Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Jasper Point Of Journey Llc during CMS and state inspections, most recent first.
The facility failed to maintain an IPCP with infection surveillance, tracking, trending, and documentation of corrective actions for infections. The DON confirmed there was no surveillance data, no line listing, and no associated analysis for several months, despite CDC guidance and facility policy requiring infection monitoring. The facility also had no heavy-duty gloves available in the laundry room, and staff reported using only disposable gloves while sorting soiled laundry.
A resident with Alzheimer's disease and moderate cognitive impairment had a bowel and bladder record tool hanging on the wall next to the bed, where it was visible in the room. A family member said visitors could read the confidential information, and a CNA confirmed the form was kept posted on the wall rather than stored in the resident's side table drawer as the Administrator believed.
Improper Involuntary Transfer/Discharge Notice: A resident with Alzheimer's disease and moderate cognitive impairment received an involuntary transfer/discharge notice that cited unresolved concerns with the responsible party, but the record did not show the facility could not meet the resident's needs or that the resident was a danger to self or others. The Administrator confirmed the resident was not a danger to self or others, and the family member stated the stated reasons were inappropriate.
A resident was transferred to the ER, but the facility did not have documentation that the resident or RR received the required written transfer notice or bed hold notice. The EMR lacked evidence of the notice, the SSD could not locate it, and the Administrator stated the transfer notice was sent to the hospital while social services called the RR.
A resident with muscle weakness, difficulty walking, and need for assistance with personal care had a fall from a Hoyer lift that caused a left shoulder contusion and closed head injury. Although the care plan documented the fall and the resident confirmed the event, the quarterly MDS did not record any falls, and the MDSC confirmed it should have been included for accuracy.
Care plans for two residents did not reflect current mental health needs. One resident had PTSD and bipolar disorder documented in the record and trauma screening, but these diagnoses were not care planned. Another resident had anxiety, depression, and psychotic disorder with hallucinations documented, along with memory problems on MDS, but the care plan did not address major depressive disorder or psychotic disorder. The MDSC confirmed both residents should have had these diagnoses included in their care plans so staff would have directions for care and behaviors.
Improper Hoyer Lift Transfer Resulted in Resident Fall: A resident with muscle weakness, difficulty walking, and dependence on staff for transfers fell from a mechanical lift during a transfer. The resident was cognitively intact and later had a contusion of the L shoulder and a closed head injury. The Administrator confirmed the lift was operated by one staff member when two staff members should have been present.
Improper Storage of Nebulizer Equipment and Oxygen Order Not Followed: A resident with COPD, respiratory failure with hypoxia, chronic cough, and bronchitis had ordered oxygen therapy and nebulizer treatments. Staff observed the resident receiving O2 at 3 LPM via NC while the nebulizer mask was left on the bedside table instead of being kept in a clean storage bag as ordered, and an ADON confirmed the mask was not stored properly.
Incomplete and Incorrect Transcription of Hospice Wound Care Order: A resident with Alzheimer’s disease and moderate cognitive impairment had a hospice verbal order for coccyx wound care that was not accurately transcribed into the EMR TAR. The TAR entries for multiple months listed different wound care instructions than the hospice order, and the VP of Clinical Services confirmed the treatment order was transcribed incorrectly as a verbal order.
A resident admitted at age 65 or older was not offered pneumococcal vaccination in line with current CDC guidance, despite having a prior PPSV23 record in the EMR. The facility policy referenced CDC-recommended pneumococcal vaccines, but the DON stated he was not aware of the current CDC pneumococcal vaccinations, and the facility also lacked an acute policy displaying the CDC recommendation.
The facility failed to conduct Fall Risk Assessments during admission and after falls for two residents. One resident, admitted with a femur fracture and Alzheimer's, experienced multiple falls without timely assessments. Another resident, under hospice care, fell and sustained injuries before a high-risk assessment was completed. Interviews confirmed that assessments should occur at admission, but lapses in protocol were noted.
The facility failed to provide adequate nursing staff on weekends, potentially affecting the care of 51 residents. The Facility Assessment Tool indicated staffing needs of 36-48 hours for licensed nurses and 105-120 hours for nurse aides per day. However, the PBJ Staffing Data Report for FY Quarter 2 2024 showed excessively low weekend staffing, with only 77 hours per day for nurse aides. Interviews confirmed awareness of this issue.
