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 Mission Point Health Campus Of Jackson during CMS and state inspections, most recent first.
Palatable Food and Temperature Deficiencies: Surveyors found that food service failed to provide palatable meals and acceptable temperatures for residents. One resident with intact cognition reported the food was terrible, often ate only small amounts, and was unsure whether alternate meals were available when intake was poor. Another resident with multiple serious diagnoses described cold, wet waffles at breakfast, and surveyors observed a lunch tray with lukewarm pork loin, mushy vegetables, gelatinous gravy, and items on the resident dislike list. The deficiency was cited as affecting 46 residents who consume food.
Food service sanitation and labeling failures were observed throughout the kitchen and dining areas. Multiple pieces of equipment and non-food-contact surfaces, including the dish machine hood, ice machine scoop caddy, chairs, ovens, fryer, char broiler, steamer table, toaster, and microwaves, were soiled with encrusted residue or mineral deposits. In addition, opened milk and several prepared food items in the reach-in cooler lacked required open, discard, or date marks, and the DM stated staff would need retraining on proper dating and labeling. Other issues included damaged dining room surfaces and loose hand sink faucet assemblies.
Unsafe and Unsanitary Facility Environment: The facility failed to maintain a safe, clean, and sanitary environment for residents and staff. A resident with multiple diagnoses, including an ileostomy and moderate cognitive impairment, had feces observed on the carpet and a fecal odor in the room after staff reported a history of the resident removing the ostomy bag and throwing feces on the floor. Surveyors also found multiple resident rooms and common areas with heavily soiled carpets, urine odor, feces, bodily fluids, food residue, dirty PTAC filters, soiled sinks, damaged drywall, and worn or missing carpeting, while lift slings were piled on the floor in disarray.
Incomplete wound assessments and inconsistent pressure ulcer documentation: Surveyors found that the facility did not maintain a consistent wound care program for residents with pressure ulcers and skin breakdown. Weekly wound assessments and skin sweeps were often missing or incomplete, wound measurements and staging were inconsistent, and some treatment orders did not match the wound site being treated. The DON stated the facility lacked a wound care provider and that weekly assessments were not being completed routinely.
Failure to Ensure Physician Oversight and Orders for Wound Care: Surveyors found that the facility did not maintain physician oversight or proper orders for wound care for three residents. One resident with severe cognitive impairment had repeated gaps in weekly wound assessments and skin sweeps for a heel pressure ulcer. Another resident with dementia had wound care performed on a 4th toe without an order for that site, and the DON stated the facility lacked a wound care provider and was not completing routine assessments. A third resident with multiple chronic conditions had an open area documented on admission and later as a stage 2 pressure ulcer, but the record lacked weekly wound assessments, physician documentation, and care plan inclusion.
Failure to maintain dignity when a resident was left without timely assistance and had to yell for help. The resident, who had a BIMS of 15 and required substantial ADL assistance, reported that her CNA did not get her up in time for PT, did not answer her call light for two hours, and later placed her wheelchair away from the call light so she could not reach it. The DON stated she had not been notified of the concern and later confirmed the resident said she could not reach her call light.
Failure to provide timely NOMNC notice for a resident with a stroke diagnosis and intact cognition. The resident did not recall receiving notice that Medicare Part A coverage was ending, while the SW stated residents were given 48 hours’ notice and acknowledged this resident was not provided the required 48-hour notice.
Failure to document and promptly resolve a grievance for missing personal items: A resident with intact cognition reported a missing shirt and said staff had not provided the Concern Information form she was told she would receive. CNA reported the resident had also been missing pants and another shirt, but only some items were found and returned, and no form was completed for the missing shirt. The NHA confirmed no Concern Information form existed and stated the facility policy required staff to complete and forward the grievance form as soon as possible.
Failure to Develop and Implement Comprehensive Care Plans: A resident with activity needs was not provided meaningful room-based activity support or documented participation, a resident with an open pressure ulcer did not have the wound included in the care plan or required wound documentation completed, and a resident with dentures had a care plan that was not followed when staff did not ensure the dentures were available or properly managed. The DON confirmed the care plan was not being implemented as written.
A resident with dementia and severe cognitive impairment did not have a quarterly care conference held with the activated DPOA, and the DPOA reported not being kept informed about the resident’s status. In a separate finding, a cognitively intact resident with diabetes and a below-the-knee amputation had non-blanchable sacral redness documented on assessment, but the care plan still reflected only blanchable redness and was not updated to match the skin finding.
Two cognitively intact residents who required substantial assistance with bathing/showering did not receive person-centered ADL care as scheduled. One resident reported only one shower since admission and had messy, matted hair, while records showed only bed baths and no documentation of refused showers. Another resident reported asking for a shower more than once but being told it was not the shower day; task charting showed only one refusal entry, and the DON could not find shower sheets for the resident.
Failure to Provide Meaningful Activities: A resident with a BIMS of 15 and significant ADL assistance needs reported she was not brought to activities and was not offered room-based items or visits. The AD stated the facility offered daily activities and one-on-one room visits, but could not document the time spent with residents, and the activity calendar showed multiple gaps with no scheduled events. The resident’s care plan listed interests such as TV, news, cell phone use, social media, and visits with family and friends.
A resident with dementia, depression, and TIA experienced a 9.88% weight loss while the facility failed to document or honor his meal preferences. He reported wanting oatmeal daily but not always receiving it, had tremors that caused food to fall to the floor, and staff noted he needed help eating but often refused assistance. The RD said preferences were honored and supplements were ordered, but the chart lacked documented likes/dislikes, the care plan did not reflect snacks or extra portions, and there was no documentation of a feeding evaluation or weighted utensil trial.
Failure to Accurately Document Tube Feeding Acceptance: A cognitively intact resident with a gastrostomy tube and esophageal cancer was changed from continuous to bolus enteral feeding after requesting the change. The resident reported the bolus feedings were too rapid and often accepted only about half of the ordered amount, while staff documented the feedings as ordered or as refusals without accurately recording the actual intake. RN and LPN interviews confirmed the amount given was estimated, not measured, and the MAR lacked a way to document partial acceptance.
Failure to provide dental services for two residents. One resident with dementia, depression, and TIA complained of mouth pain, had missing teeth, and had an order for an oral surgery referral due to tooth pain and a sore on the tongue, but staff did not respond to his requests. Another resident had dentures listed in the care plan and Kardex, but staff reported the dentures were loose and caused choking, the SW was unaware of the need for denture-related dental care, and the resident had never been seen by a dentist at the facility.
