Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Greenbough Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to develop and implement care plans for ADLs, nail care, and pressure injury prevention. A resident with severe cognitive impairment was observed with long, jagged fingernails and no nail care in the care plan. Another resident’s ADL plan for grooming and dressing was not followed, as the resident was found in a hospital gown with visible debris, facial hair, and long fingernails. A third resident had a care plan that did not include pressure injury prevention interventions, and a suspected deep tissue injury to the heel was later identified.
Pressure ulcer care was not provided appropriately for two residents. One resident developed a SDTI to the heel that progressed to a Stage 3 ulcer, with no pressure-ulcer prevention interventions in the care plan and delayed off-loading of extremities despite refusal of turning/repositioning being documented. Another resident developed a Stage II sacral ulcer, but RN staff were unaware of the wound until 2 days later, delaying MD notification, treatment orders, and wound care.
Two cognitively intact residents with trust fund accounts signed withdrawal forms for large cash amounts documented as personal use or cash advances, but reported not receiving any goods or services in return. The receptionist and Activity Director, acting under direction of a Business Office Manager, completed and processed these withdrawals, yet were unaware of how the funds were ultimately used. Facility and corporate audits later showed that the withdrawals lacked receipts and that checks were made out to the facility, indicating that resident funds were removed without required documentation to verify appropriate use, in violation of the facility’s abuse, neglect, and exploitation policy.
Resident Exposed in Dining Room: A resident was observed in the dining room waiting for lunch with pants down below the buttocks and bare skin exposed while other residents and staff were present. The ADON and DON confirmed this was unacceptable and a dignity concern. The resident had a hx of cerebral infarction and a BIMS score of 07, indicating moderately impaired cognition.
A facility failed to ensure residents received mail on Saturdays. During a Resident Council meeting, two residents stated mail was only distributed Monday through Friday, and the DON confirmed weekend mail was held until the next business day because no staff member was assigned to distribute it on weekends. The Administrator stated he was unaware of the issue until the day before the interview, and both affected residents were cognitively intact with BIMS scores of 15.
A resident was transferred to the hospital, but the facility did not complete or document the required Ombudsman notification. The DON stated there was no documentation because it was not sent, while the Administrator said the SW normally handled the notifications and MR staff were expected to do so in the SW's absence. MR staff did not recall being assigned to send the notifications.
Failure to monitor and document fluid intake for a resident on a fluid restriction. A resident with ESRD on dialysis had an active 1000 cc fluid restriction order, but the EMR contained no intake documentation. RN confirmed the missing documentation and stated intake should be monitored to ensure the restriction is followed, and the DON stated nursing staff were expected to monitor and document intake.
A resident’s psych med order was not accurately transcribed to the MAR after a dose change, and the prior Seroquel order was discontinued without the revised order being entered for 12 consecutive days. The DON confirmed the antipsychotic was stopped and not restarted until later, and that the psych recommendation was not fully implemented. The resident had multiple neuropsychiatric diagnoses and severely impaired cognition.
Failure to Follow Infection Control Practices and Store Resident Care Equipment Properly: An LPN did not use EBP during medication administration for a resident with a feeding tube, and respiratory equipment was left uncovered on a bedside table for another resident. In addition, multiple wash basins were stored uncovered on a bathroom floor instead of in a sanitary container or bag, contrary to facility policy.
Failure to provide grooming, hygiene, and nail care: A resident with dementia was observed with dirty nails, another resident with severe cognitive impairment was found with soiled clothing, facial hair, and long jagged nails, and a third resident had long jagged fingernails. CNAs and the DON confirmed staff were responsible for daily hygiene, dressing, grooming, and nail care, but the residents were left with unmet ADL needs.
Failure to obtain physician orders for a resident’s left upper arm dressing was identified after staff observed an undated dressing in place with no corresponding order in the MAR/order summary. An LPN and RN both confirmed there were no orders and did not know why the dressing remained, while the resident’s RR said it likely came from a hospital IV attempt that caused bleeding. The DON stated the arm should have been assessed on admission and orders obtained for care.
A resident with a below-knee amputation was transported by van without being secured with the vehicle's safety seat belt, resulting in a fall from the wheelchair onto the van floor. The CNA responsible admitted to not buckling the seat belt, and the facility lacked a policy on accident prevention or van transport. The resident was evaluated at the emergency room and found to have no injuries.
