Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Pine Forest Health And Rehabilitation during CMS and state inspections, most recent first.
A CNA failed to perform hand hygiene before, during, and after ADL care for a resident with trach status and dysphagia. The CNA entered the room without a gown, used the same gloves while adjusting the bed and handling the bed sheet, then continued care after contamination was observed with a urine-soiled brief and lift pad. The CNA later acknowledged the mistake, and the RN/IP and DON stated hand hygiene should have been performed on entry, during contamination, and on exit.
A resident with paraplegia, reduced mobility, and intact cognition experienced a fall from bed with head impact in the evening, was found on the floor by CNAs, and was assisted back to bed under direction of an LPN without timely assessment or notification of the resident’s representative (RR). The resident reported the fall and head injury to a Wound Care Nurse the following morning, at which point the Unit Manager, DON, and Administrator were informed, and the RR was finally notified. Facility policies on resident rights and falls required prompt RR notification and documentation of who was notified and when, but there was no documentation of RR notification on the date of the fall, resulting in a deficiency for failure to immediately inform the RR of a significant change in condition.
A resident with paraplegia, reduced mobility, and intact cognition fell from bed in the evening, landing face-down on the floor and striking the head, as later reported by CNAs and the resident. An LPN directed CNAs to return the resident to bed, but no fall was documented, and no immediate vital signs, neuro checks, pain assessment, or body audit were performed during the evening or night shifts, despite facility policy requiring these actions for unwitnessed falls and head injuries. The resident reported the fall and forehead swelling to the Wound Care Nurse the next morning, at which point the Unit Manager and DON were notified, and the primary healthcare provider and resident representative were contacted. The DON and Administrator confirmed there was no contemporaneous documentation or appropriate assessment after the fall and that staff did not follow the facility’s fall policy or timely notification requirements.
A resident who was non-ambulatory and returning from dialysis sustained a scapular fracture and multiple rib fractures after a CNA failed to lock both wheelchair wheels during van loading, causing the wheelchair to roll off the lift platform. The resident fell onto the concrete driveway and required hospital evaluation and treatment. Staff interviews and facility policy review confirmed that proper safety procedures were not followed.
Two residents with significant cognitive impairments were not provided with the structured or individualized activities outlined in their care plans. Despite documented preferences for music and therapeutic engagement, both were observed spending long periods unengaged in the dayroom. Staff interviews confirmed a lack of follow-through on care plan interventions, and facility policy requiring adherence to care plans was not met.
Two residents with severe cognitive impairment were not provided with activities tailored to their needs and interests. Both were observed spending long periods without engagement or appropriate stimulation, despite staff acknowledging the lack of suitable activities and the facility's policy requiring individualized activity planning.
A newly admitted resident with dementia and altered mental status exited the facility unsupervised after a receptionist, unaware of her status, unlocked the front door. The resident was found in a busy intersection, requiring multiple staff to retrieve her. The incident occurred during shift change, and the resident had not yet been added to the wandering risk binder. This failure to supervise and secure the exit resulted in Immediate Jeopardy and Substandard Quality of Care.
A resident with dementia and altered mental status was able to exit the facility unsupervised after a receptionist, unaware of the resident's new admission status, released the front door lock. The resident was found in a public intersection, combative and seeking to go home. Staff interviews revealed gaps in communication and monitoring, and the resident's risk for wandering was not fully identified or addressed prior to the incident.
Staff failed to follow infection control protocols during care for two residents with indwelling devices. An LPN did not wear a gown while administering medication via PEG tube, and another LPN did not use a clean section of a washcloth for each wipe during suprapubic catheter care. Both actions were contrary to facility policy and infection prevention standards.
Two residents did not receive care as outlined in their care plans. One resident with incontinence and ADL deficits was found in heavily soiled linens without scheduled peri care, as confirmed by CNAs and the DON. Another resident, requiring two-person assistance for repositioning due to significant physical impairments, was turned by a single CNA, resulting in a fall. The MDS nurse confirmed that care plans are essential and must be followed by all staff.
A resident with a stage 4 sacral pressure ulcer and severe cognitive impairment did not receive thorough perineal care, as CNAs failed to clean the area properly before applying a new brief, leaving the resident soiled with urine and feces. Staff interviews and observations confirmed that perineal care was incomplete and not performed as required by facility policy.
