Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Grove Health & Rehab Ctr, The during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, bilateral lower extremity contractures, osteopenia, and prior fractures, who required a full mechanical lift with two staff for transfers, was injured during a lift transfer when CNAs raised her from a wheelchair with her legs crossed and the lift positioned closer than usual, without the foot board in place. As the resident was elevated, her contracted lower legs, resting one atop the other, struck the enclosed motor of the lift, causing skin tears and later‑identified bruising, swelling, and tenderness. Subsequent imaging showed fractures of the right distal tibia and fibula and the left distal fibula. Facility records and hospital documentation attribute the injuries to the resident’s leg being hit on the lift during the transfer, reflecting a failure to ensure safe positioning and use of the mechanical lift in accordance with the facility’s transfer policy.
A resident with multiple cardiac and respiratory comorbidities, documented as cognitively intact and designated as full code by physician orders, POLST, and care plan, was found unresponsive without pulse or respirations by a CNA, who notified an LPN. The LPN, who later admitted he did not follow protocol and had not checked the medical record, assumed the resident was a no code based on appearance, told the CNA the resident was DNR, and did not initiate CPR. A second LPN was called to verify death, questioned whether CPR was needed, confirmed absence of heart sounds and respirations, but also did not start CPR; only later did this nurse review the chart, confirm the full-code status, and report the issue. The physician, DON, and Administrator all stated they would have expected CPR to be initiated in accordance with the resident’s documented wishes and facility CPR policy.
Multiple residents experienced misappropriation and tampering of their prescribed narcotic medications when several bottles of liquid morphine, used for pain, shortness of breath, and air hunger, were found to be clear and watery instead of the usual pink and viscous solution after prior counts and administrations had confirmed the correct appearance. In a separate event, an entire card of hydrocodone-acetaminophen (Norco) ordered three times daily for a hospice resident with chronic back pain, heart failure, and dysphagia went missing and was never located, despite narcotic counts confirming its prior presence. Facility documentation and staff interviews show that these medications were altered or disappeared between routine narcotic counts, and the individual responsible was not identified, resulting in misappropriation of residents’ medications.
The facility failed to consistently serve meals at appetizing temperatures, as shown by repeated resident council reports and grievances over several months that food was cold or not hot enough at mealtimes. Two residents interviewed reported that their food, including vegetables, was sometimes or consistently cold. These concerns persisted despite a facility policy requiring food to be palatable, attractive, and served at safe and appetizing temperatures.
A CNA left a dependent, cognitively impaired resident unattended during incontinent care while the bed was raised, and the resident rolled off the bed and fell. The resident was later transferred to the ER and diagnosed with an intracranial hemorrhage/right frontal lobe hemorrhage. Staff interviews confirmed residents should never be left unattended during incontinent care.
Two residents experienced significant delays in call light response, with one developing a pressure ulcer and another falling while attempting to self-transfer due to long wait times. Ongoing concerns about call light response were documented in resident council meetings, and the facility's policy requires timely responses.
Failure to protect residents from physical abuse: A resident with dementia and a history of hitting others struck another resident with a book after a hallway interaction, according to staff interviews and the facility investigation. The other resident also had dementia and severe cognitive impairment. The facility’s investigation noted the contact to the head, while staff accounts described the resident hitting the other resident in the shoulder and also striking staff during the same incident.
Mechanical Lift Sling Not Secured During Transfer: A resident who was cognitively intact and dependent on staff for transfers fell from a mechanical lift when the sling loops/straps were not attached properly. The resident reported fear of lift transfers and said the sling loops were rotten; the resident’s daughter stated staff said the resident was lowered to the floor when the sling straps came loose. The nurse note documented that staff did not ensure the sling loops were properly attached during the transfer.
Two residents with cognitive impairments were involved in separate incidents where they were physically struck by other residents, as witnessed and documented by staff. In both cases, the residents involved had documented histories of cognitive impairment, and the facility failed to prevent these occurrences of physical abuse, despite having policies in place to protect residents from such harm.
A facility failed to notify a resident's legal guardian of a change in medication dosage. The resident, with moderate cognitive impairment, had her Gabapentin dosage adjusted due to drowsiness, but the guardian was not informed as required by facility policy. This oversight was confirmed through interviews and a review of the resident's medical records.
