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 Advanced Rehabilitation And Healthcare Of Athens during CMS and state inspections, most recent first.
Delayed Morning Medication Administration: Two cognitively intact residents with multiple chronic conditions did not receive their morning meds at the ordered time. One resident reported receiving all morning meds around 2:00 p.m., and the other reported receiving them around 1:30 p.m. The hall 3 charge nurse said the med aide did not show up, the issue was reported to the scheduler and leadership, and the morning pass was not completed until the scheduler, who was also a MA, administered the meds later that afternoon.
Unsanitary ice handling was observed on hall 200 when a CNA used a pink water pitcher instead of a proper ice scoop, touched used resident pitcher rims, and left the pitcher in the ice chest. Ice chests on halls 2, 3, and 4 were also observed with improper drainage and black, slimy buildup, while the DON, DM, and Administrator reported there was no ice scoop available, dietary was responsible for cleaning, and the facility had no cleaning schedule or policy for when hall ice chests were to be cleaned.
A CNA provided incontinent care to a resident with dementia, diabetes, and frequent bowel and bladder incontinence without proper clean technique or hand hygiene. The CNA used soiled gloves while placing a clean brief, did not cleanse the buttocks and rectal area thoroughly, removed her gloves without washing her hands, and then dressed the resident, transferred her to a wheelchair, and brushed her hair without hand hygiene. The DON stated staff were expected to follow the facility’s perineal care process, including handwashing, glove changes, and cleaning from front to back.
The facility failed to protect several residents after staff reported that a CNA was placing non-functioning or unplugged call lights in resident rooms and moving working call lights out of reach, despite care plans requiring call lights to be accessible for residents with significant physical and cognitive impairments and fall risk. Grievances identified specific CNAs and residents, and internal interviews and staff statements confirmed prior observations of extra call lights on the floor or in residents’ hands, yet leadership did not promptly suspend the named CNAs or fully investigate when first notified. One CNA continued working on the affected hall and caring for the involved residents, and later allegedly used profane, abusive language toward a cognitively intact roommate who had repeatedly reported the call-light issues, demonstrating the facility’s failure to take immediate protective action while serious neglect and abuse allegations were under investigation.
Staff and leadership failed to protect multiple residents from neglect and verbal abuse when CNAs allegedly removed or disabled functioning call lights and provided non-functioning "dummy" call lights, leaving dependent residents without reliable access to assistance, and when a CNA allegedly cursed at a cognitively intact resident during a dispute about care for his roommate. Several residents with dementia, significant physical impairments, incontinence, and documented fall risk were care planned to have call lights within reach, yet grievances, staff statements, and family reports described working call lights being placed out of reach, extra unplugged call lights found in residents’ hands or on the floor, and ongoing delays in call light response. A resident reported that he repeatedly returned the working call light to his roommate after a CNA moved it, and he also reported that the CNA told him to "shut the [F-word] up and mind your business" when he insisted she provide care. The DON and Administrator acknowledged being informed of specific staff and rooms involved, recognized that the conduct could constitute neglect or seclusion, and were aware of prior observations of multiple call lights in one room, yet did not immediately remove the implicated staff from resident care or report the allegations to the state agency, allowing the alleged conduct to continue.
Staff reported that certain CNAs were allegedly moving working call lights out of reach and providing non-functioning "dummy" call lights to three residents who relied on call lights for assistance with ADLs and fall prevention. One resident with severe cognitive impairment, cervical spinal cord injury, and total dependence for many ADLs was repeatedly found with an unplugged or extra call light while his working call light was out of reach, and his roommate stated this had been occurring for about a month. Another cognitively intact resident with diabetes, dementia, and a history of falls reported that a night aide placed her call light out of reach and gave her an unplugged light, and a third resident with dementia and repeated falls was also named in staff grievances about dummy call lights. The SW, DON, and Administrator all became aware of these allegations, recognized they could constitute neglect or seclusion, and identified specific CNAs as possibly involved, yet the facility treated the concerns as internal grievances and did not report the alleged neglect to the state agency within the required 24-hour timeframe.
A resident with severe cognitive impairment, cervical spinal cord injury, and significant functional limitations was care-planned and Kardexed for total assist transfers using a mechanical lift with two staff. Despite this, a CNA attempted a one-person manual transfer from wheelchair to bed without using the mechanical lift or checking the Kardex, stating the resident did not have a lift pad under him. During the attempt, the CNA lost his grip and lowered the resident to the floor, after which nursing staff and another CNA assisted the resident back to bed. The roommate, an RN, and a family member’s video-recorded conversation with a nurse all confirmed that the resident was normally transferred with a mechanical lift, that a lift was available and working, and that the CNA did not use it, contrary to the resident’s care plan and the facility’s mechanical lift policy.
A resident with dementia, cognitive impairment, and a history of exploitation did not have their care plan updated to address safety, mental health, or visitor restrictions, despite clear documentation and family communication about their vulnerability and permanent placement. Staff interviews revealed a lack of awareness about the resident's history and required restrictions, and the care plan was not revised after multiple assessments, failing to reflect the resident's current needs.
A resident with dry eye syndrome and other conditions did not receive three scheduled doses of prescribed eye drops due to medication aides failing to use available resources or notify nursing staff when the medication was not found in their cart. The missed doses were not documented with reasons, and no medication error reports were completed, despite facility policy requiring such actions.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or omissions that led to this failure.
