Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Haywood Post Acute during CMS and state inspections, most recent first.
Dangerously high hot water temperatures were found in multiple resident rooms, including those shared by several cognitively impaired individuals who required assistance with ADLs. Facility policy required water temperatures to be kept below a certain threshold, but maintenance staff did not consistently monitor or document water temperatures, leading to unsafe conditions. Staff confirmed the presence of excessively hot water during care activities, and maintenance records were incomplete.
A resident with severe mental illness and cognitive impairment was prescribed a new antipsychotic medication, but the facility did not resubmit the required PASRR screening following this change. Review of records and staff interviews confirmed that the necessary PASRR update was not completed as mandated by policy and federal requirements.
A resident with epilepsy, diabetes, and lower leg contractures, who was cognitively intact but required substantial assistance with bathing, did not receive any scheduled showers over a three-month period despite a care plan specifying showers three times weekly. Documentation and interviews confirmed the lack of provided showers, and the DON acknowledged that the resident should have received this care as planned.
Staff failed to secure and properly store medications, leaving creams and pills unattended in three resident rooms and allowing expired medications to remain in a medication storage area. LPNs and the DON confirmed that medications should not be left at the bedside or in storage past expiration.
Two residents with severe cognitive impairment and psychiatric diagnoses received duplicate doses of antipsychotic medications due to concurrent orders for both brand and generic forms. Medication Administration Records showed both medications were administered at the same time over several months, and the issue persisted despite identification by pharmacy review and notification of nursing leadership.
Two residents received care that did not follow infection control protocols when an LPN failed to disinfect a multi-use insulin vial and perform hand hygiene after glove removal, and another LPN did not clean a stethoscope after verifying gastrostomy tube placement. The DON confirmed these lapses in required infection prevention practices.
A facility failed to implement effective fall interventions and complete neuro checks for residents with severe cognitive impairment. One resident with a BIMS score of 2 and a history of wandering behavior sustained a fall resulting in a right femur fracture. The care plan included reminders for assistive devices and redirection, but these measures were ineffective in preventing the resident's wandering and subsequent fall. The facility did not modify interventions or implement additional measures to address the resident's behaviors, leading to actual harm.
The facility failed to follow proper infection control practices during IV medication administration and hand hygiene during dining. An LPN did not clean an administration port before administering IV medications, and multiple staff members did not perform hand hygiene before and after resident contact and while handling food.
The facility failed to report allegations of abuse involving two residents, despite having a policy that mandates immediate reporting. The Administrator did not report the incident to the state agency within the required timeframe, deeming the altercation as minor.
The facility failed to thoroughly investigate allegations of abuse involving two residents, one with intact cognition and one with severe cognitive impairment. The incident was documented, but the investigation was incomplete, and the results were not reported to the State Agency within the required timeframe.
The facility failed to ensure a care plan meeting and interventions for two cognitively intact residents expressing sexual desires towards one another. Despite multiple incidents of inappropriate sexual behavior in public areas, there was no documentation of a care plan meeting by the IDT to address these behaviors and ensure privacy for the residents.
A resident with severe cognitive impairment and multiple diagnoses had their oxygen concentrator set at 4 liters per minute instead of the prescribed 2 liters per minute. An LPN confirmed the error and adjusted the setting, and the DON confirmed that staff should follow physician's orders.
A registered nurse left a medication cart unlocked and unattended, violating the facility's policy on medication storage. The DON confirmed that the cart should not be left unlocked and out of sight.
Failure to Maintain Safe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing dangerously elevated hot water temperatures in resident rooms. On 4/28/2025, water temperatures ranging from 128°F to 135°F were measured in six resident rooms, some of which had shared bathrooms. Facility policy required water temperatures to be kept at or below 115°F, and maintenance staff were responsible for regular checks and documentation, which was not consistently performed. Several residents affected by this deficiency were severely cognitively impaired, as indicated by low BIMS scores, and required varying levels of assistance with activities of daily living (ADLs). These residents included individuals with diagnoses such as psychosis, dementia, Parkinson's disease, and other conditions that increased their vulnerability. Observations confirmed that the hot water was present in shared bathrooms used by these residents, and staff interviews corroborated that excessively hot water was noticed during routine care activities. The Maintenance Director was unable to provide documentation of water temperature checks for a specified period, and the boiler serving the affected areas was found to be set above the recommended temperature. The facility's own policy and job descriptions outlined the need for regular monitoring and maintenance to prevent such hazards, but these procedures were not followed, resulting in the exposure of residents to unsafe water temperatures.
