Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Current River Nursing Center, Inc during CMS and state inspections, most recent first.
Kitchen sanitation and food storage were not maintained in accordance with policy. Cleaning logs showed repeated missed daily and weekly cleanings, and observations found a nonfunctioning refrigerator and plate warmer, grime buildup on the ice machine, dishwasher, vents, ceiling diffusers, and stove, as well as unlabeled bulk bins, a cracked egg in a shell egg case, and uncovered desserts on a cart. During meal prep, a dietary aide served food with only a partially placed facial hair restraint, and repair workers were in the kitchen without hair restraints while the DM and Admin acknowledged the cleaning and maintenance problems.
QAA/QAPI committee meetings were not held consistently and did not always include the required members. Meeting minutes showed one meeting with the Administrator, Infection Preventionist, HR, a CNA, and an RN, and another with the Administrator, DON, SSD, and HR, but no documentation that the DON, Medical Director, or Infection Preventionist attended as required. The Administrator stated the facility had not been consistent with quarterly meetings and could not find minutes for one meeting, with the only other meeting besides January being in June.
Infection control practices were not maintained during peri care and wound care, with staff failing to change gloves and perform hand hygiene between dirty and clean tasks, and a bed pan was placed on the floor during care. A CMT also cleaned a glucometer with an unapproved wipe instead of following the meter manufacturer’s disinfection instructions. The facility additionally had incomplete TB screening documentation for multiple residents and no documented IPCP program in the binder.
Incomplete Antibiotic Stewardship and Infection Surveillance Program: The facility failed to maintain an IPCP with antibiotic stewardship and infection surveillance protocols. The antibiotic stewardship binder had missing and incomplete logs, no infection maps, and no documentation of antibiotic indication, dose, route, duration, or lab findings. Seven residents were receiving antibiotics, and the DON and Administrator stated the former MDS Coordinator had been handling the logs before leaving, after which the binder was not maintained.
Unqualified Infection Preventionist Role: The facility failed to ensure that at least one person with specialized infection prevention and control training was responsible for IP duties. The facility’s policy required a qualified IP with specialized training, but no documentation showed any staff member had completed the training. RN M had just started the IP role and had not begun training, while the DON stated the facility had been without an IP since the previous one left and that she was handling IP duties without certification.
Unsafe and Unclean Resident Environment: Surveyors observed missing cove base, damaged walls, cracked and peeled shower caulk, a missing shower handle, missing shower ramp tiles, and unclean bathroom areas. One resident room had a strong urine odor on repeated observations, with urinals left in the room, urine-stained bedding, and debris on the floor; RN staff said the room should not have been left that way and should have been checked every two hours. The Administrator and Maintenance Director stated several of the issues were not documented on the maintenance log.
Failure to assess and care plan PTSD triggers: A resident with PTSD, anxiety, depression, dementia, and severe cognitive impairment had no trauma-informed care assessment, and the care plan only noted psychotropic medication use without addressing trauma history, triggers, behaviors, or interventions. Staff interviews confirmed the care plan should have included the cause of PTSD, triggers, and related assessments, but the resident’s assessment and care plan did not address PTSD.
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. A resident with multiple conditions did not receive consistent skin assessments and treatments, resulting in worsened skin conditions. Another resident with a pressure ulcer experienced lapses in wound care, with incorrect medication application. A third resident with Alzheimer's was not weighed weekly as ordered, missing opportunities to monitor significant weight loss. Staff interviews revealed a lack of awareness and documentation regarding these issues.
A facility failed to safely transfer two residents, resulting in a hip fracture for one. A resident with hemiplegia was transferred by an RN alone, contrary to the care plan requiring two staff, leading to a fall and hip fracture. Another resident with severe cognitive impairment was transferred without a gait belt, using improper techniques. Staff interviews revealed inadequate training and communication on transfer procedures.
The facility failed to maintain RN coverage for at least eight hours daily and lacked a DON, affecting all residents. Staffing records showed multiple days without RN coverage, and interviews confirmed the absence of a DON since November 2023. The facility relied on agency staff to fill RN gaps, with only one RN as a floor nurse and the ADON and MDS Coordinator being LPNs.
The facility failed to maintain written transfer agreements with hospitals, which are necessary for ensuring timely hospital admissions for residents when needed. Interviews and record reviews showed that no transfer agreements or related policies were available. The Administrator and ADON confirmed the absence of such agreements, affecting all 40 residents.
The facility did not inform the State agency about changes in their DON position. Records showed that the last documented DON was terminated in December 2023, and no DON was scheduled or worked from April to July 2024. The Administrator confirmed the absence of a DON since November 2023.
The facility failed to provide written transfer/discharge notifications to residents, their responsible parties, and the LTC Ombudsman for six residents transferred to the hospital. The facility lacked a transfer/discharge policy, and the Ombudsman had not received transfer logs since April. The Administrator and ADON expected charge nurses to handle notifications, but there was no clear accountability.
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives during hospital transfers. Six residents were transferred without receiving the required documentation. The ADON and Administrator acknowledged the expectation for bed-hold policies to be given, but there was no clear accountability for ensuring this was done.
