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 Mountain Meadows Health And Rehabilitation during CMS and state inspections, most recent first.
Hand Hygiene and Food Storage Lapses During Meal Preparation: Dietary staff repeatedly handled clean food items and equipment without washing hands after touching dirty surfaces, including turning off faucets with bare hands and then placing gloves on before handling strawberries, bowls, cups, and beverages for resident meals. Staff also left an opened box of fish in the walk-in freezer uncovered and unsealed, and the Dietary Manager confirmed it would result in freezer burn.
The facility failed to provide residents with a diet that met their nutritional needs and was visually pleasing. Multiple residents reported that the food was poorly cooked, lacked seasoning, and was sometimes inedible. Observations confirmed that food temperatures were not maintained at safe levels, and the Dietary Manager acknowledged issues with food preparation and seasoning.
The facility failed to ensure food was used prior to the use-by date. Multiple items in the cook's refrigerator and walk-in refrigerator were observed with expired use-by dates, and some items were found without any dates. Additionally, a bag of spaghetti was found unsealed in the dry storage area, exposing it to contamination. The Dietary Manager confirmed that leftovers are utilized for no longer than two days, and the facility's policy requires all foods to be covered, labeled, and dated.
The facility failed to ensure all pharmaceuticals were available and provided to residents during medication administration. Two residents did not receive their prescribed medications as required by physician orders. The DON confirmed that the medications should have been administered as per the orders once the hold period ended, and the correct dosages should have been available.
The facility failed to follow physician orders, resulting in a medication error rate of 22.22%. A nurse did not have a resident rinse their mouth after using an inhaler, another resident did not receive their prescribed medications, and a third resident did not receive their medication through a PEG tube. The facility's policies on medication administration, documentation, and infection control were not followed.
The facility failed to ensure proper personal hygiene and grooming for residents, as evidenced by missed showers and unshaven appearances for a resident with dementia, and long, dirty fingernails and unshaven appearance for another resident with cerebral infarction and hemiplegia. Staff interviews confirmed the need for regular grooming to maintain dignity and prevent potential risks.
The facility failed to provide a meaningful program of activities for residents, particularly on the secure unit and during weekends. Observations and resident reports revealed a lack of structured activities, with the Activity Director citing staffing shortages and recent resignations as contributing factors. The facility's policy on activity scheduling was not being followed.
The facility failed to store smokeless tobacco at the nurse's station for two residents and did not maintain a fall mat for another resident. Staff were unaware of the facility's policies, and the fall mat was torn and missing a piece, posing potential hazards.
The facility failed to ensure proper medication administration and wound care. A resident did not rinse their mouth after receiving inhaled corticosteroids, another did not receive prescribed medications, and a third did not receive proper incontinent care before wound treatment. Additionally, a resident with a UTI did not receive timely follow-up care.
The facility failed to ensure proper infection control practices for three residents. An LPN did not perform incontinent care before wound treatment for a resident with a stage 4 pressure ulcer, leading to potential cross-contamination. Another resident's PEG tube syringe was not changed or cleaned as required, and a third resident's catheter bag and nebulizer mask were improperly stored, violating infection control policies.
The facility failed to ensure that a resident with severe cognitive impairment was assessed by the IDT and had a physician's order before being allowed to self-administer updraft treatments. The resident was found unattended with a nebulizer mask not secured to their face, and staff confirmed that no self-administration order was in place.
A facility failed to accurately code a resident's MDS to indicate the presence of a PEG tube, despite the resident having diagnoses of gastrostomy status and dysphagia following a cerebral infarction. The MDS Coordinator confirmed the error, emphasizing the importance of accurate MDS coding for proper care planning.
The facility failed to ensure the care plan for a resident with dyspnea included the use of oxygen, despite multiple observations and physician orders indicating its necessity. Interviews with staff confirmed that the care plan should document oxygen use to ensure accuracy and inform staff.
The facility failed to update the care plan for a resident with an indwelling catheter, despite the 5-day MDS assessment indicating the presence of the catheter. The MDS Coordinator confirmed the care plan should have been revised, and the facility lacked a policy for timely care plan updates.
