Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Bell Minor Home, The during CMS and state inspections, most recent first.
Failure to Use Required PPE for Enhanced Barrier Precautions: A CNA entered a room with an EBP sign posted without donning the required gown and gloves and made direct contact with a resident on EBP while repositioning the resident. The resident had severe cognitive impairment, required extensive ADL assistance, and had pressure ulcers with wound treatment documented. The CNA stated she only wears PPE when changing residents, while the DON confirmed PPE was expected for all direct resident care and contact involving residents on EBP.
Two residents experienced significant changes in condition, including worsening edema, absent pedal pulses, and a rapidly progressing diabetic foot ulcer, but their medical providers and families were not notified in a timely manner as required by facility policy. One resident died after developing gangrene and sepsis, while another required a below-the-knee amputation due to gangrene. Documentation and staff interviews confirmed that notifications were not made as expected, resulting in actual harm and death.
Multiple residents experienced serious harm due to the facility's failure to prevent abuse and neglect. One resident died after staff failed to notify a physician and denied a family's request for hospital transfer following a significant change in condition. Another resident suffered a below-the-knee amputation after delayed wound care and lack of recommended interventions for a diabetic ulcer. Additionally, a resident with a history of aggressive behavior physically abused her roommate by wrapping a call light cord around her neck, despite prior incidents and insufficient preventive measures.
Nursing staff did not notify the medical provider when a resident experienced worsening edema, bruising, and absent pedal pulses, despite facility policy requiring such notification. The lack of timely communication and intervention led to the resident's condition deteriorating, culminating in an emergency hospital transfer and subsequent death. Interviews confirmed that providers were not informed of critical changes, resulting in Immediate Jeopardy.
Three residents developed or experienced worsening pressure ulcers due to the facility's failure to implement preventive interventions, timely wound assessments, and physician-ordered treatments. In two cases, significant delays in care and lack of documentation led to the progression of ulcers, with one resident's wound contributing to death and another requiring surgical debridement and hospitalization for infection. The facility did not follow its own protocols for wound care, documentation, and use of pressure-reducing devices, resulting in Immediate Jeopardy.
Facility administration failed to ensure that nursing staff identified, assessed, and reported changes in residents' skin conditions, resulting in actual harm and death. Additionally, the facility did not protect a resident from repeated abuse by another resident, despite documented incidents. The DON and Administrator acknowledged that staff did not follow established protocols, and the facility was cited for substandard quality of care, including failure to prevent and treat pressure ulcers.
The facility did not ensure that the interval between dinner and breakfast was within the required 14 hours, resulting in a 15-hour gap for most residents. Some residents reported hunger and dissatisfaction with the available evening snacks, and staff confirmed that the issue had been raised in resident council meetings without group approval for the extended interval.
Surveyors found that staff failed to follow food safety and hand hygiene protocols in the kitchen, including improper storage of clean cups with pooled water, inconsistent labeling of leftovers, and dietary aides handling ready-to-eat foods with gloved hands while also touching non-food items without changing gloves or washing hands. These actions affected nearly all residents except those on tube feeding.
Surveyors found that the dumpster area was not maintained in a sanitary manner, with garbage and refuse—including used gloves, masks, and food containers—strewn around the dumpsters and along the parking lot edge for several days. The dumpster door was left open, and a large garbage bag was hanging outside the container. Staff interviews revealed confusion over responsibility for cleaning the area, and the unsanitary conditions persisted, potentially affecting all residents.
The facility's Arbitration Agreement, signed by all current residents at admission, did not include a clause for selecting a mutually convenient venue for arbitration. The Administrator confirmed the absence of this provision and that no location criteria were present in the agreement.
The facility did not ensure that physicians responded in a timely manner to pharmacist recommendations made during monthly medication regimen reviews for several residents with cognitive impairment and psychiatric diagnoses. Documentation and interviews showed missing or delayed physician responses to recommendations for dose reductions and medication changes, with facility staff and the pharmacist confirming ongoing issues in obtaining and documenting provider actions.
Multiple residents reported that meals were consistently served cold, lacked flavor, and were missing condiments such as salt, pepper, and sugar. Surveyors observed food and beverages left at room temperature, meal service times exceeding policy limits, and the use of leftovers instead of freshly prepared food. Staff interviews confirmed that condiments were not routinely provided and that leftovers were reused for subsequent meals, leading to ongoing complaints about food quality.
