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 Faith Haven Senior Care Centre during CMS and state inspections, most recent first.
A resident with significant neurologic impairment, malnutrition, and dependence on staff developed a facility-acquired lower back pressure injury that progressed to a stage 4 wound with infection, sepsis, and surgical debridement. Surveyors observed prolonged time in the same position, a nonfunctioning air mattress, delayed meal assistance, and missing turning/repositioning documentation. Records and interviews also showed the wound worsened over time, with inadequate offloading noted in hospital documentation.
HS snacks were not consistently offered or distributed to residents. During a Resident Council meeting, six residents said they were not offered evening snacks, and most said they did not know snacks were available. Food Council minutes showed residents reported receiving nothing in January and snacks that were “various but not offered” in February. The KM stated snacks may be delivered by kitchen staff or placed in hall snack-room bins, and a bin with mostly cookies and graham crackers was observed on the 400 hall.
A cognitively impaired resident with dementia, unable to reliably communicate, was being transferred to bed with a mechanical lift when a CNA struck or tapped the resident on the head while the resident was agitated and mumbling. An LPN present reported that the CNA then moved close to the resident’s face, taunted the resident, grabbed the resident’s hands, and pushed them down after the resident raised her hands and stated she would report him, with the CNA allegedly laughing and saying nobody cared about her. The CNA admitted to hitting the resident on the head to gain attention and acknowledged the resident’s threat to report him, while denying verbal abuse. The facility’s abuse policy defines such hitting as physical abuse and disparaging language as verbal abuse, yet the administrator provided no explanation for the head strike, denied awareness of verbal abuse allegations, and there was no past non-compliance document related to this incident in the facility’s records.
A resident with dementia and severe cognitive impairment was allegedly tapped on the head, yelled at, taunted, and had her hands pushed down by a CNA after she became agitated during care, with the CNA reportedly laughing and saying that nobody cared about her when she stated she would report him. An LPN witness later described these events in detail to surveyors, but the facility’s incident file contained only an incomplete, unsigned word-processed statement lacking key details, dates, and interviewer information, while the CNA’s statement was on a formal facility form and minimized the interaction to a light tap and a request for the resident to stop saying she would report him. The administrator denied knowledge of verbal abuse allegations, could not reconcile conflicting accounts or documentation formats, and the facility failed to follow its abuse policy requiring comprehensive, signed, and dated interviews and written statements for all involved, resulting in no thorough investigation of the alleged verbal abuse or the CNA’s conduct.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to resident safety and well-being.
A deficiency was cited when a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights was not upheld by the facility.
A resident with complex medical and psychiatric needs submitted written grievances alleging that an RN threatened her life, failed to process a physician's order for pain medication, and treated her unequally. Despite these allegations being recognized as abuse, the facility did not report the incident to authorities within the required timeframe, instead delaying the report by 20 days.
A resident with a recent shoulder replacement and multiple sclerosis did not receive necessary restorative services due to a breakdown in communication and documentation within the facility. Despite recommendations for restorative therapy, the resident's care plan lacked orders for such services, resulting in a deficiency. The facility is auditing past referrals for compliance.
The facility failed to provide coffee at a palatable temperature, as reported by residents and observed during interviews. Residents noted that coffee was poured and left on the counter for extended periods, leading to it being served cold. Despite repeated complaints documented in Resident Council meetings, no effective solution was implemented. A resident, who was the Resident Council President, confirmed the issue, and the Dietary Manager acknowledged the problem but did not measure coffee temperatures upon delivery. The facility lacked a hot liquid policy, and no documentation was provided to show efforts to resolve the issue.
A resident with multiple health conditions experienced frustration and embarrassment due to the facility's failure to respond to her call light in a timely manner. Despite the call light being on for over 30 minutes, staff did not respond promptly, leading to the resident having accidents. The facility uses a pager system for call lights, but the assigned CNA did not have a pager on during the incident. Previous complaints about slow response times were noted in Resident Council Meeting minutes and Grievance Logs.
