Below 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 Waters Of Mckenzie A Rehabilitation & Nursing Ctr during CMS and state inspections, most recent first.
A black, slimy substance was observed on the inner seal of the facility's only ice machine, which was not cleaned despite being identified by the Dietary Manager and reported to maintenance. The issue persisted over multiple days, and both the Regional Dietary Manager and Administrator confirmed the unsanitary condition. At the time, 44 residents were receiving trays from the kitchen.
A resident who was dependent for transfers and cognitively intact experienced repeated, prolonged delays in being assisted to bed after activating the call light. Despite staff presence at the nurses' station and multiple requests, the resident waited up to 26 minutes and reported waiting as long as two hours for assistance, with staff either not responding promptly or deferring responsibility to others. The DON confirmed these actions did not meet facility expectations for timely response and resident dignity.
A resident with multiple chronic conditions was observed independently using a nebulizer treatment without a nurse present, despite lacking a documented assessment or physician order for self-administration of medication. Facility policy requires such an assessment and order, but these were not completed at admission, as confirmed by the DON.
A resident with severe cognitive impairment and a history of falls did not have the care plan intervention for defined bed borders in place, as required. Despite staff awareness of the intervention, observations confirmed its absence, and the resident had experienced multiple falls and injuries.
A resident with severe cognitive impairment and multiple medical diagnoses did not receive oxygen therapy as ordered by the physician. The oxygen concentrator was observed set below the prescribed 3 L/min, and staff were unaware of the correct order until prompted by surveyors, at which point the setting was corrected. Facility policy requires adherence to physician orders, which was not followed in this case.
Two residents did not have their dietary preferences properly documented or honored, resulting in one not receiving preferred breakfast items and another being served a disliked beverage, despite facility policy requiring such preferences to be recorded and followed. Observations and interviews confirmed that staff lacked access to up-to-date preference information, and tray cards did not reflect resident likes or dislikes.
A resident with significant medical needs received wound care from an LPN who failed to follow hand hygiene protocols, including touching the paper towel dispenser after washing hands, reaching into a uniform pocket with gloved hands, not performing hand hygiene between wound treatments, and not sanitizing a multiuse marker. Both the LPN and DON confirmed these actions did not meet infection control standards.
Unsanitary Ice Machine with Black Slime Observed
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, as evidenced by the presence of a black, slimy substance on the inner seal of the facility's only ice machine. Facility documentation required monthly inspections and cleaning of ice machines, including checking for cleanliness and the presence of substances such as calcium, lime, or algae. During observations and interviews with the Dietary Manager, it was confirmed that the ice machine was not clean and that maintenance was responsible for cleaning it, but the task had not been completed despite being notified. The Regional Dietary Manager also stated that maintenance was responsible for cleaning, but ultimately the kitchen was responsible for the ice machine. The Administrator acknowledged that there should not be black slime on the ice machine. At the time of the deficiency, the facility census was 46, with 44 residents receiving trays from the kitchen.
Failure to Ensure Timely Response to Resident Call Light and Dignity in Care
Penalty
Summary
The facility failed to ensure dignity and resident choice for a resident who required assistance with activities of daily living, specifically with being transferred to bed. The resident, who had no cognitive impairment and was dependent for transfers, repeatedly activated the call light to request assistance to go to bed after returning from smoking. Despite the call light being on and staff being present at the nurses' station, the resident experienced significant delays in receiving assistance. Observations showed that staff either did not respond promptly or, when responding, did not immediately address the resident's needs, instead stating they would find the assigned CNA or leaving the resident waiting further. On multiple occasions, the resident waited extended periods—up to 26 minutes and, by the resident's account, as long as two hours—before being assisted to bed. Staff were observed sitting at the nurses' station while the call light was sounding, and communication between staff members resulted in further delays. The DON confirmed that staff are expected to respond to call lights promptly and meet residents' needs, regardless of assignment, and that the observed delays were not in line with facility expectations or policy.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medication as required by its policy. The policy states that residents must be assessed at admission using a self-administration tool, and the results should be discussed with the attending physician to obtain an order if appropriate. Medical record review showed that a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Liver Disease had not received a Basic Interview for Mental Status assessment due to being a recent admission. Despite this, the resident was observed independently using a nebulizer treatment in their room without a nurse present, and there was no documented assessment or physician order for self-administration. The DON confirmed that an assessment and physician order should have been in place for self-administration of medications.
