Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bedford Care Center Of Marion during CMS and state inspections, most recent first.
Pain was not managed appropriately during wound care for a resident with a Stage 4 coccyx pressure ulcer. During the treatment, the resident moaned, stated he was hurting, and asked for pain medication, but the RN continued the procedure after turning on the call light. The resident kept expressing pain while the wound care was completed, and the RN later acknowledged she should have stopped and waited for pain medication to take effect before continuing.
A facility failed to safeguard resident trust funds by not depositing them into an interest-bearing account and by leaving residents unable to access their money after a change in ownership. Three residents reported being unable to obtain personal funds for months, including one resident with moderately impaired cognition and two cognitively intact residents with account balances ranging from $88 to more than $3,900. The Administrator confirmed the new resident trust account was not established until weeks later, the prior owner’s check had not been deposited, and residents were told they could request money from petty cash.
Failure to Provide Trust Fund Account Statements Upon Request: The facility failed to provide account statements upon request for two cognitively intact residents with facility-managed trust funds. One resident with DM reported being unable to access personal funds and never receiving the requested statement, while another resident with chronic AFib said he was given only the account balance on a piece of paper. The ADM stated the facility should provide quarterly statements and statements upon request, but instead gave residents balances on sticky notes.
Resident charts with identifying information were stored in hallway areas near the nurses' stations and were easily accessible, with names and room numbers visible on the labels. The records contained face sheets, orders, care plans, labs, advance directives, H&P, and hospital records. A resident reported removing a chart from the hallway shelf without staff noticing, and staff said the charts had been moved from a secured medical records room to the hallway so nursing staff and the MD could access them more quickly.
A resident with Bipolar Disorder and intact cognition was unable to access soap in his bathroom after a new wall-mounted dispenser was installed but never filled. The resident, CNA, LPN, and maintenance staff all confirmed the dispenser remained empty for weeks, and the resident used a bottle of soap brought by his wife instead.
Failure to honor resident food preferences: one cognitively intact resident on a pureed diet repeatedly requested that pureed bread not be served, but staff continued to send it and did not update her preference list; another cognitively intact resident requested fried eggs but continued to receive powdered eggs after the facility stopped ordering eggs for frying. Interviews with nursing and dietary staff confirmed the residents' complaints and the facility's inability to provide the requested breakfast item.
A resident with Alzheimer's Disease and severely impaired cognition was incorrectly coded on the MDS as receiving an antipsychotic medication even though there were no physician orders and no MAR documentation showing the medication was given during the lookback period. RN and DON review confirmed the MDS was coded inaccurately based on the source documents.
A resident with atrial fibrillation and intact cognition reported limited access to outdoor time and said the facility did not allow residents outside as much because of staffing limits. The AD stated weekend activity staff were not scheduled after a company buyout, the weekend activity cart required staff assistance, and a planned outdoor activity did not occur despite favorable weather. During Resident Council, multiple residents said weekends were boring, staff were unavailable to help with the activity cart, and they mostly stayed in their rooms watching TV; the Administrator acknowledged there were no organized weekend activities.
Posted menus were not followed and alternate meal items were not consistently available for two residents. A resident with DM and another resident with chronic AF, both cognitively intact, reported that meal selections listed on the menu were often not provided; one resident requested an alternate dinner but received turkey sandwiches instead, while the other requested the alternate dinner and received the regular meal instead. Survey observation also found an alternate entree listed on the menu was not prepared or available, and the DM confirmed the alternate meals were not available and had been told not to serve them.
A resident with hemiplegia required a full body lift with two-person assistance and a large sling for transfers. However, a CNA transferred the resident alone using an incorrect small sling, resulting in a fall and injuries. The CNA did not verify the sling size or check the Kardex, and the resident expressed distress during the transfer. Observations revealed continued use of the wrong sling size, and staff interviews confirmed non-compliance with the care plan and facility policies.
