Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Big Spring Care Center For Rehab And Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its own policy or FDA Food Code standards for hair and facial hair restraints during food preparation and meal service. Multiple staff members with facial hair greater than 1/2 inch, including CNAs, a NA, dietary aides, and cooks, were observed in the kitchen and at the serving line without facial hair nets while preparing food, plating resident meals, and obtaining items behind the serve-out line. Some staff wore only hair nets or ball caps, and others had no hair covering at all, despite acknowledging in interviews that hair nets and beard nets were required past the serving counter and in the kitchen. Leadership and staff reported that beard nets or facial hair nets were expected but not currently available from the facility’s vendor or in the kitchen, resulting in ongoing noncompliance with established food safety and hygiene standards.
Staff did not document notification to responsible parties or emergency contacts regarding significant changes in condition, new medication orders, or care events for three residents with complex medical needs. Despite facility policy and staff interviews confirming the requirement to notify and document, multiple instances were found where this did not occur, including after falls, new infections, and medication changes. Issues with accessing care plans in the electronic medical record were also noted.
A resident with multiple chronic conditions requested hospice services, but staff failed to document the hospice referral, assessment, or admission in the medical record. There was no physician order for hospice, and the care plan was not updated to reflect hospice services, resulting in incomplete and inaccurate documentation.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident reported to an LPN that another resident with severe cognitive impairment kissed them on the mouth without consent and made inappropriate gestures, causing the resident to feel unsafe. Although facility policy required immediate reporting of abuse allegations to the administrator and state agency within two hours, the incident was not reported to the state until three days later. Staff interviews confirmed awareness of the reporting requirements, but the notifications were not made as required.
The facility failed to employ a qualified dietary manager for its food and nutrition services. The DM, who started in December 2024, lacked necessary qualifications such as being a certified dietary manager or holding an associate's degree in food service management. Despite having a culinary arts certificate, she was not enrolled in any certification course, and her personnel file lacked documentation of required qualifications. Interviews revealed gaps in compliance, with the RD noting the need for ServSafe certification and the administrator mistakenly believing the DM met qualifications.
The facility failed to ensure dietary staff had the necessary skills and competencies, as the Dietary Manager did not provide adequate training or policy reviews. New staff, including a Dietary Aide and a Cook, reported insufficient training, and none of the kitchen staff were safe serve certified. The Administrator acknowledged the lack of training oversight and documentation.
The facility failed to maintain food safety and sanitation standards, with staff not using proper hair restraints, dented cans not removed, and inadequate labeling of food. The dishwasher's sanitation levels were not properly maintained, and hand hygiene was insufficient. Observations revealed peeling paint and rust in the kitchen, indicating a lack of adherence to cleaning schedules.
The facility failed to manage its resources effectively, resulting in late payments for laboratory services. Invoices dating back to July 2024 remained unpaid until November 2024, despite having net 30-day terms. Interviews with staff revealed a lack of clarity in the payment process, with the Business Office Manager unaware of the steps following invoice approval and the Administrator unaware of the late payments.
A long-term care facility failed to adhere to infection control procedures, including hand hygiene and Enhanced Barrier Precautions (EBP), during resident care activities. Staff did not consistently perform hand hygiene between tasks, such as peri-care, wound care, and feeding tube care. Additionally, the facility did not follow its Legionella Water Management Program, lacking documentation and testing materials. These deficiencies highlight significant lapses in the facility's infection prevention and control program.
The facility failed to maintain resident dignity by not using dignity bags for a resident's catheter, leading to exposure from the hallway. Staff inconsistently applied the policy, and the dining room environment was disrupted by staff yelling during meals. Additionally, the smoking schedule conflicted with meal times, forcing residents to choose between smoking and eating a hot meal.
The facility failed to ensure residents could access their funds promptly, restricting cash access to weekdays only, affecting three residents. Despite having intact or moderately impaired cognitive skills, residents expressed the need for weekend access to funds, which was not available. Staff interviews confirmed the limited banking hours, highlighting the deficiency in managing residents' financial affairs.
The facility failed to provide a safe and homelike environment, with deficiencies including torn chair cushions in a common area, an uncapped handrail with sharp edges, and significant wall damage in a resident's room. Staff were unaware of these issues, indicating a lack of communication and maintenance reporting.
