recliner. Staff confirmed the bed sensor was present but the chair sensor was missing, and an LPN verified the care plan listed both chair and bed sensors as fall interventions.
Failure to document monitoring for psychotropic medication side effects. A resident with Alzheimer's disease, depression, and anxiety, and two other residents with dementia and behavioral symptoms, were receiving multiple psychotropic medications including antidepressants, anxiolytics, hydroxyzine, valproic acid, and trazodone. Although care plans called for monitoring behaviors and side effects, the records contained no routine documentation of adverse effects monitoring, and the PA, DON, and Administrator confirmed the lack of documentation.
The facility failed to ensure required QAPI committee members attended quarterly meetings. Review of attendance records showed no documentation that the Infection Control Nurse attended the QAPI meetings for two consecutive quarters, and the Administrator confirmed the nurse did not attend. The facility policy required the full QAPI committee, including the Infection Control Nurse, to meet quarterly.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a resident the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) after it initiated discharge from Medicare Part A services. This affected one of three residents reviewed for beneficiary notices in a facility with a census of 72. Review of the medical record showed the resident was admitted on 05/29/25 with diagnoses including aftercare following surgery on the circulatory system, diabetes mellitus, and dementia. The quarterly MDS assessment indicated the resident was cognitively intact. The resident received skilled services under Medicare Part A from 05/29/25 through 07/18/25 and still had skilled days remaining on 07/18/25 while remaining in the facility. There was no documentation that the facility issued a NOMNC or SNF ABN. During interview, the DON confirmed the facility initiated discharge from Medicare Part A services because skilled services were ending and confirmed the record did not contain documentation showing the required notices were issued before services ended on 07/19/25. The facility policy stated a NOMNC is issued when there is a termination of Medicare Part A or Part B therapy services for coverage reasons, and that an ABN is issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare.
Failure to Timely Address Resident Dignity Concern
Penalty
Summary
The facility failed to address a resident’s concern regarding staff in a timely manner, affecting one resident reviewed for dignity and respect. Resident #31 was admitted on 07/09/21 and had diagnoses including anoxic brain damage, diabetes mellitus type two, and depression. The quarterly MDS assessment indicated he had intact cognition. During interview, Resident #31 stated a CNA had told him he was too old to be wearing a diaper. He said he did not believe the CNA was verbally abusive, but felt disrespected by the comment and acknowledged he had not reported the issue to management at the time. The DON stated she had not been aware of the dignity concern when first interviewed and later acknowledged she had not spoken directly with Resident #31 about it. Instead, the Resident Services Coordinator interviewed him, and he described the interaction as friendly back-and-forth banter but said the CNA sometimes went too far. The RSC also stated she had not been informed of the concern by the DON until later. The Administrator stated it was her expectation that staff would follow up with a resident’s concern for dignity and respect within 24 hours. The facility policy required residents to be treated with respect and dignity in a manner that promotes quality of life and recognizes individuality.
Missing Discharge Documentation for Planned Transfer
Penalty
Summary
The facility failed to complete a discharge recapitulation of stay or discharge summary when Resident #75 was discharged to another healthcare setting. Resident #75 was admitted on 10/28/25 with diagnoses including pneumonia, pulmonary fibrosis, emphysema, and COPD. The admission MDS assessment indicated the resident was cognitively intact. A Social Service Weekly Baseline and Discharge Planning tool dated 12/22/25 documented that Resident #75 would transfer to an Assisted Living facility on 12/26/25, but the tool contained no other documentation related to the discharge. Review of the medical record found no documentation supporting that a discharge recapitulation of stay or discharge summary was completed for Resident #75. During interview on 03/26/26 at 3:15 P.M., the DON confirmed the resident had a planned discharge to an Assisted Living facility and that the medical record did not contain documentation of a discharge recapitulation of stay or discharge summary. The facility policy titled Admission, Transfer, Discharge and Room Change, dated 2025, stated that transfers and discharges are to be documented in the resident's clinical record and that written notification would include the reason for transfer or discharge, effective date, appeal rights, and the Ombudsman's contact information.
