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 Donalson Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was found to have a dislocated femoral head during a hospital visit. The injury, classified as of unknown origin, was not reported to the facility's Administrator until over two days later, violating the facility's policy for immediate reporting. The delay was confirmed by the Director of Nursing and the Administrator, who emphasized the requirement for prompt notification of such incidents.
Two residents with severe cognitive impairment had handwritten signs displaying personal medical information posted in their rooms, visible to anyone entering. These signs were not requested by the residents or their representatives, and the DON confirmed staff posted them, resulting in a failure to maintain resident dignity and privacy.
The facility did not resubmit PASRR referrals to the state agency after two residents were diagnosed with new mental health conditions, including neurocognitive disorder, paranoia, delusional disorders, panic disorder, and anxiety disorder. Despite facility policy requiring prompt referral for Level II PASRR review when new diagnoses are identified, the Social Services Director confirmed that updated PASRR submissions were not made to reflect these changes.
Licensed nurses administered antihypertensive medications to three residents despite physician orders to hold the medications for low systolic blood pressure (SBP). In each case, the medication was given when the SBP was below the specified threshold, and staff did not notify the physician or obtain approval to proceed. The DON confirmed that medications should have been held according to orders, and no adverse outcomes were documented.
A resident with a feeding tube and severe cognitive impairment did not receive physician-ordered free water flushes because the feeding pump was not programmed to deliver the prescribed hydration. The issue was discovered during observation and confirmed by the ADON and NP, who noted the resident was not receiving the water flush as ordered.
A resident received insulin glargine from a medication cart where the insulin pen was not labeled with an open or expiration date, contrary to facility policy and manufacturer guidelines. The insulin was administered without verification of its expiration status, and staff confirmed the labeling omission and improper use.
A resident with hypertension received Lisinopril despite medical record entries showing systolic blood pressure below the physician-ordered threshold. Staff reported rechecking blood pressure before administration but failed to document the updated readings in the medical record, resulting in incomplete and inaccurate documentation. The DON confirmed that accurate documentation of blood pressures is expected.
Staff failed to provide hand hygiene assistance to several residents before meals, did not consistently use required PPE for residents on Enhanced Barrier Precautions during direct care, and did not perform hand hygiene during medication administration. These actions were contrary to facility policies and were confirmed by staff interviews and direct observation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's Disease and a recent femoral fracture. The resident was transferred to the emergency department due to gastrointestinal bleeding, where a computed tomography angiogram revealed a dislocation of the femoral head. Despite this finding, the injury was not reported to the facility's Administrator until over two days later, contrary to the facility's policy requiring immediate reporting of such incidents. The Director of Nursing and the Administrator confirmed that the facility's policy was not followed, as staff are expected to report any injury of unknown origin immediately. Registered Nurse D, who became aware of the injury, did not report it promptly, citing a lapse in memory regarding the incident. This delay in reporting was acknowledged during interviews with the Director of Nursing and the Administrator, who reiterated the expectation for immediate notification of any suspicious injuries.
Failure to Protect Resident Dignity and Privacy Due to Visible Medical Signage
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents by allowing medical information to be visibly posted in their rooms without the request or consent of the residents or their representatives. For one resident with severe cognitive impairment and diagnoses including Parkinson's Disease, Dementia, and Adult Failure to Thrive, a handwritten sign stating 'No Briefs to [Resident] D/T groin' was posted above the television and was visible to anyone entering the room on multiple occasions. There was no evidence in the care plan that the resident or their representative had requested this signage. Similarly, another resident with severe cognitive impairment and diagnoses including Dementia, Diabetes, and Anxiety had a handwritten sign posted above the television stating 'We are going back to [medicated cream] to [Resident]'s Buttocks. Please wash skin gently.' This sign was also visible to anyone entering the room on several occasions, and there was no documentation that the resident or their representative had requested the sign. The Director of Nursing confirmed that staff posted these signs and acknowledged that this practice failed to maintain the residents' dignity and privacy.
Failure to Resubmit PASRR Referrals After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit Pre-Admission Screening and Resident Review (PASRR) referrals to the state agency after new mental health diagnoses were identified for two residents. According to facility policy, any resident exhibiting a newly evident or possible serious mental disorder or related condition must be promptly referred for a Level II PASRR review. For one resident, the medical record showed initial PASRR screening included diagnoses of depression and anxiety, but subsequent diagnoses of neurocognitive disorder with Lewy Bodies, paranoia, and delusional disorders were not reported through a new PASRR submission. The Social Services Director confirmed that the most recent PASRR referral was not updated to reflect these new diagnoses. For another resident, the initial PASRR screening included major depression and dementia, but later diagnoses of panic disorder and anxiety disorder were not added to the PASRR. The Social Services Director attempted to update the PASRR to include new medications but was unable to add the new diagnoses, and confirmed that the PASRR had not been resubmitted after the new mental health conditions were identified. Both cases demonstrate that the facility did not coordinate assessments with the PASRR program as required by policy, resulting in a failure to refer residents for appropriate review after significant changes in their mental health status.
