Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Harris Health And Rehab during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and moderate cognitive impairment, who was known to resist care, was forced to take a shower despite clear care plan instructions to use alternative approaches when resistance occurred. Staff proceeded with the shower, resulting in the resident becoming combative and sustaining a skin tear. Interviews and documentation confirmed that the care plan and facility policies regarding resident rights and dignity were not followed.
A resident with severe cognitive impairment and a history of elopement was able to exit the facility through a front door that failed to latch and had malfunctioning alarms, despite being identified as an elopement risk. Staff and maintenance were aware of ongoing issues with the door's locking mechanism, particularly during high winds, but the problems persisted, allowing the resident to leave unnoticed and be found later by law enforcement.
The facility failed to ensure proper personal hygiene for two residents, leading to deficiencies in nail care, shaving, and oral care. One resident had long, untrimmed fingernails and dry, chapped lips, while another resident was not consistently shaved as required. Both CNAs and the DON confirmed that these care tasks should be performed daily or on shower days, but they were not.
The facility failed to provide an adequate activity program for residents, particularly in the 600 Hall secure unit and on weekends. Surveyors observed no activities or posted calendars, and the Activity Director did not maintain a log of participation. Residents expressed dissatisfaction with the lack of activities, and staff confirmed the absence of structured activities, especially on weekends.
The facility failed to ensure that the Activities Program was directed by a qualified professional. The current Activity Director did not hold a certification and had been in the role for two years. The personnel file review confirmed the absence of any training or certification records for the Activity Director. The DON confirmed that skill check-offs are performed upon hire and annually, but there was no evidence of such documentation for the Activity Director.
The facility failed to apply hand rolls to a resident with hemiplegia, resulting in a contracted left hand. Observations and interviews confirmed the absence of a device to prevent further decline in ROM, despite the facility's policy requiring such interventions.
The facility failed to notify the Ombudsman when a resident was transferred to the hospital on two separate occasions. Documentation confirming the notification was not found, and the Administrator confirmed that no such notifications were made, citing the lack of a policy on transfers.
The facility failed to update a resident's care plan to reflect a contracture in the left hand. Observations and interviews confirmed the contracture and the absence of a necessary device. The MDS Coordinator acknowledged the oversight, but the care plan remained outdated, failing to address the resident's current needs.
The facility failed to ensure that residual was checked per physician's orders from a Gastrostomy tube prior to medication administration for a resident with Dysphagia following a nontraumatic intracerebral hemorrhage. An LPN was observed administering medications without aspirating for residual contents, contrary to the physician's orders and the resident's care plan. The DON confirmed the requirement to check for placement by aspirating and auscultating before administering medications, fluids, or enteral feeding.
A facility failed to ensure proper infection control during a dressing change for a resident with a wound. A CNA removed soiled dressings without changing gloves or sanitizing hands, disposed of them improperly, and then gave the resident a shower, risking cross-contamination. The facility's infection control policy was not followed.
Failure to Honor Resident Rights and Care Plan During Shower
Penalty
Summary
The facility failed to maintain the rights and dignity of a resident with late onset Alzheimer's disease who had moderately impaired cognition. The resident was known to be resistant to care, including showering and bathing, and had a care plan in place directing staff to use alternative approaches such as postponing care, trying again later, or notifying a nurse if resistance occurred. Despite these interventions, staff proceeded to provide a shower when the resident was visibly resistant and combative, resulting in the resident receiving a skin tear during the process. Staff interviews confirmed that the resident was fighting and cussing at staff, and that the care plan was not followed as required. Documentation and interviews revealed that the staff did not attempt alternative approaches or postpone the shower as directed by the care plan. Instead, they continued with the shower despite the resident's resistance, and only after the resident became combative did the nurse instruct staff to return the resident to their room. The Director of Nursing and Administrator both confirmed that the staff did not follow the person-centered care plan, which required attempts to identify the cause of resistance and to try care at a different time or with different staff. Facility policies also required residents to be treated with dignity and to have the right to refuse care, which was not upheld in this incident.
Failure to Secure Exit Doors Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that exit doors were secured and functioning properly, resulting in a resident with severe cognitive impairment and a known history of elopement being able to exit the building without staff knowledge. The resident, who had diagnoses including alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and altered mental status, was identified as an elopement risk and had a care plan reflecting this risk. Despite this, the resident was able to leave the facility through the front entrance door after a nurse had entered, and staff only became aware of the elopement when the resident was not found in their usual locations during rounds. Staff interviews and record reviews revealed that the front door's locking mechanism was unreliable, particularly during high winds, which could prevent the door from latching and cause alarms to malfunction. Maintenance staff and nursing personnel acknowledged that the issue with the door not latching due to wind was a known problem, and a note had been posted at the door to remind staff to ensure it was closed during high winds. Additionally, staff reported that the alarms at the front and side doors were not working at the time of the incident, and the door could be opened after a short delay even when it was supposed to be locked. The resident was eventually found by law enforcement in a field behind the facility and returned safely. The incident was documented, and staff interviews confirmed that the resident was more confused when off the secure unit. The facility's failure to maintain secure exit doors and ensure proper functioning of door alarms directly contributed to the resident's ability to elope, despite the resident's documented risk and history of similar behaviors.
