Above 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 Kabul Nursing Homes Inc during CMS and state inspections, most recent first.
A resident with moderate vascular dementia and severe cognitive impairment did not have a care plan addressing dementia-related needs. The care plan lacked specific interventions or goals for dementia care, despite the resident's documented diagnoses and observed behaviors. Facility leadership confirmed the omission, and no dementia care policy was provided.
A facility failed to provide required written discharge/transfer information for two residents sent to the hospital, including ombudsman contact info, advocacy agency contact info, and appeal rights. The facility also failed to provide a discharge summary for another resident who had an unplanned discharge home, despite documentation that the resident left with meds and belongings and staff stating the paperwork should have included the required information.
Staff failed to use safe transfer techniques when repositioning a resident with severe cognitive impairment, reduced mobility, and a history of falls risk. During observation, CNAs and an LPN lifted the resident by the axillary areas and knees, pulled on the waistband to scoot the resident back in the wheelchair, and used a gait belt under the resident’s breasts during repositioning and transport. Interviews showed staff expected gait belt use for safe repositioning, but unsafe lifting methods were observed.
Incomplete Controlled Medication Reconciliation: The facility failed to maintain accurate controlled medication reconciliation records for two medication carts. Logs showed multiple missed narcotic counts and missing nurse/CMT signatures or initials, and staff interviews confirmed that counts were expected at shift change but were not consistently completed or documented. The facility also did not provide a policy for narcotic reconciliation.
An LPN left the medication cart unlocked and unattended during insulin administration for multiple residents. The cart drawer containing insulin was left open while the LPN entered resident rooms, and the insulin was returned to the open drawer after administration. Facility policy stated medication carts must be locked when not in use or in plain sight, and the RN, DON, and Administrator all stated the cart should be locked when not being used.
The facility failed to follow physician's orders and document care for residents, including not activating a bed alarm for a resident with Alzheimer's, not documenting colostomy care for a resident with ulcerative colitis, and lacking assessments for self-care and trapeze use for other residents. Staff interviews confirmed these deficiencies, which were acknowledged by the facility's administration.
The facility exceeded the acceptable medication error rate, reaching 11.54%, affecting three residents. A CMT failed to verify medications against orders for two residents and did not notify a nurse about a missing medication for another resident. Staff interviews revealed non-compliance with the facility's medication administration protocol.
An LPN left the medication cart unlocked and unattended while administering insulin to two residents. The cart was positioned facing the hallway, out of sight of staff, and remained unlocked during the process. Interviews with facility staff confirmed that the cart should always be locked when unattended, but the LPN did not follow this protocol.
The facility failed to maintain infection control during medication administration, incontinent care, and catheter management. A CMT touched medication with bare fingers and used an unclean cart, while a CNA used soiled gloves throughout care. Catheter tubing was found on the floor, and an LPN did not wear gloves during insulin administration, violating facility policies.
The facility failed to ensure a safe environment by allowing items to be placed on overbed light fixtures, which were not intended for use as shelving. Observations showed stuffed animals and picture frames on light fixtures in several rooms, posing a potential risk to all residents and staff. Interviews with staff confirmed that items should not be placed on light fixtures, but the facility lacked a policy to enforce this safety measure.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to provide a personalized care plan addressing dementia for a resident diagnosed with moderate vascular dementia and senile degeneration of the brain. The resident's medical record indicated severe cognitive impairment, moderate hearing difficulty, and the use of hearing aids. Despite these diagnoses and needs, the care plan did not include any specific problems, interventions, or goals related to dementia care. Observations showed the resident spent time both in bed and in a wheelchair, was able to feed themselves, and was seen removing wet clothing and a brief independently. Interviews with the DON and Administrator confirmed that the care plan should have addressed the resident's dementia diagnosis and needs, but this was not done. The facility also did not provide a policy regarding dementia care.
Failure to Provide Required Discharge and Appeal Information
Penalty
Summary
The facility failed to provide written discharge or transfer information to two residents who were transferred to the hospital with a return anticipated. For Resident #5 and Resident #10, the medical records did not show documentation that the resident and/or resident representative received the ombudsman contact information, the contact information for the agency responsible for the protective and advocacy of individuals with mental disorders, the contact information for the protection and advocacy of individuals with development disabilities, or appeal information. The facility census was 39, and the record review and interviews showed the discharge paperwork was expected to include this information. The facility also failed to provide a discharge summary for Resident #48 after an unplanned discharge home with return not anticipated. The discharge MDS dated 05/14/25 showed the discharge was unplanned and return was not anticipated, and a nurse's note documented the resident left home with all medications and belongings and left with a family member. However, there was no documentation that the resident and/or representative received a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status. During interviews, Medical Records and the Administrator stated the discharge paperwork should include the required information, and Medical Records said the correct discharge paperwork was not completed for Resident #48 because the resident left before expected.