A resident with Alzheimer's disease and other conditions was admitted to hospice, but the facility did not complete a Significant Change MDS Assessment as required. Staff interviews and record reviews confirmed that the assessment was not performed after the initiation of hospice services, despite facility policy and federal guidelines.
Quarterly MDS assessments were not completed within the required 92-day timeframe for three residents, including individuals with chronic conditions such as COPD, Alzheimer's disease, myasthenia gravis, heart failure, and atrial fibrillation. Staff interviews revealed that while the MDS Coordinator used the EMR system to track assessments, overdue assessments were confirmed, and there was a lack of tracking by the Regional Remote MDS nurse.
Two residents did not have their pressure ulcers and diabetic foot ulcers accurately coded on MDS assessments, despite clear documentation in medical records and ongoing wound care. The MDS Coordinator, DON, and Regional Remote MDS nurse confirmed that the assessments should have reflected the actual wound status and treatments, but the required accuracy and validation were not met, resulting in incorrect and incomplete MDS documentation.
A resident with diabetes and Alzheimer's developed a diabetic foot ulcer, but the facility did not update the care plan to include the ulcer or recommended interventions such as turning, repositioning, and use of heel boots. Although wound care and staff education were documented, these actions were not reflected in the official care plan until after the resident was hospitalized with gangrene.
A resident with severe cognitive impairment and incontinence did not consistently receive scheduled showers as required by facility policy. Staff interviews and documentation review revealed missed showers over several months, with staff citing resistance to care and staffing shortages as contributing factors. The resident was observed with greasy hair and saturated clothing, indicating a lack of proper hygiene care.
A resident with significant mobility limitations and a need for bed rails did not have required quarterly safety assessments documented, as mandated by facility policy. Staff interviews and record reviews confirmed that the electronic system did not prompt for these assessments, and only outdated paper assessments were found. This lapse was acknowledged by the DON and RDCO, with no current assessments completed for the resident.
Three residents did not receive prescribed antibiotics and pain medications as ordered due to delays in pharmacy delivery, lack of medication in contingency supplies, and issues with medication reordering and access. Staff and nurse interviews confirmed ongoing problems with timely medication availability, resulting in missed doses for residents with serious medical conditions.
Two residents experienced significant medication errors when critical medications, including cardiac drugs and insulin, were not administered as ordered due to pharmacy delivery delays, lack of access to emergency medication supplies, and expired stock. Staff identified the issues but did not consistently utilize available resources or follow facility policy, resulting in missed doses and elevated blood sugar for one resident.
The facility did not ensure proper infection control practices for two residents, including failure to use required PPE during high-contact care for a resident with a gastrostomy tube and lack of PPE availability outside the room for a resident with C. difficile. Staff demonstrated confusion about which precautions applied to which residents, and signage and PPE placement did not align with facility policy, resulting in lapses in infection prevention.
The facility failed to lock cabinets in shower rooms on A and B Halls, which contained hazardous items like razors and cleaning supplies. Observations confirmed the cabinets were unlocked, with one having a broken lock and the other lacking a lock entirely. This posed a potential risk to two residents known to wander the facility. Staff interviews revealed a lack of awareness about the issue, and the facility's policy on maintaining shower rooms was not provided.
Failure to Use Required PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff implemented infection prevention and control practices related to Enhanced Barrier Precautions for one of 13 residents on EBP. R8 was admitted with diagnoses including Parkinson's disease, hypertensive heart failure, dementia, need for assistance with personal care, and hypokalemia. The EHR, TAR, and MDS showed R8 had severe cognitive impairment, required moderate to maximal assistance with activities of daily living, and had a pressure ulcer with treatment documented for wounds to the coccyx and sacrum. During an observation, a CNA entered a room with an EBP sign posted and did not don the required gown and gloves before entering. Both residents in the room required EBP. The CNA made direct contact with R8 by leaning over the resident and placing her arm around R8's shoulder to reposition the resident, and her clothing and bare hands came into contact with R8. When interviewed, the CNA stated she only wears the gown and gloves when changing residents. The DON confirmed the expectation that staff wear the required PPE, including gown and gloves, for all resident contact involving residents on EBP, and the facility policy stated that gown and gloves are to be worn prior to high-contact care activity.