The facility failed to address grievances from residents participating in Resident Council meetings, including concerns about cold coffee temperatures and requests for a different cable package and a television in the dining room. Despite repeated documentation of these issues over several months, there was no evidence of resolution or communication back to the residents, and the facility did not meet its policy requirements for responding to concerns.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect diagnoses and discharge documentation. One resident was inaccurately coded with schizophrenia instead of bipolar disorder, another had an incorrect diagnosis of schizoaffective disorder bipolar type, and a third resident's discharge was incorrectly documented as a facility death instead of a hospital death.
A resident with a recent shoulder replacement did not receive necessary restorative therapy due to a lapse in communication and documentation between therapy and nursing departments. Despite a recommendation for therapy, the resident's care plan was not updated, resulting in unmet care needs and continued pain.
A resident developed moisture-associated skin damage (MASD) and incontinence-associated damage (IAD) to the sacrum area while in the facility. Despite a wound evaluation recommending specific interventions, the care plan was not updated to include these changes. The care plan had not been revised since October, and an observation revealed open skin areas. The wound nurse indicated that the unit manager was responsible for revising care plans, but this was not done.
The facility failed to ensure accurate diagnostic practices for two residents, leading to incorrect diagnoses in their medical records. One resident was inaccurately documented with schizophrenia instead of bipolar disorder, while another had an incorrect diagnosis of schizoaffective disorder bipolar type. Interviews revealed a lack of verification and errors in the computerized system, contributing to these inaccuracies.
A resident in a LTC facility, who required assistance with daily living activities, did not receive adequate oral hygiene care. Despite being cognitively intact and cooperative, the resident was observed with caked debris on their teeth and severe halitosis. The care plan indicated oral hygiene should be performed every shift, but the resident reported not receiving necessary supplies or assistance, and staff interviews confirmed a lack of time to provide care.
The facility failed to follow a physician's order for a resident with multiple sclerosis, delaying the administration of Trazodone for insomnia. Additionally, another resident with severe cognitive impairment was improperly positioned in a wheelchair, with feet dangling and not reaching the footrests. Communication breakdowns and lack of timely action contributed to these deficiencies.
The facility failed to ensure physician follow-up on pharmacy recommendations for two residents. One resident was on multiple pain medications without clarification on their use for different pain levels, and another had unaddressed recommendations regarding medication diagnosis and timing. The oversight was noted by the DON and RCD, with hospitalization cited as a factor.
The facility failed to adhere to medication administration parameters for a resident with hypertension, administering Lisinopril despite low blood pressure readings. Additionally, another resident with a UTI was given an inappropriate antibiotic, Bactrim DS, despite culture results indicating resistance. The delay in changing the antibiotic was due to staff absence over the holiday, and the facility did not follow expected infection screening protocols.
A facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed Prozac 40 mg for depression and bipolar disorder. Despite a plan to attempt a GDR, no reduction was ordered or attempted, and the resident's medication remained unchanged. Additionally, the resident had not been seen by behavioral health services since the GDR was supposed to be considered, and the social worker confirmed the oversight and lack of monthly follow-up.
A resident with severe cognitive impairment and multiple health conditions did not receive timely dental services for broken and lost dentures. Despite being on the list for dental visits, the resident's dentures were not repaired or replaced due to inadequate communication and coordination between the facility and dental service providers.
A facility failed to provide sanitary incontinence care for a resident with severe cognitive impairment. A CNA was observed using a cloth with feces, rinsing it in the toilet and sink, and then using it to clean the resident. The CNA admitted to the unsanitary practice, believing toilet water was the same as sink water, and was on suspension at the time of the interview.
