Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seasons Healthcare during CMS and state inspections, most recent first.
A facility failed to prevent the diversion of narcotic medications, affecting 20 residents. A nurse was observed consuming a resident's pain medication, leading to immediate jeopardy. The facility lacked secure systems for medication management, resulting in significant discrepancies in narcotic counts and improper documentation of medication destruction.
A hospice nurse observed an RN taking a resident's pain medication and consuming it, leading to a delay in reporting the incident to the administrator and State Agency. The incident was not reported until the following day, resulting in the diversion of additional medication. The facility's policy requires immediate reporting of such incidents, but the hospice nurse, not being a facility staff member, was unaware of this requirement.
The facility failed to report allegations of abuse involving five residents within the required two-hour timeframe. A nursing assistant witnessed another assistant engaging in inappropriate behavior but did not report it immediately, contacting a staffing agency the next day instead. The registered nurse on duty was aware but did not report the incidents, and the administrator was only notified the following day. This delay violated the facility's policy requiring immediate reporting of abuse allegations.
A resident with a history of chronic conditions was found with unauthorized oxycodone pills and admitted to taking them in a suicide attempt. Despite symptoms of overdose and a fall, the facility failed to notify medical personnel promptly or implement immediate safety measures. Interviews revealed a lack of communication and adherence to emergency procedures, contributing to the deficiency.
A resident with an ostomy experienced significant skin damage due to inadequate care by nursing staff, who failed to follow physician orders and proper infection control practices. The resident's ostomy appliance was not changed frequently enough, leading to skin breakdown. Observations revealed that an LPN did not adhere to prescribed procedures, using contaminated gloves and failing to apply treatments correctly. Interviews indicated a lack of staff training and competency assessments in ostomy care.
A facility failed to follow a physician's order for ostomy care, resulting in a resident's ostomy appliance not being changed frequently enough, causing skin damage. The resident's care plan lacked specific instructions for appliance replacement, and the Treatment Administration Record showed discrepancies in the frequency of changes. An LPN was observed not following proper infection control techniques during an ostomy change, using contaminated gloves and unclean equipment. The DON and a nurse practitioner identified issues with staff training and infection control practices.
A resident with an ostomy experienced significant skin damage due to infrequent appliance changes and improper infection control practices by staff. The resident reported that their ostomy appliance was not changed as frequently as ordered, leading to leakage and skin breakdown. During an observed dressing change, an LPN failed to follow infection control protocols, using contaminated gloves and unclean equipment. Interviews with staff confirmed these deficiencies, and the facility's infection control policy was not provided during the survey.
A dietary staff member failed to follow proper infection control techniques during meal preparation and service, using the same gloves to handle food, touch residents, and manipulate kitchen items without changing gloves or washing hands. The facility's hand washing policy emphasized the importance of hand hygiene, but a specific policy for the dietary department was not provided.
The facility failed to submit accurate staffing data to CMS for Q1 2024, with discrepancies in licensed nursing coverage on several dates. The administrative assistant relied on inaccurate agency data, leading to errors in the PBJ report, despite confirmation that staff worked as scheduled.
A facility failed to consistently assess, monitor, and document pressure injuries for a resident with pressure-induced deep tissue damage. Over 25 weeks, the facility did not adhere to its policy of weekly assessments for 14 weeks, lacking details such as measurements and wound characteristics. The resident required assistance for daily activities and had specific wound care orders, but weekly assessments were not documented. Interviews revealed that wound measurements were supposed to be completed weekly, but this was not consistently done, and the DON was unaware of the incomplete documentation.
A resident on contact precautions due to a Foley catheter received personal care from two NAs, one of whom failed to change gloves after providing perineal care. This NA continued to handle various items without changing gloves, contrary to the facility's infection control policy. The DON confirmed that staff are expected to perform hand hygiene and change gloves between tasks, especially after perineal care.
A facility failed to ensure a resident was offered the pneumococcal PCV-15 or PCV-20 vaccination or provided with a declination form, as per CDC recommendations. The resident's vaccinations were not up to date, and the facility's electronic health record lacked documentation of the offer or declination of the vaccines. An RN stated the facility had not started obtaining consents for these vaccinations, and although the resident reportedly refused, there was no documentation to support this. The DON mentioned plans to collaborate with a local pharmacy to facilitate vaccinations.