Failure to Notify Providers and Family of Change in Condition Resulting in Death and Harm
Penalty
Summary
The facility failed to ensure timely notification of changes in condition to medical providers and family members for two residents, resulting in death for one and actual harm for another. For one resident with multiple diagnoses including congestive heart failure, diabetes, and deep vein thrombosis, there were repeated instances where significant changes such as worsening edema, bruising, and absent pedal pulses were documented in the medical record, but not communicated to the resident's medical provider. The family was also not informed of the resident's deteriorating condition over a period of several days, despite their concerns and requests for hospital transfer, which were denied by the facility. The resident ultimately developed severe complications, including gangrene and sepsis, and died after being transferred to the hospital. In the second case, a resident with diabetes and Alzheimer's disease developed a diabetic foot ulcer that was treated in the facility. The wound increased in size and severity, with new discoloration and necrosis observed by nursing staff. However, the wound care practitioner was not notified of these changes until the following day, when the resident was transferred to the hospital. The family was not informed of the existence or progression of the wound until the resident was sent to the emergency room, at which point the resident required a below-the-knee amputation due to gangrene and necrotizing cellulitis. The facility's own policy required notification of the physician and family within 24 hours of a significant change in a resident's condition, but this was not followed in either case. Interviews with facility staff, including the DON and medical providers, confirmed that the expectation was for prompt communication of such changes. Documentation in the electronic medical record and staff statements further supported that these notifications did not occur as required, directly contributing to the negative outcomes for both residents.
Failure to Prevent Abuse and Neglect Resulting in Harm and Death
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in actual harm and death for several individuals. In one case, a resident with multiple serious medical conditions, including angioneurotic edema, CHF, DVT, and diabetes, developed a fluid-filled blister and later had unpalpable pedal pulses. Despite the family's request for hospital transfer and clear signs of a change in condition, the nurse practitioner denied the transfer, and nursing staff did not notify the physician. The resident's condition worsened, and she was eventually transferred to the hospital, where she died from complications related to the facility's failure to notify the physician and delay in treatment. Another resident with diabetes and Alzheimer's disease developed a diabetic ulcer on the right foot. Nursing staff identified the wound but delayed notifying the wound care provider, and there was a lack of timely assessment and intervention. The wound worsened significantly, with documentation showing an increase in size and necrotic tissue, but recommended interventions such as heel boots and frequent repositioning were not implemented. The resident was eventually transferred to the hospital with gangrene and underwent a below-the-knee amputation. The care plan was not updated to reflect the wound until after the amputation. A third incident involved a resident with a history of behavioral disturbances and aggression toward roommates. Despite multiple documented incidents of verbal and physical aggression, including hiding call bells, interfering with roommates' care, and escalating behaviors, the facility failed to implement effective interventions to prevent further abuse. Ultimately, this resident physically abused her roommate by wrapping a call light cord around her neck and tying it to the bedrail. Staff and social services were aware of the ongoing behaviors, but the interventions were insufficient to prevent harm. The facility's noncompliance with requirements of participation resulted in serious injury, harm, and death to residents.
Failure to Notify Provider of Resident's Change in Condition Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff used their clinical skills and judgment to identify and notify a resident's medical provider of a significant change in condition. Specifically, a resident with multiple diagnoses, including angioneurotic edema, congestive heart failure, deep vein thrombosis, and diabetes, experienced worsening edema, a bruised area on the left foot, and eventually unpalpable pedal pulses. Despite these changes, there was no documented evidence that the nursing staff notified the resident's medical provider of the worsening edema, bruising, or absence of pedal pulses prior to the provider's visit. The facility's policy required nurses to notify the provider of significant changes in a resident's condition, but this was not followed in this case. Further review revealed that the nursing staff documented the absence of palpable pedal pulses on two occasions but did not implement any nursing interventions or notify the physician. When a fluid-filled blister was observed on the resident's calf, the family requested a transfer to the emergency department, but this request was denied by the nurse practitioner, who instead ordered antibiotics for cellulitis. The resident's condition continued to deteriorate, with discolored areas and unpalpable pulses noted, and an ankle brachial index was ordered. Eventually, after further decline and the development of gangrene, the decision was made to transfer the resident to the hospital, where she died hours after arrival due to complications from the worsening skin condition. Interviews with facility staff, including the DON, nurse practitioners, and medical directors, confirmed that the expectation was for nursing staff to notify providers of significant changes in condition, such as absent pedal pulses or worsening edema. However, the providers were not made aware of these changes in a timely manner, which delayed further assessment and aggressive treatment. The facility's failure to follow its own policy and ensure timely communication of the resident's change in condition resulted in an Immediate Jeopardy situation.
