Above 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 Dugan Memorial Home during CMS and state inspections, most recent first.
Dignified Mealtime Not Maintained: A resident with dementia and severe cognitive impairment was left without her meal while two tablemates were already eating. The resident watched the others eat, then took another resident’s piece of iced cake and ate it with her hands because no silverware was in her area. An LPN and the DON both acknowledged that residents at a community table should be served at the same time to maintain dignity.
Informed consent was not obtained before a psychotropic medication was started for a resident reviewed for unnecessary meds. The resident had an order for Trazodone HCL 50 mg at bedtime for sleep, but no signed consent was in the chart. Facility policy required the resident, family, and/or resident representative to be informed of the benefits, risks, and alternatives before starting or increasing a psychotropic medication, and the ADM confirmed the consent should have been present. The resident had Parkinson’s disease, depression, and a BIMS score of 6, indicating severe cognitive impairment.
Resident Not Included in Advance Directive Decisions: A cognitively intact resident with a BIMS of 15 was not given the opportunity to discuss or complete her own advance directive, including end-of-life preferences. Her DNR form was signed by her sister instead of the resident, and staff confirmed the resident had not been involved in those decisions despite being able to make her own choices.
A cognitively impaired resident with Alzheimer's and dementia was subjected to non-consensual sexual contact by another cognitively intact resident with mental health diagnoses in a supervised common area. The incident lasted several minutes before a CNA intervened, with video footage confirming the abuse and staff unable to observe the full extent of the event due to physical barriers.
A resident with pneumonia refused multiple doses of prescribed antibiotics, but the facility failed to notify the provider as required. The LPN documented the refusals but did not inform the RN, leading to a breakdown in communication. The resident, who had a history of dementia and was rarely understood, did not complete the prescribed treatment, potentially affecting the treatment's effectiveness.
A resident with pneumonia did not receive the prescribed antibiotic due to refusals, and the facility failed to notify the provider. The care plan, which included administering Cefdinir and updating the MD, was not followed, leading to a deficiency in care. The resident has a history of shortness of breath and dementia, and is rarely understood.
A resident with MRSA was not placed on contact isolation precautions, and proper hand hygiene was not followed during wound care. The LPN used the same gloves for cleaning multiple wounds without changing them or performing hand hygiene. The Infection Control Nurse was unaware of the MRSA diagnosis, and no contact precaution signage or biohazard containers were present. Staff interviews revealed a communication lapse regarding the resident's MRSA status and necessary precautions.
A CNA in a long-term care facility was terminated after being reported for verbally abusing a resident by yelling and threatening to take away the resident's cell phone for using the call light excessively. The incident was witnessed by two other CNAs and reported to the DON. The resident, who was cognitively intact, confirmed the inappropriate behavior but was not upset as he used his cell phone to call for help. The CNA had not attended a recent in-service on abuse prevention.
Dignified Mealtime Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience when Resident #11 was not served her meal at the same time as the two other residents seated at her table. During lunch observation in the dining room, the two residents at the table had their meals and were eating while Resident #11 remained without food and watched them eat. At 12:15 PM, Resident #11 reached to her right, slid another resident’s piece of iced cake in front of herself, and began eating it with her hands; there was no silverware in her area. Facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, stated that residents are to be treated with respect and dignity and that each resident’s individuality and rights are to be protected. An LPN stated it was unacceptable for Resident #11 to be without her meal while the other residents at the table were eating and acknowledged that residents at a table should be served at the same time to promote dignity during mealtime. The DON also confirmed that residents at a community table should receive their meals at the same time and that one resident should not have to watch tablemates eat for an extended period without her own meal. Resident #11’s record showed a diagnosis of dementia, and her MDS indicated a BIMS score of 5, consistent with severe cognitive impairment.
