Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Vista Grande Villa during CMS and state inspections, most recent first.
Food service equipment, storage areas, and prep surfaces were found soiled and not maintained in clean condition. Surveyors observed residue on the walk-in cooler thermometer and shelving, clean equipment racks, a can opener, meat slicer, food processor, blender, ice scoop holder, char broiler, fryer, and paper towel dispenser, along with black buildup in the dish room and mop area. They also found an unmarked pan of liquid, a date-marked dressing bottle, damaged walls and flooring in storage and mop areas, worn pans, a torn hot box gasket, and missing lightbulbs in the pass-through heating assembly.
Unjustified Increase in Antipsychotic Medication: A resident with anxiety disorder, delusional disorders, and vascular dementia received an increased Seroquel dose despite no recent documented behaviors, hallucinations, or delusions in the chart. Psychiatry noted the resident had been stable, but hospice and nursing notes later referenced yelling out and anxiety at lunch, leading to an added afternoon Seroquel dose on top of the existing BID order. Staff interviews confirmed behavior documentation was limited.
Failure to report suspected misappropriation of a resident’s funds. A cognitively intact resident with cardiac dx and anxiety had bank statements reviewed during a Medicaid application, and staff identified withdrawals and charges that the resident could not have made. APS and the Ombudsman were notified, but staff did not call police or report the incident to the Administrator/State Agency because the resident did not want the family member in trouble and the former SW did not want to bother leadership while they were on vacation.
Failure to investigate resident fund misappropriation: A cognitively intact resident’s bank records showed unauthorized withdrawals and charges from checking and savings accounts, and staff learned a family member had been taking the resident’s money. APS and the Ombudsman were notified, but no facility incident report or investigation was found, the DON and Interim NHA were unaware of the event, and the former NHA’s response to the stolen funds was not documented.
Failure to complete required PASARR Level II screening for a resident with anxiety disorder, delusional disorders, and vascular dementia. The resident had severe cognitive impairment on BIMS, and the record showed a Level I review with Yes responses in Section II, but no DCH-3878/Level II screening was found. The SW said PASARR was handled by a third-party MDS group, and the MDS nurse could not locate the Level II form.
A facility failed to update care plans for two residents. One resident tested positive for COVID-19 and had symptoms, but the care plan did not reflect the diagnosis or TBP, and signage/PPE were not present at the door during observations. Another resident’s chart showed full code status, but the care plan still listed DNR, and the DON acknowledged the care plan was not updated.
Failure to Complete Ordered Daily Weights for Edema Monitoring: A resident with HTN and spinal stenosis had a physician order for daily weights to monitor edema, but weights were repeatedly not completed or documented as refused. The resident was observed with bilateral leg edema and reported worsening swelling, while notes showed multiple refusals and delays related to the early morning weigh time, with no documentation of completed weights or reattempts on those days.
A resident with anxiety disorder, delusional disorders, vascular dementia, and severe cognitive impairment had Seroquel ordered for anxiety, with an added afternoon dose later. Pharmacy asked to clarify the diagnosis to support antipsychotic use, and the prescriber agreed with delusional disorder/delirium, but the chart was not updated and still listed anxiety as the indication. The SW and DON both confirmed the record continued to reflect anxiety.
Failure to Maintain COVID-19 TBP for a Resident with COVID-19: A resident who tested positive for COVID-19 and had symptoms including cough, runny nose, headache, nausea, and fatigue was observed without TBP signage or PPE at the door. The DON and UM stated the resident should still have been on Droplet/Contact precautions, but the precautions were mistakenly discontinued early, and the record did not show use of the CDC test-based strategy to stop precautions.
The facility failed to send the Ombudsman a copy of the notice of transfer or discharge for two residents. One resident with heart failure was transferred to a hospital, and another resident with weakness was admitted and discharged home the same day. Staff interviews showed confusion about who was responsible for sending the monthly transfer/discharge list to the Ombudsman.
A resident with multiple health conditions and recent functional decline was subjected to mental and verbal abuse by a CNA, who displayed impatience, made derogatory remarks, and failed to provide necessary assistance during toileting. The resident was left to perform personal care alone, resulting in emotional distress. Another resident reported similar treatment by the same CNA, and staff observed the affected resident to be tearful and fearful following the incident.