Incomplete Documentation of Bolus Tube Feedings: A resident with pneumonia, esophageal cancer, severe malnutrition, and gastrostomy status was receiving bolus tube feedings after requesting a change from continuous feeding. The resident reported the boluses were initially too rapid and caused diarrhea, and staff later confirmed the resident was often accepting only about half of the ordered amount. However, the MAR documented the feedings as given as ordered without a way to record the actual amount received, and progress notes did not consistently reflect refusals or partial intake.
The facility failed to maintain a working resident call system for two residents. The call lights in their rooms and bathroom areas were observed not working as designed, with dim corridor indicators and an extremely low audible signal. Staff confirmed the system was obsolete and had been failing for weeks, and one resident stated she had to go into the corridor to find help and that it sometimes took a long time to get assistance.
Inaccurate daily nurse staffing information was posted in the facility, with the displayed staffing sheet still dated from two days earlier when surveyors observed it. During interview, the DON stated the new scheduler should have posted the weekend staffing before leaving and could not explain how changes such as hospital transfers, home discharges, or staff call-ins would be handled on weekends.
Two residents reported and staff corroborated that an LPN used profane, harsh, and dismissive language toward residents during and after fall events and when they sought help. One resident with cognitive impairment, depression, and anxiety was found on the floor after a fall, and multiple staff statements documented that the LPN used profanity and expressed annoyance about the resident frequently being on the floor, while the resident responded by calling himself derogatory names. Another cognitively intact resident, admitted with respiratory failure and heart disease, filed a grievance stating that the same LPN had a very bad attitude, told the resident to stay in the room, failed to respond to a medication request, and was "very snotty." This resident also reported that after going to get help for another resident who had fallen and was calling out, the LPN repeatedly ordered the resident back to the room and said that enough was enough, causing the resident to feel angry.
The facility failed to maintain food service equipment and date mark ready-to-eat food products, affecting 39 residents. Observations revealed soiled kitchen equipment, a damaged ceiling, and expired yogurt in the walk-in cooler. The dish machine's wash and rinse temperatures were below required levels, and kitchenettes had soiled or damaged appliances. These deficiencies increased the risk of cross-contamination and foodborne illness.
The facility failed to provide palatable and appropriately temperature-controlled food, affecting 39 residents. Several residents, including those in isolation, reported receiving cold meals, with temperature checks confirming non-compliance with FDA standards. The Director of Food and Nutrition Services acknowledged complaints and mentioned methods to maintain food temperatures, but there was a lack of clarity on reheating procedures and communication issues regarding food availability.
The facility failed to ensure proper PPE use and disinfection protocols for COVID-19 precautions. Staff did not adhere to required PPE standards, such as wearing N95 masks and proper eye protection, and signage was inadequate. Additionally, improper disinfection practices were observed, including placing medical items on surfaces without barriers and not disinfecting them properly. Another incident involved improper insulin pen preparation. These issues occurred while multiple residents tested positive for COVID-19, highlighting deficiencies in infection control practices.
The facility failed to maintain a clean and safe environment, affecting 40 residents. Observations revealed issues such as a soiled waste hopper, worn toilet seat, and damaged drywall. A sinkhole was also found near a storm drain. The facility's maintenance tracking system showed no entries addressing these concerns, indicating a gap in maintenance response.
A facility failed to develop a baseline care plan for a resident with end-stage renal disease, lacking details about the dialysis access site and necessary assessments. The resident's care plans did not specify the type or location of the dialysis access, and staff were unaware of these details. The DON confirmed that the admission assessment noted a dialysis catheter in the resident's right chest, which should have been included in the care plan.
The facility failed to ensure that the attending physician documented the review of identified medication irregularities for three residents. One resident's Metformin administration issues were not addressed due to staff leave and changes in pharmacy and Medical Director. Another resident's migraine medication concerns were signed but not addressed until months later. A third resident's MiraLAX administration recommendations were not updated in the physician's orders despite repeated pharmacy recommendations.
A resident with anxiety disorder and depression was prescribed Xanax as needed without a stop date, leading to potential unnecessary medication use. The resident was cognitively impaired, and the oversight was confirmed by the DON, who stated that PRN medications should have a stop date after 14 days.
The facility's medication error rate was 17.24% due to improper medication administration by LPNs. One LPN crushed medications on the 'do not crush' list, while another improperly prepared and administered insulin and gave a medication not ordered by the physician. The DON confirmed the procedures for medication administration and the availability of the 'do not crush' list.
A resident with a diagnosis of malignant neoplasm of the skin missed a scheduled medical appointment due to the facility's failure to arrange transportation. Although the appointment was noted in an online shared calendar, staff interviews revealed that the necessary coordination for transportation was not completed, resulting in the missed appointment.
A resident with severe dementia was not permitted to return to the facility after stabilization in a hospital, following a transfer due to behavioral issues. The decision was made by Regional Directors, and the facility lacked documentation from a physician justifying the refusal. The facility also did not have a policy for residents returning from the hospital.
The facility failed to provide written transfer/discharge notices for two residents, resulting in a deficiency. One resident, cognitively intact, was transferred to a hospital without a bed hold or transfer notice. Another resident, with incomplete cognitive assessment and unusual behavior, was also transferred without the necessary documentation. Interviews with staff confirmed the expected procedures were not followed.
A resident with severe dementia and mood disturbance did not receive prescribed Ziprasidone due to unavailability at the facility, leading to increased agitation and threatening behavior. The medication order was delayed, and the physician was not informed of the missed doses, potentially contributing to the resident's behavioral escalation.
Palatable Food and Temperature Deficiencies
Penalty
Summary
The facility failed to provide palatable food products and to ensure food and drink were served at an acceptable temperature. Surveyors observed that two sampled residents, R16 and R55, reported problems with the food they were receiving, and the deficiency was cited as affecting 46 residents who consume food. The report states that the facility did not provide palatable food products, increasing the likelihood for decreased food acceptance and nutritional decline. R55 was admitted with diagnoses including lumbar discitis and sepsis due to Group B streptococcus, and had a BIMS score of 15, indicating intact cognition. R55 told surveyors the food was terrible, that they nibbled at meals but had not found anything they liked, and that they sometimes drank Boost shakes. R55 also said they were unsure whether an alternate menu existed and did not think anything else was offered when they did not eat what was served. On observation, R55 had a breakfast tray with scrambled eggs, ham, and a biscuit, and stated the ham was good but the meal was probably cold because residents were told they could sleep in that morning. Review of the food acceptance record showed multiple meals with 0%, 25%, 50%, 75%, and 100% intake, as well as refusals, and documentation did not reflect that an alternate meal option was offered when intake was decreased. R16 was admitted with multiple diagnoses including type 2 diabetes, protein-calorie malnutrition, COPD, end stage renal disease, pancytopenia, cirrhosis, heart failure, gastric ulcer, esophageal varices, fractures, PVD, GERD, thrombocytopenia, and depression, and also had a BIMS score of 15. During breakfast observation, R16 had two waffles that did not appear toasted and were described by the resident as cold and wet, with the resident stating it appeared frozen waffles had been placed on the plate and allowed to thaw. During lunch tray observation, surveyors noted the pork loin was lukewarm, the green beans were very soft and mushy, and the gravy was gelatinous. Food temperature monitoring on R16's lunch tray showed tilapia at 137.5 degrees, rice pilaf and iced apple cake listed on the resident dislike list, winter vegetable blend at 128.4 degrees, and lemonade at 52.1 degrees. The dietary manager described the meal delivery sequence for the halls and dining room, and the report cited the 2022 FDA Model Food Code hot and cold holding standards.
