Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Weakley Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to implement nutritional interventions after significant weight loss. A resident with vascular dementia and severe cognitive impairment had repeated severe weight loss, but the RD-recommended house supplement and weekly weights were not ordered or documented as provided. Staff also did not notify the MD of the later weight loss, and the resident continued to lose weight over the following month.
The facility failed to ensure dishes and utensils were sanitized under proper conditions when the dishwasher did not reach the required sanitary temperature and staff did not accurately complete dishwasher temperature logs. During observation, soiled meal trays and utensils from droplet precaution rooms were handled in the dish room, and the final rinse temperature was 176 degrees F. The Dietary Manager stated the dishwasher used a sanitizing solution as backup, but the facility was out of sanitation testing strips, and the DON confirmed the dishwasher was not temping correctly.
Staff failed to follow infection prevention practices for residents on droplet precautions and during medication administration. Aides were observed entering and exiting resident rooms without proper PPE, wearing soiled gloves into a clean linen area, returning meal trays while still in contaminated PPE, and failing to perform hand hygiene after room exit. An LPN also failed to sanitize reusable equipment. The affected residents had diagnoses including COVID-19, dementia, Alzheimer’s disease, Parkinson’s disease, diabetes, CHF, HTN, and malnutrition.
Failure to Monitor Antipsychotic Medication: A resident with TBI, dementia, anxiety, and psychosis received ordered olanzapine, but the MAR showed no monitoring for the antipsychotic during the review period. The MDS indicated the resident had a BIMS score of 15 and was receiving an antipsychotic, and the AIT/RN confirmed monitoring should have been completed.
Unsecured medications were found in resident rooms and on med carts. A nasal spray and eye drops were left at one resident's bedside, and another resident with Alzheimer's disease, COPD, and HF had Flonase on her walker/at bedside without a self-administration assessment. In addition, an LPN left Valproic Acid on the North Hall cart and another LPN left a cup of pills on the South Hall cart, and staff confirmed meds should not be left unattended.
The facility failed to maintain safe hot water temperatures, with readings between 122.5 and 130 degrees Fahrenheit in several rooms, posing a risk to residents. Additionally, inadequate fall prevention measures led to multiple falls for a resident with severe cognitive impairment, resulting in a serious injury. The Maintenance Director's failure to document and communicate water temperature issues, along with insufficient fall interventions, contributed to the deficiencies.
A resident with a history of severe cognitive impairment and aggressive behaviors struck another resident, causing harm. The facility failed to implement effective interventions or a care plan to manage the aggressive resident's behaviors, leading to the incident. Staff acknowledged that more could have been done to ensure safety.
The facility failed to secure medications properly, as two medication carts were left unlocked and unattended during administration. An LPN left a cart unlocked while retrieving items and answering a call, and another cart was found unattended in a hallway. The DON confirmed this was against policy.
The facility administration failed to monitor hot water temperatures, resulting in dangerously elevated levels in resident rooms. Additionally, inadequate supervision led to falls and injuries among residents, with one resident sustaining a fracture. The facility also failed to prevent resident-to-resident abuse and did not provide appropriate care for a resident with behavioral issues, resulting in harm to another resident.
A resident with severe cognitive impairment was found with a self-release seat belt that functioned as a restraint, as she was unable to unlatch it independently. The facility's policy requires that restraints be used only in emergencies and with proper documentation, which was not present in this case. The DON confirmed the resident's inability to release the belt classified it as a restraint, and acknowledged the lack of necessary orders and documentation.
A facility failed to investigate and report an alleged employee-to-resident abuse incident involving a resident with respiratory failure, depression, and dementia. The incident was not reported immediately, and no incident report was completed. The Sheriff's Department found insufficient evidence for further investigation, and the facility did not notify Adult Protective Services. Interviews revealed the investigation was incomplete, highlighting deficiencies in the facility's response to the abuse allegation.
The facility failed to complete baseline care plans within 48 hours for two residents, as required by policy. Both residents had initiated care plans that were left unsigned by the resident or family, resulting in incomplete documentation. The MDS Coordinator confirmed the lack of signatures, indicating non-compliance with the facility's policy.
A resident with a history of vascular dementia and behavioral disturbances was admitted to an LTC facility, where they exhibited challenging behaviors such as wandering, entering other residents' rooms, and displaying sexually inappropriate actions. Despite being prescribed medications for agitation and anxiety, the facility failed to implement effective interventions, leading to ongoing safety concerns. Staff interviews revealed inadequate communication and follow-up, with the DON acknowledging insufficient measures to ensure safety.