A registered nurse in an LTC facility failed to administer scheduled medications to seven residents during her shift, despite being offered assistance. The residents, who had various medical conditions such as hypertension and diabetes, did not receive their medications as prescribed. The nurse later resigned after being confronted about her attitude and disclosed the list of residents who missed their medications.
The facility did not ensure that the designated Infection Preventionist (IP) completed the required training, as observed over three survey days. The facility's policy requires a certified IP to coordinate the infection prevention and control program. An LPN, unaware of the need for formal training, had not completed her WHO training. The DON confirmed that three nurses, including herself, were in training but none had completed it. The Administrator was informed of the lack of a certified IP and believed training was underway, but was unaware it was incomplete.
A resident with severe cognitive impairment was left uncovered during a bed bath without the privacy curtain pulled, compromising their dignity. The CNA providing care did not announce patient care upon entry, and interviews with staff confirmed the importance of using privacy curtains to maintain resident dignity.
A resident's wheelchair was found to be in disrepair, with a broken brake and a tattered armrest. The Maintenance Director was unaware of the issue, despite being responsible for ensuring equipment was in good working order. The resident, admitted with Hemiplegia and Hemiparesis, reported the brake had been broken for some time.
A resident in a LTC facility was denied salt with meals despite multiple requests, due to a NAS diet order for high blood pressure. The resident, who was cognitively intact, expressed dissatisfaction with the lack of salt, which affected his ability to enjoy meals. The DON acknowledged the resident's right to request salt and mentioned the possibility of signing a waiver, highlighting a failure to support resident choice as per facility policy.
A facility failed to ensure the completion of advance directive documentation for a resident with severe cognitive impairment. Despite having a physician order for a full code status, there was no signed document indicating the resident's desired end-of-life care. The Director of Nursing confirmed the lack of necessary documentation, which should have been completed by the social service director upon admission and reviewed quarterly.
A resident with severe cognitive impairment and limited mobility did not have a comprehensive care plan that included turning and repositioning, essential for preventing skin breakdown. Observations showed the resident remained in the same position for extended periods, and staff interviews confirmed the omission in the care plan, highlighting a need for improvement in care planning.
A resident was left wet during mealtime due to a misunderstanding of facility policy. A CNA delivered a lunch tray but did not change the resident, believing it was against facility rules to do so during meals. The DON clarified that aides should address such needs immediately, highlighting a communication gap that left the resident in an unsanitary condition.
A resident who was severely cognitively impaired and dependent on staff for mobility was not repositioned for several hours, contrary to facility policy requiring repositioning every two hours. Despite the oversight, a full body audit revealed no skin breakdown. Staff interviews highlighted a lack of training and communication regarding the resident's care needs.
A CNA began working at the facility without completing the required orientation competency check-off, as confirmed by her personnel record and interviews with staff. The LPN responsible for ensuring the check-off was completed admitted it was missed due to the CNA's requested days off. The DON confirmed the oversight, noting the CNA worked several days without the necessary competency verification.
Failure to Develop and Implement Care Plans for ADLs, Nail Care, and Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address residents’ identified ADL and skin integrity needs. Facility policy required each resident to have a comprehensive care plan with measurable objectives and timeframes that included all services identified in the comprehensive assessment. Review of 21 resident care plans found deficiencies related to nail care, grooming and dressing, and pressure ulcer prevention. Resident #2 was observed lying in bed wearing a hospital gown with fingernails about one-half inch long with jagged edges and a thick brown substance underneath. The MDS Coordinator confirmed the care plan had not been developed to include nail care as part of daily care. The resident had been admitted with unspecified dementia and had a quarterly MDS BIMS score of 06, indicating severely impaired cognition. Resident #4 had a care plan that noted refusal to be turned or repositioned every two hours because it interfered with watching TV, but it did not include interventions to prevent pressure ulcers. The resident developed a suspected deep tissue injury to the left heel, and the task for off-loading of extremities was not initiated until 12/10/2025. Resident #21 had an ADL care plan for bathing, hygiene, and dressing, but it was not implemented as written; the resident was observed in a hospital gown with a dried brown substance on the gown, scattered dark hair on the chin, and long jagged fingernails. Resident #24 was observed with fingernails approximately one-fourth inch past the fingertips and jagged, and the care plan did not include nail care for trimming or cleaning fingernails.