A resident with a stage 4 sacral pressure ulcer did not receive peri-care before wound care was performed by LPNs, despite being found with heavily soiled linens and a saturated brief. Wound care was completed without addressing the soiling, and the resident reported infrequent changes and prolonged periods of wetness. The DON confirmed that peri-care should have been provided prior to wound care, in accordance with facility policy.
The facility did not maintain or monitor previously implemented QAPI interventions, resulting in repeated deficiencies related to staff not following a resident's care plan and improper infection control during PEG and suprapubic catheter care for two residents. These issues persisted despite being cited in a prior survey.
A resident with cognitive impairment and right hemiparesis was physically abused by a CNA, resulting in facial injuries. The CNA admitted to using force to prevent the resident from hitting her during perineal care. Despite the resident's injuries and his account of being hit, the facility's investigation did not substantiate the abuse allegation, citing the resident as the aggressor. This indicates a deficiency in the facility's adherence to abuse prevention protocols.
A resident with cognitive impairment and hemiparesis experienced physical force from a CNA during care, resulting in injuries. The CNA did not follow the resident's care plan, which instructed staff to stop and return if the resident became agitated. Despite the resident's aggressive behavior, the care plan's directives were not implemented, leading to the incident.
A resident with paraplegia and moderate cognitive impairment was injured during a transfer when a CNA attempted to use a mechanical lift without a second staff member, contrary to facility policy and lift instructions. The resident was left unattended in the lift sling, resulting in a fall and head injury requiring staples. The CNA had been trained on proper lift use, including the need for two staff members, but failed to ensure adequate assistance.
The facility failed to ensure call lights were within reach for two residents, both with severe cognitive impairments and dependent on staff for daily activities. Observations revealed call lights on the floor, out of reach, despite staff expectations for accessibility. Interviews confirmed the importance of call lights being within reach to ensure timely responses to residents' needs.
The facility failed to acknowledge and resolve grievances promptly, affecting two residents. One resident's concerns were not addressed until family intervention, despite having no cognitive impairment. Another resident's family reported issues with care quality, but received no follow-up, despite multiple communications with staff. The facility's grievance logs did not document these issues, and concerns raised in Resident Council meetings were not treated as grievances, leading to unresolved issues and lack of communication.
The facility failed to implement individualized ADL care plans for four residents, resulting in inadequate personal hygiene care. Observations revealed untrimmed fingernails and toenails with a dark substance beneath them, and unwanted facial hair not addressed during daily care. Interviews with staff indicated a lack of communication and adherence to care plan interventions, despite care plans being accessible through facility software and kiosks. The DON and Administrator confirmed that ADL care should align with resident preferences and care plans.
The facility failed to provide necessary grooming services for four residents, including nail care and facial hair removal. Observations showed residents with long, unclean nails and unwanted facial hair, despite being dependent on staff for ADLs. Interviews revealed inconsistencies in staff responsibilities for grooming tasks, leading to unmet hygiene needs.
The facility's QAPI committee failed to address deficiencies related to comprehensive care plans for ADL care and grooming for dependent residents. Despite policies for improvement, the committee did not effectively implement measures to correct these issues, leading to re-cited deficiencies. The Administrator noted that the facility may not have monitored enough residents to ensure adequate grooming care.
Hand Hygiene Not Performed During ADL Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient during observed ADL care for one resident. During an observation of care for a resident with tracheostomy status and dysphagia, a CNA entered the room carrying supplies without a gown and did not perform hand hygiene on entry. The CNA donned gloves, adjusted the bed, and pulled back the bed sheet while wearing the same gloves, then removed the gloves and exited the room. When the CNA returned with an RT, both staff were wearing gowns, but the CNA again did not perform hand hygiene before putting on new gloves and continuing care. While providing peri care and assisting with turning the resident, the CNA handled the resident’s gown and brief, which was observed to be soiled with urine, folded the soiled brief and tucked it underneath the resident, and then adjusted the bed using the same contaminated gloves. A lift pad underneath the resident was also observed to be yellow and soiled with urine. The CNA did not perform hand hygiene before care, during glove changes, or after completing care. The CNA later stated she had made a mistake during peri care and acknowledged the care was an infection control concern. RN #1, who also served as the Infection Preventionist, and the DON both stated the CNA should have performed hand hygiene upon entering the room, during care when contamination occurred, and upon exiting the room. The resident had diagnoses including tracheostomy status and dysphagia and was dependent upon staff for care.