Informed Consent Not Obtained for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained before initiating a psychotropic medication for one resident reviewed for unnecessary medications. Resident #9 had an order dated 7/28/25 for Trazodone HCL 50 mg by mouth at bedtime for sleep, but no signed informed consent for Trazodone was present in the medical record. Facility policy titled, Use of Psychotropic Medications, states that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives, and that the facility will document that the resident or resident representative was informed in advance. During interview on 3/18/2026, the Administrator confirmed there should have been a signed consent for Trazodone but was unable to locate one. Resident #9’s record also showed diagnoses including Parkinson’s Disease and Depression, and the MDS with ARD 12/29/2025 showed a BIMS score of 6, indicating severe cognitive impairment.
Resident Not Included in Advance Directive Decisions
Penalty
Summary
The facility failed to ensure a cognitively intact resident was given the opportunity to participate in and make informed decisions about her advance directive, including end-of-life preferences. Review of the facility policy stated that residents have the right to make decisions concerning medical care, including the right to accept or refuse treatment and to formulate advance directives, but the resident’s Advance Directives/Medical Treatment Decisions form, dated 2/17/22, showed her as DNR and was signed by her sister rather than by the resident herself. The resident’s MDS with an ARD of 2/2/26 showed a BIMS score of 15, indicating she was cognitively intact. During interview, the resident stated the facility had never discussed end-of-life decisions with her and that her sister had made those decisions for her. The Social Services Director confirmed that a BIMS score of 13 or higher indicated a resident could make her own decisions, yet this resident was not provided the opportunity to discuss or complete her own advance directive. The Executive Director and Nurse Practitioner both acknowledged that, based on the resident’s cognitive status, she should have been allowed to make her own end-of-life decisions. The resident was admitted with diagnoses including rheumatoid arthritis, paraplegia, and major depressive disorder.
Failure to Prevent Sexual Abuse in Common Area
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from sexual abuse by another resident in a supervised common area. The incident involved a cognitively intact resident with mental health diagnoses who engaged in non-consensual sexual contact with a resident diagnosed with Alzheimer's Disease, Dementia, and Anxiety Disorder. The cognitively impaired resident was unable to consent, resist, or report the incident. The event occurred in a common area where the resident was seated in a geriatric chair, and the other resident approached in a wheelchair, initiated conversation, and then proceeded to lift the blanket and touch the resident inappropriately for several minutes before staff intervention. Staff interviews and video footage confirmed that the abuse occurred over a period of approximately three minutes before a CNA intervened. The positioning of the residents, staff, and physical barriers in the area made it difficult for staff to observe the inappropriate contact until it was reported by a visitor and later confirmed by video review. Facility policy required the prevention of abuse, neglect, and exploitation, but the failure to adequately supervise and protect the resident resulted in actual harm.
Failure to Notify Provider of Antibiotic Refusal
Penalty
Summary
The facility failed to notify the medical provider when a resident refused multiple doses of prescribed antibiotics. The resident, who had been diagnosed with pneumonia, was prescribed a 10-day course of Cefdinir Oral Suspension. However, the resident refused to take the medication on several occasions, specifically on the last two days of the prescribed course. Despite the refusals being documented in the Electronic Medication Administration Record (EMAR), the provider was not informed, which is a breach of the facility's policy requiring notification of medication refusals. Interviews with the facility staff revealed a breakdown in communication and procedure. A Registered Nurse (RN) stated that the Licensed Practical Nurse (LPN) is responsible for notifying the RN of any medication refusals, who would then inform the provider. However, the LPN admitted to failing to notify the RN of the refusals on the last two days, despite having documented them in the EMAR. The Director of Nursing (DON) confirmed the importance of notifying the provider to ensure appropriate care and treatment adjustments. The resident involved had a history of shortness of breath and dementia, and was admitted to the facility in 2016. The resident's mental status assessment indicated that they were rarely or never understood, which may have contributed to the medication refusals. The failure to notify the provider of the refusals meant that the resident's pneumonia treatment was not completed as prescribed, potentially impacting the effectiveness of the treatment.
