Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Jasper County Nh during CMS and state inspections, most recent first.
A resident received Geodon without an appropriate approved diagnosis and without documented informed consent. Staff and the NP stated the medication was intended for psychosis-related behaviors, but the resident did not have bipolar disorder or schizophrenia, and the DON confirmed psychosis was not an approved indication. The resident was repeatedly observed asleep in her wheelchair, often slept through meals and med passes, had no documented behaviors in the behavior log, and experienced significant meal refusals and major weight loss.
An LPN administered eye drops to a resident with glaucoma and another resident with pulmonary fibrosis without wearing gloves, and medication containers were placed on a resident’s bed and returned to the cart without sanitizing. The facility policy required medications to be given in a manner that prevents contamination or infection, and the DON stated items placed on a resident’s bed or bedside table must have a clean barrier and be sanitized before returning to the cart.
An LPN administered prescribed eye drops to a resident in the dining room while nine other residents were present, failing to provide privacy and dignity during medication administration. The facility's policy required privacy, and the DON stated medications should not be given in the dining room in front of other residents. The resident had pulmonary fibrosis and moderately impaired cognition.
MDS coding was inaccurate for two residents when one resident was marked as receiving insulin despite having an order and MAR documentation for Trulicity instead, and another resident was marked as receiving an anticoagulant despite no order or MAR documentation for that drug. The RN/MDS Coordinator confirmed both coding errors, and the DON acknowledged the inaccurate MDS assessments.
The facility failed to follow resident-specific care plans for personal hygiene and failed to develop a PTSD care plan with triggers and interventions. Two residents who were dependent on staff for ADLs were observed with long facial/chin hair despite care plan guidance for assistance with hygiene, and staff confirmed shaving had not been provided as expected. A resident with PTSD described trauma-related triggers, but the chart did not include a care plan addressing PTSD triggers or prevention of recurrence.
Failure to provide shaving as part of ADL care for two residents who were dependent on staff for bathing and personal hygiene. One resident with Alzheimer’s Disease and moderate cognitive impairment was observed with long facial hair on multiple occasions, and staff confirmed he required total assistance and had not been shaved in days, possibly about two weeks. Another resident with Alzheimer’s Disease and severe cognitive impairment was repeatedly observed with several-inch chin hairs, while staff confirmed shaving was part of shower-day ADL care and that the resident was totally dependent for care.
A resident with PTSD was admitted with the diagnosis documented, but the facility did not identify or document resident-specific triggers or interventions. The resident reported trauma-related triggers involving knives, while a CNA, an LPN, and the DON stated they were not aware of PTSD-specific triggers or any trauma-informed assessment. The record showed psych and MDS documentation of PTSD, but no assessment or care plan content addressing triggers or individualized interventions.
The facility failed to maintain an accurate clinical record when a resident was transferred to an acute hospital for further evaluation. The chart included a transfer summary and an unplanned discharge to the hospital, but no physician order was documented for the transfer. The ADON and DON both confirmed the missing order, and the DON stated that verbal orders must be entered into the computer immediately or as quickly as possible.
The facility failed to post daily nurse staffing information in a location visible to residents and the public. Surveyors observed no staffing information in the foyer or near the nursing stations on multiple survey days, and the ADON and DON confirmed the information was kept in a locked staff-only room and in binders behind the nursing station counter instead of being posted in the common areas.
An LPN in a long-term care facility failed to follow professional standards by preparing medications for two residents simultaneously, resulting in the administration of incorrect medications to a resident. This error led to the resident being admitted to the ICU due to an adverse reaction, including bradycardia and hypotension. The resident, with a history of COPD and hypertension, required immediate medical intervention and hospital transfer.
A significant medication error occurred when an LPN administered blood pressure medications to a resident that were intended for his roommate, resulting in the resident's admission to the ICU due to an adverse reaction. The LPN had pre-poured medications for both residents simultaneously, leading to the confusion and administration of the wrong medications. The resident, with a history of COPD and hypertension, experienced hypotension and bradycardia, necessitating emergency hospital transfer.
The facility failed to maintain resident dignity and privacy in two incidents. A CNA entered a resident's room without knocking or introducing herself, contrary to protocol. Additionally, clinical documentation with a resident's name was posted in a room, raising dignity concerns. The involved resident had severely impaired cognition.
