Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chatuge Regional Nursing Home during CMS and state inspections, most recent first.
A resident with allergy and COPD self-administered Flonase after an RN handed over the medication, but the resident was not assessed for self-medication, did not have a physician order authorizing self-administration, and was not care planned for it. The RN said the resident could use the nasal spray but could not confirm any assessment, and the ADON confirmed no self-medication assessment, order, or care plan was in place.
Call lights were not kept within reach for two residents. One resident with paraplegia, severe cognitive impairment, and dependence for ADLs had a call button observed hanging on the side rail and dangling through the handrail, out of reach. Another resident with cerebral palsy, functional quadriplegia, dementia, and a left humerus fracture had the call button hanging across the bed rail and later near the floor, and could not reach it. Staff and the DON confirmed the call light should be accessible and within reach.
Missing Bed-Hold Notices and Ombudsman Notification: The facility did not provide written bed-hold and transfer notices or document Ombudsman notification for several residents transferred to the hospital. Records for a severely cognitively impaired resident and other residents showed incomplete transfer notices, no bed-hold notices, and no documentation that the Ombudsman was notified, while the DON, BOM, and Administrator acknowledged gaps in the process.
Incomplete Care Planning for Positioning and Feeding Interventions: The facility did not fully care plan and implement interventions for two residents. One resident with paraplegia, dementia, and a stage 4 pressure injury was observed lying on her back without the wedge or pillows identified in the care plan to offload the coccyx, and staff confirmed the devices were not in place. Another resident with cerebral palsy and dysphagia had an SLP plan requiring head support during meals, but the care plan and Kardex did not include that intervention; during observation, a CNA stood while feeding the resident and held the back of his head.
Unnecessary Antibiotic Use for UTI: The facility failed to ensure clinical criteria were met before giving antibiotics for suspected UTIs to two residents. One resident received multiple antibiotic courses despite resistance on culture results and limited documented UTI symptoms, while the other resident received long-term prophylactic Macrodantin with no clear charted rationale for continued use. Staff interviews showed disagreement about whether confusion and brief increased incontinence met McGeer criteria, and the EMR lacked consistent documentation of qualifying symptoms.
Medication Administration Error Rate Exceeded Threshold: The facility had three medication administration errors in 47 observed opportunities, resulting in a 6% error rate. An RN allowed a resident to self-administer Flonase without an order indicating self-administration, an LPN gave vitamin B12 by mouth instead of sublingually, and another LPN administered insulin from a vial with an unclear dating issue after misreading the open and expiration dates. The DON stated nurses were responsible for following the five medication rights and checking expiration dates before administration.
The facility administration failed to address allegations of abuse, exploitation, and injury of unknown origin involving residents. The Administrator did not investigate or report incidents such as a personal relationship between a CNA and a resident, an injury of unknown origin, and multiple abuse allegations by staff. These failures were acknowledged by the Administrator, who cited misplaced documentation as a reason for the lack of action.
Two residents were subjected to abuse by CNA staff, with one resident experiencing verbal and physical abuse during a shower, and another being denied access to a bedside toilet. The facility failed to document and investigate these incidents properly, allowing the involved CNA to continue working, leading to Immediate Jeopardy.
A resident with dementia was exploited by a CNA who developed an inappropriate personal relationship with him, including being listed as his emergency contact. The resident's debit cards were declined, raising concerns about financial exploitation. The facility's Administrator failed to thoroughly investigate the allegations, dismissing them as rumors, which led to noncompliance with protecting residents from exploitation.
The facility failed to report incidents of abuse, neglect, and exploitation involving two residents to the SSA. One resident, with moderate cognitive impairment, experienced potential exploitation and sustained an unreported hip fracture. Another resident, cognitively intact, reported neglect when a CNA refused to assist with toileting. These incidents were not reported as required by the facility's policy.
The facility failed to investigate allegations of abuse, exploitation, and an injury of unknown origin involving three residents. One resident was potentially exploited by a CNA, another was verbally abused, and a third was neglected, with no thorough investigations conducted. The administrator confirmed the lack of action, indicating a pattern of inaction in addressing serious allegations.
A resident reported that a CNA did not allow her to use the bedside toilet over a weekend, instructing her to use her pull-up instead. The grievance form was incomplete, with no action taken or follow-up noted. Additionally, the facility lacked a process for anonymous grievance submissions, potentially affecting all residents.
