Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Sardis Community Nh during CMS and state inspections, most recent first.
A resident with a history of diabetes mellitus and cerebral infarction developed a new excoriated area on the sacrum that required treatment and monitoring, as documented in progress notes. Facility policy requires comprehensive care plans with measurable objectives, time frames, and service descriptions, reviewed and revised on an ongoing basis. However, record review showed no care plan was developed to address the new sacral skin breakdown. In interviews, an RN stated that care plans are used to guide staff in how to care for residents, and the MDS nurse confirmed that no care plan had been created for this newly identified skin issue, despite acknowledging that one should have been implemented.
A resident with a history of diabetes mellitus and cerebral infarction developed an excoriated, reddened sacral area, for which an RN obtained an order to cleanse with wound cleanser, pat dry, and apply zinc oxide every shift until healed. Although the facility’s skin policy required appropriate wound treatment, review of the MAR/TAR showed no documentation that the ordered treatment was provided. During interviews, the RN confirmed the absence of treatment documentation, and the DON explained that the treatment order did not appear on the MAR/TAR because an incorrect order type was selected when entering it, resulting in the treatment being missed.
A resident with moderate cognitive impairment and hemiplegia was subjected to abuse when a nurse aide pulled the resident from a seated position onto the floor, verbally berated the resident, and sprayed an aerosol substance on the resident's lower body. Multiple staff and the resident confirmed the aide's actions, which resulted in the resident experiencing fear, distress, and compromised dignity.
A resident with moderate cognitive impairment was found on the floor after an altercation with a nurse aide, who was reported by witnesses to have pulled a pillow from under the resident and sprayed them with an aerosol substance. Multiple staff provided written witness statements, but these were not included in the facility's abuse investigation documentation. The administrator dismissed the allegation due to conflicting accounts and lack of proof of intent, despite evidence from several witnesses.
Two residents did not receive appropriate care planning: one resident on anticoagulant therapy lacked a care plan for monitoring bleeding risks, and another resident with Parkinson's Disease did not receive the required assistance with bathing and showering as outlined in their ADL care plan. Both deficiencies were confirmed by staff interviews and record reviews.
A resident with Parkinson's Disease, who was cognitively intact, did not receive scheduled bathing assistance as required. Despite being on a set bathing schedule, the resident was observed with a foul odor and unchanged clothing over multiple days, and both the resident and his roommate reported no baths or showers since admission. Staff could not recall or document any bathing provided, and the DON confirmed the resident should have received this care.
A resident's room had a large area of missing paint that had not been repaired since admission, despite the resident's concerns and awareness by facility staff. The resident, who has moderate cognitive impairment, reported feeling uncomfortable with the room's condition, especially during family visits. Facility policy requires a homelike environment, but this standard was not met.
A resident with severe cognitive impairment and a history of cerebral hemorrhage was incorrectly coded on the admission MDS as having bed rails used as a restraint, despite documentation and staff interviews confirming the rails were for positioning and bed mobility. Facility staff acknowledged the coding error after review and observation.
A resident prescribed Apixaban for acute embolism and thrombosis did not have a monitoring protocol in place to observe for adverse effects such as bleeding, despite facility policy requiring such observation. Staff interviews, including those with an LPN, the MDS Coordinator, and the DON, confirmed the absence of specific monitoring orders or tasks related to the anticoagulant therapy.
A resident with a Stage 3 pressure ulcer did not have wound treatments consistently documented as administered, with fifteen days of missing entries in the ETAR despite active physician orders. Nursing staff interviews revealed that treatments may have been performed but were not always recorded, especially during busy times or on weekends. The DON confirmed the expectation for complete documentation and acknowledged the missing records.
Staff did not follow hand hygiene protocols during medication administration and wound care. An LPN failed to wash or sanitize hands before and after administering medications to two residents, and a nurse did not change gloves or perform hand hygiene between the dirty and clean steps of a wound care procedure for a resident with chronic kidney disease and dementia. These actions were not in accordance with facility policies.
