Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Betty Ann Nursing Center during CMS and state inspections, most recent first.
A resident with communication and mobility impairments reported sexual abuse by another resident. Although law enforcement was notified and the resident was relocated for safety, the facility did not notify the health department within the required two-hour window, as confirmed by staff interviews and documentation.
A resident with a history of mental health issues and moderate cognitive impairment physically assaulted eight other residents on multiple occasions. Despite repeated incidents, staff did not implement new interventions or increase monitoring, and the care plan was not updated to address the ongoing aggressive behaviors. Staff interviews confirmed a lack of special precautions or changes in care, resulting in continued resident-to-resident abuse.
A resident with behavioral health diagnoses repeatedly engaged in physical altercations with other residents, but the care plan was not updated with new interventions despite ongoing incidents and documentation. The DON confirmed the care plan remained unchanged and ineffective in addressing the resident's behaviors.
A facility failed to thoroughly investigate an abuse allegation involving a resident with schizophrenia and anxiety disorder. The investigation was limited to statements from the alleged abuser and the reporter, with no interviews conducted with other residents, staff, or visitors. The DON admitted that a more comprehensive investigation was necessary.
The facility did not ensure survey results were accessible to residents and visitors. Although policy stated results should be in the front lobby with signage, residents and staff were unaware of their location. The results were kept in a locked area, and the DON had them in their office for months, unaware they needed to be accessible. The administrator admitted the signage had been removed.
The facility failed to complete and communicate baseline care plans within 48 hours of admission for two residents. One resident with chronic conditions did not have a care plan meeting or receive a summary, and the clinical record lacked a completed care plan. Another resident with diabetes and anxiety did not receive a care plan summary, and the document was incomplete. The DON was unsure about the process and acknowledged the oversight.
The facility did not ensure holding temperatures were obtained for the noon meal service. The Food Temperatures policy required temperatures to be recorded for each meal, but the temperatures documented were taken when the food was removed from the oven, not at serving time. Cook #1 confirmed they did not obtain holding temperatures before serving, relying instead on steam from the steam table. The dietary manager was unaware of the discrepancy in the temperature log.
The facility failed to provide pureed foods at a smooth consistency for two residents on pureed diets during a noon meal. Observations revealed that the turkey, dressing, and mixed vegetables were not properly pureed, containing visible pieces and being too thin. The dietary manager confirmed the inconsistency, noting that pureed foods should resemble smooth mashed potatoes.
The facility failed to maintain proper food storage and infection control practices. Uncovered and undated food was found in a refrigerator, and kitchen staff did not follow hand hygiene protocols during meal service. A CNA delivering meals to residents' rooms also neglected hand sanitization. Additionally, the ice machine was observed in an unsanitary condition, with residues present. These deficiencies highlight lapses in adhering to established policies for food safety and infection control.
The facility failed to maintain infection control protocols during medication administration and wound care. An LPN was observed not changing gloves or sanitizing hands between tasks for residents on enhanced barrier precautions. Additionally, a CMA did not sanitize hands between residents while administering medications. The DON and infection preventionist confirmed these actions did not align with facility policies.
A resident with a history of cerebral vascular accident and hemiplegia was admitted with a weak left hand, but the facility failed to document this impairment in the admission assessment or develop a comprehensive care plan. Observations showed the resident's left hand was contracted, and staff were unaware of any limitations or interventions. The DON acknowledged the oversight in the assessment and care plan.
A resident with multiple health issues, including cerebral vascular accident and hemiplegia, did not have a comprehensive care plan addressing all their needs. The care plan only included DNR status and an indwelling catheter, despite an assessment identifying ten areas of concern. The DON admitted to not monitoring the care plan development.
A facility failed to update the care plan for a resident with a history of pressure ulcers and diabetes. Although a physician's order required wound care for the right heel, this was not reflected in the care plan. Additionally, a quarterly assessment did not document any pressure wounds, despite the presence of a closed wound on the left heel. The DON acknowledged the care plan should have been updated.
A facility failed to implement interventions for a resident with hemiplegia and hemiparesis following a cerebral infarction, leading to a deficiency in maintaining range of motion. The resident's admission assessment did not document any impairments, despite noted left hand weakness. A CNA and LPN were unaware of any interventions, and the DON confirmed the oversight in documentation.
A facility failed to consistently offer and document dietary supplements for a resident with protein calorie malnutrition, leading to a 6.76% weight loss in one month. Despite physician orders for supplements between meals, records showed they were provided only 36 out of 72 times. Staff interviews revealed inconsistencies in the process, with unclear documentation practices and occasional resident refusals.
