Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cascade Senior Care Center during CMS and state inspections, most recent first.
Two emergency crash carts were not properly checked or stocked with required items. On one unit, staff documented the cart as complete even though items were missing and one saline bag lacked a sticker and expiration date, and the checklist had inconsistent markings with no nurse initials. On another unit, the cart was missing an oxygen tank, nonrebreather masks, AED policy, IV supplies, saline flushes, and required fluids, and several checklist dates were left blank with no initials or marks.
A resident admitted with malnutrition, postprocedural complications, digestive system disorders, and an abdominal surgical wound, and who was cognitively intact per MDS, did not receive assistance with showers or bed baths for 11 days after admission. A family member reported the resident did not receive showers and was often found soiled with urine and not cleaned up for the day. Facility shower logs confirmed no bathing occurred during this period, and progress notes showed no documented refusals. The DON stated that residents are expected to receive showers twice weekly and that refusals are to be documented in the EMR, but could not explain the lack of bathing for this dependent, post-surgical resident.
A resident with intact cognition and multiple medical conditions, including malnutrition and postprocedural digestive complications, sustained bilateral calf skin tears during a transfer back to bed. The resident reported her legs were pushed against the bedframe, causing pinching and pain, and bleeding was later observed. Documentation showed the resident was non-ambulatory and required 2PA for transfers with an EZ stand, but interviews revealed that only one CNA performed the transfer and that the second staff member present was not assisting. There were conflicting accounts about whether a mechanical lift was used, and the injury was believed to have occurred when loose skin was pinched between the bedframe and transfer equipment.
The facility failed to ensure staff consistently used required PPE for Contact precautions. A resident on Contact precautions for diarrhea, with moderately impaired cognition and diagnoses including malnutrition and Type 2 DM, had a Contact precautions sign posted, yet CNAs repeatedly entered and exited the room wearing only surgical masks and without gowns or gloves, despite acknowledging that gowns and gloves were required. A PPE cart near the room lacked gloves, and the resident reported staff did not wear gowns and usually only wore gloves. A laundry aide was also observed entering multiple rooms, including a Contact precautions room, without hand hygiene and without donning additional PPE. These practices were inconsistent with the facility’s policy and stated expectations that staff wear gowns and gloves and don PPE upon room entry and discard it before exiting.
The facility did not follow required procedures for timely reporting of an alleged abuse incident involving two cognitively impaired residents. After one resident accused a staff member of attempted rape during care, the incident was not reported to the State Agency within the mandated two-hour timeframe, despite facility policy requiring immediate reporting.
Two residents with end-stage renal disease did not receive proper medication management, accurate documentation, or adherence to physician orders regarding dialysis schedules and weight monitoring. One resident missed multiple doses of a prescribed medication, had altered dialysis days without physician notification, and experienced significant weight loss without intervention or dietician oversight. Another resident missed a dialysis session due to missing equipment, with no documentation or physician notification. Required assessments and communication forms were also missing.
Two residents requiring dialysis did not have proper documentation of dialysis communication, physician notification, or weights when their dialysis schedules were altered or missed. One resident was not sent with required equipment, resulting in an incomplete dialysis session, and staff could not explain or justify changes to the dialysis schedule.
A resident with end-stage renal disease and hyperphosphatemia did not receive any doses of a prescribed medication, Sevelamer HCl, because it was not available in the facility. Despite this, the MAR inaccurately indicated that some doses were administered. The DON confirmed the medication was never in-house, and the family was only informed after several days. The resident was later transferred to a hospital due to a change in condition.
A deficiency was cited for failing to address certain general requirements under LSC Sections 18.1 and 19.1 that were not covered by the existing K-tags. The report does not specify the exact actions or omissions involved.
A resident with a history of respiratory failure and other chronic conditions was admitted from the hospital with ongoing hypoxia and required respiratory support. After reporting difficulty breathing and requesting a change from CPAP to oxygen via nasal cannula, the resident was not assessed by a licensed nurse, and as-needed inhaled medications were not administered. The resident was later found unresponsive and pronounced deceased, with staff interviews confirming a lack of follow-up assessment after the report of respiratory distress.
