Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Waters Of Dillsboro-ross Manor, The during CMS and state inspections, most recent first.
The facility failed to act promptly on repeated Resident Council concerns about delayed call light response over multiple months. Residents reported that call lights often went unanswered for 25–60 minutes, that CNAs and nursing staff sat at the nurse’s station or in offices instead of responding, and that one resident waited an hour for help to use the bathroom while another, who could not remain in a diaper due to wound care needs, waited to be changed. Although the Activity Director and Regional Director of Operations described a process using Resident Council Action Forms to document and respond to such concerns, no action forms were completed or attached to the meeting minutes for several months in which these issues were raised, contrary to the facility’s Resident Council policy requiring timely response and Administrator monitoring.
Surveyors found multiple medication carts left unlocked and unattended, with staff and residents passing nearby, and several carts containing loose, unidentified pills and debris in the drawers. One cart held an opened Novolog vial labeled to expire after 28 days that remained in use beyond that period, and another cart contained unopened, undated Novolog and Lantus insulin pens for residents. An RN and an LPN were unable to account for loose pills or cart cleaning responsibilities, while a QMA left an unlocked cart in a hallway out of view during a med pass. Facility policy and manufacturer instructions required medications to be stored securely, dated, and in clean, orderly conditions, and leadership confirmed carts should be locked when not attended by nursing staff.
A resident with an above-the-knee amputation and a history of daily prosthesis use, including during therapy, was repeatedly observed in a wheelchair with the prosthetic leg leaning against the bed and reporting something was wrong with it. Staff, including a CNA and an LPN, confirmed the resident used to wear the prosthesis and sometimes needed assistance with applying and removing it. However, the admission MDS documented the absence of the left leg but did not note a limb prosthesis, and the resident’s care plan contained no problem, goals, or interventions related to prosthesis care or use, despite facility policy and the MDS Coordinator’s acknowledgment that such a care plan should have been in place.
A resident with a history of cataract surgery, who required eyeglasses to read and participate in activities, did not receive needed optical services in a timely manner. The resident reported confusion about multiple eye appointments and not knowing the status of obtaining eyeglasses. Review of the EHR and transportation logs showed that the resident had an ophthalmology visit and an eyeglass prescription on file, but no eyeglasses had been ordered or provided. The SSD confirmed that, contrary to usual practice where prescriptions lead to eyeglasses being ordered and delivered within weeks, this prescription was uploaded without follow-up, despite a facility policy stating residents should receive appropriate vision and hearing assistive devices.
Surveyors found that the facility did not follow infection control guidelines for urinary catheters for two residents with indwelling catheters and recent UTIs. Observations on multiple occasions showed each resident’s catheter drainage bag, with a dignity flap, lying on or touching the floor while the resident was in common areas or in a room, and no dignity bag was in place to cover the drainage bag. Staff, including an LPN, a QMA, and the ADON, stated that catheter drainage bags should not touch the floor, and facility policy indicated that proper Foley catheter care is intended to prevent catheter-associated UTIs.
A resident with heart failure, hypertension, and morbid obesity was admitted at 5'3" and 365 lbs with an order for weekly Sunday weights. The EMAR showed the resident was not weighed on one scheduled Sunday and subsequently demonstrated a 24 lb weight gain over two weeks, reaching 393 lbs, without documented follow-up or intervention. SWAT notes indicated the resident was on weekly weights, noted a 5 lb gain since admission, and later stated an updated weekly weight was needed, but no further SWAT assessments or refusals to be weighed were documented. Despite facility policies requiring weekly weights, verification of significant variances, and weekly SWAT monitoring for new admissions and significant weight changes, the ordered weekly weights were not consistently obtained and the significant weight gain was not addressed.
A resident with severe cognitive impairment and Alzheimer’s disease had an ongoing order for IM Risperdal every 14 days for delusions, but did not receive scheduled doses on two occasions because the medication was not available at the pharmacy or in the facility, and it was not stocked in the EDK. Although facility staff, including an LPN and the DON, described procedures for checking the EDK, contacting pharmacies, and notifying the provider when medications are out of stock, the clinical record lacked documentation that the physician was notified when the resident missed these doses, contrary to the facility’s out-of-stock medication policy.
A resident with diabetes had a physician’s order for Lantus insulin to be administered twice daily, but review of the EMAR over two months revealed multiple blank entries where morning and bedtime doses should have been documented. There was no corresponding documentation in progress notes to indicate whether the doses were given or omitted, nor any recorded reasons for omission. An RN confirmed that EMAR entries should never be left blank and that any omitted medication must be documented with a reason, as required by the facility’s Medication Administration policy, resulting in incomplete and inaccurate medical records.
Surveyors found that the facility failed to follow infection prevention and control practices for two residents. One resident with severe cognitive impairment, renal insufficiency, neurogenic bladder, an indwelling urinary catheter, bowel incontinence, and a G-tube had a catheter drainage bag repeatedly observed lying on the floor, and staff performing incontinence care used the same washcloth to clean feces from the back, then the front perineal area, and then the catheter tubing without changing cloths. Staff also did not wear required gowns under Enhanced Barrier Precautions while providing hygiene and G-tube care to this resident. In a separate incident, an LPN preparing medications for another resident handled narcotic pills directly with bare hands before placing them into a medication cup and administering them, contrary to infection control expectations.
A resident with severe cognitive impairment, bipolar disorder, and dementia exhibited increased physical and verbal aggression and was placed on one-on-one monitoring, after which a psychiatric NP ordered 15-minute checks for 72 hours. Monitoring forms showed one-on-one supervision and later monitoring entries but did not clearly indicate when the resident transitioned to 15-minute checks or which staff documented the resident’s location. The Social Services Director could not determine the changeover point due to use of the same form for both levels of monitoring and missing staff initials, and the DON reported that staffing patterns and perceived behavior improvement led to deviations from the ordered 72-hour 15-minute monitoring period, contrary to facility policies on 15-minute monitoring and behavioral emergencies.
Staff failed to respect a resident's right to refuse ADL care, proceeding with a shower despite repeated refusals and physical resistance, which led to distress and a physical altercation. Additionally, several residents reported missing personal items, and the facility lacked required inventory lists for residents' belongings, contrary to policy. These deficiencies were identified through interviews and record reviews involving residents with cognitive and physical impairments.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. Observations and record reviews showed incomplete documentation and lapses in wound care and monitoring.
Staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for two residents with chronic wounds. In both cases, appropriate PPE such as gowns was not used, EBP signage was missing from the residents' rooms, and there were no physician orders for EBP in the clinical records. The DON confirmed that EBP should have been in place for these residents.
A resident with moderate cognitive impairment and a history of dementia was left unsupervised outside a secured dementia unit, near an exit door, without staff present. Dietary staff were unable to access the unit and left the area, and the resident was only able to return to the unit when visitors opened the door. An LPN confirmed that supervision was required but not provided, and the facility could not produce a policy on resident supervision.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed Cyproheptadine for several days due to the medication being unavailable. Documentation did not show that the physician was notified about the missed doses, despite facility policy requiring such notification. An LPN confirmed the process for handling unavailable medications, but the necessary steps were not documented in this case.
A resident with severe cognitive impairment and multiple diagnoses developed swelling and discoloration in the right lower leg, leading to a STAT x-ray order. The x-ray was not performed until more than 12 hours later, despite staff and facility policy indicating that STAT x-rays should be completed within a few hours.
A resident with severe cognitive impairment and multiple diagnoses exhibited increased behavioral issues, specifically kicking during care, over several weeks. CNAs reported these behaviors to nurses, but the required documentation was not completed in the EMAR/ETAR or progress notes, despite a physician's order to monitor behaviors every shift and facility policies emphasizing thorough documentation.
Staff did not follow the care plan for a resident with severe cognitive impairment who was resistive and combative during care. Instead of ensuring safety and allowing time for the resident to calm down as directed, staff continued providing care, disregarding the resident's right to dignity and self-determination.
The facility failed to properly store and label insulin vials on two medication carts. On one cart, a partially full Fiasp/Aspart insulin vial lacked an open date, and a discontinued Lispro insulin vial was not removed. On another cart, two Lantus insulin vials were undated. The facility's policy requires proper storage and removal of outdated medications.
The facility failed to follow physician's orders for a resident's blood pressure medication, administering it without obtaining necessary blood pressure readings or when readings were below specified parameters. Additionally, the facility did not implement fall prevention measures for another resident, as non-skid strips were not placed near the resident's recliner despite being part of the care plan after a previous fall.
A resident with multiple health issues, including diabetes and paraplegia, developed pressure ulcers after admission to an LTC facility. Despite using pressure-reducing devices, the resident's sacral wound progressed to Stage IV. A wound culture revealed an infection, but results were delayed, leading to a late start of antibiotic treatment. The facility's policy on timely wound care was not followed.
A resident recently admitted to an LTC facility expressed dissatisfaction with the meals provided, preferring dry cereal with milk and fruit for breakfast instead of the offered options. Despite being at the facility for over two weeks, no one had inquired about his food preferences, and the Dietary Manager admitted to possibly missing him. The resident's meal intake records showed multiple instances of eating 50% or less or refusing meals, yet replacement meals were not offered as per facility policy.
A resident did not receive several prescribed medications due to the facility's failure to reorder them timely. The resident, with multiple health conditions, missed doses of medications for hypertension, GERD, diabetes, COPD, and more. The ADON indicated that the pharmacy delivered medications twice daily, but there was no monitoring of daily medication orders, leading to the deficiency.
A resident with multiple health conditions experienced a delay in wound culture processing due to missing patient identifiers on the specimen container. The lab sent an affidavit to confirm the specimen's identification, but the facility did not respond, delaying the review of results indicating bacterial growth. The facility's policy for timely lab test processing was not followed, impacting the resident's care.
An LPN failed to follow infection control guidelines during medication administration by not performing hand hygiene between interactions with two residents. The LPN assisted a resident with limited hand use and then administered medication to another resident without sanitizing her hands, contrary to the facility's policy.
A facility failed to remove a lye-based chemical drain cleaner from a resident's bathroom, resulting in the resident ingesting the chemical and sustaining injuries. The maintenance staff left the nearly empty bottle unattended after unclogging a toilet. The resident, who was cognitively intact, later handed the bottle to a staff member and complained of throat pain, leading to hospitalization for esophageal and gastric injuries.
The facility failed to provide activities for residents in the Memory Springs-Dementia Unit, affecting 13 residents. Observations showed residents were often left without engagement, despite scheduled activities. The activity aide was frequently unavailable, and CNAs were too busy with other tasks to conduct activities, leading to a deficiency in meeting residents' needs.
The facility failed to provide a homelike environment in the Memory Springs-Dementia Unit, affecting 13 residents. Observations revealed a strong urine odor in the common area and dining room, despite daily cleaning routines. The Housekeeping Supervisor and a family member confirmed the persistent odor, indicating a failure to adhere to the facility's policy on maintaining a safe, sanitary, and comfortable environment.
A facility failed to develop a care plan for a moderately cognitively impaired and edentulous resident's denture needs. The resident was observed without dentures during meals and snacks, and the care plan lacked an edentulous care plan despite the facility's policy requiring comprehensive care plans within seven days of assessment.
The facility failed to follow physician's orders for wound care and TED hose application for three residents. One resident did not receive prescribed betadine treatments for an arterial wound, while two others were frequently observed without the required TED hose, leading to visible swelling. Staff interviews revealed a lack of proper documentation and awareness regarding these orders.
The facility failed to label and store medications appropriately in two of the three medication storage refrigerators observed. Open vials of Tuberculin (TB) serum with no labels indicating when they were opened were found in the medication refrigerators on Stations 1 and 3. The ADON and an LPN could not recall when the vials were last used, and the DON confirmed that TB serum vials should be dated when opened, as per the manufacturer's instructions.
The facility failed to provide routine bathing for a severely cognitively impaired resident who was totally dependent on staff for bathing. The resident received only 12 out of the 24 planned showers or complete bed baths from January to March 2024, with no documented refusals. Staff interviews confirmed that the resident should have received two showers per week, and any refusals should have been documented and reported.