Food Storage, Labeling, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to effectively clean multiple food service equipment and non-food-contact surfaces observed during the survey. The mechanical dish machine stainless steel ventilation hood was observed soiled and corroded from excessive moisture exposure. The ice machine blue plastic scoop caddy was observed soiled with accumulated and encrusted mineral deposits, and two fabric upholstered chairs adjacent to the ice machine were heavily stained with accumulated and encrusted soils. A black vinyl covered swivel chair adjacent to the 2-door reach-in cooler had both arm rest pads etched and scored. The South Bend convection oven interior and exterior surfaces were soiled with accumulated and encrusted food residue, the Pitco fryer interior cabinet and door surface had accumulated and encrusted grease deposits, the South Bend char broiler was soiled with accumulated and encrusted food residue, the steamer support table had accumulated and encrusted food residue, the commercial toaster interior and exterior surfaces had accumulated and encrusted food residue, and the Town Square Kitchenette and 200 Hall Kitchenette microwave ovens were observed with accumulated and encrusted food residue. The facility also failed to date mark and label food products stored in the reach-in cooler. One gallon of 2% milk, one-third full, was observed without an open or discard date, and one-half gallon of chocolate milk, one-fourth full, was also observed without an effective open or discard date. In addition, one hotel pan of chicken fillets marinating, one hotel pan of chicken pieces, and one hotel pan of beef broth were observed in the True 2-door reach-in cooler covered with plastic wrap but without an effective date mark. The Dietary Manager stated that all of the food products should have been dated and labeled by staff and that staff would need retraining on proper dating and labeling. The survey also identified other food service sanitation and maintenance issues. The side tabletop surface in the Private Dining Room was missing a laminate edge piece measuring approximately five feet long, and the hand sink cabinet door hinge was loose-to-mount. The Main Dining Room hand sink faucet assembly and adjacent laminate surface area were soiled with accumulated and encrusted mineral deposits, and the Town Square Kitchenette hand sink faucet assembly was loose-to-mount. The Town Square Kitchenette microwave oven and the 200 Hall Kitchenette microwave oven were observed with accumulated and encrusted food residue. Record review showed facility policies requiring food storage areas to be maintained in a clean, safe, and sanitary manner, refrigerated food outside of original packaging to be labeled and dated, equipment and utensils to be properly cleaned and sanitized, and leftovers to be handled according to food code requirements.
Unsafe and Unsanitary Facility Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 46 residents. During an observation of Resident R14's room, R14 was noted to have diagnoses including colon cancer, protein calorie malnutrition, thrombocytopenia, autistic disorder, paranoid schizophrenia, bipolar disorder, dementia, adjustment disorder, hypothyroidism, an ileostomy, and cognitive communication deficit. The resident's most recent BIMS score was 12, indicating moderate cognitive impairment. LPN V stated that foot coverings were needed before entering the room because R14 had a history of removing the ileostomy bag and throwing feces on the floor. In the room, two dark spots on the carpet in front of the couch were observed and appeared to be feces, and the room smelled of feces while R14 lay in bed and did not respond to verbal stimuli. A common area environmental tour identified multiple areas of accumulated soil and damage throughout the facility. In several resident rooms, carpeted flooring, vinyl landing strips, bedside surfaces, metal support frames, PTAC unit filters, PTAC cabinetry, discharge grills, and restroom sink fixtures were observed with accumulated and encrusted food residue, dust, dirt, mineral deposits, feces, bodily fluids, and urine odor. One room had severely soiled carpet with bodily fluids and solids, an intense malodorous condition, and worn, stained, frayed, and missing carpet outside the entrance door. Another room was observed in complete disarray with numerous personal items on furniture surfaces, heavily soiled sink basin, and etched and scored drywall behind the resident chair. Additional observations showed worn, frayed, and separated carpeting seams near the 100 Hall Nursing Station, damaged carpeting measuring approximately 12 inches by 26 feet near the 200 Hall Nursing Station, and worn, frayed, and separated carpeting near the 300 Hall Nursing Station. The 200 Hall Spa lift sling storage room was in disarray, with lift slings piled directly on the floor. The Executive Director stated the plan was to clean the room routinely and noted the resident was not educatable and had a colostomy in a bad space. Facility policy required the environment to be maintained in a safe, sanitary, orderly, and comfortable manner, but review of Direct Supply TELS work orders for the prior 120 days showed no specific entries related to the cited maintenance concerns.
Incomplete wound assessments and inconsistent pressure ulcer documentation
Penalty
Summary
The facility failed to maintain a wound care program that included weekly wound care assessments and treatments for residents with pressure ulcers and other skin breakdown. Surveyors identified that weekly wound assessments and weekly skin sweeps were not completed routinely for multiple residents, and that wound documentation, measurements, staging, and treatment orders were inconsistent or missing. The DON stated she was overseeing the wound care program, but the facility did not have a wound care provider at the time, and floor nurses were supposed to be measuring wounds and completing assessments. She also stated that weekly skin sweeps were not getting done completely and wound care assessments were not done weekly. For one resident with cerebral infarction, hemiplegia, aphasia, dysphagia, and protein-calorie malnutrition, a right heel pressure ulcer was identified and treated over time, but the record showed repeated weeks with no weekly wound assessment and no weekly skin sweep completed. The wound was noted as a small right heel ulcer with ongoing treatment, but documentation was incomplete across multiple weeks, and the DON only completed a wound care assessment after the surveyor brought the wound to her attention. The record also reflected inconsistent documentation of the wound location and measurements, with weekly skin sweeps listing skin concerns without measurements or complete descriptions. For another resident with a chronic right foot ulcer and dementia, surveyors observed wound care being performed on the right foot and heel, but the LPN measured the heel wound from an awkward angle and could not view it straight on for an accurate measurement. The record showed treatment orders for the right great toe and right heel, but the observed care included the right 4th toe even though there was no order for that site. The DON stated the facility was not completing weekly wound assessments and weekly skin sweeps routinely, and that the wound care provider had left the facility months earlier. Additional residents also lacked required wound oversight and documentation. One resident with acute kidney failure, osteomyelitis, paraplegia, and severe malnutrition had skin breakdown documented on admission and in weekly skin sweeps, but there was no weekly wound assessment documentation, no physician documentation of the wound, and no evidence the wound was included in the plan of care. Another resident with diabetes, ESRD, cirrhosis, fractures, PVD, and malnutrition had an open area on the buttock/coccyx area, but the wound was not documented with weekly wound assessments or physician notes, and the DON confirmed the care plan did not include the stage 2 pressure ulcer or interventions. A fifth resident with diabetes and an amputation had non-blanchable sacral redness on readmission, but treatment did not begin until later, and weekly skin sweeps documented unrelated sites rather than the sacral wound. Across these residents, the record showed missing weekly assessments, incomplete skin sweeps, inconsistent wound measurements, and treatment/documentation that did not match the wounds identified.
