Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Hubble Creek during CMS and state inspections, most recent first.
Failure to provide required abuse and neglect training for three CNAs and one LPN was identified during record review and interview. Employee files showed no documentation of the required in-service training, and one CNA stated he/she did not remember receiving it. The Administrator said staff had only recently been signed up for the contracted training company, while the Administrator and DON stated nursing staff should have abuse/neglect training upon hire and before working with residents.
Failure to Obtain Informed Consent for Psychotropic Medications: Multiple residents with diagnoses including dementia, anxiety, depression, bipolar disorder, schizoaffective disorder, and Alzheimer's disease had orders for psychotropic medications such as antipsychotics, antidepressants, mood stabilizers, and anxiolytics, but their records lacked documentation of consent or education about risks and benefits. The CCO stated psychotropic medication consent forms had been discussed but not yet initiated, and the DON said residents or their representatives would be expected to receive informed consents.
Failure to provide adequate supervision on a locked unit: a CNA left residents unsupervised in the dining area while bringing them in one at a time, and an unlabeled bucket of bleach water was left in the dining room and used on residents' hands, causing two residents to complain of burning. Staff also left the unit without coverage, including a period when no staff were present and another when the dining room was left unattended while a CNA assisted a resident in a room. The unit housed cognitively impaired residents with Alzheimer's disease and/or dementia who needed increased monitoring.
A resident with Alzheimer’s disease, dementia with mood disturbance, and depression missed multiple doses of ordered Seroquel, buspirone, and memantine. MARs and progress notes showed the meds were repeatedly documented as out, on order, unavailable, or waiting on pharmacy, while an LPN, DON, and pharmacist described inconsistent use of the locked med supply and repeated ordering issues.
Expired and undated medications and biologicals were found in a medication cart and the medication room, including a resident’s hydralazine and furosemide, multiple expired OTC and prescription items, and opened multidose vials without dates. One resident also received an expired dose of furosemide, and staff reported there was no scheduled process for checking carts and storage areas for expired medications.
Infection control precautions were not followed during care for a resident with a Foley catheter and EBP. Two CNAs entered with gloves but no hand hygiene or gowns, performed catheter and incontinent care without changing gloves or cleaning hands between dirty and clean tasks, and cleaned the catheter toward the insertion site. During lunch service, a CNA used the same rag from a bucket of soapy water to wash multiple residents’ hands, reusing the rag between residents.
The facility failed to maintain a safe, clean, and homelike environment, affecting all residents. Observations showed holes and missing drywall in several rooms, with one resident noting the damage had been present for months. The Maintenance Director relied on verbal reports for repairs, and the Administrator expected the building to be in good repair.
The facility failed to provide timely written notification to two residents and/or their representatives regarding transfers to the hospital. Despite policy requirements, no documentation of transfer notices was found for these residents. Interviews with the DON and Administrator confirmed the absence of these notices.
The facility failed to inform two residents and/or their representatives of the bed hold policy in writing during hospital transfers. This was identified in a sample of five residents, with the facility's census at 45. Interviews with the DON and Administrator revealed missing documentation of the policy prior to their tenure, despite expectations that it should be provided during transfers.
The facility failed to maintain safe water temperatures, with several rooms and showers exceeding the safe range of 105 to 120 degrees Fahrenheit, posing a burn risk to residents. Observations showed inconsistent thermometer readings, and interviews revealed reports of scalding and cold water. Despite recent adjustments by a plumber, the facility did not have a policy for water temperatures, leading to potential hazards for all residents.
The facility failed to date oxygen tubing for a resident with COPD and lacked a physician's order for BIPAP use for another resident with acute respiratory failure. Observations showed undated tubing and BIPAP use without an order, indicating lapses in policy adherence and documentation.
The facility failed to ensure that two nurse aides completed their training within four months of employment. Both aides were enrolled in an online program but did not finish within the required timeframe. The DON believed they had completed the program and were awaiting test permission, while the Administrator expected timely completion. This issue potentially affected all 45 residents.
The facility did not conduct annual performance reviews or provide in-service training for two CNAs, CNA D and CNA E, as required. The Administrator confirmed that no reviews or evaluations had been conducted since her start in May 2024, and there was no documentation of prior reviews. The facility also lacked a policy on CNA performance review and training requirements.