Failure to Address Repeated Resident Council Concerns About Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and follow up on resident concerns about delayed call light response that were repeatedly raised in Resident Council meetings over several months. During a Resident Council meeting held on 03/24/2026, residents reported that call lights were not answered in a timely manner and that it sometimes took up to an hour to receive assistance. Review of Resident Council meeting minutes showed that in August 2025 residents reported nursing staff were sitting in the office discussing personal matters instead of answering call lights, and that on one station it was taking 45 minutes to an hour to respond. In September 2025, residents stated they felt CNAs sat at the nurse’s station, did not respond to call lights, forgot to return, and told residents they did not have time. In October 2025, residents reported one resident waited from 11:30 p.m. to 12:30 a.m. for help to go to the bathroom, another resident waited 25 minutes for help, and another resident waited for someone to change her despite being unable to remain in a diaper due to wound care needs. In December 2025, residents again reported staff were not responding to call lights in a timely manner and that they were waiting longer than 15 minutes for assistance. Interviews and record review showed that the facility did not complete or document required follow-up to these concerns as outlined in its own Resident Council policy. The Activity Director stated she typed up concerns voiced at Resident Council meetings and distributed them to each department using a Resident Council Action Form, then attached the completed forms to the corresponding meeting minutes. The Regional Director of Operations stated that concern forms were to be completed after each Resident Council meeting, distributed to the appropriate departments, and the responses documented on the forms, which were then filed with the meeting minutes for review with residents at the next meeting. However, there were no Resident Council Action Forms completed for the August, September, October, or December 2025 meetings to show that the residents’ call light concerns were addressed. The facility’s policy “GUIDELINES FOR RESIDENT COUNCIL,” dated 06/20/2023, states that residents have the right to be involved in decisions affecting their lives, that group concerns require a timely response and resolution that satisfies the group, and that the Administrator monitors this process. The lack of completed action forms for these months demonstrates the facility’s failure to act promptly on and document resolution of the Resident Council’s call light concerns.
Improper Medication Storage and Unsecured Medication Carts
Penalty
Summary
Surveyors identified a deficiency related to improper storage and security of medications and biologicals, including insulin and oral medications, on multiple medication carts. During an initial tour, one upstairs medication cart was observed sitting in a hallway outside the nurse’s station, unlocked and unattended, while several staff members walked by before a staff member eventually locked it. When this cart was later inspected with an RN, multiple loose, unidentified pills were found in the bottom of the cart drawers, including tan, white, and green tablets; the RN identified two of the pills as Protonix and Eliquis. A second upstairs medication cart, observed with a QMA, contained an unopened and undated Novolog insulin pen for a specific resident in the top drawer, as well as an opened vial of Novolog for another resident that had been opened on 02/11/2026 and labeled to expire on 03/11/2026, but remained in use beyond that date. The drawers of this cart also contained crumbs and paper debris. The QMA stated that insulin was good for 28 days once opened. On the dementia unit, another medication cart observed with an LPN contained an unopened and undated Lantus insulin pen for a resident, along with several loose pills (round white pills, a round tan pill, and a half white pill) scattered in the drawers. The LPN reported she was unsure what the loose pills were or who was responsible for cleaning the medication carts, and indicated she attempted to clean the cart when she had time. Extended observation of the dementia unit medication cart showed it remained unlocked and unattended in a common area for over 20 minutes while residents, staff, a housekeeper, and the Maintenance Director passed by or worked near it, and the nurse remained behind a locked nurse’s station door with her back to the cart. Additionally, during a medication pass, a QMA prepared medications for a resident and left another medication cart unlocked in the hallway while going into the resident’s room, where the cart was not visible and no staff or residents were present in the hallway. In interviews, an LPN and the DON both stated that medication carts should be locked when the nurse is not present. Facility policy on medication storage required medications and biologicals to be stored safely, securely, and properly, with medication rooms, carts, and supplies locked or attended by authorized personnel, and storage areas kept clean and free of clutter. Manufacturer inserts for Novolog and Lantus, provided by the DON, described proper storage and expiration parameters for unopened insulin pens.
Failure to Develop Care Plan for Resident’s Leg Prosthesis
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan addressing a resident’s left leg prosthesis. Surveyors observed the resident, who had an above-the-knee amputation of the left leg, sitting in a wheelchair with the prosthetic leg leaning against the bed on multiple occasions. The resident reported that there was something wrong with the prosthetic leg and indicated he used to wear it. Staff interviews confirmed that the resident had previously worn the prosthesis daily, sometimes with staff assistance for putting it on and taking it off, and that he had worn it during therapy from December 2025 through February 2026. Record review showed that the resident’s admission MDS, dated 12/15/2025, documented moderate cognitive impairment and diagnoses including hypertension, diabetes, and acquired absence of the left leg, but did not indicate the presence of a limb prosthesis. The resident’s care plans, reviewed on 03/23/2026, lacked any plan of care or interventions related to the prosthetic leg. The MDS Coordinator stated she was responsible for starting baseline and admission care plans and updating them based on new orders or assessments, and acknowledged there should have been a care plan for the prosthetic leg. Facility policy required comprehensive care plans to be reviewed and updated at least quarterly and more often as needed based on changes in the resident’s condition.
Failure to Ensure Timely Optical Services for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure timely provision of optical services for a resident with visual impairment. The resident, who had previously undergone cataract removal surgery and still required eyeglasses to read, was observed sitting in her wheelchair with an activity calendar on the wall and a monthly meal menu on her bedside table, but no eyeglasses were present in the room. During interview, the resident reported needing readers to enjoy activities such as coloring and reading and described having been seen by an eye doctor, then referred to a specialist, and then referred back to the regular eye doctor, leaving her uncertain about the status of obtaining eyeglasses. Record review showed that the resident had an ophthalmology visit on 01/16/2026, and a prescription for eyeglasses from that visit had been scanned into the EHR. The Social Services Director (SSD) explained that a company routinely provided on-site ancillary vision services and that, typically, when an eye doctor examined a resident and wrote a prescription, eyeglasses would be ordered and delivered to the facility within a few weeks, after which she would distribute them to residents. Upon reviewing the records and transportation logs, the SSD confirmed the resident’s eye appointment and the presence of the eyeglass prescription in the EHR but was unsure why the prescription had been uploaded without follow-up. The SSD acknowledged that the prescription should probably have been acted on sooner. The facility’s undated policy on vision and hearing services stated that it is the organization’s standard to ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities.