The facility failed to accurately reconcile controlled medications in the E-Kit, as discrepancies were found between the physical count and the BNDD Kit Administration Record. Nursing staff did not perform required counts at shift changes, and the DON was responsible for stocking narcotics without proper documentation. The facility was transitioning to a new system, and the E-Kit process was not well-established.
A facility failed to assess and document the use of a seat belt as a restraint for a resident with quadriplegia who could not remove it independently. Despite the resident's cognitive awareness and request for the seat belt due to fear of falling, the facility did not obtain written consent, document less restrictive options, or obtain a physician's order. Staff interviews revealed a lack of awareness and adherence to the facility's restraint policy.
A resident with a history of atrial fibrillation and other conditions experienced vaginal bleeding, prompting a physician to order a CBC. However, the facility failed to obtain the CBC in a timely manner, as it was not completed by the end of January. Interviews revealed that the DON was responsible for entering lab orders, but the new lab system may have contributed to the oversight, resulting in a deficiency in meeting professional standards of care.
The facility failed to administer oxygen per physician orders for two residents with COPD and other respiratory conditions. One resident received two and a half liters per minute instead of the ordered two liters, while another received two liters instead of three. Staff interviews revealed inconsistencies in monitoring and adjusting oxygen flow rates, leading to the deficiency.
A facility failed to document routine assessment and monitoring of a dialysis site and ongoing communication with a dialysis center for a resident with end-stage renal disease. The resident's care plan required monitoring of the vascular access site, but there was no order for site assessment, and nurses did not document assessments or communication. Staff interviews revealed inconsistent use of communication forms and lack of documentation, despite expectations to check the site for complications.
A facility failed to provide trauma-informed care for a resident with a history of emotional and sexual abuse. The resident's trauma history and specific care preferences, such as discomfort with male caregivers, were not included in the care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's trauma, leading to inadequate support and care.
A facility failed to maintain a functional bariatric Hoyer scale, resulting in a resident not being weighed for six months. The resident, with a history of morbid obesity and other health conditions, had a physician's order for monthly weight monitoring. The facility rented a broken scale, and despite purchasing a new one in December, the resident's weight was not documented until January, revealing significant weight loss. Staff interviews indicated a lack of communication and awareness regarding the broken equipment and the resident's unmonitored weight.
Failure to Enforce Hair and Facial Hair Restraint Requirements in Food Service Areas
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own policy for hair restraints in the kitchen and serving areas. The facility’s Dietary Employee Personal Hygiene policy required all dietary staff to wear hair restraints, including hair nets, hats, and beard restraints, to prevent hair from contacting food, and the FDA Food Code 2022 required food employees to wear hair and beard restraints to keep hair from contacting exposed food. Despite these requirements, multiple staff members with facial hair greater than 1/2 inch were observed in the kitchen and at the serving line without facial hair nets while food was being prepared and served. One staff member was observed preparing lunch with a hair net but no facial hair net, and another CNA with facial hair applied a hair net but no facial hair net before entering the kitchen to obtain milk and wash hands behind the serve-out line. Additional observations showed a NA with facial hair repeatedly washing hands at the sink behind the serve-out line and opening the kitchen entry to request items without wearing a hair net or facial hair net. A dietary aide with a ball cap and no facial hair net prepared items and resident meal plates at the serving line, and two cooks with ball caps and facial hair greater than 1/2 inch worked in the kitchen and at the grill without facial hair nets. During interviews, the Dietary Manager, DON, and Administrator all acknowledged that staff entering the kitchen or passing the serve-out line should wear hair nets and facial hair nets when indicated, and several staff members confirmed that facial hair nets were required but reported that beard nets or facial hair nets were not currently available from the facility’s vendor or in the kitchen. These observations and interviews demonstrated that the facility did not follow its own policy or the FDA Food Code requirements for hair and facial hair restraints during food preparation and service.