Removal Plan
- Place resident in secured unit for safety and monitor by staff and nurse manager/designee.
- Re-inservice all staff on abuse prevention program and facility elopement policy.
- Assess all residents for elopement risk using elopement and wandering assessment, review care plans, and update care plans for residents at risk for elopement.
- Update elopement binder with resident pictures and demographics and inservice staff on use of elopement binder.
- Complete body audit, incident, accident and elopement form when resident is found and returned to building, including documentation of last seen, when resident was found, and notification of family and doctor.
- Recheck all doors by maintenance for working locking mechanisms.
- Contact door company to check all doors for proper working condition.
Deficiencies in Personal Hygiene Care
Penalty
Summary
The facility failed to ensure proper personal hygiene for two residents, leading to deficiencies in nail care, shaving, and oral care. Resident #45, who has a history of stroke and is moderately cognitively impaired, was observed with long, jagged, and untrimmed fingernails on multiple occasions. Additionally, Resident #45 had dry and chapped lips, indicating a lack of daily oral care. Both a CNA and the DON confirmed that oral care should be provided daily, but it was not done in this case. Resident #24, who has Parkinson's Disease and is severely cognitively impaired, was observed to need shaving on multiple occasions. The resident's care plan indicated that shaving should occur on shower days, but it was evident that this was not consistently done. Both a CNA and an LPN confirmed that the resident should be kept clean-shaven for hygiene purposes, but acknowledged that the resident had not been shaved as required. The facility's policies on fingernail care, shaving, and mouth care were not followed, leading to these deficiencies. The DON provided documentation showing that these tasks should have been completed during the residents' showers, but they were not. This failure to adhere to established care plans and policies resulted in inadequate personal hygiene for the residents involved.
Failure to Provide Adequate Activity Program
Penalty
Summary
The facility failed to ensure that the activity program was designed to meet the individual needs, interests, and abilities of residents, particularly those residing in the 600 Hall secure unit. Over several days, surveyors observed that no activities were being provided on the secure unit, and there was no activity calendar posted. The Activity Director (AD) admitted to not posting a calendar in the secure unit and only announcing activities overhead in the mornings. Additionally, the AD did not maintain a log of resident participation in activities, and there were inconsistencies in the AD's reports of activities conducted, such as gardening and popcorn distribution, which were not corroborated by other staff members or observed by surveyors. Residents expressed dissatisfaction with the lack of activities, especially on weekends. The Resident Council President and other members highlighted the absence of weekend activities, and the AD confirmed that weekend activities were limited to visits from pastors and occasional movies or games set up by the weekend RN. However, multiple CNAs working on weekends reported that no structured activities were provided, and residents were often bored. The facility's activity policy requires that activity programs support the physical, mental, and psychosocial well-being of each resident, with scheduled activities posted on bulletin boards and provided individually to residents who cannot access the board. The policy also mandates that activities be offered at convenient times, including evenings, holidays, and weekends. The facility's failure to adhere to this policy resulted in a lack of meaningful engagement for residents, particularly those in the secure unit and on weekends, contributing to their dissatisfaction and potential negative effects on their well-being.
Lack of Certified Activity Director
Penalty
Summary
The facility failed to ensure that the Activities Program was directed by a qualified professional. The Administrator confirmed that the current Activity Director did not hold a certification and had been in the role for two years. The Activity Director was unaware of the certification requirement and mentioned that there was a possibility of attending a certification class in June 2024. The personnel file review confirmed the absence of any training or certification records for the Activity Director. The Director of Nursing (DON) confirmed that skill check-offs are performed upon hire and annually, but there was no evidence of such documentation for the Activity Director. The Activity Director stated that although they receive annual training from a corporate person, no certificates are issued. The Administrator also confirmed the lack of records or certificates documenting any training for the Activity Director, noting that the previous HR person had provided ongoing training until they left the facility.
