Below 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 Aviata At Big Bend during CMS and state inspections, most recent first.
Failure to maintain clean and comfortable resident rooms was cited after multiple occupied rooms were found with soiled linens, damaged furniture, discolored fixtures, and broken or missing room features. A resident had a torn, stained pillow without a pillowcase, another resident’s bed linens remained visibly soiled for days, and several rooms had damaged curtains, walls, baseboards, flooring, and bathroom fixtures.
A resident who smoked and required staff supervision had no smoking care plan or related interventions in the chart, despite a smoking evaluation, a signed smoker agreement, and staff observations that the resident attended scheduled smoking times with supervision. The NP note also documented that the nicotine patch was discontinued because of smoking, and the care plan nurse confirmed the smoking care plan had not been added.
Failure to Document and Offer Updated COVID-19 Vaccination: The facility did not document education, consent, assessment, or offer of the updated COVID-19 vaccine for multiple residents sampled. One resident had a prior refusal on record, two residents had outdated or incomplete vaccine documentation, and one resident had no record of being assessed or offered the vaccine since admission. Staff interviews confirmed records for the updated vaccine could not be located and that several residents were not offered the current vaccination.
A shared bathroom for two residents had a call light cord that was only about 2 inches long and could not be reached from the floor. An RN confirmed the cord was too short to activate after a fall, and the Maintenance Director confirmed it needed replacement and had not been notified of the issue.
A resident reported that an RN entered his room on more than one occasion, yelled at him, called him a liar, and told him to keep her name out of his mouth, with one incident witnessed by a social work aide and another resident. The aide stated she believed the conduct was verbal abuse and reported it to social services, and multiple staff confirmed the allegation was reported to the DON and Administrator, who acknowledged that verbal abuse is a form of abuse. The RN admitted she was angry about the resident’s intention to call 911 and went to confront him, calling him a liar. The resident also filed a grievance that he did not receive scheduled baths on two dates, which was confirmed by review of the grievance log, and he felt this was retaliation. The facility’s abuse policy requires staff to respect residents’ rights, prevent abuse, and promptly report all allegations of abuse and neglect within specified time frames.
A resident reported that a RN entered the room yelling, which the resident perceived as verbal abuse and possible retaliation, and informed both the Administrator and the DON. The DON believed the Administrator had reported the allegation to state agencies, but the Administrator, who serves as Abuse Coordinator, did not do so because she did not believe it was abuse. Facility records later showed the allegation was not reported to the state agency until weeks after it was made, despite a written abuse policy requiring prompt reporting of all abuse allegations within specified time frames.
A resident reported feeling verbally abused and retaliated against by an RN, and this allegation was communicated by the SSD and HRD to the Administrator, who also served as the abuse coordinator. Despite witness statements documenting knowledge of the alleged verbal abuse and information that a staff witness existed and a false witness statement had been given, the Administrator did not suspend the RN or report the allegation to state agencies in accordance with the facility’s abuse policy. The allegation was not reported to state agencies until weeks later, contrary to policy requirements for prompt reporting of abuse allegations.
Multiple deficiencies occurred when two residents, both at risk for elopement and one under 1:1 supervision, escaped from a secured unit after repeated exit-seeking behaviors were not adequately addressed. Another resident was left immobile in her room with her deceased roommate for hours, causing significant psychosocial harm. Additionally, a resident with a history of self-harm and aggression suffered injuries and assaulted staff while under 1:1 supervision, with staff reporting inadequate training and support. The facility lacked policies for supervision and 1:1 care, resulting in Immediate Jeopardy for all residents.
The facility did not maintain an effective QAPI program, resulting in repeated incidents where residents with behavioral and psychiatric needs experienced aggression, self-harm, and elopement. Despite care plans and supervision requirements, residents were able to harm themselves and others, exit the facility, and in one case, steal a vehicle. The QAPI committee failed to analyze these events or implement improvement plans, and did not address substantiated cases of abuse or neglect in its reviews.