A resident admitted for short-term rehab with a pelvic fracture and a sacral deep tissue injury did not have a care plan addressing the wound, despite being at risk for skin breakdown. Although interventions such as a foam dressing, specialty bed, and frequent repositioning were reportedly provided, these were not documented in the care plan, resulting in a deficiency for lack of a comprehensive, measurable care plan.
A facility failed to create a care plan for a resident prescribed Apixaban, an anticoagulant, upon admission. The resident, admitted for rehabilitation and cognitively intact, lacked a care plan and physician orders to monitor for side effects like bleeding or bruising. The DON confirmed the absence of necessary monitoring protocols for this high-risk medication.
Two residents experienced deficiencies in care due to the facility's failure to update and coordinate care plans with hospice services. One resident, with severe cognitive impairment, had hygiene issues due to lack of coordination between facility and hospice CNAs. Another resident experienced pain during showers and preferred hospice CNAs, but care plans were not updated to reflect this preference. The facility's lack of documentation and understanding of hospice services led to inadequate care delivery.
A resident with severe cognitive impairment and dependent on all ADLs did not receive necessary nail care, despite family requests. Observations showed long, unclean nails, and interviews revealed a lack of coordination between facility and hospice CNAs. The care plan lacked updates to ensure comprehensive care, leading to the resident not maintaining their highest practicable well-being.
A facility failed to document the rationale for a PRN psychotropic medication order extending beyond 14 days for a resident with anxiety disorder and atrial fibrillation. The resident, cognitively intact, was prescribed Hydroxyzine Pamoate for anxiety without a stop date. The Electronic Medical Record lacked justification for the continued use of the medication, contrary to the facility's expectation of a 14-day limit.
A survey revealed improper storage and labeling of medications in a facility's medication room. A vial of Humalog insulin was found without proper labeling, and a box of Narcan nasal spray was stored in an unlocked drawer without a resident label. The facility lacked a specific policy for medication labeling, relying on education to convey expectations.
The facility failed to ensure proper communication, collaboration, and documentation of hospice services for two residents, leading to a lack of coordinated care. One resident, with severe cognitive impairment, had incomplete hospice documentation, while another, cognitively intact, experienced inconsistent care coordination between facility and hospice CNAs. Staff interviews revealed confusion and a lack of understanding of hospice care responsibilities, resulting in inadequate care.
Food Service Equipment and Storage Areas Not Kept Clean or Properly Maintained
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and food preparation areas. During observations in the kitchen and related storage areas, surveyors found the ambient air thermometer in the walk-in cooler with accumulated moist black droplets, the cooler shelving soiled with encrusted food residue, clean equipment storage pans with encrusted residue on the rims, and the clean equipment drying rack covered with black residue that transferred to a paper towel when wiped. Additional food-contact and nonfood-contact surfaces were observed soiled, including the can opener blade area, meat slicer base and blade back, food processor and blender bases, ice scoop holder with pooling water and black particles, char broiler surfaces, deep fat fryer interior burner compartment, and the paper towel dispenser undersurface in the food product serving room. The report also documented food storage and labeling concerns. A bottle of red wine dressing was observed with a facility date mark of 2/1/2026 to 3/1/2026, and the Director of Dining Services stated it was made in house and date marked one month out. A metal holding pan containing a liquid substance was observed unmarked and covered with plastic wrap; when asked what was in the pan, the Director of Dining Services stated it must be soup from the prior night. The facility policy required foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination, and the cited FDA Food Code section required refrigerated ready-to-eat TCS food held more than 24 hours to be clearly marked with a consume-or-discard date. Surveyors also found multiple sanitation and maintenance issues in the food service support areas. The chemical storage room had broken drywall creating a visible hole, missing baseboard tiles, and a soiled floor. The mop room had damaged drywall adjacent to the mop sink, and the dry storage room return air vent was soiled with dust, dirt, and black residue. The dish room floor had black buildup, the hand sink and trash receptacle had grey splash residue, and the mop sink closet contained a soiled wringer, debris in the basin, a broken glass container lid with black residue, black residue on the wall above the sink, and debris in the ceiling light with peeling paint. The report also noted worn and etched pans, a torn gasket on the Metro C5 hot box unit, and a service pass-through heating assembly with three lightbulbs out and one missing.
