Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Downs Care And Rehab during CMS and state inspections, most recent first.
Food Storage and Temp Log Deficiencies: Kitchen observation found unlabeled and undated food in the refrigerator and dry storage, including sliced cheese, noodles, gelatin, and pancake mix, along with used cooking grease containers with grayish-black substances on top. Surveyors also noted ice buildup in a freezer, items and debris around the ice machine, and incomplete refrigerator/freezer temp logs for multiple units. Dietary staff verified the findings, and the DM stated food should be labeled, dated, and sealed when received or opened.
Infection control practices were not followed when a CNA used the same soiled gloves during incontinent care for a resident, and EBP was not properly in place for two residents with urinary catheters because signage and PPE were missing from the room area. During catheter care, a CNA used the same washcloth for multiple cleansing steps and did not complete the care. The facility also had an incomplete water management plan that lacked system diagrams and documentation for flushing stagnant areas.
Failure to preserve dignity when a CNA assisted a resident toward the dining room while his pants were wet with urine. The resident was observed incontinent, with wet clothing from the buttocks to the waist and groin area, and only then was he asked if he wanted to change before going to the dining room. An Administrative Nurse stated staff should change residents' clothing when wet, and no dignity policy was provided.
A facility failed to document an appropriate indication and physician rationale for continued antipsychotic use for two residents. One resident with dementia and behavioral disturbance and another resident with Alzheimer’s disease and hallucinations were receiving Seroquel, but their records lacked documentation of unsuccessful nonpharmacological interventions and a risk-versus-benefit rationale for the medication. Observations showed an LN administering the residents’ medications, and the RN later verified both residents were receiving Seroquel.
Pharmacist consultant reviews failed to identify missing documentation for antipsychotic use in two residents. One resident with dementia and behavioral disturbance and another resident with Alzheimer’s disease and hallucinations both had Seroquel orders, but their records lacked documentation of attempted nonpharmacological interventions and physician rationale/risk-benefit justification, and the consultant did not request an approved diagnosis or indication during monthly med reviews.
Medication Error Rate Exceeded 5 Percent: An LPN crushed a resident’s delayed/extended-release aspirin and Glipizide XL and mixed them with pudding, even though the EMR had no order to crush the meds. The resident had orders for aspirin for atherosclerotic heart disease and Glipizide XL for DM, and the observed medication error rate was 5.13%.
The facility did not employ a full-time certified dietary manager, placing 40 residents at risk for inadequate nutrition. Dietary staff involved in meal preparation were not certified, and the facility did not meet its policy requirements for food and nutrition services oversight, despite having residents with specific dietary needs.
The facility failed to maintain a clean and homelike dining environment, as observed with stained and unclean maroon cloth chairs in the dining rooms. Despite regular cleaning efforts, the stains remained due to the age of the chairs. Administrative staff acknowledged the issue and the facility's policy emphasized the residents' right to a clean environment, which was not met, affecting residents' comfort and quality of life.
The facility's kitchen was found to have several fluorescent light fixtures without plastic diffusers, posing a safety risk to residents and staff. Maintenance staff acknowledged the issue and intended to replace the covers. The facility's policy mandates maintaining the food service area in good repair.
A facility failed to update a resident's care plan to include guidance for unsupervised exits, despite the resident's diagnoses of ADHD and anxiety disorder. The resident was observed exiting the building without supervision, and staff were aware of this practice. However, the care plan lacked specific instructions, and the facility chose not to update it, contrary to their policy.
A resident was discharged from the facility without a complete discharge summary, lacking essential information such as diagnoses, treatment, and medication reconciliation. This failure was confirmed by administrative staff and was against the facility's policy, placing the resident at risk of inadequate post-discharge care.
A resident with dementia and moderate cognitive impairment did not receive scheduled showers, resulting in poor personal hygiene. The facility failed to document and address the resident's refusals for showers, leading to unkempt and greasy hair, contrary to the facility's ADL policy.