The facility did not consistently respond to resident call lights in a timely manner, with multiple residents experiencing wait times ranging from 15 minutes to two hours for assistance with personal care and toileting. Documentation and resident interviews confirmed repeated delays, particularly during shift changes, and some residents reported episodes of incontinence as a result.
The facility did not provide timely and accurate NOMNC and SNF ABN forms to two residents, with both notices being signed either one day before or on the last covered day, rather than within the required advance notice period. The social worker responsible for issuing these notices was unable to explain the delay or inaccuracy.
A resident with multiple medical and cognitive conditions did not have a comprehensive care plan addressing activity preferences, resulting in boredom and lack of awareness of available activities. The resident's records lacked documentation of activity preferences, and staff interviews confirmed that expected practices for care planning and activity calendar distribution were not followed.
A resident with moderate cognitive impairment and multiple medical conditions was not provided with meaningful, individualized activities. The resident reported boredom, was unaware of any activity calendar, and had not been invited to participate in activities. Review of records showed no care plan for activity preferences and only solitary activities documented, with no evidence of group activities being offered.
Two residents were found with medications at their bedside without required assessments, physician orders, or care plans for self-administration, and an opened multi-dose vial in the medication room refrigerator was not dated as required. Staff confirmed these practices did not follow professional standards for medication storage and labeling.
A facility failed to develop a comprehensive care plan for a resident with a baclofen pump. The resident's medical records lacked documentation of the pump, and staff were unaware of its presence until informed by the resident's wife. The care plan intervention for the pump was discontinued, leading to inadequate care planning for the resident's needs.
A resident with a baclofen pump was not properly monitored due to a lack of documentation and awareness among staff. The facility failed to ensure coordination of care, as the pump's presence and management were not included in the resident's medical record or care plan. Staff interviews revealed they were unaware of the pump until informed by the resident's family, leading to a deficiency in care.
The facility failed to maintain food service equipment and properly date and store food products, affecting 55 residents. Observations included loose temperature gauges on the dish machine, soiled flooring, and undated food items in refrigerators. These conditions indicate non-compliance with the 2017 FDA Model Food Code and the facility's sanitation policy.
The facility failed to maintain a clean and safe environment, affecting 55 residents. Observations included worn and damaged furniture, soiled surfaces, heavily stained carpeting, non-functional light assemblies, and missing tiles. Record reviews indicated that existing cleaning and maintenance policies were not effectively implemented.
The facility failed to ensure that two residents, who had not been deemed incapacitated, were acting as their own responsible party and to honor the code status wishes of one resident. One resident had conflicting documentation regarding their code status, and the facility could not provide documentation to support their incapacity. Another resident had their spouse designated as their responsible party without documentation to support their incapacity.
The facility failed to ensure accurate MDS coding for two residents. One resident's discharge was incorrectly coded as a hospital discharge instead of home, and another resident's MDS inaccurately reflected antidepressant use despite no prescription. The errors were confirmed by the MDS Coordinator.
Crash carts were not properly checked or stocked
Penalty
Summary
The facility failed to ensure two emergency crash carts were checked daily and stocked with the required life-sustaining items. On the Meadows Unit, record review of the ER cart audit form showed nursing staff documented the cart as complete, but observation found a one-liter bag of normal saline without a sticker or expiration date, and a later observation found the cart missing the blood pressure cuff, paper, one IV start kit, one one-liter bag of normal saline, and one 500 mL bag of 5% dextrose. The checklist for that cart showed inconsistent documentation methods, with some entries marked by checkmarks, zeroes, Cs, and Xs, and the form did not contain any nurse initials as required, so there was no way to identify who completed the checks. On the Rehab/Nursing Unit, observation of the crash cart showed it did not have an oxygen tank, nonrebreather masks, or a laminated AED policy and procedure. The cart also had only one IV start kit, no saline flushes, no six-inch IV extensions, no one-liter bags of normal saline, and only one 500 mL bag of 5% dextrose when the checklist required more of each item. Review of the checklist showed only one date with all items checked, while several dates were blank with no initials or marks, indicating the cart was not checked for all required items and the AED was not documented as being in working order and charged. The ADON confirmed the carts did not have the required locks and stated nurses were supposed to initial the checklist and replace missing or expired items.