The facility failed to obtain signed informed consents for bed rail use for four residents, despite policy requirements. Residents R1 and R45, who were cognitively intact, reported not being informed of the risks and benefits. For residents R72 and R78, who were rarely or never understood, discussions with family or representatives were documented, but no signed consents were found. The Director of Nursing acknowledged the expectation to attempt alternatives and inform residents of risks, but no consents were provided by the exit conference.
The facility failed to remove expired medications and supplies from storage areas, potentially affecting residents. Expired items were found in the Blue Hall medication room, including Pro-Stat, Co-Q-10, Zinc Sulfate, and others. A phlebotomy cart contained expired vacutainer tubes, and a medication cart had discontinued oxycodone. Staff confirmed these items should have been removed.
The facility failed to serve meals on time for 50 residents, with lunch trays often arriving hours late, affecting those with medical conditions like diabetes and acid reflux. Staff confirmed the delays, citing communication issues between nursing and dietary departments. Family members also expressed concern over the late meal service.
The facility did not ensure the safety of bed rails for 90 out of 104 resident beds, risking potential entrapment or injury. The policy requires assessing the space between mattresses and side rails, but the annual inspection report lacked this review. Maintenance staff confirmed they did not perform safety checks on beds with side rails, contrary to the DON's expectations.
A resident, who was cognitively intact, was not assisted by the facility in obtaining necessary identification for voting, despite expressing the need for help. The Activities Director was aware of the requirement but did not take action until later, as confirmed by the Social Services Director and the DON.
The facility failed to provide written transfer notices to three residents or their representatives during emergent hospital transfers, as required by policy. The Director of Nursing and staff were unaware of the requirement, leading to verbal notifications only. This affected residents who were transferred due to changes in mental status and other symptoms, without receiving the necessary written documentation.
A facility failed to submit an annual MDS assessment for a resident within the required timeframe, as it was submitted over a month late. The MDS Coordinator acknowledged the delay was due to an incomplete audit process, and the facility lacked a specific policy for timely submissions, relying on the RAI Manual guidelines.
The facility failed to conduct care plan conferences for several residents, including those with cognitive impairments, leading to a lack of involvement in care decisions. Additionally, a resident with cerebral palsy did not have updated interventions in their care plan, despite physician orders for specific support measures. Observations confirmed the absence of required support, highlighting a systemic issue in care planning processes.
A facility failed to adhere to physician orders for a resident with cerebral palsy, who required body pillows for torso support due to lack of upper body strength and a gastric feeding tube. Observations revealed the absence of these pillows, and staff interviews indicated a lack of awareness and compliance with the order, potentially risking the resident's safety.
A resident with COPD did not receive proper respiratory care as the nebulizer equipment was not stored in a sanitary manner. The medication chamber was found with medication residue and was not rinsed or bagged as per facility policy. Staff interviews confirmed the failure to follow infection control procedures.
A consultant pharmacist did not identify or report irregularities in a resident's PRN lorazepam prescription, which exceeded the 14-day limit without a documented rationale. Despite facility policy requiring medication regimen reviews, the pharmacist failed to address the issue, and interviews confirmed the absence of necessary documentation.
A facility failed to comply with regulations for PRN antianxiety medication use for a resident with dementia and psychotic disturbance. The resident had a PRN order for lorazepam without a 14-day stop date or documented rationale for extended use. Staff interviews revealed a lack of awareness and documentation regarding these requirements, leading to a deficiency in medication management compliance.
The facility did not post complete daily nurse staffing information, omitting the facility name, census, and total hours worked by nursing staff. Observations and interviews confirmed these omissions, and there was no policy in place to ensure compliance.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to evaluate whether one resident could safely self-administer medication, and the resident administered the incorrect amount of Flonase during observation. The resident was admitted with diagnoses including unspecified allergy and COPD. The physician order for Flonase, written for one spray to each nostril twice daily for allergies, did not indicate that the resident was approved to self-administer the medication. The resident’s care plan contained no problem statement or interventions related to self-administration, and a Self-Medication Report showed no self-medication assessment for the resident. During a medication administration observation, the resident self-administered Flonase after an RN handed the bottle to the resident. The resident blew her nose, shook the bottle, and sprayed two sprays into each nostril. The RN stated the resident could self-administer the nasal spray but had to be monitored during administration, and the RN could not confirm whether the resident had been assessed for self-administration or how to verify it. The ADON later stated residents were assessed for self-medication only if they requested it, and confirmed this resident had not been assessed, did not have a physician order for self-administration, and was not care planned for it.