Pressure Ulcer Care and Offloading Failure
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident who had multiple risk factors, including hemiplegia/hemiparesis following cerebral infarction, aphasia, vascular dementia, protein-calorie malnutrition, and dependence on staff for repositioning, transfers, dressing, hygiene, and eating. The resident’s MDS reflected she was at risk for pressure ulcers and was not on a turning/repositioning program at earlier assessment points. The resident later returned from the hospital with a stage 4 pressure ulcer and continued to have a facility-acquired wound on the lower back/spinal area that was documented as unstageable/deep tissue injury and later progressed to a stage 4 pressure ulcer with exposed bone and undermining. Record review showed the wound was first documented as a new in-house pressure ulcer on the lower back with erythema, edema, slough, and eschar, and subsequent notes described worsening size, depth, undermining, pain, and seropurulent drainage. The resident was hospitalized for sepsis secondary to an infected stage 4 lumbar pressure ulcer with deep soft tissue infection, and hospital records noted surgical debridement. Infectious disease documentation stated the lumbar decubitus ulcer was associated with likely spinous process erosion in the setting of inadequate offloading and recommended aggressive offloading and nutritional supplementation. Survey observations showed the resident remained in the same bed position for extended periods, with a wedge under the hip and the bed alarm/beeping noted, while meal assistance was delayed and the resident called out for food. On another observation, the air mattress pump was not functioning and the mattress appeared deflated, with the resident sunk into the bed. Staff interviews and record review also found missing turning/repositioning documentation, and the facility could not provide a complete investigation when requested. The resident’s care plan included turning/repositioning, pressure-reducing devices, and skin checks, but the report documented that the resident’s wound developed and worsened while these measures were not consistently evidenced in the record or during observations.
HS Snacks Not Consistently Offered or Distributed
Penalty
Summary
The facility failed to ensure that a substantial HS evening snack was consistently offered and appropriately distributed to residents who attended the Resident Council Meeting. During the confidential Resident Council Meeting on 3/18/2026 at 10:00 AM, six residents participated, and all six reported they were not offered evening snacks. One resident reported seeing a bin of cookies at the nurse station but stated there were no options other than cookies and that residents had to go to the nurse station and ask for them. Five residents reported they did not know snacks were available at all. Review of the facility Food Council minutes for January and February 2026 showed that when residents were asked what they were offered for bedtime snack, the January response was “Nothing,” and the February response was “Various but not offered.” During an observation and interview on 3/19/2026 at 2:15 PM, the Kitchen Manager stated residents should receive evening snacks in two ways: if ordered by the dietitian, kitchen staff deliver labeled snacks to resident nurse stations and floor staff deliver them, or bins are placed in snack rooms on the halls. In the 400 hall snack room, a bin containing mostly individually wrapped oatmeal cream filled and chocolate cookies and graham crackers was observed. The Kitchen Manager stated staff should offer each resident evening snacks and restock supplies as needed, and noted a recent request for string cheese.
Failure to Protect a Cognitively Impaired Resident From Physical and Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a CNA. The resident had dementia with severe cognitive impairment, as evidenced by a BIMS score of 3/15, and was not reliably interviewable. On the date of the incident, the resident was in her room, agitated and mumbling, when a new LPN entered to assist a CNA with transferring the resident to bed using a mechanical lift. According to the LPN’s account, the CNA tapped or hit the resident on the head while the resident was mumbling, and the resident reacted by saying she would report him. The LPN reported that after the head strike, the CNA retrieved the resident’s communication whiteboard and wrote that the LPN was there to help, but the resident remained agitated and raised her hands. The LPN stated that the CNA then got in the resident’s face, taunted her, grabbed her hands, and pushed them down. The resident reportedly told the CNA she would report him to the state, and the CNA allegedly laughed and responded that nobody cared about her. The LPN described feeling very uncomfortable with the CNA’s aggressive treatment and remained with the resident afterward because the resident was upset, afraid, and stated she did not like being hit on the head. In his written and verbal statements, the CNA admitted to hitting or tapping the resident on the head to get her attention, acknowledging he could have chosen to tap her shoulder or arm instead. He confirmed that the resident said she would report him, though he denied verbally responding to that statement. The facility’s abuse policy defines physical abuse as including hitting and slapping, and verbal abuse as the use of disparaging or derogatory language toward residents. The administrator acknowledged the CNA’s physical contact with the resident’s head but offered no explanation for it and stated he was not aware of any verbal abuse allegation. There was no past non-compliance document related to this incident in the facility’s records, despite the reported physical and verbal interactions described by the LPN and partially acknowledged by the CNA.