Two residents were prescribed antipsychotic medications without appropriate indications or required physician documentation, placing them at risk for unnecessary psychotropic medications. One resident, with major depressive disorder and anxiety, was given Seroquel without evidence of non-drug interventions being tried first. Another resident, with dementia and agitation, received antipsychotics without documentation of attempted non-pharmacological interventions or a physician's rationale. The facility's policy on unnecessary medications was not followed, leading to inappropriate medication use.
The facility did not label insulin vials with the open or discard date, as required by policy. During an observation, it was found that insulin vials for two residents were opened but not dated. This was confirmed by both an LN and an Administrative Nurse, who stated that staff should date insulin vials upon opening. The failure to date the vials placed the residents at risk for receiving ineffective insulin.
Food Storage and Temperature Log Deficiencies
Penalty
Summary
The facility failed to store, distribute, and serve food according to professional standards for food service safety in the kitchen. On 04/13/26 at 08:10 AM, observation in the kitchen found a white upright freezer with about 1/4 inch of ice buildup along the inside and shelves, a refrigerator containing a plastic bag of sliced yellow cheese that was unlabeled and undated, and an ice machine with a plastic lid and a metal object on the floor behind it, plus a plastic green drinking cup sitting on top of the drain underneath it. The dry storage area also contained eight 15.5-pound plastic jugs of used cooking grease with numerous grayish-black substances on their tops, an approximately 1/4 full 5-pound package of undated pasta Labello egg noodles, an approximately 1/4 full 4.5-pound package of unlabeled, undated, unsealed noodles, approximately 3/4 package of undated strawberry gelatin, and an approximately 3/4 bag of unsealed buttermilk pancake mix. Record review showed the freezer and refrigerator temperature logs were not consistently completed. The March logs lacked documentation for multiple freezers and refrigerators on several dates, including the chest freezer in dry storage, a white stand-up freezer, a double door refrigerator, and a single door refrigerator. The April logs also lacked documentation for a double door freezer on two dates. On 04/13/26 at 08:20 AM, Dietary Staff CC verified the findings and stated she would ask the dietary manager what to do when she arrived. On 04/14/26 at 01:30 PM, the Dietary Manager stated staff should label and date all food placed in dry storage, refrigerator, or freezer when received, and if open, make sure they are sealed, labeled, and dated with the open date.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement adequate infection control practices during incontinent care for a resident when two CNAs assisted the resident to the toilet and one CNA provided perineal care using the same soiled gloves to pull up the resident’s pants, adjust the blouse, and touch the gait belt before removing the gloves. During the observation, the CNA acknowledged she had not changed gloves after providing perineal care and stated she should have. The facility also failed to maintain Enhanced Barrier Precautions for two residents who shared a room and had indwelling urinary catheters. On observation, the room lacked EBP signage and PPE supplies were not available on the room door, in the closet, or at the bedside area. When one CNA later brought PPE from another part of the facility, she donned a gown and gloves before entering the room to provide catheter care. During that care, she used a washcloth with soap to wipe the catheter tubing from the connection site upward to the insertion site, then used the same washcloth to wipe the resident’s groin area on both sides and stopped before completing the care. The facility also lacked a complete water management plan. Review of the plan showed it did not include the building’s water systems’ use text or flow-diagrams for identification and control measures, and it lacked documentation for flushing stagnant areas of the water system. Administrative staff and maintenance staff verified the plan was incomplete and stated the prior maintenance staff had taken information with them when they left.
Failure to Preserve Resident Dignity During Incontinent Episode
Penalty
Summary
The facility failed to treat Resident 11 with dignity when staff assisted the resident toward the dining room while his pants were wet with urine. On 06/23/2026 at 12:00 PM, the resident self-propelled out of his room in a wheelchair and was stopped by a CNA who asked if he wanted to walk to the dining room; the resident said yes because no one had come to get him for lunch. The CNA retrieved his walker and gait belt, assisted him to stand, and began walking him toward the dining room while observation revealed his pants were wet from the buttocks to the top of his waist. When another staff member asked about the wet clothing, the CNA confirmed the resident was wet, asked if he wanted to change his pants before going to the dining room, and the resident replied, "I'd better." The resident was also observed turned around with his walker and the front area from the waist down to the groin area was wet. At 12:10 PM, the CNA verified the resident was incontinent of urine, and at 12:20 PM an Administrative Nurse stated that staff should change residents' clothing when wet. The facility did not provide a dignity policy upon request.