Failure to Maintain Urinary Catheter Drainage Bags Off the Floor
Penalty
Summary
Surveyors identified that the facility failed to follow infection control guidelines for urinary catheters for two residents with indwelling catheters who had recent UTIs. For one resident with severe cognitive impairment, neurogenic bladder, and dependence on staff for care, multiple observations over several days showed the urinary catheter drainage bag, equipped with a dignity flap, lying on or touching the floor while the resident sat in a recliner in the dementia unit common area. On each occasion, there was no dignity bag covering the catheter bag. The resident’s clinical record documented an indwelling urinary catheter and recent treatment for UTIs, including new antibiotic orders on several dates related to a UTI, foul-smelling urine, and cellulitis. For another resident with upper and lower extremity impairments who was dependent on staff for care and reported having a recent UTI, surveyors observed the urinary catheter drainage bag, also with a dignity flap, hanging under the wheelchair with portions of the bag touching the floor in the resident’s room and in the dining room on multiple occasions. There was no dignity bag covering the catheter bag during these observations. Facility staff, including an LPN, a QMA, and the ADON, acknowledged during interviews that residents’ urinary catheter drainage bags should not touch the floor. The facility’s written policy on indwelling Foley catheter care stated that the main purpose of proper catheter care is to prevent catheter-associated UTIs.
Failure to Obtain Ordered Weekly Weights and Address Significant Weight Gain
Penalty
Summary
The deficiency involves the facility’s failure to obtain and monitor a newly admitted resident’s weekly weights as ordered and to address a significant weight gain. The resident, who was cognitively intact and diagnosed with heart failure, hypertension, and morbid obesity, was 5'3" and weighed 365 lbs on admission. The physician ordered weekly weights on Sundays beginning 03/01/2026. The EMAR showed the resident was weighed at 365 lbs on 03/01/2026, not weighed on 03/08/2026, and then weighed at 389 lbs on 03/15/2026 and 393 lbs on 03/22/2026, reflecting a 24 lb gain between 03/01/2026 and 03/15/2026. The DON stated that newly admitted residents were to be reviewed weekly in SWAT meetings for at least four weeks and that the resident’s weight should have been obtained weekly and the significant weight gain addressed, but the DON was unaware of the 24 lb gain. SWAT assessments documented on 03/06/2026 and 03/14/2026 indicated the resident was on weekly weights. The 03/06/2026 SWAT note stated the resident’s weight was up 5 lbs since admission and to monitor for further changes, and the 03/14/2026 SWAT note indicated the resident needed an updated weekly weight. The EHR contained no further SWAT assessments and no documentation that the resident refused to be weighed. Laboratory tests from 02/25/2026 showed high cholesterol and triglycerides and low red blood cells, hemoglobin, and hematocrit, and the resident was not receiving nutritional supplementation. Facility policy on obtaining residents’ weights required comparison of weights to prior values, reweighing for significant variances (e.g., 5 lbs more or less), correction and notation of incorrect weights, and adherence to weekly weight orders, while the SWAT policy required weekly monitoring of new admissions and residents with significant weight changes. These policies were not followed for this resident’s ordered weekly weights and significant weight gain.
Failure to Provide and Document Ordered Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a prescribed antipsychotic medication was available and administered as ordered for one resident. The resident had severe cognitive impairment with diagnoses including Alzheimer’s disease and anxiety, and had an open-ended physician order for Risperdal 2 ml IM every 14 days for delusions starting on 02/24/2026. Review of the EMAR for February and March 2026 showed the resident did not receive the ordered Risperdal doses on 02/24/2026 and 03/24/2026. Progress notes documented that on 02/24/2026 the medication was not available at the pharmacy and on 03/24/2026 the medication was not in the facility. The Emergency Drug Kit list did not include injectable Risperdal. Interviews and policy review further described the processes that should have been followed when medications were unavailable. An LPN stated that if a medication was not available, staff would check the EDK, contact the pharmacy or a local pharmacy, mark the medication as not available in the EMAR, call the physician, and document in a progress note. The DON stated that when medications were not available, staff were to check the EDK, order from the pharmacy, and notify the provider if a dose was missed, typically by verbal communication without documentation in the clinical record. The facility’s “Out of Stock Medications” policy required contacting alternative suppliers, notifying the physician when an ordered medication was not available, and allowing the physician to decide whether to hold or change the medication. The clinical record for this resident lacked documentation that the physician was notified when the resident did not receive the ordered Risperdal doses on 02/24/2026 and 03/24/2026.
Incomplete EMAR Documentation for Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to insulin administration for one resident. The resident had diabetes, as documented on an admission MDS dated 01/02/2026, and had a physician’s order for Lantus, a long-acting insulin, to be given as 10 units every morning between 8:00 A.M. and 10:00 A.M. and at bedtime between 8:00 P.M. and 10:00 P.M., starting 01/15/2026. Review of the resident’s February and March 2026 EMARs showed multiple blank spaces where administration of the ordered Lantus doses should have been documented. Specifically, there was no documentation of the bedtime dose on 02/01, 02/04, 02/08, 02/11, 02/15, 02/16, 03/03, 03/13, and 03/22, and no documentation of the morning dose on 02/26. During an interview, RN 8 stated there should not be blanks on the EMAR and that when medications are administered, they should be documented as given, and if not administered, the nurse should document that the medication was not given and the reason why. Review of the resident’s progress notes showed no entries explaining or addressing the missing documentation for these insulin doses. The facility’s Medication Administration policy, dated February 2017, required staff to circle initials on the MAR if a medication is not administered as ordered and to record the reason in the PRN/Omission Medication section of the MAR. The lack of documentation on the EMAR and in the progress notes for the ordered Lantus doses was not consistent with this policy and resulted in incomplete and inaccurate medical records for the resident.