Failure to Notify Responsible Parties of Resident Condition Changes and New Orders
Penalty
Summary
The facility failed to ensure that residents' responsible parties or emergency contacts were notified of changes in condition and new physician orders, as required by facility policy and standard practice. For three residents, staff did not document notification to responsible parties regarding significant health events, new medication orders, or changes in care. The facility's own medication order policy required staff to notify the resident's sponsor or family of new medication orders, but there was no documented policy related to notifications of resident change in condition to responsible parties or family members. One resident with multiple diagnoses, including encephalopathy, COPD, and bipolar disorder, experienced several health events such as shortness of breath, new antibiotic and insulin orders, and requests for palliative or hospice care. In each instance, staff failed to document that the responsible party was notified of these changes. Another resident with diabetes, COPD, and a traumatic amputation had incidents including a reported fall, new wounds, and new antibiotic orders, but staff did not document notification of the responsible party regarding these events or new treatments. A third resident with severe cognitive impairment and multiple chronic conditions had changes in urinary output, new catheter and antibiotic orders, and behavioral medication changes, with no documentation of responsible party notification. Interviews with staff, including CNAs, CMTs, LPNs, the DON, and the Administrator, confirmed that the expectation was for nursing staff to notify family or responsible parties of changes in condition and new orders, and to document these notifications. However, review of the medical records for the three residents showed repeated failures to document such notifications, even when significant changes or new orders occurred. Additionally, there were issues with accessing care plans in the electronic medical record for two residents, further complicating the ability to ensure proper communication and documentation.
Failure to Document Hospice Evaluation and Admission in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who requested hospice services. The resident, who had diagnoses including encephalopathy, COPD, cognitive communication deficit, and bipolar disorder, expressed a desire to be evaluated for hospice and requested that staff contact family and initiate the process. Although the Director of Nursing was notified and instructed staff to begin the hospice referral, there was no documentation in the resident's medical record regarding a hospice referral, assessment, or admission to hospice services. Additionally, there was no physician's order for hospice evaluation or admission, and the care plan was not updated to reflect hospice services. Staff interviews confirmed that nursing staff are expected to document changes in health condition, including hospice evaluation and admission, and that physician orders for hospice should be present in the chart. The facility was unable to provide a policy related to nursing documentation and medical record accuracy. The absence of documentation regarding hospice services, including the lack of hospice records, orders, and care plan updates, resulted in an incomplete and inaccurate medical record for the resident.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
Facility staff failed to fully implement abuse and neglect policies and procedures when an allegation of sexual abuse was not reported in a timely manner. A resident with intact cognitive skills and a history of depression, obesity, and panic disorder reported to an LPN that another resident, who had severe cognitive impairment and Alzheimer's disease, kissed them on the mouth without consent and made inappropriate gestures. The resident expressed feeling uncomfortable and unsafe as a result of the incident. The facility's policy required immediate reporting of any abuse allegation to the administrator and to the state survey agency within two hours. However, the LPN who received the report from the resident only texted the DON about the incident and did not escalate it further or ensure timely reporting. The DON was informed of the incident but did not notify the state agency as required. The administrator became aware of the incident days later and only after speaking directly with the resident did the full details emerge. The facility ultimately reported the incident to the state three days after the initial allegation was made, well outside the required timeframe. Interviews with staff, including the LPN, DON, administrator, and other facility personnel, confirmed knowledge of the policy and the requirement for immediate reporting of abuse allegations. Despite this, the required notifications were not made promptly, resulting in a failure to follow established procedures for reporting suspected abuse.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified dietary manager for its food and nutrition services, as required by regulatory standards. The dietary manager (DM) began her position in December 2024, having previously served as a DM assistant for a year. Despite having a certificate in culinary arts from Le Cordon Bleu, she did not possess the necessary qualifications such as being a certified dietary manager (CDM), a certified food service manager, or holding an associate's degree or higher in food service management or hospitality. Additionally, she was not enrolled in any training or certification course to meet these requirements, and there was no documentation in her personnel file to support her qualifications for the role. Interviews with facility staff revealed further gaps in compliance. The registered dietitian (RD) noted that the DM should have a ServSafe certification, but was unaware of the corporate policy regarding the timeline for obtaining this certification. The administrator believed the DM had the required qualifications and mentioned that the DM was taking the ServSafe class and test on the day of the interview. However, the facility did not have a copy of the DM's degree in culinary arts, and there was no evidence of regular contact between the DM and a registered dietitian, which is crucial for ensuring the nutritional needs of residents are met.