Unjustified Increase in Antipsychotic Medication
Penalty
Summary
The facility failed to justify an increased dose of an antipsychotic medication for one resident with diagnoses including anxiety disorder, delusional disorders, and vascular dementia. The resident’s MDS with an ARD of 1/24/26 showed severe cognitive impairment with a BIMS score of 1 out of 15. On 2/19/26, the resident was observed sitting calmly in a gerichair in the room watching television with headphones and a super ear hearing device, and was very talkative. The medical record showed Seroquel 25 mg twice daily was ordered for vascular dementia until 12/15/25, then increased to 50 mg twice daily for anxiety. A psychiatry follow-up note dated 2/4/26 stated there had been no recent behaviors of note and that the resident continued on trazodone, Seroquel, and Ativan per hospice, with Seroquel continued because it appeared to be providing stability. However, progress notes and behavior monitoring contained no documented behaviors, hallucinations, or delusions after 2/4/26. A hospice communication note dated 2/16/26 stated the resident was yelling out after lunch again, and a resident progress note on 2/18/26 documented anxiety at lunch time and a one-time Seroquel dose. A physician order dated 2/18/26 added Seroquel 25 mg in the afternoon for anxiety, in addition to the already ordered Seroquel 50 mg twice daily. Staff interviews indicated the resident had been yelling out more, but documentation of behaviors, hallucinations, and delusions was lacking, and the additional Seroquel dose was administered on 2/19/26.
Failure to Report Suspected Misappropriation of Resident Funds
Penalty
Summary
The facility failed to develop and/or implement policies and procedures for reporting a reasonable suspicion of a crime under section 1150B of the Act for one resident. Resident 15 was admitted with cardiac diagnosis and anxiety, and the MDS showed the resident was cognitively intact with a BIMS score of 14 out of 15. Review of the clinical record showed that facility staff discovered the resident’s family member had been misappropriating funds from the resident’s checking and savings accounts after reviewing bank statements during the Medicaid application process. A progress note documented that the Social Worker and biller identified the misappropriation, and APS and the Ombudsman were notified. Another note stated the Social Worker offered to help the resident notify the bank and call the police, but the resident did not want the family member to get in trouble and requested that police not be called. During interviews, the Interim NHA and DON were unaware of the misappropriation and could not locate a facility-reported incident. The biller stated she and the former Social Worker did not call the police because of the resident’s request, and the former Social Worker stated she believed it was appropriate to notify APS and the Ombudsman and honor the resident’s wishes not to involve police; she also stated she did not want to bother the former NHA or DON while they were on vacation.
Failure to Investigate Resident Fund Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation that a resident’s family member had misappropriated funds from the resident’s checking and savings accounts, and it did not document an incident report or other investigation related to the event. Resident 15 was admitted with diagnoses including a cardiac condition and anxiety, and had a BIMS score of 14 out of 15, indicating cognitive intactness. A social worker and biller discovered on 01/22/25 that the resident’s bank statements showed withdrawals and charges the resident could not have made, including charges to liquor stores, general stores, television streaming services, and other large withdrawals. The social worker documented that APS and the Ombudsman were notified and that the resident was offered help to notify the bank and call the police, but the resident did not want the family member to get in trouble and requested that police not be called. During later interviews, the Interim NHA and DON were unaware of the misappropriation and could not locate any facility-reported incident or investigation. The biller stated she and the former social worker met with the resident, who was upset and called the family member in their presence, but she was unsure how the former NHA handled the matter. The former social worker stated she emailed the former NHA about the concerns but did not call the DON or former NHA because they were on vacation, and no explanation was provided for why the former NHA failed to investigate the stolen money.
Failure to Complete Required PASARR Level II Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident. The resident was admitted with diagnoses including anxiety disorder, delusional disorders, and vascular dementia, and the MDS with an ARD of 1/24/26 showed a BIMS score of 1 out of 15, indicating severe cognitive impairment. The resident was observed sitting in a gerichair in the room watching television with headphones and a super ear hearing device, and appeared calm and very talkative. The medical record showed an Annual Resident Review Level I screening completed on 9/22/25 with Yes responses in Section II, which indicated that a Level II screening should be sent if required, but the record did not contain a DCH-3878/Level II screening. The Social Worker stated PASARR assessments were completed by a third-party MDS group and agreed the record lacked a Level II screening, and the MDS Nurse reported they could not locate a Level II screening/3878 for the resident.