Failure to Implement Bed Border Intervention for Fall Prevention
Penalty
Summary
A deficiency was identified when the facility failed to implement a care plan intervention for a resident at risk for falls. The resident, who had diagnoses including COPD, dementia, osteoarthritis, difficulty in walking, and a history of falls, was assessed as having severe cognitive impairment. The care plan included an intervention to define the borders of the bed to prevent falls, such as using a pool noodle, bolster, or a specific mattress. However, during multiple observations, it was noted that no such device or mattress was in place to define the bed borders as required by the care plan. Staff interviews confirmed that the intervention was not implemented. A CNA and the MDS Coordinator both verified that the resident's bed did not have any defined borders in place, despite the care plan directive. The Director of Nursing also acknowledged that the intervention should have been present. The resident had experienced multiple falls since admission, and at the time of observation, had visible bruising and steri strips on her right elbow, further indicating recent injury.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician for a resident with significant medical conditions, including acute ischemic heart disease, carotid artery occlusion, cerebral infarction, and hypertension. The resident was severely cognitively impaired and had a physician's order for oxygen at 3 liters per minute (L/min) as needed for shortness of breath, to maintain oxygen saturation above 91%. However, review of the Medication Administration Record showed no documentation of PRN oxygen administration, and multiple observations revealed the oxygen concentrator was set at 1.5-2 L/min, not the ordered 3 L/min. During interviews, an LPN initially stated the order was for 2 L/min, then acknowledged it had changed to 3 L/min, and subsequently adjusted the oxygen setting to 3 L/min during the surveyor's presence. The Director of Nursing confirmed that staff are expected to follow physician orders for oxygen settings. Facility policies also require staff to review and implement physician orders as written, but these were not followed in this instance.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to accommodate dietary preferences for two residents as required by its own policy and regulatory standards. The policy states that food preferences should be honored unless contraindicated, and that the Food Service Manager or designee is responsible for interviewing residents to obtain and update their food preferences, which should be reflected on the resident's tray card. However, for both residents reviewed, there was no evidence that their food preferences were properly documented or communicated to dietary staff. One resident, with a history of muscle wasting, chronic pain, and past trauma related to food deprivation, expressed a preference for pancakes and French toast, but these preferences were not discussed in quarterly nutritional reviews or reflected on the tray card. The resident reported not receiving preferred breakfast items and instead received oatmeal, which was not among his stated preferences. Observations confirmed that while pancakes were served to others, the resident did not consistently receive his preferred foods, and his tray card lacked any indication of likes or dislikes. Another resident, with diagnoses including dementia and a history of dehydration, was documented as disliking tea and being at risk for poor oral intake. Despite this, the resident's nutritional assessment was incomplete, and the tray card did not indicate beverage dislikes. The resident was observed to have tea on his tray, which he did not drink. Interviews with the Dietary Manager revealed that food preferences were not consistently documented or accessible to staff preparing trays, and the process for updating and communicating preferences was not followed as outlined in facility policy.
Failure to Follow Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure staff followed proper hand hygiene guidelines during wound care for a resident with multiple medical conditions, including cerebral infarction, muscle weakness, abnormal posture, hemiplegia, hemiparesis, and low back pain. The resident had documented skin disruptions and was severely cognitively impaired. Physician orders required specific wound care procedures, including cleaning and dressing the sacrum and applying protective ointment to the labia. The facility's policy outlined the need for hand hygiene before and after glove use, and between wound care steps. During an observed wound care procedure, an LPN washed hands but then touched the paper towel dispenser, reached into a uniform pocket with a gloved hand to retrieve a marker, used the marker on a clean dressing, and placed the marker on the bedside table without a barrier. The LPN then applied the dressing, changed gloves, and continued to the next wound without performing hand hygiene between treatments. The marker was not sanitized before being returned to the pocket and taken out of the room. Both the LPN and the DON confirmed that these actions were not in accordance with facility policy and proper infection control practices.
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What surveyors actually found near you
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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 Mc Kenzie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ahc Mckenzie | 2.6 mi | ★★★★★ | 6 | 0 |
| Huntingdon Health & Rehabilitation Center | 9.2 mi | ★★★★★ | 2 | 0 |
| Hillview Community Living Center | 14.4 mi | ★★★★★ | 9 | 0 |
| Weakley Rehabilitation And Nursing Center | 15.7 mi | ★★★★★ | 9 | 0 |
| Life Care Center Of Bruceton-hollow Rock | 16.3 mi | ★★★★★ | 3 | 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.