Failure to Follow Infection Control Practices for Indwelling Devices and Medication Administration
Penalty
Summary
Surveyors identified failures in infection prevention and control practices involving a resident with an indwelling urinary catheter and G-tube, and another resident during medication administration. For Resident 6, observations on multiple occasions showed the urinary catheter drainage bag hanging so that several inches of the bag were in direct contact with the floor, with no clean barrier in place. The resident’s bed was positioned against the wall, and staff left the catheter bag lying on the floor after care. Resident 6 had severe cognitive impairment, renal insufficiency, neurogenic bladder, an indwelling urinary catheter, bowel incontinence, and a feeding tube while in the facility. During incontinence care for Resident 6, a QMA and a CNA entered the room, donned gloves, and removed a feces-soiled brief. The CNA cleaned feces from the resident’s backside and then, after rolling the resident onto her back, cleaned feces from the front perineal area. Using the same washcloth, the CNA then cleaned the indwelling catheter tubing without changing to a clean cloth between areas. The staff changed gloves only after completing this cleaning, then applied ointment and a clean brief. The staff did not don gowns despite a sign on the resident’s door indicating Enhanced Barrier Precautions (EBP) requiring gown and glove use for hygiene and device care. After care, the catheter drainage bag remained with six to eight inches lying on the floor by the wall. For Resident 6’s G-tube care, an LPN performed site care by washing hands, donning gloves, cleaning around the abdominal entry site with liquid-soaked gauze, and applying a split gauze dressing and tape. A moderate amount of dried blood was noted on the gauze pads used to clean the site. The LPN did not wear a gown while providing this device care, despite the posted EBP sign requiring gown and glove use for device care such as feeding tubes. In a separate incident involving Resident 7, an LPN preparing medications unlocked the medication cart and narcotic drawer, popped two pills directly into her bare hands, and then placed them into a medication cup before administering them to the resident. The Infection Preventionist later indicated staff should not touch resident medications with bare hands during medication administration.
Failure to Provide and Document Ordered 15-Minute Behavioral Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required behavioral health monitoring for a resident with significant cognitive and psychiatric conditions. A quarterly MDS assessment dated 11/21/2025 showed that Resident C was severely cognitively impaired, with diagnoses including bipolar disorder and non-Alzheimer’s dementia. A psychiatric progress note dated 01/27/2026 documented increased physical and verbal aggression toward peers and indicated the resident was on one-on-one staff monitoring. The psychiatric provider ordered 15-minute monitoring for 72 hours unless the resident was accepted by an inpatient facility. Resident Location Monitoring Forms showed one-on-one monitoring began on 01/26/2026 at 3:15 P.M. and was discontinued on 01/29/2026 at 6:00 A.M., but there was no indication of when the resident transitioned from one-on-one to 15-minute checks, nor which staff member documented the resident’s location. During interviews, the Social Services Director stated the same form was used for both one-on-one and 15-minute monitoring and acknowledged she could not determine when the change in monitoring level occurred, noting that staff initials should have been present next to every entry. The DON reported that the psychiatric NP changed the order from one-on-one to 15-minute monitoring on 01/27/2026 at 10:15 A.M., but due to already scheduled staffing, the resident remained on one-on-one monitoring until midnight that day. The DON further indicated the resident was taken off 15-minute monitoring on the morning of 01/29/2026 due to decreased behaviors and then restarted on one-on-one monitoring at 6:00 P.M. that evening when behaviors increased again. After reviewing the documentation, the DON stated the resident should have remained on 15-minute monitoring for the full 72 hours after the psychiatric visit. Facility policies on fifteen-minute monitoring and behavioral emergencies required additional supervision and continuous staff presence during behavioral episodes, with possible reduction to 15-minute checks, but the facility’s documentation and implementation did not reflect adherence to the ordered 72-hour 15-minute monitoring period.
Failure to Honor Resident Rights in ADL Care and Personal Belongings Management
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity regarding Activities of Daily Living (ADL) care and the monitoring of personal belongings. One resident, who was severely cognitively impaired and dependent on staff for bathing, reported being bruised during ADL care when staff members attempted to provide a shower despite her repeated refusals. Staff interviews confirmed that the resident was resistive to care, held onto the bed rail, and expressed not wanting a particular CNA to assist her. Despite this, staff removed her fingers from the rail and proceeded with the shower, during which the resident became upset and physically grabbed a staff member. Facility policy and staff interviews indicated that residents should not be forced to receive care if they refuse, and refusals should be documented and reported to nursing staff, but an anonymous staff member reported that staff were told not to document refusals and to provide care regardless of resident wishes. Additionally, the facility failed to maintain accurate inventory lists of residents' personal belongings. Multiple residents reported missing personal items, such as a blanket and a purse, and interviews and record reviews revealed that inventory lists were either missing or not maintained in the residents' records. The Housekeeping Supervisor was unable to locate any documentation of residents' belongings, and it was noted that the previous supervisor was responsible for this task. Facility policy required that all personal belongings be listed in the resident's chart, but this was not being followed. These deficiencies were identified through interviews, observations, and record reviews, and were found to be in violation of facility policies regarding resident rights to dignity, respect, and the retention and use of personal possessions. The issues affected several residents with varying levels of cognitive impairment and medical conditions, including heart failure, stroke, hypertension, and diabetes.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent further skin breakdown were not consistently applied, and documentation of wound care was incomplete or missing in some cases.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) during wound care for two residents. In one instance, the Assistant Director of Nursing (ADON) and a Certified Nurse Aide (CNA) provided wound care to a resident with chronic wounds without donning gowns, as required by EBP protocols. The resident's room did not have signage indicating EBP status, and there was no physician's order for EBP in the clinical record. The ADON applied treatments to wounds on two separate occasions without the appropriate use of personal protective equipment (PPE). In another case, a resident with a chronic pressure wound on the right heel received wound care from an LPN who only wore gloves and did not use a gown. The resident's room lacked EBP signage, and there was no PPE available other than gloves. The clinical record also did not contain a physician's order for EBP. The Director of Nursing confirmed that residents with chronic wounds should have been on EBP, but the required precautions were not implemented for these residents.