Narcotic Diversion and Misappropriation of Resident Property
Penalty
Summary
The facility failed to prevent the diversion of narcotic medications, resulting in the misappropriation of resident property. Between November 2023 and March 2025, a significant number of controlled substances, including tramadol, oxycodone, clonazepam, hydromorphone, and hydrocodone, were diverted from the facility. This affected 20 residents, with one registered nurse (RN-A) observed consuming a resident's medication intended for pain management. The facility lacked a secure system to prevent such diversion, leading to an immediate jeopardy situation. The deficiency was highlighted when a hospice nurse witnessed RN-A swallowing a tramadol tablet meant for a resident with brain cancer, who was experiencing non-verbal signs of pain. Despite the hospice nurse's request for pain medication administration, RN-A consumed the medication herself, leaving the resident in discomfort. The facility's records indicated discrepancies in the narcotic counts, with RN-A falsely documenting the destruction of medications and failing to follow proper procedures for medication disposal. Interviews with facility staff, including the administrator, director of nursing, and contracted pharmacist, revealed a lack of adherence to policies regarding controlled substance management. The facility's processes for reconciling narcotic counts and securing the emergency medication kit were inadequate, contributing to the diversion of medications. The facility's failure to maintain accurate records and ensure proper oversight of medication destruction allowed the diversion to occur undetected for an extended period.
Removal Plan
- Updated current policies and developed a Controlled Drug Count/I-Kit Policy and Procedure and Discrepancies, Loss and/or Diversion of Medications Policy and Procedure.
- The nurse on duty completed education and policy review and put a plan in place for nurses to complete the policy review and education prior to working their shift. The education was followed by a knowledge test.
- The pharmacy consultant to set up an in-person education.
- E-Kit contents verified secure by tag number with the pharmacy.
- Controlled substance counts completed and reconciled.
Failure to Timely Report Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property in a timely manner to the administrator and State Agency. A hospice nurse observed a registered nurse (RN) taking a resident's pain medication, tramadol, and consuming it in front of her. The incident occurred while the hospice nurse was preparing to provide care to the resident, who exhibited signs of pain during the care process. The hospice nurse, shocked and unsure of how to proceed, left the facility and reported the incident to her supervisor. The hospice regional director then informed the facility's director of nursing the following day. The administrator was not notified of the incident until the day after it occurred, which delayed the reporting to the State Agency. This delay resulted in the diversion of an additional 49 tramadol tablets. The facility's policy requires all staff to report any alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property immediately, or within two hours if the event involves abuse or results in serious bodily injury. The hospice nurse, not being a facility staff member, was not aware of the facility's reporting requirements, which contributed to the delay in notification.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to immediately report allegations of abuse involving five residents to the administrator and State Agency within the required two-hour timeframe. On the evening of 11/26/24, a nursing assistant (NA-A) observed another nursing assistant (NA-B) engaging in inappropriate and abusive behavior towards residents. NA-A witnessed NA-B lying on top of one resident, making rude and sexual comments to another, and inappropriately touching and speaking to others. Despite witnessing these incidents, NA-A did not report the allegations to the facility administrator immediately but instead contacted a staffing agency representative the following morning, mistakenly believing she had up to 24 hours to report the allegations. The registered nurse (RN-A) on duty was aware of the allegations but did not report them to the administrator or the State Agency, assuming that the person who directly witnessed the incident was responsible for reporting it. The administrator only became aware of the allegations on 11/27/24 at approximately 2:30 p.m. through an email notification. The facility's policy requires all staff to report alleged violations involving abuse immediately, but no later than two hours after the allegation is made. The delay in reporting these allegations resulted in a failure to meet the reporting requirements as outlined in the facility's policy.
Failure to Address Unauthorized Narcotic Ingestion and Suicidal Ideation
Penalty
Summary
The facility failed to ensure timely notification of the on-call physician and the primary care physician regarding a resident's change in condition and suspicion of unauthorized narcotic ingestion. The resident, who was cognitively intact and had a history of chronic kidney disease, heart attack, and peripheral vascular disease, was found with 10 pink pills suspected to be oxycodone. Despite the discovery, there was no immediate notification to the on-call provider, and the potential overdose symptoms were not promptly addressed. The resident admitted to bringing oxycodone pills from home and taking seven pills in an attempt to commit suicide. Despite experiencing vomiting and a fall, the staff did not place the resident on immediate safety checks or investigate the potential suicidal ideation. The facility's documentation and interviews revealed a lack of communication and assessment regarding the resident's condition and the presence of a knife in the room, which further indicated a risk of self-harm. Interviews with staff and the director of nursing highlighted a failure to follow the facility's change of condition policy and emergency procedures. The nursing staff did not notify the appropriate medical personnel or take necessary actions to ensure the resident's safety, such as transferring the resident to the emergency room for evaluation. The facility's policies lacked clear guidelines for handling suspected overdoses and implementing safety measures, contributing to the deficiency.