The facility failed to resolve resident grievances over six months, including staff noise, premature meal tray removal, and a broken bus lift preventing outings. Despite repeated complaints, these issues remained unaddressed, leading to dissatisfaction and resignations within the resident council. Interviews revealed a lack of awareness and action from staff, with the DON acknowledging persistent issues despite previous in-servicing.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a high-risk resident with a PEG tube, as observed when an LPN administered medication without wearing a gown. The LPN acknowledged the oversight and the lack of signage or accessible PPE. Interviews with staff revealed that the facility was revising its infection control policies to include EBP guidelines, and a Performance Improvement Plan (PIP) for EBP training was underway.
A resident reported that her bathroom was not cleaned appropriately, with dust observed on the ceramic tile and her recliner. The housekeeper admitted to occasionally forgetting to clean some residents' furniture and tiles, and the Housekeeping Supervisor confirmed the oversight. The resident was cognitively intact and had a diagnosis of Type 2 Diabetes.
A resident with Parkinson's Disease and severely impaired cognition was found to be using a seatbelt in a wheelchair that functioned as a restraint, as the resident could not remove it independently. Despite being a fall risk, the resident had not experienced recent falls, and the facility failed to assess or document the seatbelt as a restraint. Staff confirmed the resident's inability to consistently remove the seatbelt, and no assessment or consent for its use was documented.
A facility failed to provide written notification to a resident's representative about the resident's transfer to a hospital. The DON acknowledged that the facility relied on phone communication instead of written documentation. The resident's representative confirmed they were informed in person but did not receive written notice. The resident had a diagnosis of Anoxic Brain Damage.
A facility failed to conduct a Level II PASARR for a resident who was prescribed Seroquel for new psychotic behaviors and hallucinations, despite the requirement for such an evaluation following significant changes in mental health status. The DON was unaware of the need for a new screening, while the Administrator expected compliance with regulations.
A facility failed to maintain a functional call light system in a resident room on Unit 4 hall. The call light was found hanging from the outlet and did not illuminate or sound when activated. A housekeeper and an LPN were unaware of the malfunction, and the residents resorted to yelling for assistance. The Maintenance Director confirmed the issue but was unaware of it prior to the incident.
Unnecessary antipsychotic use without diagnosis or consent
Penalty
Summary
The facility failed to ensure Resident #79 was free from unnecessary psychotropic medication when she received Geodon without an appropriate diagnosis and without documented informed consent. The resident was admitted with dementia and had a physician order dated 1/8/25 for ziprasidone 20 mg at bedtime for unspecified psychosis, although the NP stated the resident did not have bipolar disorder or schizophrenia and acknowledged the medication had been intended as PRN rather than scheduled daily. The DON also confirmed that psychosis was listed in the medical history but was not an approved indication for Geodon use, and the facility was unable to provide a signed consent for antipsychotic medication. RN #2 stated the facility did not retroactively seek consent after the consent process for psychotropic medications went into effect. During the survey, Resident #79 was repeatedly observed asleep in her wheelchair in common and dining areas, and staff described that she often slept through meals and was difficult to get to eat. CNA #1 stated the resident had good days and bad days and often refused meals on bad days, while LPN #3 stated she sometimes slept through medication passes and meals. The behavior monitoring log from 9/8/25 through 10/8/25 contained no documented behaviors for the resident, despite staff reporting a history of combativeness and refusal of care. The resident’s record showed 38 meal refusals during the month reviewed, a 55-pound, 25.7% weight loss over 12 months, and an RD assessment noting significant weight loss and that she needed cueing because she fell asleep while eating.
Infection Control Lapses During Eye Drop Administration
Penalty
Summary
The facility failed to follow infection prevention and control practices during medication administration for two residents. The facility’s Medication Administration Policy, dated 7/30/25, stated that medications are to be administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. During observation, an LPN administered Combigan ophthalmic solution to Resident #14, who was admitted with unspecified glaucoma and had a BIMS score of 14, without wearing gloves. The nurse also placed the plastic medication bag on the resident’s bed, retrieved it, and returned it to the medication cart without sanitizing the container. During another observation, an LPN administered artificial tears to Resident #96 without wearing gloves. Resident #96 was admitted with pulmonary fibrosis and had a BIMS score of 8. In interviews, both LPNs stated they should have worn gloves during eye drop administration, and one LPN stated medication containers should not be placed on the resident’s bed or returned to the cart without sanitizing. The DON stated that items placed on a resident’s bed or bedside table must have a clean barrier and should be sanitized before being returned to the medication cart, and that gloves should always be worn for procedures involving the eyes.