An LPN at the facility failed to properly reconcile controlled medications, specifically Lorazepam, for two residents. The facility's policy requires nurses to complete the Controlled Substance Inventory Record and maintain a running count of medications. However, discrepancies were found in the medication counts for residents with various diagnoses, including Dementia and Parkinson's Disease. The LPN admitted to not signing out the medications, and the DON confirmed the issue.
The facility did not update its Three-Day Disaster Menu to match the actual 3-Day Emergency Food Supply. The menu listed peanut butter and protein bars, but these items were missing from the emergency stock. The Dietary Supervisor and a Registered Dietician confirmed that listed items should be present in the supply.
An LPN failed to follow Enhanced Barrier Precautions during wound care for a resident with an unstageable pressure injury. The LPN did not wear a gown and used a contaminated dressing, contrary to the facility's policy requiring gowns and gloves for high-contact activities. The resident had multiple diagnoses, including dementia and malnutrition, and was severely cognitively impaired.
The facility failed to maintain safe hot water temperatures, with readings between 122.5 and 130 degrees Fahrenheit in several resident rooms, exceeding state regulations. This posed a risk to residents, especially those who were cognitively or physically impaired. Additionally, the facility did not provide adequate fall prevention measures, leading to multiple falls for a resident with severe cognitive impairment, resulting in injuries. The Maintenance Director adjusted the water heater without proper documentation or notification, and the Administrator was not adequately informed, contributing to the deficiencies.
A resident with a history of aggressive behaviors harmed another resident by hitting them with a plastic cup, causing lacerations. The facility's interventions, including medication and redirection, were ineffective in managing the aggressive resident's behaviors, and no care plan was in place prior to the incident. Staff interviews indicated that the facility did not implement adequate measures to ensure the safety of residents and staff.
The facility failed to secure medications properly, as two medication carts were left unlocked and unattended during administration. An LPN left a cart unlocked while retrieving a computer mouse and answering a phone call, and another cart was found unlocked in a hallway. The DON confirmed that carts should not be left unattended, highlighting a breach in policy.
The facility administration failed to monitor and prevent dangerously elevated hot water temperatures, leading to potential harm for residents. Additionally, inadequate supervision and fall risk assessments resulted in injuries, including a fracture. The facility also failed to prevent resident-to-resident abuse and did not provide effective care for a resident with behavioral issues, resulting in harm. Communication lapses and insufficient interventions were noted by the DON.
A resident with severe cognitive impairment was found unable to release a self-release seat belt, which was used without a physician's order, contrary to the facility's restraint-free policy. Despite initial claims by the DON that the resident could release the belt, observations confirmed the resident's inability to do so, indicating a failure to adhere to the facility's policy.
A facility failed to investigate an alleged employee-to-resident abuse incident involving a cognitively impaired resident. The incident was not reported immediately, and the investigation lacked necessary documentation, including an incident report and notification to Adult Protective Services. Interviews with the Administrator and DON confirmed the investigation was incomplete.
The facility failed to complete baseline care plans within 48 hours for two residents, as required by policy. Both residents had initiated care plans that were left unsigned by the resident or family, resulting in non-compliance with the facility's policy. Interviews confirmed the oversight, highlighting a lapse in adhering to the required timeframe for care plan completion.
A resident with a history of dementia and behavioral disturbances was admitted to an LTC facility, where they exhibited aggressive and inappropriate behaviors. Despite being prescribed medications, the facility failed to implement effective non-pharmacological interventions or adjust the care plan to manage these behaviors. Staff interviews revealed a lack of awareness and documentation, and the DON admitted that interventions were likely insufficient to ensure safety.
An LPN failed to properly reconcile controlled medications, as required by facility policy, by not signing out medications on the Controlled Substance Inventory Record and not maintaining a running count. Discrepancies were found in the Lorazepam counts for two residents, with the LPN admitting to not signing out the medications. The DON confirmed the necessity of matching controlled counts with actual pill counts.
The facility did not update its Three-Day Disaster Menu to match the actual emergency food supply. Policies required a 3-to-7-day supply of nonperishable foods, but items like peanut butter and protein bars were missing. The Dietary Supervisor and a Registered Dietician confirmed that listed items should be present in the emergency stock.
An LPN failed to follow Enhanced Barrier Precautions during wound care for a resident with an unstageable pressure injury. The LPN did not wear a gown and used a contaminated dressing, contrary to the facility's policy requiring gowns and gloves for high-contact care activities. The resident had multiple diagnoses, including dementia and malnutrition, and was severely cognitively impaired.