Two residents with severe cognitive impairment and elopement risk were able to exit a secured unit through a broken window, with one stealing an unsecured vehicle, while another resident with a history of aggression and psychiatric disorders engaged in self-harm and assaulted staff despite being on 1:1 supervision. The facility lacked policies and staff training for supervision and 1:1 monitoring, leading to multiple serious incidents and a finding of Immediate Jeopardy.
Several residents with cognitive impairments, behavioral issues, or communication difficulties did not receive the care plan interventions required for their safety and well-being. Two residents at risk for elopement were able to exit the facility due to lapses in supervision and monitoring, while another resident with aggressive behaviors was not consistently provided with 1:1 supervision or structured activities, resulting in injury. Additionally, a resident with aphasia did not receive a communication board or a referral to speech therapy as outlined in the care plan.
A staff member assigned to 1:1 monitoring was unable to maintain direct visual contact with a resident because the door was closed or partially open with the privacy curtain pulled. Interviews revealed there was no formal policy or consistent training for 1:1 observation, despite in-service education stating residents should be within eyesight and arm's reach at all times.
The facility failed to enforce its smoking policies, leading to safety concerns for six residents. Observations revealed residents with vapes and cigarettes in their rooms, despite policies requiring these items to be stored by staff. Interviews with staff showed confusion about the policy, with some believing residents could keep cigarettes but not ignition sources. The facility's policy, last revised in 2020, required all smoking materials to be stored by nursing staff and allowed electronic smoking materials only in designated areas.
Two residents did not receive the recommended restorative nursing care due to inconsistent documentation and staffing shortages. One resident, with a contracted wrist, was often without his prescribed splint, and the other received therapy less frequently than ordered. The facility's documentation was inadequate, and staff were frequently pulled from restorative duties to assist elsewhere, leading to neglect of residents' care needs.
The facility failed to maintain a sanitary environment in the dining rooms, laundry area, and a resident's room. Observations revealed dirty floors in the dining area and a resident's room, with staff confirming inconsistent cleaning practices. The laundry area had significant lint and debris buildup, with non-functional dryers and uncleaned filters. The Account Manager and Administrator were unaware of the last cleaning, indicating a lack of maintenance oversight.
A resident with a history of heart failure and dysphagia received improper tube feeding due to incorrect pump settings and unlabeled feeding bags. The feeding machine was set to deliver water flushes more frequently than ordered, which was confirmed by two LPNs. The facility's DON acknowledged the expectation for proper labeling and adherence to physician orders.
The facility did not post nurse staffing information in an accessible location with the required details on one survey date. Although dry erase boards displayed some information, it was not clear or accessible. A CNA confirmed the information was incomplete, and the Staffing Coordinator later admitted the oversight.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for 7 of 16 sampled occupied resident rooms, including rooms 100, 105, 201, 202, 206, 305, and 401. In room 100, a resident was observed on a pillow with numerous small tears and a dinner-plate-sized hole exposing inner foam stained brownish yellow, and there was no pillowcase on the pillow. The wardrobe door was hanging off the hinge, the dresser had exposed particle board along the top border of each drawer, and the privacy curtain was soiled with multiple reddish-brown splotches. Staff F, a RN, observed the damaged and soiled pillow and stated it should have been thrown away. In room 105, the privacy curtain was observed soiled along the outer border from top to bottom with splotches of dried light brown fluid. In room 201, the fitted sheet on the resident’s bed had a brown substance stain on the right side of the bed, and repeated observations over several days showed the same stain remained on the bed linens. The resident stated that linens are changed while being bathed or when they need to be changed, and that staff had not offered to change the bed linens. Staff B, a RN, later observed the same soiled fitted sheet and stated the resident was out of bed, the linens were visibly soiled, and they should have been changed. In room 202, the restroom sink faucet was discolored and there were several small holes in the bathroom wall. In room 206, the overbed table was in disrepair and missing the border, exposing rough particle board, and the restroom sink faucet handles were discolored. In room 305, the room had bubbled paint around the window, baseboards in disrepair, missing bed headboard and footboard trim, and tiles below the window in disrepair. In room 401, there were holes in the block walls with cracked block revealing concrete, missing and pulled-away plastic baseboards, a toilet that was running with a dark brown bowl, missing or peeled bathroom flooring, and rust on both sides of the bathroom doorway.