Failure to Prevent and Treat Pressure Ulcers Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three sampled residents. For two residents, significant pressure ulcers developed and worsened due to a lack of preventive interventions, delayed treatment orders, and insufficient wound assessments. In one case, a resident did not have preventive measures in place before a sacral pressure ulcer was identified, and there were no treatment orders for nine days after the ulcer was first observed. The first assessment with measurements and description of the wound was not completed until 23 days after the ulcer was noted. The wound progressed to a stage 4 ulcer, became larger and deeper, and was associated with infection. Recommendations for protective boots and a specialty pressure relief mattress were not implemented, and there was a 21-day gap without any wound assessment or measurements by either the wound care provider or facility nursing staff. The resident's pressure ulcer continued to deteriorate, and the physician indicated that the ulcer likely contributed to the resident's death. Another resident developed a new open area on the sacrum, but after returning from a hospital stay, there were no evaluations of the wound for several days, and treatment orders were not obtained until later. Wound assessments by the contracted wound company did not document the sacral wound, and the wound was found to be unstageable with 100% necrotic tissue, requiring surgical debridement. The resident was hospitalized for an infected sacral decubitus ulcer and discharged on intravenous antibiotics. The lack of preventive interventions, timely assessments, and treatment per physician orders placed the resident at risk for further infection and worsening of the pressure ulcer. The facility's own policies required weekly documentation and assessment of wounds, use of pressure-reducing devices, and implementation of preventive protocols such as turning and repositioning. However, these protocols were not followed. There were multiple instances where wound care treatments were not documented as completed, and staff interviews confirmed gaps in care, lack of documentation, and failure to implement recommended interventions. The facility was cited for Immediate Jeopardy due to noncompliance that caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Ensure Timely Assessment, Reporting, and Protection of Residents
Penalty
Summary
Facility administration failed to ensure effective use of resources to maintain residents' highest physical well-being, as evidenced by multiple failures in nursing care and oversight. Specifically, the Administrator and DON did not identify or address failures by nursing and other staff, resulting in actual harm and death among residents. The administration did not ensure that physicians or other medical providers were notified when two residents experienced changes in their skin conditions, nor did they ensure that staff identified, assessed, or reported these changes. Nursing staff neglected to recognize or report the worsening of skin conditions, and the facility failed to protect a resident from abuse by another resident, despite documentation of repeated abusive incidents. The DON confirmed that nurses had received training on change in condition policies, and that the ADON was responsible for ongoing staff education. However, despite these measures, nurses did not follow established protocols for alert charting, provider notification, assessment, or documentation when changes in condition occurred. The Administrator and DON both acknowledged that these failures were not in accordance with facility policy. The facility was cited for substandard quality of care, including failure to prevent and treat pressure ulcers, and was found to be in Immediate Jeopardy due to noncompliance that caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Maintain Required Interval Between Dinner and Breakfast
Penalty
Summary
The facility failed to ensure that the time between the evening meal and breakfast the following day did not exceed 14 hours for 99 out of 101 residents, as required. Scheduled mealtimes resulted in a 15-hour gap between dinner and breakfast, and this gap was sometimes extended further due to late meal service. The facility did not provide a substantial evening snack to compensate for the extended interval, and the resident group had not approved the 15-hour gap. The facility's Menu Planning policy did not specify maximum allowable time between meals, and the mealtimes document confirmed the 15-hour interval. Observations and interviews revealed that residents experienced hunger due to the long gap between dinner and breakfast. Some residents reported not receiving enough food at dinner and not being offered suitable snacks in the evening, with available snacks limited to chips and cookies, which were not acceptable to all residents. Staff interviews confirmed that the issue of late meals and the long gap between dinner and breakfast had been raised in resident council meetings, but no approval for the extended interval had been obtained. The Dietary Manager and Registered Dietitian acknowledged awareness of the 14-hour requirement but confirmed that the current schedule did not comply.