A resident with dementia and mood disorder did not receive a PSA test as ordered by the physician due to initial refusal and lack of follow-up by staff. Although the resident later complied with lab tests, the PSA was not conducted because it was missing from the electronic record. The DON admitted there was no monitoring to ensure labs were obtained or followed up on.
A facility failed to serve hot foods at palatable temperatures for a resident who ate meals in their room. The facility's policy required hot foods to stay above 140 degrees F, but a resident reported that meals were served cold. Observations showed that food was only slightly warm when delivered. The dietary manager noted that insulated lids and carts should be used to maintain temperatures, but the DON could not confirm if this was achieved for residents eating in their rooms.
Failure to Timely Report Alleged Abuse to Health Department
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with aphasia and weakness to the health department within the required two-hour timeframe. Documentation showed that the resident reported being sexually abused by another resident, and the incident was recorded on an incident report form. The report indicated that local law enforcement was notified and the resident was moved to another room for safety. However, the health department did not receive notification of the allegation until several hours after the initial report, exceeding the mandated reporting window. Interviews with staff confirmed that the delay in reporting occurred and that the required timeframe was not met.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical assaults, resulting in nine incidents involving one resident physically assaulting eight other residents over a four-month period. The resident responsible for the assaults had a history of mental health diagnoses, including schizophrenia, anxiety disorder, depression, restlessness, and agitation, and was known to have moderate cognitive impairment. Despite repeated incidents of aggression, the facility did not implement new or effective interventions after the initial care plan was created, nor did they update the care plan to address the ongoing behaviors. Documentation shows that after each incident, staff separated the residents involved, assessed for injuries, and noted that they would monitor and intervene if further behaviors were observed. However, there was no evidence of increased monitoring, special precautions, or additional interventions being put in place for the resident exhibiting aggressive behaviors. Interviews with staff confirmed that the resident was not on any special monitoring or precautions, and staff were not aware of any specific changes to the resident's care plan to address the repeated assaults. The facility's policy required staff to monitor for aggressive behavior, make necessary changes to care plans, and transfer residents if care could not be provided safely. Despite this, the care plan for the resident in question was not updated after multiple incidents, and interventions remained unchanged and ineffective. The lack of timely and appropriate action to address the resident's escalating behaviors resulted in continued physical assaults on other residents.
Failure to Revise Care Plan After Repeated Resident-to-Resident Altercations
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple behavioral health diagnoses, including schizophrenia, anxiety disorder, depression, restlessness, and agitation. Despite repeated incidents where the resident physically assaulted other residents, the care plan, which was initiated shortly after admission, was not updated with new interventions. Documentation showed that the resident was involved in multiple altercations, including hitting, grabbing, and causing injury to other residents over several months. Each incident was documented, and staff responded by separating residents and monitoring for further behaviors, but no new interventions were added to the care plan. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change. However, the care plan for this resident remained unchanged despite ongoing aggressive behaviors and documented incidents. The Director of Nursing confirmed that the care plan had not been updated and that the existing interventions were not effective in addressing the resident's behaviors.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident diagnosed with schizophrenia and anxiety disorder, who was severely impaired in daily decision-making. The incident report documented an allegation of abuse involving the resident and an LPN in the resident's room. However, the investigation was limited to statements from the alleged abuser and the reporter of the alleged abuse, with no interviews conducted with other residents, staff members, or visitors. The Director of Nursing (DON) acknowledged that a more comprehensive investigation should have been completed, noting that other residents were not interviewed due to cognitive impairments and other staff members were not asked to provide statements as they were not in the area.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were posted and accessible for residents and visitors. The Survey Results policy indicated that survey results should be available in the front lobby, identified with a sign. However, during a resident council meeting, four residents stated they did not know where the survey results were located. Observations confirmed that neither the survey results nor signage indicating their location were present in the facility. The activities director was unaware of the location of the survey results, and the administrator stated that the results were in a locked lobby area, inaccessible to residents without staff assistance. The DON revealed that the survey results had been in their office for approximately four months and were unaware that they needed to be accessible. The administrator acknowledged that the signage indicating the location of the survey results had been removed.
Failure to Complete and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were completed and communicated to residents or their representatives within 48 hours of admission, as required by their policy. Resident #150, who had diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and a pressure ulcer, reported not having a care plan meeting or receiving a summary of their baseline care plan after admission. A review of the clinical record confirmed that a baseline care plan had not been completed for this resident. The Director of Nursing (DON) acknowledged the oversight but could not explain why the care plan was not completed. Similarly, Resident #29, with diagnoses of diabetes, anxiety, and chronic pain, did not receive a summary of their baseline care plan. The baseline care plan document for this resident was incomplete, lacking signatures from the resident or their representative. The DON admitted uncertainty about who should receive the care plan summary and noted that resident representatives were typically contacted 10-14 days post-admission for care plan meetings. However, there was no documentation indicating that a summary of the baseline care plan had been provided to Resident #29 or their representative, and the resident confirmed that staff had not discussed the care plan with them upon admission.