The facility failed to reconcile narcotics at each shift change for three medication carts, as required by policy. A review of narcotic count logs showed numerous missed opportunities for reconciliation over several months, with many instances of no documentation. Interviews with staff confirmed the expected practice, but the logs indicated significant non-compliance.
The facility failed to document TB testing for four residents, perform proper hand hygiene and glove changes during wound and incontinent care, and lacked a water management program for Legionella. Additionally, the IPCP was outdated and missing critical information.
A facility failed to consistently document a resident's code status, resulting in discrepancies between the care plan, face sheet, and Physician's Order Sheet. The resident had chosen a DNR status, but the Physician's Order Sheet indicated a full code. Staff relied on color-coded sheets in the MAR and physician's orders to determine code status, but the facility lacked a policy to ensure consistent documentation.
The facility failed to maintain a safe and clean environment, with observations revealing damaged shower rooms and unclean, unrepaired wheelchairs for several residents. Staff interviews indicated a lack of awareness and documentation regarding maintenance and cleaning procedures. The Maintenance Director and Administrator acknowledged the issues but cited a lack of funds, although the Corporate QA RN stated funds were available.
A facility failed to assess and document the use of bed and chair alarms for a resident with Alzheimer's and osteoporosis, who experienced multiple falls. The resident was unable to remove the alarms, suggesting potential restraint use. There was no physician's order or assessment for the alarms, and staff interviews confirmed the lack of monitoring and documentation.
A resident with dementia, dysuria, muscle weakness, repeated falls, and UTIs experienced multiple falls and incidents that were not addressed in their care plan. Despite numerous documented falls and incidents, the care plan had not been updated with new interventions since the previous year. Observations showed improper wheelchair cushion positioning and lack of nonskid footwear, while interviews with staff revealed an expectation for care plan updates that were not executed.
A facility failed to collect timely urine specimens for a resident with symptoms of a UTI, resulting in an emergency room visit. The resident, with a history of dementia and UTIs, had multiple orders for urine analysis that were not completed, and the physician was not notified. Staff interviews revealed a lack of follow-through on lab orders and communication, contributing to the oversight.
The facility failed to follow physician's orders for oxygen administration for several residents, resulting in incorrect oxygen flow rates and undated tubing. A resident with COPD and lung cancer received higher oxygen flow than prescribed, while another with pneumonia and respiratory failure also received incorrect flow rates. Additionally, two residents had undated oxygen tubing, and one was without oxygen for an extended period due to the concentrator being off.
The facility failed to conduct annual performance reviews for two CNAs, as required. CNA G and CNA H did not have documented performance reviews for the specified periods. The Administrator and ADON admitted that reviews had not been conducted since the current administrator's tenure began, and they were unaware of any previous reviews. Additionally, the facility lacked a policy on annual training, despite the facility assessment outlining required training topics.
The facility failed to limit PRN orders for psychotropic medications to 14 days and did not ensure appropriate diagnoses or attempt gradual dose reductions for several residents. Interviews revealed a lack of clarity and follow-through in managing medication regimen reviews and GDRs, contributing to these deficiencies.
The facility failed to monitor and document refrigerator temperatures for medications, including insulin, as required by policy. Numerous instances of missed documentation and out-of-range temperatures were noted, with no follow-up actions taken. The ADON and Administrator confirmed the night charge nurse was responsible for this task, but the facility did not adhere to its policy.
The facility did not establish written agreements with hospice services for two residents admitted to hospice care. Despite the residents being admitted, the necessary one-time agreements with the hospice providers were not completed. The Administrator confirmed that these agreements were required but not executed.
The facility failed to maintain an effective QAPI program, lacking necessary policies and protocols to identify and correct quality deficiencies. Despite a plan outlining the program's purpose and structure, the facility did not adhere to it, with the last documented QAPI meeting held months prior. The absence of regular QAPI meetings, despite daily QAA meetings, indicates a failure to follow the established plan, potentially affecting all 40 residents.
The facility did not ensure the QAA/QAPI committee developed and implemented a plan to correct quality deficiencies using a PIP. The facility's policy required the QAPI committee to prioritize activities and implement PIPs based on data analysis. However, there was no documentation of PIPs in the QAPI binder. The Administrator was unaware of what a PIP was and confirmed no PIPs had been conducted since her tenure.
The facility did not hold quarterly QAPI meetings with the required members, as the Director of Nursing (DON) position was vacant since November 2023. The facility's policy did not specify the necessary members for the QAPI committee, and the last meeting was held without the DON, leading to non-compliance.