A resident was prescribed olanzapine, an antipsychotic medication, for insomnia, which is not an appropriate diagnosis according to the facility's policy. The resident's medical record lacked documentation for an appropriate diagnosis, and the pharmacist's monthly Medication Regimen Review did not address this issue. Both the DON and the pharmacist confirmed that insomnia is not a suitable diagnosis for antipsychotic use.
The facility had a medication error rate of 6.25% due to improper insulin pen priming by an RN, affecting two residents. The RN did not follow the manufacturer's guidelines for insulin aspart administration, believing priming was only needed initially. The facility lacked a medication error policy.
The facility failed to maintain sanitary conditions in the 400 Hall unit refrigerator, which was observed at 50°F, above the required 40°F. Unlabeled and undated food items were found, posing a risk of cross-contamination. Staff interviews revealed inconsistent monitoring and documentation of refrigerator temperatures, affecting 13 residents served from this refrigerator.
The facility failed to include an Infection Preventionist (IP) in its Quality Assessment and Assurance (QAA) committee meetings, as required. The IP did not attend the September 2024 meeting due to working as a charge nurse on the night shift. The facility also lacked a policy for the QAA Committee and did not provide attendance records prior to September 2024, potentially affecting all 45 residents.
The facility did not enforce the use of facemasks among staff during a COVID-19 outbreak, as observed with LPNs, CMTs, and RNs not wearing masks in common areas and resident rooms. There were no signs indicating outbreak status or isolation requirements, and staff interviews revealed a lack of communication about mask-wearing protocols. The DON confirmed that masks were only required in isolation rooms, contrary to CDC guidelines.
The facility failed to provide the required twelve hours of annual in-service education, including Dementia Care training, for two CNAs. The CNAs did not meet the training requirements for the period from February 2023 through February 2024. The facility lacked a policy on nurse aide training requirements, and the new DON was working to address the training deficiencies.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to provide abuse and neglect training for three CNAs and one LPN of four sampled staff hired since September 2025. Review of the facility policy titled, In-Service Training, All Staff, dated 2001, showed that required training topics include preventing abuse, neglect, exploitation, and misappropriation of resident property, and that completed training is to be documented by the staff development coordinator or designee. Review of employee files showed no documentation of abuse/neglect training for CNA B, CNA H, CNA I, and LPN D. CNA B stated during interview that he/she did not remember receiving abuse/neglect training since being employed at the facility. The Administrator stated the facility had just gotten all staff signed up through the contracted training company the prior week so staff could complete required trainings, and the Administrator and DON stated they would expect all nursing staff to have abuse/neglect training upon hire and before working with residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
Residents were not fully informed and did not have documented consent or refusal for psychotropic medications before those medications were used. Based on interview and record review, the facility failed to provide psychotropic medication consents for seven sampled residents and one additional resident outside the sample. The facility policy titled, Psychotropic Medication Use, required staff and the physician to review non-pharmacological alternatives, the indications and rationale, the potential risks and benefits, and the resident's or representative's right to accept or decline treatment before obtaining documented consent or refusal. Resident #1 had diagnoses including dementia with behavioral disturbance, dementia with agitation, anxiety, insomnia, restlessness, and agitation, and had orders for divalproex sodium ER, melatonin, donepezil ER, mirtazapine, and quetiapine, but there was no documentation of consent or education regarding risks and benefits. Resident #2 had diagnoses of dementia with agitation, anxiety, mood disturbance, and depression, and had orders for olanzapine and escitalopram, with no documentation of consent or education. Resident #4 had a diagnosis of dementia and orders for risperidone and quetiapine, and Resident #6 had diagnoses of anxiety disorder, auditory hallucinations, schizoaffective disorder, and unspecified intellectual disability with an order for Seroquel 300 mg; neither record contained documentation of consent or education. Resident #12 had diagnoses of Alzheimer's disease, dementia with mood disturbance, and depression, and had orders for citalopram, Seroquel, and buspirone without documented consent or education. Resident #13 had diagnoses of unspecified mood disorder, bipolar disorder, generalized anxiety disorder, and unspecified dementia without behavioral disturbance, and had an order for aripiprazole with no documentation of consent or education. Resident #35 had diagnoses of Alzheimer's disease with late onset, anxiety disorder, and dementia with mood disturbance, and had an order for quetiapine without documentation of consent or education. Resident #64 had diagnoses of dementia with agitation and insomnia and multiple orders including haloperidol in several forms, sertraline, memantine, morphine, and ondansetron; the record did not contain documentation of consent or education for the psychotropic medication use. During interview, the Corporate Compliance Officer stated psychotropic medication consent forms had been discussed but not yet initiated, and the Administrator and DON stated they would expect residents or their representatives to be given informed consents for psychotropic medications.