Failure to Include Smoking Needs in Care Plan
Penalty
Summary
The facility failed to develop a smoking care plan to address smoking supervision and assistance requirements for Resident #11, who was on the current smoker list and was observed smoking in the designated smoking area with staff supervision on 3/24/26 at approximately 1:25 PM and on 3/25/26 at approximately 9:34 AM and 3:33 PM. The resident had a smoking evaluation completed on 2/20/26 at 3:39 PM, and the resident's progress notes from the Nurse Practitioner dated 12/22/25 stated the nicotine patch was discontinued due to the resident's smoking. A review of the resident's care plan showed no care plan or interventions related to smoking, despite the resident requiring assistance with personal care due to weakness. A CNA stated the resident attended scheduled smoking times regularly and confirmed the resident had a current smoker agreement signed on 2/20/26. The care plan nurse confirmed on 3/26/26 at approximately 9:16 AM that there was no smoking care plan in the chart, and stated it should have been added upon admission or when the resident started smoking. The facility policy stated residents who wish to smoke are to be evaluated on admission/re-admission, quarterly, and with a change in condition, and that residents identified as needing assistance or supervision with smoking are to have that information included in the care plan.
Failure to Document and Offer Updated COVID-19 Vaccination
Penalty
Summary
The facility failed to implement its policy and procedure to ensure residents were educated on the risks and benefits of the COVID-19 vaccine and offered the vaccine in accordance with current CDC guidance for 4 of 5 residents sampled for immunizations. Resident #20 had documentation showing refusal of the COVID-19 vaccine on 03/05/2024, but there was no documentation that the resident was educated or offered the 2025/2026 COVID-19 vaccine. Resident #28 had no documentation of COVID-19 consent, education, or an offer of the vaccine since admission, and there was no documentation that the resident was offered the 2025/2026 vaccination. Resident #29 had documentation that the COVID-19 vaccine was offered on 11/21/24, but there was no documentation that the resident was offered the current 2025/2026 vaccination or a booster per CDC guidelines and facility policy. Resident #32 had signed informed consent and education for the COVID-19 vaccination on 5/2/24, but the record did not show that the resident was offered the current 2025/2026 vaccination. The IPCP stated that the vaccine is offered upon admission and re-entry during facility assessment and that administration follows facility policy and CDC guidelines. The Regional Nurse Consultant stated records for assessment and offer of the 2025-2026 COVID-19 vaccine could not be located for the 4 sampled residents and confirmed that Residents 32, 29, and 20 were not offered the updated vaccination since 2024, while Resident #28 was never offered or assessed since admission.
Nonfunctioning Bathroom Call Light Cord
Penalty
Summary
The facility failed to ensure a functioning call light system was available in a shared bathroom for two residents, Resident #4 and Resident #23, and the call light cord in that bathroom was approximately 2 inches long and not reachable from the floor. During observation, the cord was located by the toilet and could not be activated by a resident who had fallen on the floor. An RN confirmed the cord was too short to be used from the floor, and the Maintenance Director later confirmed the cord required replacement and that staff had not notified him of the issue.
Failure to Protect Resident From Verbal Abuse and Missed Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and to ensure required care was provided. On 1/19/26, a registered nurse (Staff A) entered Resident #1’s room while the Social Worker Aide (SWA) was present and loudly accused the resident of lying and stated she was going to tell her mother to get off his “slot.” The SWA reported that she instructed Staff A to leave the room and believed the interaction was verbal abuse, which she reported to the Social Service Director. Resident #1 reported that Staff A had previously entered his room yelling, telling him to keep her name out of his mouth, which was corroborated by another resident who was visiting at the time. Resident #1 stated he reported the verbal abuse to the Administrator and DON and wrote a grievance regarding missed baths. Multiple staff interviews confirmed that the allegation of verbal abuse was reported up the chain of command, including to the DON and Administrator, both of whom acknowledged that verbal abuse is a form of abuse. Staff A admitted she was angry because she had been informed that Resident #1 was threatening to call 911 and that she went to his room to confront him, calling him a liar. Review of the grievance log showed Resident #1 did not receive a shower or bath on 1/19/26 and 2/2/26, consistent with his complaint that he missed baths and felt he was being retaliated against by Staff A. The facility’s abuse policy requires all employees to respect residents’ rights, treat them with dignity, and immediately report allegations of abuse, neglect, exploitation, or mistreatment to the Administrator and appropriate officials within specified time frames.
