Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Aspire Senior Living Jonesburg during CMS and state inspections, most recent first.
Unsafe transfers and repositioning led to resident injuries. Staff did not use two staff members for mechanical lift transfers or bed mobility as required for dependent residents. One resident swung in the air during a lift transfer, another was rolled during repositioning and later found to have a fractured femur, and a separate lift incident involved one CNA using the lift alone, causing the lift to tip over and resulting in multiple fractures, a forehead bruise, and hospitalization.
Failure to notify the physician after a resident’s change in condition. A CNA repositioned a resident with left-sided paralysis and 2-person transfer needs, heard a pop, and the resident immediately complained of leg pain. The incident was reported to an LPN, but the record did not show physician notification, and the resident continued to report left hip pain the next morning.
Staff failed to complete and document ordered weekly skin assessments for a resident with moderate cognitive impairment and identified risk for skin breakdown. Facility policies required weekly head-to-to-toe skin observations and documentation in the medical record, and physician orders specified weekly skin assessments on designated shifts. Review of records showed multiple weeks with no documented assessments, during which time a DTI on the sacrum and a pressure ulcer on the left heel, both described as facility-acquired, were present. Interviews with the MDS nurse, RN, DON, and Administrator confirmed that the charge nurse was responsible for these assessments, that the EHR would have prompted them, and that all physician orders were expected to be followed, yet leadership was unaware the assessments had not been completed or documented.
A resident with severe cognitive and physical impairments developed an open area on the knee that progressed to bone protrusion and significant drainage. Nursing staff documented the change and notified the physician, but failed to promptly inform the resident's legal representative of the condition change, resulting in delayed communication about the resident's health status.
Menus, recipes, and food substitutions were not followed as planned. Staff served a breakfast that differed from the posted menu, and residents on regular, minced and moist, and pureed diets did not receive all listed food items or portioned components. The kitchen lacked visible menus for modified-texture diets, standardized recipes, and a substitution log, and the cook and dietary manager both stated they did not have the needed menus or recipes available.
Facility staff failed to store food safely, keep dishes dry and clean before stacking, perform hand hygiene correctly, and maintain kitchen surfaces and equipment. Surveyors observed raw and ready-to-eat foods stored improperly together, multiple opened or undated items, dented cans, expired products, wet stacked pans and plates, brief handwashing with bare-hand faucet contact, and dirty or damaged kitchen equipment including steam table wells, refrigerator gaskets, vents, and ice scoop containers.
Staff failed to maintain a clean, comfortable, and homelike environment when multiple resident rooms had damaged drywall, missing paint, cracked and water-damaged surfaces, broken door parts, and unfinished repairs. Staff also failed to keep several residents’ wheelchairs clean, with observations of built-up dirt, food debris, dried food, and other soil on wheelchair frames, wheels, and footrests. Interviews showed staff knew about some of the room damage but had not consistently reported it, and staff were unclear about who was responsible for wheelchair cleaning and how often it should occur.
Care plans were not updated to reflect key resident needs identified in assessments and orders. A resident's activity preferences were omitted, another resident's diabetes and insulin use were not care planned, and a third resident's pain management needs, including PRN pain meds and non-pharmacologic interventions, were not included. Staff and the DON stated these items should have been on the care plan.
Failure to Document Neurological Checks and Fall Interventions: Staff did not complete required neuro checks after unwitnessed and head-impact falls for several residents, and they did not update care plans or fall risk assessments as required. The affected residents included individuals with cognitive impairment, wheelchair use, and prior falls, and the records showed repeated gaps after multiple falls, including falls with abrasions, pain, and head impact.
Staff failed to follow hand hygiene and perineal care practices for multiple residents, including using soiled gloves for dirty-to-clean tasks, leaving rooms without washing hands, and handling clean items after stool contamination. Staff also failed to complete required two-step TB screening for several employees, and one CMT worked on the floor before the first TB test was read.
A resident who was cognitively intact and dependent on staff for wheelchair propulsion was pulled backward down the hallway in a mechanical chair while yelling and cussing, and the resident later said the action was embarrassing and made him/her feel unsafe. Another resident with severe cognitive impairment and dementia was repeatedly left in the dayroom with food debris on the face, shirt, and pants after meals, despite staff observations and staff statements that this was not dignified.
Code status was not consistently documented on the face sheet and/or POS for several residents. Record review showed some residents had DNR or Full Code information in the care plan or advance directive, but the face sheet was blank and the POS lacked a physician order. Staff interviews confirmed code status should be available in the chart and on the face sheet, and that a physician order should be entered so staff know whether to provide CPR.
Failure to obtain signed informed consent for bed rail use and to complete accurate bed rail assessments for three residents. Two residents with significant mobility and cognitive impairments and one cognitively intact resident were observed in bed with rails or assist bars upright on repeated observations, yet their records lacked signed consent and their assessments did not document recommendations for turn bars or assist bars. Staff interviews showed confusion about who completed the assessments and who obtained consent, while the DON and administrator acknowledged that consent should be obtained and oversight was their responsibility.
Failure to complete bed rail entrapment assessments and routine inspections for four residents. Records for residents with cognitive and physical impairments showed no documented entrapment risk assessment or maintenance inspection for bed rails or assist bars, while observations confirmed the rails were in use. Staff, including the MDS coordinator, maintenance director, DON, and administrator, stated assessments and measurements were not being completed and that responsibility for them was unclear.
Failure to Post Daily Nurse Staffing Census: Facility staff did not complete the required nurse staffing information to include the facility census on multiple daily staffing sheets, and observations at the nurses' station showed the posted staffing information also lacked the census. An LPN, the DON, and the administrator each stated the staffing sheet should include the census along with staff and hours worked, and that the night shift charge nurse completes the form.
