Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Big Meadows during CMS and state inspections, most recent first.
Cold Food Served to Residents: A resident council and multiple residents reported that hot food and room trays were often served cold, and one resident said ice cream arrived melted. Residents stated trays were sometimes delivered without thermal food covers, foil was being used, and the microwave did not properly heat food. The ADM acknowledged ongoing complaints and said room trays were plated at the same time and sat on racks in the halls, allowing the food to cool before service.
A resident with DM, HTN, gout, edema, weakness, anemia, and obesity had a toe nicked and bleeding during a podiatry nail-trimming visit. The DON said the injury was not reported to her, there were no treatment orders, the facility did not follow up on the secure message or the physician response, and the podiatrist's notes were still unavailable. The resident's later physician note did not address the toe injury, and a subsequent nurse assessment noted discoloration under the nail bed.
A resident who transferred with staff assistance was observed with a gait belt placed too high on the chest and under the arms during a toilet transfer, despite staff stating gait belts should be used at the waist. In a separate event, a resident with dementia, epilepsy, a history of falls, and a fall-risk care plan was found in bed with the bed alarm present but not turned on; staff confirmed the alarm should have been activated for safety and fall prevention.
A resident who required partial/moderate assistance with bathing did not receive scheduled shower care as expected. The resident said he missed showers, including one Friday when staff twice promised to help but did not, and he reported he does not refuse showers and needs staff assistance because he is afraid of falling. Review of shower schedules and available shower sheets showed the resident was assigned showers twice weekly, but the most recent documentation available did not reflect ongoing completion of the schedule. The DON stated most residents are scheduled for two showers per week and refusals should be documented.
Failure to assess a resident with a change in condition. A resident with heart failure, bipolar disorder, anxiety, type 1 DM, and moderate cognitive impairment was observed lethargic, minimally responsive, and not eating. CNAs reported she was not at baseline and repeatedly told the day RN and later the night RN that something was wrong, but no nurse documented a change-in-condition assessment or progress note during the day shift. The resident was later noted to be difficult to arouse, confused, weak, and fatigued, and was sent to the ER for altered mental status.
A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage bag and tubing touching or dragging on the floor while in a wheelchair and in the dining area. The IP stated the bag should be attached to the wheelchair and kept off the floor for infection control, and the facility policy required catheter care to promote cleanliness and acceptable infection control.
Insulin pen administration was not performed per manufacturer instructions for three residents with DM2. An RN and LPNs failed to wipe the rubber seal, failed to prime the pen before injection, and did not hold the plunger in place for the required time when giving long-acting insulin. One resident’s insulin was initially prepared, then later administered after refusal using the same pen setting with a new needle, again without wiping the stopper or following the required injection hold time.
A resident with moderate cognitive impairment, dependent on staff for daily care, was subjected to disrespectful and derogatory language by staff, including age-related remarks and suggestions that she belonged on the dementia unit. The facility's investigation confirmed that inappropriate comments were made, constituting verbal abuse as defined by facility policy.
A resident with dementia experienced an unwitnessed fall resulting in a head injury and right hip pain. Although staff attempted some assessments, there was no documentation of a neurological assessment or range of motion check in the medical record, despite the resident being sent to the ER and later diagnosed with a hip fracture. Staff interviews confirmed that required assessments were not documented as expected.
A resident with dementia and anxiety fractured a finger after becoming agitated and hitting a wall during care. The facility failed to implement care plan interventions to manage the resident's behaviors, and communication lapses between CNAs contributed to the incident.
The facility failed to provide meaningful activities for dementia residents, as observed in four cases. One resident wandered aimlessly without engagement, while another sat unengaged in a common area. A third resident expressed a desire for activities but was not invited to participate, and a fourth resident paced without staff engagement. The Activity Director was the only staff member responsible for activities during weekdays, leaving weekends without structured activities, contrary to the facility's policy.