Inadequate Training for Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff had the necessary competencies and skills to effectively carry out food and nutrition services. The Dietary Aide (DA) P, who started working in the kitchen on January 24, 2025, reported not having received adequate training or an overview of kitchen policies from the Dietary Manager (DM). DA P expressed feeling unprepared to serve lunch to residents. Similarly, Cook O, who began working on December 12, 2024, also indicated that the DM had not provided training on facility policies, procedures, or the puree process. The DM, who started on August 30, 2023, admitted that none of the kitchen staff, including themselves, were safe serve certified and that there was no orientation or training checklist for new staff. The DM also acknowledged a lack of familiarity with CMS dietary regulations and confirmed that DA P and DA N did not have sufficient training for their tasks. The Administrator confirmed that the kitchen staff had not received adequate training and that the DM was responsible for this training. The Administrator also noted that the DM should have conducted skills testing and reviewed kitchen policies and procedures with new staff. However, the Administrator did not review kitchen staff training, observe meal preparation, or oversee meal service. This lack of oversight and training documentation contributed to the deficiency in ensuring dietary staff were properly trained and competent in their roles.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and service, as evidenced by multiple observations and interviews. Staff did not consistently use effective hair restraints, with several kitchen staff members observed without beard nets despite having facial hair. Additionally, dented cans were found in the dry food storage area, which were not removed from use, posing a risk of contamination. The facility's policy required that all food be labeled and dated, but numerous items in the walk-in refrigerator were found without proper labeling or dating, including leftovers and resident food. The dishwasher machine's sanitation levels were not maintained at the appropriate level, with staff unable to properly test the sanitizer strength. Observations revealed a white powdery residue on drinking cups and coffee mugs, which staff attributed to hard water. However, the residue could be scratched off, indicating inadequate cleaning. Staff interviews revealed a lack of knowledge regarding the testing of sanitizer levels, and there was no log kept of these tests. The facility's policy required that all dishes be cleaned, rinsed, and sanitized after each use, but this was not consistently followed. Hand hygiene and equipment sanitation were also inadequate. Staff were observed not washing their hands after handling various items and not sanitizing equipment between uses. The facility's cleaning schedules were not adhered to, with peeling paint, hanging vents, and rust observed in the kitchen, which could lead to contamination. Staff interviews indicated a lack of awareness of cleaning schedules, and the administrator acknowledged that these issues could lead to food contamination and potential illness for residents.
Facility's Ineffective Resource Management Due to Late Invoice Payments
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, as evidenced by the late payment of invoices for laboratory services. The facility had a series of unpaid invoices dating back to July 2024, with amounts owed ranging from $241.41 to $3,466.70. Despite the invoices having net 30-day terms, they remained unpaid until a check was issued on November 25, 2024, for a total of $10,918.42. This delay in payment was confirmed through a review of the laboratory's accounts receivable aging detail spreadsheet and interviews with facility staff. Interviews with the Business Office Manager (BOM) and the Director of Fiscal Services revealed a lack of clarity and communication regarding the payment process. The BOM stated that invoices were received and reviewed for accuracy before being sent to the billing system for approval by the regional manager, but was unaware of the subsequent steps. The Director of Fiscal Services acknowledged the late payment but could not explain the delay. The Administrator was also unaware of the late payments, indicating a breakdown in the facility's administrative processes. The Laboratory Company Representative confirmed that the facility had not paid the bill since July 2024, highlighting the facility's failure to manage its financial obligations effectively.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control procedures, resulting in multiple deficiencies related to hand hygiene and the use of Enhanced Barrier Precautions (EBP). Staff did not consistently perform hand hygiene before and after resident care activities, including peri-care, wound care, and feeding tube care. For instance, during the care of a resident with quadriplegia and an indwelling catheter, staff did not change gloves or sanitize hands between tasks, such as cleaning the peri-area and handling soiled items. Similarly, during wound care for a resident with chronic pressure ulcers, the nurse did not perform hand hygiene between glove changes, potentially compromising the resident's safety. In another instance, a resident with a feeding tube did not receive proper care as the nurse failed to perform hand hygiene between glove changes while cleaning the stoma site and changing the dressing. Additionally, the facility did not follow its own policy on Enhanced Barrier Precautions for a resident with an indwelling catheter, as staff did not wear gowns during catheter