Staff did not report a resident-to-resident altercation involving two residents with dementia to DHSS within the required two-hour timeframe. The incident was only brought to the administrator's attention through an anonymous note days later, and documentation and interviews confirmed that the required reporting procedures were not followed.
A resident with Parkinson's disease and impaired mobility was subjected to verbal and physical abuse by a CNA, who threatened rough treatment and handled the resident aggressively during care. The incident was witnessed by a social worker, and the resident reported distress and pain. The CNA admitted to inappropriate behavior, leading to their suspension and termination.
A resident was issued an immediate discharge from a facility without proper notice or a specified new location, following an incident where the resident allegedly hit someone. The facility's discharge notice lacked required information, and the resident was left in a hospital ER without a clear relocation plan. The facility administrator confirmed the resident would not be readmitted.
The facility failed to maintain a homelike environment for residents, with observations of disrepair such as gaps in flooring, missing tiles, stains, and non-functional lighting in several rooms. Staff interviews revealed a lack of awareness and communication regarding needed repairs, despite a system for reporting issues. The Maintenance Supervisor was unaware of specific repairs needed, and the administrator acknowledged responsibility for ensuring repairs are completed.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon hospital transfer, as required by their policy. This issue was identified for three residents, with staff interviews revealing inconsistent practices in handling bed hold notifications. The administrator was unaware that bed holds were not being signed or copied for the medical record.
The facility failed to develop comprehensive care plans for three residents, neglecting to address their medical, nursing, mental, and psychosocial needs. One resident with severe cognitive impairment and hospice care had behaviors not reflected in the care plan. Another resident with moderate cognitive impairment had a care plan lacking directions for wound care and swelling. A newly admitted resident's care plan did not address elopement and psychosocial concerns. Lack of communication and oversight in updating care plans was evident.
The facility did not maintain the required RN coverage for at least eight hours daily, seven days a week. Staffing records showed gaps in RN coverage on specific dates, and interviews with staff confirmed the challenge in maintaining consistent RN presence. The facility has been advertising for the position and hired an RN for weekend coverage.
A survey revealed deficiencies in medication management at an LTC facility, including failure to destroy discontinued medications for several residents and the presence of expired and loose medications on medication carts. Interviews with staff, including an LPN, DON, and administrator, indicated a lack of awareness and responsibility for maintaining medication storage and carts, leading to oversight and non-compliance with facility policies.
The facility did not have a qualified Director of Food and Nutrition Services, as the Dietary Supervisor (DS) had not completed the required Certified Dietary Manager (CDM) course. The DS quit without notice during the survey, and the facility's registered dietitian only worked part-time as a consultant. This deficiency could impact all 60 residents.
Facility staff failed to protect resident privacy by leaving computer screens unattended and visible, displaying personal and medical information. An RN and an LPN admitted to not locking screens on treatment and medication carts, acknowledging the privacy violation. The DON and administrator confirmed the requirement to lock screens when unattended.
The facility failed to post required nurse staffing information daily, as mandated by policy. Reviews of staff hour postings for July and August 2024 showed missing census and actual hours worked for most days. Observations and interviews confirmed that postings lacked total hours and were not updated as required. The DON and an LPN acknowledged the issue, with the night shift nurse responsible for completing the postings, but this was not consistently done.
Facility staff failed to follow infection control procedures during wound care for four residents, leading to a risk of spreading bacteria. An LPN did not perform hand hygiene between glove changes and did not use gloves appropriately, as confirmed by the DON and the facility administrator.
Unsafe Transfers and Repositioning Led to Resident Injuries
Penalty
Summary
The facility failed to ensure residents were safely transferred and repositioned with adequate staff assistance. The report states staff did not use two staff members during mechanical lift transfers for one resident, did not use two staff for bed mobility for another dependent resident, and did not use two staff in a manner to assure safety for a third resident. The facility’s Safe Resident Handling and Transfers policy stated residents are to be handled and transferred safely, and that mechanical lifts are a safer alternative that should be used, with staff educated on safe handling and transfer practices. One resident was assessed as severely cognitively impaired and dependent on staff for transfer from bed to chair. The care plan noted limited physical mobility related to contractures, stroke, and weakness, and required assistance from one staff for locomotion, but did not provide transfer directions. During observation, the Social Service Director and a CNA transferred the resident with a mechanical lift while only one staff operated the lift and the other stood by the wheelchair; the resident swung in the air during the transfer. Staff interviews confirmed that two staff were expected for mechanical lift transfers, with one operating the lift and the other guiding the resident, and the CNA stated he/she had not been trained on one staff guiding the resident during a transfer. Another resident was dependent on staff for bed mobility and required two staff for transferring, turning, and repositioning. A CNA repositioned the resident by rolling him/her toward the wall, heard a pop, and the resident immediately reported pain. The resident was later transferred to the hospital with a fractured femur. A third resident, also dependent on staff for transfer, was observed being moved with a mechanical lift by one CNA and a hospice employee who stood by the wheelchair without guiding the resident; the resident swung in the air during the transfer. The CNA acknowledged that the resident could fall if other staff did not hold onto the resident. The report also describes a separate event in which a CNA used a mechanical lift alone, the resident became combative, the lift tipped over, and the resident sustained multiple fractures, a forehead bruise, and a T12 compression fracture requiring hospitalization.