Hand Hygiene and Food Storage Lapses During Meal Preparation
Penalty
Summary
The facility failed to ensure food items stored in the freezer were covered or sealed and failed to ensure staff washed their hands between dirty and clean tasks and before handling clean equipment during meal preparation and service. During observation, a Dietary Aide washed her hands, then turned off the faucet with bare hands, contaminated her hands, and put on gloves without rewashing before placing sliced strawberries on cake for lunch. The same aide later wrote dates on lids, then again put on gloves without washing and handled clean bowls used to portion dessert, contaminating the bowls. Additional observations showed other Dietary Aides handling clean food service items without washing hands after touching dirty objects. One aide turned off a food preparation sink with bare hands, then picked up cups by the rims and poured water into them for lunch. Another aide removed a beverage pitcher from the refrigerator, then handled cups by the rims and poured beverages for supper without washing hands. A fourth aide handling breakfast trays picked up cartons of yogurt, milk, milk shakes, and condiments, then handled cups with beverages by the rims without washing hands. The Dietary Manager also confirmed an opened box of fish in the walk-in freezer was not covered or sealed and would result in freezer burn.
Failure to Ensure Nutritional and Palatable Food
Penalty
Summary
The facility failed to ensure that residents received a diet that met their nutritional needs, was visually pleasing, and prepared in a manner to maintain nutritional content and taste. Resident #25, who had a diagnosis of unspecified dementia and was cognitively intact, described the meatloaf served as unappetizing and tasteless. A test tray revealed overcooked Brussels sprouts and bland mashed potatoes. Additionally, a resident council meeting confirmed that multiple residents found the food poorly cooked and lacking seasoning, with specific complaints about inedible breakfast items such as hard-cooked eggs and burned toast. Further observations revealed that food temperatures were not maintained at safe levels. Pureed food items were found to be below the recommended temperature, and the egg product served was congealed and unseasoned. Resident #55 had previously filed a grievance about the food quality, which was temporarily resolved but later resurfaced. The Dietary Manager admitted to issues with food preparation and seasoning, citing a new cook's error in overcooking Brussels sprouts. Resident #21 also expressed dissatisfaction with the food, describing it as unfit for consumption. The resident showed a half-baked potato that was served, which was inedible and poorly prepared. Despite keeping snacks in their room to avoid weight loss, Resident #21's complaint highlighted the ongoing issues with food quality and preparation in the facility.
Failure to Use Food Prior to Use-By Date
Penalty
Summary
The facility failed to ensure food was used prior to the use-by date. On 05/05/2024, multiple items in the cook's refrigerator were observed with use-by dates of or before 05/04/2024, including sliced ham, macaroni and tomatoes, stewed tomatoes, mechanical soft ham, mechanical soft meatballs, and pizza sauce. Additionally, hard-boiled eggs with a use-by date of 04/28/2024 and a bag of sliced turkey with no use-by date were found. In the walk-in refrigerator, chopped tomatoes with a use-by date of 05/04/2024 were observed. In the dry storage area, a bag of spaghetti was found unsealed, exposing it to air and contamination. A clear plastic container with 14 individually bagged sugar cookies with no date was also found. The Dietary Manager confirmed that leftovers are utilized for no longer than two days. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure all pharmaceuticals were available and provided to residents during medication administration. For Resident #79, there were physician orders for Hydrocodone-Acetaminophen and Lorazepam to be administered, but these medications were not given during the 08:00 AM medication pass on 05/07/2024. The Registered Nurse (RN) confirmed that the medications were on hold, but the Medication Administration Record (MAR) showed that the medications were not administered as required by the physician's orders. The Director of Nursing (DON) confirmed that the medications should have been administered as per the order once the hold period ended. For Resident #57, there was a physician order for Guaifenesin Oral Tablet 400 mg to be administered via PEG tube, but the medication was not available, and the resident did not receive the dose during the 08:00 AM medication pass on 05/07/2024. The Licensed Practical Nurse (LPN) stated that only the 600 mg Mucinex was available and planned to get the order changed by the Advanced Practice Registered Nurse (APRN). The DON confirmed that the correct dosage should have been available and administered as per the physician's order. The facility's policy on administering medications states that medications should be administered in a safe and timely manner as prescribed, which was not followed in these instances.