Failure to Resubmit PASRR After New Antipsychotic Medication Initiation
Penalty
Summary
The facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after a resident with a history of serious mental illness was prescribed a new antipsychotic medication. According to facility policy and federal requirements, any change in a resident's symptoms, diagnosis, or medication related to serious mental illness necessitates a new PASRR Level 1 screening. The medical record showed that the resident, who had diagnoses including Bipolar Disorder, Schizophrenia, and Anxiety Disorder, was started on Haloperidol for severe depressive symptoms with psychotic features. Despite this significant medication change, there was no documentation of a new PASRR submission following the addition of Haloperidol. The resident had a history of severe cognitive impairment, as indicated by low BIMS scores, and was receiving multiple psychotropic medications. The last PASRR on file was dated several years prior to the medication change. During an interview, the Admissions Coordinator confirmed awareness of the requirement to resubmit PASRRs upon such changes and acknowledged that a new PASRR had not been completed for this resident since the last one on record. This lapse was identified through policy review, medical record review, and staff interview.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs), specifically showering, for a resident who was unable to perform this task independently. According to facility policy, residents who cannot carry out ADLs independently are to receive necessary services, including hygiene and bathing, in accordance with their care plan. The resident in question was admitted with diagnoses of epilepsy, diabetes, and contractures of both lower legs, and was assessed as cognitively intact but requiring substantial to maximum assistance with showers or baths. The care plan specified that the resident preferred and was to receive showers three times a week at bedtime, with sponge baths as an alternative if desired. Medical record review showed that the resident did not receive any showers during the months of February, March, or April, as documented on bathing sheets. During interviews, the resident reported having received only one shower in three years of residency, expressing feelings of being deprioritized for care. Staff interviews confirmed the established shower schedule for the resident's hall, and the DON acknowledged that residents care planned for showers three times a week should be receiving them as specified. These findings indicate a failure to provide the required ADL assistance as outlined in the resident's care plan and facility policy.
Failure to Secure and Properly Store Medications, Including Expired Drugs
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were properly stored and secured, as required by facility policy and professional standards. During observations, medications were found unsecured and unattended in three resident rooms. In one instance, a medication cup containing hydrocortisone and betamethasone creams was left at the bedside of a cognitively intact resident, with a tongue depressor in the cup. In another case, a cognitively intact resident had a medication cup with several pills left in the room, which the resident picked up while preparing to go to dialysis. In a third instance, a tube of wound dressing cream was found on the bed of a resident who did not have an order for any wound cream. Staff interviews confirmed that these medications should not have been left unattended or unsecured in resident rooms. Additionally, expired medications were found in one of the medication storage rooms. Specifically, promethegan suppositories with an expiration date several months prior were discovered in the South 2 Medication Storage Room. Staff interviews, including with the DON and an RN, confirmed that expired medications should not be present in medication storage areas. These findings demonstrate a failure to adhere to medication storage and security protocols as outlined in facility policy.