Failure to Ensure Physician Oversight and Orders for Wound Care
Penalty
Summary
The facility failed to ensure physician oversight and orders were in place for care provided to three residents. The report states that the facility did not ensure residents were under a doctor’s care, and surveyors identified deficiencies involving wound care assessment, documentation, and treatment oversight for residents with pressure ulcers and other skin openings. For one resident with cerebral infarction, hemiplegia, aphasia, dysphagia, protein-calorie malnutrition, and severe cognitive impairment, the record showed a right heel pressure ulcer first noted when the resident complained of pain in the right foot. Treatment was started and changed over time, but weekly wound assessments and weekly skin sweeps were repeatedly missing for multiple weeks. The DON stated she had just completed a wound care assessment only after the surveyor brought the wound to her attention, and said she contacted the NP for new orders and discontinued old orders because of the ulcer’s status. The record also showed weekly skin sweeps without measurements and multiple gaps in weekly wound assessment documentation. For another resident with dementia, COPD, chronic pain syndrome, muscle weakness, gait abnormalities, and a chronic ulcer of the right foot, surveyors observed wound care being performed on the right foot and heel. The LPN treated a wound on the right 4th toe even though the record contained an order for the right great toe, not the 4th toe. During interview, the DON stated there was no order for the 4th toe because that was not the toe being treated, then acknowledged the great toe wound had healed but the order remained active. The DON also stated the facility did not have a wound care provider at that time, that weekly wound assessments and weekly skin sweeps were not being completed routinely, and that the existing assessments were not capturing all skin concerns. For a third resident with diabetes, protein-calorie malnutrition, COPD, ESRD, pancytopenia, cirrhosis, heart failure, fractures, PVD, GERD, thrombocytopenia, and depression, the admission/readmission assessment documented an open area on the right buttock, and later weekly skin sweeps documented open areas on the coccyx and left buttock. The record did not contain weekly wound assessment documentation, physician documentation of the wound, or evidence that the wound was included in the plan of care. The resident was observed with an open wound near the coccyx, and the DON measured it during the survey and identified it as a stage 2 pressure ulcer. The DON confirmed that the treatment order was not in place until after the wound was identified, that weekly skin sweeps and wound assessments were not completed as required, that the physician had not documented the wound, and that the care plan did not include the pressure ulcer or interventions.
Failure to Maintain Resident Dignity When Call Light Was Out of Reach
Penalty
Summary
The facility failed to maintain dignity for one resident when the resident was left without timely assistance and had to yell out for help. The resident was admitted with diagnoses including displaced trimalleolar fracture of the right lower leg, history of stroke, polyneuropathy, obesity, and rheumatoid arthritis. The most recent MDS showed a BIMS score of 15 and indicated the resident needed substantial assistance with showering and personal care and was dependent on toileting, lower body dressing, and perineal hygiene. During an observation and interview, the resident stated she was supposed to be up in her wheelchair and ready for PT, but the CNA assigned to her did not get her up in time. She reported that nobody answered her call light for two hours and that she yelled for help hoping someone would come in. The resident stated PT came to her room while she was still in bed, and that the CNA later got her up and moved her wheelchair across the room by the television without giving her the call light, leaving her with no way to call for help other than yelling out. The DON stated she had not been notified of the concern, and later confirmed the resident said she had a rough day because she was set away from her call light and could not reach it.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide timely Notice of Medicare Non-Coverage for one resident. The resident was admitted and later readmitted with diagnoses including cerebral infarction (stroke), and the Quarterly MDS with an ARD of 1/2/26 showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. On 3/2/26, the resident was observed lying in bed and did not recall receiving notification for the end of Medicare Part A services. The resident’s Notice of Medicare Non-Coverage showed the last covered day of Medicare Part A benefits was 11/18/25, and the document was signed with the resident’s name on 11/17/25. During interview, the Social Worker reported residents were given 48 hours’ notice for the Notice of Medicare Non-Coverage and acknowledged that this resident was not provided with a 48-hour notice.