Call Lights Not Kept Within Reach of Two Residents
Penalty
Summary
The facility failed to ensure call buttons were accessible for two residents. One resident was admitted with diagnoses including paraplegia, weakness, and vascular dementia, had a BIMS score of 2 out of 15 indicating severe cognitive impairment, and was dependent on staff for toileting hygiene, bathing, dressing, personal hygiene, and transfers. Her care plan identified her as at risk for falls or injury related to impaired mobility and included an intervention for the call light to be within reach with prompt response to requests. During observations, her call button was seen hanging on the side rail and dangling through the right handrail, both times out of her reach, and staff confirmed it was not within reach when care was being provided. Another resident was admitted with cerebral palsy, mild vascular dementia, functional quadriplegia, and a left humerus fracture. Her care plan stated she required assistance with ADLs, had reduced ROM to the left hand/fingers and shoulder, and included interventions to place the call light within reach and instruct on its use. During an observation with a family member present, the call button was hanging across the left handrail and was not within the resident’s reach; the resident demonstrated inability to reach it. A nurse later observed the same issue and moved the call light to the resident’s chest near the right hand. Additional observations showed the call button dangling over the left handrail near the floor and still not within reach. The DON stated the call light should be accessible to every resident and that nurses and nursing assistants are responsible for ensuring it is within reach during rounds.
Missing Bed-Hold Notices and Ombudsman Notification
Penalty
Summary
The facility failed to ensure written notices for bed holds and transfers were provided to residents and/or resident representatives and failed to notify the Ombudsman when residents were transferred to the hospital for 4 of 21 sampled residents. Facility policy titled Bed Hold and Returns required residents or resident representatives to be informed in writing of the bed-hold and return policy before transfers, including the rights and limitations regarding bed-holds, reserve bed payment policy for Medicaid residents, and the facility per diem rate for non-Medicaid residents or for holding a bed beyond the state bed-hold period. The Resident Transfer and Discharge Rights policy also required written notice of the reason for transfer or discharge, the effective date, the destination, and notification of the Office of the State Long-Term Care Ombudsman. R1 had diagnoses including pneumonia, Alzheimer’s disease, and atrial fibrillation, and was severely cognitively impaired. After being sent to the ER for evaluation and treatment, the record showed a transfer notice with blank sections for the location, notice recipient, and Ombudsman contact information, and there was no documentation that a bed hold notice was provided. During interviews, the DON stated the family member was mailed a copy, but later confirmed the transfer form did not include the transfer location, documentation that written notice was provided, or that the Ombudsman was notified. The BOM stated R1 was an automatic bed hold because she was Medicaid, but later confirmed no bed hold notice was provided and no documentation could be found that the Ombudsman was notified. For R7, the record showed transfer to the emergency department after a physician order for evaluation following a fall, but the transfer notice did not include a date for Ombudsman review and there was no bed hold notice in the record. For R83 and R94, discharge MDS records showed both residents were discharged to the hospital, and their notices of transfer or discharge contained no information regarding bed hold or any indication that a written bed hold notice had been provided to the resident or resident representative. The BOM stated the SSD called the family and Ombudsman after a resident discharged to the hospital, but this was not documented, and the Administrator stated he was aware bed hold notifications were not being provided to residents or their representatives.
Incomplete Care Planning for Positioning and Feeding Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan directing interventions for positioning for one resident with paraplegia, weakness, vascular dementia, severe cognitive impairment, and an unhealed stage four pressure injury. The resident’s care plan identified that she preferred lying on her back and had been resistive to turning and repositioning at times, with an intervention for a wedge while in bed and positioning with a pillow. However, during observation she was found lying on her back without pillows or a wedge to offload the coccyx area, including during wound care before treatment began. Staff interviews confirmed the absence of the planned positioning devices at the time of care. An LPN stated there was no wedge in use and no wedge in the room, and said the wound could worsen if the coccyx was not offloaded. The WC RN also confirmed the resident did not have a wedge or pillows in place when wound care was initiated. The DON stated that if a resident refused care or would not allow staff to implement interventions, that should be in the care plan, and that the care plan guides staff on how to care for residents. The facility also failed to develop and implement a comprehensive care plan for feeding interventions for another resident with cerebral palsy, dysphagia, GERD, severe cognitive impairment, and dependence on staff for eating. The resident’s diet order required puree and nectar thick liquids with multiple restrictions, and the SLP evaluation stated he often hyperextended his head and neck during meals and required tactile stimulation and holding to the posterior of his head to bring him forward and reduce aspiration risk. Although the care plan addressed altered nutritional status and included feeding assistance, monitoring tolerance, and allowing extra time, it did not include the head-holding intervention, and the Kardex also did not reflect it. During lunch observation, a CNA stood next to the resident while feeding him and held the back of his head; the PTA stated standing while feeding was not safe because the resident could choke, and the DON stated that if staff were to stand while feeding, it should be evaluated by speech therapy and care planned.
