Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Downs Care And Rehab during CMS and state inspections, most recent first.
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.
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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Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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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 | ★★★★★ | 38 | 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 | ★★★★★ | 12 | 0 |
| Mitchell County Hospital Health Systems Ltcu | 23.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.