care, contrary to the facility's EBP policy. These lapses in infection control practices were observed despite the facility's policies clearly outlining the need for hand hygiene and the use of personal protective equipment during high-contact care activities. Furthermore, the facility did not maintain adequate documentation or conduct regular testing as part of its Legionella Water Management Program. The Maintenance Director and Administrator acknowledged that the facility did not complete Legionella testing and lacked testing materials on-site. This oversight in the water management program could potentially increase the risk of Legionella bacteria growth, which the facility's policy aims to prevent. The lack of adherence to infection control protocols and water management practices highlights significant deficiencies in the facility's infection prevention and control program.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not providing a dignity bag for a resident's Foley catheter bag, resulting in the catheter bag being visible from the hallway. The resident, who was cognitively intact and had an indwelling urinary catheter due to neurogenic bladder, was observed multiple times with the catheter bag exposed, contrary to the care plan that required the use of a dignity pouch. Interviews with various staff members revealed inconsistencies in understanding and implementing the policy regarding the use of dignity bags, with some staff believing it was necessary only in public areas, while others stated it should always be used. Additionally, the facility's dining room environment was compromised by staff yelling to communicate with residents during meal times. The Dietary Manager and Dietary Aide were observed shouting across the dining room to check if residents had received their meals or wanted additional servings. This behavior was noted by residents and staff as unnecessary and disruptive, contributing to a loud and undignified dining experience. The Director of Nursing acknowledged the issue and had previously addressed it with the Dietary Manager, emphasizing the need for staff to use quieter voices. Furthermore, the facility's smoking schedule conflicted with meal times, forcing residents to choose between having a hot meal or taking a scheduled smoke break. Observations and interviews indicated that meals were often served late, exacerbating the issue. Residents expressed frustration at having to leave their meals to smoke or return to cold food. The Director of Nursing confirmed that residents should not have to make such choices and should be allowed to smoke after eating if meals are delayed.
Facility Fails to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to properly manage residents' funds by not maintaining access to a petty cash fund that ensured all residents could receive cash requests of less than $100.00 (or less than $50.00 if the resident received Medicaid) the same day. This deficiency affected three residents out of a sample of 17. The facility's policy on Personal Needs Allowance (PNA) did not specify how quickly residents should be able to obtain their funds, and the facility's banking hours were limited to weekdays from 10:30 A.M. to 3:00 P.M., with no access to cash on weekends. Resident #1, who had intact cognitive skills, expressed a desire to access funds on the weekend when family visited, but was unable to do so. Resident #26, also with intact cognitive skills, mentioned wanting access to personal funds on weekends if they forgot to request money during the week. Resident #44, with moderately impaired cognitive skills, noted that while they planned ahead, there was an instance when they wanted to buy a snack but couldn't due to the restricted access to funds outside the designated hours. Interviews with facility staff, including the Activity Director, Business Office Manager (BOM), Registered Nurse (RN) A, Director of Nursing (DON), and the Administrator, confirmed that residents could only access cash during the specified weekday hours. The BOM and other staff acknowledged that residents occasionally requested money outside these hours but had to wait until the next business day. The facility did not provide access to cash on weekends, which limited residents' ability to manage their financial affairs as needed.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In the 100 hall TV lounge area, two rocking chairs were found with significant tears in their cushions, exposing the foam interior and plastic piping with sharp ends. Despite the frequent use of this area by residents, staff members, including a CNA, CMT, and the DON, were unaware of the condition of the chairs, indicating a lack of communication and reporting of maintenance issues. Additionally, a handrail outside the dining room was found with its end cap off, leaving sharp connector edges exposed. This handrail was located near a hand sanitizer dispenser and a signboard, posing a potential hazard to residents. The Maintenance Request Log showed no documentation of the needed repair, and the Maintenance Director was not informed of the issue, highlighting a failure in the facility's maintenance reporting system. Resident #16's room was also found to be in disrepair, with significant damage to the walls, including gouges and missing pieces of drywall. The resident, who has severely impaired cognition and requires assistance with daily activities, expressed a desire for the walls to be fixed. However, the Maintenance Supervisor and Administrator were unaware of the condition of the room, and it was not listed for repairs, further demonstrating the facility's inadequate maintenance oversight and communication.