Lack of documented rationale for antipsychotic use
Penalty
Summary
The facility failed to ensure there was an appropriate indication or documented physician rationale for the continued use of antipsychotic medication for two residents, including documentation of unsuccessful nonpharmacological symptom management and a risk-versus-benefit review. R7’s record showed diagnoses of dementia, diabetes mellitus, and atherosclerotic heart disease, with severely impaired cognition and need for staff supervision with most ADLs. R7 was receiving Seroquel XR 50 mg at bedtime for dementia with other behavioral disturbance, but the EMR did not include documentation of nonpharmacological approaches attempted and unsuccessful for behavioral management, nor evidence of a physician rationale addressing risks and benefits for continued use. R39’s record showed diagnoses of Alzheimer’s disease, major depressive disorder, and hallucinations, with moderately impaired cognition and dependence with most ADLs. R39 was receiving Seroquel 25 mg at bedtime for Alzheimer’s disease with hallucinations, but the EMR likewise lacked documentation of nonpharmacological approaches attempted and unsuccessful for behavioral management and lacked evidence of a physician rationale including risk versus benefits for the antipsychotic. The MDS for R39 documented no hallucinations, while the CAA and care plan noted antipsychotic use and referenced the medication’s Black Box Warning. On observation, both residents received their morning medications from LN G, and the Administrative Nurse later verified both residents were receiving Seroquel.
Pharmacist Review Failed to Identify Missing Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure the consultant pharmacist completed monthly drug regimen reviews in accordance with policy and identified missing documentation for two residents receiving antipsychotic medication. For Resident 7, the EMR showed diagnoses of dementia, diabetes mellitus, and atherosclerotic heart disease, and the MDS recorded severely impaired cognition and the need for staff supervision with most ADLs. The resident’s care plan and physician order documented Seroquel XR 50 mg at bedtime for dementia with other behavioral disturbance, but the record lacked documentation of nonpharmacological approaches attempted and failed, as well as a physician rationale including risk versus benefit for the medication. Pharmacist consultant reviews on 03/03/26, 04/08/26, and 05/07/26 did not request an approved diagnosis or indication for the Seroquel. For Resident 39, the EMR showed diagnoses of Alzheimer’s disease, major depressive disorder, and hallucinations, and the quarterly MDS recorded moderately impaired cognition and dependence with most ADLs. The resident’s care plan and physician order documented Seroquel 25 mg at bedtime for Alzheimer’s disease with hallucinations, but the record lacked documentation of nonpharmacological approaches attempted and failed and lacked a physician rationale including risk versus benefit for the medication. The MDS also documented that the resident did not have hallucinations, yet pharmacist consultant reviews on 03/03/26, 04/08/26, and 05/07/26 did not request an approved diagnosis or indication for the Seroquel. On 06/24/26, an administrative nurse verified both residents received Seroquel and stated the facility would contact the physician for appropriate documentation.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with an observed error rate of 5.13 percent. The deficiency involved Resident 7, who had physician orders dated 03/11/2026 for aspirin delayed release 81 mg, one tablet daily for atherosclerotic heart disease, and dated 03/12/2026 for Glipizide XL extended release 2.5 mg, one tablet daily for diabetes mellitus. The resident’s electronic medical record did not contain an order to crush the delayed- or extended-release medications. During observation on 06/23/2026 at 08:10 AM, Licensed Nurse G crushed the resident’s pills, including the delayed/extended-release aspirin and Glipizide, and mixed them with pudding. The nurse administered one spoonful of the medication, and the resident ingested all of the medications. At 08:15 AM, Licensed Nurse G stated the resident liked to take medications with pudding and that staff crushed them so she could take them easier. On 06/24/2026 at 08:30 AM, Administrative Nurse D verified that delayed- or extended-release medications should not be crushed and stated they should be administered whole because of the extended release over time. Administrative Nurse D also stated she had administered medication to the resident in the past and had never crushed her medication before administration.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 40 residents, which placed them at risk for inadequate nutrition. Observations and interviews revealed that the dietary staff responsible for preparing meals were not certified dietary managers. Specifically, Dietary Staff BB, who was involved in meal preparation, confirmed that she was not a certified dietary manager. This was further verified by Administrative Staff A. The facility had residents with specific dietary needs, including seven on mechanical soft diets and one on a pureed diet, which required specialized oversight. The facility's policy, dated October 2024, required the employment of sufficient staff with appropriate competencies and skills to manage food and nutrition services. This included having a qualified dietician to oversee clinical nutrition and dietary services. If the dietician was not full-time, the policy mandated the employment of another qualified nutritional professional to serve as the Dietary Manager. The facility did not meet these requirements, as it failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee food-related operations, thereby placing residents at risk for inadequate nutrition.