A resident with a history of hemiplegia and moderate cognitive impairment was injured during a transfer using a mechanical lift when a CNA performed the transfer alone and used an incorrect sling size. The resident fell, resulting in a fracture and head laceration. Facility policy required two staff members for such transfers and verification of the correct sling size, but these procedures were not followed.
The facility failed to address complaints from resident council members about cold food, as their grievances were not consistently documented or communicated. Despite efforts by the DON to ensure timely meal service, the issue persisted. The Assistant Dietary Manager was unaware of the complaints, and the Administrator believed the problem was resolved, as he had not received the meeting minutes. The residents involved had varying cognitive statuses, but their complaints were not effectively addressed.
A facility failed to serve food at an appetizing temperature, affecting a resident and potentially impacting 74 others. Observations revealed cold meal trays, and a resident expressed ongoing dissatisfaction with cold breakfasts. Delays in food service and the use of non-insulated carts contributed to the issue. The resident, with a history of Bipolar and Anxiety Disorders, was cognitively intact.
The facility failed to accurately complete MDS assessments for two residents who were discharged. One resident was incorrectly documented as being discharged to a LTC facility instead of an acute care hospital, while another was documented as going to a short-term hospital instead of a LTC facility. An LPN confirmed the errors, and the DON was informed of the inaccuracies.
A resident with visual impairment did not receive necessary prescription glasses due to financial constraints. The facility's Social Services Director provided inadequate over-the-counter glasses and did not seek alternative assistance or inform the Administrator. The Director of Nursing confirmed the prescription was not filled, and the Administrator was unaware of the situation, despite the facility's policy to provide medically-related social services.
The facility failed to maintain proper chemical sanitizer concentration in a low-temperature dishwasher, resulting in inadequately cleaned dishes. A dietary staff member observed dishes with food residue, and further investigation revealed the chlorine concentration was only 10 ppm, below the required 50 ppm. The issue was due to unprimed sanitation tubing after a new container was installed.
The facility failed to document the refusal of influenza and pneumococcal vaccines for two residents, as required by their policy. Despite the DON stating that the residents had refused the vaccines, there were no signed declination forms in their medical records. The RCC, responsible for maintaining these records, confirmed the absence of documentation.
The facility failed to document the refusal of the COVID-19 vaccine for two residents, as required by their policy. Despite the Director of Nursing, Administrator, and Resident Care Coordinator acknowledging the issue, there was no evidence in the medical records to indicate whether the residents had received or refused the vaccine.
Pain Not Managed During Wound Care
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with a Stage 4 pressure ulcer to the sacrum/coccyx when nursing staff continued wound care after the resident verbalized pain and requested pain medication. During observed wound care, the resident began moaning, stated he was hurting, confirmed he was in pain, and said he needed something for pain, but the RN turned on the call light and continued the treatment instead of stopping the procedure. The resident continued to moan, groan, and use explicit words stating he was in pain while the wound care was completed. The resident had been admitted with a diagnosis including pressure ulcer of the sacral region and had cognitive impairment with poor decision-making and need for cues or supervision. The care plan included wound care treatment for the Stage 4 coccyx pressure ulcer, and the physician had ordered Hydrocodone-Acetaminophen 7.5-325 mg every 4 hours as needed for pain. The RN later confirmed the resident complained of pain during the treatment and acknowledged she should have stopped the procedure and waited until pain medication was given and had time to take effect before continuing. The DON stated that when a resident expresses pain during wound care, the nurse should stop the procedure, administer pain medication, and allow time for it to take effect before resuming treatment.