Inadequate Ostomy Care and Infection Control Practices
Penalty
Summary
The facility failed to ensure that five registered nurses and one licensed practical nurse were competent in providing ostomy care for a resident with an ostomy. The resident, identified as R2, had not had his ostomy bags changed for 21 days, resulting in significant skin damage and feces on his abdominal area. Despite the resident's understanding of his treatment and ability to articulate the ostomy orders, he reported that his ostomy appliance was not changed frequently enough, leading to skin breakdown and discomfort. During an observation, LPN-A was seen performing an ostomy care procedure on R2 without following proper infection control techniques and physician orders. LPN-A used contaminated gloves, did not disinfect scissors, and failed to follow the prescribed steps for changing the ostomy appliance. The resident's skin was observed to be open, red, and moist, and the procedure was not completed as ordered, with the vinegar soak not being applied for the required duration and the wrong size pouch initially used. Interviews with the director of nursing and nurse practitioner revealed that there was no training, competencies, or audits conducted to ensure staff competency in ostomy care. The director of nursing acknowledged the infection control concerns and the lack of a policy related to staff competencies. The nurse practitioner confirmed that the resident's skin breakdown could be attributed to the failure to follow the treatment orders and infection control practices.
Failure to Follow Ostomy Care Orders and Infection Control Protocols
Penalty
Summary
The facility failed to ensure that a physician's order for the treatment of an ostomy was appropriately documented and followed for a resident identified with an ostomy. The resident had not had their ostomy bags changed for 21 days, resulting in significant skin damage and feces on the abdominal area. The resident's cognition was moderately impaired, and they required assistance with certain activities. Despite the resident's understanding of their treatment, they reported that their ostomy appliance was not changed frequently enough, leading to skin breakdown and discomfort. During an observation, the resident's ostomy appliance was found to be undated, with the adhesive edges lifting and not adhering to the skin. The resident's care plan did not specify when staff should replace the appliance connected to the abdomen. The physician's order required the appliance to be changed three times a week, but the Treatment Administration Record indicated it was only changed twice a week. Additionally, there was no evidence to confirm that the appliance had been changed as recorded. An LPN was observed performing an ostomy change without following proper infection control techniques or the physician's order. The LPN used contaminated gloves, unclean scissors, and wipes that had been on the floor. The vinegar soak was not applied for the required duration, and the correct size pouch was not initially used. The LPN admitted to not following the physician's order and acknowledged the infection control concerns. The Director of Nursing and a nurse practitioner also identified issues with the lack of training and competencies for staff, as well as the risk of complications due to improper infection control techniques.
Inadequate Infection Control During Ostomy Care
Penalty
Summary
The facility failed to follow appropriate infection control techniques and ensure proper storage of dressing materials during the care of a resident with an ostomy. The resident, identified as R2, had not had their ostomy bags changed for 21 days, resulting in significant skin damage and feces on the abdominal area. Despite a physician's order to change the ostomy appliance three times a week, the resident reported that it was only changed once a week, leading to leakage and skin breakdown. During an observation, a licensed practical nurse (LPN) was seen performing an ostomy dressing change without adhering to infection control protocols. The LPN used contaminated gloves, did not disinfect the over-bed table, and used scissors provided by the resident without cleaning them. The LPN also used wipes stored on the floor and did not follow the physician's order for the dressing change procedure, including the duration of the compress application. The resident was observed using bare hands to clean the stoma area, and the LPN applied the new appliance without re-cleansing the site after leakage occurred. Interviews with the LPN and the director of nursing (DON) revealed a lack of adherence to physician orders and infection control practices. The DON acknowledged that the supplies should not have been stored on the floor and that the LPN should have used clean equipment. The nurse practitioner confirmed that the resident's skin breakdown could be attributed to improper infection control practices and infrequent appliance changes. The facility's ostomy policy emphasized the importance of proper cleaning and changing of the pouch, but an infection control policy was not provided during the survey.