A facility failed to complete and submit a Discharge Tracking MDS assessment for a resident transferred to a behavioral health center. The MDS Nurse missed the assessment due to a transition to a new charting system. The resident, admitted with senile degeneration of the brain, did not have the required assessment completed, as confirmed by the DON.
The facility failed to implement a care plan for a resident with Hemiplegia/Hemiparesis, neglecting oral and nail care, as observed by an LPN and confirmed by the DON. Additionally, the facility did not develop an individualized care plan for a resident with PTSD, failing to address potential triggers and fears. Interviews with staff revealed the absence of a trauma-informed care assessment, leading to a lack of specific interventions for the resident's needs.
A resident with Parkinson's Disease and other health issues was found with inadequate oral and nail care, as observed by surveyors. The facility's policies for daily oral hygiene and nail care were not followed, resulting in a yellow substance on the resident's teeth and debris under his fingernails. The LPN and DON confirmed the neglect, acknowledging that CNAs were responsible for these tasks.
A facility failed to complete a Trauma Informed Care Assessment for a resident with PTSD, despite the resident's documented history of traumatic events and a prescription for Zoloft. The resident was cognitively intact, and staff interviews confirmed awareness of the PTSD diagnosis. However, the facility's social assessment inaccurately stated no traumatic history, and the necessary assessment was not conducted to address symptoms and triggers.
Failure to Care Plan Newly Identified Sacral Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a newly identified excoriated area on the sacrum of one resident. Facility policy titled “Care Plan Process,” revised 12/24, requires that care plans include measurable objectives, time frames, and descriptions of services to attain or maintain each resident’s highest practicable well-being, and that care plans be reviewed and revised on an ongoing basis. Record review of the Care Plan Report for Resident #1 showed no care plan addressing the excoriated sacral area, despite Progress Notes dated 2/15/26 documenting the presence of a new excoriated area to the sacrum requiring treatment and monitoring. The resident’s face sheet indicated admission on 5/22/2019 with diagnoses including Diabetes Mellitus and Cerebral Infarction. In interviews, an RN stated that the purpose of the care plan was to ensure staff knew how to care for the resident, and the MDS Nurse confirmed that no care plan had been developed for the new skin breakdown and acknowledged that one should have been implemented. This deficiency reflects the facility’s failure to follow its own care plan policy and to create a care plan for the resident’s newly identified sacral skin breakdown, despite documented need for treatment and monitoring and staff acknowledgment of the care plan’s role in guiding resident care.
Failure to Provide Ordered Sacral Skin Treatment Due to Order Entry Error
Penalty
Summary
The facility failed to provide ordered treatment for a resident who developed an excoriated, slightly reddened area on the sacrum. According to the facility’s policy on Prevention and Treatment of Skin Issues, residents at risk for impaired skin integrity and pressure ulcers are to be properly identified, assessed, and provided appropriate treatment modalities. Progress notes documented that on 2/15/26 a CNA notified an RN of the skin issue, the RN assessed the resident, identified the excoriated sacral area with no drainage, notified the DON, wound care nurse, and responsible party, and obtained an order to cleanse the area with wound cleanser, pat dry, and apply zinc oxide every shift until healed. Record review of the Medication Administration Record and Treatment Administration Record for February 2026 showed no documentation that the ordered sacral treatment was ever provided. During interview and concurrent record review, the RN confirmed there was no documentation of the treatment and stated she did not know why the treatment had not triggered on the MAR/TAR, agreeing that failure to perform the treatment could have caused worsening of the area. The DON stated that although daily review of orders is conducted, the treatment order was missed and did not trigger to the MAR/TAR because an incorrect order type was selected when the order was entered on 2/15/26. The resident, who had diagnoses including diabetes mellitus and cerebral infarction and had been admitted in 2019, was later sent to the emergency department for a change in level of consciousness and did not return, with discharge documented on 2/25/26.