Pressure Ulcer Prevention and Treatment Delays
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for two residents. Resident #4 developed a suspected deep tissue injury to the left heel measuring 60 mm by 50 mm by 1 mm on 8/18/25, which later progressed to a Stage 3 pressure ulcer by 10/2/25. The care plan noted that the resident refused turning and repositioning every 2 hours because it interfered with watching TV, but it did not include interventions to prevent pressure ulcers. The task list report showed that off-loading of extremities was not initiated until 12/10/25, even though the wound had been identified months earlier as a SDTI. The DON and ADON confirmed that preventative measures were not implemented until 12/10/25 and stated that their expectation was for preventative measures to be in place before pressure ulcers developed. Resident #4 had diagnoses including other lack of coordination, type 2 DM with hyperglycemia, and peripheral vascular disease, and the quarterly MDS showed a BIMS score of 01, indicating severely impaired cognition. Resident #58 developed a Stage II pressure ulcer on the sacrum that was identified on 9/13/25. Orders to treat were not received until 9/15/25, and RN #1 stated she was unaware of the wound until that date and then performed wound care. This resulted in a 2-day delay in physician notification, obtaining treatment orders, and initiation of wound care. The DON and ADON confirmed that the wound should have been reported, orders obtained, and treated the same day it was identified, with no delay in treatment. Resident #58 had a diagnosis of giardiasis, and the quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment.
Failure to Safeguard Resident Trust Fund Withdrawals From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to safeguard resident trust fund withdrawals from misappropriation for two residents with trust fund accounts. Facility policy on Abuse, Neglect and Exploitation requires protections against misappropriation of resident property, but resident interviews and record review showed that large sums were withdrawn from resident trust funds without documentation verifying that goods or services were provided. One resident reported that $700 was taken from her trust fund, acknowledged signing a Resident Trust Fund Withdrawal form for personal use, and stated she did not receive any goods or services in return. The withdrawal form listed the receptionist as the fund custodian. For this same resident, the Activities Director stated that the Business Office Manager (BOM) instructed her that the resident needed to withdraw money for personal use. The Activities Director completed the withdrawal form, obtained the resident’s signature, and returned the form to the BOM, but did not take the resident shopping in that time period and was unaware of what the money was spent on. Audit records later showed that the $700 withdrawal had no receipt and that the check was made out to the facility, rather than being tied to documented purchases for the resident. A second resident confirmed that money had been taken from his trust fund, that he had signed withdrawal forms, and that he did not recall receiving any goods or services in return. Records showed two withdrawals for this resident, one for $1,115 and another for $1,700, both documented as cash advances, with the receptionist listed as fund custodian and various staff as witnesses. The receptionist reported that the BOM directed her to complete the forms and told her the withdrawals were to spend down the resident’s account, but she was unsure what the money was spent on. Facility and corporate audit records indicated that these withdrawals lacked receipts and that the checks were made out to the facility, demonstrating that resident funds were withdrawn without supporting documentation verifying appropriate use, contrary to facility policy.
Resident Exposed in Dining Room
Penalty
Summary
The facility failed to ensure Resident #31 was treated with dignity when staff allowed the resident to remain in the dining room awaiting lunch with her pants down underneath her buttocks and her bare skin exposed in a public area. The observation occurred while approximately 12 other residents and staff were present. When asked about her clothing, the resident stated she did not know why staff left her in that condition. Facility staff confirmed the concern during interviews. The ADON stated the resident’s pants were down past her buttocks and that the exposure was unacceptable, noting residents should not be in the dining room in that condition and that it was a dignity concern that should never occur. The DON also confirmed that residents are expected to be dressed appropriately in common areas and that staff are responsible for ensuring clothing is properly positioned to maintain dignity. Resident #31’s record showed diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, and the quarterly MDS documented a BIMS score of 07, indicating moderately impaired cognition.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure residents had reasonable access to communication methods by not delivering mail on Saturdays for two residents who attended the Resident Council meeting. Facility policy titled Resident Rights stated that residents have the right to send and receive mail, but residents reported that mail was not delivered on Saturdays and was only distributed Monday through Friday. The DON confirmed that resident mail was distributed Monday through Friday only and that mail received on Saturdays was held until the next business day because no staff member was assigned responsibility for mail distribution on weekends. The Administrator stated he was unaware until the previous day that mail was not being delivered on weekends and confirmed that residents have the right to receive mail on weekends when mail is delivered by the post office. Both affected residents were cognitively intact, with BIMS scores of 15 on their most recent MDS assessments.