Failure to Thoroughly Investigate Allegations of Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of abuse involving one resident with severe cognitive impairment and dementia. The resident was non-interviewable per a recent MDS, and was observed to be pleasantly confused. An incident file contained an unsigned word-processed statement attributed to an LPN describing an event in which a CNA tapped the resident on the head, yelled “Stop,” taunted the resident, pushed the resident’s hands down, laughed, and told the resident that nobody cared about her after she said she would report him. This document lacked basic investigative elements such as the date of the incident versus the interview date, the identity of the interviewer, and whether the interview was conducted in person or by phone. The statement also did not capture the full extent of the alleged verbal abuse and physical interaction later described by the LPN in a surveyor interview. In a subsequent phone interview with the surveyor, the LPN provided a more detailed account, stating she was a new employee and that upon entering the resident’s room she saw the CNA hit the resident on the head, yell “Stop,” retrieve the resident’s communication whiteboard, get in the resident’s face, taunt her, grab her hands, and push them down. The LPN reported that the resident said she would report the CNA to the state, and that the CNA laughed and said, “go ahead, nobody care about you.” The LPN stated she was very uncomfortable with the CNA’s aggressive treatment, remained with the resident because the resident was afraid and upset about being hit, and then reported the incident to another nurse, who told her the administrator had to be notified. The LPN stated she relayed the same chain of events to the administrator that she later described to the surveyor, but this level of detail and the alleged verbal abuse were not reflected in the facility’s written incident documentation. The CNA’s written statement, in contrast, was on a facility form that included the name and position of the person interviewed, the interviewer, the date of the interview, the date of the incident, and the location. In that statement, the CNA acknowledged tapping the resident on the head to get her attention and admitted he could have chosen to tap her shoulder or arm instead. He acknowledged the resident said she would report him and that he told her to stop saying that, but he did not document any verbal abuse. In a phone interview with the surveyor, the CNA again admitted hitting the resident on the head, denied responding when she said she would report him, and stated he learned of allegations of physical and verbal abuse from the administrator after being suspended. The administrator, however, denied awareness of any verbal abuse allegation, could not explain discrepancies between the LPN’s and CNA’s documentation, and offered no explanation for why the LPN’s interview was on an unsigned word document while the CNA’s was on a completed facility form. The facility’s abuse policy required comprehensive interviews of the resident, accused, and witnesses, with written, signed, and dated statements, but there was no documentation showing a complete investigation into the alleged verbal abuse, the CNA’s tone or intent, or whether his “go ahead” comment was abusive or encouraging of the resident’s rights, and no past non-compliance document was created for this incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report identifies a deficiency related to the facility's inability to ensure residents were safeguarded from abuse and neglect, as required by regulations. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations involving individual residents.
Failure to Timely Report Allegations of Abuse and Neglect
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. A resident with multiple medical and psychiatric diagnoses, who was cognitively intact, submitted written grievances alleging that a registered nurse threatened her life and well-being, refused to listen to her wishes, and failed to process a physician's order to increase her pain medication. The resident referenced an EMS report related to a hospital transfer and expressed ongoing concerns about the nurse's conduct, including allegations of unequal treatment and threats. The nurse had previously received disciplinary action for not following through with physician orders, and documentation showed a pattern of similar issues. Despite the resident's written allegations, which were recognized by the covering Nursing Home Administrator as abuse allegations, the facility did not report the incident to the State Agency within the required two-hour timeframe. Instead, the formal report was made 20 days after the initial grievances were submitted. The delay in reporting was confirmed through interviews and record review, indicating a failure to follow mandated reporting procedures for suspected abuse or neglect.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services for a resident, resulting in a deficiency. The resident, a cognitively intact female with a history of multiple sclerosis and recent right shoulder replacement, was admitted to the facility with a need for assistance in transfers, ambulation, and toileting. Despite having received therapy services upon admission, these services were discontinued due to insurance issues. The resident reported significant pain and limited range of motion in her right shoulder, yet there was no evidence in her medical records or care plans of her recent shoulder replacement or any restorative therapy being provided. Interviews with facility staff revealed a breakdown in communication and process regarding the implementation of restorative therapy. The Therapy Director confirmed that a recommendation for restorative therapy was made upon the resident's discharge from therapy services, but the Director of Nursing was unaware of the responsibility to add these orders to the resident's care plan. The restorative referral form was not properly communicated or documented, leading to the resident not receiving the necessary restorative therapy between the specified dates. The facility was in the process of auditing past referrals for compliance following the surveyor's investigation.