Failure to Implement Nutritional Interventions After Significant Weight Loss
Penalty
Summary
The facility failed to ensure a resident with impaired nutrition maintained acceptable nutritional status and failed to implement nutritional interventions after a significant weight loss. The resident had diagnoses including vascular dementia, anxiety, anemia, depression, and gastro-esophageal reflux disease, and the care plan identified nutritional problems with directions to monitor intake, weight, skin, labs, medication, diet tolerance, hydration status, and to inform the MD/family/POA of significant weight changes. The resident also had severe cognitive impairment with a BIMS score of 4 and required substantial to maximum assistance with meals. The resident weighed 120.8 lbs on 7/4/2025 and then 112.8 lbs on 8/6/2025, which was a severe 6.6% weight loss in one month. The dietitian assessment documented a low BMI and recommended a house supplement BID due to weight loss and weekly weights to monitor trends. However, the order review history showed no order for house supplements or weekly weights during the following month, and the facility did not implement the recommended nutritional interventions. On 9/4/2025, the resident weighed 102 lbs, reflecting another severe weight loss of 9.5%. The weight change note later documented significant losses across multiple time frames and again recommended a house supplement and weekly weight monitoring. Interviews confirmed the DON had notified the RD of the August weight loss, but the RD was not notified of the September weight loss, the medical director was not notified of the September weight loss, and staff acknowledged there was no documentation that the supplement was given or that weekly weights were obtained.
Dishwasher Not Reaching Sanitary Temperature and Temperature Logs Incomplete
Penalty
Summary
The facility failed to ensure food was served under sanitary conditions when the dishwasher did not meet the sanitary temperature requirement of 180 degrees Fahrenheit and when staff did not accurately complete dishwasher temperature logs for multiple meal service periods. Facility policy required the food service area to be maintained in a clean and sanitary manner and specified high-temperature dishwasher wash and rinse ranges. Review of the dishwasher temperature charts for 6/2025, 7/2025, and 8/2025 showed multiple missing entries for wash and final rinse temperatures across numerous shifts, including noon, evening, morning, and other meal periods. During an observation and interview on 9/8/2025, Dietary staff moved meal trays from droplet precaution rooms into the kitchen, where soiled trays, cups, and serving utensils were placed on the dish room counter and then loaded into the dishwasher. The final rinse temperature was confirmed at 176 degrees F. The Dietary Manager stated the dishwasher was a high-temp dishwasher with sanitizing solution as a backup, and the Dietary Manager acknowledged the facility was out of sanitation testing strips for the dishwasher. The DON later confirmed the dishwasher was not temping correctly and that the facility should have sanitation testing supplies to ensure proper sanitation of dinnerware and utensils.
Infection Control and PPE Noncompliance
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not consistently follow droplet precaution and hand hygiene practices for residents with COVID-19. The facility policy review stated that infection prevention and control measures included source control, universal PPE use, hand hygiene after touching a resident or the resident’s environment, and cleaning and disinfecting reusable resident-care equipment between residents. Droplet precaution signage directed staff to clean hands before donning PPE, wear a mask over the mouth and nose with eye protection, and clean hands again after PPE removal. The facility also had policies requiring transmission-based precautions when needed and requiring resident-care equipment to be cleaned and disinfected between residents. During observation, Housekeeping Aide G exited a resident’s room wearing an isolation gown and gloves, then entered the clean linen storage room with soiled gloves and obtained linens. CNA D was observed exiting two residents’ rooms while wearing an isolation gown and soiled gloves and returning meal trays to the hallway meal cart before removing PPE. Housekeeping Aide H entered a resident’s droplet precaution room without an N-95 mask, goggles, or face shield, and CNA F entered two residents’ droplet precaution rooms without a gown, gloves, and N-95 mask; CNA F also did not perform hand hygiene after exiting one room. In addition, LPN C failed to sanitize reusable equipment during medication administration. The residents involved had diagnoses including Alzheimer’s disease, dementia, Parkinson’s disease, diabetes, congestive heart failure, hypertension, malnutrition, anxiety, and COVID-19.
Failure to Monitor Antipsychotic Medication
Penalty
Summary
Ensure each resident’s drug regimen was free from unnecessary drugs was not met when the facility failed to ensure medication monitoring for an antipsychotic medication for Resident #8. The resident was admitted with diagnoses including traumatic brain injury, dementia, anxiety, and psychosis. A physician’s order dated 7/25/2025 showed olanzapine 5 mg by mouth at bedtime, and the MAR from 7/25/2025 through 9/10/2025 showed the medication was administered as ordered. However, the MAR review for that same period revealed no monitoring for the antipsychotic medication. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and also indicated the resident received an antipsychotic medication. During interview, the AIT/RN confirmed the resident had an order for olanzapine and that monitoring should have been completed.