Failure to Provide Timely Bathing and Hygiene Assistance for Dependent Post-Surgical Resident
Penalty
Summary
The facility failed to provide required assistance with activities of daily living (ADLs), specifically bathing and hygiene, for one dependent resident. The resident was admitted with diagnoses including malnutrition, postprocedural complications, and digestive system disorders, and had an abdominal surgical wound. An MDS assessment showed the resident had intact cognition with a Brief Interview for Mental Status score of 13/15. According to a family member interviewed by phone, the resident did not receive assistance with showers while in the facility and was often found soiled with urine and not cleaned up for the day. Review of the facility’s shower logs showed the resident did not receive a shower or bed bath until 11 days after admission, and review of progress notes revealed no documented refusals of bathing during that period. In an interview, the DON stated the facility’s expectation is that residents receive showers twice a week and that refusals are documented in the electronic medical record, but could not provide an explanation for the lack of showers for this post-surgical resident during the first 11 days after admission.
Failure to Provide Required Two-Person Assist During Transfer Resulting in Skin Tears
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in skin tears to both calves during a transfer back to bed. The resident had been admitted with diagnoses including malnutrition and postprocedural complications of the digestive system and had an abdominal surgical wound. An MDS assessment showed intact cognition. On the date of the incident, the resident reported feeling the backs of her legs pushing against the bedframe while being put back into bed and then feeling pinching, pain, and wetness under her legs, after which bleeding and skin tears were noted on the lateral aspects of both calves. The incident report identified that a mechanical lift (EZ stand) was in use during the transfer and that the resident experienced mild pain in her lower legs after being transferred to the bathroom and back. Interviews and record review revealed discrepancies and failures related to required transfer assistance. The DON reported that the resident required two-person assistance for transfers with an EZ stand and that a second staff member present in the room at the time of the incident was not assisting with the transfer but gathering supplies. The DON stated it was believed the resident’s loose skin was pinched between the bed frame and the EZ stand. In contrast, CNA F reported transferring the resident by herself, having the resident pivot from the wheelchair back to the bed, and stated that an EZ stand was not used and that she believed the resident was a one-person assist at the time. The resident’s care plan documented the resident as non-ambulatory with transfers requiring two-person assistance using a wheeled walker, and physician orders in effect at the time specified transfers with two-person assistance using an EZ stand.
Failure to Use Required PPE for Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement its infection prevention and control program by not ensuring required PPE use for residents on Contact precautions. A resident admitted with diagnoses including malnutrition and Type 2 Diabetes Mellitus, and with moderately impaired cognition per a recent MDS, had physician orders for Contact transmission-based precautions for diarrhea. On multiple observations, CNAs entered and exited this resident’s room, which had a Contact precautions sign posted on the door, wearing only surgical masks and without donning gowns and gloves. One CNA acknowledged that Contact precautions required a gown and gloves and confirmed that neither she nor another CNA had donned the required PPE. The resident reported that staff did not wear gowns when entering the room and normally only wore gloves. A PPE cart near the resident’s room was observed to be missing gloves, and staff had to retrieve gloves from another resident’s room. Additional observations showed that a laundry aide entered four resident rooms without performing hand hygiene and wearing only a surgical mask, and then entered a room with a Contact precautions sign without donning any additional PPE. The laundry aide stated that she normally just went in and out with clean laundry without using a gown or gloves. The Corporate Infection Control staff member reported that the facility’s expectation was that all staff entering a Contact precautions room don a gown and gloves. The facility’s written Transmission-Based Precautions policy stated that healthcare personnel caring for residents on Contact precautions wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, and that PPE is to be donned upon room entry and discarded before exiting to contain pathogens.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Two residents with cognitive impairments, one with Alzheimer's disease and severe impairment and another with unspecified dementia and moderate impairment, were involved in an incident where one resident was observed grabbing the other's foot. During care, the resident accused a staff member of attempted rape, prompting immediate cessation of care. Both residents were assessed and found to have no injuries. Law enforcement responded but could not obtain statements due to the residents' inability to recall the event. The incident occurred at 11:00 AM and was discovered at 12:30 PM, but was not reported to the State Agency until 5:02 PM, exceeding the required two-hour reporting window. The Nursing Home Administrator confirmed that abuse allegations must be reported immediately, but this protocol was not followed in this case.
