Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winston County Nursing Home during CMS and state inspections, most recent first.
Two residents receiving hemodialysis had care plan deficiencies related to ordered fluid restrictions. One resident’s dialysis care plan did not include a 1000 mL/day fluid restriction, while the other resident’s plan listed a 1200 cc restriction but staff did not track all fluids consumed, including water given during med pass and beverages brought in by family. Observations showed fluids present in the room, and the MDS nurse confirmed the care plan was not fully followed.
Fluid restrictions for dialysis residents not implemented or monitored. Three cognitively intact residents on HD had ordered fluid limits, but records showed no consistent nursing monitoring, repeated intake above ordered amounts, and bedside access to large amounts of fluid. Staff and dialysis communication indicated the restrictions were known in some cases, yet the facility did not document or control intake consistently, and one resident had no fluid restriction order in the chart despite dialysis communication that a 1200 mL limit applied.
Unclean Tray Line Cooler With Damaged Door Gasket: The tray line cooler was observed with excessive moisture, greenish-black buildup, and a black substance on the lower door gasket, which was dangling and preventing a proper seal. Dietary staff stated the substance looked like mold, said the unit should be cleaned weekly, and confirmed the condition could contaminate food and affect refrigerator temperatures. The Dietary Mgr also confirmed the unclean condition and improper door seal.
Failure to Provide Knives During Meal Service: During a meal observation, several residents who were independent with eating were not given table knives and had to wait for staff to cut their meat. One resident stated the facility did not allow knives, and staff confirmed they had been told residents could not have a butter knife. The ADM and Interim DFD both stated residents capable of the task should receive a knife with meals to support a dignified dining experience.
Unresolved Resident Grievances About Food Services: Residents repeatedly voiced complaints about food quality, menu variety, food temperature, seasoning, tough meats, and alternative meal selections, but the concerns remained unresolved across multiple Resident Council meetings. Residents and staff reported ongoing dissatisfaction with repetitive menus, poor palatability, and communication failures about food preferences. The Administrator and the Interim D/Food Services acknowledged the grievances and confirmed the dietary concerns had not been resolved.
Food Not Palatable or Consistent With Resident Preferences Residents reported repeated servings of the same vegetables, especially green beans, along with meals that were bland, overly salty, spicy, or tough to chew. Meal observations and a test tray review found pork chops difficult to cut and chew, vegetables undercooked or unpalatable, and fruit or dessert often missing. Staff and a family member confirmed ongoing concerns about food quality, appearance, and failure to reflect resident dislikes on meal tickets.
Improper Storage of Controlled Medication in Refrigerator: An LPN observed 44 Lorazepam syringes for a resident stored on the center shelf of a medication refrigerator instead of in the locked controlled-substance box. The LPN stated the syringes would not fit in the locked drawer, and the DON confirmed they were not secured there even though they should have been. The resident had Anxiety Disorder and severe cognitive impairment with a BIMS score of 00.
An LPN administered medications through a resident’s PEG tube without donning a gown as required by the facility’s EBP policy for residents with indwelling medical devices. The LPN confirmed she forgot the gown, and the DON confirmed the gown should have been worn during the medication pass. The resident had severe cognitive impairment and a PEG tube.
A facility failed to provide an effective way for residents to summon staff when the call light system was down on a unit. Staff and the DON confirmed the system had been nonfunctional since the prior day, and residents were using handbells; however, two residents did not have bells and were unaware the system was not working. One resident had moderate cognitive impairment and another had severe cognitive impairment, and an RN confirmed the call light did not work for one of them.
The facility failed to label and date food items in the kitchen, including meat in Ziploc bags, various spices, and liquids in glasses. The cook and ADD confirmed the labeling requirements were not followed, posing potential health risks.
The facility failed to submit criminal background checks for four new employees, including CNAs and RNs, hired since January 2024. The Human Resource Director admitted to not sending in fingerprint cards, resulting in the absence of background check letters. The CEO was unaware of this oversight, which could potentially put residents at risk.
The facility failed to accurately document a resident's end-of-life care preferences, leading to a discrepancy between the resident's initial full code status and a mistakenly marked Do Not Resuscitate (DNR) status. This error was confirmed by the DON and LSW, who acknowledged the potential impact on the resident's care during a cardio-pulmonary arrest.