Failure to Document Ombudsman Notification for Hospital Transfer
Penalty
Summary
The facility failed to ensure required Ombudsman notification was completed and documented when a resident was transferred to the hospital. Record review of the facility's Transfer and Discharge policy stated that for non-emergency transfers or discharges, the facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated. A progress note for Resident #55 showed that he was transferred to the hospital on [DATE]. During interview, the DON stated there was no documentation of Ombudsman notification for the resident's transfer because it was not sent. The Administrator stated the SW was responsible for sending Ombudsman notifications but was on leave during that time, and he expected MR personnel to send the notifications in the SW's absence. MR personnel stated she did not recall being assigned to send out Ombudsman notifications while the SW was out.
Failure to Monitor and Document Fluid Intake for Resident on Restriction
Penalty
Summary
The facility failed to accurately monitor and document fluid intake for a resident on fluid restriction. Resident #7 had an active order for a 1000 cc fluid restriction, with specified amounts for nursing and dietary intake, and the resident was admitted with a diagnosis of End Stage Renal Disease and was on dialysis. Review of the January 2026 EMR showed no documentation of the resident’s intake. During interview, RN #2 confirmed that the resident was on a fluid restriction related to dialysis, verified that intake documentation was missing, and stated that the resident’s intake should be monitored and documented to ensure the restriction was followed. The DON stated that it was her expectation that nursing staff monitor and document the intake of a resident with a fluid restriction.
Medication Order Transcription Error Led to Abrupt Antipsychotic Interruption
Penalty
Summary
The facility failed to ensure a newly prescribed medication was accurately transcribed onto the MAR for one resident reviewed for unnecessary medications. Resident #21’s psych progress note on 11/12/25 documented a recommendation to decrease Seroquel from 200 mg BID to 200 mg q hs, and a later psych progress note on 11/19/25 documented another recommendation to decrease Seroquel to 50 mg PO q hs from 200 mg q hs. The facility policy titled Medication Orders stated that when a new order changes the dosage of a previously prescribed medication, the previous entry should be discontinued and the new order retyped per the electronic software instructions. Review of the November 2025 MAR showed Seroquel 200 mg BID was discontinued on 11/12/25, but the revised order was not transcribed until 11/25/2025. As a result, Resident #21 did not receive Seroquel from 11/13/25 through 11/24/25, resulting in an abrupt discontinuation of the antipsychotic medication for 12 consecutive days. The DON confirmed the medication was discontinued on 11/12/25 and not restarted until 11/25/25, and stated the psychiatric recommendation from 11/12/25 was not fully implemented. Resident #21 had diagnoses including other lack of coordination, other seizures, unspecified mood disorder, pseudobulbar affect, and moderate intellectual disabilities, and the quarterly MDS with ARD 11/18/2025 showed a BIMS score of 00, indicating severely impaired cognition.
Failure to Follow Infection Control Practices and Store Resident Care Equipment Properly
Penalty
Summary
The facility failed to implement infection prevention and control practices during resident care. Facility policy for Enhanced Barrier Precautions (EBP) stated that EBP was to be used for residents with indwelling medical devices, including feeding tubes, even if they were not known to be infected or colonized with an MDRO. During medication administration for Resident #9, who had a feeding tube and diagnoses including cerebral infarction, an LPN did not wear a gown and confirmed she forgot to use EBP. The DON later confirmed that EBP should have been used during medication administration because the resident had a feeding tube used for feeding and medication administration. The facility also failed to store resident care equipment in a sanitary manner. Resident #5, who had COPD and hypertensive heart disease with heart failure and was cognitively intact, was observed with a nebulizer mask and CPAP mask lying uncovered on the bedside table rather than stored in a clean protective bag. Resident #21, who had diagnoses including other lack of coordination, seizures, mood disorder, pseudobulbar affect, and moderate intellectual disabilities, had five wash basins stored directly on the bathroom floor, uncovered and not in a bag or container. Facility policy stated oxygen delivery devices should be kept covered in a plastic bag when not in use, and reusable bath basins should be labeled and stored in a bag or container off the floor.