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure physician orders were followed, resulting in a medication error rate of 22.22%. During a medication pass, a registered nurse did not have a resident rinse their mouth after administering an inhaler, which is necessary to prevent thrush. The nurse admitted to forgetting this step when interviewed by the surveyor. Additionally, another resident did not receive their prescribed Hydrocodone-Acetaminophen and Lorazepam, and only received one drop per eye of their prescribed eye drops instead of the ordered two drops per eye. The nurse confirmed that the medications should have been administered as per the physician's orders and that the correct dosage of eye drops should have been given. Another resident did not receive their prescribed Guaifenesin oral tablet through their PEG tube. The nurse used an expired syringe to verify the placement of the tube and did not clean the syringe before placing it back in the storage bag. The nurse later stated that the order for the medication should have been clarified before the end of the medication pass. The Director of Nursing confirmed that the medications should have been administered as per the physician's orders and that the PEG tube syringe should be changed every 24 hours to prevent bacterial contamination. The facility's policies on medication administration, documentation, and infection control were not followed. The policies state that medications should be administered as prescribed, documented immediately after administration, and that infection control procedures should be followed. The failure to adhere to these policies resulted in multiple medication errors and the use of an expired syringe, which could potentially lead to adverse consequences for the residents involved.
Deficiencies in Personal Hygiene and Grooming
Penalty
Summary
The facility failed to ensure proper personal hygiene and grooming for residents, as evidenced by the observations and interviews conducted by the surveyor. Resident #81, who has a self-care performance deficit related to dementia and other conditions, did not receive showers on scheduled days and was observed to be unshaven on multiple occasions. Despite the facility's in-service training emphasizing the importance of adhering to shower schedules and proper documentation, Resident #81 missed several scheduled showers and expressed a preference for being clean-shaven, which was not met. Interviews with the RN and DON confirmed that the resident should have been bathed and shaved on scheduled days and as needed. Resident #8, diagnosed with cerebral infarction and hemiplegia, was also found to have poor personal hygiene. The resident's fingernails were observed to be excessively long, jagged, yellowing, and dirty, with a brown substance underneath. Additionally, the resident had not been shaved despite expressing a desire for nail care and shaving. Interviews with CNA #4 and LPN #1 revealed that the resident's nails were recognized as needing trimming and that the resident needed to be shaved. Both staff members acknowledged the potential risks associated with long nails and the importance of maintaining the resident's dignity through regular grooming. The facility's policy on supporting activities of daily living (ADLs) states that residents who are unable to carry out these activities independently should receive the necessary services to maintain good grooming and personal hygiene. However, the observations and interviews indicate that the facility did not adhere to this policy, resulting in deficiencies in the care provided to Residents #81 and #8. The lack of proper grooming and hygiene care for these residents highlights a failure to meet their basic needs and preferences, as well as the facility's own standards and training protocols.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide a meaningful program of activities for twelve residents reviewed for activities. Specifically, the facility did not ensure that the activity program was designed to meet the individual activity needs, interests, and abilities for residents on the secure unit. Additionally, the facility did not provide activities on the weekends for all 97 residents. Observations on multiple days revealed no activities taking place on the secure unit, and residents reported a lack of structured activities on weekends. The Activity Director (AD) acknowledged the issue, citing staffing shortages and the recent resignation of the previous AD and her assistant as contributing factors. The AD also mentioned that the Unit Coordinator, who typically handles activities on the secure unit, was on vacation, further exacerbating the problem. The AD admitted that weekend activities were not consistently provided, and no nursing staff were assigned to assist with activities during weekends. The facility's policy titled 'Preparation for Activities' indicated that the Activity Director/Coordinator is responsible for scheduling activity functions and programs, and that these programs should be coordinated with various departments such as Nursing, Therapy, Dietary, and Housekeeping Services. However, the policy was not being followed, as evidenced by the lack of activities observed and reported by residents and staff. The AD's efforts to occasionally come in on Saturdays to play bingo were insufficient to meet the needs of the residents, and the absence of structured activities on weekends and the secure unit highlighted a significant deficiency in the facility's activity program.