The facility failed to maintain the walk-in freezer, leading to ice buildup that contaminated food and posed a risk to 51 residents. Despite awareness by the CDM, Maintenance Director, and Interim Administrator, there was no documentation of repairs or service visits.
The facility did not ensure the Medical Director or their appointee attended QAPI committee meetings as required by policy. The Medical Director or designee was absent from three of six reviewed meetings, violating the policy that mandates their participation. The Regional Director confirmed the absence and lack of documentation for these meetings.
The facility failed to submit a PASARR Level II for two residents after new mental illness diagnoses were added, potentially affecting their care. One resident was diagnosed with bipolar disorder but did not receive psychological services or a PASARR Level II. Another resident, also diagnosed with bipolar disorder, was on antipsychotic medication without a PASARR Level II reevaluation. The facility lacked a Social Services Director, and the Regional Nurse Consultant could not locate the necessary documentation.
A resident receiving continuous oxygen therapy did not have a comprehensive care plan addressing this treatment, as required by facility policy. Despite having a physician's order for oxygen via nasal cannula, the care plan lacked documented goals or interventions for oxygen administration. The oversight was confirmed by the Regional Director of Clinical Operations.
The facility failed to properly store respiratory supplies for two residents, increasing the risk of infection. A resident with COPD had a nebulizer mouthpiece and tubing uncovered, while another resident's BiPAP mask was left unbagged on a nightstand. These actions did not comply with the facility's policies, potentially compromising respiratory health.
A facility failed to comply with its policy on PRN psychotropic medications, allowing a resident to have an active PRN order for Ativan without an end date. The resident, diagnosed with panic disorder and conversion disorder with seizures, received Ativan multiple times over several months. The facility's policy requires PRN orders to be limited to 14 days unless extended with documented rationale, which was not done in this case.
A medication security breach occurred when an RN left five medication cards on top of a locked cart unattended while retrieving another medication. The facility's policy requires medications to be secured and supervised, which was not followed, posing a risk of unauthorized access.
A facility failed to ensure proper hand hygiene during wound care for a resident with a stage IV pressure ulcer. The LPN did not change gloves or perform hand hygiene between cleansing the wound and applying Dakin's solution-soaked gauze, contrary to the facility's policy. The resident, who was dependent on staff for daily activities, had a care plan emphasizing proper wound care. The LPN acknowledged the mistake, and the Regional Nurse Consultant confirmed the potential risk of infection.
IPCP Surveillance and Laundry PPE Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for recording incidents of infections identified under the IPCP, including surveillance, tracking and trending, and documentation of corrective actions taken by the facility. Review of the facility’s IPCP policy and CDC NHSN guidance showed that surveillance should include the ongoing collection, analysis, interpretation, and dissemination of infection data. During an interview, the DON stated he was the current Infection Preventionist and was completing September and October 2025 infection control surveillance, but a review of data from February 2025 through August 2025 showed no surveillance, no tracking or trending, and no line listing of residents with current infections and the corrective action taken. The DON stated there was no evidence that IC audits were completed by the previous DONs and confirmed there was no surveillance data or associated analysis for that period. The facility also failed to ensure heavy-duty gloves were available in the laundry room. Review of the laundry handling policy indicated employees must don appropriate PPE, including tear-resistant reusable gloves, when sorting personal items prior to washing. During an observation of the laundry room, no heavy-duty gloves were available for staff use, and the DON confirmed this. The Accounts Manager for Laundry Services also confirmed that no heavy-duty protective gloves were present. A Laundry Aide stated she never used heavy-duty gloves when sorting soiled laundry and only used disposable gloves, and the Accounts Manager stated heavy-duty gloves were important because staff could be poked by a used needle while sorting soiled linens.
Confidential Resident Record Posted in Room
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained for one resident. R10 was admitted with a diagnosis of Alzheimer's disease and had a quarterly MDS with a BIMS score of 9 out of 15, indicating moderate cognitive impairment. During observations on 11/17/2025 and 11/18/2025, a document titled "Bowel and Bladder Record Data Collection Tool" was hanging on the right side of R10's bed in the resident's room, where it could be seen by others. During an interview, a family member stated the resident had church members who visited and that the confidential information was posted for anyone to read. A CNA confirmed the bowel and bladder record tool was always kept on R10's wall next to her bed. The Administrator later stated it was his understanding that the form was kept in R10's side table drawer and not posted on the wall in the resident's room.