Failure to Notify Physician After Resident Change in Condition
Penalty
Summary
Facility staff failed to notify the physician after a change in condition for one resident when staff assisted the resident with positioning, heard a pop, and the resident complained of pain. The resident had a diagnosis of left-sided paralysis and a care plan indicating the resident required two staff for transferring. The facility’s Notification of Changes policy required staff to immediately inform the resident, consult with the resident’s physician, and notify the resident representative when there was a significant change in the resident’s physical, mental, or psychosocial status. On 04/21/26, a CNA documented repositioning the resident by rolling him/her toward the wall when a pop was heard and the resident immediately stated ouch and reported leg pain. The CNA reported the incident to the charge nurse, and later documented that the resident continued to report pain the next morning and the incident was again reported to the charge nurse. Progress notes from 04/22/26 documented the resident sitting in a wheelchair and yelling that the left hip hurt, with staff noting this behavior was usual when the resident was in pain. The record did not show that the physician was notified after the incident. During interviews, the CNA said the incident was reported to the LPN, the LPN said he/she did not recall the report and did not contact the physician because the resident had a history of leg pain, and the administrator stated the nurse should have contacted the physician after the CNA reported hearing a popping noise and the resident was in pain.
Failure to Complete and Document Ordered Weekly Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not completing ordered weekly skin assessments for one resident. Facility policies on Skin Integrity and Skin Observation required that the medical record contain all documentation regarding skin assessments and that a full head-to-toe skin observation be conducted by an RN or LPN upon admission/re-admission and weekly thereafter. The resident’s care plan identified impaired cognition and risk for skin breakdown and pressure ulcers, and the Quarterly MDS documented moderate cognitive impairment. Physician’s orders directed weekly skin assessments on specific days and shifts. Review of the resident’s December weekly skin assessment documentation showed no recorded assessments on 12/05/25, 12/12/25, and 12/19/25, and the MDS nurse confirmed that no weekly skin assessments were documented from 11/28/25 through 12/21/25 despite existing orders. Nursing documentation showed that on 12/21/25 a deep tissue injury (DTI) was identified on the resident’s sacrum, and the resident also had a pressure ulcer on the left heel, both described by RN A as facility-acquired and expected to be documented on the weekly skin assessments. Additional physician’s orders on 01/02/26 included topical treatments to the buttocks and left heel. Interviews with the MDS nurse, RN A, the DON, and the Administrator confirmed that the charge nurse was responsible for completing and documenting weekly skin assessments, that the electronic system would have prompted these assessments, and that all physician’s orders were expected to be followed. The DON and Administrator stated they were not aware that the weekly skin assessments had not been documented during the identified period and acknowledged that if it is not documented, it is considered not completed.
Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's legal representative in a timely manner following a significant change in the resident's condition. The resident, who had severe cognitive impairment, lower extremity impairment on both sides, and was dependent on staff for transfers, toileting, and hygiene, was assessed with an open area on the right knee. Nurse notes documented the presence of a 0.5 cm open area with a white center, which progressed to a pinpoint hole with a large amount of pink-tinged drainage and bone protruding under the skin. Despite these significant findings, there was no documentation that the resident's representative was notified of the change in condition at the time it was identified. Further review showed that while the physician was notified and new orders were received for pain management and antibiotics, the resident's representative was not informed until later, after the wound had worsened and infection was suspected. Interviews with facility leadership confirmed that staff are expected to notify the resident's representative promptly after a change in condition, but in this case, notification was delayed without a valid reason. The deficiency centers on the lack of timely communication to the resident's representative regarding a significant change in the resident's health status.
Menus, Recipes, and Food Substitutions Not Followed
Penalty
Summary
Facility staff failed to use standardized recipes to prepare foods for service to all residents and failed to serve food in accordance with the nutritionally calculated menus. The facility also failed to provide menus showing the food items and portion sizes to be served for all diet types used in the facility and failed to record substitutions made to the menus. The facility census was 59, and resident diet cards showed diet types included regular, minced and moist, and pureed. Review of the facility policies showed food was to be prepared and served to meet individual resident needs, menus were to be prepared in advance and followed, and food substitutions were to be documented. On observation, the kitchen did not have visible menus for minced and moist and pureed diets, standardized recipes for staff use, or a menu substitution log. The posted breakfast menu for the regular diet directed staff to serve hot cereal or cold cereal, a breakfast sandwich, and a fresh fruit cup, but the menu did not document any substitutions. During breakfast meal service, staff served residents on regular diets hot cereal or cold cereal, scrambled eggs, and diced potatoes instead of the breakfast sandwich and fresh fruit cup listed on the menu. Residents on minced and moist diets were served hot cereal, scrambled eggs, and diced potatoes, and residents on pureed diets were served hot cereal, pureed scrambled eggs, and pureed sausage, but they did not receive the pureed breakfast sandwich, pureed fruit, or an additional pureed starch. The cook stated the breakfast served was different from the menus because the dietary manager had been mixing and matching food items due to food orders and being over budget, and said there were no recipes or documentation of substitutions. The dietary manager said staff were expected to serve the planned menus, but he/she did not know staff had substituted the breakfast meal and did not have menus or standardized recipes for minced and moist and pureed diets. The administrator said staff were expected to prepare food according to standardized recipes and serve meals according to the planned menus, including modified-texture diets, but staff did not contact him/her about the breakfast substitution and the kitchen inspections did not include checking for menus and recipes.