Failure to Update Care Plans for COVID-19 Precautions and Code Status
Penalty
Summary
The facility failed to revise care plans for two residents. One resident was diagnosed with COVID-19 after testing positive and had symptoms including an unproductive cough, runny nose, headache, nausea, and fatigue. The resident was observed in bed and reported the recent COVID-19 diagnosis, but there was no signage or PPE available at the door during observations. Review of the resident’s care plans showed they were not updated to reflect the COVID-19 diagnosis or the use of transmission-based precautions, and the DON and UM reported the precautions had been mistakenly discontinued before the resident was still supposed to be on Droplet/Contact precautions. Another resident’s record showed conflicting code status information. The medical record profile identified the resident as full code, while the care plan dated earlier indicated the resident had chosen DNR status. The DON acknowledged that the record showed full code status but the care plan still reflected DNR, and reported the care plan was not updated to match the resident’s actual code status.
Failure to Complete Ordered Daily Weights for Edema Monitoring
Penalty
Summary
The facility failed to implement a physician’s order for daily weights for edema monitoring for one resident who was admitted with diagnoses including hypertension and spinal stenosis. The resident’s MDS showed the resident was cognitively intact with a BIMS score of 15 out of 15. On observation, the resident was sitting in a recliner with both legs edematous, and the resident reported worsening edema in the legs, especially the left leg. Compression stockings were observed on the resident’s bed and later on the resident’s legs while the resident sat with legs elevated. Review of the physician’s order dated 1/8/26 showed daily weights were ordered for monitoring of edema interventions, with a scheduled time of 7:00 AM. Review of the MAR and weight summary showed multiple dates when daily weights were not completed or documented as refused. Progress notes documented several refusals, and additional notes showed the resident wanted to wait until later in the morning, until breakfast, or until before breakfast. There was no documentation that weights were completed or that reattempts were made on those days. In interview, the Unit Manager stated the resident was supposed to be weighed daily and that staff had changed the weight time to 7:00 AM because the resident did not like to get up early.
Pharmacy Recommendation Not Implemented for Antipsychotic Diagnosis
Penalty
Summary
The facility failed to implement pharmacy recommendations for one resident reviewed. The resident was admitted with diagnoses including anxiety disorder, delusional disorders, and vascular dementia, and the MDS with an ARD of 1/24/26 showed a BIMS score of 1 out of 15, indicating severe cognitive impairment. On 02/19/2026, the resident was observed sitting in a gerichair in his room watching television with headphones and a super ear hearing device, and he appeared calm and very talkative. The physician order dated 12/15/25 showed Seroquel 50 mg twice daily for anxiety, and a later order dated 2/18/26 added Seroquel 25 mg in the afternoon for anxiety. A pharmacy note dated 12/26/25 asked to clarify the Seroquel diagnosis to support antipsychotic use, and the prescriber response agreed with delusional disorder/delirium; however, the diagnosis was not updated and continued to reflect anxiety. The SW reported the medical record still showed Seroquel as prescribed for anxiety, and the DON stated pharmacy recommendations were printed for physicians to review, but agreed the diagnosis change was recommended and accepted while the indication remained anxiety.
Failure to Maintain COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident diagnosed with COVID-19. The resident was admitted to the facility and had a diagnosis of COVID-19 on 2/10/26. The MDS with an ARD of 2/1/26 showed the resident scored 15 out of 15 on the BIMS, indicating cognitive intactness. On 02/18/2026 at 9:15 AM, the resident was observed lying in bed and reported she had recently been diagnosed with COVID-19. At that time, there was no transmission-based precautions signage or PPE on the door. On 02/19/26 at 9:40 AM, the resident still did not have signage or PPE available at the door. The progress notes dated 2/10/26 documented that the resident tested positive for COVID-19 at 11:35 AM and had symptoms including unproductive cough, runny nose, headache, nausea, and fatigue for one day. During an interview on 02/19/2026 at 12:48 PM, the DON and UM reported COVID-19 transmission-based precautions should be implemented for 10 days and that the resident should still have been on Droplet/Contact precautions, but the precautions were mistakenly discontinued on 2/17/26. The record did not show that the CDC test-based strategy was used to discontinue the precautions.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for two residents reviewed. One resident had diagnoses including heart failure and was transferred out to a local hospital on 12/7/25. The other resident had diagnoses including weakness, arrived at the facility on 12/3/25, and was discharged home the same day. During interviews, the Social Worker stated she does not send the monthly list of transfers or discharges to the Ombudsman, while the Interim Nursing Home Administrator stated it was Social Work’s responsibility to send the monthly list. The DON and Executive Director stated they were not sure who was sending the list to the Ombudsman.