Failure to Provide Grooming, Hygiene, and Nail Care
Penalty
Summary
The facility failed to ensure residents who required assistance received grooming and personal hygiene, including nail care and clean clothing. During observation, Resident #2 was found lying in bed wearing a hospital gown with nails about one-half inch long with jagged edges and a thick brown substance underneath. The DON and ADON later confirmed that CNAs are responsible for keeping residents' nails clean and that the nurse is responsible for trimming nails. Resident #2's record showed an admission diagnosis of unspecified dementia and a BIMS score of 06, indicating severely impaired cognition. Resident #21 was observed lying in bed wearing a hospital gown with a dried brownish substance on the top right side of the gown, visible dark hair on her chin, and long fingernails about three-fourths of an inch in length with jagged edges. A CNA confirmed the gown was soiled, the resident had visible facial hair, and the fingernails were long and jagged. The DON and ADON stated CNAs are responsible for assisting residents with bathing or hygiene care, dressing, and grooming each morning, and that residents should not be left with soiled clothing, unaddressed facial hair, or long jagged fingernails. Resident #24 was also observed with fingernails about one-fourth inch past the fingertips and jagged; a CNA stated she thought the shower team was responsible for cutting nails, while the DON stated the shower aid handles nail care on shower days and the floor CNA should cut nails if the resident refused a shower. Resident #24's record showed a diagnosis of cognitive communication deficit, and Resident #21's record showed diagnoses including moderate intellectual disabilities and a BIMS score of 00.
Failure to Obtain Orders for Unexplained Arm Dressing
Penalty
Summary
The facility failed to ensure a resident received necessary care and treatment to maintain the highest practicable level of well-being by not obtaining physician orders for a wound dressing identified on admission. Resident #16 was re-admitted to the facility with a diagnosis of acute respiratory failure with hypoxia, and an observation showed an undated dressing on the left upper arm. A progress note documented that the resident had a pressure dressing to the left upper arm, but the December 2025 and January 2026 order summary reports contained no physician order for a dressing or treatment to that area. During interviews, an LPN confirmed the dressing was not dated and did not know why it was present, and stated the resident’s family reported it may have been placed during a recent hospital stay when IV access was attempted. An RN also confirmed there were no orders for a dressing to the left upper arm and was unsure why it remained in place or how long it had been present. The resident representative stated that during a December 2025 hospitalization, hospital staff attempted IV access to the left upper arm, which resulted in bleeding and placement of a dressing. The DON confirmed the dressing should have been removed and the arm assessed upon admission to determine the skin condition and obtain orders for care.
Failure to Secure Resident with Safety Seat Belt During Van Transport
Penalty
Summary
A deficiency occurred when a resident, who had an acquired absence of the left leg below the knee, was being transported by van to a physician's appointment. During the trip, the Certified Nursing Assistant (CNA) responsible for the transport failed to secure the resident with the vehicle-supplied safety seat belt, although the wheelchair itself was secured to the van. The CNA later admitted that the seat belt was not buckled around the resident. As a result, the resident slid out of the wheelchair and fell onto the floor of the van. Emergency Medical Services (EMS) were contacted, and the resident was transported to the emergency room, where it was determined that no injuries had occurred and no treatment was required. Further review revealed that the facility did not have a policy on accident prevention or van transport. Staff interviews confirmed that the expectation was for the safety seat belt to be used during transport, and both the Administrator and Director of Nursing acknowledged that the failure to apply the seat belt could result in injuries. The lack of a specific policy and the omission of the safety measure directly contributed to the incident.
Medication Administration Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the failure to administer scheduled medications to seven residents during a specific shift. The incident occurred when a registered nurse (RN) assigned to the medication cart for the 7:00 AM to 3:00 PM shift did not administer medications to these residents. The RN had been notified of the assignment due to a call-in and was offered assistance by the Staff Development Nurse (SDN), which she declined. The RN later resigned after being called into the Director of Nursing's (DON) office regarding her attitude and disclosed the list of residents who had not received their medications. The residents affected by the missed medication administration had various medical conditions requiring regular medication. For instance, one resident had active orders for medications such as Metoprolol, Eliquis, Cozaar, and Dilantin, which were not administered at the scheduled times. Another resident had orders for Rivaroxaban, which was also missed. The residents' medical histories included conditions such as cerebral infarction, hypertension, diabetes mellitus, and congestive heart failure, highlighting the critical nature of timely medication administration. Interviews with staff revealed that the RN had previously worked on the medication cart without issues and had been offered help on the day of the incident, which she declined. The facility's policy on administering medications emphasizes safe and timely administration, which was not adhered to in this case. The administrator confirmed that the expectation was for the RN to administer medications as ordered, and the failure to do so resulted in a significant medication error affecting multiple residents.