Failure to Promptly Notify Resident Representative After Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of a change in condition following a fall, as required by facility policy and resident rights. Facility policies on Resident Rights & Dignity Management and Falls Standard state that residents and/or their designated representatives must be fully informed of changes in medical or health status, including incidents and accidents, and that documentation must include who was notified and when. The Falls Standard further specifies that family is to be notified of a fall event. These policies were not followed for one sampled resident who experienced a fall with head impact. Resident #1, admitted with diagnoses including paraplegia, reduced mobility, and lack of coordination, was non-ambulatory and dependent for transfers. The resident’s Quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. On the evening of 12/27/25, CNAs reported finding the resident lying on her face on the floor next to her bed and, under the direction of an LPN, assisting her back into bed. The resident later reported that she had fallen from bed while reaching for something on the floor and had bumped her head. There was no documentation that the RR was notified at the time of the fall, and the resident did not receive assessment and treatment until the following morning. On the morning of 12/28/25, the resident informed the Wound Care Nurse that she had fallen the previous evening, hit her head on the floor, and had a raised, tender area on her right forehead. The Wound Care Nurse then notified the Unit Manager, who in turn notified the DON and Administrator. The facility’s incident report and investigation documented the fall as an unwitnessed event reported by the resident, with RR notification recorded at 9:46 AM on 12/28/25. The RR stated she was not notified of the fall until after 9:30 AM the following morning and expressed disapproval and disappointment with the delay, noting she observed swelling on the resident’s forehead. The Administrator confirmed there was no documentation of RR notification on the date of the fall, establishing that the facility failed to promptly notify the RR of the resident’s change in condition as required by policy and resident rights.
Failure to Assess, Monitor, Document, and Report an Unwitnessed Fall With Head Impact
Penalty
Summary
The deficiency involves the facility’s failure to follow its own fall policy and adequately assess, monitor, and report an unwitnessed fall with head impact for one resident. The facility’s Falls Standard policy required that when a resident is found on the floor, staff must investigate the reason for the fall, obtain vital signs while the resident is on the ground, perform neurological checks for unwitnessed falls or head injuries, and complete fall-related documentation including a Fall Risk Assessment, incident report, and post-fall investigation. The policy also required neurological assessments every 15 minutes for 2 hours, every 30 minutes for 2 hours, and then every shift for 72 hours, as well as timely notification of the resident’s primary healthcare provider, resident representative, DON, and others as appropriate. These procedures were not followed after the resident’s fall on the evening of 12/27/25. Resident #1 was admitted with diagnoses including paraplegia, reduced mobility, and lack of coordination, and was documented as non-ambulatory and dependent for transfers. The resident was cognitively intact with a BIMS score of 14. On the evening of 12/27/25, the resident fell from the bed while reaching for something on the floor and struck her head, resulting in a bump and swelling on the right forehead. CNA #1 and CNA #2 reported finding the resident lying on her face on the floor next to the bed at approximately 7:45–7:48 PM, and stated that an LPN instructed them to assist the resident back into bed. There was no documentation of a fall, no recorded vital signs taken while the resident was on the floor, and no neurological checks, pain assessments, or body/skin audits performed or documented during the 3:00 PM–11:00 PM or 11:00 PM–7:00 AM shifts following the incident. The fall was not reported to supervisory staff, the primary healthcare provider, or the resident representative at the time it occurred. The resident later informed the Wound Care Nurse on the morning of 12/28/25 that she had fallen the previous evening, hit her head on the floor, and had swelling and tenderness above the right eye. Only after this self-report were the Unit Manager, DON, primary healthcare provider, and resident representative notified, and an incident report and investigation initiated. The resident representative stated she was not notified of the fall until the following morning and expressed disapproval and disappointment with the delay in notification, noting that the resident had a bump on her forehead and had not received assessments or treatment until the next day. The Administrator and DON confirmed there was no documentation of the fall or appropriate assessment or evaluation on the evening and night shifts, and that nursing staff did not follow the facility’s fall policy, including required assessments, monitoring, documentation, and timely notification of the resident representative and primary healthcare provider. The DON acknowledged that the correct procedure after a fall included immediate assessment, body/skin audit, pain assessment, initiation of neurological checks and vital sign monitoring for 72 hours, and prompt notification of the primary healthcare provider, resident representative, DON, Administrator, and ambulance if needed. The DON also confirmed that failure to report incidents and provide assessments and care according to the fall policy could result in the resident having unrelieved pain, complications, or negative unidentified results from falls. Interviews with the Unit Manager and Wound Care Nurse further confirmed that falls were to be reported and documented on the 24-hour report, with incident reports and ongoing assessments, and that resident representatives should be notified right away as a change of condition. Despite these established policies and staff knowledge, the required post-fall assessments, monitoring, documentation, and timely notifications were not carried out following Resident #1’s unwitnessed fall with head impact on the evening of 12/27/25.