The facility failed to provide the required twelve hours of annual in-service education for two CNAs. CNA G had no documented training from November 2022 to November 2023, while CNA H had incomplete documentation of training topics and durations from September 2022 to September 2023. The facility's assessment highlighted the need for training in areas such as abuse, neglect, and dementia care, but no policy was provided. The Administrator and ADON confirmed the annual training requirement.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions. Review of the cleaning policy showed required cleaning frequencies for kitchen equipment and surfaces, but the August 2025 cleaning schedules documented repeated missed cleanings for daily and weekly tasks. The daily schedule showed counter tops, the steam table, blender/food processor, toaster, and refrigerator were not cleaned on 24 of 25 opportunities, and the weekly schedule showed hoods, filters, trash barrels, garbage disposals, coffee machine, storerooms, drawers, cleaning closet, shelves, ovens, and cupboards were not cleaned on all three opportunities reviewed. Observations of the kitchen showed multiple sanitation and maintenance issues, including a nonfunctioning center reach-in refrigerator and plate warmer, a window air-conditioner with brown buildup on the vents, an ice machine with white grime on exterior and interior surfaces, brown substance on the ventilation louvers, black grime on drain lines, and a floor drain with black grime buildup. The dishwasher had white grime buildup, ceiling diffusers had dust and brown substance buildup, the gas range had oily grime and food debris around each burner, and the dry storage area contained three partially full five-gallon plastic bins of sugar, salt, and oatmeal that were undated and unlabeled. A cracked egg was found inside a case of pasteurized shell eggs in the reach-in refrigerator, and uncovered individual pie desserts were left on a rolling hall cart. During meal preparation, an unidentified dietary aide served food from steam table trays with a facial hair restraint only partially in place, while a refrigeration repairman and a repair mechanic worked in the kitchen without hair restraints. The Dietary Manager stated the large bins should have been dated and not used for multiple foods, the broken egg should have been thrown out, the plate warmer had sparked and was not used again, cleaning logs had not been kept for dietary staff, and the ceiling, vents, dishwasher, ice machine, and stove should have been cleaned but were not. The Administrator and Maintenance Director also acknowledged the kitchen cleanliness issues, the damaged ceiling, the air-conditioning leak, and that outside repair workers should have worn hair restraints in the kitchen.
QAA/QAPI Committee Meetings Not Held With Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility’s census was 41. Review of the QAPI policy dated January 2024 showed the QAPI program consisted of monthly/quarterly meetings, daily quality assurance activities, QAPI tasks, and performance improvement plans, but it did not address the required members of the QAA committee. Review of QAA committee minutes showed that on one occasion the Administrator, Infection Preventionist, Human Resources, a CNA, and an RN attended, with no documentation that the DON or Medical Director attended. On another occasion, the Administrator, DON, SSD, and Human Resources attended, with no documentation that the Infection Preventionist or Medical Director attended. During interview, the Administrator stated the facility had not been consistent with quarterly meetings, had a meeting in June 2025 but could not find the minutes, did not do one in July, and the only other meeting had been in January 2025.
Infection Control Failures During Peri Care, Wound Care, Glucometer Use, and TB Screening
Penalty
Summary
The facility failed to maintain infection control practices during peri care for one resident and during wound care for another resident. During peri care, a CNA entered the room with gloves and a gown, handled a trash can and a bed pan containing urine, placed the bed pan on the floor, and then continued peri care without changing gloves or performing hand hygiene. The CNA later removed the gloves, did not perform hand hygiene, put on new gloves, and continued care before emptying the bed pan into the toilet and finishing with hand hygiene. During wound care for a resident with a coccyx wound and groin skin issues, an RN performed hand hygiene, gathered supplies, and entered the room with gloves and a gown. The RN cleaned the wound, removed gauze from plastic cups, dried the wound, cut calcium alginate with scissors, placed it in the wound bed, wrote on a bordered dressing with a marker from a pocket, and applied the dressing without changing gloves or performing hand hygiene between tasks. The RN also used the same gauze more than once on the groin areas, applied Nystatin powder, and continued care without glove changes or hand hygiene until the end of the procedure. The facility also failed to disinfect a multi-use glucometer according to manufacturer instructions during blood glucose checks for two residents. A CMT cleaned the glucometer for 15 seconds with a Wipes Plus Disinfecting Wipe and placed it on the treatment cart, but did not use an approved wipe per the meter manufacturer’s directions. The report also states the facility failed to correctly screen residents for TB, including one resident with no documentation of a two-step TST on admission, one resident with no documentation of prior TST testing or a symptom assessment for the annual period, and one resident with a first-step TST documented without a result or read date and no second-step TST. In addition, the facility’s IPCP binder contained no documentation of an IPCP program, and interviews with the Administrator, DON, and staff described general expectations for hand hygiene, glove changes, glucometer cleaning, and TB screening.
Incomplete Antibiotic Stewardship and Infection Surveillance Program
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program that included an antibiotic stewardship program with infection surveillance and antibiotic use protocols. Review of the facility’s policies showed requirements for identifying the microbe responsible for disease, documenting the rationale for antibiotic use, dosing, route, duration, discontinuation when no longer needed, and tracking antibiotic use and outcomes, as well as routine surveillance, infection logs, and mapping of infections to identify clusters or trends. However, the Antibiotic Stewardship Program Binder had no documentation for August through December 2024 and February through August 2025, and the January 2025 infection/antibiotic log was incomplete regarding the appropriate indication for antibiotic use. The binder also lacked any maps of infection to identify clusters or trends, and the facility did not document the prescribed antibiotic, appropriate dosing, route, duration of therapy, or lab reports/findings. The facility matrix dated 08/26/25 showed seven residents were receiving antibiotics. During interviews, the DON stated the former MDS Coordinator had been responsible for the antibiotic stewardship and surveillance logs and that the logs had not been updated since that person left in May 2025. The DON said she was not aware of the surveillance log binder and only printed a list of residents on antibiotics for weekly discussion, while the Administrator stated the binder had not been maintained since the former MDS Coordinator/IP left and that the DON was responsible for IP duties even though she was not certified as an IP.