Failure to Protect Resident from Mental and Verbal Abuse by CNA
Penalty
Summary
A resident admitted for short-term rehabilitation following a fall, with diagnoses including chronic obstructive pulmonary disease, repeated falls, and macular degeneration, was found to be cognitively intact according to the Brief Interview for Mental Status. On the date of the incident, the resident required assistance with toileting and was unable to lock her wheelchair or pull down her pants due to weakness. The assigned CNA displayed impatience, made a disparaging comment about residents needing to help themselves, threw a clean brief at the resident, and left her to complete peri care and brief application without assistance. The resident reported feeling scared, weak, and emotionally distressed, crying during and after the incident, and continued to be affected by the event during the surveyor's interview. A review of statements from the resident's former roommate indicated a similar experience with the same CNA, who was described as rude and unsupportive, making comments about the resident's inability to walk to the bathroom. Another CNA reported that the resident was tearful and reluctant to accept help the day after the incident, and upon inquiry, the resident disclosed the previous day's mistreatment. The facility's abuse policy defines mental, verbal, and physical abuse, and the actions of the CNA were consistent with mental and verbal abuse as described in the policy. The facility terminated the CNA's employment following the incident.
Failure to Develop and Implement Care Plan for Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a care plan addressing a deep tissue injury (DTI) for a resident admitted for short-term rehabilitation following a pelvic fracture. Upon admission, the resident was found to have a DTI on the sacrum, as documented in the skin assessment, and was identified as being at risk for skin breakdown based on a Braden Scale score. The resident reported decreased mobility and pain with movement and repositioning, and stated that nursing staff applied a cream to the affected area daily. Despite these findings, a review of the resident's care plans revealed no interventions or strategies in place to address the DTI, prevent further skin breakdown, or promote healing. During interviews, the facility's wound nurse confirmed the presence of the DTI and described interventions such as a foam dressing, specialty bed, cushion, and frequent repositioning, noting that staff assistance was needed to prevent shearing. However, these interventions were not documented in the resident's care plan. The lack of a documented care plan meant that there were no measurable actions or timetables established to address the resident's skin integrity needs, resulting in a deficiency related to the development and implementation of a comprehensive care plan.
Failure to Develop Anticoagulant Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident who was prescribed an anticoagulant medication, Apixaban, upon admission. The resident, who was cognitively intact and admitted for rehabilitation, had no care plan in place to monitor for potential side effects such as bleeding or bruising, nor were there any physician orders for such monitoring. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of both a care plan and physician orders for monitoring the high-risk medication.
Deficiencies in Care Plan Updates and Coordination
Penalty
Summary
The facility failed to revise and update comprehensive, individualized care plans for two residents, leading to potential deficiencies in care and psychosocial well-being. Resident #15, who was admitted with diagnoses including left-sided weakness from a stroke, dysphagia, vascular dementia, and Alzheimer's disease, required substantial assistance with daily activities. Despite being dependent on care, observations revealed that Resident #15's fingernails were long and dirty, indicating a lack of proper hygiene care. Interviews with family members and staff highlighted a lack of coordination between facility CNAs and hospice CNAs, with no updates made to the care plan to reflect this collaboration. Resident #26 also experienced deficiencies in care coordination. The hospice binder at the nurse's station lacked necessary documents for collaboration, such as a current calendar, plan of care, and visit notes. Interviews revealed that Resident #26 experienced pain during showers and preferred hospice CNAs for this task. However, there was no documentation of collaboration between facility and hospice CNAs in the care plan, and missed showers were not properly reported or documented. The facility's CNAs were unaware of the hospice's role, leading to inconsistencies in care delivery. The lack of updated care plans and coordination between facility and hospice staff resulted in inadequate care for both residents. The facility's failure to document and revise care plans to reflect hospice involvement and resident preferences contributed to the deficiencies observed. Interviews with staff indicated a lack of understanding of hospice services and the need for better communication and documentation practices to ensure residents receive the care they require.
