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 Chulio Hills Health And Rehab during CMS and state inspections, most recent first.
Failure to Notify Physician and Family of Resident’s Decline: A resident with multiple chronic conditions developed several days of nausea, vomiting, poor PO intake, weakness, and overall decline, but the record showed no timely MD/NP notification or increased monitoring before an unwitnessed fall. Therapy and nursing notes documented ongoing symptoms, yet only one-time Zofran was given and vital signs were not recorded during the decline. The resident later fell while vomiting, sustained facial and cervical injuries, and was hospitalized with severe electrolyte abnormalities, AKI, aspiration pneumonia/pneumonitis, respiratory failure, septic shock, and prolonged critical illness.
A resident with intact cognition, high fall risk, and multiple mobility and medical issues developed several days of nausea, vomiting, poor intake, weakness, and decline, but the record showed no timely comprehensive assessment, vital sign monitoring, or provider escalation. Nursing and therapy notes documented ongoing symptoms, meal refusals, and limited treatment with ondansetron, yet there was no clear follow-through before the resident had an unwitnessed fall while trying to vomit in the bathroom and was sent to the hospital with serious injuries and severe metabolic abnormalities.
Failure to Protect a Resident from Sexual Abuse: A resident with moderate cognitive impairment and dependence for ADLs was kissed on the mouth by another resident while lying in bed. Staff observed the interaction, removed the other resident, and the resident stated the contact was unwanted and non-consensual and that she could not express no. The other resident admitted to the kissing and minimized the behavior despite knowing the resident could not consent.
Surveyors found that the facility did not maintain a clean and safe environment, with dust-like buildup on ceiling vents and unrepaired ceiling tiles in several halls and common areas. The Administrator, ADON, and DON confirmed the dust accumulation, which could trigger respiratory issues in residents with pre-existing conditions. The Maintenance Director stated that vent cleaning was scheduled quarterly but had not identified the issue during daily rounds.
A resident with multiple medical conditions and recent weight loss began refusing meals and medications, representing a significant change in status. Despite facility policy requiring prompt notification, neither the responsible party nor the Registered Dietician were informed of these ongoing refusals. Staff interviews confirmed the change was new and significant, but documentation and communication to all relevant parties did not occur.
A resident receiving hospice care was not accurately coded as such on the Quarterly MDS assessment, as required. Review of facility policy revealed it did not provide guidance for accurate coding of hospice services, and staff interviews confirmed the omission, which affected the accuracy of the resident's care plan.
A resident with multiple respiratory diagnoses and severe cognitive impairment did not have a care plan addressing oxygen use or respiratory conditions, despite physician orders and MDS documentation indicating the need for oxygen therapy. Staff confirmed the omission and acknowledged the importance of accurate care planning for directing resident care.
A resident with multiple complex medical conditions and severe cognitive impairment, who was fully dependent for care and bed-bound, developed a pressure ulcer during a respite stay. The facility failed to consistently assess, monitor, and document the resident's skin condition, and did not provide or document required wound care after a pressure ulcer was identified, despite physician orders and facility policy requiring such interventions.
A resident with respiratory failure and CHF was not provided oxygen therapy at the physician-ordered rate of 2 LPM via nasal cannula. Observations and staff interviews confirmed the oxygen concentrator was set below the prescribed rate, contrary to facility policy and physician orders. Nursing staff did not ensure the correct flow rate was maintained.
Two residents were not instructed to rinse and spit after receiving corticosteroid inhalers, resulting in a medication error rate above 5%. LPNs failed to follow facility policy and manufacturer instructions, despite clear labeling on the medication packaging. Interviews confirmed staff awareness of the requirement, but the step was omitted during observed medication passes.
A resident with a history of stroke and difficulty eating was not consistently provided with physician-ordered built-up utensils at mealtimes, despite clear documentation and facility policy. The resident often had to request the adaptive equipment from staff, resulting in delays and cold food, as observed and confirmed by staff interviews.