Unqualified Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that at least one person with specialized training in infection prevention and control was responsible for the Infection Preventionist (IP) duties in the nursing home. The facility census was 41. Review of the facility’s Infection Prevention and Control Program policy showed that the facility would designate one or more infection preventionists responsible for the program, and that the IP would have primary professional training in a related field, be qualified by education, training, experience or certification, work at least part-time at the facility, and have completed specialized training in infection prevention and control. Review of the facility’s Infection Prevention and Control Manual for antibiotic stewardship and MDROs showed the IP was responsible for surveillance, infection definitions, education, tracking, data management, analysis of data, communication with the DON, Medical Director, and Consultant Pharmacist, and ongoing system review. The facility did not provide documentation showing any staff member had completed the specialized training required for the IP role. RN M stated he/she had just started the IP role that week and had not started the required training. The DON stated the facility did not have an IP after the previous IP left in May 2025, and that RN M had just taken over the role. The DON also stated she was responsible for the IP duties but was not certified. The Administrator stated she expected the facility to have an IP with the appropriate qualifications and certifications, and that the previous IP had left in May 2025.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for residents. Surveyors observed multiple environmental and maintenance problems across the 500 Hallway, 100 Hallway, and resident rooms, including missing vinyl cove baseboard in a room and the dining room, cracked and peeled shower wall caulk, a missing shower handle, missing ceramic tiles on a shower ramp, a large hole in drywall with exposed insulation, dents in a wall near a bed, and a section of baseboard with a brown substance behind a bathroom door. The facility’s policy required Environmental Services to develop cleaning protocols and perform routine cleaning of resident rooms and areas, and the maintenance log did not document repairs for several of the observed issues. Surveyors also observed a resident room with a strong urine odor on multiple occasions, with urinals hanging from the headboard or left on the nightstand, a bed with a large yellow stain on the sheets, and debris scattered across much of the floor. The resident stated he/she had been waiting for staff to empty the urinal and had spilled urine on the floor and bed, telling staff the bed and sheets were damp. RN staff stated the room should not smell like urine, should not have been left in that condition all day, and should have been checked at least every two hours. Housekeeping staff described routine room checks and cleaning for urine odors, wet mattresses, and debris, but one housekeeper did not remember checking the room that week. Additional observations showed a room with dark paint marks on the white ceiling above dark painted walls, holes around the HVAC unit with buildup inside the vents, and a bathroom toilet with a non-intact caulk bead and brown substance near the base. The resident said he/she was frustrated that the ceiling was not white, that there were holes around the HVAC unit, and that the toilet and floor should be clean. The Administrator and Maintenance Director stated the ceiling should remain white after painting, the toilet and shower caulk should be clean and intact, the shower faucet handle was missing, and the missing cove base and shower ramp tiles should have been documented, but they were not all recorded on the maintenance log.
Failure to Assess and Care Plan PTSD Triggers
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for one resident with PTSD, anxiety, major depressive disorder, dementia, and severe cognitive impairment. The resident’s record showed an admission date of 04/12/24, no trauma informed care assessment, and an August 2025 POS with medications related to PTSD, dementia, depression, and anxiety, including prazosin at bedtime for PTSD, donepezil, trazodone, sertraline, alprazolam, and memantine. The resident’s care plan, dated 04/12/25, noted psychotropic medication use related to PTSD but did not address trauma triggers, past trauma, or behaviors related to triggers. During interviews, the DON stated the care plan should include monitoring, medication assessments, behaviors, depression, safety, the cause of PTSD, and triggers, but she did not know what triggers the resident had. The Administrator said PTSD should be care planned with triggers and interventions, and the MDS Coordinator said the PTSD assessments should have been done and the care plan should have addressed triggers, interventions, and preventions, but the resident’s assessment and care plan did not address PTSD.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. Resident #5, diagnosed with multiple conditions including schizophrenia and cellulitis, did not receive consistent skin assessments and treatments as ordered. Observations revealed that the resident's skin condition worsened, with visible redness, swelling, and open areas on the legs. Despite having orders for specific skin treatments and assessments, there were numerous missed opportunities for care, and the resident's care plan did not address cellulitis or venous insufficiency interventions. Interviews with staff indicated a lack of awareness and documentation regarding the resident's condition and refusals of care. Resident #34, with diagnoses including congestive heart failure and a Stage 4 pressure ulcer, also experienced lapses in care. The resident's treatment orders for wound care were not consistently followed, with missed opportunities for skin assessments and incorrect application of wound care products. Observations showed that the wrong medication was used during wound care, and interviews with staff revealed misunderstandings about the treatments ordered. The facility's failure to adhere to physician's orders for wound care could potentially impact the resident's healing process. Resident #40, diagnosed with Alzheimer's disease, was not weighed weekly as ordered, resulting in missed opportunities to monitor the resident's weight. The resident experienced a significant weight loss over three weeks, but the facility failed to document weekly weights as required. Interviews with staff indicated that the resident was not included on the weekly weight list, and there was a lack of oversight in ensuring the order was followed. The physician expected the weights to be completed as ordered, highlighting a gap in the facility's adherence to care protocols.