Resident Subjected to Physical and Verbal Abuse by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, Nurse Aide (NA) #1, engaged in abusive conduct toward a resident with moderate cognitive impairment and a history of hemiplegia and hypertensive urgency. The incident involved the aide pulling the resident from a seated position onto the floor, verbally berating him, and spraying him with an aerosol substance. Multiple staff and resident interviews confirmed that the aide entered the resident's room, expressed frustration, and proceeded to remove a pillow from under the resident, causing him to fall. While the resident was on the floor, the aide continued to yell at him to get up and sprayed his lower body with an aerosol spray, which was believed to be disinfectant or air freshener. Witnesses, including housekeeping staff and another CNA, reported hearing the resident scream for help and observed the aide laughing and continuing the abusive behavior. The resident expressed fear for his life and distress over the incident, stating he was shaken and scared by the aide's actions. Staff members who entered the room found the resident on the floor and the aide sitting in a chair, laughing, and continuing to spray the resident and throw his belongings into the garbage can. Despite conflicting accounts from some staff regarding the intent and details of the incident, the totality of evidence from interviews and witness statements substantiated that abuse did occur. The resident experienced actual psychosocial harm, including fear, distress, and compromised dignity as a result of the aide's actions. The facility's failure to protect the resident from all forms of abuse constituted a violation of regulatory requirements.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident. The incident occurred when staff responded to the resident screaming for help and found the resident on the floor after an altercation with a nurse aide. The resident reported that the nurse aide pulled a pillow from under them, causing them to fall, and then sprayed them with disinfectant spray. Witness statements from housekeeping and other staff corroborated that the nurse aide was laughing, yelling at the resident, and spraying their legs with an aerosol substance. Multiple staff members wrote witness statements and submitted them to administration. Despite these accounts, the facility's abuse investigation did not include the witness statements from the staff in the documentation. The administrator determined the allegation could not be substantiated due to an inability to prove intent and conflicting accounts, but acknowledged that the determination was not supported by the totality of evidence. The resident involved had a history of moderate cognitive impairment and other medical conditions. The facility's actions did not align with its policy to thoroughly investigate all alleged violations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to care planning. For one resident prescribed an anticoagulant (Apixaban) for acute embolism and thrombosis, there was no care plan addressing the risks associated with anticoagulant therapy, such as monitoring for bleeding. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that a care plan should have been initiated when the medication order was entered. The resident was cognitively intact at the time of the deficiency. For another resident with Parkinson's Disease and dyskinesia, the facility failed to implement the care plan for Activities of Daily Living (ADLs), specifically regarding bathing and showering assistance. The resident, also cognitively intact, reported not having received a bath or shower since admission, and was observed to have a foul odor. The care plan indicated the need for partial/moderate assistance with bathing, but this intervention was not carried out as documented.
Failure to Provide Scheduled Bathing Assistance and Documentation
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living, specifically bathing, did not receive the necessary care. The facility's policy required CNAs to document daily ADL care, including bathing, as a permanent part of the resident's chart. However, observations revealed that the resident had a foul odor and was wearing the same clothing on consecutive days. The resident and his brother, who is also his roommate, both reported that the resident had not received a bath or shower since admission two weeks prior. Staff interviews confirmed uncertainty about when the resident last received a bath or shower, and documentation of bathing was absent from the resident's records for the relevant period. The resident was admitted with diagnoses including Parkinson's Disease and was assessed as cognitively intact with a BIMS score of 15. Despite being scheduled for baths on Mondays, Wednesdays, and Fridays, there was no evidence that these were provided. Both CNA and LPN staff were unable to recall or provide documentation of bathing, and the DON confirmed the resident should have received scheduled baths. The lack of documented and observed bathing care constituted a failure to provide required assistance with ADLs for this resident.