Staff failed to follow infection prevention protocols, including an LPN removing a glove box from a resident's room after wound care and a maintenance assistant not using PPE or performing hand hygiene when exiting a Contact Precautions room for candida auris. The facility also did not review or update its Infection Prevention and Control Program policy annually as required.
The facility failed to maintain an adequate Surety Bond to cover the resident trust fund account balance for three months. The bond was set at $80,000.00, while the account balances exceeded this amount in February, May, and July 2024. The Administrator confirmed the discrepancy and was unsure why the bond amount was not adjusted. The bond amount was based on past balances as recommended by the bond company, potentially affecting 62 residents.
The facility failed to ensure the Dietary Manager was certified in dietary or food service management, as required by policy and CMS guidelines. The DM, promoted from a dietary cook, lacked necessary certifications, although she was in the process of obtaining them. The Administrator expected the DM to obtain Serve Safe certification and eventually become a Certified Dietary Manager, but this had not been achieved. The facility did not use a DM from sister facilities for oversight, and the Registered Dietitian provided monthly guidance.
The facility failed to label and date food items in the dry storage and resident nourishment room, leading to unlabeled grits and resident food items. Ice build-up was found on open strawberries in the walk-in freezer. Additionally, improper sanitization procedures were observed, with dishware submerged for less time than required in the sanitizing solution.
The facility failed to implement a 14-day stop date for psychotropic medications for four residents, as required by its policy. Residents were administered lorazepam and Ativan without a documented stop date, leading to a deficiency in medication management. Despite daily reviews of new orders, the oversight occurred, and the DON acknowledged the error, stating that medications should have been reassessed before reordering.
A facility failed to refer a resident with anxiety and depressive disorders for a PASARR level two review, as required by policy. The resident was cognitively intact and on anti-anxiety and antidepressant medications. The Social Service Director did not resubmit the PASARR, believing it unnecessary due to the primary diagnosis not being a mental health issue. The Administrator expected reviews for major mental health diagnoses, but this was not done, leading to a deficiency.
A medication cart was found unlocked and unattended in a hallway, accessible to residents and unauthorized individuals. The responsible RN acknowledged the oversight, and the facility's policy requires carts to be locked when unattended. The DON noted uncertainty about night shift staff receiving relevant education.
A CNA failed to follow infection control protocols for a resident on Enhanced Barrier Precautions (EBP) due to an indwelling catheter. The CNA used the same washcloth for different body areas and did not change the basin water, contrary to facility policy. Additionally, the CNA did not wear a gown as required, despite signage and training indicating the need for PPE during high-contact care activities.
Failure to Notify Physician and Family of Resident’s Decline
Penalty
Summary
The facility failed to ensure timely physician and responsible party notification when a resident experienced a significant decline in condition before an unwitnessed fall and hospitalization. The resident was admitted with multiple chronic conditions, including cognitive communication deficits, generalized weakness, hypertension, myasthenia gravis, difficulty walking, impaired coordination, multiple orthopedic conditions, blindness in one eye, and need for assistance with personal care. The resident’s care plan identified high fall risk related to impaired mobility, weakness, impaired coordination, visual impairment, prior falls, polypharmacy, dizziness risk, and myasthenia gravis. In the days before the fall, documentation from therapy, nursing, and meal records showed persistent nausea, vomiting, decreased appetite, poor oral intake, weakness, and a general decline in condition. Therapy notes repeatedly documented nausea and low energy, and nursing documentation showed a one-time dose of ondansetron was given for nausea. However, the record did not show ongoing assessment, provider notification, or increased monitoring despite continued symptoms over several days. Vital signs were not recorded between 2/16/2026 and 2/19/2026, even though the resident was symptomatic and declining, and the only communication record entry related to the resident was after the fall. On the evening of the fall, the resident was reported to have been vomiting, felt unwell, and was carrying a basin while attempting to vomit into the toilet when she became entangled in her pant leg and fell. She sustained facial swelling, an eye injury, laceration, and bruising to the neck, and EMS transferred her to the hospital. Hospital records showed facial fractures, a closed odontoid cervical spine fracture, severe hyponatremia, hypokalemia, acute kidney injury, aspiration pneumonia/pneumonitis, acute hypoxemic respiratory failure requiring intubation, septic shock, and prolonged critical illness. Interviews with staff and the resident’s daughter confirmed that the resident had been feeling unwell for several days, that staff were aware of the symptoms, and that the daughter was not notified of the resident’s decline before the fall.