Failure to Timely Report Allegation of Verbal Abuse to State Agencies
Penalty
Summary
The facility failed to immediately identify and report an allegation of verbal abuse involving one resident. On 1/19/26, a resident stated that a RN entered his room yelling at him while a social worker aide was present. The resident reported this alleged verbal abuse and his feeling of retaliation to both the Administrator and the DON. The DON reported that he spoke with the Administrator about the allegation on the same day and believed the Administrator had reported it to the state agencies. The Administrator, who is also the facility’s Abuse Coordinator, acknowledged being informed of the allegation on 1/19/26 but stated she did not report it to the state agency because she did not feel it was abuse. The facility’s abuse policy requires that any employee who witnesses or has knowledge of an allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property must report it immediately, but no later than 2 hours if it involves abuse or serious bodily injury, or within 24 hours if it does not. Facility records showed the allegation was not reported to the state agency until 2/10/26, contrary to the policy’s reporting time frames.
Failure to Timely Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation and timely reporting of an allegation of verbal abuse involving one resident. On 1/19/26, the Social Service Director reported to the Administrator, who is also the abuse coordinator, that a resident had alleged verbal abuse by a registered nurse (Staff A) and expressed that Staff A should be suspended. The Human Resource Director, who heard this report during morning meeting, also told the Administrator that Staff A needed to be suspended and began a workplace investigation the same day. Witness statements and interviews dated 1/19/26 documented knowledge of the alleged verbal abuse. The resident later stated he had informed the Administrator and DON that he felt verbally abused by Staff A and believed he was being retaliated against. On 2/11/26, the Administrator acknowledged she had been informed of the abuse allegation on 1/19/26 but did not suspend Staff A or report the allegation to the state agency, stating she did not believe it was verbal abuse because Staff A was outside the resident’s room. On 1/21/26, the Administrator became aware that a Social Worker Aide was a witness and that Staff A had provided a false witness statement, yet Staff A still was not suspended and the allegation was not reported to state agencies at that time. Facility records show the abuse report was not filed with the state agencies until 2/10/26. This response was inconsistent with the facility’s abuse policy, which requires any employee with knowledge of an allegation of abuse to report it immediately, but no later than 2 hours if it involves abuse or serious bodily injury, or within 24 hours if it does not involve abuse and does not result in serious bodily injury, to the Administrator and appropriate state officials.
Failure to Prevent Abuse, Neglect, and Elopement in Secured Unit
Penalty
Summary
The facility failed to prevent abuse and neglect for multiple residents, resulting in several serious incidents. Two residents, both identified as elopement risks with documented cognitive impairments and behavioral issues, were able to escape from a secured and locked unit. One of these residents was under one-to-one supervision at the time. The facility lacked a policy for resident supervision or one-to-one supervision, and staff were not provided with clear expectations or training prior to the elopements. Documentation revealed repeated incidents of exit-seeking behavior, tampering with alarms, and attempts to bypass security measures, yet interventions were insufficient to prevent the eventual elopement. The escape involved breaking a window, and one resident was later found walking on an interstate, while the other was located at a store miles away from the facility. The police were involved, and the events created a potential for serious injury or death. Another incident involved a resident who was immobile and left in her room with the body of her deceased roommate for nearly three hours. Despite her requests to be moved and her visible distress, staff did not accommodate her or check on her well-being during this period. The resident experienced significant psychosocial harm, including ongoing anxiety, sleep disturbances, and the need for therapy. Staff interviews confirmed that the facility's protocol should have been to move the surviving roommate before postmortem care, but this was not followed. The facility's own policy defined involuntary seclusion as a form of abuse, which was applicable in this situation. A further deficiency was identified in the care of a resident with a history of self-harm, aggression, and complex psychiatric diagnoses. This resident, also on one-to-one supervision, suffered injuries from self-harm and was involved in multiple aggressive incidents toward staff and other residents. Staff assigned to supervise this resident reported inadequate training, lack of communication tools, and feeling unsafe. Documentation of required diversional activities was inconsistent, and there was no clear policy or guidance for staff on how to conduct one-to-one supervision. The cumulative effect of these failures placed all residents at risk for abuse and neglect, resulting in a finding of Immediate Jeopardy at a widespread scope and severity.
