Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Wyndridge Health And Rehab Ctr during CMS and state inspections, most recent first.
Failure to notify the LTC Ombudsman of resident discharges: The facility did not send discharge notifications for 152 residents, despite policy requiring transfer/discharge notices be provided to the Ombudsman and evidence maintained that the notice was sent. The SW said she could not send the notices because contact information was unavailable, while the Ombudsman stated she had provided contact information and had not received discharge notifications since starting the role. The SW later confirmed no discharge notifications had been sent since the cited start date.
Improper Refrigerated Food Storage: During a walk-in refrigerator observation with the CDM, an expired turkey breast was found available for resident use, and an opened bottle of lemon juice had no manufacturer use by date or open date. The CDM confirmed both items were available for resident use and that the turkey breast was past its use by date.
Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Failure to Maintain Clean, Comfortable, Homelike Environment: Surveyors observed broken drywall and dust behind a bed near respiratory equipment, stained and damaged tubs, toilets, tiles, and shower areas, leaking fixtures, detached baseboard, foul odors, and insects in multiple rooms and a shower room. Staff interviews confirmed ongoing insect issues in the secure unit and acknowledged the environment on the 100 and 400 hallways was not maintained in a clean, comfortable, and homelike condition.
Missing Physician Orders for respiratory support and oxygen safety issues were identified for several residents. A resident dependent on a ventilator and two residents with tracheostomies were observed receiving respiratory support, but the chart lacked orders for ventilator use, settings, suctioning, and trach type or size as applicable. The facility also failed to follow oxygen orders for one resident and did not securely store portable oxygen tanks in two residents' rooms, despite policy requiring written orders and secured cylinder storage.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the LTC Ombudsman of resident discharges in a timely manner for 152 residents discharged from 9/3/2025 through 3/25/2026. The facility policy titled, Transfer and Discharge (including AMA), dated 5/2025, stated that transfer/discharge notices would be provided to the LTC Ombudsman and that the facility would maintain evidence that the notice was sent. Review of the resident discharge report showed 152 residents were discharged during the cited period. During interview, the Social Worker stated she had been unable to send discharge notifications because the new Ombudsman had not provided contact information. The LTC Ombudsman stated she had not received discharge notifications since starting the role in 11/2025, stated she had provided contact information to the facility, and stated she had informed the facility of the need to be notified of resident discharges. The Social Worker later confirmed she had not notified the LTC Ombudsman of resident discharges since 9/3/2025.
Improper Refrigerated Food Storage
Penalty
Summary
The facility failed to properly store refrigerated food items in accordance with its Food Storage Guidelines policy. During an observation of the walk-in refrigerator with the Certified Dietary Manager, a turkey breast weighing approximately 5 pounds was found with a manufacturer use by date of 3/20/2026 and was still available for resident use even though it was expired. The same observation also identified an opened 32 fluid ounce bottle of lemon juice that was about three-quarters full but had no manufacturer use by date and no open date on the bottle. During interview, the CDM confirmed that both items were available for resident use and acknowledged that the turkey breast was expired and the lemon juice bottle lacked the required dating information.
Failure to Follow EBP, Hand Hygiene, and Catheter Practices During Respiratory, Enteral, and Daily Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. The facility’s EBP policy required staff to perform hand hygiene, review EBP signage, and don gown and gloves prior to high-contact resident care activities such as tracheostomy care, suctioning, and device care, then remove PPE and perform hand hygiene before leaving the resident’s room. For Resident #1, who had epilepsy, acute on chronic respiratory failure, a tracheostomy, and ventilator dependence, a respiratory therapist entered the room where EBP signage was posted, used pocket hand sanitizer, and donned gloves but did not don a gown or mask. The therapist placed clean gauze and used split gauze directly on the resident’s abdomen, allowed the tracheostomy inner cannula to roll from the abdomen onto the linens, and then left the room carrying a box while still wearing the same contaminated gloves, only discarding them later at the respiratory therapy cart. The therapist acknowledged not setting up supplies appropriately, not discarding gloves and performing hand hygiene before leaving the room, and not following EBP, stating she believed EBP was only required for residents with an active infection. For Resident #8, who had traumatic brain injury, quadriplegia, acute respiratory failure, and a tracheostomy, the same respiratory therapist again entered a room with EBP signage and donned gloves but no gown or mask before performing tracheal suctioning using an in-line suction catheter. The resident had reflex coughing during suctioning. After completing suctioning, the therapist discarded gloves and used pocket hand sanitizer but again did not follow the full EBP requirements. The infection preventionist later confirmed that EBP was required for high-contact care such as tracheal care and suctioning, and that gloves should be discarded before leaving the room with hand hygiene performed each time gloves are removed. The facility also failed to follow EBP and hand hygiene practices during medication administration for Resident #22, who had chronic respiratory failure, quadriplegia, tracheostomy status, and gastrostomy status, and who had long- and short-term memory deficits with severely impaired decision-making. A registered nurse entered the resident’s room, where EBP signage was posted, donned gloves but not a gown, and administered medications via the gastrostomy tube using a piston syringe, flushing with water as ordered. With the same used gloves still on, the nurse rinsed the piston syringe in the room sink, set it on paper towels to dry, and then performed OcuSoft eyelid scrubs to both eyes without changing gloves or performing hand hygiene between the different routes of care. The nurse confirmed she did not don a gown and did not perform