Fall Care Plan Interventions Not in Place
Penalty
Summary
The facility failed to ensure that a resident at risk for falls had the fall care plan interventions in place. Resident #5 was admitted with diagnoses including COPD, lymphedema, and anxiety, and the quarterly MDS showed impaired cognition and a need for moderate assistance with toileting hygiene, bed mobility, and transfers. The care plan, last revised on 01/21/26, identified the resident as being at risk for falls related to impaired mobility, weakness, a history of falls, confusion, edema, and COPD, and listed interventions including a small pad sensor to the chair and a larger sensor pad to the bed. Observation on 03/25/26 showed the resident sitting in a recliner in the reclined position with eyes closed, and there did not appear to be a sensor plugged in near the recliner. CNAs #269 and #248 confirmed there was a sensor on the bed but no sensor on the chair, and stated they were unaware the resident needed a chair alarm in the recliner. An LPN later observed the resident in the recliner, verified there was no chair sensor, and reviewed the care plan, which did list both a chair and bed sensor as fall interventions. The facility policy titled Fall Reduction stated that based on the outcome of the fall assessment, a fall risk reduction plan would be added to the plan of care.
Failure to Document Monitoring for Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to document routine monitoring for adverse side effects and behaviors for residents receiving psychotropic medications. Review of the facility policy titled Psychotropic Drugs stated that a physician, nursing, or other health care professional would document that the resident is being monitored for adverse consequences or complications of drug therapy, but the medical records reviewed did not contain such documentation for the affected residents. Resident #65 had diagnoses of Alzheimer's disease, depression, and anxiety, and the MDS showed impaired cognition. The care plan identified the resident as at risk for adverse effects or complications related to psychotropic medication use and included interventions to monitor behaviors every shift and monitor for side effects, with notification of the physician for adverse effects. The resident was receiving Zoloft 50 mg daily for depression, but there was no documentation in the medical record showing routine monitoring of behaviors or side effects. The PA stated he spoke with staff during in-person visits about medication side effects and had access to records, but had not reviewed documentation specifically for adverse effects monitoring; the Administrator and DON verified the facility did not document adverse side effects for this resident. Resident #70 had Alzheimer's disease with late onset, anxiety, and severe dementia with agitation, and the MDS showed severely impaired cognition with documented behaviors including physical and verbal behaviors, wandering, and rejection of care during the review period. The resident was receiving multiple psychotropic medications, including Celexa, hydroxyzine as needed for agitation/anxiety, valproic acid for severe agitation, and trazodone for anxiety disorder, yet there was no documentation of routine monitoring of behaviors or side effects. Resident #47 had Alzheimer's disease and dementia with behaviors, impaired cognition, and documented verbal and physical behaviors, wandering, and behaviors not directed toward others; the resident was receiving Ativan, buspirone, mirtazapine, and sertraline, but the record also lacked documentation of routine monitoring of behaviors and side effects. The PA, Administrator, and DON confirmed the absence of such documentation for these residents.
QAPI Committee Missing Required Infection Control Nurse Attendance
Penalty
Summary
The facility failed to ensure that required QAPI committee members attended the quarterly meetings as required. Review of the QAPI attendance sign-in sheets for the third quarter of 2025 and the fourth quarter of 2025 showed no documentation that the Infection Control Nurse attended either quarterly meeting. During an interview on 03/30/26 at 1:20 P.M., the Administrator confirmed that the Infection Prevention nurse did not attend the QAPI meetings for those two quarters. Review of the facility policy titled QAPI policy and procedure, dated February 2018, showed that the full QAPI committee was to meet quarterly and include the Administrator, Medical Director, Pharmacy Consultant, Social Service Designee, DON, Activity Coordinator, Food Service Supervisor, Infection Control Nurse, Environmental Service Supervisor, Restorative Nurse, and Business Office Manager.
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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.
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Nursing homes near Celina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens At Celina | 0.3 mi | ★★★★★ | 3 | 0 |
| Briarwood Village | 7.5 mi | ★★★★★ | 4 | 1 |
| Otterbein St Marys Retirement Community | 7.7 mi | ★★★★★ | 0 | 0 |
| Grande Lake Healthcare Center | 8.2 mi | ★★★★★ | 0 | 0 |
| Vancrest Of St Mary's | 9.7 mi | ★★★★★ | 5 | 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.