The facility did not follow the prescribed pureed menu for residents on pureed diets. The cook prepared and served meals without the required pureed cornbread, as confirmed by the Dietary Manager. This resulted in residents not receiving the complete meal as per their dietary needs.
A facility failed to include a bed hold policy in the packet of information for a resident transferred to the hospital. The resident experienced a drop in oxygen saturation, necessitating an emergency room transfer. The Registered Nurse was unsure if the bed hold policy was included, and the Administrator confirmed it was not, citing packet thickness as the reason for its exclusion. The facility's policy requires written notification of the bed hold policy to accompany the resident to the hospital.
A resident with moderate oral/pharyngeal dysphagia did not receive the recommended diet modifications due to a communication lapse in the facility. Despite speech therapy's advice for a mechanical soft diet and nectar thick liquids, the resident continued on a regular diet, as the recommendations were not relayed to the nursing staff. This oversight contradicts the facility's dysphagia management policy.
A facility failed to maintain a resident's adaptive equipment, impacting his range of motion. The resident, with a history of stroke and hemiplegia, had a broken arm trough on his wheelchair, which had been reported but not repaired for months. The restorative staff was unaware of the issue, and the facility lacked a policy on adaptive equipment care.
The facility failed to implement enhanced barrier precautions for two residents, leading to deficiencies in infection control. One resident with an open pressure ulcer did not have proper signage or gown use by staff, while another resident with a urinary catheter had inconsistent gown use despite posted precautions. The facility's policy requires clear signage and PPE for high-contact care, which was not consistently followed.
Cold Food Served to Residents
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for residents reviewed for dining and palatable food, including R33, R37, R66, and the resident council in a sample of 31. R33 stated she eats in her room and in the dining room and reported that her food is served cold all the time. R66 stated he eats in his room and that food that is supposed to be warm is cold by the time it gets to him; he also stated staff just drop off his tray and leave, and he was not aware he could have staff warm up his food. R37 stated that sometimes her hot food is served cold and that her lunch tray ice cream was melted. During the resident council meeting, residents stated that hot food is sometimes served cold and that they did not like it. Record review showed the February 23, 2026 Resident Council Meeting Notes documented that room trays were getting cold food, residents requested insulated covers and to stop using foil, and believed the microwave was broken because it did not properly heat food. The March 16, 2026 Resident Council minutes stated room trays were being delivered without thermal food cover containers. The April 20, 2026 Resident Food Council Minutes also documented issues with room tray delivery, including trays being delivered without thermal food cover containers and delays and other issues with food. The Administrator stated the facility had been getting cold food complaints and that room trays were plated at the same time and taken out to the halls, where they cooled off while waiting to be served.
Failure to Monitor and Treat Toe Injury After Podiatry Visit
Penalty
Summary
The facility failed to ensure foot care, including monitoring and treatment, was provided after a resident's toe was cut during a podiatry visit. The resident had diagnoses including type 2 diabetes mellitus, hypertension, gout, edema, muscle weakness, anemia, and obesity. On 3/9/26, a secure conversation documented that the resident was seen by the podiatrist, her toenails were clipped, and the left big toe was bleeding and wrapped by the podiatrist. The communication also showed the nurse asked whether a Dremel or nail grinder could be used for future podiatry visits and asked if the nurse practitioner could look at the resident's toe, but the physician response was only to add the resident to his list. The DON stated she was not aware the toe had been cut and said it was not reported to her. She later stated there were no treatment orders for the cut toe, the facility did not follow up on the secure conversation or the physician's response, and skin checks and a proper treatment plan should have been in place because the resident is diabetic. The facility still did not have the podiatrist's notes from the visit. The resident's physician note from 4/9/26 did not mention the toenail care or toe injury. A skin alteration incident completed by the DON documented that the podiatrist nicked the resident's left foot and bleeding was noted, and the resident witnessed the provider nicking her left great toe during treatment. A nurse's note entered later showed the left great toe was assessed with no open areas, but black and yellow discoloration was noted under the nail bed.