Failure to Implement Care Plan for Resident with Pneumonia
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident diagnosed with pneumonia. The care plan, which was developed to address the resident's medical needs, included administering Cefdinir for ten days and updating the medical doctor as needed. However, the care plan was not followed, as the resident refused several doses of the antibiotic, and the provider was not notified of these refusals. This oversight was confirmed by both the Director of Nursing and the Minimum Data Set Coordinator during interviews. The resident, who was admitted to the facility in 2016, has a medical history that includes shortness of breath and dementia. The resident's quarterly Minimum Data Set indicated that the resident is rarely or never understood, which may have contributed to the refusal of medication. Despite the care plan's clear instructions, the facility's failure to administer the medication as ordered and to communicate with the medical provider about the refusals resulted in a deficiency in the resident's care.
Failure to Implement Contact Precautions for MRSA
Penalty
Summary
The facility failed to initiate contact isolation precautions for a resident diagnosed with Methicillin-resistant Staphylococcus Aureus (MRSA) and did not utilize proper hand hygiene during wound care. The resident, who had two wounds on the sacrum and left buttock, was observed receiving wound care without appropriate glove changes and hand hygiene by an LPN. The LPN used the same gloves to clean both wounds and did not perform hand hygiene between glove changes, which is against the facility's policy for wound care and infection prevention. The resident had been diagnosed with MRSA in one of the wounds, but the facility did not place the resident on contact isolation precautions as required. The Infection Control Nurse was unaware of the MRSA diagnosis until it was brought to her attention during the survey. The resident's medical records confirmed the MRSA diagnosis and ongoing antibiotic treatment, yet no contact precaution signage or biohazard containers were present in the resident's room. Interviews with facility staff, including the LPN, CNA, RN, and the Director of Nursing, revealed a lack of communication and awareness regarding the resident's MRSA status. The staff acknowledged that the resident should have been on contact precautions to prevent the spread of infection. The failure to implement these precautions was attributed to a miscommunication problem, as staff members were not informed or reminded of the necessary infection control measures for the resident.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to prevent verbal abuse of a resident by a staff member, specifically a Certified Nurse Assistant (CNA). The incident involved CNA #1, who was witnessed by two other CNAs, CNA #2 and CNA #3, speaking inappropriately to a resident. CNA #1 was reported to have yelled at the resident for using the call light excessively, threatening to take away the resident's cell phone, and possibly removing the call light from the resident's reach. Despite the conflicting accounts from the witnesses and the resident, the facility's investigation led to the termination of CNA #1 due to disrespectful behavior. The resident involved, identified as Resident #1, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident confirmed that CNA #1 had taken his call light and placed it behind his bed, prompting him to use his cell phone to call the facility for assistance. Although the resident did not feel upset by the incident, he acknowledged that this was not the first time CNA #1 had spoken to him in such a manner, though he had not reported previous occurrences. The facility's policy on abuse, neglect, and exploitation was reviewed, revealing that all staff are required to be in-serviced on abuse prevention upon hire. However, CNA #1 did not attend the most recent in-service on abuse. The facility's records showed that CNA #1 had been employed since November 2023 and had acknowledged the Vulnerable Adults Act. The incident was reported to the Director of Nurses (DON) by a Registered Nurse (RN), leading to CNA #1 being sent home pending the investigation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Point Community Living Center | 1 mi | ★★★★★ | 0 | 0 |
| Baptist Memorial Hospital Gt | 13.5 mi | — | 0 | 0 |
| Vineyard Court Nursing Center | 13.7 mi | ★★★★★ | 3 | 0 |
| Starkville Manor Health Care And Rehabilitation Ce | 13.8 mi | — | 10 | 0 |
| Care Center Of Aberdeen | 15.8 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Dugan Memorial Home.
100% money-back within 48 hours.
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.