Waters of Greencastle, The

In the surveyor’s words

From the most serious findings on record at Waters of Greencastle, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 18, 2026

  Based on observation, record review, and interview, the facility failed to supervise and ensure the safety of a resident with dementia residing on the locked dementia unit when an exit glass door and an outside courtyard gate were left open by a contractor and the resident eloped from the facility and fell into a ditch for 1 of 3 residents reviewed for accidents (Resident B). The immediate jeopardy began on 6/2/26 at 1:58 p.m., when Resident B was observed via video footage exiting the gate from the locked unit courtyard. She continued across the parking lot into a grassy field. She walked at a rapid pace, carrying a blanket in front of her. She walked approximately 100 yards and veered towards the road and was observed falling on her face in a ditch. […]

• No harm, potential for more than minimal, widespreadF835Jun 18, 2026

  Based on observation, record review, and interview, the facility Administrator and Director of Nursing (DON) failed to communicate accurate information, complete accurate documentation, and pressured facility staff to provide false statements for an elopement from the memory care unit for 1 of 5 residents reviewed for accidents (Resident B). This deficiency had the potential to affect 68 of 68 residents residing at the facility who were overseen by the Administrator and DON.Findings include:During an interview on 6/15/26 at 12:29 p.m., Resident B's spouse indicated he had been caring for his wife at home and was very sad he had to make the decision to place her in a safer environment due to her dementia. His wife was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure beard restraints were worn appropriately and hand hygiene was performed after staff touched their face during 5 of 5 kitchen observations. This deficient practice had the potential to affect 68 of 68 residents who ate meals from the kitchen. Findings include: 1. During a kitchen observation, on 12/1/25 at 10:05 a.m., [NAME] 7 was observed in the food preparation area, stirring a pot on the stove and preparing other food. At the same time, [NAME] 7 was observed with a full beard and mustache. [NAME] 7 had a beard restraint in place, but it only covered a small area of the beard on his chin, leaving the mustache and sides of the face open. […]

• No harm, potential for more than minimal, patternF552Dec 5, 2025

  Based on record review and interview, the facility failed to obtain consent for treatment of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications. (Residents 7, 8, 27, and 22). Findings include:1. On 12/3/25 at 10:25 a.m., the medical record of Resident 7 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnoses included, but were not limited to, dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure) and depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at… […]

• No harm, potential for more than minimal, patternF565Dec 5, 2025

  Based on interview and record review, the facility failed to ensure the grievances expressed by the residents were addressed and resolutions were explained to the residents for 6 of 24 residents reviewed for food concerns (Residents 6, 71, 38, 24, 68, and 65). Findings include:During an interview, on 12/01/25 at 11:19 a.m., Resident 6 indicated she ate in her room. The food was often cold when she got it. The residents were not getting the food that was posted on the menus. The menu had not been right for a while. She was not sure who was ordering the food, but they frequently ran out of items. They recently had run out of coffee. […]