Improper Involuntary Transfer/Discharge Notice
Penalty
Summary
The facility failed to include proper reasons for an involuntary transfer/discharge for one resident, R10, who was reviewed for discharge among 34 sampled residents. The facility policy titled, Transfer and Discharge (including AMA), dated 3/20/2025, stated residents may only be transferred or discharged under limited circumstances, including when the resident's needs cannot be met in the facility or when the resident poses a danger to self or others. R10's EMR showed admission to the facility with a diagnosis of Alzheimer's disease, and the quarterly MDS with an ARD of 8/29/2025 showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. An involuntary transfer/discharge notice dated 10/22/2025 was sent to R10's family member stating that concerns had been addressed by the facility but were not deemed acceptable by the responsible party, and that these events caused the need for a 30-day notice to transfer or discharge. However, the clinical record did not contain evidence that staff were unable to provide care for R10, and it did not indicate that the resident was a danger to self or others. During interview, the family member stated the reasons for the notice were inappropriate and that an appeal was underway, and the Administrator confirmed that R10 was not a danger to self or others and that this was an oversight in the transfer/discharge requirements.
Missing Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that a resident and the resident representative received a written transfer agreement and bed hold notice for one resident transferred to the hospital. Review of the facility policy titled, Transfer and Discharge (including AMA), dated 3/20/2025, stated that transfer/discharge notices are to be provided to the resident and resident's representative in a language and manner they can understand and must include the specific reason and basis for transfer or discharge, the effective date, and the specific location to which the resident is being transferred or discharged. Review of the resident's progress notes showed the resident was transported to the emergency room. The electronic medical record contained no documentation that the resident or the resident representative was provided the transfer notice or bed hold notice for the hospital transfer. The Social Services Director stated she was unable to locate the transfer notice or bed hold notice for the resident's transfer to the hospital, and the Administrator stated the facility sent the transfer notice to the hospital and social services called the resident representative.
Inaccurate MDS Did Not Reflect Resident Fall
Penalty
Summary
The facility failed to ensure the comprehensive assessment accurately reflected a resident fall for R4. R4 was admitted with diagnoses of muscle weakness, difficulty walking, and need for assistance with personal care. Review of the hospital After Visit Summary showed R4 had a fall from a mechanical lift that resulted in a contusion of the left shoulder and a closed head injury. The care plan identified R4 as being at risk for falls related to impaired mobility and documented that the resident had a fall on 7/3/2025. However, the quarterly MDS with an ARD of 8/15/2025 did not indicate any falls. R4 confirmed during interview that she had fallen from the mechanical lift and was sent to the emergency room, and the Regional MDS Coordinator confirmed the fall should have been documented on the quarterly MDS to ensure accuracy.
Care Plans Did Not Reflect Current Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the care plans for two residents reflected their current level of care. For one resident, the admission record showed diagnoses of PTSD and bipolar disorder, and a trauma screening completed on 2/26/2025 indicated PTSD and bipolar disorder. However, the resident’s care plan did not document either diagnosis. The quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, and also noted that the resident sometimes self-isolated, with diagnoses of bipolar disorder and PTSD listed. During interview, the Regional MDS Coordinator confirmed the resident should have been care planned for PTSD and bipolar disorder so interventions would be in place if issues arose from those diagnoses. For the second resident, the admission record showed anxiety disorder and depression, and the record also documented psychotic disorder with hallucinations. The significant change MDS showed short- and long-term memory problems on the SAMS and listed anxiety disorder, depression, and psychotic disorder. The care plan did not address major depressive disorder or psychotic disorder with hallucinations. During interview, the Regional MDS Coordinator stated there should be care plans for major depressive disorder and psychotic disorder because the care plan gives staff directions when behaviors are exhibited.
Improper Hoyer Lift Transfer Resulted in Resident Fall
Penalty
Summary
The facility failed to ensure that one resident was properly secured during a Hoyer lift transfer, and the resident fell from the mechanical lift. The facility policy titled, Accidents and Supervision, stated that the resident environment would remain as free of accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents. The resident involved was admitted with diagnoses of muscle weakness, difficulty walking, and a need for assistance with personal care, and the quarterly MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and dependent on staff for transferring. The resident’s progress notes documented a fall from a mechanical lift, and the hospital after visit summary showed the resident sustained a contusion of the left shoulder and a closed head injury. The care plan identified the resident as at risk for falls related to impaired mobility and noted the fall from the Hoyer lift. During interview, the resident confirmed falling from the mechanical lift and being sent to the emergency room. The Administrator confirmed the lift was being operated by one staff member when two staff members should have been present, and stated the CNA involved was suspended for three days and retrained.