A resident was discharged with incorrect medications, including those belonging to another resident, due to a failure in verifying medication accuracy and documenting doses. The facility's discharge process did not adhere to its policy, resulting in a deficiency.
A resident with a history of falls and mild cognitive impairment sustained a cervical fracture and required sutures after falling due to a bedside table being out of reach. The room was also cluttered with unsecured oxygen cylinders, contributing to another fall. The facility failed to adhere to its policy of maintaining a safe environment, resulting in these incidents.
A resident with severe cognitive impairment and a history of femur fracture experienced a 9.09% weight loss over less than three months due to the facility's failure to assess, monitor, and implement necessary interventions. Despite the resident's decreased appetite following a COVID-19 diagnosis, staff were unaware of the ongoing weight loss, and the dietician was not informed of the continued decline. The facility's policy for evaluating negative weight trends was not effectively followed.
A resident with a history of seizures did not receive the prescribed oxcarbazepine due to a medication error at the LTC facility. The resident missed 28 doses, resulting in 10 seizures and eventual hospitalization. The error occurred when an LPN misread the medication order, leading to its premature discontinuation. The DON confirmed the error, and the Medical Director noted that medications should be administered as ordered.
The facility failed to provide dignified feeding assistance to five residents, as CNAs were observed standing while feeding them, contrary to the facility's policy. The residents, who required assistance due to cognitive impairments or physical limitations, were not fed in a manner that respected their dignity, as confirmed by interviews with other CNAs and the facility's policy on meal assistance.
The facility failed to discard expired blood glucose monitor control solutions for four residents who required regular blood glucose checks due to diabetes mellitus. An inspection revealed that the control solution had expired, and the facility's policy mandates proper equipment checks, which were not followed. The administrator noted that the nurse responsible should ensure control solutions are not expired.
The facility failed to follow infection control protocols, with CNAs neglecting hand hygiene and proper PPE use. CNAs did not sanitize hands between glove changes during care for residents with infections and on enhanced barrier precautions. Additionally, PPE was improperly donned, and gloves were not changed between tasks, risking cross-contamination.
The facility failed to provide adequate incontinent and peri care for four residents, leading to hygiene deficiencies. CNAs did not properly cleanse, rinse, or dry residents' skin, and failed to change gloves during care. These actions were inconsistent with the facility's policy to maintain cleanliness and prevent infections.
A resident with severe cognitive impairment and a need for eating assistance was not adequately supported by staff, leading to significant weight loss. Despite the care plan indicating a need for supervision during meals, the resident was not prompted to eat by staff and only received help from a table mate. The facility's policy on meal assistance was not followed, and there was a lack of awareness and communication among staff regarding the resident's nutritional needs.
The facility failed to promote residents' dignity by not answering call lights and addressing residents' needs in a timely manner. Multiple residents reported long wait times for call light responses, particularly during the evening shift, despite the facility's policy requiring timely responses.
The facility failed to provide sufficient staff, particularly during evening and night shifts, resulting in long wait times for resident assistance. Multiple residents with various medical conditions reported delays, with one waiting four hours for a call light response. Staffing records and interviews confirmed that CNA levels were often below required levels, leading to compromised resident care.
The facility failed to provide complete incontinent care for two residents, both severely cognitively impaired and dependent on staff for toileting hygiene. Observations revealed that essential areas were not cleansed, increasing the risk of urinary tract infections. The DON confirmed that all soiled areas should be thoroughly cleansed.
Improper Mechanical Lift Positioning Causes Resident Leg Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe full mechanical lift transfer, resulting in a resident sustaining multiple fractures. The resident had severe cognitive impairment, was dependent on staff for ADLs, and had documented contractures of both knees and ankles, a history of falls, osteopenia, and prior fractures of the right tibia and left fibula. Her care plan required a full mechanical lift with two staff for transfers and identified an alteration in musculoskeletal status related to existing fractures and osteopenia. On the date of the incident, CNAs were transferring the resident with a full mechanical lift when her leg struck the motor of the lift. The facility’s fall investigation and staff interviews document that the resident’s legs were crossed, as they typically were due to contractures, and that the foot board of the lift was not in place. The lift was positioned closer than normal to the resident, and when she was raised from the wheelchair, her lower legs, which lay one on top of the other because of contractures, came into contact with the enclosed motor of the lift, causing skin tears to the right shin. The resident was lowered back into the wheelchair, repositioned, and then transferred to bed using the lift. Subsequent nursing documentation noted bruising, swelling, and tenderness of the resident’s right lower extremity in the same area where her leg had been caught on the lift. X‑rays ordered after these findings revealed a distal tibial fracture, and hospital imaging further identified mildly displaced transverse fractures of the right distal tibial and fibular shafts, as well as an acute left distal fibular shaft fracture. Hospital records state that the nursing home reportedly hit the resident’s leg while using the lift. The facility’s transfer policy required nursing staff to ensure safe transfer techniques when using devices such as Hoyer lifts, but the positioning of the resident and the absence of the foot board during the lift transfer led to the resident’s legs striking the lift motor and sustaining fractures.