Facility Fails to Serve Coffee at Palatable Temperature
Penalty
Summary
The facility failed to provide hot liquids at a palatable temperature, specifically coffee, to residents, as observed during a group interview and individual resident interviews. Four out of five residents in a group interview reported that the coffee was consistently served cold, a complaint that had been ongoing. The residents observed that coffee was poured into cups and left on the counter for about 30 minutes before being placed on trays, which contributed to the coffee cooling down. The Resident Council meeting minutes from previous months also reflected repeated complaints about the coffee temperature, but no effective solution had been implemented. Resident 61, who was cognitively intact and the Resident Council President, expressed dissatisfaction with the coffee temperature, stating that it was cold by the time it reached their room. Despite having a lid on their coffee cup, the temperature issue persisted. The resident's meal ticket specified that coffee should be served fresh from the machine, but this was not being adhered to. The Dietary Manager acknowledged receiving complaints about cold coffee and described the process of pouring coffee when tray tickets were printed, but the coffee was not served immediately, leading to temperature loss. The facility did not have a policy for hot liquids, and the Dietary Manager admitted that they did not measure the coffee temperature when it reached the residents. During a meal service observation, a Culinary Specialist instructed staff not to pre-pour coffee but to serve it directly from the machine to maintain temperature. Despite these observations and interviews, no documentation was provided to show efforts to address the issue, and the problem remained unresolved by the exit date.
Delayed Call Light Response Leads to Resident Frustration
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, resulting in frustration and embarrassment for the resident. The resident, a cognitively intact female with a history of urinary tract infection, multiple sclerosis, and anxiety disorder, required assistance with transfers, ambulation, and toileting. On the day of the observation, the resident had her call light on for over 30 minutes, urgently needing to use the bathroom. Despite the call light being illuminated, no staff responded promptly, leading to the resident expressing that this delay in response happens frequently, causing her to have accidents. The facility uses a pager system for call lights, but on the day of the incident, the assigned Certified Nurse Aid (CNA) did not have a pager on, claiming to have started the shift without it. The call light monitoring system confirmed the call light was on for at least 16 minutes before being addressed. The facility's Clinical Care Coordinator and Nursing Home Administrator were unaware of the staff not wearing pagers and reported occasional complaints about slow response times. The resident's care plan indicated the need for one-person assistance, and previous Resident Council Meeting minutes and Grievance Logs reflected ongoing concerns about call light response times.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents participating in the Resident Council (RC) meetings were promptly resolved and responded to in a timely manner. During a confidential group meeting, RC members expressed frustration that management discussed fixing problems but did not document or communicate updates on issues. Specifically, residents repeatedly raised concerns about cold coffee temperatures and requested a different cable package that included the ABC network, as well as a television in the main dining room. Despite these issues being documented in RC meeting minutes over several months, there was no evidence of resolution or communication back to the residents. The Nursing Home Administrator (NHA) A attended a December meeting and suggested taking test trays to check coffee temperatures, which added to residents' frustration as they had consistently reported the coffee was cold. The NHA A was unable to provide documentation of follow-up actions or responses to these grievances, and there were no assistance/concern forms related to the issues. The facility's policy required responses to concerns within 15 days and a written response within 30 days, but these timeframes were not met. The lack of documented responses and follow-up actions contributed to the deficiency in addressing resident grievances.