Failure to Maintain Clean Dining Environment
Penalty
Summary
The facility, with a census of 40 residents, was found to have failed in providing a clean and homelike environment in its dining areas. During an observation of the lunch meal, it was noted that the dining rooms contained numerous maroon cloth chairs that were visibly stained with blackish-brown marks, giving them an unclean appearance. This observation was confirmed by Housekeeper U, who stated that despite using a shampooer every other week, the stains could not be removed due to the age of the chairs. Administrative Staff A acknowledged the issue, confirming that the housekeeping staff were responsible for cleaning the chairs and that the facility was aware of the stained and dirty appearance of the chairs. Although there were intentions to reupholster the chairs, no specific date had been set for this action. The facility's policy, dated September 2024, emphasized the residents' right to a safe, clean, comfortable, and homelike environment, which was not upheld in this instance, thereby impacting the residents' comfort and quality of life during meals.
Kitchen Safety Deficiency Due to Missing Light Covers
Penalty
Summary
The facility failed to provide a safe environment in the kitchen, which placed residents and staff at risk for impaired safety. During an observation on 07/30/24, it was noted that several fluorescent light fixtures in the kitchen lacked plastic light diffusers or covers. Specifically, four 2-foot x 4-foot fluorescent lights between the food preparation area and the stove, as well as five similar fixtures above the dishwasher area, were missing these covers. Each fixture contained two fluorescent tube glass light bulbs. Maintenance Staff U confirmed the absence of the diffusers and mentioned that he believed replacements were available in storage, which he intended to locate and install. The facility's Sanitization policy, dated 10/2024, requires that the food service area be maintained in a clean and sanitary manner, with all equipment kept in good repair, including seals, hinges, and fasteners.