Inaccurate Reconciliation of Controlled Medications in E-Kit
Penalty
Summary
The facility failed to maintain an accurate reconciliation of controlled medications in the Emergency Kit (E-Kit), as evidenced by discrepancies between the physical count of narcotics and the documentation on the BNDD Kit Administration Record. During a random count, it was observed that the count of Hydrocodone 5/325 mg tablets in the E-Kit did not match the log, with 6 tablets present but only 5 recorded. This discrepancy was attributed to incorrect documentation by the nursing staff, who did not perform a two-person count or a shift change count of the E-Kit. The facility's policy required a physical count of each medication in the E-Kit each time it was accessed, with documentation of the quantity on hand and any medications removed or added. However, the nursing staff did not adhere to this policy, as they only counted medications when signing them out and did not perform a full count with two nurses at each shift. The Director of Nursing (DON) was responsible for stocking the E-Kit with narcotics, but there was no documentation of medications being added to the log, and the pharmacy did not participate in this process. Interviews with the nursing staff and the DON revealed that the current E-Kit setup was temporary and had been in use for less than two months. The DON audited the E-Kit weekly, but the nursing staff did not perform daily shift audits as required. The facility was in the process of transitioning to a new system, and the Administrator acknowledged that the E-Kit process was not well-established at the time of the survey.
Failure to Properly Assess and Document Use of Restraint
Penalty
Summary
The facility failed to properly assess and document the use of a seat belt for a resident who was unable to remove it independently, which is considered a physical restraint. The resident, who has quadriplegia and other medical conditions, was observed with a seat belt in their wheelchair, which they could not remove without assistance. Despite the resident's cognitive awareness and request for the seat belt due to fear of falling, the facility did not obtain written consent, document less restrictive options, or obtain a physician's order for the seat belt's use. The facility's policy on restraints, dated December 2007, outlines that restraints should only be used for the safety and well-being of the resident after alternatives have been tried unsuccessfully. It also requires a physician's order and written consent from the resident or their representative. However, the facility did not follow these procedures for the resident in question. The resident's care plan and physician's order sheet did not include any mention of the seat belt or its necessity, and staff interviews revealed a lack of awareness and documentation regarding the restraint policy. Interviews with staff, including CNAs, RNs, the Director of Nursing, and the Administrator, highlighted a lack of communication and adherence to the facility's restraint policy. The Administrator was unaware that the seat belt was being used and stated that the facility did not allow restraints. Despite the resident's fear of falling and request for the seat belt, the facility did not complete the necessary paperwork for consent or risk assessment, leading to a deficiency in the proper use and documentation of restraints.
Failure to Obtain Timely Lab Tests for Resident
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident, leading to a deficiency in meeting professional standards of care. A resident with a history of atrial fibrillation, hyperlipidemia, chronic kidney disease, and edema was admitted with urinary incontinence and a risk of infections. On 11/29/24, a licensed practical nurse documented that the resident was experiencing vaginal bleeding, prompting a physician to order a complete blood count (CBC) to be conducted the following morning. However, the CBC was not obtained as ordered, and the resident continued to report bleeding on 12/01/24. Interviews with facility staff revealed a breakdown in the process of ordering and obtaining lab tests. The Director of Nursing (DON) was responsible for entering lab orders into the computer system, but the CBC ordered on 11/29/24 was not completed by 01/29/25. The DON and other staff members were unaware of the missing CBC results, and the new lab company system implemented on 01/01/25 may have contributed to the oversight. Despite daily checks of the lab portal and communication protocols, the facility failed to ensure the ordered lab work was completed, resulting in a deficiency in providing care according to professional standards.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident #5 and Resident #7, by not administering oxygen per physician orders. Resident #5, who has chronic obstructive pulmonary disease (COPD) and other respiratory conditions, was observed with an oxygen concentrator set at two and a half liters per minute, contrary to the physician's order of two liters per minute. Staff did not document the verification of the oxygen flow rate, and there were instances where the resident's oxygen was set incorrectly, as confirmed by interviews with staff members. Resident #7, diagnosed with chronic diastolic congestive heart failure and COPD, was also not receiving oxygen as per the physician's order of three liters per minute. Observations showed the resident receiving only two liters per minute, and at times, the resident was not wearing oxygen at all. Staff interviews revealed a lack of awareness of the correct oxygen flow rate, and documentation of the oxygen flow rate was missing from the resident's records. Interviews with various staff members, including CNAs, RNs, LPNs, the Director of Nursing, and the Administrator, highlighted inconsistencies in monitoring and adjusting oxygen flow rates according to physician orders. Staff members acknowledged the discrepancies in oxygen administration and the importance of adhering to physician orders, yet the facility's practices did not align with these standards, leading to the deficiency in providing safe and appropriate respiratory care.