Failure to Secure Wheelchair During Van Loading Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to properly secure a resident's wheelchair during the process of loading the resident onto a facility van lift platform. The facility's policy required that both wheelchair brakes be locked before operating the lift, but the CNA only locked one wheel. As a result, the wheelchair rolled backward off the lift platform while the resident was seated, causing the resident to fall onto the concrete driveway. The resident involved had a history of hemiplegia affecting the right dominant side and was non-ambulatory, requiring a wheelchair for mobility. At the time of the incident, the resident was returning from a dialysis appointment and was cognitively intact. The fall resulted in the resident sustaining a scapular fracture and multiple rib fractures, as confirmed by hospital imaging. The resident reported pain and was later transported to an acute care hospital for further evaluation and treatment. Interviews with facility staff and the resident confirmed that the CNA did not follow the required safety procedures for securing the wheelchair. The CNA admitted to failing to lock both wheels, and staff interviews corroborated that the incident occurred while the lift was on the ground. The facility's investigation concluded that the CNA's failure to adhere to established protocols directly led to the resident's fall and subsequent injuries.
Failure to Implement Individualized Activity Care Plans for Two Residents
Penalty
Summary
Surveyors found that the facility failed to implement individualized care plans for two residents regarding participation in structured activities. Observations over two days showed both residents spending extended periods in the dayroom without engagement in any planned or structured activities, despite care plans specifying their enjoyment of music and the need for therapeutic activities. One resident, who is nonverbal with a history of traumatic brain injury and a BIMS score of 0, was observed sitting in a Geri-chair, not participating in group activities such as music therapy or movies as outlined in her care plan. The other resident, diagnosed with dementia and psychosis and also with a BIMS score of 0, was similarly left unengaged, seated with her back to the television and not included in activities appropriate to her needs. Interviews with staff, including a CNA, the Activities Director, the DON, and an LPN responsible for care planning, confirmed that the residents were not provided with the individualized activities specified in their care plans. Staff acknowledged oversights and a lack of follow-through, with the Activities Director admitting to not bringing the resident to a music activity and the DON confirming the absence of stimulating activities for the second resident. Facility policy requires that residents receive services and items included in their care plans, but this was not followed for these two residents, resulting in a failure to meet their psychosocial needs as documented.
Failure to Provide Individualized Activities for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to provide activities designed to meet the physical and mental needs and interests of two residents, as required by facility policy and resident rights. Observations revealed that both residents spent extended periods in the dayroom without any structured or care-planned activities. One resident, who is nonverbal and has a history of traumatic brain injury with a BIMS score of 0, was observed sitting in a Geri-chair, not participating in activities such as music or bingo, which staff acknowledged were not appropriate for her. The other resident, diagnosed with dementia and psychosis and also with a BIMS score of 0, was repeatedly observed sitting alone with her back to the television and no engagement in any activities. Interviews with staff, including a CNA, the Activities Director, the DON, and the Administrator, confirmed the lack of individualized activities and engagement for these residents. Staff admitted to oversights in including the residents in suitable activities and acknowledged that the activities provided, such as bingo, were not appropriate for their cognitive abilities. The DON specifically recognized the need for more stimulating activities for one resident and cited a lack of staff follow-through. Facility policy requires support of resident choice and activities consistent with assessments and care plans, which was not observed in these cases.