Failure to Assess and Escalate Progressive Nausea, Vomiting, and Decline
Penalty
Summary
The facility failed to ensure timely assessment, monitoring, escalation, and clinical management of a resident who developed a progressive change in condition marked by repeated nausea, vomiting, weakness, and poor oral intake before an unwitnessed fall and hospitalization. The resident had a BIMS score of 14, required assistance with ADLs, used a walker and wheelchair, and was identified as high risk for falls. Her care plan included interventions for fall risk, weakness, fatigue, impaired balance, and monitoring for adverse medication effects, but the record showed repeated symptoms of nausea and decline without documented comprehensive assessment or escalation. Review of therapy notes, nursing documentation, CNA interviews, and the resident’s intake records showed several days of nausea, vomiting, abdominal discomfort, decreased appetite, meal refusals, and reduced intake. The resident was documented as not feeling well, nauseated, and having abdominal pain, and staff noted she requested Zofran and was drinking fluids. A one-time dose of ondansetron was given, and one nursing note stated the MD was aware and to continue the order, but the record did not show ongoing assessment, provider notification, or monitoring of the continued symptoms. Vital signs and blood pressure monitoring were not documented during the period of decline, despite the resident’s worsening condition. On the evening of the fall, the resident was found on the bathroom floor after an unwitnessed fall while attempting to vomit into the toilet and becoming entangled in her pant leg. Nursing documentation described facial swelling, eye injury, laceration, and bruising to the neck, and EMS transported her to the hospital. Hospital records showed severe hyponatremia, hypokalemia, acute kidney injury, weakness, continued vomiting, facial fractures, and a closed odontoid cervical spine fracture, followed by aspiration, respiratory failure, ICU admission, septic shock, and death after withdrawal of life support. The record also showed no timely physician or NP notification, no documented change-in-condition follow-through, and no evidence of increased monitoring before the hospitalization.
Failure to Protect a Cognitively Impaired Resident from Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to ensure a resident remained free from sexual abuse when another resident entered her room and kissed her on the mouth without consent. The resident involved had a history of left-sided hemiplegia/hemiparesis following a cerebral infarction, seizure disorder, dysphagia, cognitive communication deficit, and generalized muscle weakness and wasting. Her MDS reflected a BIMS of 11, indicating moderate cognitive impairment, and her care plan identified her as high risk for abuse and non-consensual interactions because of impaired communication, cognitive deficits, and dependence on staff for ADLs. On the day of the incident, a CNA observed the other resident inside the resident’s room while she was lying in bed and saw him kissing her on the mouth. Staff immediately removed him from the room and initiated an abuse investigation. During interviews, the resident stated the kiss occurred on her lips, described it as a wet kiss, and said it was unwanted and non-consensual. She also reported feeling uncomfortable with the other resident being in her room and said she did not know how to express no. The other resident admitted to kissing her and acknowledged he knew the conduct was wrong because of her cognitive impairment. The resident was interviewed by facility leadership and law enforcement, and documentation reflected that she later received behavioral health services related to the incident. The other resident had a BIMS of 15 and was cognitively intact, but his care plan had included prior goals related to consensual intimacy and sexual expression with another resident. After the incident, he was noted to be non-receptive to redirection and stated he believed his actions were acceptable. Law enforcement responded to the facility, interviewed both residents, and arrested him after determining the contact was inappropriate and non-consensual.