Medication Given in Dining Room in View of Other Residents
Penalty
Summary
The facility failed to ensure a resident's right to privacy and dignity during medication administration when licensed nursing staff gave prescribed eye drops to a resident in the dining room while other residents were present. During observation, an LPN administered medications to Resident #96 in the dining room with nine other residents present, despite the facility's Medication Administration Policy stating that privacy should be provided. Resident #96 was admitted with a diagnosis of pulmonary fibrosis and had a Quarterly MDS showing a BIMS score of 8, indicating moderately impaired cognition. The resident had a physician's order for Artificial Tears eye drops. During interview, the LPN stated she normally gave medications in the dining room during the morning medication pass and acknowledged privacy could be an issue when medications were given in front of other residents. The DON stated medications should not be administered in the dining room in front of other residents and that medications were expected to be given in a private setting to ensure resident dignity and privacy.
MDS Coding Errors for Insulin and Anticoagulant Use
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility inaccurately coded the MDS for two sampled residents. Facility policy required standardized assessments to be completed in a timely manner according to the current RAI Manual. For Resident #2, the admission record showed a diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The Quarterly MDS with an ARD of 8/04/2025 marked Section N, N0300 Insulin as received during the 7-day look-back period, but the order summary showed no physician order for insulin. Instead, the resident had an order for Trulicity, and the MAR for July and August 2025 documented Trulicity administration with no documentation that insulin was given. For Resident #14, the admission record showed diagnoses including Hypertensive Heart Disease with heart failure. The Quarterly MDS with an ARD of 7/28/25 marked Section N, N0415 High-Risk Drug Classes: Use and Indication as Yes for anticoagulant use during the 7-day look-back period, but the order summary showed no physician order for an anticoagulant and the July 2025 MAR showed no anticoagulant administration. During interview, the RN/MDS Coordinator confirmed Resident #14 did not have an anticoagulant order and did not receive one during the look-back period, and confirmed Resident #2 was on Trulicity rather than insulin. The DON also acknowledged the MDS errors for both residents.
Failure to Follow Care Plans for PTSD Triggers and Personal Hygiene
Penalty
Summary
The facility failed to implement resident-specific care plan interventions when staff did not provide personal hygiene shaving as identified in the care plans for two residents, and failed to develop a care plan addressing triggers and interventions for a resident with Post-Traumatic Stress Disorder (PTSD). The facility policy stated that each triggered CAA would be assessed to facilitate a plan of care based on problems identified through the assessment process. One resident was admitted with a diagnosis of PTSD and, during interview, confirmed the diagnosis and described trauma related to her husband’s death from a stab wound. She stated she no longer likes knives and does not watch knife shows. Her record showed PTSD in the MDS and psych evaluation, but there was no care plan developed with interventions that included trauma or triggers. The RN confirmed that no PTSD care plan had been developed and that no triggers were identified for prevention of recurrence. Two other residents were admitted with Alzheimer’s disease and were dependent on staff for bathing and personal hygiene. One resident was observed with long facial hair and stated staff were supposed to shave him, but he had not been shaved in a long time; a CNA confirmed he preferred to be clean-shaven and had last been shaved about two weeks earlier. The other resident was observed multiple times with long chin hair, and a CNA confirmed shaving should be completed during showers. Their care plans included general assistance with ADLs, but did not reflect the observed shaving care being provided.
Failure to Provide Shaving as Part of ADL Care
Penalty
Summary
The facility failed to provide shaving for two residents who were dependent on staff for ADLs. The facility’s undated Shaving Policy stated that male residents would be shaved daily and as needed. Resident #6 was admitted with Alzheimer’s Disease, had a BIMS score of 8, and was dependent on staff for bathing and personal hygiene. The resident was observed with long facial hair on multiple occasions, stated that staff were responsible for shaving him, and said he had not been shaved in a long time and wanted to be shaved. Staff interviews confirmed he received daily bed baths and required total assistance for ADLs except feeding, but also confirmed his facial hair appeared not to have been shaved in several days and that he had last been shaved about two weeks earlier. Resident #11 was admitted with Alzheimer’s Disease, had a BIMS score of 3, and was dependent on staff for bathing and personal hygiene. The resident was observed sitting in a wheelchair and later lying in bed with multiple long chin hairs several inches in length. Staff interviews confirmed that shaving was part of ADL care on shower days and that the resident was totally dependent for all ADLs, usually cooperative, and had long chin hair that appeared to have been present for some time. The DON also observed the long facial hair and stated that both men and women were expected to be shaved as part of bathing or shower care.