Food Storage, Dish Handling, Hand Hygiene, and Kitchen Sanitation Failures
Penalty
Summary
Facility staff failed to store food in a manner that prevented contamination and outdated use, and failed to maintain proper food storage practices in the kitchen. On 08/25/25 and 08/27/25, surveyors observed raw hot dogs, ham, turkey breast, and precooked bacon stored above ready-to-eat and leftover foods in reach-in refrigerator #1. Some items were opened and undated, and liquid from an opened turkey package dripped onto a container of tossed salad stored below. Surveyors also observed opened and undated beef patties, uncovered burritos, an unidentifiable packaged food item, and a grocery bag stored in freezer #3. In the dry goods pantry, surveyors observed dented cans of diced pears and tomato sauce, including one can with a dent on the top edge seal, along with opened and undated bags of sugar, flour, and egg noodles. Surveyors also observed multiple expired, unlabeled, or improperly stored items in the refrigerators and pantry. These included opened and undated containers of thickened juices, half and half past its use-by or best-by date, a bottle of wing sauce with a worn-off date, an uncovered pitcher of cranberry juice, leftover pizza slices in an undated bag, and an unlabeled employee coffee drink stored with resident food. The dietary manager stated raw foods should be stored below ready-to-eat foods, opened and leftover foods should be labeled and dated, staff food should not be stored with resident food, and dented cans should be discarded. The administrator also stated opened foods should be sealed and dated, staff food should not be stored with resident food, and outside food brought in for residents should be sealed, dated, labeled, and kept away from contaminated items. Facility staff failed to ensure dishes were clean and air dried before storage, failed to perform hand hygiene correctly, and failed to maintain kitchen surfaces and equipment in clean and good repair. Surveyors observed wet stacked sheet pans and food prep pans, some with food debris and soap residue, and observed sanitized plates and plate covers being stacked and stored while still wet. Staff were also observed washing hands for only a few seconds and turning off faucets with bare hands, and one dietary aide put away sanitized dishes without washing hands between dirty and clean tasks. In addition, surveyors observed a dirty foil-covered windowsill, steam table wells with sediment, food debris, oily film, and mold-like specks, torn gasket seals on refrigerators and the chest freezer, excessive ice buildup in the freezer, dirty vents and a tabletop fan, and ice scoops stored uncovered in dirty containers. The dietary manager and administrator acknowledged several of these conditions, including that dishes should air dry, hands should be washed between tasks, and food-contact items and kitchen equipment should be kept clean and in good repair.
Unmaintained Resident Rooms and Dirty Wheelchairs
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment when multiple resident rooms were observed with damaged and unfinished surfaces. Survey observations identified drywall damage, missing plaster, chipped and missing paint, black marks on doors and walls, unpainted patches, cracked windows, peeled base trim, broken plastic door parts, and bathroom ceiling cracks and water damage in several occupied rooms. Facility policy stated that staff are responsible for identifying maintenance concerns and that maintenance work requests are to be reviewed daily and completed within five days unless urgent. During interviews, a CNA, an LPN, the DON, the maintenance director, and the administrator all acknowledged that staff should report maintenance concerns in the maintenance book at the nurse’s station. The CNA and LPN said they had seen damaged walls, doors, ceilings, and base trim but had not reported some of the issues recently. The maintenance director said he reviewed the book daily and completed requests, but he had not been told about several of the observed problems, including missing ceiling plaster, base trim off walls, and unfinished painting. The administrator said staff had reported damage to walls, doors, and ceilings, and also stated that a cracked window had been allowed to “fall through the cracks.” Facility staff also failed to keep wheelchairs clean for four residents. Observations showed wheelchairs with built-up dirt, food debris, dried food on foot pedals and wheels, dark substance on the frame, hair and dried food on a brake, and dirty tape on an attached pool noodle. One resident stated he/she had never seen anyone clean the wheelchair and said the dirt and food debris bothered him/her. Facility policy required nursing staff to wipe high-touch areas daily and housekeeping to perform a weekly thorough cleaning of wheelchair surfaces. Interviews showed staff were unclear about the cleaning schedule, with the CNA, LPN, housekeeping manager, DON, and administrator giving differing descriptions of who was responsible for cleaning and how often it should occur.
Care Plans Missing Resident Preferences, Diabetes, and Pain Management
Penalty
Summary
The facility failed to review and revise comprehensive care plans for three residents after assessments identified needs and preferences that were not reflected in the plans. The facility policy stated that each resident should have a person-centered comprehensive care plan developed from the MDS and reviewed and revised by the interdisciplinary team after each assessment. Surveyors found that the care plans for Resident #6, Resident #38, and Resident #55 did not include information documented in their assessments and orders. For Resident #6, the Significant Change MDS documented activities of interest including snacks between meals, staying up past 8 P.M., listening to music, being around animals, participating in favorite activities, and spending time outdoors. The revised care plan did not contain guidance for these activities of interest. Staff interviewed stated that residents' activities of interest should be on the care plan, and the MDS Coordinator said he/she had not done activities of interest for resident care plans before, although the DON and administrator stated that anything pertaining to the resident should be included. For Resident #38, the Annual MDS showed severe cognitive impairment, diabetes mellitus, and insulin use, and the POS included an order for daily insulin aspart. The care plan did not contain direction for diabetes. For Resident #55, the MDS showed pain, use of PRN pain medication, pain affecting sleep and daily activities, a pain score of 5, and opioid use during the look-back period. The POS included pain monitoring every shift and orders for acetaminophen and tramadol PRN, but the care plan did not contain direction for pain management, including pharmacological and non-pharmacological interventions. Staff interviews confirmed that diabetes and pain should have been care planned.