Failure to Obtain Holding Temperatures for Noon Meal
Penalty
Summary
The facility failed to ensure that holding temperatures were obtained for the noon meal service, as observed on 10/01/24. The undated Food Temperatures policy required that temperatures of food items be taken and properly recorded for each meal. During the observation of the noon meal service, it was noted that the temperatures documented on the Daily Food Temperature Log were obtained when the food was removed from the oven, not at the time of serving. Cook #1 confirmed that they did not obtain holding temperatures before serving the food and relied on the steam from the steam table to assess the food's heat. The dietary manager was unaware of why the holding temperatures were not obtained or why the log indicated temperatures were taken at 11:30 a.m., despite the surveyor's presence in the kitchen at that time.
Failure to Ensure Smooth Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to a smooth consistency for residents on pureed diets during the noon meal observation. Cook #1 was observed preparing the meal, which included turkey with gravy, dressing, mixed vegetables, bread, and lemon pudding. The turkey and gravy, as well as the dressing, contained visible pieces of food and were not smooth. The mixed vegetables were processed into a thin, runny consistency with remaining pieces of vegetables. Despite these inconsistencies, the meals were plated and prepared for delivery to residents. The dietary manager confirmed that pureed foods should be the consistency of smooth mashed potatoes and acknowledged that the turkey, dressing, and mixed vegetables were not prepared correctly, being clumpy and too thin. Cook #1 stated that they processed foods until they resembled baby food and visually checked for remaining pieces, but this method failed to achieve the required consistency. The deficiency was identified during the observation of the meal preparation process, highlighting a lapse in ensuring the dietary needs of residents on pureed diets were met.
Deficiencies in Food Storage and Infection Control Practices
Penalty
Summary
The facility failed to adhere to proper food storage and infection control practices, as observed in several instances. In one of the facility's refrigerators, eleven dessert dishes with sliced peaches were found uncovered and undated, contrary to the facility's policy that requires all refrigerated foods to be covered, labeled, and dated. The dietary manager acknowledged that the staff had not followed the policy, which is essential for maintaining food safety standards. During meal service, infection control practices were not consistently followed by the kitchen staff. Cook #1 and Cook #2 were observed handling various items, including meal tickets, countertops, and food, without changing gloves or washing hands as required. Both cooks admitted to not following proper procedures, such as using gloves when touching food and handling dessert bowls by the sides. The dietary manager confirmed that staff should use gloves and utensils like tongs to maintain hygiene during food preparation and service. Additionally, a CNA delivering meal trays to residents in their rooms did not sanitize their hands after handling personal items and assisting residents, which is against the facility's policy. The CNA admitted to forgetting to sanitize their hands, and the DON confirmed that hand sanitization is required between each resident. Furthermore, the ice machine was found to be in an unsanitary condition, with a slimy pink substance and other residues observed. The dietary manager and maintenance supervisor acknowledged that the ice machine was not cleaned as frequently as necessary to prevent contamination.
Infection Control Protocol Breach During Medication Administration
Penalty
Summary
The facility failed to maintain infection control protocols during medication administration and wound care for residents on enhanced barrier precautions. On October 1st, an LPN was observed administering insulin and checking blood sugar for two residents without changing gloves or sanitizing hands between tasks. The LPN handed used supplies to another LPN, who also failed to follow proper hand hygiene protocols. This breach in protocol occurred despite the residents being on enhanced barrier precautions, which require strict adherence to infection control measures. On October 2nd, a CMA was observed preparing and administering medications without sanitizing hands between residents. The CMA acknowledged the requirement to sanitize hands between residents but did not comply. The DON and infection preventionist confirmed that staff were expected to wash or sanitize hands between resident interactions and that the observed actions did not align with the facility's infection control policies.
Failure to Accurately Assess and Plan for Resident Mobility Impairment
Penalty
Summary
The facility failed to ensure that a resident's mobility impairment was accurately assessed and included in the care plan. Resident #29, who had a history of cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis, was admitted with a noted weak left hand and no grasp due to a CVA. However, the admission assessment did not document this impairment, and the comprehensive care plan was not developed. A subsequent Functional Abilities and Goals Assessment initially failed to note any impairment, but a later assessment did document impairment to the upper and lower left side. Observations and interviews revealed that the resident's left hand appeared contracted, and no devices or restorative therapy were in place. Staff members, including a CNA and an LPN, were unaware of any limitations or interventions for the resident's left hand. The DON acknowledged that the impairment should have been included in the assessment and care plan but was not captured, and they could not explain why the assessment was not done.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis. The care plan, initiated on 08/02/24, only documented focus areas for DNR status and an indwelling catheter, neglecting other significant concerns. An admission assessment dated 08/15/24 identified ten areas of concern for care planning, such as cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence, behavioral symptoms, falls, nutritional status, dehydration fluid maintenance, dental care, pressure ulcer, and psychotropic drug use. However, only one of these concerns was included in the comprehensive care plan. The Director of Nursing acknowledged the oversight and admitted to not monitoring the care plan development.