Improper gait belt use and bed alarm not activated
Penalty
Summary
The facility failed to ensure a gait belt was applied and used correctly during a transfer for a resident who transferred with 1-2 staff into a wheelchair and did not walk. During an observation on 5/12/26, a CNA placed the gait belt loosely around the resident’s lower chest, slightly above the resident’s hanging breasts, and assisted the resident from a wheelchair to the toilet. As the transfer occurred, the gait belt moved up under the resident’s arms. The CNA stated she sometimes places the belt on the resident’s chest just under the armpits because it is more comfortable, and also stated the resident transferred with supervision and did not need the gait belt. The DON and LPN stated gait belts should be applied around the waist and not around the chest or under the arms. The resident’s care plan stated the resident transferred with 1-2 staff and had a history of a left shoulder dislocation, though the resident no longer wore a sling. The facility also failed to ensure a bed alarm was turned on for a resident who was at risk for falls and had a history of getting out of bed. On 5/13/26, the resident was observed lying in bed with a bed alarm present but not turned on. A CNA was called to the room and confirmed the alarm was off and should have been on; the CNA then turned it on and stated an agency nurse had been told the alarm needed to be activated. The CNA and DON stated the alarm was needed for the resident’s safety and fall prevention. The resident’s diagnoses included dementia, epilepsy, major depressive disorder, generalized anxiety disorder, hypertension, irritability and anger, history of falling, left artificial knee joint, tear of medial meniscus of the right knee, right shoulder rotator cuff complete tear or rupture, osteoarthritis, and failure to thrive. The care plan identified the resident as at risk for falls and included a sensor pad alarm in bed.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide shower assistance for a resident who was dependent on staff for bathing. R25 was admitted with diagnoses including shortness of breath, depression, and arthritis. His quarterly MDS showed he was cognitively intact with a BIMS score of 13 out of 15 and required partial/moderate assistance for showering and bathing. During interview, R25 stated he did not receive a shower on one Friday and said it had been about two weeks before he finally got one. He reported that he is assisted in the shower, must sit down because he is afraid of falling, and does not refuse showers because he enjoys them and feels clean afterward. Record review and staff interviews showed R25’s shower schedule was posted for Tuesday and Friday, but the most recent shower sheets available ended on 4/24/26. A CNA stated shower assignments were posted on the medication room door and shower sheets were placed there by nurses. The DON stated most residents are scheduled for two showers a week and that if a resident refuses, it should be documented on the shower sheet. The facility’s Resident Shower policy stated residents will be provided showers as per request or facility schedule protocols and based upon resident safety.
Failure to Assess Resident With Change in Condition
Penalty
Summary
The facility failed to assess a resident with a change in condition. The resident had diagnoses including heart failure, bipolar disorder, anxiety, and type 1 diabetes, and her quarterly MDS showed moderate cognitive impairment with a BIMS score of 8 out of 15. On 5/12/26, she was observed in bed, on her back, in a hospital gown, opening her eyes but not locking eyes or responding to questions, and she remained in that condition later that day. During the day shift on 5/12/26, a CNA documented that the resident was not responsive, would not talk much, would not eat, and was difficult to arouse, lethargic, confused, weak, and fatigued. The CNA stated she told the day RN several times that the resident was not right and asked both the day RN and the night RN to look at her. Another CNA stated the resident was typically alert, answered questions, and had been getting up and going to meals, but that on this day she was not responsive and did not eat. The CNA and another staff member agreed the resident was not at her baseline. No nurse documented a change-in-condition assessment, progress note, or other assessment during the day shift, and no vital signs were documented by the day shift except an oxygen saturation and temperature at 6:00 PM. The resident refused all three meals that day. Later that evening, the night RN documented that the resident was difficult to arouse, lethargic, confused, believed she was at her daughter’s house, had general weakness and fatigue, and was staying in bed all day with reduced appetite; the resident was then sent to the ER for altered mental status. The DON stated that when notified of a change in condition, a nurse should assess the resident, notify the doctor and family, and document the assessment in the progress notes, and said the day RN should have listened to the CNAs and assessed the resident.
