Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Okeena Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
The facility failed to complete timely nutritional assessments for two residents due to the absence of a registered dietitian. The assessments, required within 72 hours of admission, were delayed due to the resignation of the former dietitian and the late start of a new remote dietitian. The Director of Dietary, who was uncertified, confirmed the lack of supervision during this period.
The facility failed to maintain sanitary conditions for an ice machine, as it was observed with a white chalky substance dripping down its sides. The Dietary Director stated that an outside company was responsible for cleaning, but she was accountable for the machine. The Administrator confirmed the machine should be clean.
The facility failed to follow infection control protocols, with staff not properly removing PPE, disinfecting equipment, or performing hand hygiene. These lapses involved residents with conditions like COVID-19 and influenza, and were confirmed by the DON and ICP.
The facility failed to maintain resident dignity during meal assistance, as staff stood over a resident to feed them and used informal language, such as "girl," when addressing residents. Additionally, a CNA referred to residents as "feeders" in the hallway, contrary to the facility's policy on promoting resident dignity.
The facility failed to ensure a clean and sanitary environment in shared bathrooms, with personal hygiene items found unlabeled and uncontained. Residents with various medical conditions, including cognitive impairments and dependencies on staff for ADLs, were affected. The Director of Nursing confirmed that facility policy required these items to be stored properly, highlighting a systemic issue in maintaining sanitary conditions.
The facility failed to update care plans for residents with pressure ulcers, COVID-19, and influenza. A resident with pressure ulcers did not have a care plan reflecting prevention and treatment. Another resident tested positive for COVID-19, but the care plan was updated seven days later. A resident with influenza was in isolation, but the care plan was not revised. Lastly, a resident with COVID-19 was in transmission-based precautions, but the care plan was not updated. The facility did not follow its policy to revise care plans upon status changes.
A resident's pressure wounds were misclassified as non-pressure vascular wounds, contrary to the facility's policy requiring accurate staging and care planning. Observations and interviews confirmed the wounds were deep tissue injuries, not vascular, leading to improper care.
The facility failed to ensure a safe environment by leaving hazardous items accessible in resident rooms. A resident with cognitive impairment had air fresheners and body sprays unsecured, while another resident had an unattended razor in the bathroom. Staff confirmed these items should have been secured to prevent resident access.
The facility failed to post complete daily staffing information, omitting the scheduled total number of FTEs and their hours, as well as the actual hours worked by licensed and unlicensed staff for 31 days. The Scheduler and DON confirmed the postings were incomplete and should have included all necessary details, including changes due to call-ins.
The facility failed to properly document and manage narcotic medications, leading to discrepancies in narcotic counts and improper documentation of medication administration and destruction. For a resident, Hydrocodone/APAP administration was not documented correctly, and doses were not accounted for. Another resident's Gabapentin count showed discrepancies between the quantity left and destroyed. Additionally, a third resident's Lorazepam administration was improperly documented, with no record of medication being wasted. These issues were not identified or resolved by staff during narcotic counts or drug destruction.
A facility failed to secure medications properly when a Wound Nurse left a treatment cart unlocked and unattended. The DON confirmed the presence of medications on the cart, which included various wound treatment medications. This action violated the facility's policy requiring all drugs to be stored in locked compartments accessible only to authorized personnel.
Delayed Nutritional Assessments Due to Staffing Issues
Penalty
Summary
The facility failed to ensure comprehensive nutritional assessments were completed timely by a dietitian for two residents reviewed for new admissions. According to the facility's policy, a comprehensive nutritional assessment should be completed by a dietitian within 72 hours of admission. However, for Resident #256, who was admitted with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis, the assessment was not completed until six days after admission. Similarly, Resident #259, who was readmitted with diagnoses including Protein-Calorie Malnutrition, Toxic Encephalopathy, and Respiratory Failure, did not receive a comprehensive nutritional assessment until the eighth day after readmission. The deficiency was attributed to the absence of a registered dietitian following the resignation of the former dietitian after Christmas. The Director of Dietary, who was not certified, confirmed that there was no supervision in place during this period. The Director of Nursing confirmed that the new dietitian, working remotely, only started on January 13, 2025, which contributed to the delay in completing the nutritional assessments for the residents in question.
Unsanitary Ice Machine Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions for food storage, preparation, and service, as evidenced by a dirty ice machine. The facility's policy on ice machines and portable ice carts, dated December 1, 2024, mandates that ice machines be cleaned and maintained to prevent microbial contamination. However, during an interview, the Dietary Director stated that the cleaning and maintenance of the ice machine were contracted to an outside company, but she was responsible for the ice machine within the facility. Observations of the ice machine in the Activity Room revealed a white chalky substance dripping down the sides of the machine and the cart it was on. The Administrator confirmed that the ice machine should be clean and free of any such substances.