Failure to Document Neurological Checks and Update Fall Care Plans
Penalty
Summary
Facility staff failed to document required neurological checks and failed to update care plans and fall risk assessments after resident falls for four residents. The facility policy required immediate reporting and documentation of all falls, neurological checks for unwitnessed falls or suspected head trauma, and care plan updates with new interventions after falls. The policy also required quarterly fall risk assessments when ordered. Resident #6, who had severe cognitive impairment and used a wheelchair, had a fall out of the wheelchair with head impact on the front of the nurses’ station and a scalp abrasion, followed by another fall when found on the floor beside the bed with a small abrasion to the forehead and eyebrow. Staff did not complete neurological checks after the first fall, did not document 4 of the 15 required neurological checks after the second fall, and did not document fall interventions in the care plan after either fall. Resident #21, who had memory problems, used a wheelchair, and had a history of falls, had an unwitnessed fall with no injury. The medical record did not contain neurological checks, the quarterly fall risk assessment ordered for the resident was not documented, and the care plan was not updated with additional fall interventions. Resident #25, who was severely cognitively impaired and used a wheelchair, had multiple unwitnessed falls with no injury, and one fall included pain. The record did not contain neurological checks after several of the falls, did not contain an updated fall risk assessment, and the care plan did not document the falls or interventions. Resident #34, who was severely cognitively impaired, used a wheelchair, and had a history of falls, had multiple unwitnessed falls including one with shoulder pain, one with a scalp abrasion and bruise to a finger, and another unwitnessed fall. The record did not contain neurological checks or an updated fall risk assessment, and the care plan did not document interventions after the falls.
Hand Hygiene and TB Screening Failures
Penalty
Summary
Facility staff failed to use proper hand hygiene and perineal care practices for four residents during observed care. Resident #1 was cognitively intact, required substantial to maximal assistance with toileting, dressing, and bed mobility, and was always incontinent of bowel and bladder. During observation, a CNA performed perineal care and assisted the resident out of bed while using the same soiled gloves for multiple tasks, applied a clean brief without washing hands between glove changes, and left the room without washing hands before returning to provide additional care. Resident #5 was cognitively intact, had impairment to the upper and lower extremities, was dependent on staff for bed mobility and toileting, and was always incontinent of bowel and bladder. During observation, NA I transferred the resident with a mechanical lift, performed perineal care, and used the same soiled gloves to place a clean brief, apply cream to the buttock, wipe cream off the gloves onto the clean brief, and reattach the mechanical lift sling. The NA then removed gloves, did not wash hands, and left the room to go to another resident's room. Resident #41 had severe cognitive impairment, impairment to the upper and lower extremities, was dependent for bed mobility and toileting, and was always incontinent of bowel and bladder. During observation, NA I cleansed stool from a pillow, removed gloves, left the room without washing hands, returned with new linens, and then continued care while wiping stool off the gloves, applying cream with soiled gloves, and performing perineal care. Resident #55 was cognitively intact, always incontinent of bowel and bladder, and required maximal assistance for bed mobility and dependent assistance for personal hygiene, dressing, and bathing. During observation, CNA H removed a soiled glove and replaced it without hand hygiene, then later exited the room with soiled linens and did not wash hands before walking to the dirty utility room and returning with clean supplies. The facility also failed to follow its TB screening policy for four staff members. The policy required a two-step TB skin test for employees, with the second test given within 14 days after the first negative test and no resident contact until the first test result was obtained. Personnel records for NA S, RN P, CMT Q, and NA R did not contain documentation of the second TB test. In addition, CMT Q worked on the floor before the first TB test had been read. The DON stated the missing second TB tests were overlooked, and the BOM confirmed NA R's first floor work date.
Failure to Provide Dignified Care
Penalty
Summary
Facility staff failed to provide care and services in a dignified manner when a cognitively intact resident who used a wheelchair and was dependent on staff to propel the chair was pulled backward down the hallway in a mechanical chair. On 08/25/25 at 12:18 P.M., a NA pulled the resident out of the room backwards and then down the full length of the hallway to the administrator's office while the resident yelled and cussed. The resident later stated that being dragged backward bothered him/her, embarrassed him/her, and made him/her feel unsafe because he/she did not know if the chair would turn over. Multiple staff members stated that pulling a resident backward in a mechanical chair was unsafe and undignified. A CNA said staff should not pull a resident down the hall in a mechanical chair backwards because it is not safe and is degrading. An LPN said residents cannot see where they are going and that the action is not dignified. The DON stated staff should never pull a resident down the hallway backwards and said the resident should be propelled forward so he/she can see where he/she is going. The administrator also observed the event and stated the NA's actions were not appropriate and undignified. Facility staff also failed to maintain another resident in a dignified condition when the resident, who had severe cognitive impairment, dementia, and dependence on staff for eating, bathing, personal hygiene, and wheelchair propulsion, was left in the dayroom with food debris on clothing and face on multiple observations. The resident was seen with dried food debris down the front of the shirt, pureed meat on both pant legs, food dribbled down the chin and shirt, and brown liquid food substance on the face, mouth, shirt, and pants while other residents were present. Staff observed wiping the resident's mouth and shirt, but the resident was left in the dayroom with food stains on clothing. The CNA, LPN, DON, and administrator each stated that leaving the resident with food on clothing in the dayroom was not dignified and that the resident should have been changed.
Code Status Not Consistently Documented in Resident Records
Penalty
Summary
Facility staff failed to consistently document residents’ code status as DNR or Full Code on the face sheet and/or Physician Order Sheet for five of 24 sampled residents. The deficiency was identified during interview and record review and involved residents whose records showed code status information in some locations, such as the care plan or advance directive, but not on the face sheet and/or without a corresponding physician order on the POS. Resident #20 was assessed as cognitively intact on the quarterly MDS. The care plan documented Full Code, and the medical record contained an advance directive showing the resident was full code, but the face sheet did not document code status and the POS did not contain a physician order for code status. Resident #25 was assessed as severely cognitively impaired on the Significant Change MDS. The care plan documented DNR, and the medical record contained a signed DNR form, but the face sheet did not document code status and the POS did not contain a physician order for code status. Resident #34 was assessed as severely cognitively impaired on the admission MDS. The care plan documented DNR, the face sheet documented DNR, and the medical record contained a signed DNR form, but the POS did not contain a physician order for code status. Resident #42’s MDS tracking record showed admission to the facility, and the medical record contained a signed DNR form, but the face sheet and POS did not document code status. Resident #57’s quarterly MDS showed severe cognitive impairment, the care plan documented DNR, and the medical record contained a signed DNR form, but the face sheet and POS did not document code status.