Failure to Initiate CPR for a Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate CPR in accordance with a resident’s documented full code status, physician orders, POLST, and care plan. The resident had multiple diagnoses including hypokalemia, type 2 diabetes mellitus, emphysema, cerebellar stroke syndrome, and congestive heart failure, and was documented as cognitively intact. The physician’s orders and POLST form specified attempt resuscitation/CPR and full treatment, and the care plan stated that CPR would be initiated in the event of cardiac arrest and continued until EMS arrival or a physician order to stop. The resident’s daughter, who was POA, reported that the resident remained alert and oriented until death and had reiterated within the last year that she wished to remain a full code. On the day of the incident, a CNA found the resident unresponsive, without breathing or a pulse, at approximately 8:20 AM and notified the assigned LPN. The CNA reported that the LPN told her the resident was a DNR. The LPN went to the room, verified the resident was not breathing, and did not initiate CPR. Another LPN was called to verify death; as she went to the room, she asked if CPR was needed and believed the first LPN went to check the medical record for code status. The second LPN confirmed there were no heart sounds or respirations and did not initiate CPR. The progress note later documented that the CNA had notified the nurse around 8:20 AM that the resident was no longer breathing or had a pulse, and that another nurse verified there was no pulse/heartbeat and no breathing activity. Subsequently, the second LPN overheard the first LPN on the phone with the physician stating that the resident was a full code. After this, the second LPN reviewed the physician’s orders and confirmed the resident was indeed a full code and reported the issue to the DON. The first LPN told surveyors he did not follow protocol, assumed the resident was a no code based on her appearance, did not review her paperwork to verify code status, and stated he had only received two days of orientation. The DON and Administrator both stated they would have expected nurses to follow facility protocols and administer CPR, and the resident’s physician stated he would have expected the nurse to honor the resident’s wishes and initiate CPR. The facility’s CPR policy required that if an individual is found unresponsive and sudden cardiac arrest is likely, staff should begin CPR and verify code status, initiating basic life support unless a valid DNR order is verified.
Removal Plan
- Re-educate all licensed and direct care staff on CPR requirements, including initiation unless a valid DNR order is present
- In-service all staff on resident code status and where to check code status
- Check off all agency staff on knowledge of CPR and knowledge of code status before working
- Verify all residents' code status to ensure accuracy and accessibility
- Remove any staff involved from resident care pending re-education and competency validation
- Complete hands-on CPR return demonstrations for all staff
- Check emergency equipment (crash cart, oxygen) and confirm it is functional
- Review policy to ensure it clearly requires initiation of CPR unless a valid DNR order is verified
- Add code status verification to shift report and electronic medical record review
- Assign HR responsibility for CPR compliance and education
- Schedule routine mock code drills
- Incorporate CPR requirements into orientation for all new hires
Misappropriation and Tampering of Residents’ Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their prescribed narcotic medications. On one occasion, a nurse identified that several bottles of liquid morphine intended for residents were discolored and had a different consistency than usual. Facility documentation and staff interviews state that morphine in seven bottles, associated with four residents, appeared clear and watery instead of the usual pink and more viscous solution. Narcotic counts conducted around shift changes did not initially show discrepancies, and staff verified that the morphine had been the correct pink color when administered on prior shifts, indicating that the contents were switched to a clear liquid sometime after the last accurate count. The affected residents were receiving morphine for significant pain and symptom management. One resident had an order for concentrated morphine sulfate 20 mg/mL, 0.25 mL by mouth every hour as needed for pain or shortness of breath and had a diagnosis of polyneuropathy. Another resident was ordered morphine sulfate 10 mg/5 mL, 0.25 mL every two hours as needed for pain or shortness of breath, with diagnoses including partial intestinal obstruction and palliative care. A third resident had an order for morphine sulfate 20 mg/5 mL, 0.25 mL every two hours as needed for severe pain or air hunger and a diagnosis of compression fracture of the thoracic vertebra. A fourth resident was ordered concentrated morphine sulfate 100 mg/5 mL, 0.25 mL every hour as needed for pain, with diagnoses including diabetic neuropathy and