Unsecured Medications Left in Resident Rooms and on Medication Carts
Penalty
Summary
Medications and biologicals were not stored in accordance with facility policy when unsecured and unattended medications were found in resident rooms and on medication carts. The facility policy titled, "Storage of Medication," stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, that compartments containing drugs and biologicals are locked while in use, and that unlocked medication carts are not left unattended. Survey observations and interviews confirmed that a nasal spray and eye drops were left on a resident's bedside table in her room, and a nurse acknowledged that medication should not be left at bedside unsecured and unattended. The Administrator in Training/RN also confirmed that medications should not be left in a resident's room at bedside unsecured and unattended. A second resident, who had diagnoses including Alzheimer's disease, COPD, and heart failure, was observed with a bottle of Flonase nasal spray on her walker while ambulating and later sitting at bedside with the spray still on the walker. The resident stated the nasal spray was hers and that she kept it at bedside, but the Administrator confirmed there was no self-administration assessment and that medications should not be at bedside. In addition, a medication cup containing Valproic Acid was left unattended on the North Hall cart by an LPN, and another medication cup with five pills was left unattended on the South Hall cart by a different LPN. Both nurses acknowledged medications should not be left unsecure and unattended on the medication carts, and the Director of Clinical Services also stated medications should not be left unsecure or unattended.
Unsafe Hot Water Temperatures and Inadequate Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that hot water temperatures in resident rooms were within the safe range of 105 to 115 degrees Fahrenheit, as required by state licensure regulations. On multiple occasions, dangerously elevated hot water temperatures ranging from 122.5 to 130 degrees Fahrenheit were recorded in several resident rooms. This failure placed residents, particularly those who were cognitively or physically impaired, at risk of serious harm. The Maintenance Director admitted to adjusting the water heater to a higher temperature without adequately monitoring or documenting the changes, leading to the unsafe conditions. Additionally, the facility did not provide adequate supervision and interventions to prevent falls among residents. Resident #11, who was severely cognitively impaired and had a history of falls, experienced multiple falls resulting in a serious injury—a closed fracture of the left distal femur. Despite the resident's known fall risk, the facility's interventions were insufficient and inconsistently implemented, as evidenced by the lack of timely and effective measures to prevent further falls. The facility's Fall Committee meetings and care plan revisions did not result in effective strategies to mitigate the resident's fall risk. The facility's leadership, including the Administrator and Maintenance Director, failed to communicate and address the issues effectively. The Administrator was not informed of the dangerously high water temperatures or the adjustments made to the water heater. Furthermore, the Maintenance Director did not document or report the water temperature issues or the corrective actions taken, leading to ongoing noncompliance with safety standards. The lack of communication and documentation contributed to the facility's inability to ensure a safe environment for its residents.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in actual harm. Resident #42 sustained two lacerations to the forehead when Resident #166 struck him with a hard plastic drinking cup. The facility's policies on abuse prevention and resident abuse were not effectively implemented, as Resident #166's aggressive behaviors were not adequately managed or documented prior to the incident. Resident #166 had a history of severe cognitive impairment and aggressive behaviors, including wandering, entering other residents' rooms, and physical aggression towards staff and other residents. Despite being on medications for agitation and anxiety, these interventions were ineffective in controlling his behaviors. The facility did not have a care plan in place for Resident #166's behaviors before his discharge, indicating a lack of proactive measures to address his known behavioral issues. Interviews with staff revealed that interventions to manage Resident #166's behaviors were insufficient. The Director of Nursing acknowledged that more could have been done to ensure the safety of residents and staff. The lack of one-on-one supervision and inadequate behavioral interventions contributed to the incident where Resident #166 harmed Resident #42, highlighting a significant deficiency in the facility's ability to protect residents from abuse.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, as evidenced by two incidents involving medication carts being left unlocked and unattended. The facility's policy mandates that all medications must be stored in locked compartments and that medication carts should be locked when not in use during medication administration. However, during an observation, an LPN left the Northeast Medication Cart unlocked and unattended while retrieving a computer mouse and answering a telephone call. Additionally, the LPN prepared medications for a resident and left the cart outside the resident's room unlocked and unattended. In another instance, a random observation revealed that the west medication cart was left unlocked and unattended in the hallway outside a resident's room. An LPN exited another resident's room and subsequently locked the cart. During an interview, the Director of Nursing confirmed that medication carts should not be left unlocked and unattended by nursing staff during medication administration, indicating a breach of the facility's medication storage and administration policies.
