Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baptist Homes, Tri-county during CMS and state inspections, most recent first.
Kitchen surfaces and equipment were observed with heavy and moderate buildup of oily substance, dust, debris, food runs, and liquid runs on multiple air units, vents, an electrical box, exhaust fan, steamer oven, freezer, fire suppression boxes, fryer, stovetop/oven, upright oven, and refrigerator. A Dietary Aide said staff had no specific daily, weekly, or cleaning duties, and the Dietary Mgr stated the areas were expected to be clean and sanitized but the dept had no set cleaning lists or logs.
Resident trust funds were not properly reconciled or documented. Record review showed no monthly reconciliation of bank statements to month-end trust fund records, including outstanding checks and petty cash, for several months. The BOM said she managed resident petty cash, kept about $400 in the account, issued vouchers for withdrawals, and calculated replenishment amounts in her head using sticky notes rather than maintaining a written reconciliation; the administrator expected monthly reconciliation.
A facility failed to ensure residents received mail on regular USPS delivery days, including Saturdays. Residents said they did not get mail on Saturdays, an LPN said Saturday mail was placed in the medication room until Monday, the ADON said Saturday mail was held at the post office with no staff retrieving it, and the DON said it was picked up and delivered on Monday instead of being given to residents when delivered.
Residents were not informed how to file grievances, where grievance forms were located, or how to complete them. Residents said they would only tell nursing staff or the SSD about concerns, were unsure if forms existed, and did not receive timely responses or written rationales. The resident bulletin board had no posted grievance procedure or forms, and the SSD, AD, ADON, DON, and Administrator were unaware of a clear grievance form or log process; there was also no anonymous grievance process in place.
A resident with a feeding tube received bolus Osmolite and medication administration that did not follow the physician’s orders or facility policy: staff diluted the formula with tap water, used nonsterile water, did not verify tube placement as ordered, gave incorrect flush volumes, and mixed crushed meds together for G-tube delivery. Another resident with MS, MDD, stroke, and dysphagia did not have ordered lithium monitoring completed, and the chart showed no lithium level was obtained when due after the prior low result.
Medication error rate exceeded 5% after surveyors found 2 errors in 30 opportunities. A CMT did not prime a NovoLog FlexPen before giving ordered insulin and did not hold the needle in place long enough, and another CMT misread an order for Tramadol 50 mg at bedtime, documented two tablets as given, but prepared to administer only one tablet.
Stock medications were found unlabeled and some were expired in the med cart and east med room. Surveyors observed opened OTCs and other stock meds, including acetaminophen, ibuprofen, cetirizine, vitamin B1, Refresh Tears, Azo Urinary Pain Relief, Benadryl, Geri-Tussin, and Compazine suppositories, with missing open dates and several past expiration dates. The CMT said opened stock meds should be labeled and expired meds removed, and the DON said the routine checks for labeling and expiration dates had not been done.
Food was not consistently served at safe, appetizing temperatures or in a palatable form. Residents reported cold meals, tough meat, bland or dry items, and unappetizing dishes, and resident council minutes reflected repeated complaints about cold food and overcooked vegetables. During meal observations, plated food was placed in a heated cart but temperatures dropped during service, and a test tray later showed meatloaf, mashed potatoes, and vegetables all below 120 degrees Fahrenheit and cool to the taste; another meal observation found turkey crunch very salty and hard to chew, stuffing dry, and cake dry.
Failure to Routinely Offer Nourishing Bedtime Snacks: Staff did not routinely offer bedtime snacks to residents who wanted them, including cognitively intact residents and residents with DM. During a resident council meeting, residents said bedtime snacks were not passed, and an observation found mostly sweets and drinks available. A CNA said snacks were only given if requested, while the DON, Administrator, and Medical Director stated residents should be offered bedtime snacks, including nutritious options.
The facility failed to ensure the QAA/QAPI group had the required IP attendance at quarterly meetings. The QAPI plan listed the IP as a required member, but attendance records showed the IP was absent from multiple QAPI meetings, and no evidence was provided for a fourth-quarter meeting. The IP said she worked weekend shifts and sent infection-related reports for the DON to present, while the DON and Administrator confirmed the IP did not attend the meetings in person.
Multiple infection control failures were observed during resident care, glucose monitoring, catheter management, nebulizer storage, and meal assistance. Staff changed from dirty to clean tasks without hand hygiene or glove changes while providing peri-care and feeding residents, used the same glucometer between residents without proper cleaning or a barrier, allowed a catheter bag and tubing to drag on the floor and looped tubing so urine would not drain, and left nebulizer equipment unbagged on a bedside table. The DON and IP also reported gaps in infection tracking and the facility’s IPCP policy only addressed COVID-19.