Failure to Supervise Resident Outside Secured Dementia Unit
Penalty
Summary
Staff failed to provide adequate supervision for a resident with moderate cognitive impairment and a history of Alzheimer's disease, non-Alzheimer's dementia, and diabetes, who resided on a secured dementia unit. On multiple occasions, the resident was observed sitting in the dining room outside the locked unit without any staff present, despite being at moderate risk for wandering according to a recent assessment. There was an exit door located approximately ten feet from where the resident was seated, and no staff were observed monitoring the area during this time. Further observations revealed that dietary staff were unable to access the locked unit and left the area without ensuring supervision for the resident. Later, the resident was able to re-enter the dementia unit only when visitors held the door open for her. Interviews confirmed that the resident should have been supervised when off the secured unit, but no staff were present. The facility was unable to provide a policy specifically related to resident supervision, and the only policy provided addressed incident and accident reporting.
Failure to Provide Timely Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including hypertension, non-Alzheimer's dementia, and malnutrition, did not receive prescribed Cyproheptadine 4 mg three times daily for itching. According to the electronic medication administration record, the medication was not available and was not administered for several consecutive days for both morning and afternoon doses. The clinical record did not contain documentation that the physician was notified about the unavailability of the medication. During an interview, an LPN described the process for handling unavailable medications, which includes contacting the pharmacy, checking the emergency drug kit, documenting the situation in the EMAR, and notifying the physician. However, in this instance, the required physician notification was not documented, and the facility's policies on pharmacy services and following physician orders were not followed.
Delay in STAT X-ray for Resident with Lower Leg Swelling
Penalty
Summary
The facility failed to obtain a STAT x-ray in a timely manner for a resident who was severely cognitively impaired and had diagnoses including hypertension, non-Alzheimer's dementia, and malnutrition. The resident was observed to have swelling and discoloration in the right lower leg, prompting a nurse practitioner to order a STAT x-ray of the knee, ankle, and extended tibia/fibula. Despite the urgent nature of the order, the x-ray was not performed until the following day, more than 12 hours after the order was placed. Interviews with nursing staff confirmed that a STAT x-ray should be obtained within a few hours, with the Assistant Director of Nursing specifying a four-hour window. The facility's policy requires that diagnostic services, including radiology, be provided promptly to meet residents' needs. The delay in obtaining the x-ray did not align with the facility's policy or staff expectations for timely diagnostic services.
Failure to Document Resident Behaviors as Required
Penalty
Summary
The facility failed to document a resident's behaviors as required for one of three residents reviewed. Certified Nurse Aides (CNAs) observed that the resident had increased behavioral issues, specifically kicking during care, over a period of two to three weeks. The CNAs reported these behaviors to the nurses, as they did not have access to document behaviors themselves. Licensed Practical Nurses (LPNs) confirmed that such behaviors should be documented in the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) or in a progress note. However, a review of the resident's clinical record and progress notes for the relevant period showed no documentation of these behaviors, despite a physician's order requiring staff to monitor the resident's behavior every shift. The resident in question was noted to be severely cognitively impaired and had diagnoses including hypertension, non-Alzheimer's dementia, and malnutrition. Facility policies provided by the Assistant Director of Nursing (ADON) emphasized the critical importance of thorough documentation of resident behaviors, including details such as time, causative factors, actual behavior, interventions, and outcomes. Despite these policies and the physician's order, the required documentation was not present in the resident's record for the specified dates.
Failure to Honor Resident's Right to Dignity During Resistive Care
Penalty
Summary
Staff failed to honor a resident's right to dignity and self-determination when they continued to provide care to a resident who was actively resistive and combative, despite the resident's clear desire to be left alone. Progress notes indicated that the resident, who was severely cognitively impaired and had diagnoses including non-Alzheimer's dementia, anxiety, and depression, was hitting, pinching, and spitting at staff during care. The care plan for this resident specified that if the resident declined care, staff should ensure the resident's safety, leave, and re-approach after five minutes or have another staff member attempt care. Despite these interventions being outlined in the care plan, interviews with CNAs revealed that staff continued to provide care to the resident while the resident was upset and combative, rather than following the care plan's direction to allow the resident time to calm down. This failure to follow the resident's care plan and respect the resident's wishes resulted in the resident not being treated with dignity and respect during care interactions.
Improper Storage and Labeling of Insulin Vials
Penalty
Summary
The facility failed to store medications appropriately, specifically insulin vials, on two of the three medication carts reviewed. On Station 3, Medication Cart 2 contained a Fiasp/Aspart insulin vial for a resident that was partially full, with no open date on the vial or storage bottle, despite the resident receiving insulin four times a day. Additionally, a Lispro insulin vial for another resident was found, which should have been removed as it was no longer in use. The LPN confirmed that insulin vials should be dated when opened and labeled with an expiration date. On Station 2, the medication cart contained two Lantus insulin vials for two different residents, both of which were not dated. The QMA indicated that insulin is usually good for 30 days, but did not manage the insulin for the residents. A sign on the refrigerator in the medication room reminded staff to date insulin containers when opened, but the QMA noted that insulin was no longer kept in that refrigerator. The facility's policy requires staff to store multi-dose vials according to the manufacturer's suggested storage conditions and to remove discontinued or outdated medications for proper disposal.
Failure to Follow Physician Orders and Implement Fall Interventions
Penalty
Summary
The facility failed to adhere to physician's orders for Resident 13 regarding the administration of Losartan, a blood pressure medication. The orders specified that the medication should be held if the systolic blood pressure (SBP) was less than 110 or the diastolic blood pressure (DBP) was less than 70. However, the Electronic Medication Administration Record (EMAR) showed that the medication was administered on multiple occasions without obtaining the resident's blood pressure, or when the blood pressure readings were below the specified parameters. This oversight occurred repeatedly throughout January and February 2025, despite the resident's severe cognitive impairment and diagnoses of heart failure, hypertension, dementia, anxiety, and depression. Additionally, the facility did not implement fall prevention interventions for Resident 54, who was moderately cognitively impaired and had a history of falls. The resident's care plan included an intervention to place non-skid strips on the floor near his recliner, following a fall incident in November 2024. However, observations in March 2025 revealed that these strips were not in place, even after the resident had moved rooms. The absence of non-skid strips was confirmed by a Certified Nurse Aide, who noted that the intervention should have been implemented after the room change, as per the facility's guidelines for incidents and falls.