Failure to Provide Adequate Supervision on Locked Unit
Penalty
Summary
The facility failed to provide adequate supervision when residents on a locked unit were left unattended with an unlabeled bucket of an unknown liquid substance that smelled strongly of bleach. The unit housed 14 cognitively impaired residents with diagnoses of Alzheimer's disease and/or dementia who exhibited behaviors and needed increased monitoring. During observation, a CNA brought residents to the dining room one at a time and left those already in the dining room unsupervised while going to get the next resident. A cart in the dining room held 15 uncovered cups and an unlabeled bucket containing the unknown liquid, and residents passed by the cart without staff monitoring. On another observation, a CNA used the rag from the bucket to wash residents' hands, and two residents complained that their hands were burning. The CNA stated he/she did not know what was in the bucket and thought it was soap and water, while the DSM identified it as bleach water used for wiping tables and said it was not supposed to be used on residents' skin. The facility also failed to provide adequate supervision on the locked unit when staff were not present with the residents. Observation showed no staff on the unit at one point, and during lunch preparation the CNA attempted to redirect residents while they repeatedly got up and walked away from the dining room tables. The CNA stated the facility regularly staffed only one CNA on the locked unit and that it was very difficult to monitor all residents while providing care to one resident in a room. The CNA also stated help from float staff was inconsistent. Another observation showed the dining room left unsupervised for four minutes while the CNA assisted a resident to the bathroom in the resident's room. The DON stated there was usually one staff member assigned to the locked unit, that staff should always be on the unit with the residents, and that if the unit staff member needed a break, another staff member was expected to take over before leaving.
Failure to Provide Ordered Medications
Penalty
Summary
The facility failed to provide routine and emergency medications and biologicals for one resident, who had diagnoses of Alzheimer’s disease, dementia with mood disturbance, and depression. The resident had orders for Seroquel 25 mg 0.5 tablet twice daily, buspirone 5 mg twice daily, and memantine 5 mg twice daily. Review of the MAR showed multiple missed doses of these medications over several dates, including missed Seroquel doses in November and December, missed buspirone doses in November and January, and missed memantine doses in January. Progress notes documented that the medications were repeatedly noted as “on order,” “out,” “unavailable,” or “waiting on pharmacy” during the same periods when doses were missed. The notes also showed repeated ordering activity for Seroquel, buspirone, and memantine across November, December, January, and February. The facility policy stated that medications needing refills must be reordered at least three days before the last dose is administered, and that medications without a specified duration or number of doses are subject to automatic stop orders. During interviews, an LPN stated that if a medication was not in the cart, staff could check a locked medication stock supply, but the paper list might not be accurate and he/she did not rely on it. The DON stated medications should be ordered before they ran out and that the pharmacy delivered daily except on weekends, but did not know the next step if the stock supply did not work. The pharmacist stated the pharmacy did daily deliveries, had an on-call pharmacist, and that the facility had a locked medication supply that could be used; the pharmacist also stated there should be no reason for the facility to document the resident’s medications as not administered because they were out or on order.