A resident's leaking nephrostomy catheter bag was not addressed by the facility, despite the resident informing multiple staff members. The resident had to use zip-lock bags to contain the leakage. The RN Supervisor and DON were unaware of the issue until it was brought to their attention during interviews, acknowledging the facility's failure to provide necessary care.
Failure to Address Dialysis Fluid Restrictions in Care Plans
Penalty
Summary
The facility failed to develop and implement care plans to address physician-ordered fluid restrictions for two dialysis residents. For Resident #43, the dialysis care plan identified end-stage renal disease with hemodialysis, but it did not mention the ordered 1000 mL fluid restriction. Records showed the resident received hemodialysis Monday, Wednesday, and Friday, had a 1000 mL per 24-hour fluid restriction, and had a nutritional risk assessment documenting fluid intake of 1000-1499 mL/day. Progress notes also documented the resident stating he was going back to dialysis because he had too much fluid and later reporting not feeling well after back-to-back dialysis treatments. The Administrator confirmed the resident was on a 1000 mL per day fluid restriction, and the MDS nurse confirmed the care plan had not been fully developed to include it. For Resident #58, the care plan for hemodialysis included a 1200 cc fluid restriction, but staff did not track all fluids consumed. During observation, a 32-ounce water pitcher full of water was at the bedside, along with a case of bottled water and Diet Mountain Dew in the room. An LPN stated the resident’s water intake given during medication administration was not documented on the MAR, and a CNA stated family brought beverages into the room but she only documented fluids consumed during meals. The MDS nurse confirmed the plan of care was not followed because fluids were not tracked and the resident exceeded the prescribed limit on several occasions. Records showed the resident had ESRD/chronic kidney disease and was cognitively intact with a BIMS score of 15.
Fluid restrictions for dialysis residents not implemented or monitored
Penalty
Summary
The facility failed to ensure physician-ordered fluid restrictions were implemented and monitored for three dialysis residents. The record review showed the facility did not have a policy specific to fluid restrictions for dialysis residents, and a statement on facility letterhead confirmed this. The deficiency involved residents with chronic kidney disease and dependence on renal dialysis, all of whom were cognitively intact based on BIMS scores of 15. For Resident #12, an observation found a 32-ounce pitcher of ice water at the bedside, and the resident stated she attended dialysis three times weekly and was not aware of a fluid restriction. The medical record showed an order for hemodialysis, but no physician order for a fluid restriction was present in the facility chart. The QA Nurse stated the resident had never been on a fluid restriction since starting dialysis, while the RD stated the resident was supposed to have a 1200 mL restriction and that dialysis had communicated this to the facility. The dialysis RD also stated the resident should not have had a water pitcher in the room. Nursing documentation showed no monitoring of fluid intake to ensure the resident did not exceed a prescribed restriction. For Resident #43, the record showed orders for hemodialysis and a 1000 mL fluid restriction every 24 hours, but MAR review revealed no documentation of monitoring related to the restriction. The intake flowsheet showed repeated daily fluid intake above the ordered limit across multiple dates, and dialysis communication forms noted the resident was heavy with fluid, did not reach EDW, and needed help with fluid restriction control. For Resident #58, observation found a full 32-ounce water pitcher and additional bottled water and soft drinks in the room, and the resident stated she was not aware of a fluid restriction. The record showed a 1200 mL daily fluid restriction order, but the MAR showed multiple days when intake exceeded that amount. An LPN stated water given with medications was not documented, and a CNA stated every resident received a water pitcher unless on thickened liquids, even if on a fluid restriction.
Unclean Tray Line Cooler With Damaged Door Gasket
Penalty
Summary
The facility failed to store foods in kitchen refrigeration that was maintained in a clean, sanitary condition and good repair. During the initial kitchen tour, the tray line cooler was observed with an excessive amount of moisture on the interior lower metal surface and greenish-black substance in spotty patches. The interior lower door gasket was covered with a black substance and was dangling from the refrigerator door, visibly preventing a proper seal. Dietary Staff #3 confirmed the refrigerator was unclean and stated the black substance looked like mold. She also stated the refrigerator was supposed to be cleaned weekly and, based on its appearance, had not been cleaned in some time. She confirmed the condition of the refrigerator could contaminate food and make someone sick, and that the loose gasket could prevent a proper seal and potentially affect the temperature inside the refrigerator. The Dietary Manager also confirmed the refrigerator was unclean and that the lower gasket was dislodged from the door, creating an improper door seal, and stated the lack of a proper seal could result in improper food storage temperatures inside the refrigerator.