Resident Trust Funds Not Available After Ownership Change
Penalty
Summary
The facility failed to safeguard and ensure residents had access to personal funds entrusted to it when it did not deposit resident trust funds into an interest-bearing account and did not ensure residents could access their funds after the change of ownership. The facility’s Resident Personal Funds policy required resident funds over $100 to be placed in an interest-bearing account and required a separate accounting of each resident’s personal funds. A review of the resident trust fund list showed 43 residents had facility-managed trust funds, and two undeposited checks from the previous owner dated 12/31/25 represented resident trust funds in the amounts of $55,638.16 and $506.94. Resident #62 had diagnoses including Peripheral Vascular Disease and a BIMS score of 12, indicating moderately impaired cognition. The resident’s statement landscape showed a balance of $3,921.48 and four withdrawals during the quarter. During interview, the resident reported being told personal funds were not available after the ownership change and stated he wanted to withdraw funds to avoid exceeding Medicaid asset limits but was not given a timeframe for access. Resident #65 had diagnoses including Diabetes Mellitus and a BIMS score of 15, indicating intact cognition. The resident had a balance of $88.00 and reported being unable to access personal funds since the ownership change, with staff stating the facility was waiting to receive funds from the previous ownership. Resident #74 had diagnoses including Chronic Atrial Fibrillation and a BIMS score of 15. The resident’s statement landscape showed a balance of $2,227.81 and one withdrawal during the quarter. The resident reported being unable to access personal funds since the facility changed ownership and said the previous owner had stated the funds would transfer within about one week, but they had not been available for approximately three months. The Administrator confirmed the facility did not establish a new resident trust account until 03/06/26, the prior owner’s check had not yet been deposited, and resident funds were not available during that time. He also stated residents were told they could request money from petty cash, while the Social Worker reported multiple resident complaints about access to funds and said the January Resident Council minutes did not document the discussion about resident trust funds.
Failure to Provide Trust Fund Account Statements Upon Request
Penalty
Summary
The facility failed to provide account statements upon request for two residents with facility-managed trust funds. The facility’s Resident Personal Funds policy stated that a resident has the right to know in advance what charges may be imposed against personal funds and that the individual financial record must be available to the resident upon request. A review of the facility’s list of residents with trust funds showed 43 residents had facility-managed trust funds. Resident #65 was admitted with diabetes mellitus and had a BIMS score of 15, indicating cognitive intactness. During interview, the resident stated that since the change of ownership in January, he was unable to access personal funds and had requested a statement from his account but never received it. Resident #74 was admitted with chronic atrial fibrillation and also had a BIMS score of 15. During interview, the resident reported being unable to access personal funds since the facility changed ownership on 1/1/26 and said that when he asked for a statement, he was given the balance of his account on a piece of paper. The Administrator stated the facility provides quarterly statements and upon request, but when residents requested account balances, he did not provide a printed statement and instead wrote the balance amount on a sticky note.
Resident Charts Stored in Hallway Near Nurses' Stations
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when resident charts containing identifying information were stored in hallways near the nurses' stations on two observed halls. The charts were visible and easily accessible from the hallway, with resident names and room numbers on the labels, and the records contained Face Sheets, Physician's Orders, Care Plans, labs, Advance Directives, History and Physicals, and hospital records. Facility policy required privacy and confidentiality, and the confidentiality agreement stated staff were not to leave workstations unattended without securing hard copy information and were to follow HIPAA requirements. During observation, multiple resident medical charts were seen stored in gray plastic folders in the hallway near the nurses' stations on Dogwood Hall and Magnolia Hall. A resident reported that a chart had been taken from the hallway shelf and kept in the resident's possession for a period of time without staff noticing or addressing the removal. Staff interviews confirmed the charts had been moved from the secured medical records room to the hallway about two weeks earlier after a new company assumed management, so nursing staff and the medical director could access them more quickly, and that the hallway placement was intended as a temporary arrangement until a permanent storage cubby could be built.