Facility Oversight Failures Lead to Safety and Behavioral Issues
Penalty
Summary
The facility administration failed to provide adequate oversight and ensure a safe environment for residents, leading to several deficiencies. The administration did not monitor and prevent dangerously elevated hot water temperatures in resident care areas. On two occasions, hot water temperatures ranging from 123 to 130 degrees Fahrenheit were recorded in eight resident rooms, posing a risk to residents, including those who were physically and cognitively impaired. The administrator was unaware of the issue, as the maintenance director did not communicate the problem effectively. Additionally, the facility failed to provide adequate supervision to prevent falls and injuries among residents. Seven residents were affected, with one resident sustaining a fracture. The facility did not conduct fall risk assessments quarterly or after each fall, as required by their policy. The director of nursing acknowledged the lack of appropriate interventions for a resident with worsening dementia, indicating a failure to implement effective fall prevention measures. The facility also failed to prevent resident-to-resident abuse and did not provide appropriate care for a resident with behavioral issues. One resident was harmed when another resident hit them with a hard plastic cup, resulting in lacerations. The resident with behavioral issues exhibited aggressive and inappropriate behaviors, including wandering, disrobing, and physical aggression towards staff and other residents. Despite being prescribed medications, the behaviors were not effectively managed, and the director of nursing admitted that adequate interventions were not in place to ensure safety.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. It specifies that restraints may only be used in emergency situations for brief periods and that a physician's order alone is not sufficient to justify their use. The policy also requires documentation of the anticipated length of restraint use, the frequency of release, and the type of monitoring provided. Resident #9, who was admitted with Alzheimer's Disease, Dementia, and Non-Traumatic Brain Dysfunction, was observed with a self-release seat belt that she was unable to unlatch independently. Despite the care plan indicating the use of a self-release seat belt following a fall, there was no physician's order for its use. Observations and interviews revealed that the resident was unable to release the seat belt on multiple occasions, indicating it functioned as a restraint. The Director of Nursing confirmed that the resident's inability to release the seat belt classified it as a restraint, and acknowledged that there should have been an order and documentation for its use, which was absent.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of employee-to-resident abuse involving a resident with a history of respiratory failure, depression, and dementia. The facility's policy required immediate notification of a supervisor and completion of an incident report by the charge nurse, but these steps were not followed. The incident occurred on 10/22/2023, but was not reported to the Abuse Coordinator until the following day, and no incident report or summary was provided. The Sheriff's Department concluded there was insufficient evidence to continue an investigation, and the facility could not provide documentation of a report to Adult Protective Services. Interviews with the Administrator and Director of Nursing revealed that the investigation was incomplete, with the Administrator admitting that an incident report was not completed and the Director of Nursing acknowledging the need for a narrative. The facility's failure to conduct a thorough investigation and report the incident immediately, as well as the lack of documentation and notification to Adult Protective Services, were identified as deficiencies in handling the abuse allegation.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours for two residents, as required by their policy. The policy mandates that a baseline care plan, which includes essential healthcare information and initial goals based on admission orders, must be developed within 48 hours of a resident's admission. This plan should be verified by a supervising nurse and signed by the resident or their family. However, for Resident #21, who was admitted with conditions such as Metabolic Encephalopathy and End Stage Renal Disease, the baseline care plan was initiated but left unsigned by the resident or family, thus not completed within the required timeframe. Similarly, Resident #369, admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure, also had an incomplete baseline care plan due to the lack of a signature from the resident or family. Interviews with the MDS Coordinator confirmed that the baseline care plans for both residents were not signed within 48 hours of admission, indicating a failure to adhere to the facility's policy for timely completion of baseline care plans.
Inadequate Behavioral Health Services for Resident
Penalty
Summary
The facility failed to provide adequate behavioral health services and effective behavior monitoring for a resident with significant behavioral health needs. The resident, who had a history of vascular dementia and behavioral disturbances, was admitted to the facility from a psychiatric hospital. Despite being prescribed multiple medications for agitation, anxiety, and depression, the resident exhibited a range of challenging behaviors, including wandering, entering other residents' rooms, rummaging through belongings, and displaying sexually inappropriate behaviors. These behaviors persisted from the time of admission until discharge, indicating a lack of effective interventions to manage the resident's needs. The facility's policy on behavioral health services emphasized the importance of person-centered care and monitoring for expressions of distress. However, the medical records and staff interviews revealed that the facility did not implement sufficient strategies to address the resident's behaviors. Staff documented numerous incidents where the resident was resistant to redirection and engaged in aggressive actions towards staff and other residents. The use of PRN medications like Ativan was noted, but these interventions were ineffective in controlling the resident's behaviors. Interviews with facility staff, including an LPN and a CNA, highlighted a lack of consistent communication and follow-up regarding the resident's behaviors. The Director of Nursing acknowledged that the interventions in place were inadequate to ensure the safety of both staff and residents. The facility's failure to implement effective behavioral health services and monitoring resulted in ongoing safety concerns and unmet behavioral health needs for the resident.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled medications, specifically Lorazepam, due to the inaction of an LPN who did not sign out the medications on the Controlled Substance Inventory Record and maintain an accurate running count. The facility's policy on narcotic control, dated August 2023, mandates that each time a controlled medication is administered, the nurse must complete the Controlled Substance Inventory Record and keep a running count of medications used and on-hand. However, during a review, it was found that the LPN did not adhere to this policy, resulting in discrepancies in the medication counts for two residents. Resident #22, diagnosed with Dementia, Carotid Artery Stenosis, Hypertension, Depression, and Generalized Anxiety Disorder, had a physician's order for Lorazepam 0.5mg three times a day. The medication card showed 4 tablets, but the inventory record indicated 5 tablets. Similarly, Resident #32, with Parkinson's Disease, Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Generalized Anxiety Disorder, had a physician's order for Lorazepam 0.5mg twice a day. The medication card had 29 tablets, while the inventory record showed 30 tablets. The LPN acknowledged the failure to sign out the medications and maintain accurate records, which was confirmed by the DON during an interview.
