Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 The Springs Of Fairfield Bay during CMS and state inspections, most recent first.
A facility failed to protect multiple residents from sexual abuse behavior by another resident. One resident with severe cognitive impairment and another with severe cognitive impairment were both reported by CNAs to have been touched in the genital area, while two other residents stated the same resident had previously touched them inappropriately. The abuse policy did not address sexual abuse, and the record showed inconsistent incident documentation, missing witness statements, incomplete body audits, and leadership minimizing the behavior as comfort or hand-holding rather than abuse.
Failure to Report Alleged Resident-to-Resident Sexual Abuse: A facility did not report multiple allegations of resident-to-resident sexual abuse involving residents with varying cognitive and physical impairments. Staff described incidents where one resident touched another resident's genital area, including while the resident was asleep or seated in a common area, and reported the events to the RN, ADON, and DON. The facility's abuse policy did not address sexual abuse, there was no documented definition or training on recognizing it, incident documentation was incomplete or inaccurate, and families and police were not notified.
Failure to fully investigate alleged sexual abuse involving multiple residents. Staff reported and witnessed inappropriate genital touching involving a resident with a history of cognitive impairment and other residents with varying levels of cognition and mobility, but the DON, ADON, and Administrator gave inconsistent accounts, key witness statements were missing or altered, family notification was not documented, and the facility lacked complete investigation records. The abuse policy did not address sexual abuse, and there was no definition, recognition training, or prevention interventions described.
An expired histamine two medication bottle with a broken seal was found in the East-Hall med cart and was available for administration even though no resident had an active order for it. An LPN stated an expired medication could have a different effect and should not be given, while the ADON and Administrator described routine monitoring and disposal processes but could not provide the disposal log or identify the last pharmacist check.
Survey results were not readily accessible to residents, family members, and legal representatives. The survey book was kept in the front lobby near the assisted living and independent apartment area, while the LTC unit was behind locked double doors at the back of the building with keypad access. The DON, ADON, RN consultant, and Administrator all acknowledged that LTC residents would need staff assistance to get to the book, and only two of thirty-four residents were identified as able to access the front area without help.
The facility failed to ensure proper food storage and handling, leading to potential foodborne illness risks. Observations showed unlabeled and expired food items in storage areas, with ice crystals indicating improper storage. During lunch service, dietary staff did not follow hand hygiene protocols, increasing cross-contamination risks. The facility's policies on handwashing and cleanliness were not adhered to, contributing to the deficiencies.
Two residents did not receive their prescribed nutritional supplements due to the facility running out of stock. One resident had abnormal weight loss, and the other had dementia and vitamin deficiencies. The supplements were unavailable for about a week, affecting the residents' care plans aimed at addressing nutritional deficits.
A facility failed to ensure a hazard-free environment for a resident with severe cognitive impairment. Perineal cleanser and antiseptic mouthwash, both with warning labels, were found in the resident's bathroom. Staff, including CNAs and an LPN, confirmed these items should not be stored there, and the DON acknowledged the oversight.
The facility failed to prepare food in the proper form for residents on mechanical soft diets, resulting in large chunks of meat in the puree. This was observed during meal preparation, and staff confirmed the inconsistency with dietary requirements, posing a choking risk. The facility's policy requires food to be prepared to meet each resident's needs, which was not followed.
A resident with a facial wound requiring enhanced barrier precautions was not provided with proper infection control measures. The DON and a CNA repositioned and transferred the resident without wearing gloves or gowns, and a hospice care aide showered the resident without a protective gown. Interviews confirmed the failure to adhere to the facility's policy on enhanced barrier precautions, which mandates gown and glove use during high-contact activities.