Failure to Document and Resolve Grievance for Missing Personal Items
Penalty
Summary
The facility failed to provide and document evidence of prompt resolution to a grievance involving missing personal items for one resident. The resident was admitted with multiple diagnoses including type 2 diabetes, protein-calorie malnutrition, COPD, end stage renal disease, pancytopenia, cirrhosis, heart failure, gastric ulcer, esophageal varices, fractures of the left femur, patella, and tibia, PVD, GERD, thrombocytopenia, and depression. The most recent MDS showed a BIMS score of 15, indicating intact cognition. During observation and interview, the resident stated that a shirt had been lost at the facility, that she had informed CNA Q, and that staff had been unable to find it. She also stated that staff were supposed to bring her a Concern Information form but had not done so, and that she had reported the missing shirt the previous week. Review of the grievance log did not show that the resident had filed a Concern Information form. In interview, CNA Q stated the resident had reported missing one pair of pants and two shirts, that the pants and one shirt were found and returned, and that she had not completed a Concern Information form for the shirt that could not be located. CNA Q said the event occurred the previous week and could not explain why the form was not completed or provided to the resident. The NHA confirmed there were no Concern Information forms for the resident and stated it was his expectation and the facility policy that a Concern Information form be completed for missing clothing. The facility policy required the staff member receiving the grievance to record the nature and specifics of the grievance on a designated resident assistance form or assist the resident or family member to complete the form and forward it to the Grievance Officer as soon as possible.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with different needs. For one resident, the record showed a care plan focused on therapeutic activities and leisure participation, including TV programs, news, cell phone use, social media, and visits with family and friends, with an intervention to provide room supplies upon request and encourage group participation. However, the resident stated she did not get down to activities because it took too much effort to get her up in a wheelchair, and she reported that activity staff had not brought items to her room. No activity materials were observed in her room, and the activity director stated that room visits were documented as task-based and that the amount of time spent with residents could not be documented. The resident also stated that nobody had talked with her about activities she would enjoy during her stay. For another resident, the record reflected multiple diagnoses including diabetes, malnutrition, COPD, end stage renal disease, pancytopenia, cirrhosis, heart failure, gastric ulcer, esophageal varices, fractures, PVD, GERD, thrombocytopenia, and depression. The resident was cognitively intact and was observed lying in bed with an open area on the bottom. The medical record showed skin assessments identifying open areas on the buttock, coccyx, and sacrum, but there was no Wound Assessment document completed weekly, no physician documentation of the wound, and no evidence that the wound had been included in the plan of care. A physician order for wound care was present, and during observation the wound was cleansed, measured, and identified by the DON as a stage 2 pressure ulcer, but the care plan still did not include the wound or interventions related to it. For the third resident, the record showed diagnoses including encephalopathy, chronic respiratory failure, COPD, diabetes, lung cancer, edema, heart disease, hypertension, depression, anemia, myocardial infarction, hyperlipidemia, cardiomegaly, syphilis, and cognitive communication deficit. The resident had severe cognitive impairment and stated that staff would not give him his dentures. He demonstrated that he had no teeth or dentures present and could not explain where the dentures were located. The care plan and Kardex both stated that he had dentures and that staff should assist to ensure they fit properly and were securely in place, but CNA staff reported the dentures were loose and caused choking, and the DON confirmed the plan of care was not being followed and could not explain why it was not being implemented.
Care Conference Not Held and Care Plan Not Updated for Skin Changes
Penalty
Summary
The facility failed to develop and revise care plans and to hold a care conference with Resident #7 and the resident’s activated DPOA. Resident #7 was admitted with dementia and had severe cognitive impairment, scoring 3 out of 15 on the BIMS. The clinical record showed an activated DPOA for health care was in place. During interview, the DPOA stated they lived out of state and had not been kept informed or updated on the resident’s status, and reported they had been told care conferences occurred about every 90 days but that this had not been happening. The Social Worker stated she was responsible for arranging and inviting participants to care conferences, including activated DPOAs, and that care conferences were held within 72 hours and then with the MDS/quarterly thereafter. Review of the record with the Social Worker showed the resident’s quarterly MDS did not have a coinciding care conference, and no explanation was provided for why a care conference was not held in February 2026. The facility also failed to update Resident #46’s care plan to reflect a change in skin condition. Resident #46 was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia, diabetes, and acquired absence of the left leg below the knee. The admission MDS showed the resident was cognitively intact and at risk for pressure ulcers/injuries. On observation, the resident was lying in bed with a dressing on the bottom, and the resident stated a rash had been present before admission and that the dressing had been changed the night before. The admission/readmission assessment documented non-blanchable redness to the sacrum, and a nurse practitioner note reflected a wound coccyx dressing order. However, the care plan, revised on 1/15/26, still identified only a healed scar and blanchable redness on the coccyx. The DON acknowledged that at the time of readmission the resident had non-blanchable redness on the sacrum, indicating a stage one pressure ulcer, and that the care plan had not been updated to reflect this finding.
Failure to Provide Scheduled Bathing and Person-Centered ADL Care
Penalty
Summary
The facility failed to provide person-centered ADL care to two dependent residents, R31 and R55, both of whom were cognitively intact and required assistance with bathing and showering. R31 was admitted with diagnoses including a displaced trimalleolar fracture of the right lower leg, history of stroke, polyneuropathy, obesity, and rheumatoid arthritis. Her MDS showed she needed substantial assistance with showering and personal care and was dependent for toileting, lower body dressing, and perineal hygiene. During observation, R31 stated she had only received one shower since admission, was wearing a hospital gown, and had messy, matted hair. She reported washing her hair at home several times a week and said it had not been washed for more than a week. Records showed only three bed baths in the last 30 days, no documentation of refused showers or baths, and a care plan that called for showers or baths twice weekly and as needed. CNAs stated they tried to prioritize care, sometimes had to wait for help from other halls, and were unsure why R31 had not received showers as scheduled. R55 was admitted with diagnoses including lumbar discitis and sepsis due to Group B streptococcus, and the admission MDS showed substantial/maximal assistance was needed for showering/bathing and tub/shower transfers. R55 stated they had not received a shower at the facility and had asked for one more than once but was told it was not their shower day. CNA task documentation showed only one refusal entry for bathing/showering and no further documentation of offered bathing or showers. R55’s care plan also identified the resident’s preference to choose between a tub bath, shower, or bed bath and scheduled bathing twice weekly and as needed. CNA staff reported showers were documented in task charting and on shower sheets, but the DON could not find shower sheets for R55 and found only the refusal documentation for 2/27/26.
Failure to Provide Meaningful Activities
Penalty
Summary
The facility failed to provide meaningful activities to one resident, R31. R31 was admitted with diagnoses including displaced tri malleolar fracture of the right lower leg, history of stroke, polyneuropathy, obesity, and rheumatoid arthritis. Her most recent MDS showed a BIMS score of 15 out of 15, and she required substantial assistance with showering and personal care and was dependent on toileting, lower body dressing, and perineal hygiene. During observation and interview, R31 stated she did not get down to activities because it took so much to get her up in her wheelchair and taken to the activity area, and she reported that the activity department did not bring things to do in her room. No activity information, calendar, or items were visible in her room. The Activity Director stated the facility had four activities daily, with additional exercise offered by therapy on Fridays, and that staff also provided one-on-one room visits, word puzzles, puzzles, crafts, magazines, and books. However, the Activity Director also stated they could not document the amount of time spent with residents during one-on-one visits, and room visits were not documented with the intent or plan for the visit. Review of the activity calendar showed several periods with no activities listed, including mornings that began with TV programming and other times with no scheduled events. R31’s care plan identified leisure interests such as TV programs, news, cell phone use, social media, and conversations and visits with family and friends, and it directed that room supplies be provided upon request and that she be encouraged to join groups of interest. R31 stated that nobody had talked with her about doing things she would enjoy during her time at the facility.