Failure to Update Emergency Food Supply Menu
Penalty
Summary
The facility failed to update and revise its Three-Day Disaster Menu to accurately reflect the 3-Day Emergency Food Supply. The facility's policy on Emergency Food Supply, dated April 2022, requires maintaining a 3-to-7-day supply of nonperishable foods, with rotation and replenishment every six months. However, a review of the undated facility policy on Disaster Planning and the Three-Day Disaster Menu revealed inconsistencies. Specifically, the menu listed peanut butter and protein bars for breakfast on Days 1 and 3, but the facility's 3-Day Supply list did not include these items. During an observation and interview in the kitchen, it was confirmed that the Emergency Food Supply Menu listed peanut butter and protein bars, yet these items were absent from the Emergency Stock. The Dietary Supervisor acknowledged that food items on the menu should be present in the emergency food supply. Additionally, a Registered Dietician confirmed that any food item on the 3-day Emergency Food Supply Menu should be included in the actual supply, indicating a failure to align the menu with the available stock.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions policy during wound care for a resident, leading to a deficiency in infection prevention and control. The policy, dated May 30, 2024, mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. However, during an observation on June 26, 2024, an LPN did not wear a gown while performing wound care on a resident with an unstageable pressure injury to the coccyx. Additionally, the LPN used a strip of calcium alginate that had been dropped onto a contaminated surface, further compromising the wound care process. The resident involved was admitted with multiple diagnoses, including hemiplegia, carcinoma of the skin, dementia, and malnutrition, and was severely cognitively impaired. The resident's medical records indicated a physician's order for daily wound care, but there was no order for Enhanced Barrier Precautions. Interviews with the Infection Preventionist and the LPN confirmed that the correct PPE should have been used, and the contaminated dressing should have been disposed of, highlighting the failure to follow established infection control protocols.
Unsafe Hot Water Temperatures and Inadequate Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by allowing dangerously elevated hot water temperatures in several resident rooms, ranging from 122.5 to 130 degrees Fahrenheit, which is above the state regulation limit of 105 to 115 degrees Fahrenheit. This issue was identified in multiple rooms, including those occupied by residents who were cognitively and/or physically impaired, placing them at risk of scalding. The Maintenance Director admitted to adjusting the water heater to a higher temperature without proper documentation or notification to the Administrator, leading to the unsafe conditions. Additionally, the facility did not provide adequate supervision and fall prevention measures for residents at risk of falls. Resident #11, who had a history of falls and severe cognitive impairment, experienced multiple falls resulting in injuries, including a closed fracture of the left distal femur. The facility's fall prevention interventions were insufficient and inconsistently implemented, as evidenced by the lack of immediate and effective measures following each fall incident. The facility's failure to address these safety hazards and implement effective interventions for fall prevention resulted in Immediate Jeopardy, a situation where the noncompliance had the potential to cause serious harm to residents. The Administrator and Maintenance Director were not adequately informed or responsive to the ongoing issues, contributing to the persistence of these deficiencies.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in actual harm. Resident #42 sustained two lacerations to the forehead when Resident #166 hit him with a hard plastic drinking cup. The facility's policies on abuse prevention and resident abuse were not effectively implemented, as Resident #166 exhibited aggressive behaviors from the time of admission, which were not adequately addressed. Resident #166 had a history of vascular dementia and was admitted to the facility with a diagnosis of dementia with agitation and behaviors. From the time of admission, Resident #166 displayed behaviors such as wandering, entering other residents' rooms, and physical aggression towards staff. Despite being prescribed antipsychotic, antidepressant, and anxiety medications, these interventions were ineffective in managing Resident #166's behaviors. The facility did not have a care plan in place for Resident #166's behaviors prior to the incident with Resident #42. Interviews with staff revealed that Resident #166 was difficult to manage and that interventions such as redirection and medication were not sufficient to ensure the safety of other residents and staff. The Director of Nursing acknowledged that adequate interventions were not put in place to keep residents and staff safe. The lack of effective measures to address Resident #166's behaviors led to the incident where Resident #42 was harmed.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were properly stored and secured, as evidenced by two incidents involving medication carts being left unlocked and unattended. The facility's policy mandates that all medications must be stored in locked compartments and that medication carts should be locked when not in use during medication administration. However, during an observation, an LPN left the Northeast Medication Cart unlocked and unattended while retrieving a computer mouse and answering a telephone call. Additionally, the LPN prepared medications for a resident and left the cart outside the resident's room unlocked and unattended. In another instance, a random observation revealed that the west medication cart was left unlocked and unattended in the hallway outside a resident's room. An LPN exited another resident's room and subsequently locked the cart. During an interview, the Director of Nursing confirmed that medication carts should not be left unlocked and unattended by nursing staff during medication administration, indicating a breach of the facility's medication storage and administration policies.
