Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Veteran Village during CMS and state inspections, most recent first.
A resident in a long-term care facility experienced a significant worsening of a pressure ulcer and the development of a new Stage III ulcer due to a malfunctioning air mattress. The resident, at risk for skin breakdown due to multiple health conditions, was not adequately repositioned, and the facility failed to document the mattress incident or the resident's refusal to be repositioned. Interviews revealed that the mattress deflation contributed to the pressure injuries, and an incident report was not completed.
A resident with an indwelling urinary catheter was hospitalized for a complicated UTI after the facility failed to promptly notify the Medical Provider of urinalysis results. The resident, diagnosed with incomplete paraplegia and neuromuscular dysfunction of the bladder, had a STAT urinalysis ordered due to cloudy urine. The results indicated contamination, but the Medical Provider was not informed, and no recollection was documented. Subsequent tests showed resistance to prescribed antibiotics, but the Medical Provider was not notified until the resident required hospital transfer.
Facility staff failed to implement corrective actions for an abuse allegation involving a resident with congestive heart failure. The resident reported being pushed by an LPN after calling for assistance. Despite the facility's plan to relocate the LPN, they returned to work and provided care to the resident, contrary to the corrective actions outlined in the investigation.
The facility failed to implement comprehensive care plans for two residents. One resident's g-tube placement was not assessed before medication administration, risking incorrect delivery. Another resident with Diabetes lacked interventions for hypoglycemia, with low blood sugar episodes not properly addressed. Staff were unaware of specific protocols, highlighting deficiencies in care planning and implementation.
A resident with multiple health conditions received medications through a g-tube without proper verification of tube placement or residual checks, contrary to facility protocol. The LPN failed to auscultate for g-tube placement and did not flush the tube between medications, risking potential complications. The DON confirmed the protocol breach, which could lead to serious health issues.
A resident with a history of diabetes and neuropathy experienced severe pain during dressing changes for pressure wounds, which was not adequately managed by the facility. Despite being on Tramadol, the resident's pain was dismissed as behavioral by staff, and there was a lack of communication and follow-up regarding pain management. The Director of Nursing was unaware of the resident's pain issues, and no competency training for pain assessment was documented.
Pressure Ulcer Worsening Due to Mattress Malfunction
Penalty
Summary
The facility failed to prevent the significant worsening of a pressure ulcer and the development of a new Stage III pressure ulcer for a resident. The resident's air mattress malfunctioned, leading to the increase in size of an existing pressure ulcer and the development of another. The resident, who was at risk for skin breakdown due to conditions such as diabetes, morbid obesity, and peripheral vascular disease, was found to have a malfunctioning mattress that deflated, contributing to the pressure injuries. The facility's policy on wound intervention and prevention was not adequately followed, as evidenced by the lack of proper tissue load management and failure to document the incident of the mattress malfunction. The resident's care plan included interventions such as pressure relieving devices, turning and repositioning programs, and nutritional supplements, but these were not effectively implemented or documented. The resident's refusal to be turned and repositioned was not consistently documented in the nursing notes, and the facility did not complete an incident report for the mattress malfunction. Interviews with the wound physician and wound care nurse revealed that the mattress malfunction contributed to the worsening of the sacral wound and the development of the right buttock ulcer. The wound physician noted that the resident's noncompliance with care and the mattress malfunction were factors in the pressure injuries. The director of nursing acknowledged that an incident report should have been completed for the mattress malfunction, but it was not done, and the duration of the mattress deflation was unknown.
Failure to Notify Medical Provider of Urinalysis Results Leads to Hospitalization
Penalty
Summary
The facility failed to notify the Medical Provider of urinalysis results for a resident with an indwelling urinary catheter, leading to a hospitalization for a complicated urinary tract infection. The resident, who had a primary diagnosis of incomplete paraplegia and a secondary diagnosis of neuromuscular dysfunction of the bladder, was ordered a STAT urinalysis on 06/25/24 due to cloudy urine. The results, received on 06/26/24, indicated contamination and recommended recollection, but there was no documentation that the Medical Provider was notified or that another sample was collected. A subsequent order for a urinalysis and Macrobid was made on 07/01/24, but the results from 07/04/24 were not acknowledged by any medical professional. The resident's condition worsened, with dark, bloody urine observed on 07/10/24, and a urine culture on the same day identified Klebsiella Pneumoniae resistant to Macrobid. Despite this, there was no record of the Medical Provider being informed of the resistance until 07/15/24, when the resident was transferred to the hospital for treatment. The Director of Nursing confirmed that the delay in notifying the Medical Provider of the initial urinalysis results likely contributed to the resident's hospitalization.