A facility failed to update a care plan for a resident with Alzheimer's and dementia, who exhibited wandering and exit-seeking behaviors. Despite observations and staff confirmation of these behaviors, the care plan lacked documentation addressing them, and no elopement assessment was found in the resident's records.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect four residents from sexual abuse behavior by another resident. The abuse policy required protection from abuse, neglect, exploitation, and misappropriation by anyone, including other residents, but the policy did not address sexual abuse and did not include a definition, training for recognition of signs and symptoms, or interventions to prevent sexual abuse. The report also states that the DON and staff were educated on the abuse prevention program, but the deficiency remained tied to the lack of sexual abuse content in the policy and the handling of the incidents. Resident #1 had dementia with severe cognitive impairment, was incontinent of bowel and bladder, and later had hospice services ordered for vascular dementia with behavioral disturbance. Resident #10 had unspecified dementia with severe cognitive impairment, needed supervision and assistance with all decision making, and had cataracts with inability to see. Resident #9 was cognitively intact but had significant physical limitations from a prior cerebral infarction and hemiplegia. Resident #12 was cognitively intact but had limited physical mobility related to chronic pain and muscle wasting. These residents were identified in the report as the victims of inappropriate sexual contact by Resident #2. The report describes multiple allegations and observations involving Resident #2 touching other residents’ genital areas or placing a hand under clothing or blankets. CNA #8 reported seeing Resident #2 grab Resident #10’s genitalia and make a rubbing motion. CNA #6 reported seeing Resident #2 place a hand inside Resident #1’s pants in the genital area and make jerking motions. Resident #9 stated Resident #2 grabbed the resident’s genitalia under a blanket while asleep, and Resident #12 stated Resident #2 tried to touch the resident’s genital area and rubbed the thigh area moving toward the genital area. Staff interviews showed the incidents were reported to nursing leadership, but the facility’s documentation was inconsistent, including missing or altered witness statements, incomplete body audits, and an incident list that did not include one of the events. The DON and Administrator described the behavior as a comfort gesture or hand-holding, while staff witnesses described sexual assault or inappropriate touching, and the police department stated they were not notified of any related incidents.
Failure to Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report alleged resident-to-resident sexual abuse involving four residents to the proper authorities. The report states that the facility policy required investigation and reporting of allegations within federal timeframes, but the abuse policy did not address sexual abuse, and there was no definition, training for recognition of signs and symptoms, or interventions to prevent sexual abuse. Facility inservice education on the abuse, neglect, exploitation, and misappropriation prevention program was documented, but the events described were not reported as required. Resident #1 was admitted with dementia, psychotic disturbance, mood disturbance, anxiety, and depression, and later had a BIMS score of 0, indicating severe cognitive impairment. A CNA stated that while Resident #1 was seated in a recliner in the activity room, Resident #2 placed a hand inside Resident #1's pants in the genital area and made jerking motions. The CNA said she separated the residents and reported the incident to the RN, ADON, and DON. The CNA also stated she wrote a witness statement describing the sexual assault, but later was asked by the DON to rewrite it without the words sexual assault and to state only that Resident #2 put a hand on Resident #1's hand. The facility's incident documentation did not list the event, and the resident's family stated they were not notified. Resident #9 was admitted with sequelae of cerebral infarction and flaccid hemiplegia, and had a BIMS score of 15. Resident #9 stated that Resident #2 grabbed the resident's genitalia under the blanket while the resident was asleep in bed, and CNA #6 stated she had reported more than one incident of inappropriate touching of Resident #9 to the ADON. Resident #10 was admitted with unspecified dementia, bipolar disorder, major depressive disorders, mixed receptive-expressive language disorder, and need for assistance with personal care, and had a BIMS score of 2. CNA #8 stated she saw Resident #2 grabbing Resident #10's genitalia and making a rubbing motion, and she reported it immediately to RN #1. Resident #10's family stated they were not notified, and the facility's incident documentation listed the event only as other. The Administrator later stated there was no documentation on the investigation for that incident. Resident #12 was admitted with essential tremor, generalized anxiety disorder, bipolar disorder, depression, and heart disease, and had a BIMS score of 14. Resident #12 stated Resident #2 had tried to touch the resident's genital area in the past and described a rubbing motion moving toward the genital area. RN #1 stated she had also been told that Resident #2 touched Resident #12 inappropriately in the past. The report further states that the DON and ADON were aware of the allegations involving Resident #1 and Resident #10, and the DON stated she should have reported the incidents to the State Agency. The police department stated they were not notified of any related incidents.
