Below 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 Hardin County Nh during CMS and state inspections, most recent first.
PASRR was not resubmitted for two residents after new mental health diagnoses were added. One resident’s record later included bipolar disorder after a psychiatric evaluation recommended adding it, and the other resident developed psychotic disorder with delusions, anxiety, and depression with associated psychotropic medications and MDS findings of hallucinations and delusions. An LPN and the DON acknowledged PASRR should be updated when diagnoses or psych meds change, but no updated PASRR documentation was found.
A resident with diagnoses including hemiplegia, depression, anxiety, and a fractured fibula had multiple ordered medications and skin treatments missed, including Nystatin powder, Aquaphor ointment, Skin Prep, and moisture barrier cream. The TAR showed several omitted doses across day, evening, and night shifts, and during wound care observation redness was noted to the right heel. The DON stated staff should administer medications as ordered by the Physician.
A LTC facility failed to provide adequate supervision and assistance to prevent falls, resulting in harm to a resident who sustained fractures after falling from a toilet. The facility also did not perform fall assessments per policy for several residents at high risk for falls, failing to complete necessary assessments after falls or significant condition changes. This lack of supervision and assessment led to multiple fall incidents, highlighting systemic issues in fall prevention.
The facility did not submit the required Payroll-Based Journal (PBJ) data for the first quarter of 2024, as mandated by their policy. This was confirmed by the Administrator during an interview.
The facility failed to maintain sanitary conditions in the kitchen, with observations of unclean deep fryer grease and carbon build-up on stove eyes. Additionally, a dietary staff member did not sanitize the thermometer between uses when checking food temperatures, contrary to facility policy. The CDM confirmed these deficiencies and the need for proper cleaning and sanitization practices.
A facility failed to include a resident and their family in care plan conferences, as required by policy. Despite being cognitively intact, the resident reported never being invited to such meetings. Staff interviews revealed a lack of documentation and communication regarding the resident's participation, with the Social Services Director admitting to not documenting meetings in the EMR.
PASRR Not Updated After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit Preadmission Screening and Resident Review (PASRR) evaluations after new mental illness diagnoses were added for 2 sampled residents. The facility policy stated that if a significant change in status assessment occurs for an individual known or suspected to have a mental illness, a referral to the State Mental Health authority for a possible Level II PASRR evaluation must promptly occur, and the facility should not wait until the assessment is complete. One resident was admitted with diagnoses including depression, conduct disorder, impulse disorder, and anxiety. The resident’s PASRR did not note bipolar disorder, but a quarterly MDS assessment later listed bipolar disorder among the resident’s diagnoses and showed a BIMS score of 15, indicating cognitive intactness. A psychiatric evaluation recommended adding bipolar disorder to the diagnosis list, but the record contained no documentation that PASRR was resubmitted after bipolar disorder was added. The second resident was admitted with diagnoses including Parkinson’s disease, hyperlipidemia, and hypertension, and the initial PASRR indicated no mental health diagnosis, no known mental health behaviors, and no psychoactive medications. Later psychiatric documentation described increasing distressing delusions, paranoia, depression, and psychosis related to Parkinson’s disease, and new diagnoses were added for psychotic disorder with delusions, anxiety disorder, and depression. The resident’s MDS showed a BIMS score of 13, hallucinations and delusions during the assessment period, and active diagnoses of anxiety disorder and psychotic disorder, with orders for Prozac and Seroquel. Interviews with an LPN and the DON confirmed awareness that PASRR should be updated when there are new mental health diagnoses or changes related to psych medications, but the record showed no PASRR update for the new diagnoses.
Missed Ordered Medications and Treatments
Penalty
Summary
The facility failed to ensure medications and treatments were administered according to Physician's Orders for Resident #5. The resident was admitted with diagnoses including Presence of Artificial Larynx, Hemiplegia, Depression, Anxiety, and Fractured Fibula, and the admission MDS showed a BIMS score of 14, indicating the resident was cognitively intact. The facility policy titled, Administration of Drugs, stated to give medications per physician's orders. Review of the medical record and TAR showed multiple missed administrations of ordered treatments. Nystatin external powder ordered for yeast was not given on several occasions, Aquaphor Adv Therapy Healing External Ointment ordered daily for dry skin was not given on two dates, Skin Prep ordered for the right heel and left lateral ankle was not given on multiple dates, and Moisture Barrier cream ordered to bilateral buttocks every day shift and night shift was not given on several shifts. During wound care observation, redness was noted to the right heel. The DON stated that staff should administer medications as ordered by the Physician.