Delayed Identification and Treatment of Pressure Wound Infection
Penalty
Summary
The facility failed to promptly identify and treat a pressure wound infection for a resident who was at risk for pressure ulcers. The resident, who was cognitively intact, had multiple diagnoses including non-traumatic spinal cord dysfunction, heart failure, and diabetes, and was admitted with an unhealed unstageable pressure ulcer. Despite utilizing pressure-reducing devices and receiving treatments, the resident developed additional pressure ulcers on the left and right buttocks shortly after admission. The resident's sacral wound, initially unstageable, was later classified as a Stage IV pressure ulcer. The facility's Wound Nurse Practitioner noted that the resident's wounds had improved significantly, but there was a delay in identifying and treating a wound infection. A wound culture taken on December 9th revealed a heavy growth of proteus mirabilis and beta hemolytic streptococci, but the results were not reviewed until December 16th, leading to a delay in starting appropriate antibiotic treatment. The Director of Nursing acknowledged that the facility typically received lab results within 48 to 72 hours, but in this case, the results were not followed up on promptly. The facility's policy emphasized the importance of timely identification and intervention for pressure injuries, but this was not adhered to, resulting in a delay in addressing the resident's wound infection.
Failure to Identify and Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences were identified and replacement meal options were offered. A resident, who was recently admitted, expressed dissatisfaction with the meals provided, stating that he did not like the food options such as eggs, sausage, and oatmeal for breakfast. He preferred dry cereal with milk and fruit, and liked to drink his coffee with breakfast, not before. Despite being at the facility for over two weeks, no one had inquired about his food preferences. The Dietary Manager admitted that she might have missed speaking with him upon his admission, and there was no record of his food preferences in the system. The resident's meal intake records showed multiple instances where he ate 50% or less of his meals or refused meals altogether, yet he was not offered replacement meals as per the facility's policy. The policy required that a dietary professional or nursing staff identify a resident's food preferences within 72 hours of admission. The resident's care plan indicated that staff should offer substitutions when the resident consumed 50% or less of a meal, but this was not consistently done. The resident's clinical record indicated he was cognitively intact and had no eating or swallowing problems, with diagnoses including coronary artery disease, atrial fibrillation, heart failure, and hypertension.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were available, impacting one of the five residents observed for pharmacy services. During a medication administration observation, an LPN discovered that the resident did not have the physician-prescribed Gabapentin 200 mg available. The medication was supposed to be administered at 11:00 A.M. and 4:00 P.M., but the LPN indicated that the medication had not been reordered since the initial order. The resident's clinical record showed that the medication was ordered previously, but it was not reordered, leading to its unavailability. The resident, who was cognitively intact, had multiple diagnoses including GERD, stroke, hypertension, diabetes, COPD, and respiratory failure. The EMAR/ETAR and progress notes revealed that the resident missed several doses of various medications, including Losartan Potassium, Famotidine, Metformin, Anoro Ellipta inhaler, Cholestyramine, Lasix, Jardiance, and Metoprolol, due to the facility waiting on pharmacy deliveries. These medications were not new orders, and the resident's pain level was monitored, showing a rating of three out of ten on one occasion. Interviews with the ADON revealed that the pharmacy delivered medications twice daily, and the nursing staff was responsible for ordering medications. The ADON was unaware of any staff member monitoring daily medication orders, and the facility's policy indicated that the CUBEX Station was not intended for routine medication dosing. The deficiency was attributed to the failure to reorder medications timely, resulting in the resident not receiving necessary medications as prescribed.
Delayed Wound Culture Processing Due to Missing Patient Identifiers
Penalty
Summary
The facility failed to obtain a wound culture in a timely manner for a resident with multiple health conditions, including a non-traumatic spinal cord dysfunction, heart failure, multi-drug-resistant organism infection, diabetes, paraplegia, and malnutrition. The resident was at risk for pressure ulcers and had an unhealed pressure ulcer upon admission. A physician ordered a wound culture on the resident's sacral wound, which was collected and sent to the lab on the same day. However, the lab results, indicating heavy growth of Proteus Mirabilis and Beta Hemolytic Streptococci bacteria, were not reviewed by the Nurse Practitioner until several days later due to missing patient identifiers on the specimen container. The lab sent an affidavit to the facility to confirm the specimen's patient identification, but the facility did not respond, leading to a delay in addressing the resident's infection. The Assistant Director of Nursing/Infection Preventionist was unaware of the issue, and the Director of Nursing acknowledged that the results should have been followed up on sooner. The facility's policy requires systematic scheduling and tracking of lab tests to ensure timely results, but this was not adhered to in this case, resulting in a delay in the resident's care.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control guidelines during medication administration, as observed with two residents. An LPN was seen preparing and administering medications without performing hand hygiene between resident interactions. Specifically, the LPN assisted a resident with limited hand use by adjusting their straw and wheelchair foot pedals, then proceeded to administer medication to another resident without sanitizing her hands. This lack of hand hygiene was observed as the LPN continued to interact with various surfaces and residents without cleansing her hands. The facility's current medication administration policy, dated July 2024, clearly states that hand hygiene should be performed before beginning medication administration and before contact with each resident. However, the LPN did not follow this protocol, as confirmed during an interview immediately following the observation. The LPN acknowledged the oversight, indicating awareness of the requirement to use hand sanitizer or wash hands between assisting residents. This deficiency highlights a breach in infection control practices, as outlined in the facility's policy.
Failure to Remove Hazardous Chemical Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the removal of a lye-based chemical drain cleaner from the bathroom of a vulnerable resident, leading to the resident ingesting the chemical. The incident involved a maintenance staff member who entered the resident's room to unclog a toilet and left the nearly empty bottle of drain cleaner unattended. The resident, who was cognitively intact and had no prior history of consuming harmful chemicals, later handed the bottle to a staff member and complained of throat pain. The resident was subsequently sent to the emergency room and admitted to the intensive care unit with low-grade esophageal and moderate-grade gastric injuries from the lye ingestion. The facility's policy on chemical safety and storage, which mandates that hazardous chemicals be kept in a locked area inaccessible to residents, was not followed. This oversight resulted in the resident's hospitalization and injury.