Infection Preventionist Training Deficiency
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed the required training for the role, as observed over three survey days. The facility's policy, revised in October 2018, mandates that the infection prevention and control program be coordinated by a certified infection preventionist. However, during an interview, an LPN revealed that she was unaware of the need for formal training or certification when she assumed the role in January. Although she had begun training with the World Health Organization, she had not completed it. The Director of Nurses confirmed that three nurses, including herself, were undergoing training, but none had completed it. The Administrator, who took the position in April, was informed of the lack of a certified IP and was under the impression that the necessary training was being pursued, but was unaware of its incomplete status.
Failure to Ensure Resident Privacy During Bed Bath
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident during a bed bath, as observed by a State Agent. Resident #33 was found lying in bed uncovered, with only a brief on, and the privacy curtain was not pulled between her and her roommate. This lack of privacy occurred while Certified Nurse Assistant (CNA) #2 was providing care and did not announce patient care when the State Agent knocked on the door. Resident #33, who has medical diagnoses including Moderate Intellectual Disabilities and Pseudobulbar Affect, was unable to communicate effectively during the observation. Interviews with CNA #2, CNA #3, and the Director of Nurses (DON) confirmed that the privacy curtain should have been pulled to maintain the resident's dignity and privacy. CNA #2 admitted to not pulling the curtain, acknowledging it should have been done. CNA #3 and the DON emphasized the importance of using the privacy curtain during any type of care to protect residents' dignity. The Minimum Data Set (MDS) for Resident #33 indicated a severe cognitive impairment, highlighting the need for staff to be vigilant in maintaining privacy for vulnerable residents.
Facility Fails to Maintain Resident's Wheelchair in Good Repair
Penalty
Summary
The facility failed to provide a resident with a wheelchair in good repair, as evidenced by a broken brake and a tattered armrest. During an observation and interview, the resident reported that the wheelchair brake had been broken for some time, with the right brake hanging down loosely and unable to secure the wheel. Additionally, the right armrest was tattered and torn, exposing black foam. This deficiency was identified for one of the 17 sampled residents. The Maintenance Director was unaware of the wheelchair's disrepair and acknowledged his responsibility for ensuring resident equipment was in good working order. He confirmed the need for a new armrest and stated that the brake could be repaired. The Director of Nursing explained that aides were responsible for washing and cleaning wheelchairs at night and notifying the Maintenance Director of any equipment in disrepair. The resident involved had been admitted to the facility with a medical diagnosis of Hemiplegia and Hemiparesis following Cerebrovascular Disease affecting the right dominant side.
Failure to Honor Resident's Choice for Salt with Meals
Penalty
Summary
The facility failed to honor a resident's choice for salt with meals, which is a violation of the resident's rights to self-determination. The incident involved a resident who had repeatedly requested salt to be added to his meals, as he found the food unpalatable without it. Despite his requests, the staff denied him salt due to a physician's order for a No Added Salt (NAS) diet, which was prescribed because of his high blood pressure. The resident, who was cognitively intact with a BIMS score of 14, expressed his dissatisfaction during an observation and interview, stating that he could not enjoy his meals without salt. The Dietary Supervisor confirmed that the resident had a NAS diet order and had been educated about the potential health risks of consuming salt, such as swelling, due to his high blood pressure. However, the Director of Nursing acknowledged that the resident had the right to request and be given salt with his meals and mentioned that the resident could have signed a waiver to receive salt. The facility's policy on resident rights, which aims to ensure residents are not deprived of their rights, was not adhered to in this case, as the resident's choice was not supported or facilitated.
Failure to Complete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the advance directive for code status preference was discussed and completed for a resident. The facility's policy on advance directives, revised on 11/14/18, mandates that the center will honor all properly executed advance directives provided by the resident or their representative. The process requires the Social Service Director or Business Development Coordinator to communicate with the resident or their representative about their right to make choices concerning health care and treatments upon admission and to review these directives quarterly. However, for one resident, there was a physician order for a full code status dated 2/1/18, but no signed document indicating the desired end-of-life care was found in the resident's electronic or paper records. The Director of Nursing confirmed that the resident had an electronic order for a full code but lacked the necessary advance directive document indicating the resident's or representative's end-of-life care preferences. The responsibility for completing this documentation on admission and quarterly was assigned to the social service director, who failed to ensure accurate documentation. The resident, who was admitted with diagnoses including dementia with behavioral disturbance, congestive heart failure, and type 2 diabetes mellitus, had a Brief Interview for Mental Status score indicating severe cognitive impairment, further emphasizing the need for proper documentation and communication with the resident's representative.