A facility failed to maintain an adequate audible call system and failed to answer call lights timely for two residents. Observations showed room indicators did not work, the pager at the nurses’ station only beeped softly, and staff did not carry pagers, so they relied on the monitor or chime to know when a call light was activated. One resident with hemiplegia, impaired balance, and dependence for toileting waited 40 minutes for help to use the bathroom, while residents and a family member reported other prolonged waits for assistance. The DON and Administrator said the facility did not actively monitor call light response times and had no call light logs available.
A strong urine odor was repeatedly noted in the hallway outside one resident’s room and adjoining rooms, with surveyors observing a wet-looking sheet under the resident and a partially filled urinal without a lid on the floor. The resident often refused hygiene and bathing assistance, and housekeeping said the room was difficult to clean because the resident would yell at staff and tell them to leave. A nearby resident, a family member, and the DON all acknowledged the persistent odor, which at times reached the therapy room.
The facility failed to monitor PRN psychotropic meds for two residents by allowing open-ended orders for Haldol and alprazolam to continue without the required 14-day limit or documented provider rationale. One resident with impaired cognition, anxiety, malnutrition, and hospice care received PRN Haldol multiple times, and another resident with stroke, dementia, anxiety, depression, and hospice care received repeated PRN alprazolam doses. The record showed no pharmacy recommendation and no physician documentation supporting continued use.
The facility failed to keep care plans comprehensive and resident-specific for two residents. One resident had worsening skin issues, including moisture-associated skin damage, open lesions, a skin tear, and a later stage 3 coccyx pressure injury, but the care plan did not reflect the active skin concerns or interventions. Another resident with COPD, asthma, acute respiratory failure with hypoxia, pneumonia due to COVID-19, and bronchiectasis had orders for ipratropium-albuterol nebulizer treatments, but the care plan did not include COPD or nebulizer use. The DON stated care plans were expected to be up to date and revised with resident changes.
Improper Transfer Technique for a Non-Weight-Bearing Resident: Staff transferred a resident with severe cognitive impairment, stroke history, hospice status, and a care plan requiring 2-person assist and Hoyer lift use without using a gait belt or mechanical lift. Observations showed staff lifting the resident under the arms from a Broda chair to the bed and toilet, with the resident's knees bent, feet sliding across the floor, and no weight bearing. Staff interviews confirmed uncertainty about the correct transfer method, while the DOR and DON stated a mechanical lift should be used when the resident could not bear weight.
The facility failed to complete annual performance reviews and related in-service education for two CNAs. The facility assessment required nurse aide training to address weaknesses identified in performance reviews, but the files for two CNAs contained no documentation of evaluations, competencies, or annual reviews. The DON stated she had not completed any nurse aide evaluations or annual performance reviews, and the Administrator said CNAs employed over 12 months should have had a performance evaluation and additional education as needed.
Failure to document rationale for continuing a high-dose melatonin order after pharmacy review. A resident with insomnia remained on melatonin 10 mg HS even after the pharmacist flagged doses above 6 mg/day and offered a dose reduction option. The physician selected no change, but no prescriber comments explained why the recommendation was not accepted. The resident was repeatedly observed asleep in a wheelchair, slept through meals, and had notes of poor sleep and a fall from the wheelchair; the DON said pharmacy reviews were sent to the physician, and the physician said he knew CMS expected a rationale when continuing an abnormal dose.
The facility failed to provide sufficient nursing staff, resulting in inadequate incontinence care and supervision for residents. One resident with severe cognitive impairment was left soiled for extended periods due to staffing shortages on the East Hall. The memory care unit, typically staffed with only one CNA, was unable to meet residents' needs for care and supervision, leading to incidents where residents were left unattended. These deficiencies highlight the facility's failure to adhere to its staffing policy and meet the care needs of its residents.
A resident with severe cognitive impairment and incontinence was left in soiled conditions for extended periods, despite requiring staff assistance for toileting and personal hygiene. Observations revealed the resident was not changed or toileted for several hours, resulting in a strong odor and dried feces on their skin. Staff interviews confirmed the resident should have been checked every two hours, but this was not adhered to.
A resident with severe cognitive impairment and a history of stroke was not properly assessed upon readmission to the facility. The staff failed to document vital signs consistently and did not update the care plan to reflect the resident's current condition, including the presence of a heart monitor. Therapy services were not resumed as ordered, and the heart monitor was not functioning due to a misplaced transmitter. These deficiencies contributed to the resident's readmission to the hospital with bradycardia.
The facility failed to follow proper infection control measures during wound care for two residents, leading to deficiencies in hand hygiene and the use of Enhanced Barrier Precautions (EBP). An LPN did not wash hands or change gloves between handling different wounds, used the same gauze pad for multiple wounds, and failed to apply EBP. The facility's Infection Preventionist and DON acknowledged these failures, highlighting a lack of adherence to established procedures.