Facility Oversight Failures in Safety and Behavioral Management
Penalty
Summary
The facility administration failed to provide oversight to monitor and prevent dangerously elevated hot water temperatures in resident care areas. On two separate occasions, hot water temperatures ranging from 123 to 130 degrees Fahrenheit were recorded in eight resident rooms. Despite the Maintenance Director being aware of the issue, the Administrator was not informed of the specific temperatures or the immediate jeopardy posed by the situation. This lack of communication and oversight resulted in residents, including those who were physically and cognitively impaired, being exposed to potentially harmful conditions. The administration also failed to ensure a safe environment and adequate supervision to prevent falls and injuries among residents. Seven residents were identified as having experienced falls, with one resident sustaining a fracture. The facility did not conduct fall risk assessments quarterly or after each fall, as required by their policy. The Director of Nursing (DON) acknowledged the inadequacy of interventions for a resident with worsening dementia, indicating a lack of appropriate measures to prevent accidents. Additionally, the facility failed to prevent resident-to-resident abuse and did not provide appropriate care for a resident with behavioral issues. Resident #166 exhibited aggressive and inappropriate behaviors, including hitting another resident with a hard plastic cup, resulting in harm. Despite being referred to psychiatric services and prescribed medications, the interventions were ineffective. The DON admitted that adequate measures were not in place to ensure the safety of staff and residents, highlighting a significant oversight in managing behavioral health needs.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. It specifies that restraints may only be used in emergency situations for brief periods and that a physician's order alone is not sufficient to warrant their use. In this case, the facility's policy was not followed, as there was no physician's order for the self-release seat belt used on the resident. The resident in question, who was severely cognitively impaired and required maximum assistance for mobility, was observed multiple times unable to release the self-release seat belt. Despite the Director of Nursing's initial belief that the resident could release the belt, it was confirmed through observation and interview that the resident could not do so without assistance. This oversight was acknowledged by the Director of Nursing, who admitted that the situation constituted a restraint and that there should have been documentation on the Treatment Administration Record to ensure the resident's ability to release the seat belt.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of employee-to-resident abuse involving a resident with a history of respiratory failure, depression, and dementia. The resident, who was moderately cognitively impaired, was involved in an incident that occurred on 10/22/2023, but the facility did not report it to the Abuse Coordinator until the following day. The facility's policy required immediate notification and investigation, but these steps were not followed. The investigation lacked an incident report or summary, and there was no documentation of a report made to Adult Protective Services. Interviews with the Administrator and Director of Nursing revealed that the investigation was incomplete. The Administrator admitted that an incident report was not completed and that the investigation was not documented as required. The Director of Nursing acknowledged that a narrative would have been beneficial. The Sheriff's Department concluded there was insufficient evidence to continue their investigation, and the facility did not provide evidence of notifying Adult Protective Services, as required by their policy.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours for two residents, as required by their policy. The policy, revised on December 5, 2022, mandates that a baseline care plan be developed and implemented within 48 hours of a resident's admission. This plan should include initial goals based on admission orders, physician orders, dietary orders, and therapy services. However, for Resident #21, who was admitted with diagnoses including Metabolic Encephalopathy, Chronic Atrial Fibrillation, Diabetes, Dialysis, and End Stage Renal Disease, the baseline care plan was initiated but left unsigned by the resident or family, thus not completed within the required timeframe. Similarly, Resident #369, admitted with diagnoses such as Chronic Obstructive Pulmonary Disease, Pneumonia, Congestive Heart Failure, Diabetes, Hypertension, and Benign Prostatic Hypertrophy, also had an incomplete baseline care plan. The plan was initiated but remained unsigned by the resident or family. Interviews with the MDS Coordinator confirmed that the baseline care plans for both residents were not signed within 48 hours of admission, indicating a failure to adhere to the facility's policy for timely completion of baseline care plans.