Unsafe Resident Transfers Leading to Injury
Penalty
Summary
The facility failed to provide a safe transfer for Resident #23, who had a history of hemiplegia and hemiparesis following a stroke, among other conditions. The resident's care plan required a minimum of two staff for transfers. However, on the day of the incident, a Registered Nurse (RN) attempted to transfer the resident alone using a gait belt. During the transfer, the resident began leaning due to left-sided weakness, and despite the RN's attempt to correct the position, both the RN and the resident fell. The resident sustained a hip fracture and was later admitted to the hospital for surgery. In another incident, the facility failed to safely transfer Resident #8, who had severe cognitive impairment and required substantial assistance for activities of daily living. The resident's care card indicated the need for a mechanical lift with two staff for transfers. However, during an observed transfer, the resident was lifted from a shower chair without a gait belt, and the transfer was conducted by placing arms under the resident's axillary area, which is against the facility's policy. The staff involved were not adequately trained, and the hospice aide led the transfer without proper equipment. Interviews with staff revealed a lack of consistent training and communication regarding transfer procedures. The Assistant Director of Nursing and the Corporate Quality Assurance RN confirmed that the transfers were not conducted safely, as the residents were not transferred using the appropriate equipment or techniques. The facility's failure to adhere to the care plans and policies resulted in unsafe transfer practices for both residents.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours per day, seven days a week, and also failed to have a Director of Nursing (DON) in place. This deficiency had the potential to affect all residents, with a census of 40. The facility's assessment indicated that the DON should work five days a week for eight hours, and licensed nurses should include an RN for eight hours per day when the DON is not available and on weekends. However, the facility's daily nursing staffing sheets revealed multiple days without RN coverage, with 19 out of 102 opportunities missed between April and July 2024. Interviews with facility staff, including the Administrator and the Assistant Director of Nursing (ADON), confirmed the absence of a DON since November 2023 and the reliance on agency staff to fill RN coverage gaps. The facility's current staff list showed only one RN as a floor nurse, with the ADON and Minimum Data Set (MDS) Coordinator being Licensed Practical Nurses (LPNs). The Administrator acknowledged the lack of a DON and the challenges in maintaining consistent RN coverage, despite efforts to use agency staff to address the issue.
Lack of Hospital Transfer Agreements
Penalty
Summary
The facility failed to ensure that written transfer agreements with hospitals were in place to guarantee timely hospital admissions for residents when medically necessary. This deficiency was identified through interviews and record reviews, revealing that the facility did not have any transfer agreements with hospitals, nor could they provide a policy on transfer agreements. During an interview, the Administrator and the Assistant Director of Nursing (ADON) acknowledged that the corporate Quality Assurance Registered Nurse was unable to locate any transfer agreements with hospitals. The Administrator admitted to having no knowledge of any existing transfer agreements. This oversight had the potential to affect all 40 residents of the facility.
Failure to Notify State Agency of DON Changes
Penalty
Summary
The facility failed to notify the State agency responsible for licensing about changes in their Director of Nursing (DON) position. The facility's assessment indicated that the DON should work five days a week for eight hours, and a Registered Nurse (RN) should cover when the DON is unavailable. However, records showed that RN I was hired as the DON in June 2022 and terminated in May 2023, while RN J was hired in November 2023 and terminated in December 2023. The last documented change of DON form was from July 2022, indicating RN I's employment. Nursing schedules from April to July 2024 showed no documentation of a DON being scheduled or working, with 107 days missed. During an interview, the Administrator confirmed that the facility had not had a DON since November 2023.
Failure to Provide Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to residents, their responsible parties, and the Office of the Long-Term Care (LTC) Ombudsman for six residents. These residents were transferred to the hospital on various dates, but there was no documentation of the required written notifications. The facility also did not have a transfer or discharge policy in place. This deficiency affected all six sampled residents, with the facility census being 40. Interviews revealed that the Ombudsman had not received transfer logs from the facility since April 2024. The Administrator acknowledged that it was her responsibility to send these logs monthly, but this had not been done. The Assistant Director of Nursing (ADON) and the Administrator stated that they expected transfer and discharge notices to be given for each hospital transfer/discharge, with the charge nurse responsible for ensuring this. However, there was no clear accountability, as management was supposed to check on these notices, but it was not assigned to a specific individual.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents and/or their representatives at the time of transfer to a hospital for six residents. This deficiency was identified through interviews and record reviews, revealing that none of the sampled residents received the required documentation. The facility census was 40, and the affected residents were transferred to the hospital on various dates without the necessary bed-hold policy notification. During an interview, the Assistant Director of Nursing and the Administrator acknowledged the expectation that bed-hold policies should be given for each hospital transfer or discharge. They indicated that the charge nurse responsible for transferring or discharging the resident should ensure the policy is provided. However, it was noted that there was no clear accountability, as management expected the policies to be placed under office doors and checked, but it was not solely one person's responsibility to ensure completion.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure that staff reconciled narcotics at each shift change for three out of three medication carts, potentially affecting all residents. The facility's policy required that all Schedule II-V medications be counted at every change of shift by two Certified Medication Technicians (CMT) or one CMT and one licensed nursing staff, with both personnel signing verification of the correct count. However, a review of the narcotic count logs for the 100/200, 300/400, and 500 Hall Nurse carts revealed numerous missed opportunities for reconciliation over several months, with many instances of no documentation of the narcotic reconciliation being completed. Interviews with staff, including a CMT and the Assistant Director of Nursing (ADON), confirmed that the expected practice was for the off-going and on-coming staff to complete the narcotic count and sign the log. The ADON stated that the narcotic counts should be completed at the beginning and end of each shift and any other time there was a change in the involved staff. Despite these expectations, the logs showed significant non-compliance with the policy, indicating a systemic issue in the reconciliation process.