Kitchen surfaces and equipment found heavily soiled
Penalty
Summary
Food service equipment and surfaces were not maintained in a clean and sanitary condition in accordance with professional standards. During observations in the kitchen, surveyors identified multiple areas with heavy, moderate, or crusted buildup of oily substance, dust, debris, food runs, and liquid runs, including ceiling-mounted air units and vents, sprinkler system drain piping, an electrical box behind the coffee maker, a wall-mounted exhaust fan, the top of the steamer oven, the top of the white upright freezer, fire suppression control boxes and piping above a food preparation table, the front and left side of the deep fryer, the four-burner stovetop/oven, the four-door upright oven, and the top of the two-door upright refrigerator. Clean cups, coffee equipment, food preparation equipment, and food contact areas were located near several of these unclean surfaces. The facility policy required the food service area, kitchens, dining areas, equipment, food contact surfaces, and utensils to be kept clean and sanitized. During interview, a Dietary Aide stated staff did not have specific daily, weekly, or cleaning duties and were expected to clean as they go, with a sheet listing only some evening tasks such as sweeping, mopping, wiping counters, changing steam table water, and cleaning dining rooms. The Dietary Manager stated she was not aware of the condition of the identified areas, expected them to be clean and sanitized, said staff cleaned these areas at least once a month, and confirmed the dietary department had no set daily, weekly, or monthly cleaning lists or logs.
Resident Trust Fund Reconciliation Not Maintained
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Record review showed that for December 2025, January 2026, and February 2026, there was no documentation that the facility reconciled the monthly bank statements with the month-ending resident trust fund records, including outstanding checks and petty cash, to ensure an accurate accounting of all resident funds. The facility managed funds for 37 residents, and the census was 58. During interview, the Business Office Manager stated she was responsible for the resident trust fund account and resident petty cash. She said the petty cash account was maintained from money withdrawn monthly from the resident trust account, and that she typically kept $400 in the petty cash account. She stated she issued vouchers to residents when cash was withdrawn and filed them monthly, and that she counted the petty cash each month and then withdrew whatever was needed to restore the account to $400 for the next month. She also stated she did not maintain a written record of the monthly reconciliation and instead figured it in her head and used sticky notes to determine how much to withdraw. The administrator stated he expected the BOM to reconcile the residents' petty cash fund to the resident trust fund statements monthly.
Failure to Deliver Resident Mail on Saturday
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when residents did not receive mail on regular USPS delivery days, including Saturdays. The facility census was 58, and the admission packet included a resident right to send and receive unopened mail. The facility policy stated residents may communicate privately and that mail and packages would be delivered within 24 hours of delivery on premises or to the facility's post office box, including Saturday deliveries. During a group interview, residents said they did not receive mail on Saturdays. An LPN stated that when USPS mail was delivered on Saturdays, staff did not pass it out and any mail delivered that day was placed in the medication room until Monday. The ADON said the facility had stopped the post office from delivering mail to the facility about a year earlier because mail had been left unattended at the nurses' station, and Saturday mail was held at the post office with no staff going to retrieve it. The DON said Saturday mail was picked up on Monday and then delivered to residents, and the administrator said he expected mail to come on Saturdays and was unaware it was not being delivered to residents that day.
Residents Not Informed How to File Grievances
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance, where grievance forms were located, or how to complete a grievance form. The facility census was 58. Review of the admission packet and Resident Rights showed residents were to be encouraged and assisted to voice grievances, that a staff person would be designated to receive grievances, and that residents would be informed of and provided with a viable format for recommending changes in policy and services. The facility grievance policy stated residents and representatives had the right to file grievances orally or in writing, that grievances could be filed anonymously, and that written information on how to file a grievance or complaint would be provided upon admission. During the resident council group interview, residents said they did not know how to file a grievance and were not sure whether grievance forms were available. They stated that if they had a problem or complaint, they would just tell nursing staff, and one resident said concerns would be verbally told to the SSD. The residents also said they did not receive a quick response from staff regarding concerns and did not receive a written rationale for the response to verbal grievances. Observation of the resident bulletin board showed no copy of the grievance/complaint procedure posted and no forms available for residents to complete a written grievance. Staff interviews showed the AD said she took resident council concerns to the Administrator and departments, but did not fill out a grievance form and was not aware of any specific grievance form. The SSD said she had been the grievance official since August 2024, had no training on handling grievances, did not have a grievance log, and was unaware there should be a paper grievance form or log. The ADON and DON were also unaware of grievance forms being available, and the Administrator stated the SSD was responsible for grievances, but the SSD did not have a grievance log. Prior to the survey, there was no process in place for residents to file grievances anonymously.