Resident Bathroom Soap Dispenser Left Empty
Penalty
Summary
The facility failed to ensure reasonable accommodation of a resident’s individual needs when Resident #50 did not have soap available in the bathroom after a wall-mounted soap dispenser was installed. Resident #50 was admitted on 7/18/23 with diagnoses including Bipolar Disorder, and the quarterly MDS with an ARD of 2/16/26 indicated a BIMS score of 15, showing the resident was cognitively intact. Section GG showed the resident required supervision or touching assistance for toileting and personal hygiene. During an observation and interview on 3/9/26, Resident #50 stated there was no hand soap in the bathroom and reported the wall-mounted dispenser had been installed about one month earlier but had never been filled. The resident said staff told him the facility did not order enough soap for the new dispensers, and his wife had purchased a bottle of soap for him to use. The wall-mounted dispenser in the resident’s bathroom was observed empty on multiple occasions, including 3/9/26, 3/10/26, and 3/11/26. A small bottle of soap was seen on the sink, which the resident said his wife had brought because the dispenser had no soap. CNA #1 confirmed the resident had not had soap in the dispenser since it was installed, and LPN #1 also confirmed the dispenser had remained empty. Housekeeping/Maintenance staff stated the facility had replaced the previous soap and towel dispensers with new wall-mounted dispensers but did not have enough soap available for them, and one staff member said the soap had been on back order. The Administrator stated the resident’s dispenser may have been overlooked when soap was distributed and expected residents to have access to soap at all times.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food preferences and self-determination for two residents. Resident #68, who had a BIMS score of 13 and was cognitively intact, was on a pureed diet after admission for diagnoses including hemiplegia. She reported that she had told nursing and dietary staff she did not want pureed bread served on her meal trays because it was too thick and she believed she could choke on it. During observation, she was also served oatmeal and grits on the same plate, and her tray card and dietary questionnaire documented likes of oatmeal and grits and a dislike of cheese, but not bread. An LPN confirmed the resident had complained about the bread and stated she had not notified dietary staff, while dietary staff acknowledged the resident had recently said she did not want bread and that her preference list should have been updated. Resident #49, who had a BIMS score of 15 and was cognitively intact, was admitted with diagnoses including type 2 diabetes mellitus and was ordered a low concentrated sweets, no salt packet diet with regular texture. She reported dissatisfaction with breakfast meals and stated she had requested fried eggs on several occasions but was told they were not available. Staff interviews confirmed she continued to receive powdered eggs, and dietary staff stated the facility had been instructed to stop ordering eggs used for frying after a new dietary company began providing services. Dietary staff also stated pre-boiled eggs were still available for residents who requested boiled eggs. The Administrator stated he expected staff to honor residents' choices and preferences whenever possible and to notify the appropriate department if a preference could not be accommodated.
Incorrect MDS Coding for Antipsychotic Use
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessment for one resident when it coded the resident as receiving an antipsychotic medication despite there being no physician orders and no MAR documentation showing administration of any antipsychotic during the lookback period. The resident was admitted with a diagnosis of Alzheimer's Disease, and the quarterly MDS with an ARD of 01/28/26 showed a BIMS score of 3, indicating severely impaired cognition. Section N of that assessment was coded to indicate antipsychotic use during the last 7 days. Record review showed no active physician orders for an antipsychotic medication and no antipsychotic medications administered on the January 2026 MAR. During interview and record review, RN #2 confirmed the MDS was coded to show antipsychotic use even though the orders and MAR did not support it, and stated the MDS nurse is responsible for coding accurately using physician orders and MARs as source documents. The DON also reviewed the assessment and confirmed it was coded incorrectly to reflect antipsychotic use.