Indwelling catheter tubing and drainage bag were left on the floor
Penalty
Summary
An indwelling urinary catheter was not maintained in a manner to prevent cross contamination for one resident. The resident was admitted with diagnoses including cerebral infarction due to embolism of bilateral anterior cerebral arteries, dysphagia, hypertension, acute kidney failure with tubular necrosis, hypokalemia, retention of urine, and obstructive and reflux uropathy. The resident’s assessment identified an indwelling urinary catheter, and the care plan directed staff to observe the catheter tubing to ensure it was flowing properly and positioned correctly at the bedside, in a chair, or in a wheelchair. During observations, the resident was seen in a wheelchair in the activity area with the catheter drainage bag touching the floor and the tubing on the floor. The same condition was observed later in the dining room, with the drainage bag touching the floor and tubing under the chair on the floor. On another observation, the resident was independently propelling the wheelchair down the hallway with the catheter bag and tubing dragging on the floor. The infection preventionist stated the catheter bag should be in a privacy bag and attached to the wheelchair so it is up off the floor and not dragging on the floor for infection control purposes. The facility policy stated catheter and perineal care would be provided in a manner that promotes cleanliness and acceptable infection control.
Insulin Pen Administration Not Performed per Manufacturer Instructions
Penalty
Summary
The facility failed to administer insulin in accordance with the manufacturer’s instructions for 3 of 3 residents reviewed for insulin use. R6, who was admitted with diagnoses including type 2 diabetes, dementia, and depression, received 12 units of long-acting insulin every 12 hours. During administration, the RN attached the needle to the insulin pen without wiping the rubber seal with alcohol, did not prime the pen, and held the pen to the resident’s skin for less than two seconds after depressing the plunger. The manufacturer’s instructions required wiping the rubber seal, priming the pen needle before each injection, and holding the injection button down for 10 seconds after the dose window showed 0. The facility’s insulin pen policy also required wiping the rubber seal, priming the pen, and keeping the needle in the skin for 6 to 10 seconds after full depression of the plunger. R38, admitted with diagnoses including type 2 diabetes, stroke, and weakness, had a one-time order for 18 units of long-acting insulin. The LPN attached the needle without wiping the rubber seal, did not prime the pen, and held the plunger for less than 3 seconds after injecting. R43, admitted with diagnoses including type 2 diabetes, dementia, and depression, was scheduled to receive 16 units of long-acting insulin daily. One LPN initially prepared the insulin pen without wiping the rubber seal or priming it, then the resident refused the injection and the pen was set aside. When the resident later agreed to receive insulin, another LPN reused the same pen setting, attached a new needle without wiping the rubber stopper, and administered the insulin while holding the plunger for less than 3 seconds. The DON stated staff were expected to follow the manufacturer’s instructions and that priming and holding the plunger were intended to ensure the full dose was administered.
Resident Subjected to Verbal Abuse by Staff
Penalty
Summary
A resident with moderate cognitive impairment, dependent on staff for activities of daily living and mobility, reported being subjected to disrespectful and derogatory language by facility staff during care. The resident recalled staff making age-related disparaging remarks, including comments such as, 'Well, if you weren't so old,' and, 'I don't know why they send you (old) people here.' The resident stated that when she asked the staff to stop, her request was ignored. Documentation from a Certified Nursing Assistant (CNA) indicated that the resident reported being hurt by two aides and that one aide admitted to making a comment suggesting the resident belonged on the dementia unit if she continued certain behaviors. The facility's investigation substantiated the occurrence of verbal abuse, as defined by their Abuse Program Policy, which prohibits the use of disparaging or derogatory language toward residents. The involved staff members denied the events, but the investigation included written statements and interviews that confirmed inappropriate comments were made within the resident's hearing. The incident was reported to facility administration, and an investigation was initiated following the resident's complaint.