Unnecessary Antibiotic Use for UTI
Penalty
Summary
The facility failed to ensure clinical criteria were met before prescribing and administering antibiotics for urinary tract infections for two residents reviewed for unnecessary medications. The deficiency involved Resident 5 and Resident 34, and the record review, interviews, and facility policy review showed that antibiotics were given despite documentation gaps and inconsistent application of the facility’s infection surveillance criteria. For Resident 5, the record showed a history of frequent UTIs and episodes of confusion. Nursing notes documented increased confusion and discomfort with urination, and a physician ordered a catheterized urinalysis with reflex culture and sensitivity. The resident was started on Macrobid, but the urine culture later showed resistance to Macrobid. The antibiotic was then changed to cefuroxime. Later, another episode of increased confusion led to another catheterized urine test, which grew greater than 100,000 cfu/ml of bacteria, and cefuroxime was again ordered. The record also showed a later urine culture with greater than 100,000 growth, but no UTI symptoms were documented in the EMR. The resident stated she had no symptoms and did not know why the test was done. The Infection Preventionist stated the facility used McGeer criteria, but also relied on increased confusion and increased incontinence, while the DON stated altered mental status was not a good reason for a UA and that one day of increased incontinence did not meet criteria for marked increase in incontinence/frequency. For Resident 34, the record showed repeated antibiotic use over many months, including prophylactic Macrodantin for a history of UTIs and additional antibiotic courses for other reasons. The EMR did not contain documentation explaining why prophylactic antibiotic therapy was ordered, such as failed treatments or negative outcomes. The resident’s chart showed no documented UTI symptoms other than confusion in some notes, and the care plan referenced monitoring for urine color, odor, urgency, frequency, or burning. The Infection Preventionist stated she had told the physician that the prophylactic antibiotic was against McGeer criteria, but the physician still prescribed it. The physician stated the prophylactic antibiotic was appropriate because of prior treatments and frequent UTIs, and a letter from the physician stated the resident suffered from chronic urinary infections that necessitated continued prophylactic treatment.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent during observed medication administration, with three errors identified in 47 opportunities for a six percent error rate. The errors affected three residents: R27, R42, and R87. The report states that medication errors have the potential to result in adverse health outcomes. For R27, the physician order for Flonase nasal spray did not indicate that the resident could self-administer, yet RN1 handed the medication bottle to R27, who self-administered two sprays into each nostril while RN1 monitored. For R42, the order for vitamin B12 1000 mcg specified sublingual administration, but LPN4 placed the tablet in a medication cup and administered it by mouth, and the resident swallowed it whole with water. For R87, LPN1 drew sliding scale insulin from an insulin aspart vial that had a handwritten open date of 10/30/25 and end date of 11/28/2025 on the box; the vial itself was not dated. LPN1 stated she misread the dates and believed the insulin had been recently opened. The DON stated nurses were responsible for following the five medication rights and checking expiration dates on all medication packaging before administration.
Failure to Address Allegations of Abuse and Exploitation
Penalty
Summary
The facility administration failed to provide protective oversight to ensure the highest practicable physical and psychosocial well-being of residents. Specifically, the Administrator did not take appropriate action on several allegations of employee-to-resident abuse, exploitation, and injury of unknown origin. These incidents included a personal relationship between a CNA and a resident, an injury of unknown origin, and multiple allegations of abuse by staff members towards residents. The Administrator did not identify these situations as potential abuse or exploitation, failed to investigate or report them, and did not protect the residents involved. The report highlights specific incidents where the Administrator was informed of potential abuse or exploitation but failed to act. For instance, an allegation of exploitation involving a CNA and a resident was not investigated or reported. Additionally, an injury of unknown origin was not addressed, and allegations of abuse by a CNA towards two residents were not investigated or reported. The Administrator acknowledged these incidents as indicative of abuse but admitted to not reporting them timely or investigating them thoroughly, citing misplaced documentation as a reason.