Failure to Follow Physician Orders for Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to follow physician's orders regarding the administration of blood pressure medications for three residents who had specific parameters for holding antihypertensive medications based on systolic blood pressure (SBP) readings. Facility policy required licensed nurses to administer medications as ordered, including holding medications if vital signs were outside prescribed parameters and documenting these actions on the medication administration record (MAR). However, medical record reviews revealed that medications were administered to residents even when their SBP was below the threshold specified in the physician's orders. For one resident with hypertension and cognitive communication deficit, Losartan was ordered to be held if SBP was less than 110. Despite this, the medication was administered on multiple occasions when the resident's SBP was below the ordered parameter. Interviews with the LPNs involved confirmed that they administered the medication despite the low SBP and did not notify the physician or obtain approval to proceed. The DON confirmed that the medication should have been held and that the expectation was for staff to follow physician's orders. Similar deficiencies were found for two other residents with orders for Metoprolol to be held for SBP below specified levels. In both cases, the medication was administered when SBP readings were below the ordered parameters, and the nurses involved acknowledged the error during interviews. The DON reiterated that medications should have been held in these situations. No adverse outcomes were documented for any of the residents involved.
Failure to Administer Ordered Water Flushes via Feeding Tube
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube and severe cognitive impairment did not receive physician-ordered free water flushes at 60 ml/hr for 22 hours per day. The resident's care plan and medical orders specified the need for continuous tube feeding and water flushes, but during observation, the water flush bag was found full and connected to the feeding pump, which had not been programmed to deliver the water flush as ordered. The Assistant Director of Nursing (ADON) confirmed that the pump was not set to administer the water flush and that the resident was not receiving the prescribed hydration. The ADON explained that the feeding pump had been placed on hold during medication administration and may not have been properly resumed to include the water flushes. The issue was identified during a review and confirmed through interviews with both the ADON and the Nurse Practitioner, who acknowledged that the resident had not received the water flush as ordered. The resident was assessed and found to have no adverse outcomes from the missed water flushes.
Failure to Label Insulin Pen with Open and Expiration Dates
Penalty
Summary
The facility failed to ensure that an insulin medication was properly labeled with an open and expiration date in one of four medication carts observed, which had the potential to affect a resident who was receiving insulin therapy. Facility policy required insulin pens to be clearly labeled with the resident's name and expiration date, and to be discarded if the label was missing or if the pen was expired. Manufacturer's guidelines also specified that insulin glargine pens should not be used for more than 28 days after first use. During observation, an insulin glargine pen in the medication cart was found to be opened and not labeled with an open date for the resident. The Infection Preventionist confirmed that the insulin pen was the only one available for the resident and that it had been used for medication administration without proper labeling, making it impossible to verify if it was within the 28-day expiration period. The Director of Nursing and the Pharmacist both confirmed that insulin medications should be checked for expiration dates prior to administration and that the insulin should have been labeled with an open date and expiration date upon first use. The improperly labeled insulin glargine was administered to the resident, who had a history of diabetes, hypertension, and muscle weakness, and was cognitively intact according to recent assessments. The Medication Administration Record showed that the resident received insulin as ordered, and blood sugar levels remained at baseline with no negative outcomes reported. However, the lack of proper labeling meant that the facility could not ensure the medication's effectiveness or compliance with policy and manufacturer guidelines.
Failure to Accurately Document Blood Pressure Readings Prior to Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident who was prescribed Lisinopril for hypertension. According to the facility's policy, all medications administered must be ordered by a physician and nursing personnel are responsible for proper documentation. The resident, who was cognitively intact and had diagnoses including anxiety, hypertension, and depression, had a physician's order for Lisinopril to be held if the systolic blood pressure (SBP) was less than 120. However, the Medication Administration Record (MAR) showed that Lisinopril was administered on several occasions when the recorded SBP was below 120. Interviews with the staff involved revealed that both the Infection Preventionist (IP) and an LPN stated they would recheck the blood pressure if the SBP was less than 120 before administering the medication, but they failed to document the rechecked blood pressure in the medical record. The Director of Nursing (DON) confirmed that it was her expectation for blood pressures to be documented accurately in the medical record. This lack of accurate documentation led to a deficiency in maintaining complete and accurate medical records for the resident.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by multiple lapses in hand hygiene and use of personal protective equipment (PPE) during resident care and meal service. Staff did not offer or assist with hand hygiene for five residents prior to meals, despite facility policy requiring this practice. Observations showed that staff delivering meal trays to residents in their rooms did not provide hand hygiene assistance, and interviews with staff confirmed that this was not routinely done for residents eating in their rooms, even though it was acknowledged as necessary by both the Infection Preventionist (IP) and the Director of Nursing (DON). Additionally, the facility did not ensure that staff donned appropriate PPE for residents on Enhanced Barrier Precautions (EBP). In two observed cases, staff provided direct care, such as changing briefs and linens, to residents on EBP while wearing only gloves and not gowns, contrary to facility policy and care plans. Staff interviews revealed a lack of consistent understanding and communication regarding which residents required EBP and the specific PPE needed. There was also confusion about how outside care providers and families would be informed of EBP requirements. Further deficiencies were observed in hand hygiene practices during medication administration. The IP was seen providing care to one resident, then preparing and administering medication to another resident without performing hand hygiene before or after the process, despite facility policy mandating hand hygiene at these times. The IP and DON both confirmed that hand hygiene should have been performed before and after resident contact and medication administration, but this was not done.
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Illustrative
What surveyors actually found near you
We read the 77 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elk River Health & Rehabilitation Of Fayetteville | 2 mi | ★★★★★ | 16 | 0 |
| Lynchburg Nursing Center | 12.9 mi | ★★★★★ | 5 | 0 |
| Nhc Healthcare, Tullahoma | 21.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Tullahoma | 22.3 mi | ★★★★★ | 5 | 0 |
| Elk River Health And Nursing Center Of Ardmore, Ll | 22.4 mi | ★★★★★ | 11 | 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.