Resident Elopement Due to Failure in Supervision and Door Security
Penalty
Summary
A deficiency occurred when a newly admitted resident with diagnoses of unspecified dementia and altered mental status was able to exit the facility unsupervised and unmonitored. The resident left through the front door after the receptionist, not recognizing her as a resident, unlocked the door. No staff or visitors were present to intervene as the resident exited. The resident was subsequently found sitting on the back of a trailer attached to a pickup truck in the middle of a busy intersection approximately 600 feet from the facility, surrounded by several cars. Multiple staff members, including nursing and administrative personnel, responded to retrieve the resident, who was combative and resistant to returning to the facility. Interviews with staff revealed that the incident occurred during a shift change, and several staff members, including LPNs, the DON, ADON, and the Administrator, did not witness the resident leaving the building but responded after hearing staff yelling about the resident's elopement. The receptionist admitted to unlocking the door for the resident, stating she did not recognize her due to the resident's recent admission. The admissions coordinator and nursing staff did not identify any significant concerns in the preadmission documents, although the resident's daughter had mentioned increased difficulty managing her at home. The social services director had not yet updated the wandering risk binder to include the new resident, as she was off work at the time of admission and had planned to complete the assessment the following day. The facility's policy on abuse, neglect, and exploitation prohibits acts of neglect, defined as the failure to provide necessary services to avoid physical harm. The resident's elopement and exposure to a hazardous situation in a busy intersection constituted a failure to protect her from neglect. The initial assessment of the resident upon return revealed no injuries, but the event was determined to be Immediate Jeopardy and Substandard Quality of Care due to the risk of serious harm.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention. The resident, who had been admitted the previous day with diagnoses including unspecified dementia and altered mental status, was able to leave the building through the front door after the receptionist released the door lock. The receptionist did not recognize the resident as a new admission and allowed her to exit unaccompanied. The resident was later found approximately 600 feet from the facility, seated on a trailer in a public intersection surrounded by traffic, and was described as combative and yelling that she wanted to go home. Interviews with staff revealed that several employees, including LPNs, the DON, the Administrator, and CNAs, responded after hearing shouting and ran outside to retrieve the resident. None of the staff interviewed witnessed the actual elopement, only the aftermath. The receptionist confirmed that she had unlocked the door for the resident, not realizing she was a new admission, and the resident's representative stated she had told the receptionist to let the resident out, also not realizing the resident was new. The facility's policy required all residents to be assessed for wandering risk prior to or upon admission, but the assessment did not identify the resident's history of wandering as reported by the family. Further review indicated that the facility's process for identifying and monitoring residents at risk for wandering was not fully implemented for this resident. The Social Services Director had not yet added the resident to the wandering binder due to being off work at the time of admission, and the nurse who completed the assessment attributed the resident's confusion to a urinary tract infection, not being aware of the family-reported wandering history. The lack of effective communication and monitoring allowed the resident to exit the facility unsupervised, resulting in a situation determined to be Immediate Jeopardy and Substandard Quality of Care.
Failure to Follow Infection Control Protocols During Device Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during care for two residents with indwelling medical devices. In one instance, an LPN administered medication via a percutaneous endoscopic gastrostomy (PEG) tube without donning a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy and CDC recommendations. The LPN acknowledged she was trained on EBP and recognized the omission, and both the Infection Preventionist and Director of Nursing confirmed that a gown should have been worn to prevent potential transmission of infection. In another instance, an LPN provided suprapubic catheter care to a resident but did not follow the facility's policy for cleaning the catheter site. The LPN used the same section of a washcloth in a circular motion multiple times before flipping to a clean section, rather than using a clean section for each wipe as required. The LPN, Infection Preventionist, and Director of Nursing all confirmed that this technique could transfer bacteria and increase the risk of infection. Both residents involved had relevant medical conditions requiring these devices and care procedures.
Failure to Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with bladder incontinence and an ADL self-care performance deficit, the care plan required incontinence care every two hours and as needed, with total assistance to keep the skin clean and dry. However, during an observation, the resident was found wearing a heavily soiled brief, turn pad, and draw sheet, all soaked with urine and emitting a putrid odor. Both CNAs interviewed confirmed that the care plan was not followed, and the resident had not received peri care as scheduled. The DON also confirmed that leaving a resident unclean and heavily soiled with urine increases the risk of infection and that peri care should be performed every two hours. Another resident with a self-care performance deficit required two staff members to assist with repositioning and turning in bed, as documented in the care plan. Despite this, a CNA repositioned the resident alone at the resident's request, resulting in the mattress sliding and the resident falling onto the floor. The CNA acknowledged that the care plan specified two-person assistance and admitted fault for not seeking help. The resident's medical history included Guillain-Barre Syndrome, paraplegia, restlessness, agitation, lack of coordination, and muscle weakness, and the resident was cognitively intact according to the most recent assessment. The MDS nurse confirmed that care plans are essential for determining and meeting residents' needs and should be followed by all staff.