Failure to Identify PTSD Triggers and Resident-Specific Interventions
Penalty
Summary
The facility failed to ensure triggers and resident-specific interventions were identified and initiated for a resident with Post-Traumatic Stress Disorder (PTSD). Resident #2 was admitted with a current diagnosis of PTSD and had a BIMS score of 15, indicating she was cognitively intact. The record included orders for psychiatric consultation as needed and a quarterly MDS that identified PTSD as an active diagnosis, but the CNA Kardex/behavior monitoring document did not identify any resident-specific PTSD triggers. The resident’s medical record also did not show that she had been evaluated to identify PTSD triggers or that any individualized interventions had been developed or implemented. The resident told staff she had PTSD related to the death of her husband and stated she no longer liked knives and did not watch television shows involving knives. During interviews, a CNA and an LPN stated they were not aware of PTSD-related triggers, and the DON stated she was not aware of any trauma-informed or PTSD-specific assessments being completed for residents. The DON confirmed there was no documentation identifying PTSD-related triggers, acknowledged staff would be unable to recognize or avoid potential triggers without that information, and stated the facility did not have a PTSD policy. The initial psych evaluation, completed four months after admission, referenced trauma-related history and PTSD in past medical history but did not identify triggers or interventions.
Missing Physician Order for Hospital Transfer
Penalty
Summary
The facility failed to maintain an accurate resident clinical record related to a physician’s order for a hospital transfer for one resident. Resident #7 was admitted with current diagnoses including Type 2 Diabetes Mellitus, and the discharge MDS indicated the resident was transferred from the facility to a short-term general hospital due to an unplanned discharge. Progress notes documented a Transfer to Hospital Summary note stating the resident had been sent to an acute hospital for further evaluation. A review of the clinical record showed there was no physician order documented for the resident’s transfer to the hospital. The facility’s Physician’s Orders Policy stated that the nurse noting the order is responsible for transcribing the orders to the appropriate place. During interviews, the ADON and DON both confirmed that no physician order was present in the record for the hospital transfer, and the DON stated that when a verbal order is received, the nurse must enter it into the computer immediately or as quickly as possible.
Nurse Staffing Information Not Posted in Visible Areas
Penalty
Summary
The facility failed to ensure nurse staffing information was posted daily in a location visible to residents and the public. The facility’s Posting Daily Staffing Information Policy stated that nurse staffing information would be posted daily in the foyer of the building, but a review of the common areas on the survey dates found no posted staffing information visible in the foyer or near the nursing stations on Unit 200, Unit 300, and Unit 400. During interview, the ADON stated the daily nurse staffing information was completed each day, but it was posted inside a locked room near the time clock with a sign marked Staff Only, and also kept in a binder behind the nursing station counter. The DON confirmed that no nurse staffing information was posted in the common areas near Units 200, 300, or 400 and stated that the information was kept in binders behind the nursing station counter.
Medication Administration Error Leads to ICU Admission
Penalty
Summary
The facility failed to ensure that services provided met current professional standards when an LPN prepared medications for two residents simultaneously, resulting in the administration of incorrect medications to a resident. This error led to the resident being admitted to the ICU of a local acute care hospital due to an adverse reaction. The facility's policy on medication administration, which requires identifying residents by photo in the electronic medication administration record, was not followed. The incident occurred when the LPN pre-poured medications for two residents at the same time and took them into the room together, leading to confusion and the administration of the wrong medications. The resident received medications prescribed for another resident, including Lisinopril, Lipitor, Carvedilol, Hydroxyzine, and Seroquel, which caused bradycardia and hypotension. The resident's condition required immediate medical intervention, including IV fluids and Levophed, and resulted in a transfer to the hospital's ICU. The resident involved had a history of COPD and hypertension and was moderately cognitively impaired. The error was identified when the resident's blood pressure dropped significantly, prompting the nursing staff to notify the physician and arrange for the resident's transfer to the hospital. The facility's Director of Nursing confirmed that the LPN did not adhere to the standards of practice or facility policy, which contributed to the medication error.