Failure to Maintain Effective QAPI Program for Resident Safety and Supervision
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to ensure adequate supervision and safety for residents at risk for elopement, self-harm, and aggressive behaviors. Multiple residents with complex behavioral and psychiatric needs, including diagnoses such as schizoaffective disorder, impulse disorder, and major depressive disorder, experienced repeated incidents of aggression, self-injury, and elopement. The facility's QAPI committee did not perform or document thorough analysis or root cause investigations following these events, nor did it develop or implement improvement plans to address the ongoing risks and incidents. One resident with a history of agitation, aggression, and elopement risk was subject to multiple behavioral incidents, including physical aggression towards staff and other residents, self-harm, and repeated attempts to exit the facility. Despite a care plan that called for 1:1 supervision and specific interventions, the resident was able to overpower staff, exit the building, and sustain injuries. The facility issued a discharge notice stating it could not meet the resident's needs, but subsequently readmitted the resident without documented changes in condition or services, and without evidence of a QAPI review or improvement plan addressing the repeated behavioral incidents and safety concerns. Two other residents eloped from the facility by breaking a window, with one stealing an unsecured staff vehicle and traveling a significant distance before being apprehended. The facility's investigation and QAPI documentation lacked data analysis, root cause identification, or evidence of systematic review as outlined in the facility's own QAPI plan. Additionally, QAPI meeting minutes and records failed to reflect recognition of substantiated abuse, neglect, or misappropriation as issues requiring action or further investigation. The facility's failure to follow its QAPI processes and to address these serious incidents resulted in a finding of Immediate Jeopardy at a widespread scope and severity.
Failure to Supervise High-Risk Residents Results in Elopement and Aggression
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for residents identified as high risk for elopement and physical aggression. Two residents with severe cognitive impairment and documented elopement risk were not properly supervised, resulting in both exiting the secured, locked unit through a broken window. One of these residents was assigned to one-to-one (1:1) supervision at the time but was left unsupervised when the assigned CNA left the unit to use the restroom. The residents were able to break a window, exit the facility, and one subsequently stole an unsecured vehicle from the facility parking lot, driving it a significant distance before being apprehended. Documentation revealed repeated incidents of these residents tampering with security devices, refusing monitoring devices, and exhibiting exit-seeking behaviors, yet the facility lacked a policy for supervision or 1:1 monitoring and failed to implement effective interventions to prevent elopement. Another resident with a history of schizoaffective disorder, impulse control issues, and aggressive behaviors was also not adequately supervised despite being on 1:1 observation. This resident engaged in self-injurious behavior and physically assaulted staff on multiple occasions, including punching a nurse in the face and assaulting law enforcement. Staff interviews revealed a lack of training and clear protocols for managing aggressive or self-harming behaviors, with staff expressing uncertainty about how to intervene during such incidents. The care plan for this resident included instructions for 1:1 supervision and specific monitoring, but staff reported only general abuse and neglect training and no specific guidance for handling violent or self-harming behaviors. The facility did not have policies in place for resident supervision or 1:1 observation, and staff were not provided with clear expectations or training prior to the incidents. The lack of effective supervision, absence of policies, and failure to address known risks led to multiple serious incidents, including elopement, self-injury, and physical assaults. The cumulative effect of these failures resulted in a finding of Immediate Jeopardy, with the situation ongoing at the time of the survey exit.