Failure to Maintain Homelike Resident Environment Due to Unrepaired Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for one resident, as evidenced by a large area of missing paint, approximately two feet by four feet, on the wall in the resident's room across from the bathroom door. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 12, expressed concern about the appearance of the room, noting that it had been in that condition since admission and that it was not acceptable for family visits. The Maintenance Director acknowledged awareness of the issue but had not addressed it, and the Administrator admitted to not noticing the problem during rounds. Facility policy requires maintaining a safe, clean, and homelike environment, which was not upheld in this instance.
Inaccurate MDS Coding of Bed Rails as Restraint
Penalty
Summary
The facility failed to accurately code an admission Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment for a resident with a history of traumatic hemorrhage of the left cerebrum and severe cognitive impairment was incorrectly coded to indicate that bed rails were being used as a restraint. However, the resident's care plan documented that the side rails were in place for bed mobility and positioning, not as a restraint. Observation confirmed the presence of half side rails on the resident's bed. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that the bed rails were not intended as restraints but rather to assist with positioning. Both staff members acknowledged the error in the MDS coding, with the DON emphasizing that the facility does not use restraints. The deficiency was identified through a review of facility policy, resident records, staff interviews, and direct observation.
Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
The facility failed to monitor for adverse effects of an anticoagulant medication for one resident who was prescribed Apixaban for acute embolism and thrombosis of the femoral vein. Review of the resident's physician orders, medication administration record, and treatment administration record revealed that there was no monitoring protocol in place to observe for side effects associated with anticoagulant therapy, such as bleeding or excessive bruising. The facility's policy required observation for adverse effects and physician notification if any occurred, but this was not implemented for the resident in question. Interviews with staff, including an LPN, the MDS Coordinator, and the DON, confirmed that there were no specific orders or monitoring tasks in place to assess for bleeding risks related to the anticoagulant medication. Staff emphasized the importance of such monitoring and acknowledged its absence, noting that monitoring should begin whenever an anticoagulant is prescribed. The resident involved was cognitively intact and had been admitted with a diagnosis of acute embolism and thrombosis.
Failure to Document Wound Treatments for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to document wound treatments as ordered for a resident with a Stage 3 pressure ulcer. Review of the Electronic Treatment Administration Record (ETAR) for this resident revealed multiple instances across April, May, and June where wound care treatments were not documented as administered, despite active physician orders. Specifically, there were fifteen days with missing documentation for wound care treatments, including cleaning, application of medications, and dressing changes. Interviews with nursing staff indicated that while treatments may have been performed, documentation was not consistently completed in the ETAR. The Director of Nursing confirmed the expectation that all treatments should be documented and acknowledged the missing entries. The resident involved had a history of chronic kidney disease and dementia and was rarely or never understood, according to the Minimum Data Set. The wound was observed to have pink granulation tissue at the time of survey, and staff interviews indicated that wound management services were provided weekly. However, both the treatment nurse and other nursing staff admitted to occasional lapses in documentation, particularly during busy periods or on weekends, leading to incomplete records of wound care provided.
Failure to Perform Proper Hand Hygiene During Medication Administration and Wound Care
Penalty
Summary
Staff failed to perform proper hand hygiene during three of nine direct care observations, as required by facility policy. Specifically, an LPN did not wash or sanitize her hands before setting up or administering medications to two residents, nor did she perform hand hygiene between medication administrations. The LPN acknowledged not following hand hygiene protocols and indicated a lack of immediate access to hand sanitizer on her medication cart. Additionally, a registered nurse did not change gloves or perform hand hygiene between the dirty and clean steps of a wound care procedure for a resident with chronic kidney disease and dementia. The RN removed soiled dressings, cleaned the wound, and applied new dressings without changing gloves or washing hands between steps, which was confirmed during an interview. Facility policies reviewed required hand hygiene between resident contacts and during wound care procedures, but these were not followed during the observed incidents.