Deficiencies in Infection Control and Documentation
Penalty
Summary
The facility failed to provide appropriate documentation of tuberculosis (TB) testing for four residents out of five sampled. This included missing annual screenings, improper timing between test administration and reading, and lack of documentation for two-step testing. These deficiencies indicate a lack of adherence to the guidelines for TB testing and documentation as required by the Missouri Department of Health and the facility's own policies. The facility also failed to perform proper hand hygiene and glove changes during wound care and incontinent care. In one instance, an LPN did not change gloves or perform hand hygiene when transitioning from dirty to clean care during wound treatment for a resident with a coccyx wound. Similarly, during incontinent care for another resident, CNAs did not change gloves or perform hand hygiene when moving from dirty to clean tasks, leading to potential cross-contamination. Additionally, the facility lacked a water management program to monitor for Legionella bacteria, which could affect all residents, staff, and the public. The Maintenance Supervisor was unaware of such a program and only checked water temperatures in random rooms. Furthermore, the facility's Infection Prevention and Control Program (IPCP) was outdated, lacking an annual review, and missing critical information such as pathogen names and lab results in the antibiotic stewardship logs.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to consistently document the code status for a resident, leading to a discrepancy in the resident's medical records. The resident's care plan and face sheet indicated a Do Not Resuscitate (DNR) status, while the Physician's Order Sheet showed a full code status. Additionally, the Medication Administration Record (MAR) included a red DNR code sheet, which was meant to indicate the resident's DNR status. This inconsistency in documentation could lead to confusion among staff regarding the resident's wishes in the event of a medical emergency. Interviews with the resident and facility staff revealed that the resident had discussed and decided on a DNR status with their family. However, the facility did not have a policy regarding a resident's code status, and staff relied on color-coded sheets in the MAR and physician's orders to determine a resident's code status. The Assistant Director of Nursing explained that red sheets indicated DNR, green sheets indicated full code, and purple sheets could show either status. Despite these systems, the documentation did not consistently reflect the resident's chosen code status, highlighting a gap in the facility's record-keeping practices.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by the poor condition of shower rooms and wheelchairs. Observations revealed that the 500 Hall shower room had an elevated tiled shower base and discolored caulking, while the 300 Hall shower room had missing tiles, an unattached fiberglass shower unit, and missing ceramic tile base sections. Interviews with staff indicated that these issues had been reported verbally but were not documented in the maintenance logs, and there were no plans to repair the damage despite the showers being used by residents. The facility also failed to clean and repair wheelchairs for several residents. Observations showed that Resident #22's wheelchair was dirty, with stained and pilled arm wraps and a seat cushion hanging over the edge. Resident #20's wheelchair had cracks and splits, and was dirty with food and debris. Resident #9's wheelchair was missing an armrest, and Resident #6's wheelchair had exposed foam fill on the armrests. Interviews with staff revealed a lack of awareness and documentation regarding the cleaning and maintenance of wheelchairs, with some staff unsure of the procedures and others indicating that repairs were reported verbally but not documented. The Maintenance Director and Administrator acknowledged the issues but cited a lack of funds for new wheelchairs, although the Corporate QA RN stated that funds were available. The maintenance logs did not document any repair concerns for the shower rooms or wheelchairs, and there was no documentation of when wheelchairs were cleaned. The facility's failure to address these issues resulted in a deficiency in providing a safe and homelike environment for residents.
Failure to Assess and Document Use of Bed and Chair Alarms
Penalty
Summary
The facility failed to properly assess and document the use of bed and chair alarms for a resident diagnosed with Alzheimer's Disease, altered mental status, and osteoporosis. The resident, who required assistance for toileting and was dependent for most activities of daily living, experienced multiple falls, some unwitnessed, over a period of time. Despite these incidents, there was no documentation of a physician's order for the bed and chair alarms, nor was there an assessment conducted to determine if these alarms were being used as restraints. Observations revealed that the resident was unable to remove the bed and chair alarms, indicating a potential restraint use. The facility's policy required documentation of the date and time the alarms were ordered, the type of restraint, reasons for use, and the resident's response, none of which were completed. Interviews with facility staff, including the MDS Coordinator and the Administrator, confirmed that assessments and monitoring of the alarms were not conducted as expected, and there was a lack of physician's orders for the alarms.