Expired and Undated Medications Found in Cart and Medication Room
Penalty
Summary
Drugs and biologicals were not labeled and stored according to accepted practices in one medication cart and one medication storage room. On the 100 Hall medication cart, hydralazine 25 mg for Resident #39 was found expired on 06/30/25, and furosemide 20 mg PRN for Resident #9 was found expired on 07/08/25. Resident #9’s MAR showed one dose of furosemide was administered on 02/01/26, 177 days after the expiration date, and the record contained no documentation of an adverse reaction to that dose. In the medication room, surveyors found multiple expired items, including vitamins, antacid, wound care powder, thiamine, zinc, bisacodyl, Resident #37’s divalproex 500 mg delayed release, Resident #58’s cholecalciferol, and discharged residents’ amiodarone and pantoprazole with no expiration dates. Resident #19’s lorazepam open bottle was undated, and several multidose vials of Afluria and stock Aplisol were opened and undated, with some expired. Staff interviews showed there was no scheduled process for checking carts and the medication room for expired medications, and the DON stated staff checked medications when they could rather than on a set schedule.
Infection Control Failures During Catheter Care and Meal Service
Penalty
Summary
The facility failed to follow infection control precautions for a resident with a Foley catheter and enhanced barrier precautions (EBP). Resident #54 had diagnoses of neuromuscular dysfunction of the bladder and obstructive and reflux uropathy, with orders for monthly catheter changes, catheter care every shift, and EBP related to the Foley catheter. During observation of incontinent and catheter care, two CNAs entered the room with gloves on but did not perform hand hygiene, and they did not put on gowns despite EBP signage and PPE being present on the door. One CNA cleaned the resident’s front peri area without changing gloves or performing hand hygiene, and the other CNA cleaned the buttocks and rectal area, changed gloves, and did not perform hand hygiene. The same observation showed additional breaks in infection control during catheter care and resident care activities. The CNAs changed bed linens, rolled the resident side-to-side, and one CNA cleaned the catheter insertion site and then wiped the catheter toward the insertion site rather than away from the body. Gloves were not changed and hand hygiene was not performed between dirty and clean tasks. One CNA exited the room with bagged trash and soiled linens while still wearing gloves, and the other CNA adjusted the blanket, hung the catheter bag on the bedframe, picked up the resident’s cup, re-entered the room with the cup of ice, poured tea, and placed the lid on the cup without changing gloves or performing hand hygiene. The facility also failed to use proper infection control technique during lunch service in the main dining room. On multiple observations over three days, a CNA washed residents’ hands with the same rag taken from a bucket of soapy water and reused that same rag for multiple residents, placing it back into the bucket between residents. The CNA stated that the same rag was used on each resident and washed in the bucket between residents. Facility leadership later stated that it was not appropriate for staff to use the same rag to clean multiple residents’ hands.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment, which had the potential to affect all 45 residents. Observations revealed multiple deficiencies in the physical environment. In one room, there was a one-foot by six-inch hole in the drywall on the right side of the window. Another room had several issues, including a three-inch by six-inch hole in the drywall at the foot of the bed, a similar-sized hole under the bathroom sink, missing drywall exposing metal corner mold by the bathroom door, and multiple scraped areas along the wall by the room exit door. A resident in this room mentioned that the walls had been in this condition for at least a few months. Additionally, a two-foot missing section of base cove was observed around the corner of another room. The Maintenance Director indicated that repairs were typically communicated verbally rather than through formal documentation, and the Administrator expected the building to be in good repair.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and/or their representatives regarding facility-initiated transfers to the hospital. This deficiency was identified for two residents out of a sample of five. Resident #6 was transferred to the hospital on April 9, 2024, and readmitted to the facility later, but there was no documentation of written notification to the resident or their representative about the transfer. Similarly, Resident #30 was transferred to the hospital on March 8, 2024, and readmitted later, with no written notification documented. The facility's policy requires a signed transfer or discharge notice to be given to the resident and/or their representative, with allowances for emergency transfers to be documented as soon as possible. Interviews with the Director of Nursing and the Administrator confirmed the absence of these notices, which they acknowledged should have been provided.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform two residents and/or their representatives of the bed hold policy in writing at the time of their transfer to the hospital. This deficiency was identified during a review of the medical records of two residents out of a sample of five, with the facility's census being 45. Resident #6 was transferred to the hospital on April 9, 2024, and readmitted to the facility on an unspecified date, with no documentation indicating that the bed hold policy was communicated in writing. Similarly, Resident #30 was transferred on March 8, 2024, and readmitted on an unspecified date, also lacking documentation of written notification of the bed hold policy. Interviews with the Director of Nursing and the Administrator revealed that the bed hold policies prior to their tenure were not found, and the Administrator expected that such policies should be provided during hospital transfers.