Failure to Follow Tube Feeding Orders and Monitor Lithium Levels
Penalty
Summary
The facility failed to provide services that met professional standards of practice for two residents. One resident had a feeding tube, received most calories through tube feeding, and had orders for NPO status, bolus Osmolite 1.5 Cal feedings, and specified water flushes. During observation, the MDS/Care Plan Coordinator mixed Osmolite with tap water in a graduate, diluted the formula, did not check G-tube placement, and administered the mixture by gravity. The resident did not receive the ordered amount of water, and the staff member stated the water and formula were mixed to thin the formula and prevent clogging. A second observation showed an LPN administering the same resident’s tube feeding in a manner that did not match the physician’s order or facility policy. The LPN used tap water, checked tube placement by pushing air and water and listening to the abdomen, gave a water flush that did not match the ordered amount, and repeatedly added Osmolite and water into the syringe during the feeding. The LPN also stated the resident should receive a different total amount of water than ordered, used a disposable cup to measure formula, added water to the formula to make it go quicker and lessen clogging, and crushed and mixed medications together with water for G-tube administration. The DON stated staff were to follow physician orders for medications and tube feedings, and the physician stated staff should check tube placement before feeding, follow the ordered water amount, and administer medications individually unless pharmacy approval and a physician order allowed combining them. The facility also failed to obtain a lithium level for another resident with multiple sclerosis, major depressive disorder, stroke, and dysphagia. The resident had standing orders for lithium levels every three months and lithium carbonate by mouth, later changed to lithium carbonate via tube after hospice admission. The record showed the last lithium level was obtained and resulted below normal, but there was no documentation that the physician was notified of that result. The next lithium level due in February was not obtained, and there was no documentation in the record through the review date that the ordered lithium level had been drawn. The DON stated the lithium level should have been obtained but was not because the nurse who took the order was new and did not complete a lab requisition, and the physician stated ordered lithium monitoring was required and not optional.
Medication Error Rate Exceeded 5% Due to Insulin and Tramadol Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5% when surveyors identified 2 medication errors out of 30 opportunities for error, resulting in a 6.67% error rate. The facility census was 58. Review of the facility policy showed medications are to be administered safely and as prescribed, and insulin pen use requires priming before each injection to remove air bubbles and ensure the resident receives the full dose. For one resident, a CMT checked the blood glucose, obtained a reading of 218, applied a needle to the NovoLog FlexPen, did not prime the pen, dialed up 4 units as ordered, injected the insulin into the resident's right upper arm, and held it for three seconds before removing the needle. The CMT stated he/she had never primed an insulin pen before administering insulin and had not received additional education or training on insulin administration, including priming and holding the needle in the skin. For another resident, a CMT removed Tramadol 50 mg from the narcotic lock box, pushed one tablet into a medication cup, documented that two tablets were administered at bedtime, and then prepared to give only one tablet; when asked to verify the order, the CMT stated he/she had not read the medication order correctly.
Stock Medications Left Unlabeled and Expired
Penalty
Summary
The facility failed to ensure stock medications and biologicals were labeled in accordance with accepted professional principles and were stored appropriately. During observation of the 200-hall medication cart, surveyors found previously opened stock bottles of acetaminophen 500 mg, ibuprofen 200 mg, cetirizine 10 mg, and vitamin B1 250 mg in the first drawer, and none had an open date. In the east medication room, surveyors observed a previously opened bottle of Refresh Tears on the countertop with no open date and an expiration date of 07/2025, a previously opened bottle of Azo Urinary Pain Relief tabs in the overhead cabinet with no open date and an expiration date of 12/2025, a previously opened bottle of Benadryl 25 mg in the overhead cabinet with no open date and an expiration date of 02/2026, a previously opened 16-ounce bottle of Geri-Tussin in the cabinet below the countertop that had been opened on 05/13/25 and expired on 11/2025, and a previously opened card of Compazine Suppositories 10 mg in the refrigerator with no open date and an expiration date of 01/2026. During interview, the CMT stated that stock medications should be labeled when opened and expired medications should be removed and/or replaced, and said the Refresh Tears bottle should have been labeled with an open date and resident's name. The CMT also stated that the medications in the east medication room were in-use medications and not medications to be destroyed. The DON stated the facility previously had a system for checking medications for labeling and expiration dates every Monday and Tuesday by the charge nurse, but this had not been done.
Food Served Cold and Poorly Palatable
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature. Resident council minutes documented complaints that vegetables were cooked too long and that food on the west hall was cold, with staff telling residents the plate warmer had broken. During interviews, one resident reported receiving an unrecognizable casserole that did not look appetizing and could not be eaten, described the food as horrid, said the meat was tough and hard to chew, and stated resident complaints had not led to any change. Another resident said meals eaten in the dining room were often served cold and that concerns raised in resident council meetings were never addressed. At a resident council meeting, several residents again reported that food was often served cold. On 03/03/26, lunch menu items included meatloaf, mashed potatoes, and mixed vegetables. Although the food items were initially observed at proper temperatures on the steam table, dietary staff placed plated meals into an electric temperature-controlled insulated food cart, transported it to the west dining room, and served trays over an extended period while cart temperatures dropped from 153 degrees Fahrenheit to 116 degrees Fahrenheit. After the cart was unplugged and room trays were served, the test tray food temperatures were 111.7 degrees Fahrenheit for meatloaf, 107.4 degrees Fahrenheit for mashed potatoes and gravy, and 112.2 degrees Fahrenheit for mixed vegetables, and the food was cool to the taste. On 03/04/26, a test tray showed turkey crunch that was very salty and hard to chew, stuffing that was dry and had minimal flavor, and chocolate cake that was dry. Residents also reported the turkey was too hard to chew, the food was awful or bland, and the meat was too tough to chew. The Dietary Manager stated she was not aware the lunch meal temperatures were below 120 degrees Fahrenheit and acknowledged that residents had concerns with food temperature and texture.