Failure to Update Care Plan for Resident with Recurrent Falls and UTIs
Penalty
Summary
The facility failed to update and revise care plans with specific interventions tailored to meet the individual needs of a resident, identified as Resident #22. The resident, who was admitted with diagnoses including dementia, dysuria, muscle weakness, repeated falls, and urinary tract infections (UTIs), experienced multiple falls and incidents that were not adequately addressed in the care plan. Despite the resident's recurrent falls and UTIs, the care plan had not been updated with new interventions since November of the previous year. The resident's medical records and nurses' notes documented numerous falls and incidents, including unwitnessed falls, falls from a wheelchair, and skin tears, yet the care plan did not reflect any new strategies to mitigate these risks. Observations showed that the resident's wheelchair cushion was improperly positioned, and there was no mention of nonskid footwear or assessments for UTIs, which were contributing factors to the resident's condition. The facility's policy required ongoing assessment and revision of care plans as changes occurred in the resident's condition, but this was not adhered to. Interviews with facility staff, including the Minimum Data Set (MDS) Coordinator and the Assistant Director of Nursing (ADON), revealed an expectation that the care plan should have been updated to address the resident's falls and recurrent UTIs. However, the responsibility for updating the care plans was not effectively executed, leading to a deficiency in the care provided to the resident.
Failure to Obtain Timely Urine Specimens Leads to Emergency Room Visit
Penalty
Summary
The facility failed to obtain timely urine specimens for a resident who exhibited symptoms of a urinary tract infection (UTI) and did not notify the physician when the specimens were not collected. This oversight resulted in the resident being sent to the emergency room. The resident, who had a history of dementia, dysuria, muscle weakness, repeated falls, and UTIs, had orders for urine analysis (UA) with culture and sensitivity (C&S) on multiple occasions, specifically on 03/19/24, 05/07/24, and 06/01/24. However, there was no documentation of completed UA lab results for these dates, nor was there any notification to the physician about the uncompleted orders. Interviews with facility staff revealed a lack of follow-through on lab orders and communication with the physician. The Assistant Director of Nursing (ADON) acknowledged that a specimen collected on 05/07/24 was rejected due to incorrect labeling, and no subsequent specimen was collected. The ADON also admitted that it was the nursing staff's responsibility to follow up on lab orders and results, which did not occur in this case. The physician expressed an expectation for the facility to follow orders and be notified if they were not completed. The failure to collect and process the urine specimens as ordered led to the resident's emergency room visit and subsequent diagnosis of a UTI.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen administration for three residents, resulting in discrepancies in the oxygen flow rates. Resident #6, diagnosed with COPD and lung cancer, was observed receiving oxygen at higher flow rates than the prescribed 3 liters per minute (LPM). Despite the resident's awareness of the correct setting, the oxygen flow was consistently higher, reaching up to 5 LPM. Similarly, Resident #36, with diagnoses including pneumonia and respiratory failure, was observed receiving oxygen at 4 LPM and 3.5 LPM, contrary to the physician's order of 2 LPM. Additionally, the facility did not ensure that oxygen tubing was dated when changed for two residents. Resident #195, with pneumonia and atherosclerotic heart disease, was observed with undated oxygen tubing and a nasal cannula that was improperly stored. The resident's portable oxygen tubing was also undated and not stored in a sealed container. Resident #245, with multiple diagnoses including COPD and heart failure, was observed with undated oxygen tubing and a humidifier. The resident was also found without oxygen for an extended period due to the concentrator being turned off, despite having orders for continuous oxygen. The facility's policy on oxygen administration was not followed, as evidenced by the lack of adherence to prescribed oxygen flow rates and the failure to date oxygen tubing. These deficiencies were observed during multiple instances and interviews with the residents confirmed the discrepancies between the prescribed and administered oxygen settings. The facility's failure to comply with its own policy and physician orders resulted in inadequate respiratory care for the affected residents.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Assistants (CNAs), identified as CNA G and CNA H, received their annual performance reviews. This deficiency was identified through interviews and record reviews. CNA G, who was hired on November 8, 2022, had no documentation of an annual performance review in their employee file for the period from November 8, 2022, to November 8, 2023. Similarly, CNA H, hired on September 5, 2019, also lacked documentation of an annual performance review for the period from September 5, 2022, to September 5, 2023. During an interview, the Administrator and Assistant Director of Nursing (ADON) acknowledged that annual performance reviews for CNAs should have been conducted, but none had been done since the current administrator started, and they were unaware of any previous reviews or their locations. Additionally, the facility did not provide a policy regarding annual training, despite the facility assessment dated March 7, 2024, indicating that staff competencies and annual training requirements should include topics such as Abuse, Neglect, Exploitation and Misappropriation, Care/Management for persons with dementia, Infection Control, Culture change, Person-centered care, Disaster planning, Communication, and Resident rights.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the use of psychotropic medications for several residents. Specifically, the facility did not limit the use of PRN orders for psychotropic medications to 14 days for two residents, and did not ensure an appropriate diagnosis or attempt a gradual dose reduction (GDR) for three residents. Resident #3 had a PRN order for lorazepam without a 14-day stop date, and Resident #33 also had a similar order without a stop date, along with an inappropriate diagnosis for quetiapine. Resident #5 had multiple psychotropic medications prescribed without a documented GDR evaluation since December 2022. Resident #31 had several psychotropic medications prescribed, but there was no documentation of GDR attempts or responses to pharmacy consultant recommendations. Interviews with facility staff revealed a lack of clarity and follow-through in the process of managing medication regimen reviews (MRRs) and GDRs. The Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) nurse were responsible for handling MRRs, but there was uncertainty about when GDRs should be completed. The Administrator acknowledged that MRRs were sent to physicians, but responses were not always received, and there was no effective system in place to ensure follow-up. This lack of coordination and oversight contributed to the deficiencies in managing psychotropic medication use in the facility.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to properly monitor refrigerator temperatures for stored medications, including insulin, which is used to treat diabetes. This deficiency was identified through interviews and record reviews, revealing that the facility did not consistently document refrigerator temperatures as required by their policy. The policy mandates that all refrigerators used for resident medication must be checked daily, with temperatures logged in a binder at the nurse's station. However, numerous instances of missed documentation were noted across several months, with significant gaps in April, May, June, and early July. Additionally, there were instances where recorded temperatures were outside the acceptable range of 36 - 42 degrees, specifically on July 1st and July 4th, without appropriate follow-up actions being taken. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that the responsibility for checking and documenting refrigerator temperatures fell to the night charge nurse, with the ADON overseeing the logs. Despite this, the facility did not adhere to its policy, as evidenced by the lack of documentation and failure to address out-of-range temperatures. This oversight had the potential to affect all residents, given the importance of maintaining proper storage conditions for medications like insulin.