a history of healed traumatic fracture. Staff interviews and facility reports confirm that the morphine for these residents had been altered and that the liquid in the bottles did not match the expected color and viscosity. A separate incident involved misappropriation of a different resident’s hydrocodone-acetaminophen (Norco). This resident, who had chronic back pain, was on hospice for heart failure and dysphagia and had an order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth three times daily for pain, not to exceed 4 g/day. Facility documentation and staff interviews state that an entire card of 60 hydrocodone tablets for this resident went missing over a period of days. Narcotic counts before and after the disappearance confirmed that the card had been present during one count and was no longer present at a subsequent count, and the card was never located. In both the morphine and hydrocodone incidents, the facility’s own reports and staff statements confirm that residents’ prescribed narcotic medications were either altered or missing and that the responsible individual was not identified, resulting in misappropriation of residents’ personal property in the form of their medications.
Failure to Consistently Serve Meals at Appetizing Temperatures
Penalty
Summary
The facility failed to ensure food was prepared and served at an appetizing temperature, affecting two residents reviewed for dietary services. Resident council minutes from three consecutive monthly meetings documented ongoing concerns that food was cold or not hot enough at mealtimes. Multiple grievances over the same period also reported that food was cold or not hot enough during meals. During interviews, one resident stated that the food is sometimes cold, especially vegetables, and another resident stated that the food is cold. The facility’s written policy on food palatability requires that food be prepared to conserve nutritive value, flavor, and appearance, and that it be palatable, attractive, and served at safe and appetizing temperatures, but the repeated resident complaints and interview statements showed this standard was not consistently met. The census at the time of the survey was documented as 143 residents, and the deficiency was identified through review of resident council minutes, grievance records, and resident interviews, which collectively demonstrated a pattern of concerns about food temperature despite the existence of a policy requiring food to be served at safe and appetizing temperatures.
Unsafe Incontinent Care Resulted in Resident Fall From Bed
Penalty
Summary
The facility failed to provide a safe transfer for one resident reviewed for transfers. The resident had diagnoses including unspecified sequelae of cerebrovascular disease, hemiplegia and hemiparesis following cerebrovascular disease, dementia, and insomnia, and the MDS documented moderate cognitive impairment and dependence for rolling left and right. The care plan identified the resident as a high fall risk due to confusion, gait and balance problems, a history of syncope, seizure disorder, stroke with right-sided weakness, falls, weakness, unsteady gait, and bowel/bladder incontinence. During incontinent care, a CNA reported the resident had a large bowel movement and left the room to get toilet paper while the resident was on the bed. The resident then fell off the bed and was sent for evaluation; the health status note documented no immediate pain or head abnormalities at the time, but the resident was later transferred to the emergency room and diagnosed with a right frontal lobe hemorrhage/intracranial hemorrhage. Staff interviews stated they were never to leave a resident unattended during incontinent care and that if supplies were needed, the resident should not be left alone with the bed raised.
Delayed Call Light Response Leads to Resident Harm and Complaints
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for two out of three residents reviewed for accommodation of needs. One resident, who is dependent on staff for toileting and has a stage 2 pressure ulcer, reported having to press her call light multiple times and waiting over two hours for assistance, which she attributed to the development of her bedsore. This resident also attends dialysis three times a week and requires prompt assistance upon return due to fatigue. Another resident, with a history of stroke and left-sided hemiparesis, reported waiting one to two hours for call light responses, leading her to attempt self-transfer, resulting in a fall. She also reported delays in assistance after incontinence episodes. Resident Council minutes from multiple months documented ongoing concerns about long call light wait times, including staff walking by active call lights without responding and call lights being turned off without providing assistance. The facility's policy requires call lights to be answered within a reasonable amount of time. The administrator acknowledged that complaints about call light response times have been raised in resident council meetings, and audits and education have been conducted in response.