Failure to Include Turning and Repositioning in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was dependent on staff for turning and repositioning. The care plan for this resident, who had a self-care performance deficit related to confusion and limited mobility, did not include specific instructions for turning and repositioning, which are essential to prevent skin breakdown and pressure ulcers. Observations on multiple occasions revealed that the resident remained in the same position for extended periods, indicating a lack of adherence to a two-hour turning schedule. Interviews with facility staff, including an LPN and a CNA, confirmed that the resident's care plan lacked specific instructions for turning and repositioning, despite the resident's need for extensive assistance. The staff acknowledged that turning and repositioning should be included in the care plan to guide care and prevent complications. The Director of Nursing also confirmed the omission and recognized the need for improvement in the care planning process. The resident's medical history included severe cognitive impairment and a need for substantial assistance with mobility, underscoring the importance of a detailed care plan.
Failure to Maintain Resident Hygiene During Mealtimes
Penalty
Summary
The facility failed to ensure a resident was clean and dry, as observed during a survey. A Certified Nurse Aide (CNA) delivered a lunch tray to a resident but did not address the resident's need for changing, despite the resident indicating that the bed was wet. The resident was found lying in bed with a saturated disposable pad, and the CNA only provided a sheet to cover the resident's legs, citing a facility rule against changing residents during mealtimes. Interviews with the Director of Nursing (DON) and the CNA revealed a misunderstanding of facility policy. The DON stated that aides and nurses are responsible for changing and toileting residents during mealtimes if needed, and leaving a resident wet is unacceptable. However, the CNA believed that changing a resident during mealtime could cause infection concerns for others in the room. This misinterpretation led to the resident remaining wet, which could potentially cause skin concerns.
Failure to Reposition Dependent Resident
Penalty
Summary
The facility failed to reposition a resident, identified as Resident #18, who was dependent on staff for mobility. Observations on June 4, 2024, revealed that the resident remained in the same position in bed with the head of the bed elevated at 90 degrees from 8:15 AM to 12:30 PM. Certified Nurse Assistant (CNA) #1 admitted to not turning the resident, citing a lack of training and familiarity with the resident, despite having prior experience as a CNA. Interviews with other staff, including the Licensed Practical Nurse (LPN) supervisor and the Director of Nurses (DON), confirmed that the expectation was for residents to be turned every two hours to prevent skin breakdown, and that staff should use common sense or ask for guidance if unsure. Resident #18 was noted to be severely cognitively impaired and required substantial assistance with bed mobility, as indicated in their Minimum Data Set (MDS) assessment. The resident was totally dependent on staff for all activities, including feeding. Despite the lack of repositioning, a full body audit conducted by the LPN/Wound Nurse found no issues of skin breakdown or pressure wounds. The facility's policy on contracture prevention emphasized the need for frequent repositioning of residents who are unable to move themselves, aligning with the staff's acknowledgment of the necessity to turn residents every two hours.
Failure to Complete CNA Competency Check-Off
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) completed an orientation competency check-off before caring for residents. The facility's policy requires new employees to undergo orientation, which includes a skills competency check-off to ensure they are competent in their roles. However, a review of CNA #1's personnel record revealed that this check-off was not completed. CNA #1, who had been at the facility for two weeks, confirmed in an interview that she was not trained and was put to work immediately. Further interviews revealed that the responsibility for ensuring the completion of the competency check-off fell to a Licensed Practical Nurse (LPN), who admitted that the process was missed due to the CNA's requested days off. The Director of Nurses (DON) confirmed that the CNA should have completed the orientation skills check-off before starting work. The CNA's timesheet showed she had worked multiple days without the required competency verification.
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Illustrative
What surveyors actually found near you
We read the 5 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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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 Clarksdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clarksdale Nursing Center | 5 mi | ★★★★★ | 0 | 0 |
| Oak Grove Retirement Home | 11 mi | ★★★★★ | 5 | 0 |
| Diversicare Of Shelby | 17 mi | ★★★★★ | 0 | 0 |
| Quitman County Health & Rehab Llc | 21.3 mi | ★★★★★ | 0 | 0 |
| Crestpark Helena, Llc | 25.4 mi | ★★★★★ | 11 | 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.