Improper Storage of Nebulizer Equipment and Oxygen Order Not Followed
Penalty
Summary
Respiratory care was not provided in accordance with professional standards for one resident with COPD, respiratory failure with hypoxia, chronic cough, and bronchitis. The resident’s record showed orders for oxygen therapy, oxygen as needed for hypoxia when oxygen saturation was below 90%, and nebulizer treatments as ordered. The care plan identified the resident as at risk for altered respiratory status and ineffective gas exchange and included oxygen therapy and nebulizer treatments as ordered. During multiple observations, the resident was seen in bed or in the room receiving oxygen at 3 LPM via nasal cannula, while the nebulizer mask was left sitting on the bedside table and not stored in a clean storage bag as ordered. The physician order required the nebulizer mask to be kept in a clean storage bag at all times every shift. An ADON later confirmed at the resident’s bedside that the oxygen was set at 3 liters and the nebulizer was not in a storage bag.
Incomplete and Incorrect Transcription of Hospice Wound Care Order
Penalty
Summary
The facility failed to ensure that R10’s clinical record was complete and that the hospice wound care order was transcribed correctly. R10 was admitted with a diagnosis of Alzheimer’s disease and had a quarterly MDS with a BIMS score of 9 out of 15, indicating moderate cognitive impairment. A hospice patient care verbal order for pressure wound care directed staff to use aseptic technique, cleanse the coccyx wound, apply skin prep to intact surrounding skin, pack the wound with gauze packing, cover it with a comfort foam dressing, and redress the wound 7 times per week and as needed for displacement or soiled dressings. Review of the EMR TAR for September, October, and November 2025 showed wound care instructions that did not match the hospice verbal order, including directions to clean the sacral wound with wound cleanser, fill the wound bed with kerlix soaked in wound cleanser, and cover with xeroform and a sacral pad, with varying daily/PRN wording. Physician orders dated 11/4/2025 and 11/5/2025 also reflected wound care instructions for the sacral wound, and the VP of Clinical Services confirmed during interview that the treatment order had been transcribed incorrectly and that it came through as a verbal order.
Failure to Offer Pneumococcal Vaccination and Maintain Current CDC Guidance
Penalty
Summary
The facility failed to offer one of five reviewed residents, Resident 26, the opportunity to receive flu and pneumonia vaccinations in accordance with nationally recognized standards. Resident 26 was admitted to the facility at age 65 or older, and the electronic medical record showed a prior Pneumovax 23 vaccination on 1/27/2010. The facility policy titled Infection Prevention and Control Program, dated 3/20/2025, stated that residents would be offered the pneumococcal vaccines recommended by the CDC upon admission unless contraindicated or received elsewhere. Review of the facility’s admission packet showed an Informed Consent for Pneumococcal Vaccine that referenced the Advisory Committee on Immunization Practice recommendations for adults 65 years of age or older, including PCV13 and PPSV23 guidance. During an interview on 11/21/2025 at 1:26 pm, the DON stated he was not aware of the current CDC pneumococcal vaccinations and said it was important to have an accurate policy on vaccinations so staff could provide the most accurate information to residents and/or their representatives. The report also stated the facility failed to have an acute policy displaying the CDC’s recommendation.
Failure to Conduct Timely Fall Risk Assessments
Penalty
Summary
The facility failed to complete Fall Risk Assessments during the admission process and after falls for two residents, R3 and R4, who were reviewed for falls. R3 was admitted with diagnoses including a fracture of the left femur and Alzheimer's disease. Despite experiencing falls on three occasions, there was no evidence of a Fall Risk Assessment being completed at admission or after each fall. A fall risk evaluation was eventually completed, indicating a high risk. R4, admitted under hospice care, also did not have a Fall Risk Assessment completed at admission. After a fall resulting in a skin tear and pain, a Morse Falls Risk Evaluation was conducted, showing a high risk for falls. Interviews with the Director of Nursing (DON) and an LPN confirmed that fall risk assessments should be completed during admission, even for hospice residents. The DON, who started working at the facility after the admissions of R3 and R4, was unaware of who was responsible for the assessments prior to her tenure. The facility's Administrator expressed the expectation that all nurses complete required assessments, highlighting a lapse in protocol adherence regarding fall risk assessments for new admissions.
