Above average — CMS composite of the measures below.
The next survey window likely opens around July 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 Suwannee Valley Nursing Center during CMS and state inspections, most recent first.
A resident's MDS was coded incorrectly in Section N for high-risk drug classes, showing antipsychotic use even though the MAR showed no antipsychotic medications during the look-back period. The DON stated the resident had not taken an antipsychotic during the stay, and the Corporate MDS Coordinator confirmed the MDS was incorrect and that "yes" had been selected in error for lamotrigine.
A resident with a documented hx of TBI had a PASRR that did not check the related condition, even though the admission MDS and physician notes identified TBI and other significant diagnoses including vascular dementia, AFib, anemia, HTN, HLD, pulmonary fibrosis, speech and language deficits, cerebrovascular disease, and Parkinson’s disease. The DON confirmed the TBI hx should have been reflected on the PASRR and that the PASRR needed to be updated.
Failure to Include Bipolar Disorder and Anxiety in Care Plan: A resident with bipolar disorder, anxiety, depression, and dementia had psychiatry notes documenting ongoing symptoms and medication management, but the care plan did not include focus areas for bipolar disorder or anxiety. The MDS coordinator confirmed these diagnoses were not included in the care plan.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
A resident approved for self-administration had multiple medications left unsecured in her room, including an inhaler, eye drops, nasal sprays, and nebulizer vials. The resident said her room did not lock and she did not have a lockbox, while an LPN was unsure whether room-kept meds needed to be locked and the DON confirmed the resident had not been offered a lockbox.
The facility failed to properly label and store food items in the kitchen. During an inspection, thirteen bags of various frozen meats were found without identifying labels, and one bag of chicken was left open, exposing it to freezer burn. The CDM confirmed these issues, which were not in compliance with the facility's Date Marking for Food Safety policy.
An LPN failed to perform proper hand hygiene and infection control during medication administration for a resident. After cleaning the resident's eyes, the LPN did not change gloves or wash hands before administering medications through a G-tube, and used a gloved finger to mix medication. This was against the facility's policies on hand hygiene and infection prevention.
The facility failed to ensure accurate resident assessments for two residents using CPAP machines. Both residents were observed and confirmed using CPAP machines, but their MDS Quarterly assessments documented otherwise. The MDS Coordinator confirmed these discrepancies.
The facility failed to ensure an attending practitioner's orders for CPAP/BIPAP devices for a resident with CHF, COPD, and Pulmonary Edema. The resident had a CPAP machine in his room, but no orders were documented, and the care plan indicated monitoring Bi-Pap use. The DON confirmed the lack of current orders, and no policy on physician's orders was provided during the survey.
Incomplete and Inaccurate MDS Assessment
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for Resident #11. The MDS titled Significant Change dated 05/20/26 documented Section N, High-Risk Drug Classes, antipsychotics as "yes," but review of the resident's Medication Administration Record for May 2026 showed no antipsychotic medications were administered during the look-back period for the MDS. During interview, the DON stated Resident #11 had not taken an antipsychotic medication during her stay at the facility. The Corporate MDS Coordinator stated the MDS was incorrect and that antipsychotic medication had been clicked "yes" instead of "no" for lamotrigine.
PASRR Did Not Reflect Resident’s Traumatic Brain Injury
Penalty
Summary
The facility failed to ensure that a resident with a known history of traumatic brain injury had a coordinated PASRR review that reflected the diagnosis. Review of the resident’s PASRR showed no related conditions, including traumatic brain injury, checked off, while the admission MDS documented personal history of traumatic brain injury under active diagnoses. Physician progress notes also identified a past medical history that included traumatic brain injury along with vascular dementia, atrial fibrillation, anemia, hypertension, hyperlipidemia, pulmonary fibrosis, speech and language deficits, cerebrovascular disease, and Parkinson’s disease. During interview, the DON confirmed the resident had a history of traumatic brain injury and stated the PASRR needed to be updated. The facility policy stated residents with a newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred promptly for a level II resident review, including when a related condition was not previously identified and evaluated through PASARR.