Infection Control Breach in Dietary Department
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed by dietary personnel during meal preparation and service. During an observation, the cook, identified as C-A, was seen preparing and serving food without changing gloves or performing hand hygiene between tasks. C-A used the same gloves to handle food, touch residents, and manipulate various kitchen items, such as utensils and containers, without changing gloves or washing hands. This practice was observed during the noon meal service, where C-A served pork roast, mashed potatoes, stewed tomatoes, dinner rolls, and apple pie to residents. The food service manager confirmed that C-A was aware of the requirement to use gloves or utensils when handling food and that gloves should be changed after serving a meal to a resident. The facility's hand washing policy emphasized the importance of hand hygiene to prevent cross-contamination, but a specific hand hygiene policy for the dietary department was not provided. The administrator also expressed the expectation that infection control procedures should be followed during food preparation and service.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate and complete staffing data to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2024. The CMS payroll-based journal (PBJ) staffing data report identified several dates where the facility did not have licensed nursing coverage for 24 hours a day. Despite the staffing coordinator's assertion that licensed nursing staff were scheduled for each shift on those dates, the PBJ data submitted did not reflect this. The staffing coordinator identified both employed and agency nurses scheduled for the shifts in question, but the data submitted to CMS was inaccurate. The administrative assistant responsible for submitting the PBJ data admitted to relying on data provided by agencies, which was not always accurate. Upon review, timecard and agency billing information confirmed that the licensed nursing staff worked as scheduled on the infraction dates. The facility's policy indicated that the PBJ system was auditable to ensure accuracy, but the manual entry of agency staff hours led to discrepancies in the data submitted to CMS.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to consistently assess, monitor, and document pressure injuries for a resident identified with pressure-induced deep tissue damage. Over a period of 25 weeks, the facility did not adhere to its policy of weekly assessments and documentation for 14 of those weeks. The documentation was inconsistent, lacking details such as the date of observation, location, measurements, appearance, discharge, surrounding tissue appearance, and pain presence. This inconsistency was observed in the resident's weekly bath/skin assessments, progress notes, and treatment records. The resident, who had intact cognition and required assistance for most activities of daily living, was admitted with pressure ulcers and other medical conditions including high blood pressure, renal insufficiency, arthritis, anxiety disorder, and depression. The care plan included repositioning every 2-3 hours, pain medication as needed, and specific wound care orders. However, there was no identification of weekly assessment, monitoring, and documentation of the resident's pressure wounds, as required by the facility's policy. Interviews with nursing staff revealed that wound measurements were supposed to be completed weekly, but this was not consistently documented. The Director of Nursing was unaware that complete wound assessments were not being completed and documented weekly. The facility's policy required all skin issues and wounds to be identified and treated appropriately, with licensed nurses responsible for measuring wounds weekly and documenting progression and treatments in the electronic medical record system.
Infection Control Deficiency During Personal Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques during the provision of personal care for a resident identified as being on contact precautions due to an indwelling Foley catheter. During an observation, two nursing assistants (NAs) were involved in changing the resident's brief and transferring him from his bed to a wheelchair. Although both NAs initially washed their hands and donned gowns and gloves, one of the NAs, NA-D, did not change her gloves after providing perineal care. Instead, she continued to handle various items, including the urinary drainage bag, blankets, and lift sling, without changing gloves, which is against the facility's infection control policy. The director of nursing (DON) confirmed that the expectation for all staff is to perform hand hygiene and change gloves between clean and dirty tasks, especially after providing perineal care. The facility's hand washing policy outlines specific instances when hand hygiene should be performed, including after contact with body fluids or potentially contaminated items. Despite annual education on infection control measures, the failure to change gloves after providing personal care was identified as a deficiency in the facility's infection prevention and control program.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident, identified as R128, was offered the pneumococcal PCV-15 or PCV-20 vaccination or provided with a declination form, as recommended by the Centers for Disease Control (CDC). The resident's admission Minimal Data Set (MDS) indicated that their pneumococcal vaccinations were not up to date. The facility's electronic health record, MatrixCare, lacked documentation to support whether R128 had been offered or declined the PCV-15 or PCV-20 vaccines, which is necessary to comply with current CDC guidelines. During an interview, a registered nurse (RN) stated that the facility had not initiated the process of obtaining facility-wide consents for the PCV-15 or PCV-20 vaccinations. Although the RN mentioned that R128 had refused vaccinations, there was no documentation to support this claim. The director of nursing (DON) indicated that the facility planned to collaborate with a local pharmacy to facilitate the administration of these vaccines to residents who wanted them. The facility's policy required assessing residents' immunization status upon admission, providing education about the vaccines, and documenting any refusals in the electronic medical record.
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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 Trimont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Methodist Health Care Center | 14.4 mi | ★★★★★ | 12 | 0 |
| Truman Senior Living | 15 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Society - St James | 15.5 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Mountain Lake | 16.8 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society - Jackson | 17.2 mi | ★★★★★ | 0 | 0 |
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