Failure to Maintain Clean and Safe Environment Due to Dust Accumulation and Damaged Ceiling Tiles
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, including the 100, 200, and 300 Halls, the common area near the nurse station, and the lobby. Specifically, there was a delay in repairing damaged ceiling tiles and a noticeable accumulation of dust-like material on ceiling vents. The facility's policy on cleaning and disinfection required regular cleaning of environmental surfaces and wet dusting of horizontal surfaces with EPA-registered disinfectant, but these standards were not met as evidenced by the visible dust and unrepaired ceiling damage. During interviews and observations with the Administrator, ADON, and DON, all confirmed the presence of dust accumulation on vents throughout the facility, acknowledging that such buildup could provoke allergic reactions and respiratory distress in residents with pre-existing respiratory conditions. The Maintenance Director reported that vent cleaning was scheduled every three months and monitored through the TELS system, but admitted he had not noticed the dust accumulation during his daily rounds. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Notify Responsible Party and Dietician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party and the Registered Dietician (RD) of a significant change in a resident's condition, specifically regarding ongoing refusals of meals and medications. The resident, who had a history of hypertension, cognitive impairment, dysphagia, chronic kidney disease, and recent abnormal weight loss, began refusing meals and medications over several days. Documentation showed that the resident consumed less than 25% of meals or refused them entirely on multiple occasions, and also refused several doses of prescribed medications. Despite these changes, there was no documentation that the resident's representative or the RD were informed of the ongoing refusals and significant change in status. Staff interviews confirmed that the resident's behavior of refusing meals and medications was new and represented a significant change from previous patterns. The LPN stated that refusals were documented and the physician was notified, but the RD was not informed. The RD herself confirmed she was unaware of the refusals and would have reassessed the resident's nutritional plan had she been notified. The resident's representative also reported not being informed about the refusals and was unaware of the change in the resident's condition until contacted by surveyors. Facility policy required prompt notification of the resident, physician, and representative of significant changes in condition, including those requiring alterations in treatment. However, interviews with staff, including the MDS RN, Infection Preventionist/Unit Manager, DON, and Administrator, revealed inconsistent understanding and application of these policies. The lack of notification to the RD and responsible party was not documented, and staff acknowledged the importance of such communication but failed to ensure it occurred in this case.
Quarterly MDS Assessment Failed to Reflect Hospice Services
Penalty
Summary
The facility failed to accurately complete the Quarterly Minimum Data Set (MDS) assessment for one resident who was receiving hospice services. Review of the facility's policy on Maintaining Minimum Data Set (MDS) Assessments showed that it addressed record maintenance and retention but did not provide guidance to ensure accurate coding of services, such as hospice care, on Quarterly MDS assessments. The electronic medical record indicated that the resident was admitted to hospice services, but the corresponding Quarterly MDS assessment did not reflect this in section O, which covers Special Treatments, Procedures, and Programs. Staff interviews confirmed that hospice services were not coded on the assessment, and both the MDS RN and DON acknowledged the importance of accurate MDS coding for care planning.
Failure to Develop and Implement Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with multiple respiratory diagnoses, including Alzheimer's Disease, COPD, respiratory failure, asthma, and heart failure. Despite the resident's Minimum Data Set (MDS) assessment indicating severe cognitive impairment and the need for oxygen therapy, the care plan did not include any problems or interventions related to respiratory conditions or oxygen use. Physician's orders documented the need for oxygen administration at 2 L/min via nasal cannula, weekly changes of oxygen tubing, weekly cleaning of the oxygen concentrator filter, and elevating the head of the bed for shortness of breath, but these were not reflected in the care plan. Observations confirmed that the resident was using oxygen as ordered, but interviews with the resident revealed uncertainty about the frequency of oxygen use. Staff interviews, including with the MDS RN and DON, confirmed that the care plan was missing required information regarding oxygen use and respiratory diagnoses. The MDS RN acknowledged that the omission was an oversight and emphasized the importance of accurate MDS coding for care planning. The DON also confirmed that the care plan should direct all aspects of resident care and must be accurate.