Failure to Follow Food Safety and Hand Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to maintain proper food service practices in the kitchen, resulting in potential risks for foodborne illness for 99 out of 101 residents. During multiple inspections, surveyors observed stacks of plastic cups stored as clean but with pooled water and condensation between them, indicating that the cups were not properly air dried before being stacked. The Dietary Manager confirmed that cups should be air dried to prevent bacterial growth. Additionally, leftover foods in the refrigerator were inconsistently labeled, making it unclear whether the dates indicated when the food was stored or when it should be discarded. The facility's policy required both the date of storage and the use-by date to be clearly labeled, but this was not consistently followed. During meal service observations, two dietary aides were seen handling ready-to-eat foods such as hoagie buns and potato chips with gloved hands, while also touching various non-food items like utensil handles, tray cards, plates, counters, and refrigerator handles without changing gloves or performing hand hygiene. Both the Dietary Manager and Registered Dietitian confirmed that gloves are intended for single use and should not be used to touch multiple surfaces. The aides acknowledged they had not considered the risk of cross-contamination from touching multiple items with the same gloves. These actions were in direct violation of the facility's hand washing and food labeling policies.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster area in a sanitary condition, as required by its Waste Disposal policy, which states that all garbage should be disposed of daily and the surrounding area kept clean. Over the course of three days, surveyors observed garbage strewn around the dumpsters and along the edge of the parking lot, including items such as cigarette butts, plastic food containers, cardboard, used latex gloves, wipes, surgical masks, toothbrushes, soda bottles, straws, cigarette boxes, paper, and medication cups. The side door to the regular garbage dumpster was left open, and a large garbage bag was stuck in the lid and hanging outside the dumpster. No staff were observed disposing of garbage during these times. Interviews with facility staff revealed confusion regarding responsibility for maintaining the cleanliness of the dumpster area. The Dietary Manager stated that maintenance was responsible for cleaning the area, while the Maintenance Director indicated that dietary and housekeeping staff should maintain the area when disposing of garbage, with maintenance responsible for a weekly cleanup. The Maintenance Director acknowledged missing the scheduled cleaning for that week and confirmed the presence of garbage and the bag hanging outside the dumpster. The unsanitary conditions persisted for several days, affecting the environment for all residents at the facility.
Arbitration Agreement Lacks Mutually Convenient Venue Clause
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement presented to residents and their representatives at admission included a clause specifying that the venue for arbitration would be mutually convenient and agreeable to both parties. Review of the undated Arbitration Agreement revealed the absence of any provision for selecting a mutually convenient venue or any location criteria. According to the Administrator, all 101 current residents had signed this agreement upon admission, and no arbitrations had been conducted since 2019. The Administrator confirmed during interviews that the agreement lacked the required clause, and the facility did not provide an arbitration agreement policy when requested by surveyors.
Failure to Ensure Timely Physician Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacist recommendations made during monthly medication regimen reviews for four out of five residents reviewed for unnecessary medications. According to the facility's policy, pharmacist recommendations should be acted upon within 30 days, and physicians are required to document their acceptance or rejection of these recommendations, including the rationale for any rejections. However, documentation and interviews revealed that physician responses were missing or significantly delayed for multiple residents, and in some cases, there was no evidence that recommendations were reviewed or addressed at all. For one resident with severe cognitive impairment and multiple psychiatric diagnoses, there were no documented pharmacist recommendations or physician responses regarding antidepressant and antipsychotic medications for several months. Another resident with dementia and psychotic disturbance had pharmacist recommendations for medication dose evaluation and PRN medication duration, but the responses were not provided until five months later, and one recommendation was not fully addressed. A third resident with moderate cognitive impairment and multiple psychotropic medications had several pharmacist recommendations for dose reductions and medication changes, but there was no documentation of physician responses. The fourth resident, admitted with dementia and psychotic disturbance, had a pharmacist recommendation for a dose reduction of an antipsychotic, but there was no physician response documented, and the medication regimen remained unchanged. Interviews with the DON, pharmacist, and regional clinical leadership confirmed ongoing issues with obtaining timely physician responses to pharmacist recommendations. The outgoing medical director was specifically identified as not returning responses, and the facility was unable to locate required documentation in the electronic medical record for the affected residents. The pharmacist reported routinely resubmitting recommendations due to lack of provider response, and facility leadership acknowledged the deficiency in following up on and documenting physician actions regarding pharmacy recommendations.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and at a safe and appetizing temperature, as required by their own Test Tray policy. Multiple residents with intact cognition reported that meals were consistently served cold or not hot, lacked flavor, and that condiments such as salt, pepper, sugar, and sugar substitute were not provided as indicated on the menu. Residents also reported that leftovers were routinely served instead of freshly prepared food, and these concerns were repeatedly documented in resident council meeting minutes over several months. Direct observations by surveyors confirmed that food and beverages were left sitting at room temperature for extended periods, and that meal service times exceeded the facility's policy of serving trays within 20 minutes of assembly. For example, one meal cart took 38 minutes from loading to final service, resulting in food temperatures below policy standards. Test trays evaluated by the Dietary Manager and surveyor showed hot foods served at temperatures as low as 95°F, well below the required 130°F-150°F, and cold foods not meeting the required cold temperature standards. Additionally, condiments were not present on tray lines or dining tables, and staff did not offer them to residents during meal service. Interviews with dietary staff, the Dietary Manager, and the Registered Dietitian revealed that leftovers, including scrambled eggs and pureed foods, were routinely reused for subsequent meals, contrary to best practices for food palatability. The Registered Dietitian confirmed that such practices should not occur and that food should be served hot and with appropriate condiments. The Social Worker and Resident Council minutes further corroborated ongoing resident complaints about cold and unpalatable food, indicating a persistent and unaddressed issue with the facility's food service practices.