Failure in Medication Management, Documentation, and Adherence to Physician Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure proper medication management, accurate documentation, recognition of changes in condition, and adherence to physician orders for two residents with end-stage renal disease dependent on dialysis. For one resident, there was an active physician order for transport to dialysis on specific days and notification of the physician for missed appointments, as well as weight monitoring. The resident's dialysis schedule was altered without justification or documentation, and there was no evidence of physician notification or weight documentation for missed or changed dialysis sessions. Additionally, the resident did not receive the prescribed Sevelamer HCl for chronic kidney disease, with multiple doses marked as administered on the MAR despite the medication not being available in-house. Nurses' notes indicated the medication was not available, and the DON confirmed the MAR entries were inaccurate and that the medication was never present during the resident's admission. The same resident experienced poor oral intake, with documentation showing less than 75% meal consumption at every meal and no evidence that snacks or alternatives were offered. There was only one recorded weight during the admission, reflecting a significant weight loss, with no documentation addressing the cause or interventions. The resident did not receive a Registered Dietician consultation or progress notes, and required social services assessments were not completed until after discharge. The social worker reported being unable to complete assessments due to the resident's lethargy but did not notify nursing staff, and there was no documentation of assessment attempts. Family members reported concerns about the resident's eating difficulties and mood changes, which were not addressed by the facility. For the second resident, there was also a failure to adhere to the prescribed dialysis schedule and to notify the physician or document weights when dialysis was missed or altered. The resident missed a dialysis session due to the facility not sending the required Hoyer sling, and there was no documentation of physician notification or weight monitoring. Dialysis communication forms were missing from the medical record, and staff could not explain the changes to the dialysis schedule. These deficiencies demonstrate a lack of compliance with physician orders, medication management, documentation, and recognition of changes in condition for residents requiring complex care.
Failure to Maintain Dialysis Coordination and Documentation
Penalty
Summary
The facility failed to maintain required dialysis coordination and communication documentation for two residents who required dialysis services. Both residents had physician orders specifying dialysis schedules and instructions to notify the physician of missed appointments and to obtain weights. However, the medical records for both residents lacked dialysis communication forms, documentation of physician notification, and records of weights when dialysis appointments were missed or altered. Staff were unable to explain or justify changes to the dialysis schedules, and there was no documentation to support why the residents' dialysis days were changed from the ordered schedule, despite the dialysis center being open on the originally scheduled days. One resident was not sent with the necessary Hoyer sling for transfer at the dialysis center, resulting in an incomplete dialysis session, and there was no documentation that the physician was notified or that a weight was obtained. The other resident's dialysis days were altered without explanation or documentation, and again, there was no evidence of physician notification or weight documentation. The Director of Nursing acknowledged that dialysis communication forms could not be located and that the facility was working to improve the process.
Failure to Accurately Document and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure accurate documentation and proper maintenance of medical records for a resident admitted with end-stage renal disease dependent on dialysis and a disorder of phosphorus metabolism. The resident was prescribed Sevelamer HCl, an oral medication to manage hyperphosphatemia, to be administered three times daily with meals. Review of the Medication Administration Record (MAR) showed multiple instances where doses were marked as "OS" (see nurses' note) or as administered, but corresponding nurses' notes indicated the medication was not available. The MAR inaccurately reflected that some doses were given when, in fact, the medication was never present in the facility during the resident's stay. Interviews with the family member and the Director of Nursing (DON) confirmed that the resident did not receive any doses of Sevelamer from admission until discharge, as the medication could not be obtained from the pharmacy. The DON verified that the medication was not in the facility at any time and acknowledged that the MAR entries indicating administration were not accurate. The family was notified of the issue only after several days, and the resident was eventually transferred to a hospital due to a change in condition. The inaccurate documentation and failure to provide the ordered medication constituted a deficiency in maintaining accurate and complete medical records.
Unaddressed General Life Safety Code Requirements
Penalty
Summary
A deficiency was identified regarding general requirements under Life Safety Code (LSC) Sections 18.1 and 19.1 that were not addressed by the provided K-tags. The report notes that there are unmet general requirements, but does not specify the exact actions or omissions that led to the deficiency. No specific details about residents, staff, or events are provided in the report.