Unsafe Resident Repositioning and Transfer Technique
Penalty
Summary
The facility failed to ensure staff used safe transfer techniques for one resident when repositioning and lifting the resident in a wheelchair. The resident had an admission diagnosis list that included unspecified dementia with behavioral disturbance, hypertension, reduced mobility, hearing loss, type 2 diabetes, and metabolic encephalopathy. The admission MDS showed severely impaired cognition, partial/moderate assistance needed for bed mobility and sit-to-stand, and use of a manual wheelchair. The care plan identified the resident as at risk for injury from falls due to poor safety awareness, frequent attempts to get up without assistance, and combative behavior with care at times. During observation, staff repositioned the resident multiple times using unsafe methods. One CNA and one LPN placed their hands under the resident’s axillary areas and under the knees to lift and reposition the resident in the wheelchair. Another CNA grabbed the back waistband of the resident’s pants and lifted the resident’s buttocks to scoot the resident back in the wheelchair, after which the resident propelled through the hall and dining room and slid forward again. Later, staff again lifted the resident by the axillary areas and knees, and another staff member used a gait belt placed under the resident’s breasts while pushing the resident to the room. Interviews with the LPNs, CNAs, and the DON showed staff expected gait belt use for safety, and staff stated they would not normally reposition a resident by lifting under the axillary areas and knees.
Incomplete Controlled Medication Reconciliation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of all controlled medications in sufficient detail to allow accurate reconciliation of controlled medications. Surveyors found that nursing staff did not consistently sign at the beginning and end of each shift for two medication carts sampled, and the facility did not provide a policy regarding narcotic reconciliation. Review of the North Hall Medication Cart Controlled Medication Package Count Log for July 2025 showed 26 missed opportunities with no documented narcotic quantity out of 93 opportunities and 46 opportunities with no signature or initials by the nurse or CMT out of 186 opportunities. The same log for August 2025 showed eight missed opportunities with no documented narcotic quantity out of 40 opportunities and 15 opportunities with no signature or initials out of 80 opportunities. Review of the North/South Hall Medication Cart Controlled Medication Package Count Log for July 2025 showed 25 missed opportunities with no documented narcotic quantity out of 93 opportunities and 45 opportunities with no signature or initials out of 186 opportunities. For August 2025, the log showed six missed opportunities with no documented narcotic quantity out of 40 opportunities and 16 opportunities with no signature or initials out of 80 opportunities. During interviews, CMT D stated the narcotic count should be completed by the on-coming and off-going nurse and/or CMT at the start and end of shifts and signed by both staff. CMT C stated he/she had not counted the North/South Hall medication cart before administering medications and should have counted and signed the reconciliation sheet before taking the cart keys. LPN A stated the on-coming and off-going nurses should count together and sign the narcotic reconciliation sheet at shift change, and the DON stated everyone should count narcotics for the on-coming and off-going staff for each shift and sign the log together at that time.
Unsecured Medication Cart During Insulin Administration
Penalty
Summary
The facility failed to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended. During observation of insulin administration for Resident #38, an LPN obtained blood sugar reading supplies from the medication cart, shut the drawer, and did not lock the cart. The LPN then entered the resident’s room with the cart facing the hallway, unlocked and unattended, performed the blood sugar check, returned to the cart, removed the resident’s insulin from the top drawer, left the drawer open, and again entered the room with the cart unlocked and out of the line of sight of staff before administering the insulin. After the injection, the LPN returned the insulin to the open drawer without locking the cart. Similar observations were made during insulin administration for Resident #22 and Resident #6. In both instances, the LPN removed the resident’s insulin from the top drawer of the medication cart, left the drawer open, failed to lock the cart, administered the insulin, and then returned the insulin to the open, unlocked drawer. The facility’s policy stated that medication carts must be kept locked when not in use or in plain sight. During interviews, the LPN, RN, DON, and Administrator all stated that the medication cart should be locked when not being used, and the RN added that if left unlocked it should be in front of the resident door and facing toward the door.