Inadequate Supervision and Fall Risk Assessment in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent fall accidents for several residents, leading to actual harm in one case. Resident #3, who was severely cognitively impaired and required maximal assistance with toileting, fell from the toilet and sustained significant fractures due to a lack of supervision. The care plan intervention for staff to remain with the resident while in the bathroom was not followed, as the CNA stepped away to assist another resident, resulting in the fall and subsequent injuries. Additionally, the facility did not perform fall assessments per its policy for multiple residents, including Residents #5, #12, #14, #22, #26, and #187. These residents were identified as being at high risk for falls, yet the facility failed to complete necessary fall risk assessments after falls occurred or when there were significant changes in their conditions. This lack of assessment and documentation contributed to the inability to effectively manage and mitigate fall risks for these residents. The facility's failure to adhere to its fall prevention policy and to conduct timely fall risk assessments resulted in multiple incidents where residents experienced falls, some with injuries. The lack of proper supervision and assessment highlights a systemic issue in the facility's approach to fall prevention, impacting the safety and well-being of its residents.
Failure to Submit PBJ Data for Q1 2024
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of 2024, covering the period from October 1, 2024, to December 31, 2024. This deficiency was identified through a review of the facility's policy on Reporting Direct-Care Staffing Information and the Quarterly Payroll Based Journal (PBJ) for the specified period. The facility's policy mandates that direct-care staffing and census information be reported electronically to CMS via the PBJ system. However, the review revealed that the facility did not submit the required data for the quarter. During an interview on January 23, 2025, the Administrator confirmed the failure to submit the PBJ data by the required deadline.
Sanitation Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The deep fryer contained dark brown cooking grease with brown crumbs floating on top, and the cooking stove eyes had black carbon build-up. These observations were made on two separate occasions, indicating a lack of regular cleaning and maintenance. The Certified Dietary Manager (CDM) confirmed that the deep fryer should be cleaned weekly and that the grease should be clear, while the carbon build-up on the stove eyes should have been removed. Additionally, a dietary staff member, identified as Dietary [NAME] B, failed to sanitize the thermometer between uses when taking the temperature of various food items, including broccoli, roast beef, and several pureed vegetables. This practice was contrary to the facility's policy, which requires the use of a new alcohol pad to clean the thermometer before each use. The CDM confirmed the correct procedure and acknowledged the failure to adhere to it, which compromised the sanitary handling of food.
Failure to Include Resident in Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences with a resident and/or their family representative, as required by their policy. The policy mandates that care plan meetings are conducted to ensure person-centered care and involve the resident, family, or representative in the planning process. However, for one resident, there was no documentation of their involvement in care plan meetings on multiple occasions, including quarterly and significant change conferences. The resident, who was cognitively intact, confirmed that neither they nor their daughter had been invited to any care plan meetings. Interviews with facility staff, including the MDS Coordinator, Social Services Director, and Director of Nursing, revealed a lack of documentation and communication regarding the resident's participation in care plan meetings. The Social Services Director admitted to not documenting the meetings in the electronic medical record, and the Director of Nursing confirmed that a sign-in sheet should be completed for all attendees, including those joining by phone. Despite these procedures, the facility was unable to provide evidence of the resident's or their representative's involvement in the care planning process.
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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 Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hardin Home | 0.6 mi | ★★★★★ | 1 | 0 |
| Park Rest Hardin County Health Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Savannah Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
| Adamsville Healthcare And Rehabilitation Center | 8.6 mi | ★★★★★ | 0 | 0 |
| Harbert Hills Academy N H | 9.5 mi | ★★★★★ | 4 | 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.