Failure to Complete Significant Change MDS Assessment After Hospice Initiation
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment for a resident after the initiation of hospice services, as required by federal regulations and the facility's own policy. The resident, who had diagnoses including Alzheimer's disease, atrioventricular block, and hypertension, was admitted to hospice services. Despite this significant change in condition, a review of the electronic medical record and MDS assessments revealed that a Significant Change Assessment was not completed within the required timeframe following the start of hospice care. Interviews with facility staff confirmed the omission. The MDS Coordinator, an LPN, stated that she followed the RAI manual for assessment timing, and that either a corporate RN or the DON signed off on her completed assessments. However, both the MDS Coordinator and the Unit Manager/Infection Preventionist verified that the required Significant Change Assessment was not performed after the resident began hospice services, in direct contradiction to facility policy and federal guidelines.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed at least once every three months for three residents. According to the facility's policy and the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly assessments must be completed at least every 92 days following the previous OBRA assessment. Record reviews showed that one resident with chronic obstructive pulmonary disease and a collapsed vertebra, another with Alzheimer's disease and myasthenia gravis, and a third with heart failure and atrial fibrillation all had overdue MDS assessments, with the most recent assessments exceeding the required 92-day interval. Interviews with facility staff revealed that the MDS Coordinator was responsible for tracking and completing assessments using the electronic medical record (EMR) system and believed she was not behind in completing them. However, upon review, she confirmed that the assessments for the three residents were past due. The Regional Remote MDS nurse stated that she or the DON signed the MDS assessments but did not track the timing, and the DON expected the MDS Coordinator to complete assessments in a timely manner.
Inaccurate MDS Assessment and Coding of Pressure and Diabetic Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to the documentation and coding of pressure ulcers and diabetic foot ulcers. For one resident with a history of atherosclerotic heart disease and dementia, medical records indicated the presence of a pressure ulcer to the sacrum as early as 10/2/2024, with subsequent documentation by a wound care physician describing the ulcer as unstageable and later as a Stage 4 pressure wound. However, the significant change MDS assessment completed on 10/17/2024 did not reflect the presence of any pressure ulcers or risk for developing them. Additionally, a quarterly MDS assessment incorrectly coded the Stage 4 sacral pressure ulcer as a deep tissue injury (DTI), despite clear documentation of its stage and characteristics in wound care notes. For another resident with diabetes and Alzheimer's disease, records showed ongoing treatment for a diabetic ulcer on the right lateral foot, including physician orders and wound care notes spanning several weeks. Despite this, the annual MDS assessment failed to document the presence of the diabetic foot ulcer or the associated skin treatments, instead indicating that the resident had no ulcers, wounds, or skin problems. Interviews with facility staff, including the MDS Coordinator, DON, and Regional Remote MDS nurse, confirmed that the assessments should have accurately reflected the residents' conditions and that the diabetic foot ulcer should have been coded on the MDS. The facility's policy required each individual completing a portion of the MDS to certify its accuracy, and the RAI Manual emphasized the importance of validating information for the specified observation period. Despite these requirements, the interdisciplinary team did not ensure that the MDS assessments accurately represented the residents' actual status, leading to incorrect coding and incomplete documentation of significant wounds and treatments.