Failure to Protect Residents from Abuse by CNA Staff
Penalty
Summary
The facility failed to protect two residents from abuse by Certified Nursing Assistant (CNA) staff. One resident, identified as R78, who was severely cognitively impaired with a BIMS score of zero, was subjected to verbal and physical abuse during a shower. A CNA reportedly spoke harshly to R78, threw the resident into a shower chair, and threatened to punch the resident if they vomited. The incident was reported by another CNA, but the facility's investigation was inadequate, with no documentation of the outcome, and the abusive CNA continued to provide care to the resident. Another resident, R107, who was cognitively intact with a BIMS score of 15, filed a grievance after being denied access to a bedside toilet over a weekend. The resident was told to use a pull-up instead, despite having received an enema. The grievance was not properly documented, and the CNA involved continued to work with residents. The Director of Nursing (DON) and the Administrator were aware of the incidents but failed to take appropriate action to protect the residents. The facility's noncompliance with abuse prevention policies led to the identification of Immediate Jeopardy, indicating a situation that could cause serious harm to residents. The facility's failure to document and investigate the incidents properly, along with allowing the involved CNA to continue working, demonstrated a significant lapse in ensuring resident safety and compliance with federal regulations.
Failure to Protect Resident from Exploitation by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R71, from exploitation by a Certified Nurse Aide (CNA 1). R71, who was moderately cognitively impaired with a diagnosis of dementia and delusions, was reportedly involved in a personal relationship with CNA 1. The Administrator documented that CNA 1 was spending excessive time with R71, including staying with him until 2:00 am and holding hands, which crossed professional boundaries. Despite being informed of these concerns, CNA 1 was only reassigned to another hall rather than being suspended or further investigated. The situation escalated when R71 attempted to pay his bill with three debit cards, all of which were declined, leading him to express confusion about who was spending his money. Further investigation revealed that CNA 1 was listed as R71's emergency contact on hospital records. Despite these red flags, the Administrator admitted to not thoroughly investigating the allegations of exploitation, dismissing them as rumors. This lack of action and oversight contributed to the facility's noncompliance with protecting residents from exploitation.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of abuse, neglect, and exploitation to the State Survey Agency (SSA) as required by their policy. Specifically, two residents were involved in these incidents. One resident, who was moderately cognitively impaired, was involved in a situation with a Certified Nursing Aide (CNA) who spent excessive time in the resident's room and was observed holding hands with the resident, suggesting a potential exploitation. Additionally, this resident left the facility against medical advice and reported issues with his debit cards being declined, indicating possible financial exploitation. Furthermore, the resident sustained a hip fracture from an injury of unknown origin, which was not reported to the SSA. Another resident, who was cognitively intact, reported that a CNA refused to assist him to the bathroom over a weekend, instructing him to use his pull-up instead. This incident of verbal abuse and neglect was also not reported to the SSA. The facility's Administrator confirmed that these incidents were not reported, which constitutes a failure to comply with the facility's abuse reporting policy and state regulations.
Failure to Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, exploitation, and an injury of unknown origin involving three residents. For one resident, there was a suspected personal relationship with a CNA, which led to neglect of other residents and potential financial exploitation. Despite reassignment of the CNA, there was no evidence of a thorough investigation into these allegations. Additionally, the resident experienced a fall resulting in a hip fracture while on a leave of absence, but the facility did not investigate the injury's origin. Another resident, who was severely cognitively impaired, was reportedly verbally abused by a CNA. Although the administrator claimed to have investigated the incident, the documentation was misplaced, and the CNA continued to provide care without any reported outcome of the investigation. This lack of documentation and follow-up indicates a failure to address the abuse allegations properly. A third resident, who was cognitively intact, reported neglect by the same CNA, who allegedly refused to assist with toileting needs over a weekend. Despite the grievance filed by the resident's family, there was no evidence of an investigation into the abuse allegations. The administrator confirmed the lack of a thorough investigation, highlighting a pattern of inaction in addressing serious allegations of abuse and neglect.