Medication Error Leads to ICU Admission
Penalty
Summary
A significant medication error occurred when an LPN administered blood pressure medications to a resident that were intended for his roommate. This error resulted in the resident being admitted to the ICU of a local acute care hospital due to an adverse reaction. The facility's policy on medication administration, which requires identifying residents by photo in the electronic medication administration record (EMAR), was not followed. The LPN had pre-poured medications for both residents simultaneously and took both cups into the room, leading to the confusion and administration of the wrong medications. The incident note from the facility detailed the sequence of events following the error. The resident was initially awake, alert, and oriented, but his blood pressure decreased significantly after receiving the wrong medications. Despite being placed in the Trendelenburg position to manage his blood pressure, the resident's condition worsened, leading to difficulty breathing and further decrease in blood pressure. Emergency services were called, and the resident was transferred to the hospital for treatment of hypotension and bradycardia, where he was admitted to the ICU. Interviews with the resident, the resident's representative, and the Director of Nursing (DON) confirmed the sequence of events and the failure to adhere to medication administration standards. The DON's investigation revealed that the LPN had not followed the facility's policy by preparing medications for more than one resident at a time, which led to the error. The resident, who had a history of COPD and hypertension, experienced a significant adverse reaction due to the administration of medications not prescribed for him.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to dignity and privacy in two separate incidents. In the first incident, a Certified Nurse Aide (CNA) entered a resident's room without knocking, addressing the resident, or introducing herself. This action was observed by a Licensed Practical Nurse (LPN), who noted that the CNA's behavior did not align with the facility's protocol, which requires knocking, waiting for a response, and explaining the purpose of the visit. The CNA admitted to skipping this step due to familiarity with the resident, despite being aware of the facility's policy. The Director of Nursing (DON) confirmed that the CNA should have followed the protocol to maintain the resident's dignity. In the second incident, clinical documentation containing a resident's name and care details was posted on a wall in the resident's room. This documentation was intended to assist staff in providing specific care, but its visibility raised concerns about the resident's dignity. The LPN and DON acknowledged that the information, which was also available in the Electronic Medical Record (EMR), could be considered a dignity issue. The resident involved had a severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3.
Unresolved Resident Grievances Over Six Months
Penalty
Summary
The facility failed to consistently resolve grievances raised by resident council members over a six-month period. The resident council minutes from May to October documented recurring complaints about staff noise, premature removal of meal trays, and a malfunctioning lift on the facility bus, which hindered resident outings. Despite these issues being raised repeatedly, they remained unresolved, leading to dissatisfaction among residents and the resignation of the council's president and vice president. Interviews with facility staff revealed a lack of awareness and action regarding these grievances. The Social Services Director confirmed that department heads were responsible for addressing complaints but had not done so effectively. The Activity Director was unaware of the transportation issues, and the Administrator acknowledged the bus had been out of service for six months. The DON admitted that staff had been previously in-serviced on noise reduction and meal tray timing, but these issues persisted, indicating a failure to implement and monitor corrective measures effectively.
Failure to Implement Enhanced Barrier Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident identified as high risk for acquiring multi-drug-resistant organisms (MDROs). During an observation, a Licensed Practical Nurse (LPN) entered the resident's room to administer medication via a Percutaneous Endoscopic Gastrostomy (PEG) tube without wearing a gown, which is required under EBP protocols. The LPN admitted to forgetting to wear a gown and noted the absence of signage or indicators to alert staff about the need for EBP, as well as the lack of readily accessible personal protective equipment (PPE). Interviews with facility staff, including the Director of Nursing (DON) and a Registered Nurse (RN), revealed that while the facility follows standard precautions and uses transmission-based precautions, there were no existing policies incorporating EBP. The facility was in the process of revising its infection control policies to include EBP guidelines. The Licensed Nursing Home Administrator (LNHA) confirmed that the facility was under a Performance Improvement Plan (PIP) for EBP training, initiated in September 2024, to enhance compliance with EBP guidelines.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for one of the resident rooms on Unit 2, affecting a resident. During an observation and interview, the resident reported that her bathroom was not cleaned appropriately, with a thick white substance, identified as dust, observed on the ceramic tile in her bathroom and on the back of her recliner. The facility's Environmental Policy emphasizes the importance of providing a safe, clean, comfortable, and homelike environment, which was not adhered to in this instance. Interviews with the housekeeper and the Housekeeping Supervisor confirmed the oversight in cleaning the resident's bathroom and furniture. The housekeeper admitted to occasionally forgetting to clean some residents' furniture and ceramic tiles, while the supervisor acknowledged the failure to clean the dust in the resident's bathroom and on her recliner. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had a diagnosis of Type 2 Diabetes.