Failure to Document Post-Fall Assessment After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to conduct and document a comprehensive assessment for a resident following an unwitnessed fall. The resident, who had a diagnosis of unspecified dementia and resided on the dementia unit, was found on the floor with a pool of blood at his head and was yelling for help. Although the incident report included vital signs, it did not document a range of motion (ROM) or neurological assessment, despite the presence of an obvious head injury. The resident complained of right hip pain and was unable to bear weight on the right hip before being sent to the emergency room, where a closed right hip fracture was diagnosed. Interviews with staff revealed that while some assessment attempts were made, such as checking vital signs and attempting to assess ROM and pupils, these were not documented in the medical record. The RN involved acknowledged that the assessments should have been documented, especially given the resident's complaints of pain and visible injuries. The Director of Nursing confirmed that the required assessments, including ROM and neuro checks, were missing from the documentation. The facility did not have a specific policy for post-fall assessments, but staff agreed that documentation of these assessments was expected.
Failure to Implement Dementia Care Interventions
Penalty
Summary
The facility failed to implement care planned interventions to manage a resident's dementia-related anxiety and aggressive behaviors, resulting in the resident fracturing a finger after punching a wall. The resident, who had diagnoses of anxiety and dementia with behavioral disturbances, became agitated during care and swung at a CNA, hitting the wall in the process. The care plan for the resident included interventions such as offering a soda or calling the resident's son to de-escalate behaviors, but these were not implemented during the incident. On the night of the incident, the CNA assigned to the resident did not inform the covering CNA about the resident's ongoing aggressive behaviors before taking a break. The covering CNA attempted to change the resident without giving him a break, despite his agitation, leading to the resident's aggressive response. The facility's Behavioral Management policy emphasizes the use of non-pharmacological interventions and staff awareness of de-escalation strategies, which were not effectively communicated or executed in this case.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide meaningful activities to dementia residents, as observed in four residents. One resident, diagnosed with dementia, was seen wandering the hallways aimlessly on multiple occasions without being engaged in any activities. Despite having a care plan that included preferences for individual and group activities, the resident was not offered any engagement, particularly on weekends when no activities were scheduled. Staff acknowledged the resident's behavior but did not attempt to involve him in any activities. Another resident, also with dementia, was observed sitting in a common area without any engagement or activities offered. The resident's care plan indicated a preference for fresh air and religious activities, but no such activities were provided. Staff members, including CNAs, confirmed that they were not conducting activities on weekends, and the activity calendar showed a lack of scheduled activities during the observed times. A third resident, with dementia and COPD, expressed a desire for activities but reported that no one invited him to participate. The Activity Director admitted to being the only staff member responsible for activities during weekdays, leaving weekends without structured activities. A fourth resident, with a care plan emphasizing the importance of music and outdoor activities, was observed pacing and expressing a desire to go outside, yet no staff engaged him in any activities. The facility's policy on activities was not adhered to, as staff failed to provide a comprehensive program that met the residents' needs.
Failure to Follow Pureed Menu for Residents
Penalty
Summary
The facility failed to adhere to the prescribed pureed menu for eight residents who were on pureed or liquidized pureed diets. On the specified date, the cook, identified as V20, was observed preparing the pureed meal but did not include pureed cornbread as required by the menu. Instead, only pureed BBQ turkey, creamed corn, and dessert were prepared and served. This omission was confirmed by the Dietary Manager, V21, who acknowledged that the menu should have been followed. As a result, residents did not receive the complete meal as indicated by their dietary requirements, specifically lacking the pureed cornbread component.