Failure to Resolve Resident Grievance and Lack of Anonymous Submission Process
Penalty
Summary
The facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one resident out of 27 sampled residents. The resident, identified as R107, submitted a grievance form to the Social Services Director, reporting that over a weekend, a Certified Nurse Aide (CNA) did not allow her to use the bedside toilet and instructed her to use her pull-up instead. The resident stated she was kept in bed all weekend and did not get up until the following Monday. The grievance form's investigation section noted that the staff member in charge of the resident claimed the resident was advised against using the toilet due to having had an enema and being tired. However, the sections for 'Action Taken' and 'Person making the complaint has been informed of results' were left blank, indicating a lack of follow-up and resolution. Additionally, the facility did not have a process in place for residents to file grievances anonymously, which could potentially affect all residents. During interviews, the Administrator acknowledged the absence of an anonymous grievance submission process and confirmed that grievances should be directed to the appropriate department for resolution. The Director of Nursing emphasized the importance of completing grievance forms and stated that the Social Services Director would be involved in every grievance. Despite these acknowledgments, the facility's grievance policy was not effectively implemented, as evidenced by the incomplete handling of R107's grievance.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that informed consents were signed prior to the use of bedrails for four of the 27 sampled residents. The policy titled 'Proper Use of Side Rails' requires that consent for side rail use be obtained from the resident or legal representative after presenting potential benefits and risks. However, for residents R1, R45, R72, and R78, there were no signed informed consents found in the electronic medical records (EMR), despite documentation indicating that risks and benefits had been discussed. Resident R1, who was cognitively intact, expressed dissatisfaction with the bed rails, stating that he was not informed of the risks and benefits. Similarly, resident R45, also cognitively intact, reported that no one had reviewed the risks and benefits of the bed rail with him. For residents R72 and R78, who were rarely or never understood, the facility documented discussions with family or representatives, but again, no signed consents were found in the EMR. Observations confirmed the presence of bed rails in use for these residents. The Director of Nursing acknowledged the expectation that alternatives to side rails should be attempted first, and that residents should be assessed and informed of risks and benefits. Despite this, no signed consents were provided for any of the four residents by the time of the exit conference, indicating a failure to adhere to the facility's policy and potentially placing residents at risk of injury, entrapment, or death.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to ensure that expired medications and supplies were removed from their storage areas, which could potentially affect any resident who might be administered these expired items. During an observation in the Blue Hall medication room, several expired medications were found, including Pro-Stat, Co-Q-10, Zinc Sulfate, L-Methylfolate Calcium Tablets, Omeprazole, Pink Bismuth, Saccharomyces Boulardii, Iron supplement liquid, and Centrum Adults. A Registered Nurse confirmed the presence of these expired medications, acknowledging that they should have been given to the Director of Nursing for destruction. Additionally, a Licensed Practical Nurse stated that expiration dates should be checked upon receiving medications from the pharmacy, and that night shift nurses were responsible for checking for expired medications. Further observations revealed expired phlebotomy supplies on a cart located at the nurses' station, including a black top vacutainer tube and a container of light blue top vacutainer tubes. A Registered Nurse verified these items were still available for use. Additionally, a medication cart inspection revealed a card of discontinued oxycodone, which should have been removed the day it was discontinued. The Director of Nursing confirmed that expired medications should not be available for use and should be removed immediately.
Consistent Delays in Meal Service for Residents
Penalty
Summary
The facility failed to serve meals according to resident preferences and designated meal times for 50 residents on the green and pink halls. Observations and interviews revealed that lunch trays were consistently delivered late, sometimes as late as 2:15 pm, despite the designated meal time being 12:00 pm. Residents, including those with medical conditions such as diabetes and acid reflux, expressed concerns about the impact of late meals on their health. Staff interviews confirmed the consistent delay in meal delivery, with some trays arriving as late as 3:00 pm, which interfered with their ability to complete other resident care tasks. The Registered Dietician and Dietary Manager acknowledged the designated meal times but did not provide a policy for meal service. The Dietary Manager cited a lack of communication between nursing and dietary staff as a reason for the delays. The Director of Nursing stated that meal service should be timely throughout the day. Unit Managers were unaware of the extent of the delays and agreed that receiving meals at 2:00 pm was too late, impacting other resident care. Family members also noted the late meal service, expressing concern for their relatives' well-being.