Failure to Provide Knives During Meal Service
Penalty
Summary
The facility failed to promote dignity and maintain independence during meal service by not providing table knives to residents who were capable of independently cutting their own food. During a lunch meal observation in the Cypress Cottage, residents were served pork chop with gravy, rice, squash and zucchini, and a roll, but six of eight residents reviewed were not given a knife. Resident #6 was observed trying to cut her pork chop with a fork and then a spoon, and stated the facility did not allow knives and only allowed a plastic knife. Residents #16, #34, #49, #70, and #90 were also observed unable to cut their meat because they did not have a knife, and Resident #90 stated they had to wait for an aide to cut up their meat. The residents were observed to be independent with eating but were required to request assistance and wait for staff to help them cut their meat. Facility interviews confirmed the practice. The Ambassador of Food Service #2 stated she had been told residents could not have a butter knife and had to wait for nursing staff or aides to assist with cutting meat, and she acknowledged the residents were independent and capable of performing the task. The Administrator stated she was not aware residents were not receiving a knife at meals and confirmed residents who were capable should be allowed to independently cut up their own meat. The Interim Director of Food Services also stated she was not aware residents were not receiving a knife with meals and said every meal tray should include a spoon, fork, and knife to promote a dignified dining experience. Record review showed the affected residents had diagnoses including CKD, DM2, HTN, atrial fibrillation, osteoporosis, vitamin deficiencies, and varying cognitive status, and their MDS assessments indicated they required only set-up or clean-up assistance with meals.
Unresolved Resident Grievances About Food Services
Penalty
Summary
The facility failed to make prompt efforts to resolve resident grievances related to food quality, food preferences, alternative menu selections, meal variety, food temperature, and food palatability. Review of the facility grievance policy stated that residents and family members have the right to voice grievances without discrimination, reprisal, or fear of discrimination, and that the facility will make prompt efforts to resolve grievances. However, Resident Council meeting minutes from multiple months documented repeated complaints about poor food quality, repetitive menu items, food that was too tough, excessive or insufficient seasoning, and alternative menu requests not being honored. Resident interviews confirmed that these concerns were ongoing and unresolved. Residents reported that the food was awful, lacked flavor, was frequently repetitive, and often included the same items such as green beans or chicken. Several residents stated meats were tough to chew, food was sometimes overly spicy or salty, breakfast items were limited, and fruit and desserts were not regularly available. During an observed lunch meal, residents continued to voice concerns about tough meats, excessive seasoning, repetitive menu items, and alternative meal requests not being honored. Staff interviews and record review showed the concerns were known to the facility. An LPN stated residents had complained for an extended period about food quality, appearance, repetitive menu items, and disliked foods. The Dietary Meal Server stated residents constantly complained and that nothing gets done. The Administrator acknowledged awareness of resident dissatisfaction with dietary services and confirmed the grievances had not been addressed and resolved. The Interim Director of Food Services stated there had been significant breakdowns in communication regarding resident food preferences and that disliked foods were not consistently reflected on meal tickets. Residents involved included individuals with varying cognitive status, including some who were cognitively intact and others with moderate or severe cognitive impairment.