Inadequate Weekend Staffing
Penalty
Summary
The facility failed to ensure adequate nursing staff on weekends, which had the potential to affect the care provided to the 51 residents residing in the facility. The Facility Assessment Tool dated 4/17/2024 indicated that the average daily census was 57 residents, with staffing needs of 36-48 hours for licensed nurses and 105-120 hours for nurse aides per day. However, the PBJ Staffing Data Report for FY Quarter 2 2024 revealed excessively low weekend staffing, with an average of only 77 hours per day for nurse aides on weekends. Interviews with the Regional Director of Clinical Operations and the Regional Nurse Consultant confirmed their awareness of the excessively low weekend staffing issue for the second quarter of 2024. This deficiency was identified through record reviews, staff interviews, and facility document reviews, highlighting the facility's failure to meet the required staffing levels on weekends.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to maintain the walk-in freezer properly, resulting in significant ice buildup on the freezer unit, shelving, and floor. This issue was observed during a survey, with ice formations ranging from 6 inches in diameter at the top to less than 1 inch at the floor. The Certified Dietary Manager (CDM) confirmed the ice buildup and noted that it had led to the discarding of numerous cases of food due to contamination concerns. The Maintenance Director was aware of the issue and manually removed ice periodically, but there was no documentation of a service visit or repair by an outside company, despite the freezer having been inspected previously. Interviews with facility staff, including the CDM, Maintenance Director, Regional Director of Environmental Services, and Interim Administrator, revealed a lack of communication and documentation regarding the freezer's condition and necessary repairs. The Interim Administrator and Maintenance Director were aware of the problem, but neither could provide documentation of any service visits or recommendations from the outside service provider. The Regional Director of Environmental Services was unaware of the issue until the survey. The ongoing ice formation posed a risk of food contamination for the 51 residents receiving meals from the kitchen.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or an appointee of the Medical Director attended and participated in the Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly, as required by their policy. The facility's policy, implemented on 8/1/2023, mandates that the QAPI committee be interdisciplinary and include the Director of Nursing, the Medical Director or their designee, and at least three other staff members, including the Administrator or another leader, and the Infection Preventionist. However, a review of the QAPI committee meeting sign-in sheets for six meetings revealed that neither the Medical Director nor their appointee attended three of these meetings, specifically on 11/2/2023, 1/26/2024, and 4/25/2024. During an interview, the Regional Director of Clinical Operations confirmed the absence of the Medical Director or their designee at these meetings and acknowledged the lack of documentation to indicate their participation. This absence indicates a failure to comply with the facility's policy regarding the composition and attendance requirements of the QAPI committee.
Failure to Submit PASARR Level II for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to submit a PASARR Level II for two residents after new mental illness diagnoses were added, which could affect the level of care and services provided. Resident 5 was admitted with diagnoses including generalized anxiety disorder, migraine, and major depressive disorder, and later diagnosed with bipolar disorder. Despite this new diagnosis, there was no documentation of psychological services in the past 12 months, and no PASARR Level II was submitted. The facility lacked a Social Services Director, and the Director of Nursing was unavailable for an interview. The Interim Administrator confirmed the absence of a PASARR Level II for Resident 5 and acknowledged the responsibility of the Social Services Director in submitting the necessary documentation. Resident 19 was admitted without a significant mental health diagnosis but later diagnosed with panic disorder and bipolar disorder. The PASARR Level I did not reflect these new diagnoses, and there was no evidence of reevaluation for a PASARR Level II. The resident was receiving olanzapine for bipolar disorder, but no psychological therapies or treatments were documented. The Regional Nurse Consultant was unable to locate a PASARR Level II for Resident 19 and could not contact the former Social Worker for clarification.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as R15, who was receiving oxygen therapy. The facility's policy on Comprehensive Care Plans requires that the care plan describe the services necessary to maintain the resident's highest practicable well-being. Additionally, the policy on Oxygen Administration mandates that the care plan identify interventions for oxygen therapy based on the resident's assessment and orders. However, a review of R15's care plan revealed no documented care area, goals, or interventions for the administration of oxygen, despite the resident having a physician's order for continuous oxygen via a nasal cannula at 2 liters per minute. Observations and interviews confirmed that R15 was receiving oxygen as ordered, and the resident reported wearing the oxygen most of the time, except during meals and showers. The Regional Director of Clinical Operations verified the absence of a care plan area for oxygen administration and acknowledged that it should have been included. The omission was attributed to an oversight by the MDS Coordinator, who is responsible for ensuring the care plan reflects the current services and care provided to the resident.