Failure to Inspect Bed Rails for Safety
Penalty
Summary
The facility failed to ensure the safety of bed rails for 90 out of 104 resident beds, which could potentially lead to serious injury due to entrapment or other resident injuries. The policy titled Proper Use of Side Rails, revised in December 2016, mandates that the space between the mattress and side rails be assessed to reduce the risk of entrapment. However, the facility's Nursing Home Inspection Report Upon Receipt of Equipment, which is completed annually, did not include a review of bed rails for secure attachment or gaps, as recommended by the FDA guidelines. Interviews conducted during the survey revealed that the maintenance staff did not perform safety checks on beds with side rails. The Director of Nursing confirmed that the expectation was for maintenance to inspect the beds, including bedrails, for safety and security. A list compiled by a Restorative Nurse Aide indicated that 90 residents had one or two side rails on their beds, highlighting the widespread nature of the issue within the facility.
Failure to Assist Resident in Obtaining Voting Identification
Penalty
Summary
The facility failed to assist a resident, identified as R56, in obtaining identification necessary for voting, which compromised the resident's right to vote. R56, who was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), expressed the need for assistance in renewing his identification card to vote. During an interview, R56 stated that he had previously attempted to vote with a copy of his identification card, which was not accepted, resulting in his vote not being counted. Despite the resident's request for help, the Activities Director (AD) acknowledged awareness of the need but had not taken any action to assist R56 until later. The Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the AD was responsible for ensuring the resident's identification card was updated.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to three residents (R1, R72, and R101) or their representatives during emergent hospital transfers. This deficiency was identified through record reviews and interviews, revealing that the facility did not comply with its own policy, which mandates written notification containing specific information such as the reason for transfer, effective date, location, appeal rights, and contact details for the State Long Term Care Ombudsman. The Director of Nursing and staff were unaware of the requirement for written notices, as they only informed residents and their families verbally. Resident R1, who was cognitively intact, was transferred to the hospital due to a change in mental status and other symptoms, but neither he nor his representative received a written notice. Similarly, R72 was transferred following a change in mental status and other symptoms, with only a phone notification to the representative. R101 was sent to the ER for labored breathing without a written notice provided to him or his representative. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the lack of written notifications, indicating a systemic issue in the facility's transfer process.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure that an annual Minimum Data Set (MDS) assessment for a resident was submitted within the required 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System. The deficiency was identified during a review of the resident's assessment data, which revealed that the assessment reference date (ARD) for the last comprehensive MDS was 4/11/2024, but it was not submitted until 5/30/2024. This delay was confirmed by the MDS Coordinator, who acknowledged that the assessment was closed and the care plan signature was present, but the final audit to close it was not completed, leading to the late submission. The MDS Coordinator and the Director of Nursing (DON) both confirmed that the facility did not have a specific policy regarding the timely submission of assessments, relying instead on the guidelines provided in the Resident Assessment Instrument (RAI) Manual. The lack of a formal policy contributed to the oversight, as the MDS Coordinator did not notice the incomplete audit process that delayed the submission. This deficiency had the potential to adversely affect the care planning and provision for the resident involved, as timely and comprehensive assessments are crucial for ensuring appropriate care.
Failure to Conduct Care Plan Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure that care plan conferences were scheduled and conducted for three residents, leading to a lack of involvement in care decisions and potential unmet care needs. Resident 56, who was cognitively intact, was admitted with hemiparesis and had only one care plan conference since admission, which did not involve him in planning his care. Resident 44, also cognitively intact, was admitted with dementia and seizure disorder and had only two care plan conferences since admission. Resident 17, with Alzheimer's Disease and moderate cognitive impairment, had only one care plan conference since admission. During a group interview, several residents, including Residents 44 and 17, expressed that they had never been invited to a care plan conference and were unaware of their existence. Additionally, the facility failed to update the comprehensive care plan for Resident 3, who was admitted with cerebral palsy and required specific interventions for torso support due to a lack of upper body core strength and a gastric feeding tube. Despite physician orders for bilateral body pillows to be placed under the fitted sheet for support, observations revealed that Resident 3 was in bed without the pillows on multiple occasions. The MDS Coordinator acknowledged the lack of care plan conferences since COVID and mentioned that a new process would be implemented. The Director of Nursing was unaware of the issue until it was brought to her attention, indicating a systemic failure in conducting care plan conferences.