Inadequate Behavioral Health Services and Monitoring
Penalty
Summary
The facility failed to provide adequate behavioral health services and effective behavior monitoring for a resident with significant behavioral health needs. The resident, who had a history of vascular dementia and behavioral disturbances, was admitted to the facility from a psychiatric hospital. Despite being prescribed multiple medications for agitation and anxiety, the resident exhibited a range of disruptive and aggressive behaviors, including wandering into other residents' rooms, rummaging through belongings, and displaying sexually inappropriate behavior. These behaviors persisted throughout the resident's stay, indicating a lack of effective interventions to manage the resident's needs. The facility's policy on behavioral health services emphasized the importance of person-centered care and monitoring for expressions of distress. However, the facility did not implement sufficient measures to address the resident's behaviors. Staff documented numerous incidents of the resident's aggressive and inappropriate actions, but there was a lack of effective non-pharmacological interventions or adjustments to the care plan to mitigate these behaviors. The resident's care plan, developed after discharge, highlighted the various behavioral issues but did not reflect proactive measures taken during the resident's stay. Interviews with facility staff revealed a lack of awareness and memory regarding specific incidents involving the resident. The LPN and CNA involved in the incidents could not recall details or confirm if appropriate documentation and follow-up occurred. The Director of Nursing acknowledged the challenges in managing the resident's behaviors and admitted that the interventions in place were likely insufficient to ensure the safety of both staff and other residents. This deficiency in behavioral health services and monitoring contributed to an unsafe environment for both the resident and others in the facility.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled medications, as evidenced by a Licensed Practical Nurse (LPN) not signing out controlled medications on the Controlled Substance Inventory Record and failing to maintain a running count of medications on hand. The facility's policy, dated August 2023, requires that each time a controlled medication is administered, the nurse must complete the Controlled Substance Inventory Record and keep a running count of medications used and on-hand. Verification of the quantities of controlled substances must be recorded on the Controlled Dosage System - Controlled Substance - Shift Change Count Check Sheet. During a medication storage review, discrepancies were found in the controlled medication counts for two residents. One resident's Lorazepam medication card had 29 tablets, while the Controlled Substance Inventory Record showed a count of 30 tablets. The LPN admitted to administering the medication but had not signed it out on the controlled sheet. Another resident's Lorazepam medication card had 4 tablets, but the Controlled Substance Inventory Record showed a count of 5 tablets. The LPN confirmed that she should have signed the medications out in the controlled book when administering them. The Director of Nursing confirmed that nursing staff should sign the medications out on the resident's Controlled Substance Inventory Record as the medications are pulled and administered, and that the narcotic controlled counts should match the actual pill count in the medication card.
Failure to Update Emergency Food Supply
Penalty
Summary
The facility failed to update and revise its Three-Day Disaster Menu to accurately reflect the 3-Day Emergency Food Supply. The facility's policy on Emergency Food Supply, dated April 2022, requires maintaining a 3-to-7-day supply of nonperishable foods, with rotation and replenishment every six months. However, the undated policy on Disaster Planning and the Three-Day Disaster Menu included items such as peanut butter and protein bars, which were not present in the actual emergency food supply. During an observation and interview in the kitchen, it was confirmed that the Emergency Food Supply Menu listed peanut butter and protein bars, but these items were missing from the emergency stock. The Dietary Supervisor acknowledged that items listed on the menu should be available in the emergency food supply. Additionally, a Registered Dietician confirmed that any food item on the 3-day Emergency Food Supply Menu should be included in the actual supply.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions policy during wound care for a resident, leading to a deficiency in infection prevention and control. The policy, dated May 30, 2024, mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. However, during an observation on June 26, 2024, an LPN did not wear a gown while performing wound care on a resident with an unstageable pressure injury to the coccyx. Additionally, the LPN used a strip of calcium alginate that had been dropped onto a contaminated surface, further compromising the wound care process. The resident involved was admitted with multiple diagnoses, including hemiplegia, carcinoma of the skin, dementia, and malnutrition, and was severely cognitively impaired. The resident's medical records indicated a physician's order for daily wound care, but there was no order for Enhanced Barrier Precautions. Interviews with the Infection Preventionist and the LPN confirmed that the correct PPE should have been used, and the contaminated dressing should have been disposed of, highlighting the failure to follow established infection control protocols.
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 44 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 Dresden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillview Community Living Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Diversicare Of Martin | 9.7 mi | ★★★★★ | 0 | 0 |
| Vanayer Senior Living And Rehabilitation | 9.8 mi | ★★★★★ | 4 | 0 |
| Waters Of Mckenzie A Rehabilitation & Nursing Ctr | 15.7 mi | ★★★★★ | 0 | 0 |
| Ahc Mckenzie | 15.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.