Failure to Prevent and Treat Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to ensure that appropriate pressure ulcer prevention interventions were initiated, implemented, monitored, and documented for a resident identified as being at risk for pressure injuries, who developed a pressure ulcer during their stay. The facility's policy required comprehensive skin assessments upon admission and weekly for four weeks, as well as head-to-toe skin observations during showers and regular repositioning for bed-bound residents. However, documentation revealed that only limited skin assessments were completed during the resident's five-day respite stay, with no evidence of consistent monitoring or timely intervention when skin changes were noted. The resident in question was admitted for respite care with multiple complex medical conditions, including morbid obesity, acute respiratory failure, chronic heart failure, peripheral vascular disease, and severe cognitive impairment. The care plan indicated the resident was bed-bound, fully dependent for all activities of daily living, and required total assistance with bed mobility and self-care. Despite these risk factors, the electronic medical record showed that only two skin assessments were documented, and there was no evidence of regular repositioning or implementation of other pressure ulcer prevention measures as outlined in the facility's policy. When a pressure ulcer was identified on the resident's left heel, a physician's order for wound care was written, but there was no documentation that the treatment was provided or that the order was carried out. Interviews with staff confirmed that wounds should be reported and treated promptly, but no treatment notes or interventions were found in the record. Additionally, there was no documentation of care plan updates or evidence that staff addressed difficulties with repositioning the resident, despite reports of such challenges. This lack of assessment, intervention, and documentation contributed to the development and lack of treatment for the pressure ulcer.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of respiratory failure, hypoxia, pneumonia, and congestive heart failure was not administered oxygen therapy in accordance with the physician's orders. The resident's care plan specified continuous oxygen via nasal cannula at 2 liters per minute (LPM). However, multiple observations revealed that the oxygen concentrator was set below the prescribed 2 LPM, with flow rates recorded between 1.5 and 2 LPM. Staff interviews confirmed that the oxygen flow was not consistently set to the ordered rate, and the concentrator's marker was not properly aligned with the prescribed setting. Facility policy required nurses to initiate oxygen use as ordered, label tubing, and ensure orders for filter cleaning and humidification were entered into the system, as well as to check oxygen saturations as ordered by the physician. Despite these requirements, staff did not ensure the oxygen concentrator was set to the correct flow rate. Both the ADON and DON acknowledged that the oxygen was not set according to the physician's order and that nurses are responsible for monitoring and adjusting concentrators as needed.
Failure to Ensure Proper Administration of Corticosteroid Inhalers
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and manufacturer instructions. During 35 observed medication administration opportunities, two medication errors were identified, resulting in a 5.71% error rate. Specifically, during two separate medication passes, nursing staff did not instruct residents to rinse and spit after administering corticosteroid inhalers, despite clear facility policy and manufacturer instructions requiring this step. Both inhaler boxes had bright green notes stating, "Rinse mouth thoroughly after each use," but this directive was not followed during the observed administrations. Interviews with the involved LPNs revealed uncertainty and forgetfulness regarding the requirement to provide water and instruct residents to rinse and spit after inhaler use. The pharmacist confirmed that rinsing the mouth after using inhaled corticosteroids is necessary to prevent oral candidiasis and stated that staff were alerted to this requirement through labeling on the medication packaging. The DON and ADON also acknowledged that mouth rinsing is recommended for steroid inhalers and that staff were expected to encourage this practice, as indicated on the medication packaging.
Failure to Provide Required Feeding Adaptive Equipment at Meals
Penalty
Summary
Staff failed to provide a resident with the required feeding adaptive equipment at each meal, despite a physician's order and clear documentation on the resident's meal card indicating the need for built-up utensils. The resident, who had a history of stroke and significant difficulty eating without adaptive equipment, reported that the specialized utensils were usually missing from her meal tray. On multiple observed occasions, the resident's tray was delivered without the necessary adaptive device, and she had to request assistance from a CNA to obtain it, resulting in her food becoming cold before she could eat. Review of facility policy confirmed that residents should be assessed for adaptive equipment and provided with it as needed to facilitate independence. Interviews with the Dietary Manager and Administrator confirmed that there were sufficient devices available and that staff were expected to provide them when ordered by a physician. However, observations and interviews demonstrated that the process was not consistently followed, leading to the resident not receiving the required adaptive equipment at mealtimes.