Failure to Complete Discharge Tracking MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Discharge Tracking Minimum Data Set (MDS) resident assessment to the Centers for Medicare and Medicaid Services (CMS) for a resident who was transferred to an acute care facility. This deficiency was identified for one of the 16 MDS assessments reviewed, specifically for Resident #38. The facility's policy, titled MDS Process, outlines the requirements for MDS coding guidelines, time schedules, and requirements, which were not adhered to in this case. Resident #38 was transferred to a behavioral health center and returned to the facility, but the discharge tracking assessment was not completed. The Director of Nursing (DON) confirmed that the assessment was not done, and the MDS Nurse admitted to missing the assessment due to the facility transitioning to a new charting system at the time. Resident #38 was admitted to the facility with a diagnosis of senile degeneration of the brain.
Deficiencies in Care Planning for Residents with Specific Needs
Penalty
Summary
The facility failed to implement a care plan for nail and oral care for Resident #31, who has a diagnosis of Hemiplegia/Hemiparesis on the right side. Observations on two consecutive days revealed that Resident #31 was lying in bed with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. The Licensed Practical Nurse (LPN) confirmed the presence of the yellow buildup on the resident's teeth, which could lead to tooth decay and other oral health issues. The Director of Nursing (DON) acknowledged that the staff did not follow the care plan, resulting in the neglect of oral and nail care for Resident #31. Additionally, the facility failed to develop an individualized comprehensive care plan for Resident #37, who has a diagnosis of Post Traumatic Stress Disorder (PTSD). The care plan did not address potential triggers, fears, or behavioral expressions related to the resident's history of trauma. Interviews with the Social Services staff and LPN revealed that Resident #37 exhibited inappropriate touching behaviors and did not like to be hugged. The DON confirmed that a comprehensive care plan was not developed due to the absence of a completed trauma-informed care assessment, and the Minimum Data Set (MDS) Nurse confirmed that the care plan was not individualized to address the resident's specific needs related to PTSD.
Failure to Provide Adequate Oral and Nail Care
Penalty
Summary
The facility failed to provide adequate oral and nail care for a resident, as observed during a survey. The facility's policies for oral hygiene and nail care were not followed, resulting in a resident being found with a yellow substance covering his teeth and a brown substance under the fingernails of his left hand. The Licensed Practical Nurse (LPN) confirmed that the resident's mouth care had not been performed, and the Certified Nursing Assistants (CNAs) were responsible for this task. The LPN also acknowledged the presence of debris under the resident's fingernails and stated that nail care should be checked daily, although it was scheduled weekly. The Director of Nursing (DON) confirmed that mouth care was supposed to be completed at least once a day and that CNAs were responsible for both oral and nail care. The DON expressed dissatisfaction with the failure to provide these essential care activities, acknowledging that such neglect could lead to health issues. The resident involved had a medical history including Parkinson's Disease, Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit, which may have contributed to his inability to perform these activities of daily living independently.
Failure to Complete Trauma Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to complete a Trauma Informed Care Assessment for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a documented history of traumatic events and was prescribed Zoloft for PTSD symptoms following a behavioral health stay. Despite this, the facility's social assessment inaccurately stated that the resident had not experienced any traumatic events or trauma-related symptoms. Interviews with facility staff, including Social Services and the Director of Nursing, confirmed the absence of a trauma informed care assessment for the resident. The social services staff acknowledged awareness of the resident's traumatic history but had not completed the necessary assessment. Additionally, the Licensed Practical Nurse caring for the resident was aware of the PTSD diagnosis and noted the resident's aversion to physical contact, such as hugging. The Director of Nursing confirmed that the assessment should have been conducted to address the resident's symptoms and potential triggers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sardis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Batesville | 9.1 mi | ★★★★★ | 0 | 0 |
| Senatobia Healthcare & Rehab | 13.5 mi | ★★★★★ | 3 | 0 |
| Oxford Health & Rehab Center | 22.3 mi | ★★★★★ | 13 | 0 |
| Quitman County Health & Rehab Llc | 25.5 mi | ★★★★★ | 0 | 0 |
| Yalobusha County Nursing Home | 25.6 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sardis Community Nh.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.