Failure to Maintain Nutrition With Significant Weight Loss
Penalty
Summary
The facility failed to provide enough food and fluids to maintain a resident’s health when it did not prevent a significant weight loss for Resident #5, a male with diagnoses including dementia, depression, and transient ischemic attack. The resident was cognitively intact on the Brief Interview for Mental Status and told the surveyor that he had lost weight because he was not getting the foods he liked. He stated he wanted oatmeal every day, but depending on which CNA was working, he may or may not receive it. During observation, scrambled egg was seen on the floor in his room, and the resident was noted to have tremors in both hands. A CNA reported that he needed help eating because his hands and body shook and food fell to the floor, but he refused assistance with being fed. The resident’s record showed a weight of 131.6 pounds on 01/05/2026 and 118.6 pounds on 02/18/2026, a 9.88% loss. The RD documented that food preferences were honored, but the record contained no documentation of the resident’s food preferences. The nutritional care plan identified only a beverage preference of water and did not list meal or snack likes or dislikes. Interdisciplinary notes reflected discussion of the resident’s decline, weight loss, and behaviors, with encouragement of snacks and extra portions, but the care plan did not reflect extra portions or that snacks were to be encouraged. The RD stated the resident had a poor appetite, significant weight loss, and supplements were ordered, but she had not talked with or observed him eat since the weight loss and was not present at the IDT meeting. The meal ticket only noted that he disliked salad and did not document what he liked, and the rehab director could not locate documentation related to a trial of weighted utensils or any screening or evaluation of his ability to feed himself.
Failure to Accurately Document Partial Tube Feeding Acceptance
Penalty
Summary
The facility failed to follow physician orders for enteral feeding and failed to accurately document the amount of tube feeding accepted by a cognitively intact resident with a gastrostomy tube. The resident was admitted and readmitted with diagnoses including pneumonia, esophageal cancer, severe protein-calorie malnutrition, and gastrostomy status. The quarterly MDS reflected the resident was cognitively intact with a BIMS score of 15 out of 15 and received 51% or more of total calories through tube feeding. The resident was observed in bed with the head of bed elevated and reported receiving bolus tube feedings four times per day, but stated the bolus rate felt too rapid and caused diarrhea. The resident had requested a change from continuous feeding to bolus feeding, and the RD ordered a bolus regimen of one carton four times daily with water flushes before and after each feeding. The MAR reflected that bolus feedings began on 2/26/26, but also showed refusals of evening feedings on 2/26/26, 2/27/26, and 2/28/26. Progress notes documented that the resident requested half the bolus amount and later accepted only 50% of a morning bolus feeding. Staff did not accurately document the actual amount of formula administered, and the MAR did not provide an option to record partial intake. RN and LPN interviews confirmed the resident was often accepting only about half of the ordered bolus feeding, that the amount was estimated rather than measured, and that the resident did not receive the full ordered amount on some shifts despite the MAR reflecting ordered administrations. Staff also reported that the provider and RD were not promptly aware that the resident was not accepting the full bolus feedings, and progress notes for 3/1/26 and 3/2/26 did not reflect refusal of the full ordered amount.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for two residents reviewed for dental care. One resident, a cognitively intact male with diagnoses including dementia, depression, and transient ischemic attack, was observed sitting in his room in a wheelchair and complained of mouth pain. He was observed to have some missing teeth and reported that he had told several staff members he needed to see a dentist again because of the pain, but he had not received a response. His physician order dated 01/07/26 reflected that he needed a referral to an oral surgeon due to tooth pain and a sore on his tongue. A second resident had a care plan and Kardex indicating dentures and the need for assistance to ensure they fit properly and were securely in place, but staff reported the resident had not used the dentures because they were loose and caused choking. The CNA could not explain where the dentures were located. The SW stated she was responsible for arranging dental services through a visiting dentist, but she was not aware the resident needed dental services related to dentures and confirmed there was no consent for dental services in the medical record. She also confirmed the resident had never been seen by a dentist while at the facility. The DON stated dental services were coordinated by Social Services and could not explain why the resident had not received routine dental services or services for loose-fitting dentures.
Incomplete Documentation of Bolus Tube Feedings
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was admitted and readmitted with diagnoses including pneumonia, esophageal cancer, severe protein-calorie malnutrition, and gastrostomy status. The resident’s Quarterly MDS showed they were cognitively intact and received 51% or more of total calories through tube feeding. On observation, the resident was in bed with the head of the bed elevated and reported receiving bolus tube feedings through the feeding tube, but stated the feedings were being given too rapidly and were causing diarrhea. Later, the resident reported that the bolus feedings had improved and were being administered more slowly four times daily. The record showed the resident requested bolus feeding on 2/26/26, and the RD recommended a new enteral nutrition order for [NAME] Farms Peptide 1.5, one carton (325 mL), four times daily with 100 mL water flushes before and after each feeding. The MAR reflected the bolus feedings were started on 2/26/26 and documented them as administered as ordered, but it did not include an option to record the actual amount received. Progress notes documented that the resident requested half the bolus amount and that on 3/3/26 the resident received 50% of the morning bolus because they refused the full amount. RN and LPN interviews confirmed the resident had been accepting only about half of the ordered feeding, that the amount accepted was not measured, and that the MAR documentation did not match what was actually given on 3/2/26. The resident’s progress notes for 3/1/26 and 3/2/26 did not reflect refusal of the full ordered bolus tube feeding.
Resident Call System Not Functioning in Two Rooms
Penalty
Summary
The facility failed to effectively maintain the resident call system for two sampled residents, R21 and R55, in their rooms and bathroom/bathing areas. The report states that the call system was not working as designed, with the corridor visual light dimly lit and the audible signal extremely low in volume. The facility’s resident call system was described as a hard-wired system installed in 2010 and obsolete since 2020, with staff reporting that the system failure had been occurring since late December 2025 or early January 2026. For R21, the clinical record showed a female resident admitted with dysphonia, depression, and anxiety, with a BIMS score of 14. During observation, the bathroom call light was tested and there was no noted change in the light when the cord was pulled. Staff stated the bathroom light should turn red, but the visual indicator did not function properly. The resident was also observed in bed with the nightstand out of reach, and the resident stated that staff had moved the bells out of reach. R21 reported that she had to go out into the corridor to find someone to help her and that sometimes it takes a long time to get help. For R55, the call system in the room was also observed not working as designed, with the corridor visual light dimly lit and the audible signal extremely low. Facility staff confirmed that the same issue was affecting both R21 and R55. Interviews further revealed that work orders had been initiated for R21’s room and that staff had placed substitute bells in the rooms after the call system failed. The facility policy stated that the call system should allow residents to call for staff assistance from each resident’s bedside, toilet, and bathing facilities, but the observed system did not function properly in the affected rooms.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted for each shift in accordance with State Operations Manual, Appendix PP. On 03/01/2026 at 09:10 AM, surveyors observed that the staffing information posted in the facility was dated 2/27/26. During an interview on 03/03/2026 at 10:43 AM, the DON stated that the new scheduler should have posted the staffing for the weekend on Friday before leaving. When asked how staffing changes such as resident transfers to the hospital, discharges home, and staff call-ins would be handled, and who was responsible for weekend posting, the DON stated she would have to review and devise a plan.