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #66 was admitted with a diagnosis of bipolar disorder, but the MDS assessments inaccurately included a diagnosis of schizophrenia. Interviews with the Social Work Director, Unit Manager, and Regional Clinical Director revealed confusion and acknowledgment of the inaccuracy, as the schizophrenia diagnosis was not supported by the resident's medical history. Resident #64's medical record showed a diagnosis of schizoaffective disorder bipolar type, which was incorrect. The resident's MDS inaccurately documented schizophrenia, despite the resident having a history of bipolar disorder. The Social Worker and Nursing Home Administrator were unable to explain the source of the incorrect diagnosis, and the Regional Clinical Director noted that the computerized system may have automatically listed the wrong diagnosis, which should have been manually corrected. Resident #89's MDS inaccurately documented the type of discharge as a death in the facility, although the resident had died in the emergency department after being transferred for a routine visit. The Regional Clinical Director clarified that the MDS should have been coded as a discharge-return anticipated, as the resident was not admitted to the hospital. This error was identified through a review of the Resident Assessment Instrument manual and hospital records.
Failure to Implement Restorative Therapy for Resident Post-Surgery
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident who had undergone a right total shoulder replacement. The resident, a cognitively intact female with multiple diagnoses including multiple sclerosis and anxiety disorder, was admitted to the facility and initially received therapy services. However, these services were discontinued due to insurance issues. Despite a recommendation for restorative therapy made by the therapy department upon discharge from therapy services, the resident did not receive the necessary restorative therapy for over a month. This resulted in unmet care needs, including limited range of motion and significant pain. The deficiency was further compounded by a lack of communication and documentation. The therapy department completed a restorative therapy referral, which was not properly communicated to the nursing department, as evidenced by the blank nursing signature line on the referral form. The Director of Nursing, who had been in the position for over six months, was unaware of the referral until the surveyor investigation. The resident's care plans and electronic medical records did not reflect the need for restorative therapy or the recent shoulder replacement, indicating a failure in updating and implementing the care plan to meet the resident's needs.
Failure to Revise Care Plan for Skin Breakdown
Penalty
Summary
The facility failed to revise the care plan for one resident, who was admitted with a risk for skin breakdown due to incontinence. The resident developed moisture-associated skin damage (MASD) and incontinence-associated damage (IAD) to the sacrum area while in the facility. Despite a wound evaluation identifying these issues and recommending interventions such as a heel suspension/protection device, a mattress with a pump, a positioning wedge, and a turning/repositioning program, the care plan was not updated to reflect these changes. The care plan had not been revised since October 9, 2024, and did not include the new interventions for the MASD/IAD issue. An observation on January 3, 2025, revealed three open skin areas on the resident. The wound nurse stated that the unit manager was responsible for revising care plans when new skin breakdowns were identified, but this had not occurred in this case.
Inaccurate Diagnostic Practices in Resident Records
Penalty
Summary
The facility failed to ensure that diagnostic practices met professional standards for two residents, leading to inaccuracies in their medical records. Resident #66 was admitted with a diagnosis of bipolar disorder, but their medical record inaccurately included a diagnosis of schizophrenia. This discrepancy was not addressed in the Preadmission Screening/Annual Resident Review (PASARR) or the behavioral services notes. Interviews with the Social Work Director, Unit Manager, and Regional Clinical Director revealed uncertainty and acknowledgment of the inaccuracy, but no corrective information was provided before the survey exit. Resident #64's medical record also contained inaccuracies. Although the resident was diagnosed with schizoaffective disorder bipolar type, the hospital discharge records did not support this diagnosis. The Minimum Data Set (MDS) inaccurately documented schizophrenia, and the PASARR indicated a diagnosis of bipolar disorder. Interviews with the Social Worker and Nursing Home Administrator revealed a lack of verification of diagnoses with hospital records and an error in the computerized system that automatically listed schizoaffective disorder bipolar type instead of bipolar disorder. The deficiencies in diagnostic practices were highlighted by the facility's failure to accurately document and verify residents' diagnoses. The inaccuracies in the medical records of both residents were acknowledged by the Regional Clinical Director, who noted that the computerized system contributed to the errors. The facility's staff did not provide explanations for the discrepancies, and the necessary corrections to the residents' diagnoses records and MDS were not made before the survey exit.