Failure to Prevent Duplicate Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and administration of antipsychotic medications for two residents with severe cognitive impairment and multiple psychiatric diagnoses. For one resident with psychosis, depression, anxiety, and atrial fibrillation, medical records showed duplicate orders for Risperidone and Risperdal, resulting in the resident receiving both medications at the same dosage and time over several months. This duplication was reflected in the Medication Administration Records (MAR) from January through mid-April, with both the brand and generic forms administered concurrently each evening. Similarly, another resident with dementia, PTSD, anxiety, depression, and psychotic disorder had duplicate orders for Quetiapine and Seroquel, leading to both being administered at the same dosage and time over multiple months. The MARs indicated this duplication persisted from late February through mid-April, despite a pharmacist's report identifying the duplicate orders and requesting discontinuation of one. The Director of Nursing confirmed the presence of these duplicate orders and that the nurse practitioner had been notified.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. In one instance, an LPN withdrew insulin from a multi-use vial without disinfecting the vial top as required by facility policy, administered the injection, removed gloves, and did not perform hand hygiene afterward. The resident involved had diabetes and was unable to be assessed for mental status due to communication limitations. Facility policy mandates cleaning the vial with an alcohol wipe and performing hand hygiene immediately after glove removal, but these steps were not followed. In another instance, an LPN administered medications via a gastrostomy tube to a resident and used a stethoscope to verify tube placement. After completing the procedure, the LPN exited the room and signed out medications without cleaning the stethoscope, contrary to facility policy requiring reusable equipment to be cleaned and disinfected between residents. The resident had a gastrostomy and was also unable to be assessed for mental status. The DON confirmed during interview that the required infection control practices were not followed in both cases.
Fall Prevention and Neuro Check Deficiencies Identified
Penalty
Summary
The facility failed to ensure effective fall interventions were in place to prevent injury, and failed to complete neuro checks for two out of three sampled residents reviewed for accidents. In the case of Resident #23, who had severe cognitive impairment with a BIMS score of 2, the facility did not implement appropriate interventions despite the resident's history of wandering behavior and attempts to enter other residents' rooms. This lack of effective interventions led to Resident #23 sustaining a fall with a right femur fracture, resulting in actual harm. The facility's failure to follow its policy on fall prevention, including educating residents with a BIMS score of 13 or greater on the use of call lights and modifying interventions as necessary, contributed to the deficiency. Additionally, the facility's care plan for Resident #23 included reminders to use ambulation and transfer assist devices, call for assistance before moving, and redirection for wandering behavior. However, these interventions proved ineffective as Resident #23 continued to exhibit wandering behavior, entering other residents' rooms and attempting to take food and drink items. Despite Resident #23's severe cognitive impairment and documented behaviors, the facility did not adequately modify interventions or implement additional measures to prevent further incidents. The lack of appropriate actions to address Resident #23's behaviors ultimately led to the fall and subsequent fracture.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during IV medication administration and hand hygiene during dining. Specifically, an LPN did not clean an administration port before administering IV medications and fluids to a resident with a PICC line, which was confirmed by the Director of Nursing. Additionally, multiple staff members, including CNAs and the Life Enrichment Coordinator, did not perform hand hygiene before and after resident contact and while handling food during dining observations. The deficiencies were observed in several instances, such as an LPN laying the PICC tubing on the bed and administering a Heparin flush without cleaning the port, and CNAs handling food and repositioning residents without performing hand hygiene. These actions were confirmed by the Director of Nursing, who acknowledged that proper hand hygiene and cleaning protocols were not followed, increasing the risk of infection spread among residents.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse for two residents, despite having a policy that mandates immediate reporting of such incidents. Resident #68, who had intact cognition, and Resident #185, who had severe cognitive impairment, were involved in a physical altercation where Resident #185 struck Resident #68. The incident was documented in a nurse's note, and the Director of Nursing (DON) was notified. However, the Administrator did not report the incident to the state agency within the required timeframe, as mandated by the facility's abuse prohibition policy. During interviews, it was revealed that the incident was not reported to the state because the Administrator deemed the altercation as minor. The Administrator admitted to not following the policy that requires reporting all allegations of abuse to the state within two hours and completing an investigation within five days. This failure to report the incident to the state agency constitutes a deficiency in adhering to federal and state regulations regarding abuse reporting in long-term care facilities.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. Resident #68, who has intact cognition, was involved in a physical altercation with Resident #185, who has severe cognitive impairment. The incident occurred in the 200 hallway where Resident #68 struck Resident #185 in the back of the head. Although the incident was documented, the facility did not follow its policy to conduct a thorough investigation, including interviewing all relevant parties and documenting witness statements. The Director of Nursing (DON) was notified, but the investigation was incomplete, and the results were not reported to the State Agency within the required timeframe. During interviews, staff members, including an LPN and the Administrator, acknowledged the incident but did not ensure a comprehensive investigation was conducted. The Administrator admitted that the incident should have been investigated but downplayed its severity. The facility's failure to complete a thorough investigation for the allegations of abuse led to a deficiency in adhering to their Abuse Prohibition Plan and state reporting requirements.