Failure to Implement Care Plan Interventions for Supervision, Elopement Risk, and Communication Needs
Penalty
Summary
The facility failed to implement care plan interventions for multiple residents, resulting in significant deficiencies. For several residents identified as being at risk for elopement or exhibiting wandering behaviors, the facility did not consistently follow care plan interventions such as providing adequate supervision, maintaining electronic monitoring devices, or ensuring 1:1 supervision as ordered. In one instance, two residents with severe cognitive impairments and documented elopement risk were able to exit the facility by breaking a window, with one resident later found walking on a highway and the other located at a store. Documentation revealed that staff assigned to 1:1 supervision were not present at critical times, and the facility lacked policies or clear expectations for supervision or 1:1 monitoring prior to these incidents. Another resident with a history of aggressive and impulsive behaviors, as well as a risk for elopement, was not consistently provided with the required 1:1 supervision or engagement in structured activities as outlined in the care plan. Documentation of 1:1 activities was sporadic, and the resident was able to leave the facility, resulting in self-injury and injury to others. Staff reports and progress notes indicated that the resident's behavioral interventions were not reliably implemented, and there were multiple incidents of aggression and attempts to exit the building, some resulting in physical altercations and injuries. Additionally, a resident with communication difficulties and aphasia did not receive the care plan intervention of a communication board, nor was there evidence of referral to speech therapy as required. Despite repeated requests from the resident and his roommate, and documentation in the care plan that a communication board should be provided and evaluated for use, the intervention was not implemented. The care plan also called for a referral to speech therapy, but no such referral or therapy order was found in the resident's records.
Failure to Provide Adequate 1:1 Supervision Due to Lack of Policy and Training
Penalty
Summary
The facility failed to provide adequate supervision to prevent incidents for a resident requiring 1:1 monitoring. During multiple observations, a staff member assigned to 1:1 monitoring was unable to maintain direct visual contact with the resident due to the resident's door being closed or only slightly open with the privacy curtain pulled. Interviews with facility staff revealed that there was no formal policy in place for 1:1 observation, and staff assigned to this duty had not received formal training on the procedures. A review of staff in-service training showed that education on 1:1 monitoring had been conducted, stating that the resident should be within eyesight and arm's reach at all times, but this was not consistently implemented. There was no facility policy to guide staff on 1:1 observation practices.
Non-Compliance with Smoking Policies
Penalty
Summary
The facility failed to ensure adherence to its smoking policies, resulting in safety concerns for six residents. During a tour, Resident #42 was observed with a vape around her neck, and she was unsure if she was allowed to keep it. Her records showed inconsistencies regarding her smoking status, with some documents indicating she was a smoker and others not. Resident #37 was found with a vape on her bed, and although she believed staff should keep it, no one had confiscated it. Her care plan acknowledged her as a smoker, but there was no admission data available for review. Resident #65 was seen moving through the facility with a cigarette, indicating a lack of enforcement of the smoking policy. His records confirmed he was a smoker, with a care plan in place. Resident #36 was caught using a vape in his room and had a history of being evaluated as both a safe and unsafe smoker. His records showed inconsistencies in his smoking status. Resident #6, who required supervision and a smoking apron, was observed with cigarettes in his pocket and smoking under supervision, but his care plan did not mention the need for an apron. Resident #30 was also seen with cigarettes, and although considered a safe smoker, he was noted to be non-compliant with the smoking policy at times. Interviews with staff revealed confusion about the facility's smoking policy. Staff A and B had differing understandings of whether residents could keep smoking materials in their rooms. The DON stated that residents could keep cigarettes but not ignition sources, yet the policy indicated no smoking supplies should be kept in rooms. The facility's policy, last revised in 2020, required that all smoking materials be stored by nursing staff, and electronic smoking materials were only allowed in designated areas.