Failure to Provide Adequate Oral Hygiene for Resident
Penalty
Summary
The facility failed to provide adequate daily oral hygiene for a resident who required assistance with activities of daily living. The resident, who was cognitively intact and had diagnoses including anxiety and depression, was observed multiple times with caked debris on their lower teeth and severe halitosis. Despite the care plan and kardex indicating that oral hygiene should be performed every shift and as needed, the resident's oral care was neglected. Interviews with staff revealed that the midnight shift was responsible for the resident's morning care, and the resident was cooperative with assistance. However, the resident reported not receiving the necessary oral care supplies and assistance, stating that staff claimed they did not have time to help. The resident's clinical record showed that they had been seen by a dentist twice, with findings of calculus and plaque buildup, and recommendations for staff assistance with daily hygiene. Despite these recommendations, the resident continued to experience inadequate oral care, as evidenced by the persistent debris and halitosis. The Registered Nurse/Unit Manager acknowledged the need for oral care after meals, at night, and as needed, but offered no explanation for the lack of care provided. The resident expressed dissatisfaction with the situation, highlighting a lack of necessary supplies and assistance for oral hygiene over several weeks.
Failure to Follow Physician's Orders and Properly Position Residents
Penalty
Summary
The facility failed to follow a physician's order and appropriately position two residents, leading to potential unmet care needs. Resident #67, a cognitively intact female with multiple sclerosis and recent right shoulder replacement, was not administered Trazodone as recommended by a psych consult for adjustment insomnia. Despite the recommendation being made on 12/19/24, the order was not added to the electronic medical record until 1/06/25. Interviews with the Director of Nursing, Unit Manager, and Social Worker revealed a breakdown in communication and process, as the consult notes were not reviewed or acted upon in a timely manner. Resident #6, who has severe cognitive impairment and left-sided hemiparesis, was observed multiple times sitting in a high-back wheelchair with feet dangling, indicating improper positioning. The footrests were attached, but the resident's feet did not reach them, which was not noticed by the Registered Nurse/Unit Manager. The therapy department was responsible for assessing and issuing the wheelchair, but no assessment or fitting documentation was provided by the end of the survey.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy medication recommendations were followed up by the physician for two residents. Resident 41 was admitted with a diagnosis of a sacrum fracture and was prescribed three pain medications: Tylenol, Oxycodone, and Tramadol. A pharmacy recommendation dated 11/28/2024 requested clarification on which medication should be used for mild, moderate, and severe pain. However, there was no physician follow-up on this recommendation, as confirmed by the Director of Nursing during an interview. Resident 66, admitted with diagnoses including GERD, diabetes, and COPD, had a physician's order for Metformin and Glycopyrrolate. A pharmacy recommendation on 11/12/2024 suggested providing a diagnosis for Glycopyrrolate and adjusting the timing of Metformin administration. These recommendations were not addressed, and no documentation from the physician explained why. The Director of Nursing and Regional Clinical Director noted that the facility had 30 days to act on recommendations, but the resident's hospitalization from 11/26/24 to 11/29/24 was cited as a factor in the oversight.