Failure to Obtain Bed Rail Consent and Complete Bed Rail Assessments
Penalty
Summary
Facility staff failed to obtain signed informed consent for bed rail use and failed to assess three of four sampled residents for bed rail use. The facility policy dated 01/30/2024 stated that bed rails are adjustable metal or rigid plastic bars attached to the bed, including grab bars, assist bars, side rails, and safety rails, and that the facility should review risks and benefits with the resident or representative, obtain informed consent before installation, and maintain evidence of that information. The policy also stated the resident's need for bed rails should be assessed and documented in the resident's record. Resident #2's significant change MDS dated 07/28/25 showed moderate cognitive impairment, lower extremity impairment on one side, dependence with toileting and transfers, and dependence with rolling left and right, sit to lying, and lying to sitting on the bed side. The resident's bed rail assessment dated 07/14/25 did not contain recommendations for turn bars or assist bars, and the medical record did not contain a signed informed consent for bed rail use. Observations on 08/25/25, 08/26/25, 08/27/25, and 08/28/25 showed the resident in bed with both bed rails in the upright position. Resident #5's quarterly MDS showed cognitive intactness, upper and lower extremity impairment on both sides, and dependence with bed mobility, toileting, and transfers. The resident's bed rail assessment did not contain recommendations for turn bars or assist bars, and the medical record did not contain a signed informed consent for bed rail use. Resident #15's quarterly MDS showed severe cognitive impairment, upper extremity impairment on one side, lower extremity impairment on both sides, and dependence with bed mobility, toileting, and transfers; the bed rail assessment dated 07/30/25 did not contain recommendations for turn bars or assist bars, and the medical record did not contain a signed informed consent for bed rail use. Observations on 08/25/25 through 08/28/25 showed both residents in bed with assist bars in the upright position on both sides. Staff interviews showed uncertainty about who was responsible for completing bed rail assessments and obtaining consent, and the DON and administrator stated that consent should be obtained and that oversight responsibility rested with leadership.
Failure to complete bed rail entrapment assessments and inspections
Penalty
Summary
Facility staff failed to complete entrapment assessments and regular inspections of bed frames, mattresses, and bed rails for four sampled residents who had bed rails or assist bars in use. The facility policies titled "Bed Rail" and "Bed and Bed rail Maintenance to reduce/prevent entrapment," both dated 01/30/24, stated residents should be assessed for entrapment risk before bed rail use and that the bed and bed rails should be assessed and documented prior to use. Review of the records for Residents #2, #3, #5, and #15 showed no entrapment risk assessment and no maintenance inspection documenting that the bed rails were properly secured to the beds. Resident #2's MDS showed moderate cognitive impairment, lower extremity impairment on one side, and dependence with rolling, sit-to-lying, and lying-to-sitting. Resident #3's MDS showed cognitive intactness, substantial to maximal assistance with bed mobility and transfers, and dependence with toileting. Resident #5's MDS showed cognitive intactness, upper and lower extremity impairment on both sides, and dependence with bed mobility, toileting, and transfers. Resident #15's MDS showed severe cognitive impairment, upper extremity impairment on one side, lower extremity impairment on both sides, and dependence with bed mobility, toileting, and transfers. Observations over several days showed each of the four residents in bed with bed rails or assist bars in the upright position, including both rails up for Residents #2, #5, and #15 and a half rail up on the right side for Resident #3. During interviews, staff stated the new charting system did not prompt entrapment measurements, that staff did not complete entrapment assessments or measurements, that maintenance placed the rails on the beds without measuring them, and that the maintenance director did not regularly inspect the beds to ensure the rails were working properly. The DON and administrator stated they were unsure who completed entrapment assessments, and the administrator said he/she did not know there was an entrapment assessment.
Failure to Post Daily Nurse Staffing Census
Penalty
Summary
Facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 59.1. Review of the facility policy titled Nurse Staffing Information, dated 01/30/24, showed the facility must post resident census daily at the beginning of each shift in a clear and readable format. Review of the facility's August daily nurse staffing sheets showed the sheets did not contain a facility census on 08/07, 08/08, 08/12-08/15, 08/18, 08/19, and 08/25-08/28/25. Observations on 08/25/25 at 11:49 A.M., 08/26/25 at 10:13 A.M., 08/27/25 at 8:49 A.M., and 08/28/25 at 08:35 A.M. showed the nurse staff posting located by the nurses' station did not contain a facility census. During interviews on 08/28/25, an LPN said the night shift charge nurse fills out the daily staffing sheet and that it should include the census, number of staff, and hours worked; the DON said the sheet should include the number of staff, hours worked, date, and census and that it was his/her responsibility to ensure the forms were filled out correctly; and the administrator said the sheet should include the census, date, total staff, and hours worked.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report a resident-to-resident altercation to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. According to the facility's policy, all alleged violations of abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made. The incident involved one resident with severe cognitive impairment and dementia who slapped another resident with mild cognitive impairment and dementia. Documentation showed that after the noon meal, the altercation occurred, but there was no evidence that it was reported to DHSS within the mandated timeframe. The incident came to the attention of the facility administrator via an anonymous note left under her door two days after the event. Interviews revealed that a CNA witnessed the altercation and reported it to the charge nurse, who assumed that social services had reported the incident to the administrator. The charge nurse did not follow up or ensure the incident was reported, and the administrator only became aware of the situation upon reading the anonymous note. Review of progress notes and investigation forms confirmed the lack of timely reporting to DHSS.