Failure to Assess and Monitor Respiratory Status Following Resident Distress
Penalty
Summary
The facility failed to adequately assess and monitor the respiratory status of a resident with a history of respiratory failure, COPD, obstructive sleep apnea, type 2 diabetes, and heart failure. Upon admission from the hospital, the resident arrived hypoxic, requiring high-flow oxygen and BiPAP, with persistent low oxygen saturation and increased work of breathing. Despite these critical symptoms, there was no documentation of a comprehensive respiratory assessment or clear orders for the use of CPAP or BiPAP in the medical record, and the admission assessment did not indicate the use of these devices. On the morning of the incident, the resident requested removal of their CPAP and assistance with oxygen via nasal cannula, reporting difficulty breathing. A CNA assisted with this request and reported the resident's oxygen saturation as 90-91%. However, there was no evidence that a licensed nurse performed a follow-up assessment after the resident reported respiratory distress. The resident was later found unresponsive, with signs of lividity and rigor mortis, and was pronounced deceased. The medical record also showed that as-needed inhaled medications for shortness of breath were not administered or documented as given. Interviews with staff revealed uncertainty regarding the oxygen flow rate and a lack of clarity about the resident's respiratory status prior to being found unresponsive. The facility's Regional Clinical Director acknowledged that a follow-up nursing assessment should have occurred after the resident reported difficulty breathing. The failure to assess and monitor the resident's respiratory status after a report of distress directly contributed to the deficiency.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights for five residents, as evidenced by direct observations, resident interviews, and review of call light response time reports. Residents with moderate cognitive impairment, diabetes, heart failure, peripheral vascular disease, and end stage renal disease reported waiting between 15 minutes to as long as two hours for staff assistance after activating their call lights. These delays occurred across multiple shifts, with some residents specifically noting longer wait times during shift changes. Call light response reports confirmed that call lights remained on for over 20 minutes on numerous occasions, with the longest single wait times ranging from 33 to 39 minutes for individual residents. Residents described waiting extended periods for assistance with toileting, transfers, and other personal care needs, sometimes resulting in episodes of incontinence. The facility's own records corroborated these reports, showing repeated instances where call lights were not answered within the facility's stated goal of 10 minutes. The Nursing Home Administrator acknowledged awareness of the issue and ongoing complaints regarding delayed response times.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and accurate Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents. For one resident, the NOMNC indicated the last covered day under Medicare A would be 4/16/25, but the notice was signed only one day prior, on 4/15/25, not meeting the required advance notice period. The corresponding SNF ABN was also signed on 4/15/25, stating that private billing would begin on 4/18/25. For another resident, the NOMNC showed the last covered day as 2/19/25, but the form was signed and dated on the same day, again failing to provide the required notice period. During an interview, the social worker responsible for issuing these notices confirmed her responsibility and usual practice of providing three days' notice, but could not explain why the notices for these two residents were issued late and inaccurately.
Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the activity preferences and needs of a resident with multiple complex medical diagnoses, including neurocognitive disorder, depression, and chronic pain. The resident, who had moderate cognitive impairment, reported feeling bored and was unaware of any activity calendar or invitations to participate in facility activities. Observations confirmed that no activity calendar was posted in the resident's room during initial visits, and the medical record lacked documentation of a care plan for activity preferences, despite the Life Enrichment Assessment indicating that functional status related to activities should be addressed in the care plan. Interviews with facility staff, including the Nursing Home Administrator and Activity Assistant, revealed that it was expected for all residents to have documented activity preferences in their care plans and to receive an activity calendar. However, the resident's records did not reflect these practices, and activity participation documentation showed mostly solitary activities, with limited staff involvement and no evidence of group activities being offered. The deficiency was identified through observation, interview, and record review, highlighting the facility's failure to ensure a comprehensive, individualized care plan for the resident's activity needs.