Food Not Palatable or Consistent With Resident Preferences
Penalty
Summary
The facility failed to ensure food was palatable and consistent with resident food preferences and dislikes for nine residents reviewed in the Elm and Cypress cottages. The cited concerns included repetitive menu items, meats that were tough and difficult to chew, foods that were excessively salty, spicy, undercooked, or otherwise unpalatable, and failure to honor resident food preferences and alternative meal requests. The facility policy required a designated team member to taste prepared food items before meal service and assess seasoning, eye appeal, and whether food was overcooked or undercooked. Resident interviews and meal observations documented repeated complaints about the same vegetables being served frequently, especially green beans, and the absence of fruit or dessert with meals. One resident stated green beans were served morning, noon, and night, while another said the food was awful and lacked flavor. A family member reported residents were not receiving a balanced diet, often did not receive desserts or fruit, and were frequently served foods they did not like. Staff also acknowledged ongoing resident dissatisfaction with food quality, appearance, and repeated menu items, and one staff member stated residents often refused certain menu items and meals were frequently served without fruit or dessert. During a lunch observation, residents were served pork chops with gravy, rice, squash, zucchini, and a roll, and multiple residents reported the pork chop was excessively tough and difficult to cut or chew. Residents also reported the vegetables were overly spicy and the meat was salty. A test tray review found the pork chop difficult to cut and chew, the squash and zucchini firm and appearing undercooked, and the pureed meat and vegetables excessively salty or otherwise not palatable. The Interim Director of Food Services confirmed residents should receive food pleasing to the palate and consistent with their preferences, and stated resident dislikes and preferences should be reflected on meal tickets, adding that this was not being done.
Improper Storage of Controlled Medication in Refrigerator
Penalty
Summary
The facility failed to ensure medications were stored in a properly secured refrigerator for one of four medication storage rooms on C Hall. During observation on 6/16/2026 at 10:05 AM, the medication storage room contained 44 Lorazepam syringes prescribed to Resident #50, and they were maintained on the center shelf of the refrigerator rather than in the locked, affixed controlled-substance storage box. Facility policy titled Medication Storage-Controlled Medication Storage, revised 2/1/23, stated that controlled substances are subject to special handling, storage, disposal, and record keeping in accordance with applicable laws and regulations. During interview, the LPN stated the syringes would not fit in the locked storage drawer in the refrigerator. The DON later confirmed that the syringes were not in the locked drawer because they would not all fit, but stated they should have been locked and secured. Resident #50 was admitted on 1/09/2025 with a diagnosis of Anxiety Disorder, Unspecified, and the MDS dated 4/05/2026 showed a BIMS score of 00, indicating severe cognitive impairment.
Failure to Use Enhanced Barrier Precautions During PEG Medication Administration
Penalty
Summary
The facility failed to ensure staff implemented Enhanced Barrier Precautions during medication administration for Resident #9, who had a PEG tube and severe cognitive impairment with a BIMS score of 03. During an observation of medication administration, an LPN administered medications through the resident’s PEG tube without donning a gown, even though the facility policy required Enhanced Barrier Precautions for residents with indwelling medical devices such as feeding tubes. The LPN later confirmed she forgot to wear the gown, and the DON confirmed the gown should have been worn to administer the PEG medications.
Nonfunctional Call Light System and Inconsistent Access to Handbells
Penalty
Summary
The facility failed to provide an effective system for residents to summon staff assistance when the call light system was nonfunctional for two residents on Unit C. During observations, surveyors found the call light system was not working and residents were using handbells to request assistance. Staff confirmed the system had been down since the prior day, and the DON stated the problem began midday Friday after maintenance work on the roof caused the system to go down. The Maintenance Director had contacted the company for repair, with repair expected the following day. Resident #52, who had recently moved to the room and had diagnoses including encounter for other orthopedic aftercare and other fracture of T9-T10 vertebra with routine healing, had a BIMS score of 10 indicating moderate cognitive impairment. She stated she was not aware the call system was not working and had not been given a handbell. RN #1 confirmed the call light did not light up or alarm for her and stated residents were supposed to have handbells at bedside. Resident #95, who had diagnoses including encounter for surgical aftercare following surgery on the digestive system and acute gastric ulcer with perforation, had a BIMS score of 5 indicating severe cognitive impairment. She also stated she did not have a handbell and was not aware the call system was not working properly. Maintenance staff stated some residents received bells and some did not, and he did not know which residents had received them.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that items in the kitchen refrigerator, freezer, and dry goods spices were labeled and dated. During a kitchen tour, it was observed that four clear gallon-size Ziploc bags containing fish and red meat were not labeled or dated. Additionally, several 28-ounce containers of various spices, including Nutmeg, Montreal Steak seasoning, Cinnamon, Onion Powder, Garlic Powder, Rubbed Sage, Rotisserie Chicken Seasoning, Lemon Pepper Salt, and Ground Cumin, were found opened and unlabeled. A stainless steel container with a creamy white substance, identified as bacon grease, was also found without a label or date. The cook admitted to not labeling the items due to being busy, and the Assistant Dietary Director (ADD) confirmed the labeling and dating requirements were not followed. Further observations revealed a tray with eight glasses of brown liquid and three glasses of white liquid in the Oak Cottage kitchen, all without labels. Interviews with the Dietary Aide and the Administrator confirmed that all items prepared and stored should be labeled and dated to prevent potential health risks. The Administrator acknowledged that failing to label and date food items could result in someone consuming something they might be allergic to or getting sick from old food.
