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 Wharton Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically and verbally abused by a family member in an LTC facility. The abuse was witnessed by a CNA who reported the incident to a nurse. The resident was found with bruises and a head injury, and the facility failed to prevent the abuse, placing residents in Immediate Jeopardy.
A facility failed to report an abuse allegation involving a cognitively impaired resident who was physically abused by a family member. Despite the facility's policy requiring immediate reporting, the Administrator did not report the incident, honoring the family's request to handle it privately. This inaction placed residents in Immediate Jeopardy, leading to a citation for substandard quality of care.
A resident with severe cognitive impairment experienced verbal and physical abuse by a family member, but the facility failed to update the care plan to ensure safety and monitor psychosocial wellbeing. Despite visible injuries and the resident's report of being 'roughed up,' the care plan was not revised, placing all residents in Immediate Jeopardy.
A resident with severe cognitive impairment experienced multiple falls due to ineffective interventions and inadequate supervision. Despite being care planned for assistance and safety measures, the resident continued to fall, resulting in actual harm. The facility's interventions, such as reminder signs and verbal reminders, were not suitable for the resident's condition, leading to repeated incidents and eventual injury.
The facility failed to complete side rail assessments for the risk of entrapment and did not obtain consents for side rails for six residents with various cognitive and physical impairments. Despite the presence of side rails on their beds, there were no documented entrapment risk safety assessments or consents in their medical records. The Administrator and DON confirmed the lack of assessments, consents, and a facility policy for side rails.
A resident with dementia and severe memory impairment experienced four falls due to ineffective and repetitive interventions by the facility's QAPI program. Despite the resident's high fall risk, the interventions were not appropriate for their cognitive condition, leading to repeated falls and eventual harm.
The facility failed to ensure medical information was not visible for five residents, compromising their dignity and privacy. Signs detailing the type and size of adult briefs used by residents were posted on closet doors, and a sign stating 'NO IM or IV Sticks' was observed above a resident's bed. These signs were visible to anyone entering the rooms, and the residents did not request or approve their placement.
The facility failed to offer hand hygiene assistance to three residents before meals, despite the policy requiring it. Staff members confirmed they were aware of the policy but did not follow it during meal distribution.
Failure to Protect Resident from Family Member Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by a family member. The incident involved a vulnerable and severely cognitively impaired resident who was observed being mentally and physically abused by a family member. The abuse was witnessed by a Certified Nursing Assistant (CNA) who heard the family member yelling at the resident and saw the family member forcefully trying to feed the resident. The CNA reported the incident to a nurse, who found the resident covered in food with a noticeable injury on the head. The resident, who had a history of severe cognitive impairment, was admitted to the facility with multiple diagnoses, including cerebral infarction, pneumonia, and diabetes. On the day of the incident, the resident was found with scattered bruising and abrasions, and a knot on the head was later discovered. The resident indicated that the family member had "roughed him up," which was corroborated by the CNA's observations and the resident's consistent account of the events. The facility's policy on abuse, neglect, and exploitation requires immediate reporting and investigation of any allegations of abuse. However, the facility did not prevent the abuse from occurring, as they were unaware of the family dynamics and did not have measures in place to identify potential risks from family members. The failure to protect the resident from abuse placed the resident and others in the facility in an Immediate Jeopardy situation, which required immediate correction.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a vulnerable and severely cognitively impaired resident, who was observed being mentally and physically abused by a family member. The incident occurred when a family member was forcefully attempting to feed the resident, resulting in a physical altercation that left the resident with a noticeable injury. Despite the severity of the situation, the facility did not report the incident to the appropriate authorities within the required timeframe. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of any alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes. However, in this case, the Administrator chose to honor the wishes of the resident's family member, who requested that the incident not be reported, citing it as a family matter. This decision was made despite the Administrator's acknowledgment that the incident was a reportable allegation of abuse. The failure to report the abuse placed the resident and potentially all other residents in the facility in an Immediate Jeopardy situation, as the noncompliance with reporting requirements could result in serious harm or injury. The facility's inaction in this matter was identified during a survey, leading to the citation of Immediate Jeopardy at a scope and severity of J, indicating substandard quality of care.
Failure to Update Care Plan After Abuse Incident
Penalty
Summary
The facility failed to develop a comprehensive care plan and implement appropriate interventions for a resident following an abusive incident by a family member. On the date of the incident, a family member was observed being verbally and physically abusive towards the resident, which included forcefully feeding the resident and yelling at them. Despite the incident, the facility did not update the resident's care plan to ensure their safety, monitor for psychosocial wellbeing, or inform staff that the abusive family member was not allowed in the facility. The resident involved had a history of severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5. The resident's medical record showed no updates or interventions related to the incident, even though the resident had visible injuries and reported being 'roughed up' by the family member. Interviews with facility staff, including a Certified Nursing Assistant and the Administrator, confirmed that the care plan was not updated to reflect the incident or to monitor for any emotional or physical changes in the resident. The facility's failure to address the incident and update the care plan placed the resident and all other residents in an Immediate Jeopardy situation, as it did not ensure the resident's safety or address their psychosocial needs. The lack of a comprehensive care plan and appropriate interventions had the potential to impact all residents in the facility, as it did not provide a framework for staff to follow in preventing further abuse or addressing the resident's wellbeing.