Failure to Provide Individualized Activities and Activity Planning
Penalty
Summary
The facility failed to provide meaningful, individualized activities for one resident with multiple complex medical conditions, including Lewy Body Dementia, depression, and schizoaffective disorder. The resident was observed multiple times sitting alone in her room and expressed feeling bored. She reported not being aware of any activity calendar or being invited to participate in facility activities. No activity calendar was observed in her room during initial observations, and her medical record did not include a care plan outlining her activity preferences or interests. The Life Enrichment Assessment indicated a need to address functional status in the care plan, but this was not reflected in her records. Documentation of the resident's activity participation over the past 30 days showed only solitary activities, such as conversation/reminiscing, with several instances occurring without staff involvement. There was no evidence of group activities being offered. Interviews with facility staff confirmed that it was expected for all residents to receive an activity calendar and have their activity preferences included in their care plan, but this was not done for this resident. The deficiency was identified through observations, interviews, and record reviews, which demonstrated a lack of individualized activity programming and failure to follow facility expectations for activity provision and documentation.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents. One resident was observed with a Trelegy inhaler and Azelastine nasal solution at her bedside and reported self-administering these medications without nurse supervision. There was no physician order, self-administration assessment, or care plan in place for this resident to self-administer medication. Another resident was found with a dulera inhaler and fluticasone nasal spray on her bedside table, which had been left by a nurse without being administered. This resident stated she does not self-administer medication, and there was no assessment, physician order, or care plan for self-administration in her record. Additionally, during a review of the medication storage room, an opened multi-dose vial of tuberculin was found in the refrigerator without a date indicating when it was opened. Staff interviews confirmed that it is professional practice to date multi-dose vials upon opening, and the LPN acknowledged the vial should have been dated and would be disposed of. These findings demonstrate failures in medication storage, labeling, and adherence to professional standards for medication management.
Failure to Implement Comprehensive Care Plan for Resident with Baclofen Pump
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a baclofen pump. The resident was admitted with diagnoses including dementia and a baclofen pump, which was not properly documented in the care plan. The medical records from the physician's office managing the baclofen pump indicated a scheduled decrease in dosage and a plan for oral baclofen administration, but this information was not included in the resident's medical record at the facility. Consequently, there were no orders or care plans indicating the presence of the baclofen pump until shortly before the resident's death. Interviews with facility staff, including LPNs, the Clinical Care Coordinator, and the Director of Nursing, revealed a lack of awareness about the resident's baclofen pump until it was mentioned by the resident's wife. The staff reported that if a resident had a baclofen pump, it should have been included in the care plan. The facility's documentation showed that the baclofen pump was last filled on a specific date, but the care plan intervention for the pump was discontinued, leading staff to believe it was no longer in use. This oversight resulted in a failure to provide appropriate care planning for the resident's medical needs.
Failure to Monitor Baclofen Pump in Resident
Penalty
Summary
The facility failed to ensure proper coordination of care and monitoring for a resident with a baclofen pump, an implanted device that delivers muscle relaxant medication directly into the spinal fluid. The resident, who had diagnoses including dementia and muscle contracture, was admitted with a baclofen pump that was not adequately documented or monitored. The family reported that the pump was due to run out of medication, but the facility had no records or care plans indicating the presence of the pump or the need for monitoring for baclofen withdrawal. Interviews with staff revealed a lack of awareness about the resident's baclofen pump. Several Licensed Practical Nurses (LPNs), the Clinical Care Coordinator (CCC), and the Director of Nursing (DON) were unaware of the pump until informed by the resident's family. The facility's documentation showed that the baclofen pump was last filled several months prior, and there was no subsequent documentation or care planning for the pump's management or the resident's potential withdrawal symptoms. The facility's failure to document and monitor the baclofen pump led to a lack of appropriate care for the resident. The resident's medical record did not include necessary orders or care plans for the baclofen pump, and there was no monitoring for withdrawal symptoms after the pump was empty. This oversight resulted in a deficiency in the coordination of care for the resident, as the staff was not informed or prepared to manage the resident's condition effectively.