Failure to Identify and Document Seatbelt as Restraint
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints by not identifying and documenting the use of a seatbelt as a restraint for one of the sampled residents. The facility's Restraint Policy defines physical restraints as any device that the resident cannot remove easily, which restricts freedom of movement. During observations, it was noted that the resident was unable to remove the seatbelt independently, indicating it functioned as a restraint. Interviews with staff confirmed that the resident could not consistently remove the seatbelt on command, and the facility had not assessed or documented the seatbelt as a restraint. The resident involved had a history of Parkinson's Disease and was admitted to the facility with severely impaired cognition, as indicated by a low BIMS score. Despite being a fall risk, the resident had not experienced recent falls. The facility's staff, including CNAs, LPNs, and the DON, acknowledged the resident's inability to remove the seatbelt independently and confirmed that the seatbelt was not identified as a restraint. The facility had not conducted an assessment or obtained consent for the seatbelt's use, and the resident's medical records lacked documentation of any restraint assessment.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the resident's transfer to an acute care hospital. This deficiency was identified for one of the sampled residents. The Discharge Minimum Data Set indicated that the resident was discharged to a hospital with the anticipation of returning to the facility. During interviews, the Director of Nursing acknowledged that the facility did not provide written documentation to the resident's representative, instead relying on phone communication. The resident's representative confirmed that while they were informed in person about the hospitalization, they did not receive any written documentation. The facility's administrator also acknowledged the failure to provide written notification regarding the hospitalization. The resident involved was admitted to the facility with a diagnosis of Anoxic Brain Damage. The deficiency was identified through staff and resident representative interviews, as well as a review of the resident's records.
Failure to Conduct Level II PASARR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident who was receiving psychotropic medications and had a new mental health diagnosis. The resident was initially admitted with no indication of mental illness or the use of psychotropic medications, as per the Pre-Admission Screening (PAS) dated March 25, 2022. However, on August 7, 2023, the resident was prescribed Seroquel for increased psychotic behaviors and hallucinations, and was diagnosed with Unspecified Psychosis Not Due to a Substance or Known Physiological Condition and Unspecified Hallucinations. The Director of Nursing (DON) confirmed that the initial PAS did not indicate the need for a Level II evaluation and acknowledged that the resident experienced a change in mental health status with a new diagnosis and prescription of psychotropic medication. The DON was unaware that such changes necessitated another screening for a Level II evaluation. The Administrator confirmed awareness of the requirement for a Level II PASARR in cases of significant change, including new diagnoses or medications, and expected staff to adhere to these regulations.
Nonfunctional Call Light System in Resident Room
Penalty
Summary
The facility failed to maintain a functional call light system in one of the rooms on Unit 4 hall. During an observation, the call light in the room was found hanging from the outlet and did not illuminate or sound when activated by the resident. A housekeeper and an LPN both attempted to activate the call light without success, and neither was aware of the malfunction prior to the observation. The residents in the room were also unaware of how long the call light had been nonfunctional and resorted to yelling for assistance when the call light did not work. The Maintenance Director confirmed the call light was not working and required replacement, but he was unaware of the issue before the incident.
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Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bay Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care Center Of Laurel | 18.8 mi | ★★★★★ | 0 | 0 |
| Laurelwood Community Living Center | 19 mi | ★★★★★ | 3 | 0 |
| Comfort Care Nursing Center | 19 mi | ★★★★★ | 8 | 0 |
| Ms Care Center Of Raleigh | 19.3 mi | ★★★★★ | 0 | 0 |
| Jones Co Rest Home | 23.4 mi | ★★★★★ | 1 | 1 |
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