Failure to Prevent Falls for Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent accidents related to falls for a resident with severe cognitive impairment, resulting in actual harm. The resident, who had a history of falls and a high fall risk score, experienced multiple unwitnessed falls despite being care planned for assistance with transfers and ambulation, keeping call light and personal items within reach, and maintaining adequate lighting and clutter-free floors. The interventions implemented after each fall, such as reminder signs to use the call light and encouraging the use of a walker, were ineffective due to the resident's severe dementia and poor memory retention. The resident had four falls within a short period, with the first fall occurring when the resident attempted to close the blinds and slipped out of her recliner. Subsequent falls happened in the hallway and in the resident's room, with the resident often found on the floor without using her assistive devices. The interventions after each fall were not modified appropriately to address the resident's cognitive impairment, leading to repeated incidents. The facility's policy required identifying hazards, implementing interventions, and monitoring their effectiveness, but the interventions chosen were not suitable for the resident's condition. The Director of Nursing (DON) and other staff confirmed that the interventions, such as reminder signs and verbal reminders to use the call light, were not appropriate for a resident with severe dementia. The resident's final fall resulted in a nosebleed and a skin tear, requiring transfer to the emergency room for evaluation. The facility's failure to implement effective fall prevention strategies and provide adequate supervision for the cognitively impaired resident led to actual harm, as confirmed by the DON, Administrator, and Medical Director.
Failure to Complete Side Rail Assessments and Obtain Consents
Penalty
Summary
The facility failed to complete side rail assessments for the risk of entrapment and did not obtain consents for side rails for six residents. These residents had various diagnoses, including cognitive impairments, quadriplegia, Alzheimer's disease, and vascular dementia. Despite the presence of side rails on their beds, there were no documented entrapment risk safety assessments or consents in their medical records. Observations confirmed the presence of side rails without visible gaps between the mattress and side rails, but the necessary assessments and consents were missing. Resident #1, with moderate cognitive impairment and total dependence on staff for toileting, had side rails on their bed without any documented safety assessments or consent. Similarly, Resident #34, who required supervision for transfers, also had side rails without the necessary documentation. Resident #5, who was cognitively intact but required supervision for various transfers, had side rails without any entrapment risk assessments or consent. The same issue was observed for Residents #23, #25, and #45, who had varying degrees of cognitive impairment and physical dependence. The Administrator and Director of Nursing confirmed that the side rails came attached to the facility beds and had not been added by the facility. They also confirmed that no alternatives had been attempted, no nursing assessments had been conducted for risks of entrapment, and no consents were obtained from the residents or their representatives. Additionally, there was no facility policy for side rails.
Inadequate Fall Prevention Measures for Resident with Dementia
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) program failed to implement effective action plans and monitor interventions to prevent falls for a resident with dementia and severe memory impairment. The resident, who had a history of multiple falls and cognitive impairments, experienced four falls within a short period. Despite the resident's high risk for falls, the interventions put in place were either repetitive or inappropriate given the resident's cognitive condition. For instance, the care plan included reminders to use the call light and keep the room well-lit, which were not new or effective interventions for a resident with severe memory problems. The first fall occurred when the resident attempted to get out of a recliner to close the blinds, resulting in a slip and fall. The intervention was to place reminder signs in the room, which proved ineffective as the resident fell again in the hallway a few days later. The subsequent intervention was to encourage the use of a walker and keep the bed in the lowest position, despite the fall not being related to bed height. The resident continued to fall, with the third fall occurring while trying to go to the bathroom, and the intervention was again to remind the resident to use the call light and keep the room clutter-free, which were already existing measures. The fourth fall resulted in the resident being sent to the emergency room with a nosebleed and a skin tear. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's QAPI program did not identify any issues with the fall interventions and failed to implement new, appropriate measures. Both the DON and the Administrator acknowledged that the interventions were not suitable for a resident with severe dementia and that the QAPI program did not effectively address the resident's fall risk.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure medical information was not visible for five residents, compromising their dignity and privacy. Observations revealed that signs detailing the type and size of adult briefs used by residents were posted on closet doors in the rooms of Residents #1, #3, #4, and #22. These signs were visible to anyone entering the rooms. Interviews with the residents and their representatives confirmed that they did not request or approve the placement of these signs. The Assistant Director of Nursing (ADON) acknowledged the issue and confirmed that the signs were supposed to be taken down but were still present during the surveyor's visit. Additionally, a sign stating
Failure to Offer Hand Hygiene Assistance Before Meals
Penalty
Summary
The facility failed to offer hand hygiene assistance to residents prior to meals for three residents observed during meal tray distribution. The facility's policy, updated on 8/21/2023, mandates that hand hygiene should be performed to prevent the spread of infection, including offering hand hygiene to residents before meals. However, during observations on 2/12/2024, it was noted that neither the Certified Nursing Assistant (CNA) nor the Licensed Practical Nurse (LPN) offered hand hygiene assistance to the residents before their lunch meals. Specifically, CNA #1 did not offer hand hygiene assistance to Resident #156 and Resident #157, and LPN #1 did not offer hand hygiene assistance to Resident #44. Interviews with the staff confirmed that they were aware of the policy but failed to follow it during the observed meal distribution. Resident #44, who has severe cognitive impairment and is independent for eating and personal hygiene, was not offered hand hygiene assistance by LPN #1. Similarly, Resident #156, who also has severe cognitive impairment and requires setup or cleanup assistance with personal hygiene, was not offered hand hygiene assistance by CNA #1. Resident #157, who has multiple diagnoses including Parkinson's Disease and is independent for eating, was also not offered hand hygiene assistance by CNA #1. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that it is the facility's expectation and policy to offer hand hygiene assistance to residents before meals, and acknowledged that the staff had been educated on this process.
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 20 citations issued within 25 miles in the last 12 months — 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 Pleasant Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Crossville | 9.6 mi | ★★★★★ | 4 | 0 |
| Wyndridge Health And Rehab Ctr | 10.1 mi | ★★★★★ | 10 | 0 |
| Standing Stone Care And Rehab | 12.6 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Sparta | 14.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Sparta | 16 mi | ★★★★★ | 0 | 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.