Failure to Update Care Plan for Resident with Wound Care Needs
Penalty
Summary
The facility failed to ensure the care plan was revised and updated for a resident with a history of pressure ulcers and diabetes type II. The resident's care plan initially documented a wound to the left heel, which was noted as resolved. However, a physician's order later indicated the need for wound care on the right heel, which was not reflected in the care plan. A quarterly assessment also failed to document any deep tissue injuries or pressure wounds, despite the presence of a closed wound on the left heel observed during wound care. The Director of Nursing acknowledged that the care plan should have been updated to reflect the current wound care needs.
Failure to Implement ROM Interventions for Resident with Hemiplegia
Penalty
Summary
The facility failed to implement necessary interventions to prevent a reduction in range of motion and mobility for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident was admitted with left hand weakness and no grasp due to a cerebrovascular accident, yet the admission assessment did not document any impairments to the upper or lower body. A CNA noted that the resident did not allow any interaction with their left hand and observed no supportive devices in the room. An LPN, unfamiliar with the resident, reported no limitations in range of motion and no interventions in place. The DON acknowledged that the resident's left hand was not fully functional and should have been documented in the assessment and care plan, but it was not captured.
Inconsistent Provision and Documentation of Dietary Supplements
Penalty
Summary
The facility failed to ensure that dietary supplements were consistently offered and documented for a resident diagnosed with moderate protein calorie malnutrition. The resident was 26% below their ideal body weight and had a physician's order for dietary supplements to be provided between meals. Despite this, the facility's records showed that supplements were documented as provided or offered only 36 times out of 72 opportunities. This inconsistency in documentation and provision of supplements contributed to a significant weight loss of 6.76% over one month for the resident. Interviews with facility staff revealed a lack of clarity and consistency in the process of providing and documenting supplements. The dietary department was responsible for providing supplements, while the nursing department was tasked with documenting the amount consumed. However, there were discrepancies in the documentation process, with some entries marked as 'response not required' without clear justification. The resident confirmed being offered snacks and shakes multiple times a day but admitted to occasionally refusing them. This situation highlights a breakdown in communication and procedure adherence among the facility's staff, leading to inadequate nutritional support for the resident.
Failure to Obtain Physician-Ordered Labs
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered by the physician for a resident reviewed for unnecessary medications. The resident, who had diagnoses including dementia, mood disorder, and unspecified psychosis, had a physician's order dated April 23, 2024, for a lipid panel and PSA for annual labs. However, the PSA was not obtained as ordered. The resident initially refused the lab tests for three days, but later complied in June and July 2024 after staff explained the tests to them. Despite this compliance, the PSA was not conducted because it was no longer in the electronic clinical record. The Director of Nursing (DON) acknowledged that there was no documentation of staff explaining the lab to the resident in April 2024 and admitted that there was no monitoring to ensure the labs ordered by the physician were obtained or followed up on if the resident initially refused.
Failure to Serve Hot Foods at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at palatable temperatures for a resident who was reviewed for food. The facility's undated Food Temperatures policy required that hot foods stay above 140 degrees F and cold foods stay below 40 degrees F during the portioning, transporting, and serving process. However, a resident reported that hot foods were consistently served cold, particularly when meals were eaten in their room. During an observation, meal trays were prepared and placed on a metal cart with a plastic zippered cover. A test tray was used to assess the temperature of the food, which included penne pasta with chicken and alfredo sauce, green beans, bread, and spiced apples. When the test tray was checked after delivery, the penne pasta and green beans were only slightly warm. The dietary manager stated that food holding temperatures should be obtained before serving, and insulated lids and food carts should be used to maintain palatable temperatures. The DON was unable to confirm if hot foods were served hot to residents eating in their rooms.
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 37 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Lake Villa | 0.1 mi | ★★★★★ | 10 | 3 |
| Grove Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Monroe Manor | 10.5 mi | ★★★★★ | 0 | 0 |
| Maple Healthcare And Rehab | 12.5 mi | ★★★★★ | 0 | 0 |
| Mcdonald County Living Center | 18.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.