Failure to Provide Activities in Dementia Unit
Penalty
Summary
The facility failed to provide activities for residents in the Memory Springs-Dementia Unit, affecting 13 of the 68 residents. During an interview, a family member indicated that the Memory Springs Station never had any activities. Continuous observations revealed that residents were often left without engagement or activities, despite the activity calendar indicating scheduled activities such as laundry folding and horseshoes. Staff were present but not engaging residents in any meaningful activities, and residents were often observed sleeping or aimlessly moving around the area without direction or stimulation. During the observations, it was noted that the activity aide was not present, and the responsibility of conducting activities fell on the CNAs, who were often too busy with other tasks such as serving drinks and attending to call lights. The Activity Director confirmed that the activity department consisted of only two staff members, herself and one other, and that the activity aide was responsible for ensuring activities were completed. However, the aide was frequently unavailable, and the CNAs were not always able to fill in due to their workload. The facility's policy on activities indicated that an ongoing program should be provided to meet the physical, mental, and psychosocial well-being of the residents, including specialized activities for those with dementia. However, the observations and interviews demonstrated that this policy was not being effectively implemented in the Memory Springs-Dementia Unit. The lack of structured activities and engagement for the residents was evident, leading to a deficiency in meeting the residents' needs as per the comprehensive assessment and facility policy.
Failure to Maintain Homelike Environment Due to Persistent Urine Odor
Penalty
Summary
The facility failed to provide a homelike environment related to odors in the Memory Springs-Dementia Unit, affecting 13 of the 68 residents. Observations on multiple dates revealed a strong urine odor in the common area and dining room of Memory Springs. The common area had several recliners with cloth pads covering the seats, and residents were observed sitting in these recliners. The Housekeeping Supervisor confirmed that the housekeeping staff cleaned resident rooms daily, but the nursing staff were responsible for cleaning the recliners in the common area. Despite these cleaning routines, the urine odor persisted, as noted by both the Housekeeping Supervisor and a family member of a resident. During an interview, the Housekeeping Supervisor acknowledged the urine odor in the common area and indicated that it was stronger in the area with the recliners. The facility's policy on maintaining a homelike environment was provided by the Administrator, which stated that the environment should be safe, sanitary, functional, and comfortable, de-emphasizing the institutional character of the setting. However, the persistent urine odor in the Memory Springs unit indicated a failure to adhere to this policy, compromising the comfort and homelike atmosphere for the residents.
Failure to Develop Denture Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan related to dentures for a resident who was moderately cognitively impaired and edentulous. During interviews and observations, it was noted that the resident did not have his dentures in and was not offered them, despite being assisted out of bed, eating snacks, and having meals. The resident's family member indicated that the dentures were taken away because the resident kept playing with them, and they were never offered back. The resident himself was unsure of the whereabouts of his dentures. The clinical record review revealed that the resident's care plan lacked an edentulous care plan, despite the resident's condition and needs. The facility's policy indicated that a comprehensive care plan should be finalized within seven days of the full assessment, but this was not adhered to in the case of this resident. The Administrator confirmed that the management team was responsible for completing assessments and developing care plans upon admission, but this was not done for the resident's denture care needs.
Failure to Follow Physician Orders for Wound Care and TED Hose
Penalty
Summary
The facility failed to follow physician's orders related to wound treatments and the application of TED hose for three residents. Resident 44, who had an arterial wound on his left foot, did not receive the prescribed betadine treatments on multiple occasions as documented in the EMAR/ETAR. The Director of Nursing acknowledged that blanks in the EMAR/ETAR could indicate either a failure to administer the treatment or a failure to document it properly, both of which are unacceptable practices. Resident 61, who had congestive heart failure and required TED hose to manage edema, was frequently observed without the prescribed TED hose. Despite the EMAR/ETAR indicating that the TED hose had been applied daily, the resident reported and was observed multiple times without them, leading to visible swelling in their feet and ankles. The LPN indicated that CNAs were responsible for applying the TED hose and should report any refusals, but there was no indication that refusals were reported or documented. Resident 30, who had coronary artery disease, diabetes, hypertension, and Parkinson's disease, was also observed multiple times without the prescribed TED hose, despite the EMAR indicating daily application. The resident's feet and lower legs were visibly swollen and reddish-pink in color. Interviews with staff revealed a lack of awareness and proper documentation regarding the resident's need for TED hose, indicating a systemic issue in following physician orders and ensuring proper care.
Failure to Label and Store Medications Appropriately
Penalty
Summary
The facility failed to label and store medications appropriately in two of the three medication storage refrigerators observed. During an inspection, an open vial of Tuberculin (TB) serum with no label indicating when it was opened was found in the medication refrigerator on Station 1. The Assistant Director of Nursing (ADON) could not recall when the last resident was admitted to the unit. Similarly, an open vial of TB serum with no label indicating when it was opened was found in the medication refrigerator on Station 3. The Licensed Practical Nurse (LPN) present indicated she had administered the serum to a resident the previous week. The Director of Nursing (DON) confirmed that TB serum vials should be dated when opened, as per the manufacturer's instructions, which state that a vial in use for 30 days should be discarded. The facility's medication storage policy also mandates that medications and biologicals be stored safely and properly following manufacturer recommendations.
Failure to Provide Routine Bathing for Resident
Penalty
Summary
The facility failed to provide routine bathing for a resident who was severely cognitively impaired and totally dependent on staff for bathing. The resident, diagnosed with dementia and hypertension, was observed eating with her bare hands in the dining room, indicating a need for assistance with ADLs. A review of the resident's clinical records and shower sheets from January to March 2024 revealed that the resident received only 12 out of the 24 planned showers or complete bed baths. There were no documented refusals of bathing by the resident in either the paper or electronic records. Interviews with staff members, including a CNA and an LPN, confirmed that the resident should have received two showers per week and that any refusals should have been documented and reported to the nurse on duty. The facility's ADL policy, which was undated, stated that residents should receive routine daily care to promote hygiene and comfort. The failure to provide the required number of showers or bed baths for the resident was a clear deficiency in the facility's care practices.
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Illustrative
What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silver Memories Health Care | 10.8 mi | ★★★★★ | 11 | 0 |
| Ripley Crossing | 10.9 mi | ★★★★★ | 12 | 0 |
| Ridgewood Health Campus | 11.3 mi | ★★★★★ | 0 | 0 |
| Envive Of Lawrenceburg | 11.5 mi | ★★★★★ | 15 | 0 |
| Shady Nook Care Center | 11.7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.