hand hygiene or change gloves between the feeding tube medication administration and the eye care, and the infection preventionist confirmed that EBP and hand hygiene with glove changes were expected between administering medications by different routes. Additional deficiencies were identified in hand hygiene assistance before meals and urinary catheter management. The facility’s resident handwashing policy required staff to offer hand hygiene before meals. Resident #47, who had acute and chronic respiratory failure, epilepsy, atrial fibrillation, and chronic pulmonary edema and was dependent for hygiene and feeding assistance, received a lunch tray from a CNA who set up the tray and left without offering hand hygiene assistance. Resident #31, with COPD, acute and chronic respiratory failure, morbid obesity, and a care plan indicating partial to moderate assistance with hygiene, also had a lunch tray delivered and set up by a CNA who exited without offering hand hygiene. Resident #66, with COPD, chronic respiratory failure, generalized muscle weakness, and substantial to maximal ADL needs including meal assistance, likewise had a lunch tray delivered and set up without being offered hand hygiene. One CNA acknowledged residents were to be offered hand hygiene before meals, and another stated she had not offered hand hygiene unless residents mentioned it. The infection preventionist confirmed staff were expected to offer hand hygiene assistance to all residents prior to meals. The facility further failed to maintain proper urinary catheter bag positioning for Resident #15, who had chronic osteomyelitis, depression, anxiety, paraplegia, and required assistance with ADLs, including urinary catheter care per orders and protocol. During observation, the resident was in bed with the urinary catheter drainage bag lying on the floor beside the bed. A licensed practical nurse confirmed the catheter bag should be hung from the bed, and the infection preventionist confirmed catheter bags were to be suspended off the ground to prevent infection. These observations demonstrated non-adherence to the facility’s infection prevention and control practices related to EBP, hand hygiene, and catheter management across multiple residents and care situations.
Failure to Maintain Clean, Comfortable, Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for 2 of 4 units observed. Facility policies reviewed stated that environmental surfaces in patient care areas were to be thoroughly scrubbed, that resident rooms were to be cleaned daily on each shift by housekeeping, nursing staff, and respiratory therapy, and that environmental equipment such as sinks, commodes, and floors were to be cleaned on a daily schedule and as needed. In room [ROOM NUMBER], surveyors observed a significant amount of broken drywall material and drywall dust on the floor behind Bed A, adjacent to the resident's respiratory equipment. The drywall behind the bed near the baseboard was damaged with numerous visible penetrations. In the same room, the ADON later confirmed the drywall damage and debris needed to be reported to the maintenance director and corrected immediately. The report also noted a pest control invoice showing spraying in the kitchen, dining room, and two rooms. In room [ROOM NUMBER], the bathtub had pink, brown, and gray streaks, brown, black, and pink stains around the drain, a paper towel in the drain, discolored caulking, black debris at the faucet, and a leaking faucet. The vinyl baseboard below the sink was detached. In another room, orange and brown substance was splattered on tiles around the bathtub faucet and in the tub, with additional streaks and stains near the drain and toilet paper rolls placed on the tub rim. In the 100 Hall Shower Room, surveyors observed cracked, chipped, and broken tiles, pink and brown staining, a black spotted substance near the floor, a leaking shower head, and a blue plastic razor on the floor; a CNA stated there should not be bugs in the shower room and the razor was not supposed to be on the floor. In another room, surveyors observed brown staining in the toilet bowl, a damaged and stained toilet seat, yellow staining under the seat, a foul odor, and several flying insects around the toilet. An LPN stated the facility had intermittent issues with insects in the secure unit for the past few months, and the Administrator and Maintenance Director confirmed the facility failed to provide a clean, comfortable, and homelike environment on the 100 hallway and 400 hallway.
Missing Physician Orders for Respiratory Support and Oxygen Safety Issues
Penalty
Summary
Physician's Orders were not obtained for respiratory care for multiple residents receiving ventilator and tracheostomy support. Resident #1, who had diagnoses including epilepsy, acute on chronic respiratory failure, tracheostomy, and dependence on ventilator, was observed in bed with a tracheostomy connected to a mechanical ventilator, but the Physician's Orders contained no orders for ventilator use, ventilator settings, suctioning, tracheostomy use, or tracheostomy care, type, or size, and no orders authorizing respiratory therapy to manage ventilator settings. Resident #8, who had diagnoses including traumatic brain injury, quadriplegia, acute respiratory failure, and tracheostomy, was also observed with a tracheostomy in place, but the Physician's Orders contained no orders for suctioning or for tracheostomy use, care, type, or size. Resident #9, who had diagnoses including chronic respiratory failure, dependence on ventilator, and tracheostomy, was observed with a tracheostomy connected to a mechanical ventilator, but the Physician's Orders did not include the tracheostomy type or size. The facility also failed to ensure oxygen was administered according to Physician's Orders for Resident #65 and failed to safely secure portable oxygen tanks in residents' rooms for Residents #88 and #69. The facility's oxygen policy stated oxygen therapy is administered upon written physician order and that oxygen cylinders must be stored in racks, sturdy portable carts, or approved stands and may not be left free standing. The report documents that the Director of Nursing confirmed Physician's Orders were required to direct resident care, including respiratory support with tracheostomy and ventilator use.
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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 Crossville
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 | 1.6 mi | ★★★★★ | 4 | 0 |
| Wharton Nursing Home | 10.1 mi | ★★★★★ | 0 | 0 |
| The Preserve At Fairfield Glade | 10.4 mi | ★★★★★ | 0 | 0 |
| Standing Stone Care And Rehab | 19.2 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Rockwood Rehab & Wellness | 20.7 mi | ★★★★★ | 0 | 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.