Unsafe Water Temperatures Pose Burn Risk
Penalty
Summary
The facility failed to maintain safe water temperatures in resident rooms and community showers, posing a risk of burns to residents. Observations revealed that water temperatures in several rooms and showers exceeded the safe range of 105 to 120 degrees Fahrenheit, with some readings as high as 141 degrees Fahrenheit. The facility did not have a policy regarding water temperatures, and the mechanical rooms showed inconsistent thermometer readings, indicating a lack of proper monitoring and control of water temperatures. Interviews with staff and residents highlighted the inconsistency in water temperatures, with one resident reporting scalding hot water and another reporting cold water. The Maintenance Supervisor mentioned that a plumber had recently adjusted the water heater settings, but the temperatures remained outside the expected range. The Administrator acknowledged the expectation for water temperatures to be maintained within the safe range, yet the facility failed to ensure this, leading to a potential hazard for all residents.
Deficiencies in Oxygen Administration and Documentation
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen administration and documentation. For one resident with chronic obstructive pulmonary disease and chronic kidney disease, the facility did not date the oxygen tubing as required by their policy. Observations on two separate occasions showed the resident using oxygen at 2 liters per minute via nasal cannula, but the tubing was not dated. The resident was unsure when the tubing was last changed, indicating a lapse in adherence to the facility's policy on oxygen equipment maintenance. For another resident with acute respiratory failure, heart failure, and chronic kidney disease, the facility did not have a physician's order for the use of a BIPAP machine with oxygen. The resident's care plan did not address the BIPAP, and observations showed the resident using the BIPAP with oxygen bled in, but without a corresponding order. Interviews with nursing staff and the Director of Nursing revealed that there was an expectation for an order specifying the BIPAP settings, which was not present, indicating a failure to follow physician orders and ensure proper documentation.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that two nurse aides, who were employed for more than four months, completed a nurse aide training program within the required timeframe. Nurse Aide B was hired on June 12, 2024, and Nurse Aide C was hired on June 25, 2024. Both were enrolled in an online nurse aide program but did not complete it within four months of their hire dates. During interviews, the Director of Nursing mentioned that the nurse aides were taking the training online and believed they had completed the program but were waiting for permission to take their tests. The Administrator expected the nurse aides to complete the training within the specified period. This deficiency had the potential to affect all 45 residents in the facility.
Failure to Conduct CNA Performance Reviews and Training
Penalty
Summary
The facility failed to conduct annual individual performance reviews or evaluations and did not provide annual in-service training based on the outcomes of these reviews for two Certified Nurse Assistants (CNAs), identified as CNA D and CNA E. CNA D, hired on February 22, 2022, did not receive a performance review or evaluation, nor any annual in-service training from February 2023 through February 2024. Similarly, CNA E, hired on February 18, 2015, also did not receive a performance review or evaluation, nor any annual in-service training for the same period. During an interview, the Administrator, who started in May 2024, confirmed that no employee performance reviews or evaluations had been conducted since her tenure began, and there was no documentation of such reviews being done prior to her employment. Additionally, the facility did not provide a policy on CNA performance review and training requirements.
Inappropriate Antipsychotic Prescription for Insomnia
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for one resident out of five sampled residents. The resident, identified as Resident #37, was admitted with diagnoses of dementia, generalized anxiety disorder, depression, and insomnia. Despite these diagnoses, there was an order for olanzapine, an antipsychotic medication, to be administered at bedtime for insomnia, which is not an appropriate diagnosis for such medication. The facility's policy on antipsychotic medication use specifies that these medications should only be used for certain conditions, none of which include insomnia. The monthly Medication Regimen Review (MRR) conducted by the pharmacist for September and October 2024 did not include a recommendation for an appropriate diagnosis for the olanzapine prescribed to Resident #37. During interviews, both the Director of Nursing and the pharmacist acknowledged that insomnia was not an appropriate diagnosis for the use of an antipsychotic medication. The pharmacist noted that the physician orders were reviewed monthly, but since the olanzapine was not due for a gradual dose reduction, it may not have been reviewed during the MRR.