Failure to fully investigate alleged sexual abuse involving multiple residents
Penalty
Summary
The facility failed to ensure that alleged sexual abuse incidents were fully investigated for four residents. The report states the facility had a policy on abuse, neglect, exploitation, and misappropriation, but the policy did not address sexual abuse and there was no definition, training for recognition of signs and symptoms, or interventions to prevent sexual abuse. Facility inservice education on the abuse policy was documented, but the investigation process described in the report did not include complete documentation for the allegations involving the residents. Resident #1 had severe cognitive impairment with a BIMS score of 0, dementia, psychotic disturbance, mood disturbance, anxiety, depression, and required extensive assistance with care. CNA #6 reported witnessing Resident #2 with a hand under Resident #1's pants and making up-and-down motions at the genital area in the activity room. CNA #6 stated she reported the incident to RN #1, the ADON, and the DON, and said she was later asked to rewrite her statement to remove the words sexual assault. The witness statement provided by CNA #6 described Resident #2 placing a hand down Resident #1's pants and continuing sexual assaulting the resident, but the facility's incident documentation contained a different statement signed by RN #1 that said no witness personally saw anything. Resident #1's family stated they were not notified about the incident. Resident #9 had a BIMS score of 15 and was cognitively intact, with limited physical mobility related to contractures and stroke. Resident #9 stated Resident #2 grabbed the resident's genitalia under the blanket while the resident was asleep in bed and said the resident had reported the incident to the previous administrator. CNA #6 also stated she had reported more than one time that Resident #2 touched Resident #9 inappropriately. Resident #10 had severe cognitive impairment, dementia, bipolar disorder, major depressive disorder, mixed receptive-expressive language disorder, and cataracts with inability to see. CNA #8 witnessed Resident #2 touching Resident #10 inappropriately by placing a hand on the resident's genital area and making a rubbing motion, and reported it immediately to RN #1. Resident #10's family stated they were not notified, and the facility could not produce completed investigation documentation for the incident when requested. Resident #12 had a BIMS score of 14 and was cognitively intact, with limited physical mobility related to chronic pain and muscle wasting. Resident #12 stated Resident #2 had tried to touch the resident's genital area in the past and described a rubbing motion moving toward the genital area. Resident #12 said the incident was not reported at the time and was only disclosed later when a social worker collected witness statements for another incident. RN #1, the ADON, the DON, the Administrator, and other staff gave differing accounts of the incidents, and the report states the facility lacked documentation for the investigation of the 06/08/2026 incident and did not have the witness statements from CNA #6 or CNA #8 available in the completed investigation file.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly discard an expired histamine two medication that was found in the East-Hall medication cart with the seal broken and an expiration date of 01/2026. During a concurrent observation and interview, an LPN stated that if a resident were given an expired medication, it could have a different effect and should not be given. Review of the medication order list showed no residents had active orders for the histamine two medication. During interviews, the ADON stated that medication carts were monitored for recalls and that expired medications were placed in a secured bin at least once a month and documented by prescription number and resident, while OTC medications were logged under a general description. However, the ADON was unable to provide the disposal log for review. The Administrator stated staff should routinely check medication expiration dates and that the consultant pharmacist should also check for expired medications, but he was unaware of the last pharmacist check and stated he expected expired medications would not be available for use on the medication carts.
Survey Results Not Readily Accessible to LTC Residents
Penalty
Summary
The facility failed to make survey results readily accessible to residents, family members, and legal representatives of residents. On observation, the survey book was located by the main entrance in the assisted living and independent apartment area, not in the LTC unit at the back of the building behind wooden doors accessible only by a coded keypad. During interviews, the DON stated the survey book was at the front of the building and that residents could go up there to meet with family, while identifying only two of thirty-four residents as having the capacity to access the front of the building without assistance. The ADON stated the placement of the survey book had been made a long time ago and acknowledged the LTC unit was behind locked doors on the healthcare side. The RN consultant stated LTC residents would need staff assistance to look at the book because they were behind locked double doors at the back of the building. The Administrator stated the survey book should be readily available, but acknowledged it was kept in the lobby and was not readily available because residents would have to be brought up with staff assistance to see it.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which could lead to foodborne illnesses. Observations revealed that food items in the walk-in cooler, freezer, and dry storage areas were not labeled with receive dates, and some items were expired. The Dietary Manager confirmed these findings, acknowledging the absence of receive dates on various food items, including onions, tomatoes, tortillas, pizza sticks, fish fillets, and more. Additionally, ice crystals and signs of frostbite were observed on several frozen items, indicating improper storage conditions. During lunch service, cross-contamination risks were identified due to improper hand hygiene and glove use by dietary staff. The staff was observed touching food surfaces and handling food without washing hands between tasks or after changing gloves. The Dietary Manager and staff acknowledged the importance of hand hygiene and the risks of cross-contamination, yet these practices were not consistently followed. The report highlights instances where dietary staff touched the food surface area of plates, scoops, and bowls, further increasing the risk of contamination. The facility's policies on handwashing and maintaining a clean and sanitary environment were not adhered to, as evidenced by the unclean grease traps and improper food handling practices. The Dietary Manager admitted that the grease traps were not cleaned daily as required. The facility's failure to enforce its policies and ensure staff compliance with food safety standards contributed to the deficiencies observed during the survey.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for two residents, leading to a deficiency in care. Resident #21, diagnosed with abnormal weight loss, had a physician's order for nutritional supplements to be administered twice daily to promote weight gain. Similarly, Resident #27, with diagnoses including dementia and vitamin deficiencies, also had an order for supplements twice daily to maintain stable weight. Both residents had care plans indicating the need for these supplements to address potential nutritional deficits. The deficiency occurred because the facility ran out of the required nutritional supplements approximately one week before the survey began. On September 5, 2024, it was confirmed by an LPN and a CNA that the supplements had been unavailable since August 25, 2024, and were only restocked on September 3, 2024. The Director of Nursing, responsible for ordering the supplements, verified that the residents could not have received the supplements as ordered due to the lack of availability in the facility.