Weekend Activities Not Provided as Scheduled
Penalty
Summary
The facility failed to provide an ongoing activities program designed to meet residents’ interests and preferences when scheduled weekend activities were not conducted and residents reported limited opportunities for activities on weekends. The facility policy stated that activities are scheduled daily and are to be offered at hours convenient to residents, including evenings, holidays, and weekends. The activity calendars for January and February 2026 listed an Activity Cart each Saturday and Devotion and Bingo each Sunday, and the March 2026 calendar listed an outdoor activity for 3/7/26. Resident #74 was admitted on 9/22/2023 with diagnoses including atrial fibrillation. The Quarterly MDS with an ARD of 01/05/2026 showed a BIMS score of 15, indicating no cognitive impairment. The Annual Comprehensive MDS with an ARD of 07/17/2025 showed preferences that it was very important to do things with groups of people, do favorite activities, and go outside to get fresh air when the weather is good. During interview, the resident reported not liking being inside all day and wanting to enjoy the sunshine, and stated the facility did not allow residents to go outside as much as when the previous owners operated the facility because there were not enough staff members available to monitor residents. During interviews, the Activities Director reported that since the company buyout there had not been an AD or assistant scheduled on weekends, and that residents were given access to an activities cart when activity staff were not present Monday through Friday. She also reported that a CNA was expected to accompany residents for outdoor activities on weekends, that there was no documentation system before 03/01/26 to verify whether weekend activities were completed, and that the scheduled outdoor activity for 03/07/26 did not occur despite no weather conditions preventing it. At the Resident Council meeting, residents reported that weekend activities were lacking, that the Activity Cart required staff assistance but staff were not available on Saturdays, that weekends were boring, and that they usually stayed in their rooms watching television. The Administrator acknowledged that weekend activity staff were not scheduled and that residents did not have organized weekend activities, and the DON stated her expectation was for nursing and CNA staff to be available on weekends to assist residents with activities.
Posted Menu and Alternate Meal Options Not Followed
Penalty
Summary
The facility failed to follow the posted menu as written and failed to ensure alternate menu items were available as listed on the menu for two residents reviewed for food services. The facility policy stated that alternate foods and beverages are to be prepared or available at each meal and that menu changes will be posted. During observation of the lunch meal preparation, country fried steak was listed as an alternate entree on the posted menu, but it was not prepared or available on the steam table. A review of the posted menu also showed an alternate dinner option of beef tips, buttered rice, and spinach, but the Dietary Manager confirmed that the facility did not have that alternate entree available for dinner and stated she had been instructed by supervisors not to serve the alternate meals. Resident #65, admitted with Type 2 Diabetes Mellitus and assessed as cognitively intact with a BIMS score of 15, reported that the menu is frequently not followed and that staff sometimes say the kitchen has run out of food, with no alternate meal available when requested. The resident stated that on one occasion, after requesting the alternate dinner meal of beef tips, rice, and spinach, the resident instead received two turkey sandwiches that were not requested. Resident #74, admitted with Chronic Atrial Fibrillation and also cognitively intact with a BIMS score of 15, reported that menus are often not followed and alternate meals are not consistently available. The resident stated that after requesting the alternate dinner meal listed on the menu, the resident received the regular meal of pork chop, cabbage, and a sweet potato patty instead of the requested alternate meal.
Failure to Implement Comprehensive Care Plan for Resident Transfers
Penalty
Summary
The facility failed to implement comprehensive care plan interventions related to resident transfers, resulting in a significant incident involving a resident. The resident, who had been admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, required a full body lift with two-person assistance and a large sling for transfers. However, a Certified Nurse Aide (CNA) transferred the resident alone, using an incorrect small sling size, which led to the resident falling and sustaining a fracture and head laceration. The incident occurred when the CNA operated the lift without verifying the sling size and without assistance, despite the care plan specifying the need for two-person assistance. The CNA admitted to using the sling already attached to the lift and not checking the Kardex for the required sling size. The resident expressed distress during the transfer, indicating that something was not right, and subsequently experienced severe pain and required hospitalization. Further observations revealed that the incorrect sling size was used again during a later transfer, indicating a continued failure to adhere to the care plan. Interviews with staff, including the Licensed Practical Nurse (LPN) and the Administrator, confirmed that the facility's policy required two staff members to be present during lift transfers and that the care plan was not updated following the fall. The Administrator was unaware of the continued use of the wrong sling size, despite staff education on proper lift pad identification and the availability of sufficient lift pads.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in a fall that caused a fracture and head laceration. The incident involved a Certified Nurse Aide (CNA) who performed the transfer alone without assistance and used an incorrect sling size. The facility's policy required two staff members to assist with transfers and to verify the correct sling size according to the resident's care plan. However, the CNA used a medium sling instead of the required large sling, leading to the resident sliding out of the sling and sustaining injuries. The resident involved in the incident had a history of hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, and was non-weight-bearing. The resident was found on the floor with a laceration on the forehead and a hematoma on the forearm. The resident was sent to the emergency room, where a displaced femur fracture was diagnosed, requiring surgery. The resident's cognitive status was moderately impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of eight. Interviews and observations revealed that the CNA admitted to transferring the resident without assistance and using the sling already attached to the lift without checking the Kardex for the correct size. Other staff members confirmed that the resident required a large sling and that two staff members should have been present during the transfer. The facility's administrator acknowledged that staff had been educated on proper lift pad identification and the need to check the Kardex before using the lift, but the incident still occurred due to non-compliance with these procedures.