Failure to Treat Residents with Dignity and Respect During Falls and Assistance Requests
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and respect in interactions with nursing staff. One resident with Alzheimer's disease, depression, and anxiety, and moderately impaired cognition, had a history of frequent falls. After an unwitnessed fall, the resident was found on the floor beside the bed. Multiple staff witness statements documented that an LPN used profanity and harsh language toward the resident in connection with these falls. One CNA reported that the LPN asked the resident, "Why do you keep doing this sh*t?" and repeatedly questioned why he was on the floor, to which the resident responded by calling himself an "*sshole." An RN reported hearing the LPN say in a harsh and annoyed tone that she was sick of this "sh*t," that the resident's "*ss is always on the God d*mn floor," and that the situation was "bullsh*t," with the resident again apologizing and calling himself an "*sshole." The LPN denied making inappropriate statements, but the witness accounts were documented in the facility-reported incident file. A second resident, admitted with respiratory failure and heart disease and assessed as cognitively intact, reported concerns about the same LPN's attitude and behavior on a grievance form. The resident stated that the LPN had a very bad attitude, told the resident to stay in the room, did not respond to a request for medication, and was "very snotty." In a subsequent interview, this resident described an incident in which another resident across the hall had fallen and was calling out for help for approximately 15 minutes. After going in a wheelchair to find help and notifying a CNA, the resident reported that, while returning to the room, the LPN repeatedly told the resident to go back to the room and said that "enough is enough," which made the resident feel angry. The facility's resident rights policy states that residents have the right to be treated with respect and dignity.
Deficiencies in Food Service Equipment Maintenance and Food Safety Practices
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and date mark all potentially hazardous ready-to-eat food products, affecting 39 residents. During an initial tour of the food service area, several deficiencies were noted, including a damaged ceiling surface with a black watery substance near the pot and pan storage rack, and various kitchen equipment such as the South Bend convection oven, stove, griddle, char broiler, and ventilation hood filters were observed to be soiled with accumulated and encrusted food residue. Additionally, the can opener assembly was also found to be soiled. In the walk-in cooler, a full case of Yoplait Natural Yogurt was found with a manufacturer's use-by-date that had already passed. The mechanical dish machine was observed to have a wash temperature gauge reading below the required minimum, and the final rinse temperature was insufficient for effective hot water sanitization. The facility's kitchenettes also had issues, with the General Electric refrigerator/freezer and microwave oven being soiled or damaged. Record reviews of the facility's policies and procedures revealed that equipment and utensils were not being properly cleaned and sanitized, and food storage areas were not maintained in a clean, safe, and sanitary manner. The dish machine usage policy was not followed, as the recorded temperatures did not meet the required standards for sanitization. The facility's failure to adhere to these policies and procedures increased the likelihood of cross-contamination, bacterial harborage, and resident foodborne illness.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food to its residents, affecting 39 individuals. Observations and interviews revealed that several residents, including those in isolation due to COVID-19, consistently received meals that were cold or not at the correct temperature. For instance, Resident #243 reported that their meals were generally not warm, and items were missing from their meal tray. Similarly, Resident #21 expressed dissatisfaction with the taste and temperature of the food, noting that scrambled eggs were cold and pancakes were tough. Temperature checks conducted on food trays confirmed that several items did not meet the required temperature standards as per the 2017 FDA Model Food Code. For example, the green beans and cherry crisp on Resident #243's tray were below the required temperature, as were the Salisbury steak and mashed potatoes on Resident #21's tray. Additionally, Resident #145, who was in isolation, reported receiving an ice-cold breakfast and was unable to have it reheated due to isolation protocols, leading to them not eating breakfast. The Director of Food and Nutrition Services acknowledged complaints about food temperature and stated that methods to maintain food temperatures included using heated plates with insulated covers. However, there was a lack of clarity on whether nursing staff took temperatures after reheating food, and there was a discrepancy in communication regarding the availability of certain food items, such as cheerios, which were reportedly in stock but not provided to Resident #145.
Inadequate PPE Use and Disinfection Practices in COVID-19 Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and disinfection protocols for COVID-19 transmission-based precautions. Upon entrance, it was noted that a resident, identified as R145, was positive for COVID-19. Observations revealed that staff, including an LPN, did not adhere to the required PPE protocols, such as wearing an N95 mask and using eye protection like goggles or a face shield. Instead, staff were observed wearing surgical masks and regular eyeglasses, which do not meet the required standards. Additionally, there was a lack of proper signage indicating the necessary precautions and PPE before entering the resident's room. The report also highlighted improper disinfection practices. An LPN was observed entering R145's room with a Symbicort inhaler and a glucometer, placing them directly on the overbed table without a barrier. After exiting the room, the LPN did not disinfect the inhaler before placing it back in the medication cart and only partially disinfected the glucometer. The top of the medication cart, where these items were placed, was not disinfected, and the LPN continued to wear the same surgical mask while caring for other residents. Another resident, R20, was involved in a separate incident where an LPN failed to follow proper disinfection procedures while preparing and administering insulin. The LPN did not wipe the pen tip with an alcohol swab before attaching the needle, as required by the manufacturer's instructions. These deficiencies were observed during a time when the facility had multiple residents testing positive for COVID-19, indicating a broader issue with infection control practices.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 40 residents and increasing the likelihood of cross-contamination and bacterial harborage. During an interview, the Director of Environmental Services mentioned a recent transition from the Maintenance Care system to the TELS program, which may have contributed to the oversight. Observations during a common area environmental tour revealed several maintenance issues, including a soiled waste hopper basin, a worn toilet seat, and a soiled kitchenette cabinet. Additionally, the sunroom ceiling had visible damage, and the kitchenette in the 200 Hall had a damaged laminate backsplash and cabinet door hinges. Further inspection of the building grounds uncovered a sinkhole near the storm drain catch basin, posing a potential safety risk. In resident rooms, damaged drywall surfaces were noted, indicating a lack of timely maintenance. A review of the facility's policy on maintaining a safe and homelike environment highlighted the expectation for housekeeping and maintenance services to ensure a sanitary and comfortable setting. However, a review of the TELS Maintenance Work Orders showed no entries addressing these specific maintenance concerns, suggesting a gap in the facility's maintenance tracking and response system.