Failure to Provide Adequate Perineal and Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide appropriate perineal care to a resident with a stage 4 sacral pressure ulcer and severely impaired cognition. During an observation, a CNA applied a clean brief without thoroughly cleaning the resident, as evidenced by repeated wipes that continued to show brown residue. Both the assisting CNA and the CNA performing care acknowledged that the cleaning was incomplete and that proper procedure was not followed. The Director of Nursing confirmed that perineal care should continue until the area is clean and that a clean wipe should be used each time. Further observations revealed that the resident was left heavily soiled with urine and feces, with soiled linens emitting a putrid odor. Interviews with staff confirmed that the resident was not properly cleaned and that perineal care had not been performed as scheduled. The resident, who is dependent for hygiene and toilet care, was not assigned to the CNA who provided care, and there was no documentation of refusal or reassignment. The facility's policy requires perineal care to maintain cleanliness and prevent infection, but this was not adhered to in the care of this resident.
Failure to Provide Proper Wound Care and Hygiene Prior to Dressing Change
Penalty
Summary
A deficiency occurred when wound care for a resident with a stage 4 sacral pressure ulcer was not performed in accordance with facility policy and infection control standards. During an observed wound care procedure, LPNs removed a wound vacuum and dressing from the resident while the resident's bed linens and brief were heavily soiled with yellow and brown urine. Peri-care was not performed prior to the wound care, and the LPN acknowledged not noticing the soiled condition until after the procedure was completed. The wound care nurse confirmed that wound care was initiated despite the resident being visibly soiled and that peri-care is typically provided beforehand with CNA assistance. The resident, who has severe cognitive impairment, reported being changed only once at night and remaining wet for long periods, with staff not checking on her during the night. The Director of Nursing confirmed that peri-care should have been completed before wound care and that failure to do so could lead to contamination and further skin breakdown. Facility policy requires dressing changes to be performed as ordered and infection control policies to be followed to prevent contamination in individuals with pressure ulcers.
Failure to Sustain QAPI Oversight for Care Plan and Infection Control Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain and monitor implemented procedures and interventions that were put in place to address previously identified deficiencies. Specifically, the committee did not sustain effective oversight for two deficiencies originally cited in December 2023: failure to follow a resident's care plan and improper infection control practices. Record reviews and interviews confirmed that these deficiencies persisted during the current survey, indicating that the corrective actions previously established were not maintained or monitored as required by the facility's own QAPI policy. For the care plan deficiency (F656), a Certified Nursing Assistant did not follow the comprehensive care plan when repositioning a sampled resident. Regarding infection control (F880), observations revealed that staff failed to prevent the potential spread of infection during PEG care for one resident and suprapubic catheter care for another, as noted in two out of five care observations. These findings were corroborated by record reviews, interviews, and policy reviews, confirming that the same issues identified in the prior survey were still present.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nurse Aide (CNA). The incident involved a cognitively impaired resident with right hemiparesis, who was found with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead. The CNA admitted to using physical force on the resident's left arm and face to prevent the resident from hitting her. The facility's policy on abuse prevention was not adhered to, as the CNA did not leave the room when the resident resisted care, which is against the facility's protocol. The incident occurred when the CNA attempted to provide perineal care to the resident, who was reportedly resistant and aggressive. The CNA applied pressure to the resident's arm and face, resulting in injuries. Despite the resident's cognitive impairment, he communicated that the CNA hit him, and this was corroborated by his physical injuries. The facility's investigation concluded that the abuse allegation was unsubstantiated, citing the resident as the aggressor, but the evidence of physical injuries and the CNA's admission of using force contradict this conclusion. Interviews with other staff and the resident's roommate revealed inconsistencies in the accounts of the incident. The roommate heard a loud pop and commotion but did not witness any hitting. Other CNAs and the LPN noted the resident's injuries and his frightened demeanor after the incident. The facility's failure to substantiate the abuse allegation despite the evidence suggests a deficiency in their investigation process and adherence to abuse prevention protocols.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with cognitive impairment and right hemiparesis. During an incident, a CNA used physical force on the resident, resulting in purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead. The care plan for the resident, which was supposed to guide staff in handling the resident's behavior during care, was not followed. The plan included directives to use simple communication and to stop and return if the resident became agitated. The incident occurred when the CNA attempted to change the resident's brief, and the resident became aggressive, swatting at the CNA. Despite the care plan's instructions to stop and return later if the resident became agitated, the CNA continued to apply pressure to the resident's functional arm and used force on the resident's face. The resident, who had a BIMS score indicating severe cognitive impairment, was dependent on staff for toileting hygiene and was always incontinent of urine. Interviews with facility staff, including the LPN responsible for MDS and care planning, confirmed that the CNA did not follow the care plan. The Director of Nursing also acknowledged that the CNA should have left the room and returned later to provide care, as per the care plan. The facility's investigation concluded that the allegation of abuse could not be substantiated because the resident was the aggressor, but the care plan was not implemented as required.