Failure to Routinely Offer Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to ensure evening and bedtime snacks were routinely offered to residents in accordance with their needs, preferences, and requests. During a resident council meeting, four residents stated staff did not pass bedtime snacks and that they would take a bedtime snack if offered. Review of the facility policy showed that nourishing snacks were to be available between meals, evening snacks were to be offered routinely to all residents, and residents were to be offered nourishing snacks when the time between the evening meal and breakfast exceeded 14 hours. Resident records showed that Resident #01, Resident #03, Resident #32, and Resident #39 were cognitively intact and had indicated that snacks between meals were very important to them; Resident #01 and Resident #39 also had diagnoses of DM. An evening observation found chips, cookies, snack cakes, pudding cups, and juices available in the dining room, and a CNA stated staff only passed bedtime snacks if residents asked for them and that there were no fruit or nutritious snacks available. The Dietary Manager said a snack cart was prepared for nursing staff with items such as snack cakes, pudding, peanut butter and crackers, and applesauce, while the DON said she was not sure bedtime snacks were offered to all residents and wanted something of substance available. The Administrator and Medical Director both stated they would expect residents to be offered bedtime snacks, including nutritious options, especially for residents with DM.
QAPI Committee Lacked Required IP Attendance
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QAA) group included the required Infection Preventionist (IP) attendance at QAPI meetings. The facility’s QAPI Plan, dated 06/23/25, listed the required committee members as the Administrator, Medical Director, DON, Pharmacy Consultant, IP, MDS Coordinator, and Social Services Director, and stated the committee meets quarterly. Review of quarterly QAPI meeting attendance showed the IP was absent from the 04/29/25, 07/24/25, and 10/27/25 meetings, and the facility did not provide evidence of a fourth quarter 2025 QAPI meeting. During interview, the IP stated she worked six weekend shifts per month, was part of the QAPI team, and did not attend the meetings in person because they were held during the week; she instead prepared a three-month report of infections, antibiotics, culture results, and interventions, which the DON presented to the QAPI team. The DON and Administrator both stated the IP had not attended the QAPI meetings and that she sent information for review instead. The Administrator said he was not aware the IP was required to attend the QAPI meetings and stated the facility did not have a fourth quarter QAPI meeting in 2025 due to a COVID-19 outbreak in the facility.
Infection control lapses during resident care, glucose monitoring, catheter use, and nebulizer storage
Penalty
Summary
The facility failed to provide appropriate infection control practices during resident care and assistance with eating for multiple residents. During incontinence care for Resident #59, a CNA used gloves to provide peri-care, then handled a clean brief, repositioned the resident, and adjusted the pillow and bed controls without changing gloves or performing hand hygiene after removing the gloves. Resident #46 was observed receiving peri-care from two aides who touched soiled briefs and the resident’s body with gloved hands, moved between dirty and clean tasks without changing gloves or cleaning hands, and handled clean items and the call light without hand hygiene. During dining room assistance, NA D fed multiple residents in succession, handled each resident’s spoon and food items, and did not perform hand hygiene between residents while alternating between them. The facility also failed to follow infection control practices for blood glucose monitoring equipment. Resident #1 and Resident #2 each had blood glucose checks performed by a CMT who used the same glucometer between residents without cleaning or sanitizing it and placed the device directly on the medication cart without a barrier. Resident #48 was also tested with the same glucometer after it had not been cleaned before entering the room, and the device was only wiped briefly with a germicidal wipe after use. Resident #44’s blood glucose check was performed with the glucometer placed directly on the medication cart without a barrier, and the device was cleaned only with an 80% isopropyl alcohol pad rather than the facility’s germicidal wipe. Staff interviews showed uncertainty about the correct cleaning method and drying time, and the DON and Infection Preventionist stated the glucometer should be cleaned between residents and placed on a clean barrier. Additional infection control failures involved urinary catheter care and nebulizer equipment. Resident #9’s catheter bag was observed hanging under the wheelchair and dragging on the floor, and the catheter tubing was looped so urine could not drain properly into the bag; the bag and tubing contained urine and the floor beneath was sticky. Resident #36’s nebulizer mask and tubing were repeatedly observed sitting directly on the bedside table, connected to the machine, and not stored in a bag, with no bag available in the room. The facility also lacked a complete infection prevention and control program policy beyond COVID-19, and the Infection Preventionist stated she was part-time and the only staff member tracking infections, with no one else running infection reports when she was not working.