Medication Administration Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 6.25%. This deficiency was identified through observation, interview, and record review, affecting two residents out of six sampled. Specifically, the errors involved the administration of insulin aspart, where the Registered Nurse (RN) failed to prime the insulin pen before administering the medication to the residents. The facility did not have a medication error policy in place, which contributed to the oversight. Resident #33 had a physician's order for insulin aspart 18 units to be administered subcutaneously at specified times with meals. However, during an observation, RN G did not prime the insulin pen before administering the dose. Similarly, Resident #195 had an order for insulin aspart 10 units, and the same error was observed. RN G believed that priming was only necessary the first time the pen was used, contrary to the manufacturer's guidelines. The Director of Nursing and the Administrator acknowledged that staff should follow the manufacturer's instructions for medication administration.
Improper Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store and distribute food under sanitary conditions, as evidenced by multiple observations of the 400 Hall unit refrigerator. The refrigerator was found to have a temperature of 50 degrees Fahrenheit, which is above the facility's policy requirement of 40 degrees Fahrenheit or below for perishable items. Additionally, there were several instances of opened containers of milk and pitchers of liquids that were unlabeled and undated, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect the thirteen residents who were served food from this refrigerator. Interviews with staff revealed a lack of consistent monitoring and documentation of refrigerator temperatures. Nurse Aide B indicated that the refrigerator was used for both employee and resident food storage, while CNA A admitted to not dating the milk container when it was opened. The Maintenance Supervisor claimed to monitor refrigerator temperatures and keep a log, but the Dietary Manager stated that logs were not maintained for unit refrigerators. The Administrator expressed an expectation for regular temperature checks and maintenance below 41 degrees Fahrenheit, highlighting a disconnect between expected practices and actual procedures.
Infection Preventionist Absence in QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included an Infection Preventionist (IP) in its meetings, as required. This deficiency was identified through interviews and record reviews, which revealed that the IP did not attend the QAA meeting in September 2024. The facility's administrator explained that the IP was unable to attend because they were working as the charge nurse on the night shift. Additionally, the facility did not provide a policy regarding the QAA Committee or attendance records prior to September 2024. This oversight had the potential to affect all 45 residents residing at the facility, as the IP's participation is crucial for addressing infection control issues.
Failure to Enforce Source Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain a safe and sanitary environment during a COVID-19 outbreak by not enforcing the use of source control, such as facemasks, among staff members. Observations revealed that staff, including LPNs, CMTs, and RNs, were not wearing masks while performing their duties in common areas and resident rooms, despite the facility being in an outbreak status. There were no signs posted at the facility entrance or on the doors of COVID-19 positive residents' rooms to indicate the outbreak status or isolation requirements. Interviews with staff members, including a housekeeper and a CNA, indicated a lack of communication and understanding regarding the necessity of wearing masks outside of COVID-19 positive rooms. The Director of Nursing confirmed that the facility's protocol was for staff to wear masks only in isolation rooms, which contradicts the CDC guidelines for source control during an outbreak. The Administrator and DON expressed an expectation for staff to follow CDC guidelines, yet the observations and interviews demonstrated a failure to implement these practices effectively.
Deficiency in CNA Training and Education
Penalty
Summary
The facility failed to ensure that certified nurse assistants (CNAs) received the required twelve hours of in-service education annually, including training on Dementia Care. This deficiency was identified for two CNAs, CNA D and CNA E, who did not attend the necessary annual competency in-service training on Dementia Care and had less than twelve hours of in-service education for the period from February 2023 through February 2024. CNA D was hired on February 22, 2022, and CNA E was hired on February 18, 2015. The facility did not have a policy on nurse aide training requirements. The Director of Nursing, who started in May 2024, acknowledged the lapse in training and was attempting to address the issue. The Administrator expected all CNAs to complete the required training, including Dementia Care, annually.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jackson Manor | 3 mi | ★★★★★ | 9 | 0 |
| Fountainbleau Lodge | 4.2 mi | ★★★★★ | 7 | 0 |
| Heartland Care And Rehabilitation Center | 4.3 mi | ★★★★★ | 4 | 0 |
| Chateau Girardeau | 5.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Cape Girardeau | 6.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.