Failure to Secure Resident in Mechanical Lift Leads to Injury
Penalty
Summary
The facility failed to secure a resident in a mechanical lift and provide necessary supervision during a transfer, resulting in a laceration that required staples and an Emergency Department visit. The incident involved a resident with paraplegia and moderate cognitive impairment, who was dependent on staff for bed-to-chair transfers. On the morning of the incident, a CNA attempted to transfer the resident using a mechanical lift without the assistance of a second staff member, as required by the facility's policy and the lift manufacturer's instructions. The CNA left the resident suspended in the lift sling unattended while she went to the door to call for help, during which time the resident slid out of the sling and fell, sustaining a head injury. Interviews with facility staff, including the CNA involved, revealed that the CNA was aware of the requirement for two staff members to assist with such transfers and had received training on the use of mechanical lifts. The CNA confirmed that other staff were available to assist but she was the only one present in the room at the time. The Director of Nursing confirmed that the investigation determined the fall was due to the CNA's failure to ensure adequate staff were present for a safe transfer. The facility's Staff Educator emphasized that training included the importance of not leaving residents unattended in a lift.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #3, who was observed awake and resting in bed, had her call light on the floor by her bed. She was unable to locate it despite being able to use it. Resident #3 had a severe cognitive impairment with a BIMS score of 6 and was dependent on staff for all activities of daily living. Similarly, Resident #6 was found with her call light coiled up on the floor at the end of her bed, out of reach. She also had a severe cognitive impairment with a BIMS score of 7 and required staff assistance for daily activities. Interviews with facility staff, including CNAs and an LPN, confirmed that call lights were expected to be within reach of residents to ensure timely responses to their needs. The Director of Nurses and the Administrator both expressed expectations that call lights should be accessible to residents and answered promptly. Despite these expectations, the observations of the call lights being out of reach for Residents #3 and #6 indicate a failure to adhere to the facility's policy and ensure the safety and well-being of the residents.
Failure to Address and Communicate Grievances
Penalty
Summary
The facility failed to acknowledge and resolve grievances promptly, as well as communicate progress toward resolution with residents and their families. This deficiency was identified through interviews, record reviews, and policy reviews, affecting two of the seven sampled residents. The facility's policy on grievances, revised in January 2025, outlines that the Administrator is responsible for the Grievance Program, with Social Service staff designated as the Grievance Official. However, the facility did not adhere to its policy, as grievances were not documented or resolved in a timely manner, and there was a lack of communication with the residents and their families regarding the status of their grievances. Resident #2 reported concerns in December 2024 to the facility administration, which were not addressed until the resident's family intervened. The family member of Resident #2 attended a care conference to discuss these concerns, considering it an official grievance, but was uncertain about the facility's definition of an official grievance. The resident had a BIMS score of 15, indicating no cognitive impairment, and was admitted to the facility in February 2024 with a diagnosis of paraplegia. Resident #3's family expressed concerns about the quality of care, including issues with linens, the resident being left wet, food on clothes and bedding, and falls. Despite multiple communications with staff, including the ADON, DON, Administrator, and Social Worker, the family did not receive follow-up on their grievances. The resident, admitted in November 2024 with a diagnosis of cerebral infarction, had a BIMS score of 6, indicating severe cognitive impairment. The facility's grievance logs from October to December 2024 did not document these grievances, and concerns raised in Resident Council meetings were not treated as grievances, leading to unresolved issues and a lack of follow-up communication.