Call Light System Not Audible and Responses Delayed
Penalty
Summary
The facility failed to maintain an adequate audible call system in resident bathrooms and bathing areas and failed to ensure call lights were answered timely for two residents. The facility’s wireless call light exception had expired, and observations showed that indicator lights outside resident rooms did not work, the pager at the nurses’ station only beeped softly, and staff did not carry pagers while on duty. Staff interviews confirmed that the only ways to know a call light was activated were to hear the chime at the nurses’ station or check the monitor, because the hallway lights and room indicators were not functioning. During observation, multiple call lights were activated for extended periods before staff responded. One resident’s call light remained on for 24 minutes before it was answered, and another was answered after 16 minutes. For one resident who needed bathroom assistance and had hemiplegia, impaired balance, and dependence for toileting, the call light was observed on for 40 minutes before staff entered the room. The resident stated he/she had to use the bathroom and had waited a long time for nursing staff. The resident’s room was shown as green on the kiosk when the call light was first activated and later red when it had been waiting more than 15 minutes, with no sound emitted from the kiosk. Interviews with residents and family members described prolonged waits for call light response, including reports of waiting 30 to 35 minutes and even up to two hours. A family member of one resident said the resident had a history of falls, was on hospice, needed more help with ADLs, and had called because staff did not come after the call light was pushed. The DON and Administrator stated the facility did not actively monitor call light response times, had no call light logs available for review, and were unaware that the wireless call light system exception had expired.
Persistent Urine Odor in Hallway and Resident Room
Penalty
Summary
The facility failed to adequately address a strong and pervasive urine odor at its source in the hallway outside one resident’s room and adjoining resident rooms. On multiple observations, surveyors noted a strong urine odor in the hallway, the resident’s door partially open, and the resident in bed unclothed with a towel covering the private area. The fitted sheet beneath the resident had a dark circular ring that appeared wet, and later the resident was sitting on the side of the bed with the same wet-looking sheet and a partially filled urinal without a lid on the floor beside the resident’s legs. No policy regarding addressing odors was provided by the facility upon request. Other residents and visitors on the same hall reported the odor as well. A resident next door said there was a terrible smell in the hallway at times, and a family member of another resident two rooms away said a bad smell was always noticed in the hall during daily visits. Housekeeping staff said they tried to clean the room every day but sometimes the resident yelled at staff and told them to get out, and they would return when the resident was sleeping to mop the floor. CNA staff said the resident was independent with toileting, often refused bathing and hygiene assistance, and staff could not force the resident to clean up. The DON acknowledged awareness of the strong odors from the resident’s room that permeated the hallway, and the administrator stated he would expect housekeeping to make additional efforts as needed to keep the facility free from odors when a resident refused housekeeping services.
Open-Ended PRN Psychotropic Orders Lacked Required Review
Penalty
Summary
The facility failed to monitor the drug regimen for unnecessary psychotropic medications by allowing PRN psychotropic orders to remain open-ended without the required 14-day limit or documented clinical rationale for continued use. The deficiency involved two residents, one receiving PRN Haldol for agitation/hallucinations and the other receiving PRN alprazolam for anxiety. The facility policy stated PRN antipsychotic orders would not be renewed beyond 14 days unless the practitioner evaluated the resident and documented the rationale for continued use. One resident had moderately impaired cognition, malnutrition, anxiety, and hospice care, and was ordered Haldol 2 mg/ml, 0.5 ml by mouth every six hours PRN agitation/hallucinations with no stop date. The record showed the resident received PRN Haldol multiple times after the order had been in place for more than 14 days, including doses documented as effective and ineffective. The record contained no pharmacy recommendation and no documentation that the physician evaluated the resident for the appropriateness of continued PRN Haldol use or documented the rationale for continuing the medication. The second resident had stroke, dementia, anxiety, depression, and hospice care, and was ordered alprazolam 0.25 mg PRN anxiety twice daily with no stop date. The MAR showed repeated PRN administrations over several weeks, all documented as effective, while the record contained no pharmacy recommendation and no documentation that the physician evaluated the resident for the appropriateness of continued PRN alprazolam use or documented the rationale for continued use. During interview, the DON stated PRN antipsychotics should have 14-day stop dates, other PRN psychotropics could be ordered for six months, and that PRN psychotropic medications were mostly monitored by pharmacy, though she said it sometimes slipped through the cracks.