Failure to Establish Hospice Agreements
Penalty
Summary
The facility failed to establish a written agreement with hospice services for two residents out of eight sampled, despite both being admitted to hospice care. Resident #3 was admitted to hospice services on April 5, 2024, and Resident #33 on March 19, 2023. However, the facility did not provide hospice agreements with the respective hospice service providers for these residents. During an interview, the Administrator acknowledged that the facility typically completed one-time agreements with hospice providers that were not the primary company used by the facility. In these cases, the necessary one-time agreements were not completed upon the residents' admission to the hospice program.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the absence of policies and protocols necessary to identify and correct quality deficiencies. The facility's QAPI plan, dated September 2022, outlined the purpose and structure of the program, including the establishment of performance indicators and regular reporting by the QAPI Steering Committee. However, a review of the facility's QAPI binder revealed that the facility did not adhere to its own plan, as it lacked documentation of necessary policies and protocols for tracking and measuring performance, as well as setting goals and thresholds for performance measurement. The last documented QAPI meeting occurred several months prior, and the facility had not conducted any subsequent meetings, despite the requirement for quarterly meetings. During an interview, the Administrator confirmed that the last QAPI meeting was held in February, and acknowledged that the facility had not held any since. Although Quality Assurance and Assessment (QAA) meetings were reportedly conducted daily with department heads, the absence of regular QAPI meetings indicates a failure to follow the established plan, potentially affecting all 40 residents in the facility.
Failure to Implement Performance Improvement Projects
Penalty
Summary
The facility failed to ensure that the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies using a Performance Improvement Project (PIP). The facility's policy, dated September 2022, outlined that the QAPI committee should prioritize activities, endorse policies, and monitor improvements through a self-assessment. It also stated that the QAPI Steering Committee should implement PIP topics indicated by data analysis. However, a review of the QAPI binder showed no documentation of the required PIP documentation. During an interview, the Administrator admitted to not knowing what a PIP was and confirmed that no PIPs had been conducted since she became the administrator, with no documentation of previous PIPs available.
QAPI Committee Membership Deficiency
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's policy, dated September 2022, did not specify the necessary members for the QAPI committee. A review of the QAPI attendance sheets from February 21, 2024, revealed that the Director of Nursing (DON) did not attend the meeting. During an interview, the Administrator confirmed that the last QAPI meeting was held on February 21, 2024, and acknowledged the absence of a DON since November 2023. The QAPI committee required the DON to be a member, but the position had been vacant, leading to non-compliance with the committee's membership requirements.
Deficiency in Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of annual in-service education for two Certified Nurse Assistants (CNAs), identified as CNA G and CNA H, as required by regulatory authorities and facility policy. CNA G, hired on November 8, 2022, had no documentation of any annual in-service training from November 2022 through November 2023. CNA H, hired on September 5, 2019, had documentation of eight topics covered in annual in-service training from September 2022 through September 2023, but there was no record of the duration of each training session. The facility's assessment, dated March 7, 2024, outlined the need for staff competencies and annual training in areas such as abuse, neglect, dementia care, and infection control, but the facility did not provide a policy regarding these annual training requirements. During an interview, the Administrator and Assistant Director of Nursing confirmed that aides should receive 12 hours of training annually, including specific topics like abuse, neglect, and dementia 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 12 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 Doniphan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corning Therapy And Living Center | 19.5 mi | ★★★★★ | 5 | 0 |
| Westwood Hills Health & Rehabilitation Center | 22.3 mi | ★★★★★ | 6 | 0 |
| Cedargate Health Care Center | 24 mi | ★★★★★ | 1 | 0 |
| Manor, The | 24.9 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Poplar Bluff | 25 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.