Infection Control Lapses in PPE Removal and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, as evidenced by multiple staff members not following proper procedures. One Certified Nursing Assistant (CNA) did not remove personal protective equipment (PPE) correctly after exiting an isolation room, instead discarding it in the hallway. Another staff member, a Certified Occupational Therapist Assistant (COTA), did not properly disinfect a wheelchair before moving it from an isolation room to a therapy gym, acknowledging that the equipment should have been cleaned thoroughly inside the resident's room. Additionally, there were instances of staff failing to perform hand hygiene. One CNA handled a resident's food with bare hands after touching potentially contaminated items, while another CNA moved a floor mat and then assisted a resident with their meal without performing hand hygiene. These actions were observed during dining services and involved residents with various medical conditions, including COVID-19, influenza, and dementia. The deficiencies were confirmed through interviews with the Director of Nursing (DON) and the Infection Control Preventionist (ICP), who acknowledged the lapses in protocol adherence. The report highlights the need for staff to follow established procedures for PPE removal, equipment disinfection, and hand hygiene to prevent the spread of infections within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving staff interactions with residents during meal times. One incident involved a Certified Nursing Assistant (CNA) standing over a resident with heart disease, dementia, and depression to assist with feeding, which was acknowledged by the CNA as inappropriate. Another incident involved a CNA addressing a resident with severe cognitive impairment in an informal manner, using the term "girl," which is not in line with the facility's policy of using courtesy titles. Additionally, during a dining observation, a CNA referred to two residents as "feeders" in the hallway, which was confirmed by the Director of Nursing as inappropriate. The residents involved had varying degrees of cognitive impairment and required different levels of assistance with meals. These actions were contrary to the facility's policy on promoting and maintaining resident dignity, which emphasizes treating residents with respect and recognizing their individuality.
Failure to Maintain Sanitary Conditions in Shared Bathrooms
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in shared bathrooms for several residents. Observations revealed that personal hygiene items such as wash basins, bedpans, toothbrush holders, and denture cups were found unlabeled and uncontained in shared bathrooms. These items were often placed on the floor, on the back of toilets, or on sinks, contrary to the facility's policy of storing them in designated areas like bedside tables or wardrobes. The residents involved had various medical conditions, including chronic diseases, cognitive impairments, and dependencies on staff for activities of daily living (ADLs) and toileting. Many of the residents were incontinent of bowel and bladder, requiring assistance with personal hygiene. The lack of proper labeling and containment of personal hygiene items posed a risk of cross-contamination and did not honor the residents' right to a safe and homelike environment. During an interview, the Director of Nursing confirmed that the facility's policy required personal hygiene items to be stored in plastic bags and placed in specific storage areas, not left in bathrooms. The failure to adhere to these guidelines was observed in multiple shared bathrooms, affecting numerous residents and indicating a systemic issue in maintaining sanitary conditions within the facility.
Failure to Revise Care Plans for Residents with Health Changes
Penalty
Summary
The facility failed to revise care plans for four residents experiencing various health issues, including pressure ulcers, COVID-19, and influenza. Resident #12, who was admitted with multiple diagnoses including dementia and peripheral vascular disease, developed unstageable pressure ulcers on both heels. Despite the presence of these pressure injuries, the care plan was not updated to address the prevention and treatment of these ulcers. The Director of Nursing confirmed that the care plan should have been revised to reflect the resident's risk and treatment for pressure ulcers. Resident #38 tested positive for COVID-19, and although the resident was placed in isolation with appropriate precautions, the care plan was not updated until seven days after the positive test result. The Director of Nursing and the Infection Control Preventionist acknowledged that the care plan should have been revised to include the infection and transmission-based precautions. Similarly, Resident #80, who was diagnosed with influenza, was moved to droplet isolation, but the care plan did not reflect this status change. The Director of Nursing confirmed the omission in the care plan documentation. Resident #92, who was also diagnosed with COVID-19, was placed in transmission-based precautions, but the care plan was not updated to reflect this. The Director of Nursing and the Infection Control Preventionist confirmed that the care plan should have been revised to include the infection and precautions. These deficiencies highlight the facility's failure to adhere to its policy of revising care plans upon a resident's status change, as evidenced by the lack of timely updates to the care plans for these residents.