Failure to Implement Corrective Actions for Abuse Allegation
Penalty
Summary
Facility staff failed to implement corrective actions as indicated in the facility's investigative report for an allegation of abuse involving a resident with congestive heart failure and functional limitations. The resident, who had an intact cognition, reported an incident where an LPN entered their room, lectured them, and pushed them on the shoulder after the resident called out for assistance due to an unreachable call light. The resident described the encounter as intimidating and felt the LPN should not be working with older people. The facility's investigative report indicated that the LPN would be reeducated and moved to another unit upon return from suspension. However, the LPN returned to work and provided care to the resident on two occasions, contrary to the corrective actions outlined in the investigation. The Director of Nursing and the Administrator confirmed the LPN's return to the same unit, attributing the failure to relocate the LPN to a delay in notification.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for two residents. For one resident, the facility did not assess the placement of a gastrostomy (g-tube) tube prior to the administration of medications. The resident had multiple diagnoses, including Chronic Obstructive Pulmonary Disease, severe Protein-Calorie Malnutrition, and Dysphagia. During an observation, an LPN administered medications through the resident's g-tube without checking for residual gastric contents or confirming the correct placement of the g-tube. The LPN admitted to not following the protocol of checking the g-tube placement, which could lead to medications being administered incorrectly. For another resident with Diabetes, the facility failed to develop and implement interventions for episodes of hypoglycemia. The resident's care plan included a focus on hypo/hyperglycemia risk but did not provide specific interventions for responding to these conditions. The resident's blood glucose records showed several instances of low blood sugar levels, but there were no corresponding progress notes indicating that the resident was assessed for symptoms, that the Medical Provider was notified, or that any actions were taken to address the low blood sugar levels. An LPN interviewed was not aware of any specific policies or procedures for responding to hypoglycemia, and the Director of Nursing confirmed that the facility had not developed a policy for this condition. The Director of Nursing and the Administrator both expressed expectations that staff should follow care plans and provide appropriate care for residents. However, the lack of specific interventions and adherence to protocols in these cases indicates a deficiency in the facility's care planning and implementation processes.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent potential complications of enteral feeding for a resident who received medications through a gastrostomy tube (g-tube). The Licensed Practical Nurse (LPN) administered medications to the resident without checking for residual gastric contents or verifying the proper placement of the g-tube by auscultation. The facility's policy required that the g-tube placement be checked by injecting air into the tube and listening for a gurgling sound in the stomach area, which was not done. Additionally, the LPN did not flush the g-tube between administering two different medications, which is against the facility's protocol. The resident involved had multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), severe protein-calorie malnutrition, and other conditions, and was at risk for complications related to tube feeding. The resident's care plan indicated the need to check g-tube placement and residuals per facility protocol, which was not followed. Interviews with the LPN and another nurse revealed that the failure to check the g-tube placement could lead to medications being administered into incorrect areas, potentially causing serious complications. The Director of Nurses confirmed that the facility's protocol was not followed, which could result in medications entering the abdominal wall and creating an abscess.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R21, who experienced significant pain during dressing changes for pressure wounds. R21, who was cognitively intact, had a history of diabetes mellitus with diabetic arthropathy, peripheral autonomic neuropathy, and morbid obesity. Despite having a care plan that included pain management interventions, the facility did not adequately address R21's pain, which was evident during wound care procedures. R21's medical records indicated an order for Tramadol to be administered twice daily and for pain levels to be assessed every shift. However, during an observation, R21 expressed severe pain, rating it as a 10 out of 10, particularly during repositioning and wound care. The resident's verbal and non-verbal indicators of pain, such as yelling and grimacing, were dismissed by facility staff as behavioral rather than genuine pain responses. The Wound Care Nurse (WCN) acknowledged that R21 typically yelled during dressing changes but did not take further action to address the pain. Interviews with the WCN and the Director of Nursing (DON) revealed a lack of communication and follow-up regarding R21's pain management. The WCN stated that addressing unresolved pain was the responsibility of the primary nursing team, while the DON was unaware of the resident's pain during treatment changes. The DON also noted that pain evaluations were expected to be part of the nurses' competency training, but no such training was documented. This lack of coordination and failure to adjust pain management strategies contributed to the deficiency in care for R21.
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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 Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southland Health Care Center | 1 mi | ★★★★★ | 2 | 0 |
| Heritage Post Acute | 1.5 mi | ★★★★★ | 7 | 0 |
| Faith Healthcare Center | 2 mi | ★★★★★ | 5 | 1 |
| Honorage Nursing Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Carlyle Senior Care Of Florence | 4.8 mi | ★★★★★ | 10 | 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.