Failure to Include Bipolar Disorder and Anxiety in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #11, who was reviewed for unnecessary medications. Review of the resident’s psychiatry note dated 04/29/26 documented diagnoses of bipolar disorder and other anxiety disorder, with the note stating that the resident had chronic episodes of depression and manic-like symptoms causing distress and functional impairment, and that mood stabilizer medication needed to be continued long term. A later psychiatry note dated 07/29/26 documented a past psychiatric history of bipolar disorder, depression, anxiety, and dementia, and stated that trazodone and Prozac were managing depression, donepezil was helping dementia, lamotrigine was assisting with bipolar disorder, and clonazepam was assisting with anxiety. Review of Resident #11’s care plan showed that it did not include a focus area for bipolar disorder or anxiety disorder. During interview on 08/12/26 at 1:25 PM, the Corporate MDS Coordinator stated that anxiety disorder and bipolar disorder were not included in the resident’s care plan and would be added. The facility’s policy on care plans stated that the comprehensive, person-centered care plan will describe the services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Unsecured Self-Administered Medications in Resident Room
Penalty
Summary
The facility failed to ensure medications were securely stored when unattended for 1 of 5 hallways. Resident #41 had a physician’s order dated 07/06/26 allowing self-administration of medications, and the self-administration evaluation dated the same day stated the resident was completely capable and could demonstrate secure storage of medications kept in the room. However, during an observation on 08/10/26, an inhaler was seen unsecured on top of a small dresser under the resident’s television, and lubricant eye drops were unsecured on the bedside table. Further observations on 08/11/26 showed nasal sprays in an unlocked bathroom drawer, an inhaler in a wicker box on a dresser, and nebulizer vials on the nightstand. The resident stated the bedroom did not lock and that she would prefer a lock so other residents could not enter; she also stated she did not have a lockbox and did not know one could be requested. Staff B, LPN, stated the resident managed her own medications but was unsure whether medications kept in the room needed to be locked. The DON stated the resident kept inhalers and artificial tears in the room, oral medications were locked in the medication cart, and the resident had not been offered a lockbox. The facility policy stated bedside storage is permitted only when medications are stored safely and securely, with lockable drawers or cabinets required if needed.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in the kitchen, as observed during an inspection. During the initial tour of the kitchen, it was noted that there were thirteen bags of various frozen meats without identifying labels. Additionally, one bag of chicken was found left open, exposing the product to ice particle buildup and the appearance of freezer burn. The Certified Dietary Manager (CDM) confirmed these observations. The facility's policy on Date Marking for Food Safety, revised in January 2025, requires a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded, which was not adhered to in this instance.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during medication administration for a resident. During an observation, an LPN prepared medications for a resident, including using Baby Shampoo on a wet washcloth to clean the resident's eyelids. The LPN did not remove her gloves or perform hand hygiene after cleaning the resident's eyes and before administering medications through the resident's gastrostomy tube. Additionally, the LPN used her gloved finger to stir a crushed pill of Amlodipine mixed with water before administering it through the G-tube. The facility's policies on medication administration, infection prevention, and hand hygiene were not followed. The LPN acknowledged that she should have washed her hands and changed her gloves after cleaning the resident's eyes and before administering medications. The Director of Nursing confirmed that for a resident on Enhanced Barrier Precautions, the nurse should wash hands and change gloves before administering medications through a gastric tube and should use a spoon to mix medications. The facility's policies emphasize the importance of hand hygiene to prevent contamination and infection, which were not adhered to in this instance.
Inaccurate Resident Assessments for Respiratory Care
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for two residents reviewed for respiratory care. Resident #1, who was admitted with diagnoses including COPD and OSA, confirmed during an interview that she was still using her CPAP machine, which was observed on her nightstand. However, her MDS Quarterly assessment documented that she was not using a CPAP machine. Similarly, Resident #5, who was readmitted with diagnoses including CHF, COPD, and Pulmonary Edema, was observed with a CPAP machine on his nightstand and confirmed its use during an interview. Despite this, his MDS Quarterly assessment also documented that he was not using a CPAP machine. The MDS Coordinator confirmed the discrepancies in the assessments for both residents.
Failure to Ensure Physician's Orders for CPAP/BIPAP Use
Penalty
Summary
The facility failed to ensure an attending practitioner's orders and indication of use for CPAP (Continuous Positive Airway Pressure) or BIPAP (Bi-level Positive Airway Pressure) devices for one resident reviewed for respiratory care services. Resident #5, who was readmitted to the facility with diagnoses including CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and Pulmonary Edema, had a CPAP machine observed on the nightstand next to his bed. However, there were no physician's orders for the use or care of the CPAP machine documented as of 5/21/24. The resident confirmed the CPAP machine belonged to him. The care plan dated 7/25/22 indicated monitoring the use of a Bi-Pap machine as ordered, but the Director of Nursing confirmed that no current orders existed for the CPAP or BIPAP machine. Additionally, a policy on physician's orders was not provided during the survey.
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Illustrative
What surveyors actually found near you
We read the 22 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 Jasper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Surrey Place Nursing Center | 15.8 mi | ★★★★★ | 0 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 16.2 mi | ★★★★★ | 11 | 0 |
| Good Samaritan Center | 24.5 mi | ★★★★★ | 11 | 0 |
| Madison Health And Rehabilitation Center | 27.3 mi | ★★★★★ | 0 | 0 |
| Lake Park Of Madison Nursing And Rehabilitation Ce | 28.4 mi | ★★★★★ | 2 | 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.