Failure to Protect Residents From Physical Abuse
Penalty
Summary
The facility failed to ensure physical abuse did not occur for 1 of 2 residents reviewed for abuse. R112, admitted 10/10/2023, had diagnoses including heart failure, dementia, anemia, dysphagia, and hypertension, and was documented as moderately cognitively impaired on the MDS. R88, admitted 5/12/2023, had diagnoses including dementia, type 2 diabetes, osteoarthritis, dysphagia, and hearing loss, and was documented as severely cognitively impaired on the MDS. Both residents had care plans addressing behaviors related to dementia, including R112’s history of hitting others and R88’s hollering out behavior. The facility’s investigation documented that staff reported R112 had a hold of a puzzle book that made contact with R88 on the right side of her head. Additional staff interviews described that R88 bumped into R112 in the hallway, after which R112 took her book and hit R88 in the shoulder area; staff separated the residents and notified the nurse. One CNA interview also stated R112 hit another resident with her book twice and then hit staff while yelling and using inappropriate language. The facility concluded the allegation of willful physical abuse was unsubstantiated, and the abuse policy stated residents are to be protected from abuse by anyone, including other residents.
Mechanical Lift Sling Not Secured During Resident Transfer
Penalty
Summary
The facility failed to attach a mechanical lift sling in the appropriate manner for one resident, R12, during a transfer, resulting in R12 falling from the mechanical lift. R12’s record shows an admission date of 03/01/2025 and diagnoses including acute osteomyelitis of the right humerus, arthritis due to other bacteria of the right elbow, an unspecified fracture of the upper end of the right humerus with routine healing, and low back pain. Her MDS indicates she is cognitively intact, dependent on staff for toileting, showering, lower body dressing, rolling, and transferring, and she is frequently incontinent of urine and always incontinent of bowel. R12 stated she was afraid of transferring with the mechanical lift and reported that she fell because the loops on the sling were rotten and she fell to the floor. Her daughter stated that R12 fell from the mechanical lift sometime last year and that staff told her the resident was lowered to the floor when the sling straps came loose. The nurse progress notes document that staff transferred R12 using a mechanical lift without ensuring the loops to the sling were attached properly, and staff were educated. The facility’s transfer policy states that nursing staff are responsible for safe transfer techniques and that when using a mechanical lift, the sling must be properly positioned and the straps securely placed in the strap holder.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents for two individuals with cognitive impairments. In one incident, a resident with cerebral palsy and moderate cognitive impairment alleged that her roommate, who was severely cognitively impaired, hit her in the face. This was corroborated by a certified nurse aide who witnessed the event. Documentation shows that the resident was able to recall the incident and requested a new roommate, while the alleged aggressor was noted to have a history of hitting. Both residents were assessed, and no signs of psychosocial or mental anguish were documented at the time. In a separate incident, another resident with severe cognitive impairment was reported to have been struck on the head by a fellow resident, also with severe cognitive impairment, in a hallway. The alleged aggressor denied hitting but admitted to possibly bumping wheelchairs. Staff documentation indicated that the aggressor also attempted to hit a nurse and used inappropriate language after being confronted. Care plans and health status notes confirm the altercation and the cognitive status of those involved. The facility's abuse policy requires protection from abuse, but these incidents demonstrate a failure to prevent resident-to-resident physical abuse.
Failure to Notify Guardian of Medication Change
Penalty
Summary
The facility failed to notify a resident's legal guardian of a change in medication for one of the residents reviewed. Specifically, the resident, identified as R2, experienced a change in her Gabapentin dosage due to it causing drowsiness. The Registered Nurse, V6, acknowledged that she did not inform R2's daughter and legal guardian, V15, about the medication adjustment, despite recognizing that she should have done so. This oversight was confirmed during interviews with both R2 and V15, who stated they were not informed of the change. R2's medical records indicate that V15 was appointed as her legal guardian by the court, and R2 has a moderate cognitive impairment with a BIMS score of 11. The facility's policy requires documentation of any changes in a resident's condition, including notifying family and physicians, which was not adhered to in this case. The lack of notification was further evidenced by the absence of documentation in R2's progress notes regarding the addition of Neurontin, highlighting a failure in communication and adherence to the facility's documentation policy.