Failure to Maintain Infection Control Practices and Policy Review
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices as evidenced by multiple observed breaches and lack of policy review. During wound care, an LPN brought a full box of gloves into a resident's room, used gloves from the box, and then removed the same box for use with other residents, despite acknowledging that this practice could create a contamination risk. Additionally, a maintenance assistant exited a room under Contact Precautions for candida auris without wearing required PPE (gown or gloves) and did not perform hand hygiene after leaving the isolation room. The assistant also indicated a lack of knowledge regarding infection prevention protocols and had not received relevant training. Further review revealed that the facility's Infection Prevention and Control Program policy, last revised in October 2018, had not been reviewed or updated annually as required by the facility's own policy. Staff interviews confirmed that all personnel are expected to adhere to PPE and hand hygiene protocols, and that glove boxes used in resident rooms should not be removed to prevent cross-contamination. These failures were identified through observations, staff and resident interviews, and record review.
Inadequate Surety Bond Coverage for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for three of the six months reviewed. The Surety Bond was set at $80,000.00, which was insufficient to cover the ending balances of the resident trust fund account for February, May, and July 2024, which were $92,715.87, $93,849.05, and $95,520.15, respectively. This discrepancy was identified through a review of the facility's bank statements and the facility's policy titled 'Resident Trust Fund Accounting Policies and Procedures.' The Administrator confirmed the Surety Bond amount and the resident trust fund balances during an interview. She expressed uncertainty as to why the bond amount was not adjusted to exceed the highest monthly balance. The facility's Corporate Human Resources had based the bond amount on the resident trust fund balances from August 2021 to January 2022, as recommended by the bond company. This oversight had the potential to adversely affect the finances of 62 residents with trust fund accounts managed by the facility.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the staff designated as the Dietary Manager (DM) was certified in dietary or food service management, as required by their policy and CMS guidelines. The DM, who was promoted from a dietary cook position, did not possess any dietary certifications at the time of the survey. Although the DM was in the process of obtaining certification, she had not yet completed the necessary test. The facility policy required the DM to maintain current Serve Safe Food Handler certification and obtain Certified Dietary Manager (CDM) certification, which had not been fulfilled. The Administrator acknowledged that there was an expectation for the DM to at least obtain the Serve Safe Food Manager certification and eventually become a Certified Dietary Manager. However, the facility was not utilizing a DM from any sister facilities to assist with dietary oversight. The Registered Dietitian visited the facility once a month to provide dietary guidance, but the lack of a certified DM on staff at the time of the survey constituted a deficiency in meeting the required standards for food and nutrition services.
Deficiencies in Food Labeling, Storage, and Sanitization Procedures
Penalty
Summary
The facility failed to adhere to its policies regarding food labeling and storage, as well as proper sanitization procedures, leading to several deficiencies. In the dry storage area, an opened five-pound bag of grits was found without an open date, which was confirmed by the Dietary Manager (DM) as a failure to follow the facility's policy. In the walk-in freezer, an open case of frozen strawberries was observed with ice build-up on top, which the DM acknowledged was due to the air condenser's issues and confirmed that dietary staff had been removing the ice as needed. Additionally, in the resident nourishment room, several food items, including Styrofoam containers and frozen pizzas, were found without resident names or dates, which the DM and Administrator confirmed was the responsibility of the nursing staff, who had been previously educated on this requirement. Furthermore, the facility did not demonstrate proper sanitization procedures in the three-compartment sink. The dietary cook was observed submerging dish items in a quaternary sanitizing solution for only 20-30 seconds, contrary to the posted instructions that required at least one minute of immersion. The DM confirmed the discrepancy between the cook's practice and the posted guidelines, acknowledging that the dietary staff should have adhered to the one-minute immersion time as indicated by the posters above the sink.
Failure to Implement Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to implement a stop date not exceeding 14 days for psychotropic medications for four residents, leading to a deficiency in medication management. The facility's policy requires that PRN orders for psychotropic drugs are limited to 14 days unless the prescribing practitioner documents a rationale for extending the order. However, the review of medical records revealed that residents were administered lorazepam and Ativan without a documented stop date, contrary to the facility's policy. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) Unit Managers indicated that the oversight occurred despite daily reviews of new medication orders. For instance, one resident had an order for lorazepam with an indefinite end date and was administered the medication multiple times over a month. Another resident had a similar order for lorazepam for agitation, also without a stop date, and was administered the medication on several occasions. The DON acknowledged the lack of stop dates and stated that the medication should have been reassessed before reordering. The facility's failure to adhere to its policy on psychotropic medication orders resulted in the deficiency identified by the surveyors.