Failure to Document Dialysis Care and Communication
Penalty
Summary
The facility failed to provide dialysis services per professional standards of practice for a resident with end-stage renal disease who required hemodialysis three times a week. The facility did not document routine assessment and monitoring of the dialysis site, nor did they document ongoing communication with the dialysis center. The facility's policy required detailed records of pre and post-dialysis assessments and communication with the dialysis center, but these were not maintained for the resident. The resident's care plan indicated a risk for infection related to hemodialysis and required ongoing monitoring and care of the vascular access site. However, the facility did not have an order for dialysis site assessment, and nurses did not document assessments of the dialysis site or communication with the dialysis center. Interviews with staff revealed that communication forms were not sent or received consistently, and assessments of the dialysis site were not documented, despite the expectation that nurses should check the site for signs of infection or complications. The Director of Nursing and the Administrator both acknowledged the lack of documentation and communication regarding the resident's dialysis care. The facility had dialysis communication forms, but they were not utilized effectively, and there was no physician order for dialysis site assessment. The failure to document and communicate effectively with the dialysis center represents a deficiency in the facility's adherence to its own dialysis policy and professional standards of practice.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who had a history of emotional and sexual abuse. The resident, who had been admitted from a hotel and was previously homeless, had a documented history of trauma, including being sexually assaulted by siblings. Despite this, the facility did not develop a care plan that addressed the resident's trauma history or identified specific triggers, such as discomfort with male caregivers, which the resident had expressed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's trauma history. Certified Nurse Aide L, Certified Medication Technician J, and the Director of Physical Therapy were not informed of the resident's past trauma or any specific triggers. The Social Services Director was aware of the resident's history of sexual abuse but did not know of any specific triggers. The MDS/Care Plan Coordinator acknowledged that the trauma should have been included in the resident's care plan, but this was only initiated after the issue was raised. The Director of Nursing and the Administrator were also unaware of the resident's trauma history and specific care preferences. The facility's policy on trauma-informed care was not followed, as staff were not adequately trained or informed about the resident's needs, leading to a failure in providing appropriate care and support for the resident's trauma-related issues.
Failure to Maintain Functional Bariatric Hoyer Scale
Penalty
Summary
The facility failed to maintain a functional environment for its residents by not ensuring the availability of a working bariatric Hoyer weight scale. This deficiency affected a resident who was unable to have their weight monitored for six months, from July 2024 to January 2025. The resident, who had a history of morbid obesity and other health conditions such as atrial fibrillation and chronic kidney disease, had a physician's order for monthly weight monitoring. However, due to the broken scale, the resident's weight was not recorded during this period, despite the facility's policy requiring monthly weight assessments. The issue began when the facility rented a bariatric Hoyer lift scale that was delivered broken. Although a replacement was provided, it was also returned due to malfunction. The facility eventually purchased a new scale in December 2024, but the resident's weight was not documented until January 2025, revealing a significant weight loss. Interviews with staff, including CNAs, RNs, and the Director of Nursing, indicated a lack of communication and awareness regarding the broken equipment and the resident's unmonitored weight. The facility's administration, including the Administrator and Director of Nursing, were unaware of the extent of the issue until late December 2024. The Administrator expected staff to report broken equipment and document any significant weight changes, but this did not occur. The deficiency highlights a failure in communication and equipment management, resulting in the resident's weight not being monitored as required by their care plan and physician's orders.
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 25 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Humansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwood Hills Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Parkview Health Care Facility | 14.5 mi | ★★★★★ | 0 | 0 |
| Lake Stockton Healthcare Facility | 14.6 mi | ★★★★★ | 1 | 0 |
| Citizens Memorial Healthcare Facility | 14.7 mi | ★★★★★ | 11 | 0 |
| Hermitage Nursing & Rehab | 17.7 mi | ★★★★★ | 13 | 1 |
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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.