Medication Discharge Error
Penalty
Summary
The facility failed to verify the accuracy and number of doses of medications sent home with a resident upon discharge. This deficiency was identified during an interview and record review, where it was found that a resident, referred to as R4, was discharged with medication cards that included medications belonging to another resident, R5. The Clinical Manager, V8, confirmed that R4's caregiver brought back medication cards that included seven different medications intended for R5. The Director of Nursing, V2, acknowledged that the nurse responsible for R4's discharge mistakenly included R5's medications, and this was discovered three days after R4's discharge when R4 visited a physician's office. The facility's discharge process was found lacking as it did not document the number of doses of each medication sent with the resident. R4's discharge plan indicated that medication reconciliation was completed, but it failed to specify the number of doses discharged. R4's clinical record noted severe cognitive impairment, which underscores the importance of accurate medication management. The facility's policy required verification of medication labels against physician orders and documentation of the number of doses, but this was not adhered to, leading to the deficiency.
Failure to Maintain Safe Environment Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, resulting in a significant injury. The resident, who was admitted with diagnoses of repeated falls, mild cognitive impairment, and was under palliative care, sustained a cervical fracture and required sutures after falling while attempting to use a urinal at the bedside. The fall occurred because the bedside table, which held the urinal, was not placed within reach, causing the resident to lose balance and fall when trying to access it. Additionally, the resident's room was found to be cluttered with unsecured oxygen cylinders, which posed a further risk of injury. The presence of these cylinders was not adequately addressed by the facility staff, as they were left in the room despite being unnecessary for the resident's care. This clutter contributed to another incident where the resident fell and was found with his head leaning on the oxygen tanks, although he did not sustain serious injury in this instance. The facility's policy on accidents and incidents required immediate investigation and intervention, but the failure to maintain a clutter-free environment and ensure personal items were within reach indicates a lapse in adherence to these protocols. The resident's care plan had interventions to keep the environment free from clutter and personal belongings within reach, but these were not effectively implemented, leading to the resident's falls and injuries.
Failure to Prevent Resident's Weight Loss
Penalty
Summary
The facility failed to adequately assess, monitor, and implement interventions to prevent weight loss in a resident identified as R323. This resident, who was admitted with a fracture of the neck of the left femur, unspecified fall, and unspecified dementia, experienced a 9.09% weight loss over a period of less than three months. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for supervision or assistance with eating. Despite these needs, the care plan only documented the requirement for set-up and assistance as needed, without specific interventions to address the resident's nutritional needs. Interviews and observations revealed that staff, including certified nursing assistants and the assistant director of nursing, were not fully aware of the resident's ongoing weight loss. The dietician, who was responsible for reviewing weight records monthly, was not informed of the continued weight loss after the resident's initial decrease in appetite following a COVID-19 diagnosis. Although nutritional shakes and supplements were initiated, no new interventions were implemented for the current month. The facility's policy required evaluation of negative weight trends, but this was not effectively carried out, leading to the resident's significant weight loss.
Failure to Administer Prescribed Seizure Medication
Penalty
Summary
The facility failed to administer physician-prescribed medication to a resident, identified as R223, who was admitted with diagnoses including metabolic encephalopathy, convulsions, and schizophrenia. The resident was cognitively intact and had been prescribed Trileptal (oxcarbazepine) by their neurologist to manage breakthrough seizures. The order was to start with 300 mg twice a day for one week, then increase to 600 mg twice a day. However, the medication was not administered as prescribed, resulting in the resident missing 28 doses of oxcarbazepine. During the period from August 2 to August 11, 2024, the resident experienced 10 seizures and was eventually discharged to the hospital. The resident's health status notes document multiple instances of seizures, including one witnessed by a nurse practitioner, and subsequent hospital visits. The hospital records indicated that the resident's seizures were likely due to suboptimal management of her medications while in the nursing home, as she was not receiving the prescribed dose of oxcarbazepine. The Director of Nurses (V2) investigated the discontinuation of the medication and found that a Licensed Practical Nurse (V33) had misread the order, leading to the premature discontinuation of the medication. The Medical Director (V34) acknowledged that the medication should have been administered as ordered, although he could not definitively state if the lack of medication directly harmed the resident due to the complexity of her case. The facility administrator (V1) expressed uncertainty about which policy would address this medication error but emphasized that medications should be given as prescribed.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to provide assistance during feeding in a dignified manner for five residents. Observations revealed that CNAs were standing while feeding residents, which is against the facility's policy that requires staff to sit while assisting residents with meals. This was observed during the noon meal in the dining room, where CNAs were seen standing and feeding residents from a spoon, sanitizing their hands, and then feeding another resident. This included residents who were dependent on staff for eating due to cognitive impairments or physical limitations. The residents involved had various medical conditions, including dementia, Alzheimer's, metabolic encephalopathy, and type 2 diabetes. Their care plans documented the need for one-person physical assistance during meals. Despite this, the CNAs did not adhere to the facility's policy of sitting while feeding, which was confirmed by interviews with other CNAs who stated that they are supposed to sit while feeding residents. The facility's policy and a pamphlet on residents' rights emphasize the importance of providing services that maintain residents' physical and mental health and satisfaction, which was not upheld in these instances.