Failure to Revise Care Plan for Unsupervised Exits
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R25, to include guidance for staff regarding the resident's unsupervised exits from the building. R25 had diagnoses of ADHD and anxiety disorder and was documented as being independent with most activities of daily living, requiring staff supervision for ambulation over certain distances. Despite this, the care plan, last revised on 06/25/24, did not provide instructions for staff on how to handle situations when R25 exited the building without supervision. Observations on 07/29/24 revealed that R25 was able to ambulate independently using a walker and exited the facility through the south exit door without staff supervision, with no alarm sounding at the exit door. A Certified Medication Aide confirmed that the facility doors were supposed to alarm at the nurse's station when someone exited without entering a code, and staff were aware that R25 was allowed to exit unsupervised. However, the care plan lacked specific instructions for such situations. An Administrative Nurse acknowledged the omission and noted that other residents were also allowed to exit unsupervised, but the facility decided not to update the care plans, which was against their Comprehensive Assessment Policy.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to develop a comprehensive discharge summary for a resident, identified as R42, who was discharged from the facility to home. The resident's electronic medical record (EMR) did not include a complete recapitulation of their stay, which is a concise summary of the resident's stay and course of treatment in the facility. This deficiency was identified during a review of R42's records, which showed that the discharge summary lacked essential information such as diagnoses, course of illness, treatment or therapy, and a reconciliation of pre-discharge and post-discharge medications. The facility's policy, revised in September 2023, mandates that a discharge summary should be completed at the time of discharge, including a recapitulation of the resident's stay and a final summary of the resident's status. However, this was not adhered to in the case of R42, as confirmed by Administrative Staff A, who acknowledged the incomplete recapitulation. The absence of a complete discharge summary placed the resident at risk of receiving inadequate care post-discharge.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident, identified as R37, who was unable to perform activities of daily living independently. R37 had diagnoses of adult failure to thrive and dementia, with a moderate cognitive impairment indicated by a BIMS score of 12. The resident required set-up and clean-up assistance for most ADLs, including bathing, as documented in the care plan. However, the facility's records showed significant gaps in providing scheduled showers, with the resident receiving a bath or shower only sporadically over several months. The documentation also lacked records of the resident's refusals for showers, which were noted by staff but not followed up on to understand the underlying reasons. Observations revealed that R37 was often left with unkempt and greasy hair, indicating a lack of proper hygiene care. The facility's policy required staff to ensure residents unable to carry out ADLs receive necessary care, including hygiene, and to investigate any refusals of care. Despite this, the facility did not adequately address the resident's refusal to have her hair washed or her apprehension about getting her ears wet, leading to a failure in maintaining the resident's personal hygiene and dignity.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure appropriate indications and required physician documentation for the use of antipsychotic medications for two residents, placing them at risk for unnecessary psychotropic medications. Resident 31, diagnosed with major depressive disorder and anxiety disorder, was prescribed Seroquel for behavior management without evidence of non-drug interventions being tried and failed before starting the medication. The resident's electronic medical record lacked a physician-documented rationale, including risk versus benefits, for the continued use of Seroquel. Despite the facility's policy requiring antipsychotic medications to be used only when necessary for specific conditions, the documentation was insufficient. Resident 38, diagnosed with dementia with agitation and heart failure, was also prescribed antipsychotic medications without appropriate documentation. The resident's care plan noted severe cognitive impairment and behaviors such as wandering and verbal rambling. Despite these behaviors, the facility's records did not include documentation of attempted non-pharmacological interventions or a physician's rationale for the continued use of Seroquel and clonazepam. The facility's policy stated that antipsychotic medications should not be used for discipline or staff convenience, yet the necessary documentation to justify the medication use was missing. Observations revealed that Resident 31 was able to interact politely with family, while Resident 38 exhibited confusion and wandering behavior. Administrative staff acknowledged the lack of appropriate indications and documentation for the use of antipsychotic medications in both cases. The facility's failure to adhere to its own policy on unnecessary medications resulted in the inappropriate use of psychotropic drugs for these residents.
Failure to Date Insulin Vials
Penalty
Summary
The facility failed to properly label insulin vials with the open or discard date, as required by their Insulin Administration policy. During an observation of the west medication cart, it was found that insulin glargine vials for two residents were opened but not dated. This oversight was confirmed by both a Licensed Nurse and an Administrative Nurse, who acknowledged that staff were supposed to date insulin vials upon opening to track expiration. According to Medlineplus.gov, unrefrigerated insulin glargine vials must be used within 28 days, after which they should be discarded. The failure to date the vials placed the residents at risk for receiving ineffective insulin medication.
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What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Downs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Health And Rehabilitation Center | 8.8 mi | ★★★★★ | 0 | 0 |
| Smith Center Health And Rehab | 15.2 mi | ★★★★★ | 0 | 0 |
| Sunporch Of Smith County | 22.1 mi | ★★★★★ | 0 | 0 |
| Hilltop Lodge Health And Rehabilitation Center | 23.3 mi | ★★★★★ | 13 | 0 |
| Mitchell County Hospital Health Systems Ltcu | 23.4 mi | ★★★★★ | 0 | 0 |
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