Failure to Develop and Implement Person-Centered Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a diabetic foot ulcer. Despite the resident having a history of diabetes and Alzheimer's disease, and documented orders for wound care including betadine application, the care plan was not updated to reflect the presence of the diabetic ulcer or the specific interventions recommended by the wound care provider. Documentation in the resident's medical record and wound progress notes indicated ongoing wound care and staff education regarding monitoring for infection, turning and repositioning, and the use of heel boots to relieve pressure. However, these interventions were not incorporated into the resident's official care plan prior to the resident's hospitalization. The resident's Minimum Data Set (MDS) did not indicate the presence of a diabetic foot ulcer or related treatment, and the care plan focus area for the ulcer was only initiated after the resident was discharged to the hospital with gangrene. Interviews with facility leadership confirmed that recommendations such as floating heels, heel booties, and frequent turning were made by the wound care provider and discussed in meetings, but these were not reflected in the care plan as required by facility policy. The lack of timely and comprehensive care planning had the potential to result in unmet care needs for the resident.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with diagnoses of congestive heart failure and dementia did not consistently receive scheduled showers as required by facility policy. The resident, who was severely cognitively impaired and required moderate assistance with activities of daily living, including toileting, hygiene, and bathing, was observed with greasy hair and saturated clothing due to incontinence. The facility's policy required showers for cleanliness, circulation, and comfort, with documentation of completion, and the care plan specified showers twice weekly, with alternative sponge baths if a full shower could not be tolerated. Interviews with CNAs confirmed that the resident was a heavy wetter, required frequent changing, and was sometimes resistant to care but could usually be persuaded to comply. However, review of shower documentation revealed that the resident did not receive all scheduled showers over several months, with missed showers in November, December, January, and March. An LPN acknowledged that showers were sometimes not completed due to staffing shortages. The lack of consistent showering created the potential for poor hygiene and odor, as observed during the survey.
Failure to Complete Quarterly Bed Rail Safety Assessments
Penalty
Summary
The facility failed to complete required quarterly assessments for the continued use and safety of bed rails for one resident. According to the facility's policy, bed rail use must be regularly assessed for safety risks, including factors such as medical condition, cognition, mobility, and risk of entrapment. For the resident in question, who had abnormal posture and kyphosis and was cognitively intact, there was documentation of an initial bed rail assessment and physician orders for bed rails to assist with positioning and safety. However, there were no documented quarterly bed rail assessments in the electronic medical record for the year, and only older paper assessments from before 2024 were found. Observations confirmed that the resident used full-length side rails and relied on them for repositioning due to her medical condition and fear of falling. Interviews with staff revealed that the required quarterly bed rail assessments had not been completed, and the process for triggering these assessments in the electronic system was not activated when the bed rail order was entered. The DON and RDCO both confirmed the absence of current bed rail assessments, acknowledging that this oversight was only recently discovered. This failure had the potential to affect all residents using bed rails in the facility.
Failure to Provide Timely Access to Prescribed Medications
Penalty
Summary
The facility failed to provide timely access to prescribed antibiotic and pain medications for three of five sampled residents, as required by their own policy and federal regulations. For one resident with severe cognitive impairment and a history of heart failure, daptomycin IV was not administered on multiple occasions due to the medication not being in stock, with documentation showing pharmacy notification and delayed delivery. Another resident with severe cognitive impairment and a diagnosis of C. difficile infection missed several doses of vancomycin oral suspension, with progress notes indicating the medication was on order and pending delivery from the pharmacy. Neither daptomycin nor vancomycin was available in the facility's contingency supply (Pyxis) at the time. A third resident, who was cognitively intact and had a history of neuropathy, diabetes, and hemiplegia, did not receive prescribed pain medications (Baclofen and Tramadol) on several occasions. Documentation revealed that Baclofen was out of stock and on order, and Tramadol was not available for three days, with repeated notes of awaiting pharmacy delivery. The resident reported experiencing pain during these periods without medication. Staff interviews confirmed ongoing issues with timely medication delivery from the pharmacy, difficulties accessing the Pyxis system (especially for agency nurses), and delays in reordering medications due to pharmacy policies. The facility's policy required prompt communication with the pharmacy for new and emergency medication orders, and the use of contingency supplies when available. However, interviews with nursing staff, the DON, and the infection preventionist confirmed that medications were not always delivered or available as needed, and that there were recurring problems with both pharmacy responsiveness and internal processes for medication reordering and access. These failures resulted in missed doses of critical antibiotics and pain medications for multiple residents.