Misclassification of Pressure Wounds Leads to Deficiency
Penalty
Summary
The facility failed to correctly stage pressure wounds for a resident, leading to a deficiency in pressure ulcer care. The facility's policy on Pressure Injury Prevention and Management requires clear identification of pressure injury stages and the development of a care plan with measurable goals and interventions. However, the medical record review revealed that the resident, who was admitted with multiple diagnoses including dementia and peripheral vascular disease, did not have a care plan for pressure injuries. Initial and weekly wound assessments incorrectly identified the resident's heel wounds as non-pressure vascular wounds, despite the facility's pressure ulcer list and a wound care company's evaluation indicating they were deep tissue pressure injuries. Observations and interviews further confirmed the misclassification of the wounds. During an observation, the wound nurse identified the resident's heel wounds as deep tissue injuries, not vascular. The Director of Nursing confirmed that a physician's diagnosis is required to classify a wound as vascular and that the wound nurse is expected to stage wounds correctly. This misclassification led to improper care and treatment of the resident's wounds, as the facility did not adhere to its policy for pressure injury management.
Failure to Secure Hazardous Items in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free of accident hazards, as evidenced by the presence of hazardous personal items in resident rooms. Resident #2, who was moderately cognitively impaired and required assistance with activities of daily living, had several potentially hazardous items, including an air freshener and body sprays, stored on a wooden bookshelf in their room. These items were easily accessible and not stored in a manner that would prevent resident access, contrary to the facility's policy. Both a Licensed Practical Nurse and the Director of Nursing confirmed that these items should have been stored in plastic bags and kept out of reach in the resident's drawer. Similarly, Resident #71, who was also moderately cognitively impaired and required supervision for activities of daily living, had an unsecured disposable razor left unattended on the bathroom vanity. The resident was mobile via wheelchair, which could have facilitated access to the razor. The Director of Nursing confirmed that the razor should not have been left unsecured and should have been placed in a sharps container. These oversights indicate a failure to adhere to safety protocols designed to protect residents from potential hazards.
Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to post the scheduled total number of full-time employees (FTEs) and their total FTE hours for each shift, as well as the total actual hours worked by licensed and unlicensed staff responsible for resident care, for all 31 sampled days. A review of the facility's Today's Staffing documents from December 9, 2024, to January 10, 2025, revealed these omissions. During an interview, the Scheduler confirmed that the daily staff postings were incomplete and should have included the number of FTEs scheduled, the total hours worked every shift for both licensed and non-licensed staff, and any changes due to call-ins. The Director of Nursing also confirmed the incompleteness of the daily staff postings, emphasizing the need for them to reflect the total FTEs and hours worked by both licensed and non-licensed staff, including any changes due to call-ins.
Improper Documentation and Management of Narcotic Medications
Penalty
Summary
The facility failed to properly document and manage narcotic medications, leading to discrepancies in narcotic counts and improper documentation of medication administration and destruction. The facility's policy on controlled medications requires clear documentation and accountability for all doses, including those administered, wasted, or destroyed. However, the facility did not adhere to these guidelines, resulting in multiple instances of improper documentation and unresolved discrepancies. For Resident #57, the facility failed to document the administration of Hydrocodone/APAP on the Medication Administration Record (MAR) and did not properly account for doses that were signed out in error or wasted. The Controlled Drug Receipt/Record/Disposition Form showed inconsistencies in the number of tablets left after administration, and the medication was not documented as given or wasted on certain dates. Similarly, for Resident #258, there was a discrepancy between the quantity of Gabapentin left after the last documented administration and the quantity destroyed, which was not identified by the staff or during the drug destruction process. Resident #353's Lorazepam administration was also improperly documented, with entries being crossed out incorrectly and no documentation of medication being wasted. The discrepancies in the narcotic counts and documentation were not identified by the staff responsible for placing medications in the drop box or during the drug destruction process. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed these documentation errors and discrepancies, which were not investigated or resolved in a timely manner.
Improper Storage and Security of Medications
Penalty
Summary
The facility failed to ensure the proper storage and security of medications when a staff member, identified as the Wound Nurse, left a treatment cart unlocked, unattended, and out of sight. This incident was observed on the 300 hall, where the Director of Nursing (DON) confirmed that medications were present on the cart and acknowledged that it should not have been left unlocked and unattended. Further observation on the 300/400 hall revealed various medications used for treating wounds and skin issues, including Medihoney, B & C wound dressing, hydrogel, Mipircron ointment, and Nyamyc topical powder, were left unsecured on the treatment cart. The Wound Nurse confirmed these medications were used for wounds and skin issues, indicating a breach of the facility's policy on medication storage, which mandates that all drugs and biologicals be stored in locked compartments accessible only to authorized personnel.
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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 Dyersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dyersburg Health And Rehabilitation Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Oakwood Community Living Center | 0.3 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of Ridgely Rehab&wellness Ctr | 15.9 mi | ★★★★★ | 0 | 0 |
| Southgate Living Center | 18.7 mi | ★★★★★ | 0 | 0 |
| Dyer Nursing And Rehabilitation Center | 20.4 mi | ★★★★★ | 8 | 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.