Care Plans Missing Skin and Nebulizer Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan that included services to maintain residents’ highest practicable physical, mental, and psychosocial well-being for two sampled residents. The facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables, developed from the resident assessment and updated when conditions changed. In a review of 19 sampled residents, the facility census was 58. For one resident with moderately impaired cognition and a history of skin integrity issues, the baseline care plan noted scalp lesions and skin history, and the admission MDS showed the resident was at risk for pressure ulcers or injuries and had moisture-associated skin damage. Subsequent skin checks documented a new skin tear to the right elbow, open lesion to the frontal scalp, moisture-associated skin damage to both buttocks, and an open lesion to the genitalia. A physician order was entered for Calmoseptine to open or excoriated areas on the genitalia and buttocks, and a wound care note later identified a new stage 3 pressure ulcer/injury to the coccyx with debridement and daily wound treatment orders. The resident’s updated care plan documented only weekly skin inspection and did not include active skin concerns, breakdowns, or interventions, and the current care plan had no documentation of skin concerns or pressure ulcers. For another resident with COPD, acute respiratory failure with hypoxia, asthma, pneumonia due to COVID-19, and bronchiectasis, physician orders included ipratropium-albuterol inhalation solution every four hours as needed for shortness of breath or wheezing and every morning and at bedtime for chronic cough. The resident’s updated care plan did not document COPD or the need for nebulizer treatments. During interview, the DON stated she expected care plans to be up to date, resident specific, and revised with changes to the resident.
Improper Transfer Technique for a Non-Weight-Bearing Resident
Penalty
Summary
The facility failed to ensure staff used appropriate transfer technique for a resident who was dependent on staff for transfers and documented as non-weight bearing. The resident had severe cognitive impairment, a history of stroke, was on hospice care, and the care plan directed that the resident was totally dependent on two staff for transferring and that a Hoyer lift be used as needed. The resident was also dependent for multiple activities of daily living and was incontinent of bowel and bladder. During observation in the resident's room, a CNA removed the resident's shirt, placed a gown over the resident's head, instructed the resident to give a hug, placed arms under the resident's armpits, and lifted the resident from a Broda chair to the bed without using a gait belt or mechanical lift. The resident's knees were bent during the transfer and the resident did not bear weight. The CNA stated the resident could not stand on his/her own and was unsure whether a gait belt was appropriate, while also stating the resident did not take steps and needed help standing up. During a later observation in the shower room, two staff members transferred the resident from the Broda chair to the toilet and back without a gait belt or mechanical lift. The resident's feet slid across the floor during the transfer, the resident was unable to stand, the knees remained bent, and the resident did not bear weight. Staff interviews showed uncertainty about transfer technique, and both the director of therapy and the DON stated that a mechanical lift should be used when a resident was unable to bear weight and that staff should not pull up under a resident's arms during transfers.
Failure to Complete CNA Performance Reviews and Required In-Service Training
Penalty
Summary
The facility failed to complete a performance review of each nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews for two CNAs, CNA F and CNA G. Review of the facility assessment showed that required in-service training for nurse aides must address areas of weakness identified in nurse aide performance reviews and facility assessment. CNA F’s employee file showed a hire date of 09/26/24 with no documentation of nurse aide evaluation, competencies, or annual performance review. CNA G’s employee file showed a hire date of 04/02/24 with no documentation of nurse aide evaluation, competencies, or annual performance review. During interview, the DON stated she had not done any nurse aide evaluations, competencies, or annual performance reviews, and the Administrator stated he expected CNAs employed greater than 12 months to have a performance evaluation completed and to receive additional education as needed based on the results.
Failure to Document Rationale for Continuing High-Dose Melatonin
Penalty
Summary
The facility failed to ensure the physician documented a rationale for not changing a medication after the pharmacist recommended a review of Resident #9’s melatonin dose during the monthly drug regimen review. Resident #9 was admitted with a diagnosis of insomnia and had orders for melatonin, including a 10 mg bedtime dose. The facility policy required the physician to respond appropriately by changing or stopping problematic medications or clearly documenting why the benefits outweighed the risks, and the psychotropic medication policy required documentation of the rationale when a medication was continued despite possible adverse consequences. The pharmacist’s recommendation identified melatonin doses greater than 6 mg per day as a concern and offered two options: reduce the dose to 5 mg daily or continue the current dose with no change indicated. The physician selected the option to continue the current dose, but no prescriber comments were provided explaining why the change was not indicated. The resident was observed and documented multiple times as sleeping in a wheelchair, including sleeping through meals and being found asleep during several observations, and progress notes also documented periods of not sleeping and a fall from the wheelchair. During interview, the DON stated the pharmacy completed monthly drug regimen reviews and sent recommendations to the physician, and the physician stated he was aware CMS expected a rationale for continuing an abnormal dose or not completing a GDR, but did not have time to review every resident’s record when reviewing pharmacy recommendations.