Failure to Address Resident Complaints About Cold Food
Penalty
Summary
The facility failed to ensure that complaints from resident council members regarding cold food were recorded and resolved in a timely manner. Nine out of eleven resident council members had repeatedly complained about the issue, but their grievances were not consistently documented in the meeting minutes. The Social Services Assistant (SSA) admitted to forgetting to record these complaints in the April and May 2024 minutes, although the issue had been discussed in daily stand-up meetings with the interdisciplinary team. The Director of Nursing (DON) was aware of the complaints and had taken steps to ensure nurses were timely in serving meals, believing this was the cause of the cold food. However, the problem persisted despite these efforts. The Assistant Dietary Manager was unaware of the complaints, as she had not received any communication from the resident council or the Dietary Manager, who was absent at the time. The Administrator also believed the issue had been resolved and was not informed of ongoing complaints, as he had not received the resident council meeting minutes for June 2024. The residents involved in the complaints were a mix of cognitively intact and moderately impaired individuals, as indicated by their Brief Interview for Mental Status (BIMS) scores. Despite their cognitive status, their grievances about cold food were not adequately addressed or communicated to the necessary parties, leading to a failure in resolving the issue effectively.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature, affecting one of the 15 sampled residents and potentially impacting 74 residents receiving food from the kitchen. The deficiency was identified through observations, interviews, and record reviews. The facility's policy on food preparation guidelines emphasized serving food at a safe and appetizing temperature, but this was not adhered to. During an observation, two lunch meal trays were found to be cold to taste and touch. A resident expressed dissatisfaction with consistently receiving cold breakfast, and the issue had been ongoing for some time. The resident had to request reheating of her meals, indicating a failure in the facility's food service process. Further investigation revealed that the dietary staff faced challenges in maintaining food temperatures due to procedural delays. The cook was unable to prepare meal trays for residents in the hall until all dining room residents were served, causing delays. Additionally, the use of an open metal tray cart, instead of insulated ones, contributed to the food cooling down before reaching the residents. Temperature checks confirmed that the food was not at an appetizing temperature, with significant drops from the initial cooking temperatures. The administrator acknowledged the complaints but was unaware that the resident council continued to express dissatisfaction. The resident involved had a history of Bipolar Disorder and Anxiety Disorder and was cognitively intact, as indicated by her BIMS score.
Inaccurate MDS Assessments for Discharged Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents who were discharged. Resident #77 was admitted with diagnoses including Hemiplegia and Hemiparesis. The Discharge MDS indicated that Resident #77 was discharged to a long-term care facility, but a progress note revealed that the resident was actually transferred to an acute care hospital. Similarly, Resident #79, admitted with Type 2 Diabetes Mellitus, had a Discharge MDS indicating discharge to a short-term general hospital, while the discharge summary and progress notes confirmed the resident was discharged to a long-term care facility. Interviews with the Licensed Practical Nurse (LPN) responsible for the MDS assessments and the Director of Nursing (DON) confirmed the inaccuracies in the MDS assessments for both residents. The LPN acknowledged the errors but was unsure how they occurred. The DON was made aware of the inaccuracies and stated that the facility was working on making corrections for the affected residents.