Failure to Maintain Hazard-Free Environment
Penalty
Summary
The facility failed to maintain an accident/hazard-free environment for a resident diagnosed with Alzheimer's disease and dementia, who was severely cognitively impaired. The resident's care plan indicated an inability to care for themselves, necessitating a safe environment. However, during an observation, perineal skin cleanser and antiseptic mouthwash were found in the resident's bathroom, both of which had warning labels advising to keep them out of the reach of children. Interviews with staff, including two CNAs and an LPN, confirmed that these items should not have been stored in the resident's bathroom due to the warning labels. The Director of Nursing also acknowledged that these items should not be accessible to the resident, indicating a lapse in ensuring a safe environment for the resident, which is a requirement according to the facility's policy on safety and supervision of residents.
Improper Preparation of Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure that food was prepared in the proper form to meet the needs of residents on mechanical soft diets. During an observation, the Dietary staff member was seen slicing meat and adding it to a blender to grind for residents requiring a mechanical soft diet. However, the process resulted in large chunks of meat remaining in the puree, which was not suitable for the residents' dietary needs. This was confirmed by a staff member who noted that the ground meat was chunkier than usual and required additional mixing to achieve the proper consistency. The Dietary Manager acknowledged that the mechanical soft meat served during lunch had large chunks, posing a choking risk to residents on this diet. The facility's policy states that food should be prepared in a manner that meets each resident's needs, which was not adhered to in this instance.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control for a resident with a facial wound requiring enhanced barrier precautions. The resident had diagnoses including malignant neoplasm of the mandible and was placed on enhanced barrier precautions as per the care plan, which required staff to wear gloves and gowns during high-contact care activities. However, observations revealed that the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) repositioned and transferred the resident without wearing gloves or gowns, contrary to the care plan instructions. Further observations showed a hospice care aide showering the resident without wearing a protective gown, despite the requirement for enhanced barrier precautions. Interviews with the DON and the Infection Prevention Nurse confirmed that the necessary precautions were not followed. The facility's policy on enhanced barrier precautions, dated March 2024, indicated that gowns and gloves should be used during high-contact activities to prevent the transmission of multi-drug-resistant organisms, but these guidelines were not adhered to during the care of the resident.
Failure to Address Wandering and Exit-Seeking Behaviors in Care Plan
Penalty
Summary
The facility failed to initiate and update a comprehensive care plan for a resident with wandering and exit-seeking behaviors. The care plan for the resident, who had diagnoses of Alzheimer's disease and dementia, was initiated on 08/20/24. However, it did not address the resident's wandering and exit-seeking behaviors, as observed on 09/04/24 and confirmed by a CNA on 09/05/24. The resident was seen wandering down multiple halls and pushing on exit doors, yet the care plan dated 06/14/2024 lacked documentation addressing these behaviors. Additionally, there was no elopement assessment found in the resident's electronic health record or paper chart, despite a document titled DHS-703 indicating a high potential for elopement. The Director of Nursing confirmed the care plan's inadequacy in addressing the resident's behaviors. The facility was in the process of scanning records into their electronic medical record system, but the necessary assessments and care plan updates had not been completed for this resident.
What surveyors are citing around you — mapped
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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 12 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairfield Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ozark Health Nursing And Rehab Center | 11.3 mi | ★★★★★ | 0 | 0 |
| The Springs Of Greers Ferry | 15.1 mi | ★★★★★ | 4 | 0 |
| Southridge Village Nursing And Rehab | 17.1 mi | ★★★★★ | 5 | 0 |
| The Blossoms At Mountain View Rehab & Nursing Cen | 19.5 mi | ★★★★★ | 3 | 0 |
| Greenbrier Nursing And Rehabilitation Center | 28.1 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.