Failure to Ensure Privacy and Intimacy for Cognitively Intact Residents
Penalty
Summary
The facility failed to ensure a care plan meeting was scheduled and interventions implemented for two cognitively intact residents expressing sexual desires towards one another. The facility's policy on Sexual Expression of the Resident, revised on 10/24/2022, mandates that residents with decisional capacity have the right to privacy, including private space for sexual expression. However, the interdisciplinary team (IDT) did not conduct a care plan meeting to ensure the residents' right to privacy and intimacy was respected and documented in their care plans. Resident #31, admitted with diagnoses including Hemiplegia, Anxiety, Depression, Cognitive Communication Deficit, and Schizophrenia, had a BIMS score indicating cognitive intactness. Despite multiple incidents of inappropriate sexual behavior in public areas, including the courtyard and front lobby, there was no documentation of a care plan meeting by the IDT to address these behaviors and ensure privacy for the resident. The resident's care plan and clinical notes repeatedly highlighted inappropriate sexual behaviors and the need for privacy, but no formal care plan meeting was conducted. Similarly, Resident #61, admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory with Hypoxia, and Depression, also had a BIMS score indicating cognitive intactness. The resident was involved in inappropriate sexual behavior with Resident #31 in public areas. Despite being informed about appropriate and inappropriate locations for such behavior, there was no documentation of a care plan meeting by the IDT to ensure the resident's right to privacy and intimacy. The facility's failure to conduct these care plan meetings resulted in a deficiency in respecting the residents' rights to privacy and intimacy.
Failure to Follow Prescribed Oxygen Administration Orders
Penalty
Summary
The facility failed to follow the prescribed physician orders for oxygen administration for a resident with severe cognitive impairment and multiple diagnoses, including Chronic Obstructive Pulmonary Disease and Hemiplegia. The physician's order specified that oxygen should be administered at 2 liters per minute via nasal cannula as needed for dyspnea or when oxygen saturation levels fell below 88%. However, observations on multiple occasions revealed that the resident's oxygen concentrator was set at 4 liters per minute, which is double the prescribed rate. During an interview, an LPN confirmed that the correct oxygen level according to the physician's order was 2 liters per minute and subsequently adjusted the concentrator to the correct setting. The Director of Nursing also confirmed that staff should follow physician's orders. This discrepancy in oxygen administration was observed over several days, indicating a failure to adhere to the prescribed medical regimen for the resident's respiratory care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately when a registered nurse (RN A) left a medication cart unlocked, unattended, and out of line of sight. The facility's policy, revised on 9/5/2023, mandates that all medications be stored in locked compartments and only accessible to authorized personnel. However, during an observation on 4/26/2024, the surveyor found the medication cart in the 400 hallway next to the Nurse's office unlocked. RN A initially stood with the surveyor to observe the cart's contents but subsequently walked away into the Nurse's office, leaving the cart unattended and out of view. During an interview on the same day, the Director of Nursing (DON) confirmed that the medication cart should not be left unlocked and unattended if it is not in the line of sight. This incident highlights a failure in adhering to the facility's medication storage policy, thereby compromising the security and proper handling of medications.
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 56 citations issued within 25 miles in the last 12 months — including the 1 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 Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lauderdale Community Living Center | 11.3 mi | ★★★★★ | 29 | 1 |
| Ripley Healthcare And Rehab Center | 11.6 mi | ★★★★★ | 3 | 0 |
| Alamo Nursing And Rehabilitation Center | 15.7 mi | ★★★★★ | 4 | 0 |
| Bells Nursing And Rehabilitation Center | 16.6 mi | ★★★★★ | 4 | 0 |
| Covington Post Acute | 18.9 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Haywood Post Acute.
100% money-back within 48 hours.
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.