Failure to Provide Necessary Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care to a resident who was dependent on all activities of daily living (ADLs). The resident, who had severe cognitive impairment and required maximum assistance for tasks such as oral hygiene, toileting, and bathing, was observed with long fingernails and a brown substance under them. Despite the family's requests for regular nail care, the resident's nails were not trimmed or cleaned as needed. The resident's care plan indicated that showers were provided by both facility and hospice CNAs, but there was no evidence of collaboration between the two to ensure comprehensive care, including nail care. Interviews and observations revealed that the facility's unit manager was unaware of the resident's nail condition until it was pointed out. The care plan review showed that the resident received showers on specific dates, but nail care was neglected. Additionally, there was no hospice CNA care plan available to clarify responsibilities, leading to a lack of coordination in providing essential care for the resident. This oversight resulted in the resident not receiving the necessary care to maintain their highest practicable well-being.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to document the rationale for as-needed (PRN) psychotropic medication orders that extended beyond 14 days for a resident, resulting in the potential for an unnecessary medication regimen and adverse side effects. The resident was admitted with diagnoses including generalized anxiety disorder and atrial fibrillation and was cognitively intact, scoring 14 out of 15 on the Brief Interview for Mental Status. The resident was prescribed Hydroxyzine Pamoate capsules 25 milligrams for anxiety, to be taken every 12 hours as needed, with no stop date provided. The Electronic Medical Record lacked documentation justifying the continued use of the anti-anxiety medication beyond the 14-day period. During an interview, the Director of Nursing stated that the expectation for residents prescribed a PRN medication is to have a stop date that does not exceed 14 days.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in its medication room, as observed during a survey. A vial of Humalog insulin was found in the medication refrigerator without a label indicating the date it was opened or any resident information. The vial was inside its original box, which had been opened, and the box had the numbers '1102' handwritten on it. Additionally, a box containing Narcan nasal spray was discovered in an unlocked drawer, with the resident label removed and not stored with other resident-specific medications. The Licensed Practical Nurse (LPN) present during the observation acknowledged that the insulin would need to be destroyed due to improper labeling. The Director of Nursing (DON) later confirmed that both the insulin vial and the Narcan nasal spray would be discarded. The facility did not have a specific policy for medication labeling, as confirmed by the Nursing Home Administrator (NHA). The DON stated that the expectation for labeling multi-use insulin vials included the resident's name and room number, physician's name, and date opened, but this information was provided through education rather than a formal policy.
Lack of Coordination and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure proper communication, collaboration, and documentation of hospice services for two residents, resulting in a lack of coordination of care. Resident #15, who was admitted with severe cognitive impairment and multiple health issues, did not have a complete hospice binder or electronic medical record (EMR) documentation. The hospice binder lacked a Plan of Care, CNA care plan, current physician orders, and a medication list. Interviews revealed confusion among staff and hospice liaisons about the process for updating hospice information, leading to missing documentation and uncoordinated care. Resident #26, who was cognitively intact but required assistance with daily activities, also experienced a lack of coordination between facility and hospice services. The hospice binder for this resident was missing essential documents, and there was no evidence of collaboration in the EMR. The resident reported receiving showers from both facility and hospice CNAs, but documentation was inconsistent, and there was no clear plan for coordinating these services. Interviews with staff indicated a lack of understanding of hospice care responsibilities and documentation requirements. The deficiency was further highlighted by the absence of updated care plans and coordination of care between facility and hospice staff. Facility CNAs were unaware of hospice rules and did not consistently document or report missed showers or refusals. The Director of Nursing and Unit Manager acknowledged the issues but did not have a clear process for ensuring that hospice documentation was complete and accessible. This lack of coordination and documentation led to inadequate care for the residents involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Jackson | 1.8 mi | ★★★★★ | 25 | 1 |
| Jackson County Medical Care Facility | 2.1 mi | ★★★★★ | 13 | 0 |
| Mission Point Health Campus Of Jackson | 3 mi | ★★★★★ | 25 | 0 |
| Cascade Senior Care Center | 3.3 mi | ★★★★★ | 8 | 0 |
| Faith Haven Senior Care Centre | 4.1 mi | ★★★★★ | 17 | 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.