Failure to Follow Physician Orders for Resident Positioning
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with cerebral palsy, who required bilateral body pillows for torso support due to lack of upper body core strength and the presence of a gastric feeding tube. The physician order, dated 9/21/2023, specified that the body pillows should be placed under the fitted sheet when the resident was in bed to help maintain an upright position and potentially prevent aspiration. However, during multiple observations on 6/5/2024 and 6/6/2024, the resident was found in bed without the body pillows in place. Interviews with facility staff revealed a lack of awareness and adherence to the physician's order. A CNA and an LPN both stated they were unaware of the requirement for body pillows under the fitted sheet, and neither had placed them for the resident. Another LPN acknowledged awareness of the order but could not explain why the pillows were not in place or when they had been removed. This oversight in following the physician's orders had the potential to put the resident at risk of aspirating.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The deficiency was identified through observations, record reviews, and interviews. The facility's policy on the prevention of infection associated with respiratory tasks and equipment was not followed. Specifically, the nebulizer equipment used by the resident was not stored in a sanitary manner. The nebulizer medication chamber was observed to still contain medication and was not rinsed or stored in a plastic storage bag as required by the facility's policy. Interviews with the resident and staff revealed that the nebulizer equipment was placed in a basket behind the resident's bed without being rinsed. The resident mentioned that initial instructions included boiling the mouthpiece and medication chamber after use, which was not being done. A registered nurse confirmed the improper handling of the equipment, acknowledging that it should have been rinsed, dried, and bagged after use. The Director of Nursing also stated that the equipment should be washed with soap and water, dried, and stored in a bag after each use, which was not adhered to in this instance.
Pharmacist Fails to Address PRN Lorazepam Irregularity
Penalty
Summary
The consultant pharmacist failed to identify and report irregularities in the medication regimen review for a resident prescribed PRN lorazepam beyond the 14-day limit without a documented rationale or duration for its continued use. The facility's policy requires the pharmacist to conduct medication regimen reviews and make recommendations based on the resident's health record. However, the pharmacist did not address the lack of a 14-day stop date or request a rationale from the physician for the continued use of lorazepam. The resident, who was admitted with a diagnosis of dementia, had a BIMS score indicating no cognitive impairment and was receiving antianxiety medications. Despite the ongoing prescription for lorazepam, the resident's medication regimen reviews from May 2023 to May 2024 did not include any recommendations from the pharmacist. Interviews with the physician and LPN confirmed the absence of documentation regarding the rationale for the continued use of lorazepam, and the pharmacist acknowledged that the monthly reviews did not address this issue.
Failure to Document Rationale for Extended PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to adhere to regulations regarding the use of PRN orders for antianxiety medication, specifically lorazepam, for a resident diagnosed with dementia and psychotic disturbance. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a PRN order for lorazepam 0.5 mg three times a day for anxiety, dated from May 9, 2023. The facility's policy requires a 14-day stop date for PRN orders of antianxiety medications, but this was not implemented, and there was no documented rationale for extending the PRN order beyond this period. Interviews with facility staff, including a registered nurse, a physician, and a pharmacist, revealed a lack of awareness and documentation regarding the necessity of a 14-day stop date and the requirement for a documented rationale for continued use. The physician acknowledged the need for documentation due to the resident's Parkinson's disease and related anxiety but had not recorded this justification in the progress notes. The pharmacist was aware of the 14-day requirement but did not address it, leading to a deficiency in the facility's compliance with medication management regulations.
Deficiency in Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted included essential details such as the name of the facility, the facility census, and the total number and actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. During an observation, it was noted that the staffing grid chart displayed in the lobby only showed the number of staff for each category across three shifts but lacked the required information. A review of previous months' postings revealed similar omissions. Interviews with the Human Resources staff and the Director of Nursing confirmed the absence of a policy regarding nurse staff posting and acknowledged that the postings did not meet the expected requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hiawassee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clay County Health And Rehabilitation | 7.4 mi | ★★★★★ | 11 | 0 |
| Union County Nursing Home | 12.7 mi | ★★★★★ | 3 | 0 |
| Valley View Care And Rehabilitation | 17.9 mi | ★★★★★ | 7 | 0 |
| Mountain View Health Care | 20.9 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab | 22.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.