Deficiencies in Food Service Equipment Maintenance and Food Storage
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, date mark all potentially hazardous ready-to-eat food products, and properly date, label, and store food products, affecting 55 residents. During a comprehensive tour of the food service area, several deficiencies were noted, including loose and fogged temperature gauges on the mechanical dish machine, soiled flooring surfaces in the Dietary Manager's office and walk-in cooler, and an improperly mounted garbage disposal spray arm valve assembly. Additionally, the can opener mounting bracket and the door gaskets of the True 2-door reach-in cooler were observed with accumulated food residue and dirt deposits. Further observations revealed that the reach-in refrigerator contained uncovered frozen vegetables, expired grapes, and an opened half-gallon of whole milk without a date. The walk-in refrigerator also contained an undated container of pasta salad. These findings indicate a failure to adhere to the 2017 FDA Model Food Code, which requires proper maintenance of equipment, cleanliness of food-contact surfaces, and appropriate date marking of potentially hazardous ready-to-eat food products. The facility's policy on sanitation inspection, dated 08-11-2022, was reviewed and found to be in non-compliance with state and federal regulations. The policy mandates that all food service areas be kept clean, sanitary, and free from litter and rubbish. However, the observed conditions, including soiled equipment and improper food storage practices, demonstrate a significant lapse in maintaining the required standards of cleanliness and food safety, thereby increasing the potential for cross-contamination and foodborne illnesses among residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 55 residents. During an environmental tour, several deficiencies were noted, including worn and damaged furniture, soiled and encrusted surfaces, and heavily stained and soiled carpeting. Specific areas of concern included the nurses' stations, beauty shop, rehabilitation unit, memory care unit, dining rooms, janitor closets, and activity rooms. Additionally, non-functional light assemblies and missing tiles were observed, indicating a lack of proper maintenance and cleaning routines. Record reviews revealed that the facility had policies in place for routine cleaning and disinfection, as well as environmental services inspections. However, the observations made during the tour indicated that these policies were not being effectively implemented. The deficiencies noted increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality, posing a risk to the health and safety of the residents, staff, and the public.
Failure to Honor Resident's Code Status and Decision-Making Rights
Penalty
Summary
The facility failed to ensure that two residents, who had not been deemed incapacitated, were acting as their own responsible party and to honor the code status wishes of one resident. Resident #37, who was cognitively intact with a BIMS score of 13 out of 15, had conflicting documentation in their medical record regarding their code status. Despite having a DNR document signed by the resident, the Director of Nursing (DON) reported that the resident was not their own responsible party and that the DNR was invalid. However, there was no documentation provided to support that Resident #37 had been deemed incompetent to make their own medical decisions. Additionally, the resident's OBRA Level II Evaluation indicated that they acted as their own person for medical and daily choices, although they had a conservator for financial decisions due to a traumatic brain injury. The facility failed to provide documentation to the survey team that supported the resident's incapacity to make medical decisions before the survey exit date. Furthermore, the DON reported that the resident had expressed a desire to be a full code status upon returning from the hospital, contradicting the previously signed DNR document. This inconsistency in honoring the resident's code status wishes was a significant deficiency in the facility's care practices. Resident #3, who had severe cognitive impairment with a BIMS score of 5 out of 15, had their spouse designated as their responsible party. However, there was no documentation to support that Resident #3 had been deemed incompetent to make their own medical decisions. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both reported that the resident's spouse was making medical decisions on their behalf, but they were unable to provide any capacity determination documentation. This lack of documentation to support the resident's incapacity to make their own medical decisions was another significant deficiency in the facility's care practices.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for two residents. Resident #54 was admitted to the facility and later discharged home, but the Discharge MDS incorrectly indicated that the resident was discharged to the hospital. This error was confirmed by the MDS Coordinator during an interview. Resident #37, who had diagnoses including diabetes, depression, and schizophrenia, was found to have an error in the quarterly MDS. The MDS incorrectly reflected the use of an antidepressant, although the resident had not been prescribed any antidepressant since admission. The MDS Coordinator acknowledged the coding error, attributing it to a possible misclassification of an antipsychotic medication as an antidepressant.
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What surveyors actually found near you
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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
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Health Campus Of Jackson | 0.3 mi | ★★★★★ | 25 | 0 |
| Jackson County Medical Care Facility | 2.9 mi | ★★★★★ | 13 | 0 |
| Faith Haven Senior Care Centre | 3 mi | ★★★★★ | 17 | 0 |
| Regency At Jackson | 3 mi | ★★★★★ | 25 | 1 |
| Vista Grande Villa | 3.3 mi | ★★★★★ | 18 | 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.