Failure to Develop Baseline Care Plan for Dialysis Access
Penalty
Summary
The facility failed to develop a baseline care plan with necessary healthcare information for a resident, identified as R145, who was admitted and readmitted with diagnoses including end-stage renal disease, dependence on renal dialysis, diabetes, and COVID-19. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment. Upon review, it was found that R145's care plans and orders lacked details about the type or location of the dialysis access site, and there were no orders to assess or monitor the site. During an interview, an LPN reported being unaware of the location of R145's dialysis access site or any necessary assessments or monitoring. The Director of Nursing confirmed that the admission assessment noted a dialysis catheter in the resident's right chest, information that should have been included in the care plan.
Failure to Document Physician Review of Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of identified medication irregularities, the actions taken, or the rationale for no changes in the medical records of three residents. For Resident #21, the Medication Regimen Review (MRR) dated 10/24/24 identified issues with the administration of Metformin and recommended checking vitamin B-12 and folate levels. However, the physician did not sign the review or provide a response. The Director of Nursing (DON) reported that this oversight was due to the medical records staff being on leave and changes in the contracted pharmacy and Medical Director. For Resident #35, the MRR dated 9/17/24 highlighted concerns about the use of multiple migraine medications that could lead to excessive blood vessel narrowing. Although the physician signed the review on 9/26/24, no response was provided. The DON confirmed that the issue was not addressed until 12/12/24, following a change in the Medical Director. Resident #20's records showed that pharmacy recommendations for MiraLAX administration were not updated in the physician's orders from June to November 2024, despite repeated recommendations. The DON acknowledged that these recommendations were not completed for June and July.
Failure to Provide Stop Date for PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to provide a duration of use for a PRN (as needed) medication for a resident, leading to the potential for unnecessary medication use and adverse reactions. The resident, who was admitted with diagnoses including anxiety disorder and depression, was cognitively impaired with a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS). The resident had a physician order for Xanax, an anti-anxiety medication, to be given every 8 hours as needed for anxiety, but the order did not include a stop date. This oversight was identified during an interview with the Director of Nursing, who acknowledged that PRN anti-anxiety medications should have a stop date after 14 days.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 17.24% due to five observed medication errors out of 29 opportunities. For one resident, an LPN was observed crushing medications that were on the facility's 'do not crush' list, including omeprazole, enteric-coated aspirin, and ferrous sulfate. The LPN confirmed the presence of omeprazole and enteric-coated aspirin on the list but did not find ferrous sulfate. The physician's order allowed for crushing only crushable medications or using liquid forms if the resident could not take solid dosage forms. Another resident experienced medication errors when an LPN improperly prepared and administered insulin using a Lantus Solostar pen. The LPN did not wipe the pen tip with an alcohol swab before attaching the needle and failed to perform a safety test by not expelling 2 units of insulin before administering the dose. Additionally, the LPN administered Senna S, which included docusate sodium, contrary to the physician's order for Senna without docusate sodium. The Director of Nursing confirmed the procedures for insulin pen preparation and the availability of the 'do not crush' list on medication carts.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to arrange and provide transportation for a resident's medical appointment, resulting in a missed appointment and potential delay of care. The resident, who was admitted with a diagnosis of malignant neoplasm of the skin, had a follow-up physician's appointment scheduled. However, the medical record did not mention this appointment. Interviews with staff revealed that appointments are tracked via an online shared calendar. On the day of the appointment, it was discovered that transportation had not been arranged, leading to the resident missing the appointment. The Director of Nursing confirmed that while the appointment was added to the calendar, the necessary coordination for transportation did not occur.
Facility Fails to Readmit Stabilized Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as R214, to return after stabilization following an emergency hospital transfer. R214 was initially admitted with a diagnosis of severe unspecified dementia with mood disturbance. During the stay, R214 exhibited frightening behavior, including screaming and threatening staff and a roommate, which led to a transfer to an acute care hospital for safety concerns. After psychiatric evaluation and stabilization on medication, the hospital attempted to transfer R214 back to the facility. However, the facility declined to readmit R214, stating they would not accept the resident back under any circumstances. The decision to refuse R214's return was made by two Regional Directors, as explained by the Nursing Home Administrator, who acknowledged the likelihood of being cited for this action. The facility's electronic medical record did not contain documentation from a physician justifying the refusal to readmit R214. Additionally, the facility lacked a policy regarding the return of residents from the hospital. The physician involved in R214's care was not part of the decision-making process and was unaware of the refusal to readmit the resident.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide a written reason for transfer or discharge for two residents, resulting in a deficiency. Resident #212 was admitted to the facility and was cognitively intact as per the Minimum Data Set (MDS) assessment. On a specific date, the resident experienced a change in condition and was transferred to a hospital. However, there was no evidence in the Electronic Medical Record of a bed hold or a transfer notice being provided to the resident or responsible party. Interviews with the Licensed Practical Nurse and the Director of Nursing confirmed that the expected procedure of providing a transfer notice and bed hold documentation was not followed. Similarly, Resident #214 was transferred to a hospital due to a change in condition, but the facility failed to provide the necessary transfer notice and bed hold documentation. The resident's cognitive assessment was incomplete, and the admission assessment noted unusual behavior. Despite the expectation to provide the required documentation, interviews with facility staff, including the Director of Nursing and a Regional Consultant, revealed that no such documentation was found in the resident's records by the time of the survey exit.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication as ordered for a resident diagnosed with severe unspecified dementia with mood disturbance. The resident was admitted to the facility with a prescription for Ziprasidone, an atypical antipsychotic, to be taken twice daily. However, the medication was unavailable at the facility from the time of admission, leading to missed doses over two days. During this period, the resident exhibited progressively agitated behavior, including crawling on the floor, hallucinating, yelling, and threatening others. Interviews and record reviews revealed that the medication order was not sent to the pharmacy until the day after admission, and the medication was not delivered until after midnight on the third day. The staff, including the unit manager and consultant pharmacist, acknowledged the delay in medication administration. The physician was not informed of the missed doses, which could have contributed to the resident's escalating behaviors. The National Alliance on Mental Illness emphasizes the importance of continuous medication administration to prevent symptom relapse, highlighting the potential impact of the missed doses.
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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.
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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) |
|---|---|---|---|---|
| Cascade Senior Care Center | 0.3 mi | ★★★★★ | 8 | 0 |
| Jackson County Medical Care Facility | 2.8 mi | ★★★★★ | 13 | 0 |
| Faith Haven Senior Care Centre | 2.8 mi | ★★★★★ | 17 | 0 |
| Regency At Jackson | 2.9 mi | ★★★★★ | 25 | 1 |
| Vista Grande Villa | 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.