Expired Blood Glucose Control Solutions Not Discarded
Penalty
Summary
The facility failed to discard expired blood glucose monitor control solutions for four residents who were reviewed for medication storage. During an inspection of the North South medication cart, it was observed that the blood glucose machine High Control Solution had expired. The facility's list of residents receiving blood glucose monitoring included four individuals who were affected by this oversight. These residents had physician orders for regular blood glucose checks due to diabetes mellitus, with varying frequencies ranging from four times a day to once at bedtime. The facility's policy on obtaining blood glucose levels requires ensuring that equipment and devices are functioning properly, which includes performing calibrations or checks as instructed by the manufacturer or the facility. However, the administrator acknowledged that the nurse responsible for calibration should ensure that control solutions are not expired, indicating a lapse in adherence to this policy.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in hand hygiene and the use of personal protective equipment (PPE). On multiple occasions, certified nursing assistants (CNAs) did not perform hand hygiene before donning and after doffing gloves, which is crucial to prevent cross-contamination. For instance, after transferring a resident with a urinary tract infection and hemiplegia, CNAs did not sanitize their hands between glove changes while providing perineal care. Similarly, another CNA failed to sanitize hands before donning gloves and did not secure a gown properly, which led to the gown touching a resident's bed during care. This resident was on enhanced barrier precautions due to a colostomy, indicating a higher risk of infection. Additionally, there were instances where CNAs did not change gloves between tasks, such as during incontinent care, leading to potential cross-contamination. One CNA used the same gloves to provide care and then touched other surfaces and applied barrier cream to a resident. Another CNA did not change gloves or perform hand hygiene after providing peri-care to a resident with dementia and a femur fracture, who was also on enhanced barrier precautions. The facility's policies on hand washing, incontinence care, and isolation equipment were not followed, contributing to these deficiencies.
Deficiencies in Incontinent and Peri Care
Penalty
Summary
The facility failed to provide complete incontinent and peri care for four residents, leading to deficiencies in maintaining hygiene and preventing infections. For one resident, a CNA did not dry the cleaned areas after using a rinse-free peri wash and improperly cleansed the rectal area from back to front, leaving soapy suds on the skin before fastening a new brief. This resident had a history of urinary tract infection and required assistance with peri-care to remain clean and dry. Another resident, who required substantial assistance with toileting hygiene, was not provided with proper hand hygiene by the CNA, who failed to change gloves after wiping the resident and did not dry the peri region before dressing the resident. This resident had a diagnosis of dementia and a fracture, necessitating careful assistance with hygiene to prevent skin issues. Additional deficiencies were observed with two other residents. One resident did not have the labia separated and cleansed during care, and the peri area was not dried before applying a new diaper. Another resident was not rinsed or dried properly after cleansing, and the CNA used the same gloves to touch various surfaces and apply barrier cream, compromising hygiene. These actions were contrary to the facility's incontinence care policy, which mandates washing and drying all soiled skin areas to prevent irritation and odor.