Failure to Submit Criminal Background Checks for New Employees
Penalty
Summary
The facility failed to submit criminal background checks for four out of five new employees reviewed during the survey. The facility's policy requires a Criminal History Record Check (CHRC) to be performed after a negative drug test, including fingerprinting and submission to the state agency. However, the Administrator and Human Resource Director confirmed that background checks had not been performed on any employees hired since the first week of January 2024. The Human Resource Director admitted to not sending in the fingerprint cards due to falling behind on the task, which resulted in the absence of background check letters in the employee files. The employees in question, who serve as Certified Nursing Assistants (CNAs) and Registered Nurses (RNs), had Nurse Aid Registry searches that showed no disqualifying events but lacked the fingerprint letters that would reveal any criminal charges in the last two years. The Chief Executive Officer (CEO) of the hospital/nursing home was unaware of the oversight and acknowledged that failing to submit and receive background check information could potentially put residents at risk by hiring individuals with criminal backgrounds.
Failure to Accurately Document Resident's End-of-Life Care Preferences
Penalty
Summary
The facility failed to ensure a resident's choice for end-of-life care was accurately indicated on medical records. Specifically, Resident #56's advance directive was incorrectly documented as Do Not Resuscitate (DNR) on the Advance Directive Acknowledgement Review form dated 12/19/23, despite the resident's initial choice of full code status upon admission and the corresponding physician's electronic order. This discrepancy was confirmed during interviews with the Director of Nursing (DON) and the Licensed Social Worker (LSW), who acknowledged the error and its potential impact on the resident's care during a cardio-pulmonary arrest. Resident #56, who was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6, had multiple medical diagnoses including chronic obstructive pulmonary disease, heart failure, type 2 diabetes mellitus, atrial fibrillation, and congestive heart failure. The LSW admitted to mistakenly marking the resident's status as DNR during the annual review, despite no request for change from the resident or their representative. This error could have led to the resident's wishes not being honored in a critical situation, as the incorrect DNR status was prominently placed at the front of the resident's paper medical chart.
Failure to Address Leaking Nephrostomy Catheter Bag
Penalty
Summary
The facility failed to ensure a resident received the necessary care and treatment for a nephrostomy. The resident's urinary catheter bag was leaking, and the resident had to use zip-lock bags to prevent urine from leaking into his privacy bag. Despite informing the nursing staff about the issue, the resident's request for a new catheter bag was not addressed. The RN Supervisor confirmed that the nurses were responsible for inspecting the catheter bag each shift and notifying her or the DON if there was a problem, but she had not been informed of any issues. The RN Supervisor acknowledged that the resident did not have a new catheter bag ordered and felt that the facility had failed the resident in this regard. Further interviews revealed that the resident had been using zip-lock bags for quite some time and had informed multiple staff members about the leaking catheter bag. RN #1 admitted to providing the resident with zip-lock bags and noticing the leak but did not notify anyone about ordering a new catheter bag or inform the resident's primary physician. The DON was also unaware of the issue until it was brought to her attention during the interview. The DON confirmed that the problem had been communicated to several staff members and should have been addressed immediately, acknowledging the facility's failure to provide the necessary care for the resident's nephrostomy.
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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 Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Louisville Healthcare Llc | 0.9 mi | ★★★★★ | 0 | 0 |
| Choctaw Nursing And Rehabilitation Center | 15.2 mi | ★★★★★ | 0 | 0 |
| Choctaw Residential Center | 24.6 mi | ★★★★★ | 2 | 0 |
| Carrington, Llc D/b/a The Carrington | 25.6 mi | ★★★★★ | 5 | 0 |
| Neshoba County Nursing Home | 25.9 mi | ★★★★★ | 10 | 1 |
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