Failure to Implement Individualized ADL Care Plans
Penalty
Summary
The facility failed to implement individualized care plans for Activities of Daily Living (ADL) care related to personal hygiene for four residents. Observations and interviews revealed that residents had untrimmed fingernails and toenails with a dark brownish substance beneath them, indicating inadequate grooming. One resident expressed dissatisfaction with the length of their fingernails, stating they were unable to trim them independently and had not been offered assistance by staff. Another resident was observed with unwanted facial hair, which they were unable to remove themselves, and it was confirmed that this should have been addressed during daily ADL care. Interviews with facility staff, including CNAs, LPNs, and the Director of Nurses, highlighted a lack of communication and adherence to care plan interventions. CNAs were unaware of how care plan interventions were communicated, relying on nurses for instructions. The care plans, which were accessible through facility software and wall-mounted kiosks, were not consistently followed, resulting in unmet personal hygiene needs for the residents. The Director of Nurses and the Administrator confirmed that ADL care, including grooming and removal of unwanted facial hair, should be provided according to resident preferences and care plans.
Inadequate Grooming Care for Residents
Penalty
Summary
The facility failed to ensure that dependent residents received necessary grooming services, specifically related to nail care and the removal of unwanted facial hair. Observations and interviews revealed that four residents had issues with inadequate grooming. Resident #1 had short, smooth fingernails with a dark substance beneath them, and the resident's representative noted incidents of inadequate grooming. Resident #5 had long fingernails with a dark substance beneath them and long, curved toenails. Both residents were dependent on staff for all activities of daily living (ADLs) and had cognitive impairments. Resident #6 had long fingernails with a brownish substance underneath and expressed a preference for shorter nails but was unable to trim them himself. The resident had no cognitive impairment and was dependent on staff for ADLs. Resident #7 had a thick patch of unwanted facial hair and expressed a dislike for it but was unable to remove it herself. The resident had moderate cognitive impairment and was also dependent on staff for ADLs. Interviews with staff revealed a lack of consistent grooming care, with CNAs and nurses not adequately addressing the residents' grooming needs. The facility's policy required staff to assist residents with bathing, nail care, and facial hair removal to maintain proper hygiene and prevent infections. However, staff interviews indicated a lack of clarity and responsibility regarding these tasks. The facility's Director of Nurses and Administrator acknowledged the importance of meeting residents' grooming needs for their physical and psychosocial well-being, but the observations and interviews highlighted a failure to consistently provide these services according to residents' preferences and care plans.
Failure in QAPI Committee Leads to Re-cited Deficiencies
Penalty
Summary
The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee, as evidenced by two re-cited deficiencies originally identified in December 2023. The deficiencies were related to the facility's inability to implement comprehensive care plans for Activities of Daily Living (ADL) care and ensure adequate grooming for dependent residents. During a complaint survey conducted in July 2024, it was observed that the facility did not provide necessary services to maintain adequate grooming, including the removal of unwanted facial hair and fingernail care, for dependent residents. The facility's Quality Assurance Committee did not effectively identify, develop, and implement measures to correct these issues or prevent the recurrence of deficiencies. Despite the facility's policy outlining the use of Root Cause Analysis and the 'Plan, Do, Study, Act' cycle for improvement, the committee failed to address and prioritize identified problems adequately. The Administrator acknowledged that while audit results were presented and reviewed in QAPI meetings, the facility may not have monitored a sufficient number of residents to ensure comprehensive grooming care, given the facility's size and census.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manhattan Community Care Center | 2.5 mi | ★★★★★ | 7 | 1 |
| Magnolia Senior Care, Llc | 2.7 mi | ★★★★★ | 5 | 0 |
| Alyce G Clarke Center For Medically Fragile Childr | 3.5 mi | — | 0 | 0 |
| Lakeland Community Care Center | 3.6 mi | ★★★★★ | 5 | 0 |
| Highland Home | 4.2 mi | ★★★★★ | 1 | 1 |
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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.