Failure to Apply Hand Rolls for Resident with Contracture
Penalty
Summary
The facility failed to ensure that hand rolls were applied to prevent further decline in range of motion (ROM) for a resident with hemiplegia affecting the left side. The resident's care plan, dated 03/30/2023, did not document a contracture but noted limited physical mobility and weakness in the left hand, specifically the 4th and 5th digits. Observations on 04/15/2024 and 04/16/2024 revealed that the resident's left hand appeared contracted with no device present to prevent injury or decline in ROM. The resident confirmed that staff did not place a device in their hand. Interviews with a CNA and the DON confirmed that the resident's left hand was contracted and that a device should have been present to prevent further contracture or injury. The facility's policy on 'Resident Mobility and Range of Motion,' revised in July 2017, stated that residents should not experience an avoidable reduction in ROM and that those with limited ROM should receive appropriate services, equipment, and assistance to maintain or improve mobility. The policy also required the care plan to include specific interventions, exercises, and therapies to maintain or improve ROM. However, the care plan for this resident did not include such interventions, leading to the deficiency noted in the report.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure the Ombudsman was notified when residents were transferred to the hospital. This deficiency was identified through interviews and record reviews. Specifically, one resident was admitted to the facility, transferred to the hospital on two separate occasions, and returned to the facility each time. The surveyor was unable to locate documentation indicating that the Ombudsman had been notified of these transfers. When asked, the Administrator and Business Office Consultant confirmed that the Ombudsman had not been notified. The Administrator also stated that there was no policy on transfers because it was considered a state issue rather than a federal one.
Failure to Update Care Plan for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a resident's individualized plan of care was revised to reflect the current needs, specifically regarding contractures. Resident #45's care plan, dated 03/30/2023, did not document a contracture but only mentioned limited physical mobility related to hemiplegia affecting the left side. Observations by the surveyor on multiple occasions confirmed that the resident's left hand appeared to be contracted, and no device was present to address this condition. Interviews with the resident, CNA, and DON confirmed that the resident's left hand was contracted and that a device should have been used to prevent further contracture or injury. However, the device was not in use, and the care plan had not been updated to reflect the resident's current condition. The MDS Coordinator acknowledged that the resident's condition had progressed to a contracture and that it should have been documented in the care plan. The coordinator also mentioned that restorative measures would be initiated to address the contracture. Despite this acknowledgment, the deficiency lies in the failure to update the care plan in a timely manner to reflect the resident's current needs and to implement appropriate interventions to prevent further deterioration of the resident's condition.
Failure to Check Residuals Before Administering Medications via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that residual was checked per physician's orders from a Gastrostomy tube prior to medication administration for Resident #32. Resident #32 was admitted with a diagnosis of Dysphagia following a nontraumatic intracerebral hemorrhage. On 04/17/2024 at 09:00 AM, an LPN was observed administering medications via tube feeding without aspirating for residual contents as per the physician's orders. The physician's order dated 03/25/2021 required verification of gastrostomy tube placement via aspirate and auscultation before medication administration, feeding, or flushes, and to wait one hour and recheck if more than 150 ml of residual was found. The care plan dated 07/05/2022 also documented the same requirements. When questioned, the LPN stated that they should auscultate before administering enteral feedings but did not mention aspirating for residual contents. The Director of Nursing (DON) confirmed that nurses are expected to check for placement by aspirating and auscultating before administering medications, fluids, or enteral feeding, and that aspirating would show the residual. The DON provided a policy titled 'Administering Medications through an Enteral Tube,' which outlined the procedure for the safe administration of medications through an enteral tube, including verifying physician's medication orders.
Infection Control Lapse During Dressing Change
Penalty
Summary
The facility failed to ensure proper infection control measures during a dressing change for a resident with a wound on the left lower leg. On multiple occasions, the resident's bandage was observed to be soiled with yellow and red drainage. During a shower, a CNA removed the soiled dressings without changing gloves or sanitizing hands, and disposed of the dressings in a regular trash receptacle instead of a biohazard bag. The CNA then proceeded to give the resident a shower without changing gloves, thereby risking cross-contamination and infection. The Treatment Nurse confirmed that normally a nurse should handle such dressings to avoid improper removal and potential harm. The CNA admitted to not following proper infection control procedures, including not changing gloves or sanitizing hands after handling soiled dressings. The facility's infection control policy mandates that all personnel be trained on infection control practices, but the CNA's actions demonstrated a lack of adherence to these protocols. The CNA acknowledged the importance of changing gloves and sanitizing hands to prevent the spread of germs and infection, but failed to implement these measures during the observed incident.
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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 Osceola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manila Healthcare Center | 9.6 mi | ★★★★★ | 9 | 0 |
| Heritage Square Healthcare Center | 14.5 mi | ★★★★★ | 0 | 0 |
| Gosnell Health And Rehab | 15 mi | ★★★★★ | 6 | 0 |
| Monette Manor, Llc | 19.2 mi | ★★★★★ | 11 | 0 |
| Lakeside Health And Rehab | 22 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.