Failure to Refer Resident for PASARR Level Two Review
Penalty
Summary
The facility failed to refer a resident for a preadmission screening and resident review (PASARR) level two, as required by their policy. The resident, identified as R33, was admitted with diagnoses including general anxiety disorder and major depressive disorder. Despite these diagnoses, the facility did not resubmit a PASARR for a level two review. The facility's policy mandates that any resident with a newly evident or possible serious mental disorder, intellectual disability, or related condition should be referred for a level two review. However, the Social Service Director did not believe a level two PASARR was necessary for R33, as the primary diagnosis was not considered a mental health diagnosis. Observations of R33 showed that she was cognitively intact, with no signs of depression or psychosis, and was receiving anti-anxiety and antidepressant medications. Interviews revealed that the facility was in the process of changing mental health service providers, and R33 was not currently receiving psychiatric services. The Administrator stated that the expectation was for the Social Service Director to review each resident's diagnosis and resubmit the PASARR for a level two review if a major mental health diagnosis was present. The failure to obtain a level two PASARR for R33 was identified as a deficiency, potentially placing the resident at risk for improper placement and inadequate mental health care.
Unattended Medication Cart Found Unlocked
Penalty
Summary
The facility failed to ensure that one of three medication carts was locked and secured when left unattended by a nurse, as observed during an initial tour. The medication cart was found unlocked and unattended in a hallway, with its drawers facing the hallway, making it easily accessible to residents, unauthorized staff, and visitors. A registered nurse (RN) responsible for the cart walked by it twice without securing it, and a resident was observed self-propelling past the cart. Upon being interviewed, the RN acknowledged the cart was unlocked and unattended but declined further comment. The facility's policy on medication storage requires that medication carts be locked or attended by authorized personnel. Interviews with the Administrator and the Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when unattended. The DON mentioned that a pharmacy consultant conducted random audits and provided monthly education to nursing staff, but there was uncertainty about whether night shift nurses received this education. The failure to lock the medication cart increased the risk of unauthorized access to medications.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques while providing care to a resident on Enhanced Barrier Precautions (EBP). The facility's policy required staff to change the basin water, use a clean washcloth, perform hand hygiene, and don new gloves after washing and before rinsing the resident. Additionally, the policy specified that cleaning should begin at the face and work over the body, with the groin and buttocks cleaned last. However, during an observation, a Certified Nursing Assistant (CNA) did not follow these guidelines. The CNA used the same washcloth to clean the resident's catheter site, groin area, and entire front body, and used the same basin of water for washing and rinsing. Furthermore, the CNA did not don a gown while providing the resident with a bed bath, incontinent care, linen change, and dressing, despite the resident being on EBP due to an indwelling catheter. The CNA admitted to not wearing a gown and was unaware of the requirement to use PPE when caring for residents with Foley catheters, feeding tubes, PICC lines, or IVs. The CNA also stated she did not see the sign on the resident's door indicating EBP and had never read it. The Infection Control Preventionist (ICP) confirmed that staff were expected to wear gowns and gloves when providing care to residents on EBP and that all staff had received training on EBP. The ICP also stated that signs were posted on residents' rooms indicating the required PPE. Despite this, the CNA did not follow the proper procedures, leading to a potential risk of spreading infection within the facility.
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Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Health And Rehabilitation Center | 5.8 mi | ★★★★★ | 10 | 0 |
| Winthrop Health And Rehabilitation | 6 mi | ★★★★★ | 4 | 0 |
| Etowah Landing | 8.1 mi | ★★★★★ | 7 | 0 |
| Fifth Avenue Health Care | 8.4 mi | ★★★★★ | 9 | 0 |
| Pruitthealth - Rome | 10.3 mi | ★★★★★ | 7 | 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.