Deficiencies in Adhering to Physician Orders and Documentation
Penalty
Summary
The facility failed to adhere to physician's orders and provide necessary assessments and documentation for several residents, leading to deficiencies in care. For Resident #17, the facility did not ensure the bed alarm was activated as per the physician's order, despite the resident's Alzheimer's diagnosis and the care plan indicating the need for such a device to alert staff when the resident attempted to get up unassisted. Observations showed the bed alarm was turned off, and interviews with staff confirmed the expectation that the alarm should be on when the resident was in bed. Resident #20, who has ulcerative colitis and a colostomy, had an order to change the colostomy wafer or bag as needed. However, there was no documentation of these changes being made, despite the resident performing the changes with staff assistance. Interviews with nursing staff and the resident confirmed the lack of documentation, which was acknowledged by the Director of Nurses and the Administrator as an expectation that was not met. For Resident #31, who has a colostomy, there was no assessment or documentation for self-care of the colostomy, despite the resident performing their own care with staff assistance. The facility did not document the education provided to the resident for colostomy care, and no self-care assessments were completed. Similarly, Resident #34, who uses a trapeze for bed mobility, had no physician's order or assessment for the trapeze's use, despite its presence and use in the resident's care plan. Interviews confirmed the lack of documentation and assessments, which were expected by the facility's administration.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 11.54% during the survey. This deficiency affected three residents out of the seven sampled. The errors involved improper medication administration practices by a Certified Medication Technician (CMT), identified as CMT F. For Resident #2, who had a diagnosis of gastroesophageal reflux disease, CMT F administered ondansetron without comparing the medication against the order. Similarly, for Resident #29, who had a diagnosis of stroke and hemiplegia, CMT F administered Lyrica without verifying it against the medication order. Additionally, for Resident #20, who had a diagnosis of depression, CMT F failed to administer fluoxetine because it was not available in the medication cart and did not notify the nurse about the missing medication. Interviews with staff, including a Registered Nurse (RN), the Administrator, and the Director of Nursing (DON), revealed that the facility's protocol was not followed. The protocol required medications to be triple-checked and the nurse to be notified if a medication was not available, so it could be sourced from the emergency kit if necessary.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to store medications securely, as observed during the insulin administration for two residents. An LPN was seen leaving the medication cart unlocked and unattended while administering insulin to a resident. The cart was positioned facing the hallway, out of sight of staff, and remained unlocked during the process. This occurred twice, with the LPN leaving the cart unattended and unlocked while performing blood sugar readings and administering insulin. Interviews with facility staff, including a Certified Medication Technician, a Registered Nurse, the Administrator, and the Director of Nursing, confirmed that the medication cart should always be locked when unattended. Despite this policy, the LPN did not adhere to the protocol, leaving the cart vulnerable and accessible, which could potentially affect all residents in the facility.
Infection Control Deficiencies in Medication and Personal Care
Penalty
Summary
The facility failed to maintain adequate infection control practices during medication administration for two residents. A Certified Medication Technician (CMT) was observed touching medication with bare fingers and allowing medication to come into contact with an unclean medication cart. This occurred during the administration of ondansetron and a multivitamin, where the CMT used improper techniques, such as using a spoon and medication package to pick up a dropped tablet and touching capsules with bare fingers. The facility's policy clearly stated that medication should not be touched with hands, yet this was not adhered to, leading to potential contamination. In another instance, the facility did not ensure proper infection control during incontinent care for a resident. A Certified Nurse Assistant (CNA) was observed using the same soiled gloves throughout the care process, which included cleaning fecal material and handling various clean items and surfaces. This was against the facility's policy, which required changing gloves and performing hand hygiene when moving from dirty to clean care. The CNA's actions were inconsistent with the expected standards of care, as confirmed by interviews with the staff, including the Director of Nursing (DON) and the Administrator. Additionally, the facility failed to maintain proper catheter care for two residents. Observations showed that catheter tubing and drainage bags were allowed to rest on the floor, contrary to the facility's policy, which required the drainage bag to be positioned below the bladder and not on the floor. Furthermore, during insulin administration for a resident, a Licensed Practical Nurse (LPN) did not wear gloves, despite the potential for blood contact, and failed to perform hand hygiene after removing gloves. These actions were in direct violation of the facility's insulin administration policy, which emphasized the importance of hand hygiene and glove use.
Unsafe Use of Light Fixtures as Shelving
Penalty
Summary
The facility failed to maintain a safe environment for residents and staff by allowing miscellaneous items to be placed on top of overbed light fixtures. Observations revealed that several rooms had items such as stuffed animals and picture frames placed on light fixtures, which were not intended to be used as shelving. This practice was observed in multiple rooms, indicating a widespread issue that had the potential to affect all residents and staff in the facility. The facility census at the time was 43. Interviews with staff, including housekeepers, the Maintenance Director, the Director of Nursing, and the Administrator, confirmed that items should not be placed on light fixtures due to safety concerns. Housekeeping staff mentioned that they typically checked and removed items from light fixtures during cleaning, informing residents of the fire hazard. However, the presence of items on light fixtures during the survey indicates a lapse in adherence to these safety protocols. The facility did not provide a policy regarding maintaining a safe environment, contributing to the deficiency.
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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 Cabool
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Oaks Caring Center | 8.6 mi | ★★★★★ | 1 | 0 |
| Willow Care Nursing Home | 11.4 mi | ★★★★★ | 8 | 0 |
| Houston House | 15.2 mi | ★★★★★ | 1 | 0 |
| Rocky Ridge Manor | 22.1 mi | ★★★★★ | 3 | 0 |
| Mountain View Healthcare | 23.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.