Failure to Provide Eating Assistance
Penalty
Summary
The facility failed to provide necessary eating assistance to a resident, identified as R323, who was admitted with a diagnosis including a fracture of the neck of the left femur and unspecified dementia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for supervision or touching assistance with eating. Despite this, observations on a specific date revealed that R323 was not prompted by staff to eat during a meal, and only received assistance from a table mate. The resident's care plan documented a self-care deficit requiring assistance with activities of daily living, including eating, but this was not adequately provided. The resident experienced significant weight loss, documented as a 9.09% decrease from July to September. Interviews with staff, including a CNA and the assistant director of nursing, revealed a lack of awareness regarding the resident's continued weight loss and insufficient communication about the resident's nutritional needs. The dietician was also unaware of the increased weight loss and had not initiated new interventions for the resident. The facility's policy on providing meal assistance was not followed, as staff failed to encourage or assist the resident with eating, contributing to the deficiency.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to promote residents' dignity by not answering call lights and addressing residents' needs in a timely manner for four of the eleven residents reviewed. Resident 1, who is cognitively intact, reported that it takes hours for call lights to be answered. Resident 5, who is moderately impaired, stated that she often sits in the doorway of her room to get staff attention because call lights take a while to be answered. Resident 6, who is cognitively intact and has diagnoses of hemiplegia, paralysis, and a history of falls, mentioned that the evening shift is particularly problematic in terms of staff availability and timely response to call lights. Resident 7, who is also cognitively intact and has diagnoses including COPD and repeated falls, reported that there aren't enough staff to assist her, especially in the evenings, which delays her ability to get out of bed and receive necessary care such as changing or using the bedpan. Resident 10, who is cognitively intact and has diagnoses of syncope, repeated falls, congestive heart failure, and COPD, stated that she has had to wait 45 minutes for her call light to be answered. The Resident Council Minutes from April 2024 also document concerns about call light response times. The Assistant Director of Nursing (ADON) acknowledged that call lights are expected to be answered in a timely manner. The facility's call light policy, dated July 1, 2023, states that resident call lights should be responded to within a reasonable amount of time, which was not adhered to in these instances.
Insufficient Staffing Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, particularly during the evening and night shifts. Multiple residents reported long wait times for assistance, with one resident stating that it took four hours for staff to respond to a call light. The residents involved had various medical conditions, including hemiplegia, COPD, repeated falls, and chronic heart failure, and were cognitively intact, making them aware of the delays in care. The facility's staffing sheets confirmed that there were often only two CNAs available for halls with a significant number of residents requiring two-person assistance, exacerbating the issue of delayed care. Interviews with CNAs and the Director of Nurses revealed that the facility did not have a policy on staffing, and the current staffing levels were insufficient to meet the needs of the residents. CNAs reported that they were overworked and that residents had to wait longer for assistance due to the high number of residents requiring two-person assists. The facility's staffing records corroborated these statements, showing that the number of CNAs on duty was often below the required levels, particularly after 10 PM. This lack of adequate staffing led to delays in providing essential care to the residents, compromising their well-being.
Incomplete Incontinent Care Leading to Potential UTIs
Penalty
Summary
The facility failed to provide complete incontinent care to prevent urinary tract infections for two residents. Resident 19, who has Alzheimer's Disease and Chronic Kidney Disease Stage 3, was observed to have incomplete cleansing during incontinent care. The CNA did not cleanse the penile glans, indwelling catheter tubing, rectal area, and buttocks, which are essential areas to prevent infections. This resident is severely cognitively impaired and dependent on staff for toileting hygiene, making thorough care crucial. Similarly, Resident 20, who has Alzheimer's Disease and Down Syndrome, was also observed to receive incomplete incontinent care. The CNA failed to cleanse the inner thighs, back of the thighs, and buttocks, even though these areas were noted to be red and potentially irritated. This resident is always incontinent of bowel and bladder and is also severely cognitively impaired, requiring complete and thorough care to maintain hygiene and prevent infections. The Director of Nursing confirmed that all soiled areas should be cleansed thoroughly, including catheter tubing and the meatus for residents with indwelling catheters.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 57 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Village Healthcare Ctr | 1 mi | ★★★★★ | 7 | 1 |
| Arcadia Care Jacksonville | 1.1 mi | ★★★★★ | 1 | 0 |
| Jacksonville Skld Nur & Rehab | 1.4 mi | ★★★★★ | 2 | 0 |
| Cass County Senior Living & Rehabilitation Llc | 15.1 mi | ★★★★★ | 16 | 0 |
| Scott County Nursing Center | 17.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.