Failure to Provide Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that two residents received the recommended restorative nursing care. Resident #31, who has a contracted left wrist and hemiplegia, was observed multiple times without his prescribed splint, which was supposed to be worn for up to 1.5 hours to prevent complications related to immobility. Despite having a care plan that included the application of a splint and range of motion exercises, documentation was inconsistent and lacked specific details about the exercises performed or the duration the splint was worn. Interviews with staff revealed that restorative services were not consistently provided, partly due to staffing shortages and the pulling of restorative staff to assist with other duties. Resident #55 was also affected by the facility's failure to provide restorative services as ordered. Although the resident was supposed to receive restorative therapy three times a week, records showed that services were only provided six times in the last 30 days. The Director of Nursing acknowledged that the restorative notes had not been completed since she took over the program, and staff confirmed that the resident was not receiving the prescribed frequency of therapy. The Director of Rehabilitation noted that the lack of consistent restorative services undermined the efforts of the therapy team. The facility's policy required detailed documentation of restorative interventions, but this was not adhered to, as evidenced by the lack of specific and measurable records. The Director of Nursing admitted that the documentation needed improvement and that a performance improvement plan was initiated. However, the deficiency persisted due to inadequate staffing and the absence of a dedicated restorative nurse, which led to the neglect of the residents' restorative care needs.
Sanitation Deficiencies in Facility's Dining, Laundry, and Resident Areas
Penalty
Summary
The facility failed to maintain a sanitary environment in several areas, including the dining rooms, laundry area, and a resident's room. During a tour of the dining and kitchen area, the floor was observed to have several spills, dry food, crumbs, and red stains. Staff interviews revealed that the floors were not consistently cleaned after each meal, contrary to the facility's expectations. In a resident's room, the floor around the beds was dirty with wet and discolored areas, and debris was present. A resident confirmed that the floor remained dirty, even for those who could not leave their beds. Further inspection of the facility revealed additional sanitation issues. In the Soiled Utility Room, a specimen was found double-bagged but unlabeled, and linens were not properly bagged. The laundry area had a significant buildup of lint and debris, with filters on washing machines not cleaned as instructed. The dryer area had a torn ceiling with lint buildup, and two out of three dryers were non-functional. The only working dryer had a buildup of red/brown matter inside the drum, and the lint area contained foreign objects. The Account Manager and Administrator were unaware of the last cleaning of these areas, indicating a lack of maintenance oversight.
Improper Administration of Tube Feeding and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that physician orders for tube feeding were followed and that tube feeding was administered properly for a resident. During multiple observations, the resident was found with an unlabeled tube feeding bag, and the tube feeding machine was set incorrectly. The machine was set to instill tube feeding at 60 mL/hr and water flush at 100 mL every 2 hours, contrary to the physician's orders which specified a water flush of 100 mL every 6 hours. This discrepancy was confirmed by two LPNs who reviewed the resident's medical record and acknowledged the incorrect settings on the tube feeding pump. The resident involved had a medical history of congestive heart failure, muscle weakness, dysphagia, and spinal stenosis with bone infection. The resident was cognitively intact and had a care plan in place for tube feeding due to swallowing problems. The facility's Director of Nursing acknowledged that the resident was the first to have continuous tube feeding in a long time and confirmed that the staff were expected to label the tube feeding bag properly and follow the physician's orders regarding the feeding and water flush rates. The facility's policy on enteral feeding required nurses to administer enteral feeding as ordered by the physician.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in an accessible location with the required details on one of the three survey dates. On 12/16/24, during an observation at approximately 12:00 PM, it was noted that no staffing information was posted as required anywhere in the facility. Although the dry erase boards in both the east and west wings displayed a date and the total number of actual hours worked by staff, the information was not presented in a clear and readable format accessible to residents and visitors. At approximately 1:00 PM on the same day, a Certified Nursing Assistant (CNA) acknowledged that the staffing information was incomplete on the dry erase board. Photographic evidence was obtained to support this observation. On 12/18/24, during an interview with the Staffing Coordinator Scheduler, she initially claimed that staffing was posted daily but later admitted that the staffing information was not posted on 12/16/24 as required.
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Illustrative
What surveyors actually found near you
We read the 27 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
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Illustrative
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Nursing homes near Perry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Center | 23 mi | ★★★★★ | 11 | 0 |
| Greenville Nursing And Rehab Center | 23.8 mi | ★★★★★ | 16 | 0 |
| Lake Park Of Madison Nursing And Rehabilitation Ce | 25.7 mi | ★★★★★ | 2 | 0 |
| Lafayette Nursing And Rehabilitation Center | 25.7 mi | ★★★★★ | 11 | 0 |
| Madison Health And Rehabilitation Center | 25.8 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 July 2026) and official state health department websites.