Failure to Prevent Accident Hazards and Maintain Safety Equipment
Penalty
Summary
The facility failed to ensure that smokeless tobacco was kept at the nurse's station to prevent accidents for two residents. Resident #45 was observed with two plastic containers of wintergreen snuff on their bedside table, one of which was missing a lid, and brown liquid was seen dripping down their chin. Staff members, including a CNA and an LPN, were unaware of the facility's policy that smokeless tobacco should be stored at the nurse's station. Similarly, Resident #67 was observed multiple times with chewing tobacco in their mouth and in their possession, despite the care plan stating that smokeless tobacco should be used only under supervision and stored at the nurse's station. The facility's smoking policy also indicated that residents without independent smoking privileges should not have access to tobacco products. The facility also failed to ensure that a fall mat was well maintained for Resident #20. The resident, who had a history of falls and was at risk for falls due to impaired mobility and severe cognitive impairment, was observed with a fall mat that had a tear near the center and a piece missing from the side. Both a CNA and the Director of Nursing confirmed that the fall mat should not be torn or have pieces missing, as it could pose a hazard to the resident and staff. The facility's policy on hazardous areas, devices, and equipment emphasized the importance of maintaining equipment to ensure resident safety and mitigate accident hazards. These deficiencies highlight the facility's failure to adhere to its own policies regarding the storage and supervision of smokeless tobacco and the maintenance of safety equipment. The lack of proper supervision and maintenance could lead to potential accidents and injuries, compromising the safety and well-being of the residents involved.
Medication Administration and Wound Care Deficiencies
Penalty
Summary
The facility failed to ensure that residents receiving inhaled corticosteroids were instructed to rinse their mouths to prevent irritation and infection. Specifically, Resident #67, who was readmitted with chronic obstructive pulmonary disease and chronic respiratory failure, did not rinse their mouth after receiving corticosteroid medication via inhaler. The Registered Nurse (RN) administering the medication acknowledged forgetting this step, which is crucial to prevent the risk of thrush, as per the manufacturer's guidelines. The facility also failed to ensure that residents received medications as ordered. Resident #79, diagnosed with osteoarthritis, dementia, and blepharitis, did not receive the prescribed doses of Hydrocodone-Acetaminophen and Lorazepam. Additionally, the resident received only one drop per eye of the ordered eye drops instead of the prescribed two drops. The RN administering the medication confirmed that the medications should have been given as per the physician's orders. Furthermore, the facility did not perform wound care in a manner that prevented contamination and infection. Resident #19, who had a stage 4 pressure ulcer, did not receive proper incontinent care before wound treatment. Solid waste was observed on the wound dressing, and the Licensed Practical Nurse (LPN) performing the care admitted to not having recent experience in changing briefs. Additionally, Resident #22, diagnosed with Alzheimer's disease and a urinary tract infection, exhibited symptoms of a UTI that were reported by CNAs but not adequately followed up by nursing staff, leading to a delay in appropriate treatment.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in three separate instances involving different residents. For Resident #19, who had multiple sclerosis and a stage 4 pressure ulcer, the Licensed Practical Nurse (LPN) did not perform incontinent care before wound treatment. During the wound care procedure, solid waste was observed contaminating the wound area, and the LPN acknowledged the potential for cross-contamination but did not take appropriate steps to mitigate it. The facility's policy did not address the need to perform incontinent care before wound treatment, contributing to the deficiency. For Resident #57, who had severe cognitive impairment and a PEG tube, the facility failed to change or properly clean the feeding tube syringe as required. The syringe, which had an expiration date of 02/05/2024, was observed to be reused without cleaning, and the LPN admitted to not following the protocol of changing the syringe every 24 hours. The Director of Nursing confirmed that the syringe should be changed daily to prevent bacterial contamination, but this practice was not followed. Resident #67, who had a diagnosis of urine retention, was found with a catheter bag on the floor and uncovered, which had an ant crawling on it. Additionally, the resident's nebulizer mask was not stored in a plastic bag as required. The Registered Nurse (RN) confirmed that the catheter bag should have been in a privacy bag and the nebulizer mask should have been properly stored. The facility's infection control policy indicated that all personnel should be trained on infection control practices, but these practices were not adhered to in this case.