Resident Subjected to Verbal and Physical Abuse by CNA
Penalty
Summary
The facility staff failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact but had a diagnosis of Parkinson's disease, compression fractures, and impaired mobility. The resident required moderate assistance for transfers and had a care plan indicating a risk of falls due to weakness and impaired balance. On the day of the incident, the CNA threatened the resident with rough treatment if they did not cooperate with care, which was witnessed by a social worker. The social worker observed the CNA handling the resident aggressively, including grabbing the resident's legs, sitting them up on the bed, and moving them abruptly to a wheelchair. The CNA then pushed the resident to the bathroom and attempted to have them hold the grab bars, but when the resident was unable to do so, the CNA lifted the resident by yanking their pants and placed them on the toilet without allowing them to pivot their feet. The resident reported feeling hurt and was crying during the incident. Interviews with the CNA and the resident confirmed the aggressive handling and verbal threat. The CNA admitted to using the term "manhandle" and acknowledged that it was inappropriate. The resident expressed distress and did not recall all the details due to crying. The facility's investigation documented the social worker's observations and the resident's account of the incident, leading to the CNA's suspension and eventual termination.
Failure to Provide Proper Discharge Notice and Refusal to Readmit Resident
Penalty
Summary
The facility staff failed to provide an appropriate emergency discharge notice for a resident and did not allow the resident to return to the facility after being discharged from the hospital. The facility's Transfer and Discharge policy requires that residents be notified at least thirty days prior to an anticipated transfer, except in cases where the safety of individuals in the facility is endangered. The policy also mandates that the notice include specific information such as the location to which the resident is being transferred, the right to appeal, and contact information for the State Long-Term Care Ombudsman. However, the Immediate Discharge Notice for the resident did not include this required information. The resident was issued an immediate discharge due to the facility's claim of being unable to provide adequate care and ensure the safety of others, following an incident where the resident allegedly hit someone. The discharge notice was given without specifying a new location for the resident, and the resident's family was informed by phone. The resident was left in a hospital emergency room without a clear plan for relocation, and the facility administrator confirmed that they would not be taking the resident back. This situation left the resident without a proper discharge plan or location, violating the facility's own policies and regulatory requirements.
Facility Fails to Maintain Homelike Environment Due to Disrepair
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents, as evidenced by multiple observations of disrepair in resident rooms. Observations included gaps in flooring between rooms and hallways, missing tiles in bathrooms, brown stains on floors and toilet bowls, peeled baseboards, frayed and cracked fall mats, and a damaged sink vanity top with exposed particle board. Additionally, a bathroom light was found to be non-functional. These issues were noted in several occupied resident rooms over a span of three days. Interviews with facility staff revealed a lack of awareness and communication regarding the needed repairs. Although staff were instructed to write repair requests in a maintenance log book located at the nurses' desk, the Maintenance Supervisor was unaware of the specific repairs needed in the resident rooms despite conducting daily rounds. The administrator confirmed that maintenance is responsible for repairs, but ultimately, the administrator is accountable for ensuring repairs are completed. Despite a system in place for reporting and addressing maintenance issues, the deficiencies persisted, indicating a breakdown in the process.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for three residents who were discharged to the hospital. The facility's policy mandates that residents or their representatives be informed of the bed hold policy upon admission, at the time of transfer, and during non-covered therapeutic leave. Additionally, a signed authorization for bed hold must be obtained within 48 hours of transfer or by the next business day if the transfer occurs on a weekend or holiday. However, the medical records for the three residents did not contain documentation of such notifications. Interviews with facility staff revealed a lack of consistent practice in handling bed hold notifications. The administrator believed that bed hold paperwork was sent with residents upon discharge but acknowledged that copies were not made for the medical record. A registered nurse expressed uncertainty about whether bed holds were being completed, and the Director of Nursing mentioned a bed hold book at the nurse station but was unsure if the forms were being sent with residents. The administrator admitted responsibility for ensuring bed holds were completed but was unaware that they were not being signed or copied for the medical record.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #41, who had severe cognitive impairment and was on hospice care, exhibited disruptive behaviors such as clapping and yelling, but the care plan lacked guidance for these behaviors and hospice services. Despite observations of the resident's behaviors and interviews indicating a decline in condition, the care plan was not updated due to a lack of communication between staff and the MDS Coordinator. Resident #44, with moderate cognitive impairment and a diagnosis of dementia, had a care plan that did not address the resident's lower extremity swelling or wound care needs. The resident had an order for wound care on the right shin, but the care plan failed to include directions for managing the swelling or wound. Observations showed the resident with swollen legs and a bandage, and interviews revealed that the resident often refused to lay down, which could have benefited the healing process. Resident #164, newly admitted to the facility, had a baseline care plan that did not address risks of elopement, wandering, or psychosocial concerns. The resident was documented as exit-seeking and displaying aggressive behavior towards staff, yet these issues were not reflected in the care plan. Interviews with the MDS Coordinator, DON, and administrator highlighted a lack of communication and oversight in updating care plans, which are essential for directing staff in providing appropriate care.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's assessment indicated that an RN should be present for at least 8 hours daily, but a review of the nurse staffing records from August 1 to August 22, 2024, revealed that there was no RN coverage for the required hours on August 3, 4, and 17. Interviews with RN K, the Director of Nursing (DON), and the Administrator confirmed the lack of consistent RN coverage. RN K mentioned that there are times when no RN is present in the building, and the DON acknowledged the difficulty in maintaining RN coverage, especially on weekends. The Administrator stated that while they attempt to have RN coverage daily, they sometimes rely on phone availability when an RN is not physically present. The facility has been actively advertising for the position, and a new RN has been hired to work every other weekend.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to destroy medications in a timely manner for several residents, as observed during a survey. Medications for seven residents were found in a storage room cabinet labeled 'To be destroyed,' including antipsychotics, antispasmodics, opioids, antihistamines, antiemetics, antidepressants, and antidiabetics. These medications had been discontinued but were not returned to the issuing pharmacy or destroyed as per the facility's policy. Interviews with the LPN and DON revealed a lack of awareness and responsibility regarding the medications' prolonged presence in the cabinet. Additionally, the survey identified expired medications and improperly stored medications on the facility's medication carts. An expired bottle of gas relief pills was found on the evening shift medication cart, and loose pills were observed on both the day and evening shift carts. The RN and DON acknowledged that maintaining the medication carts is a shared responsibility among staff, but there were no set days for checking the carts, leading to oversight and the presence of expired and loose medications. Interviews with the DON and the administrator highlighted a lack of consistent oversight and accountability for maintaining medication storage and carts. The DON stated that any CMT or nurse on the medication cart is responsible for its maintenance, while the administrator emphasized that the DON and charge nurses should ensure daily checks. However, both were unaware of the deficiencies found, indicating a gap in communication and adherence to the facility's medication management policies.