Failure to Prevent Significant Medication Errors Due to Medication Unavailability and Access Issues
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, as required by policy and regulation. For one resident with severe cognitive impairment and diagnoses including hypertensive heart disease and heart failure, multiple doses of critical medications (isosorbide dinitrate and metoprolol succinate) were not administered over several days following a recent hospital admission. Documentation indicated that these medications were not available due to pending pharmacy delivery, despite being stocked in the facility’s Pyxis emergency medication supply. Agency nurses reported not having access to the Pyxis and stated they informed management when unable to obtain medications. The nurse practitioner and DON confirmed that medications in the Pyxis should have been used if available, and that missed doses were reviewed by management. Another resident with diabetes mellitus and intact cognition did not receive a scheduled morning dose of insulin because the available vial had expired. The LPN identified the expired medication and contacted the on-call physician and pharmacy for a replacement, but the insulin was not available in the emergency kit and was not administered until later in the day. The resident’s blood sugar was elevated, and staff continued to monitor glucose levels throughout the day. The unit manager confirmed that the insulin was not in the emergency kit and that the resident’s sliding scale insulin was also unavailable due to a transcription error. Interviews with staff, including LPNs, the nurse practitioner, the DON, and the regional director, revealed ongoing issues with timely pharmacy deliveries, access to emergency medication supplies, and medication cart checks. Facility policies required the use of emergency kits and prompt notification of pharmacy and physicians when medications were unavailable, but these procedures were not consistently followed, resulting in significant medication errors for both residents.
Failure to Implement and Follow Infection Control Practices for PPE and Precautions
Penalty
Summary
The facility failed to follow its own infection prevention and control policies for two residents regarding the use of personal protective equipment (PPE) and the implementation of enhanced barrier precautions (EBP) and transmission-based precautions. For one resident with a gastrostomy tube, staff did not don a gown while performing high-contact care activities such as checking tube placement, flushing the tube, and administering medication, despite facility policy and posted signage requiring both gloves and a gown for such activities. Additionally, the signage for EBP was posted inside the room, and PPE supplies were only available inside, not outside the room as required for proper donning before entry. A visitor was also allowed to enter the room without any PPE, and staff demonstrated confusion about which resident the posted precautions applied to. For another resident diagnosed with Clostridium difficile, there was a lack of clear identification regarding which resident in a shared room was on EBP or transmission-based precautions. Staff interviews revealed inconsistent understanding of when and for whom EBP should be used, with some staff relying on verbal reports rather than clear signage. PPE was not available outside the room for staff to don before entry, contrary to facility policy and standard infection control practices for transmission-based precautions. Interviews with nursing staff and facility leadership highlighted discrepancies in knowledge and application of EBP and transmission-based precautions. Some staff believed EBP was not required for certain activities, such as flushing or administering medications via a gastrostomy tube, while others stated that gowns and gloves should be used for all high-contact care. The facility's policies and CDC guidelines were not consistently followed, and there was confusion about the placement of PPE and signage, leading to lapses in infection control practices.
Unlocked Cabinets in Shower Rooms Pose Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not keeping cabinets locked in the shower rooms on A and B Halls. These cabinets contained potentially dangerous items such as cleaning supplies, toiletries, and disposable razors. Observations revealed that the cabinet in the A Hall shower room was unlocked with a broken lock, and the cabinet in the B Hall shower room was also unlocked with no lock present. This oversight had the potential to harm two residents who were known to wander the facility. Interviews with staff, including an LPN and a CMA-Tech, confirmed the unlocked status of the cabinets. The Director of Nursing (DON) was unaware of the situation and speculated that the keys might have been lost, leading to the locks being broken without informing the administration. The facility's policy on maintaining shower rooms and supplies was requested but not provided before the survey exit. The Administrator later confirmed that two residents were known to wander the facility, typically staying in the hallways.
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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 Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Horizons Limestone | 0.9 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Limestone | 1.4 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court At Lanier Village Estates | 6.3 mi | ★★★★★ | 3 | 0 |
| Crossroads Of Flowery Branch Of Journey Llc, The | 11.4 mi | ★★★★★ | 15 | 0 |
| Gateway Health And Rehab | 15.5 mi | ★★★★★ | 3 | 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.