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that before a resident was allowed to self-administer updraft treatments, the Interdisciplinary Team (IDT) conducted an assessment to determine if this practice was safe, obtain a physician order for self-administration, and develop a care plan to address educating the resident on self-administration. This deficiency was observed in the case of Resident #64, who had severe cognitive impairment as indicated by a score of 00 on a Brief Interview for Mental Status. The resident's physician orders did not include a self-administration order, and the care plan did not reference self-administration of medication. On the day of the observation, Resident #64 was found lying in bed with a nebulizer treatment running, but the mask was not secured to the resident's face, and no nurse was present in the room. Multiple staff members, including a Registered Nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), confirmed that Resident #64 did not have a self-administration order and should not have been left unattended. The facility's policies on self-administration of medications and administering medications were not followed, as they require an assessment by the IDT and a physician's order before a resident can self-administer medications safely.
Inaccurate MDS Coding for PEG Tube
Penalty
Summary
The facility failed to ensure a Minimum Data Set (MDS) was accurately coded to indicate the presence of a Percutaneous Endoscopic Gastrostomy (PEG) tube for one resident. The resident had diagnoses of gastrostomy status and dysphagia following a cerebral infarction. A quarterly MDS assessment indicated that the resident did not have a feeding tube, despite having a PEG tube. The MDS Coordinator confirmed the error during an interview, acknowledging the importance of an accurate MDS for providing the correct plan of care. The facility's policy requires all personnel completing any portion of the MDS to certify the accuracy of their entries.
Failure to Document Oxygen Use in Care Plan
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident #54 was individualized to address the appropriate care and services for the use of oxygen. Resident #54 was admitted with a diagnosis of dyspnea and was observed receiving oxygen via nasal cannula on multiple occasions. Despite this, the care plan revised on 05/06/2024 did not indicate that the resident was receiving oxygen. This omission was confirmed through interviews with the MDS Coordinator and the Director of Nursing, both of whom acknowledged that the care plan should document oxygen use to ensure accuracy and inform staff of the resident's needs. The deficiency was identified during a survey when the Surveyor observed a lab technician conducting a chest x-ray for Resident #54, who stated that the x-ray was due to breathing difficulties. The Physician Orders also revealed an order for oxygen as needed for shortness of breath. However, the care plan failed to reflect this critical aspect of the resident's care, highlighting a lapse in the facility's adherence to its policy on developing individualized comprehensive care plans.
Failure to Update Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that changes in the status or care of a resident were reflected in the care plan in a timely manner. Resident #67, who had a diagnosis of urine retention, was readmitted with an indwelling catheter as indicated in the 5-day Minimum Data Set (MDS) assessment. Despite this, the care plan for Resident #67 was not revised to include the indwelling catheter. The MDS Coordinator confirmed that the care plan should have been updated to reflect this change. Additionally, the facility did not have a policy or procedure concerning the timely revision of care plans.
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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 Batesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wood-lawn Heights | 4.3 mi | ★★★★★ | 2 | 0 |
| The Springs Batesville | 5.7 mi | ★★★★★ | 8 | 0 |
| Cave City Nursing Home Inc | 17.1 mi | ★★★★★ | 0 | 0 |
| The Blossoms At White River Rehab & Nursing Center | 21.6 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Newport Rehab & Nursing Center | 22.3 mi | ★★★★★ | 5 | 0 |
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