Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 D Scott Hudgens Center For Skilled Nursing, The during CMS and state inspections, most recent first.
A resident’s health information was left visible on an unattended med cart when an RN walked away from the cart in the hallway, and later two residents’ information was visible on the eMAR in a common area with prepared meds left on the cart table. The RN confirmed she forgot to minimize the eMAR screen, and the DON and Administrator stated staff were expected to minimize the screen, use privacy screens, or log out when leaving it unattended.
Unlocked Medication Cart During Medication Pass: An RN left a medication cart on the 200 hallway unattended and unlocked during med pass while retrieving gloves and tissue. The cart was positioned in the hallway facing the common area, and the RN confirmed she forgot to lock it. The DON and Administrator stated medication carts are expected to be locked when unattended.
The facility inaccurately reported staffing data to CMS, indicating insufficient RN and licensed nursing coverage on specific dates. However, a review showed that staff was present, and discrepancies may have arisen from manual data entry and salaried staff not clocking in.
The facility failed to have a qualified Infection Preventionist (IP) as required by their policies. The DON, responsible for infection control, had not completed the necessary specialized training, and no other staff member was certified as an IP. This placed all 31 residents at risk for potential transmission of infections.
The facility failed to develop comprehensive care plans for two residents, one with dementia and Rhett's Syndrome, and another with schizophrenia. The first resident's care plan lacked interventions for cognitive deficits, while the second resident's care plan did not address antipsychotic medication use. The MDS Coordinator and DON acknowledged these oversights, indicating a lapse in the facility's care planning process.
Resident Health Information Left Visible on Unattended Medication Cart
Penalty
Summary
The facility failed to ensure the privacy of resident health information for two of 14 sampled residents, R16 and R4, during medication administration. On 9/17/2025 at 9:15 am, RN AA walked away from the medication cart in the resident hallway with the cart facing away from R16’s room, leaving R16’s information on the eMAR visible while the cart was unattended. Later that morning at 9:53 am, RN AA left the medication cart unattended in the common area with prepared medications on the med cart table and the eMAR screen visible to other residents and visitors while R4’s information was displayed. During an interview on 9/17/2025 at 12:15 pm, RN AA confirmed she forgot to minimize the eMAR screen while it was unattended during medication administration for R4 and stated it was important to minimize the screen so no one could see resident information. The DON stated on 9/17/2025 at 2:30 pm that nurses were expected to minimize the eMAR screen while unattended, and that leaving the eMAR visible could lead to a HIPAA violation. The Administrator stated on 9/18/2025 at 4:00 pm that staff were expected to use privacy screens or log out if leaving the device unattended, and to lock documents away if working in an office.
Unlocked Medication Cart During Medication Pass
Penalty
Summary
The facility failed to ensure the medication cart located on the 200 hallway was locked when unattended during medication pass. Review of the facility’s policy titled, Administering Medications, revised April 2019, stated that during medication administration the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide, and that no medications are to be kept on top of the cart. The policy also stated the cart must be clearly visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by. On 9/17/2025 at 9:15 AM, observation showed RN AA walked away from the medication cart on the 200 hallway, leaving it unattended and unlocked while it was facing away from the resident’s room. RN AA returned to the cart twice to get gloves and tissue, and the cart remained unlocked and unattended during those times. During interview, RN AA confirmed she forgot to lock the cart while away from it during medication administration and stated the unlocked cart was in the hallway facing the common area visible to visitors, staff, and other residents. The DON and Administrator both stated their expectation was that medication carts be locked when unattended.
Inaccurate Staffing Data Reporting to CMS
Penalty
Summary
The facility failed to accurately report its staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of fiscal year 2024. Specifically, the facility's Payroll Based Journal (PBJ) report indicated that there was no Registered Nurse (RN) coverage for at least eight hours on several dates in October and December 2023. Additionally, the report showed a lack of licensed nursing coverage for 24 hours on multiple dates in December 2023. However, a review of the facility's staffing hours and payroll verification revealed that an RN was present on the dates in question, and licensed staff was available 24 hours on the specified December dates. Interviews with facility staff, including the Accounting Assistant (AA) and the Administrator, revealed potential reasons for the discrepancies. The AA, who was responsible for manually uploading staffing hours into the CMS reporting system, suggested that inaccurate information might have been provided by the Payroll Specialist (PS), who was unavailable for comment. The Administrator noted that the facility's salaried staff, including some licensed staff, did not clock in, which may have contributed to the reporting errors. The facility relied on an electronic payroll system to document and verify hours, but the manual process of uploading data to CMS may have led to the inaccuracies reported.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the infection prevention and control program, as required by their own policies. The facility's policy mandates that the IP must be qualified by education, training, experience, or certification and must have completed specialized training in infection prevention and control. However, the Director of Nursing (DON), who was identified as the person responsible for infection control practices, had not completed the necessary specialized training. The DON had only completed one module of the required training, and there was no other staff member certified as an IP at the facility. This deficiency was identified through staff interviews and a review of the facility's policies. The Administrator confirmed that the DON was responsible for coordinating the infection control practices, despite the lack of specialized training. This oversight placed all 31 residents at risk for potential transmission of infections and communicable diseases, as the facility did not have a qualified individual overseeing the infection prevention and control program.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, R13 and R29, as required by their policy. For R13, who has diagnoses including dementia, Rhett's Syndrome, anxiety disorder, major depressive disorder, and profound intellectual disabilities, the care plan lacked individualized interventions for cognitive deficits/dementia. Although R13's care plan included interventions for antidepressant and psychotropic medication use, as well as behavior management related to Rhett's Syndrome, it did not address cognitive concerns or monitor progress towards therapeutic goals. The MDS Coordinator acknowledged the absence of these interventions and confirmed that they should have been included. For R29, who has schizophrenia and receives antipsychotic medications, the care plan did not include a focus area, goals, or interventions related to the use of these medications. Despite the physician's orders for clozapine and Risperdal, the care plan failed to address the management of these medications. The MDS Coordinator admitted that the inclusion of antipsychotic medication use in R29's care plan was overlooked, and the DON confirmed that such oversight was not in line with the facility's expectations. Interviews with the MDS Coordinator and the DON revealed that the facility's process for developing and reviewing care plans was not adequately followed. The MDS Coordinator was responsible for ensuring care plans were accurate and up-to-date, while the DON or another RN was supposed to review them for accuracy. However, the lack of individualized interventions for cognitive impairments in R13's care plan and the absence of a focus area for antipsychotic medication use in R29's care plan indicate a failure in this process.
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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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