Failure to Include Bed Hold Policy in Hospital Transfer Packet
Penalty
Summary
The facility failed to ensure that a bed hold policy was included in the resident's packet of information for a resident who was transferred to the hospital. The deficiency was identified during a review of the facility's procedures for handling hospital transfers. The resident, identified as R33, experienced a change in condition with oxygen saturation levels dropping to 86 percent, prompting a transfer to the emergency room. The nurse practitioner was notified, and the resident's power of attorney was informed, with necessary paperwork faxed to the hospital. During the investigation, it was revealed that the facility's bed hold policy was not included in the packet of information sent with the resident to the hospital. The Registered Nurse, V17, was unsure if the bed hold policy was included, and the Administrator, V1, confirmed that the policy was not sent with the resident. The Administrator explained that the bed hold policy used to be included in the packet but was removed due to the packets becoming too thick. The facility's undated Bed Hold Policy and Readmission document states that written notification of the bed hold policy should be provided to the family or legal representative within 24 hours of transfer, and a copy should accompany the resident to the hospital.
Failure to Implement Speech Therapy Recommendations for Dysphagia
Penalty
Summary
The facility failed to implement speech therapy recommendations for a resident with moderate oral/pharyngeal dysphagia, leading to a deficiency in care. The resident, who was on droplet/contact precautions, was observed on two separate occasions with meals that did not align with the recommended diet for her condition. Despite having a regular diet listed on her diet card, the speech therapy evaluation recommended a downgrade to a mechanical soft consistency and nectar thick liquids due to new onset of coughing and choking during oral intake. The Licensed Practical Nurse was unaware of any swallowing problems, and the Administrator acknowledged that the speech therapy recommendations were not communicated to the nursing staff. The Physician Order Sheets confirmed the resident was still on a regular diet, contrary to the speech therapy's recommendations. The facility's Management of Dysphagia Policy emphasizes the importance of appropriate management to prevent complications, yet the necessary dietary adjustments and swallowing strategies were not implemented for the resident.
Failure to Maintain Resident's Adaptive Equipment
Penalty
Summary
The facility failed to ensure that a resident's adaptive equipment was functioning properly, which affected the resident's ability to maintain or improve range of motion. The resident, who had a history of stroke and hemiplegia, was observed sitting in a wheelchair with a broken arm trough that was supposed to support his left arm. The resident reported that the arm trough had been broken for several months, and although he had informed the staff, it had not been repaired. This lack of functioning equipment led to the resident's left arm dangling by his side, potentially impacting his comfort and positioning. The restorative staff member, upon being informed of the issue, was unaware that the adaptive device was broken and confirmed that the arm trough was not correctly positioned for use. Further inspection revealed that the trough did not fit the wheelchair properly. The facility did not have a policy on the use and care of adaptive equipment, which contributed to the oversight and delay in addressing the resident's needs. This deficiency highlights a lapse in ensuring that necessary equipment is maintained and functional for resident care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents, leading to deficiencies in infection control. For one resident, there was no sign posted on the door indicating the need for enhanced barrier precautions, and a CNA provided incontinence care without wearing a gown, despite the resident having an open pressure ulcer on the coccyx. The Assistant Director of Nursing confirmed that the resident should have been on enhanced barrier precautions due to the wound, but the Physician Order Sheets did not reflect this requirement. In another instance, a resident with a urinary catheter had an Enhanced Barrier Precaution sign posted inside the room, but a CNA assisted with the resident's leg bag without wearing a gown. The RN confirmed that the resident was on enhanced barrier precautions due to the urinary catheter, and staff were required to use gowns and gloves for catheter care. The facility's policy mandates clear signage and the use of personal protective equipment for high-contact resident care activities, which was not consistently followed in these cases.
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Illustrative
What surveyors actually found near you
We read the 82 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 Savanna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Mt Carroll | 7.9 mi | ★★★★★ | 0 | 0 |
| Eagle Point Nursing And Rehabilitation | 15.3 mi | ★★★★★ | 7 | 0 |
| The Alverno Health Care Facility | 16.7 mi | ★★★★★ | 8 | 0 |
| Allure Of Stockton | 18.7 mi | ★★★★★ | 0 | 0 |
| Mill Valley Care Center | 18.9 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.