Lack of Qualified Nutrition Services Director
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Supervisor (DS), who had been in the position for about three years, had not completed the Certified Dietary Manager (CDM) course or any other dietary management training, despite being aware of the requirement. The DS quit without notice during the survey, leaving the housekeeping supervisor to assist in the kitchen. The facility's registered dietitian only worked as a consultant on a part-time basis, and there were no certified or clinically qualified nutritional staff employed full-time. This deficiency has the potential to affect all 60 residents of the facility.
Failure to Protect Resident Privacy
Penalty
Summary
Facility staff failed to maintain the confidentiality of residents' personal and medical records by leaving computer screens unattended and visible to the public. Specifically, a registered nurse (RN) did not minimize or lock the computer screens on treatment carts when entering the rooms of two residents, resulting in their medical information being displayed. The RN acknowledged the oversight, attributing it to nervousness and a lapse in judgment. Additionally, medication carts on two different halls were observed unattended with computer screens open, displaying resident medication information. A licensed practical nurse (LPN) admitted to forgetting to close the screen, recognizing it as a privacy violation. The Director of Nursing (DON) and the facility administrator confirmed that computer screens should be locked when unattended to protect resident privacy, and they were unaware of staff leaving screens open.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a manner that is easily accessible to residents and visitors. The facility's policy mandates that the nurse staffing information should include the facility name, current date, total number, and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) per shift, along with the resident census. This information must be posted at the beginning of each shift in a prominent place. However, a review of the facility's Staff Hour Posting for July and August 2024 revealed significant omissions. In July, the census and actual hours worked were not documented for 28 out of 31 days, and in August, the census was missing for 19 out of 22 days, with actual hours not documented for all 22 days reviewed. Observations and interviews further highlighted the deficiency. On August 22, 2024, the nurse staff posting was observed to lack the total number of hours. Interviews with an LPN and the Director of Nursing (DON) confirmed that the postings were incomplete and not updated as required. The LPN acknowledged that the postings should include the total number of workers and actual hours worked, while the DON admitted awareness of the issue and stated that the night shift nurse is responsible for completing the staff hour posting. The administrator also confirmed that the charge nurse should update the staff posting at the beginning of each shift, but this was not being done consistently, leading to incomplete and inaccurate postings.
Infection Control Deficiency During Wound Care
Penalty
Summary
Facility staff failed to use appropriate infection control procedures during wound care for four residents, leading to a risk of spreading bacteria. The facility's policy on wound care and treatment, dated 03/2015, requires staff to wash their hands between glove changes and before and after wound care tasks. However, observations showed that an LPN did not follow these procedures. For Resident #1, the LPN did not perform hand hygiene between glove changes while providing wound care to the resident's left foot toe. Similarly, for Resident #2, the LPN did not wash hands between glove changes while treating a pressure ulcer on the resident's left heel. The same pattern was observed with Resident #3, where the LPN did not perform hand hygiene while treating a pressure ulcer on the resident's right ankle. For Resident #4, the LPN failed to wash hands before and after handling wound packing sponge and did not use gloves appropriately, leading to potential contamination of the wound care supplies. Interviews with the LPN and the Director of Nursing (DON) confirmed that the staff did not adhere to the facility's infection control policies. The LPN admitted to not performing hand hygiene due to nervousness and acknowledged the risk of spreading germs and infection. The DON and the facility administrator both stated that it is their expectation for staff to perform hand hygiene when entering and exiting a resident's room and between tasks during wound care. They also emphasized the importance of using gloves when handling wound care supplies to prevent infection control concerns.
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What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Jonesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warrenton Manor | 9.5 mi | ★★★★★ | 7 | 0 |
| Aspire Senior Living New Florence | 9.5 mi | ★★★★★ | 18 | 0 |
| Stonebridge Hermann | 13.9 mi | ★★★★★ | 0 | 0 |
| New Haven Care Center | 18 mi | ★★★★★ | 0 | 0 |
| Troy Manor | 20 mi | ★★★★★ | 0 | 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.