Failure to Provide Vision Services to Resident
Penalty
Summary
The facility failed to provide necessary vision services to a resident who was visually impaired. The resident, who was admitted with a diagnosis of hypothyroidism, had a prescription for corrective lenses following an eye exam. However, the prescription was not filled because the resident could not afford the glasses, and the facility did not take steps to assist the resident in obtaining them. The Social Services Director (SSD) was aware of the resident's inability to pay and provided over-the-counter reading glasses, which were inadequate for the resident's needs. The SSD did not seek assistance from community support agencies or inform the Administrator about the resident's financial situation. The Director of Nursing (DON) confirmed that the prescription was not filled due to the resident's lack of funds and acknowledged that the facility did not explore other means to assist the resident. The Administrator was unaware of the resident's financial constraints and stated that the facility had previously purchased glasses and dentures for residents in need. The facility's policy required the provision of medically-related social services to help residents attain their highest practicable well-being, which was not adhered to in this case. The resident, who was cognitively intact, expressed difficulty in reading due to the inadequate glasses provided by the facility.
Dishwasher Sanitization Deficiency
Penalty
Summary
The facility failed to ensure the chemical sanitizer for a low-temperature dishwasher had a concentration of at least 50 parts per million (ppm) during one of two dishwasher observations. During an observation, a dietary staff member noticed that dishes were not being cleaned properly, with some having large amounts of dried food and others having small specks of food residue. The staff member set aside these dishes and did not use them for meal preparation. The issue was confirmed by another dietary staff member who acknowledged ongoing problems with the dishwasher, which had been rebuilt two months prior. Further investigation revealed that the dishwasher's chlorine concentration was only 10 ppm, significantly below the required 50 ppm. The Corporate Dietary Consultant identified that the sanitation tubing had not been primed after a new container of sanitation was installed, leading to the inadequate chlorine concentration. This oversight resulted in dishes not being properly sanitized, as confirmed by the dietary staff and the facility's policy requirements.
Failure to Document Vaccine Refusal
Penalty
Summary
The facility failed to provide evidence that two residents refused the influenza and pneumococcal vaccines, as required by their policy. The policy mandates that all residents be offered vaccines and that any refusal be documented in the resident's medical record. However, for two residents, there was no documentation indicating whether they had received or refused these vaccinations. This lack of documentation was confirmed during interviews with the Director of Nursing (DON), the Administrator, and the Resident Care Coordinator (RCC). Resident #22 was admitted with diagnoses including Hemiplegia and Hemiparesis, while Resident #37 had Chronic Atrial Fibrillation. Despite the DON stating that both residents had refused the vaccines, there were no signed declination or refusal forms in their medical records. The RCC, who was responsible for maintaining these records, confirmed the absence of documentation and acknowledged her responsibility in ensuring the records were complete. The Administrator also acknowledged the deficiency, noting that the RCC was expected to maintain the necessary documentation.
Failure to Document COVID-19 Vaccine Refusal
Penalty
Summary
The facility failed to provide evidence that two residents refused the COVID-19 vaccine, as required by their policy on vaccination of residents. The policy mandates that all residents be offered vaccines and that any refusal be documented in the resident's medical record. However, for two residents, there was no documentation indicating whether they had received or refused the COVID-19 vaccination. This lack of documentation was identified during a review of the residents' medical records. Interviews with the Director of Nursing (DON), the Administrator, and the Resident Care Coordinator (RCC) confirmed the absence of signed declination or refusal forms for the two residents. The DON and the Administrator acknowledged the issue, stating that the RCC was responsible for maintaining immunization records. The RCC admitted to being unable to provide the necessary documentation and confirmed her responsibility for ensuring these records were properly maintained.
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Illustrative
What surveyors actually found near you
We read the 17 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
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Illustrative
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Pointe Health & Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Meridian | 2 mi | ★★★★★ | 3 | 0 |
| The Oaks Rehabilitation And Healthcare Center | 2.5 mi | ★★★★★ | 4 | 0 |
| Trend Health & Rehab Of Meridian Llc | 2.9 mi | ★★★★★ | 2 | 0 |
| Poplar Springs Nursing Ctr, Llc | 3.2 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.