Improper Storage of Respiratory Supplies
Penalty
Summary
The facility failed to properly store respiratory supplies for two residents, R14 and R27, increasing the risk of spreading microorganisms and potentially leading to respiratory infections. For R14, who has a history of acute chronic diastolic congestive heart failure, pleural effusion, acute respiratory failure with hypoxia, viral pneumonia, and COPD, observations revealed that her nebulizer mouthpiece and tubing were not stored in protective bags as required by the facility's policy. The nebulizer mouthpiece was found lying on top of the oxygen concentrator and the tubing was in a drawer, both uncovered. The Regional Nurse Consultant confirmed these observations and acknowledged that the charge nurse was responsible for ensuring the equipment was clean and stored properly. Similarly, for R27, who has chronic respiratory failure with hypoxia and hypercapnia, morbid obesity with alveolar hypoventilation, and COPD, the BiPAP machine's mask was observed lying directly on the nightstand without a protective covering. R27 confirmed that the staff assisted her with the BiPAP machine at night but did not place the mask in a bag or protective covering, and she was unsure if it was cleaned. These observations indicate a failure to adhere to the facility's policies on respiratory equipment cleaning and storage, potentially compromising the residents' respiratory health.
Failure to Adhere to PRN Psychotropic Medication Policy
Penalty
Summary
The facility failed to ensure compliance with its policy on the use of psychotropic medications, specifically regarding the administration of PRN orders for antianxiety medication. The policy mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed condition and for a limited duration of 14 days unless extended by a physician with documented rationale. However, a resident with diagnoses of panic disorder and conversion disorder with seizures had an active PRN order for Ativan injection without an end date, which was not reviewed or updated by the Director of Nursing as required. The resident received Ativan on multiple occasions over several months, indicating a lack of adherence to the policy's stipulation for limited duration. The medication was administered for seizures and panic attacks, with one instance noted in the nurse's notes where the resident was agitated and unable to be redirected, leading to the administration of Ativan with good results. Despite the facility's policy and the presence of a duplicate order identified by the pharmacist, the PRN order continued without proper documentation or an end date, as confirmed by the Regional Nurse Consultant.
Medication Security Breach on 300 Hall Cart
Penalty
Summary
The facility failed to maintain medications in a locked and secure environment when not under direct supervision of the nurse, specifically involving the 300 Hall medication cart. During an observation, it was noted that a Registered Nurse (RN) left the medication cart locked but with five medication cards containing medications on top of the cart unattended while she went to the medication room to retrieve another medication. This incident occurred over a span of four minutes, during which the medications were not secured as per the facility's policy. The facility's policy on Medication Storage, implemented on 2/12/2022, mandates that all medications must be stored securely and under direct supervision during medication pass. The RN acknowledged the lapse in protocol, admitting that she should have locked the medications in the cart before leaving it unattended. The Regional Nurse Consultant confirmed that the expectation is for medications to be locked in the cart unless attended by a nurse, highlighting the risk of unauthorized access to medications by residents, staff, or visitors.
Failure in Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with a stage IV pressure ulcer in the sacral region. The facility's policy on clean dressing change, implemented on 2/12/2022, requires hand washing and the use of clean gloves to prevent infection and cross-contamination. However, during an observation, an LPN did not change gloves or perform hand hygiene between cleansing the wound and applying Dakin's solution-soaked gauze, which is a deviation from the facility's policy. The resident involved had a history of pressure ulcers and was dependent on staff for daily activities, including dressing, bathing, and toileting. The resident's care plan emphasized the need for frequent checks for wetness and soiling, and proper wound care as per physician's orders. Despite these guidelines, the LPN admitted to not following the correct procedure during wound care, which was confirmed by the Regional Nurse Consultant, who stated that this practice could potentially lead to a wound infection.
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 18 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 Jasper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Jasper | 7.1 mi | ★★★★★ | 0 | 0 |
| Wildwood Health And Rehab | 9.9 mi | ★★★★★ | 2 | 0 |
| Parkside Center For Nursing And Rehab At Ellijay | 13.5 mi | ★★★★★ | 8 | 0 |
| Canton Center For Nursing And Healing Llc | 16.7 mi | ★★★★★ | 8 | 0 |
| Cherokee Center For Nursing And Healing Llc | 17.7 mi | ★★★★★ | 0 | 0 |
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