Medication Administration and Antibiotic Selection Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered within the prescribed parameters for Resident #66, who was admitted with a diagnosis of hypertension. The physician's order specified that Lisinopril should be held if the resident's systolic blood pressure was less than 110. However, the medication was administered on three occasions when the resident's systolic blood pressure was 108. The Unit Manager acknowledged the error but could not explain why the medication was administered against the order. For Resident #45, the facility failed to administer the appropriate antibiotic for a urinary tract infection. The resident, who had multiple diagnoses including a subarachnoid hemorrhage and severe cognitive impairment, was initially prescribed Bactrim DS. However, a urine culture later revealed that the bacteria were resistant to this antibiotic. Despite receiving the culture results on December 31, 2024, the facility did not change the antibiotic until January 2, 2025. The Clinical Care Coordinator explained that the delay was due to her absence over the holiday and that she only reviewed the results upon her return. The Corporate Director of Infection Control confirmed that the facility was expected to follow the McGeer Criteria for infection screening and that a risk-benefit analysis should be conducted if these criteria were not followed. However, no such analysis was found for Resident #45. The Director also stated that nursing staff were expected to notify medical providers of test results promptly, which did not occur in this case, leading to a delay in administering the appropriate treatment.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted for a resident in order to reduce the use of a psychotropic medication. The resident was admitted to the facility and was prescribed Prozac 40 mg for depression and bipolar disorder. Despite a note in the behavioral health services Physician's notes indicating that a GDR would be attempted and documented in the resident's chart, no GDR was ordered or attempted. The resident's medication administration record showed that the Prozac dosage remained unchanged from the initial prescription date. Additionally, the resident had not been seen by behavioral health services since the date when the GDR was supposed to be considered. During an interview, a social worker acknowledged that the GDR had not been attempted and confirmed the lack of follow-up by behavioral health services. The social worker also noted that the resident should have been seen monthly by behavioral health services, indicating a lapse in the facility's protocol for managing psychotropic medications and behavioral health follow-up.
Failure to Provide Timely Dental Services for a Resident
Penalty
Summary
The facility failed to ensure timely dental services for a resident, identified as R7, who was admitted with diagnoses including congestive heart failure, diabetes, and dementia. R7 had severe cognitive impairment and was receiving hospice services. The Minimum Data Set (MDS) assessments indicated that R7 had a broken or loosely fitting full or partial denture from March to December 2024. Despite this, the facility did not facilitate the timely repair or replacement of R7's dentures. Observations and interviews revealed that R7's upper denture had been broken since April, and the bottom denture was lost, yet the dentures had not been replaced. The facility's social services and dental service provider communications were inadequate, leading to delays in dental care. A social service note from February 2024 indicated that a referral was made to a dental service provider, but the provider had not seen R7. Subsequent notes revealed that the dental provider could not repair the dentures as they were not originally provided by them. Despite impressions being taken in October 2024, there were no further dental notes, and R7 remained without dentures. The Social Work Director was unable to explain why R7 was not seen by the dentist in December, despite being on the list for dental visits, highlighting a lack of coordination and follow-up in providing necessary dental care for R7.
Unsanitary Incontinence Care
Penalty
Summary
The facility failed to ensure incontinence care was provided in a sanitary manner for Resident #6. Resident #6, who had severe cognitive impairment and was frequently incontinent of bladder and occasionally incontinent of bowel, was observed to have been cleaned improperly by CNA D. Confidential Staff F reported that CNA D dipped a cloth with feces on it into the toilet, rinsed it in the sink, and then used the same cloth to wash Resident #6's buttocks. Despite being told by CS F to stop, CNA D continued to use the cloth on the resident. During a phone interview, CNA D admitted to the unsanitary practice, explaining that she believed the water in the toilet was the same as the water from the sink. CNA D, who had been a CNA for eight years and employed by the facility for four months, was on suspension at the time of the interview. She acknowledged that her actions were wrong and that she no longer considered toilet water to be clean and sanitary.
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What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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 | 2.8 mi | ★★★★★ | 25 | 0 |
| Cascade Senior Care Center | 3 mi | ★★★★★ | 8 | 0 |
| Arbor Manor Rehabilitation And Nursing Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Vista Grande Villa | 4.1 mi | ★★★★★ | 18 | 0 |
| Regency At Jackson | 5.1 mi | ★★★★★ | 25 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.