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the inadequate incontinence care and personal hygiene maintenance for two residents. The facility's staffing policy required sufficient numbers of nursing staff with appropriate skills and competency to provide care and services for all residents. However, the facility's daily nursing assignment sheets showed consistent shortages in Certified Nurse Assistant (CNA) hours compared to the facility's assessment needs. This staffing inadequacy led to residents being left soiled and wet for extended periods, as staff were unable to provide timely incontinence care and maintain good personal hygiene. One resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was not provided with timely incontinence care. Observations showed the resident sitting in a wheelchair with a strong urine odor, and interviews with staff confirmed that the resident had not been toileted or changed for several hours. The resident's care plan indicated a need for total assistance with toileting, yet the staffing shortages on the East Hall, where the resident resided, prevented staff from meeting these needs. The East Hall was typically staffed with only two CNAs, despite many residents requiring two-person mechanical lift transfers and total care. Additionally, the facility failed to ensure adequate supervision and care on the memory care unit, which was usually staffed with only one CNA. This staffing level was insufficient to meet the residents' needs for meals, incontinence care, showers, safety monitoring, and activities. Observations showed a resident in the memory care unit yelling for help and shuffling out of the bathroom with pants down, while the sole CNA was occupied with other residents. Interviews with staff confirmed that one CNA was not enough to provide the necessary care and supervision for the memory care unit residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care and maintain good personal hygiene for a resident identified as incontinent and requiring staff assistance. The resident, who had severely impaired cognition and was frequently incontinent of urine and always incontinent of bowel, was observed on multiple occasions sitting in a wheelchair with a strong urine odor emanating from them. Despite being dependent on staff for toileting and personal hygiene, the resident was left in soiled and wet conditions for extended periods, as noted during observations and interviews with staff. On one occasion, the resident was not toileted or changed from 9:00 A.M. until after lunch, resulting in a strong odor of urine and feces. When finally attended to, the resident's incontinence brief was found to be saturated with urine and feces, with dried feces stuck to their skin, indicating prolonged neglect. Interviews with CNAs and the Director of Nursing confirmed that the resident should have been checked and changed every two hours, but this standard was not met, leading to the deficiency.
Failure to Provide Appropriate Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident following their readmission after hospitalization. The resident, who had a history of severe cognitive impairment, stroke, and other medical conditions, was not assessed properly upon readmission. The staff did not complete a clinical assessment or document vital signs consistently, missing crucial information such as blood pressure, respirations, and temperature on multiple occasions. Additionally, the resident's care plan was not updated to reflect their current condition and care needs, including the presence of a heart monitor. The resident was discharged from the hospital with orders for therapy services and a Zio heart monitor, but these were not implemented correctly. The heart monitor was not functioning as intended due to the absence of a transmitter, which was later found misplaced at the nurses' desk. Therapy services were not resumed following the resident's discharge from the hospital, and there was no communication with therapy staff regarding the continuation of services. The lack of proper implementation of the heart monitor and therapy services contributed to the resident's readmission to the hospital with bradycardia. Interviews with facility staff revealed systemic issues in the admission and readmission process, including the failure to complete necessary assessments and documentation. The charge nurse was responsible for obtaining orders and completing assessments, but these tasks were not performed consistently. The facility's electronic medical record system was supposed to trigger required assessments, but staff did not follow through with the necessary documentation and care plan updates. The Director of Nursing and other staff acknowledged these deficiencies, indicating a lack of adherence to professional standards of practice.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control measures during wound care for two residents, leading to deficiencies in hand hygiene and the use of Enhanced Barrier Precautions (EBP). For Resident #3, the Licensed Practical Nurse (LPN) did not follow the facility's hand hygiene policy, as they did not wash hands or change gloves between handling different wounds. The LPN used the same gauze pad to clean multiple wounds, which is against the facility's infection control policy. Additionally, there was no EBP signage or personal protective equipment (PPE) available at the resident's room, and the LPN did not apply EBP during the wound care process. Resident #3 had a care plan indicating a risk for impaired skin integrity and required assistance with activities of daily living due to severe cognitive impairment and mobility issues. The resident had multiple wounds, including a Stage II pressure ulcer and skin tears, which required specific wound care orders. However, the LPN failed to follow these orders correctly, leaving one wound uncovered and applying a pressure-relieving boot directly over an open wound. For Resident #7, the LPN initially followed some EBP protocols by washing hands and applying a gown and gloves. However, the LPN did not change gloves or wash hands after removing a soiled dressing and before handling the resident's bed controller. The LPN also failed to apply EBP when obtaining additional dressing supplies and did not wash hands between glove changes. This lack of adherence to infection control protocols was acknowledged by the LPN, the facility's Infection Preventionist, and the Director of Nursing during interviews, highlighting a failure to follow established procedures for preventing cross-contamination during wound care.
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 48 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
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 Vandalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westview Nursing Home | 13.8 mi | ★★★★★ | 0 | 0 |
| Country View Nursing | 15.4 mi | ★★★★★ | 35 | 0 |
| Wellsville Health Care Center | 16.7 mi | ★★★★★ | 1 | 0 |
| Pin Oaks Living Center | 23.5 mi | ★★★★★ | 10 | 0 |
| Avenir At Maple Grove | 24.9 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.