The facility failed to maintain sanitary conditions in the kitchen as the Dishwasher was observed not wearing a hairnet and using water at 106 F, below the required 120 F, for dish sanitization. The issue was linked to the simultaneous use of laundry machines, which depleted hot water reserves. Despite previous repairs, the problem persisted, affecting the dishwashing process.
The facility failed to inform residents of their right to file grievances and how to do so. Interviews and record reviews revealed that residents were not aware of the grievance process, and the AD and Administrator admitted to not explaining the grievance forms or their location. The facility's grievance policy requires residents to be informed of their rights, which was not adhered to.
The facility failed to accurately code the PASRR on MDS assessments for two residents, leading to potential misclassification of their mental health status. One resident with bipolar disorder and major depressive disorder was incorrectly marked as not having a serious mental illness, while another with bipolar disorder and schizophrenia was similarly misclassified. The MDS RN misunderstood the connection between active diagnoses and PASRR documentation, resulting in these inaccuracies.
A facility failed to document hemodialysis orders in the EHR for a resident with End Stage Renal Disease, despite her being scheduled for treatment three times a week. The resident, who was cognitively intact, confirmed her dialysis schedule, but the orders were missing from her records following a hospital readmission. Interviews revealed that the ADONs were responsible for entering these orders, but they were not re-entered, violating the facility's policy on maintaining accurate clinical records.
A facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. An LVN did not cleanse an injection site before administering insulin to a resident with diabetes, contrary to facility policy. Another LVN failed to wear appropriate PPE while administering medications via a feeding tube to a cognitively impaired resident, despite clear EBP signage. The Infection Preventionist confirmed these lapses in protocol, which are crucial for preventing disease transmission.
Two residents with moderately impaired cognition were involved in a verbal and physical altercation in the dining room. One resident blocked the other's access to the coffee pot, leading to a verbal threat and a physical response. The incident was witnessed by the AD, who intervened, but the physical altercation still occurred. Both residents were assessed with no injuries found, and the facility's investigation confirmed the abuse incident.
A facility failed to ensure a resident received necessary specialist referrals following hospital discharge instructions. The resident, with multiple health conditions, was supposed to follow up with a cardiologist and neurologist, but no referrals were made. Interviews revealed that the responsibility for referrals was unclear, and the transportation book used for scheduling was missing, leading to a lapse in care coordination.
Delayed Morning Medication Administration
Penalty
Summary
The facility failed to ensure that two residents received their morning medications at the time ordered by the physician on 5/13/2026. Resident #1, a cognitively intact female with diagnoses including diverticulitis, colostomy, anxiety disorder, insomnia, chronic atrial fibrillation, chronic pain syndrome, COPD, acute respiratory failure, obesity, and MRSA infection, stated that she received all of her morning medications around 2:00 p.m. Resident #2, also cognitively intact, with diagnoses including peripheral vascular disease, acute embolism and thrombosis of the left lower extremity, chronic diastolic heart disease, anemia, overactive bladder, bursitis, abnormal gait, muscle weakness, adjustment disorder with anxiety, dyspnea, osteoarthritis, and hypertension, stated that she received her morning medications about 1:30 p.m. The charge nurse for hall 3 stated that between 6:30 A.M. and 7:00 A.M. she reported to the scheduler that the medication aide for hall 3 had not shown up and there was no one to give medications. She further stated that during the morning department head meeting around 9:00 A.M., she informed the DON, ADON, Administrator, and Social Worker that there was still no medication aide for the morning medication pass. She stated she was told by the DON it would be taken care of, and that she passed some pain medications, but the morning medications, which were anytime medications, were not passed until around 1:30 P.M. to 2:00 P.M. by the scheduler, who was also a medication aide. The DON stated she had instructed the scheduler, who was also a MA, to pass the medications and assumed it was done, but it was not done until after 1:30 P.M. The scheduler stated she was on a training call that day, knew the facility was short staffed, and believed the issue had been covered and resolved; she was not notified until about 1:00 P.M. that medications had not been passed, at which time she went to the cart and administered all medications. The facility policy required medications to be administered in accordance with physician orders and within 60 minutes before or after the prescribed dosing time.
Unsanitary Ice Handling and Dirty Ice Chests
Penalty
Summary
The facility failed to distribute ice under sanitary conditions on hall 200. During observation, a CNA was seen passing ice without a proper scoop, using a pink water pitcher as a scoop, allowing the scoop to touch the rims of used residents’ pitchers before dipping it back into the ice chest, and leaving the pink water pitcher in the ice chest. During interview, the CNA stated she knew she was not supposed to use a pitcher for a scoop and that the pitcher should not be left in the ice chest, but she was not sure how the ice chest was cleaned or who was responsible for cleaning it. During observation of the ice chests on halls 2, 3, and 4, all had improper drainage and were dirty with black, slimy scum and buildup on the bottom. The DON stated there were no more ice scoops and that the CNA was using a pink pitcher as an ice scoop, but she did not know the CNA was leaving it in the ice chest. The DM stated dietary was responsible for cleaning the ice chest, while the CNA’s job was to get the ice chest to the kitchen. Review of the Dietary Cleaning Log showed no cleaning schedule for the ice chest, and the Administrator stated the facility did not have a policy for dietary on how and when the hall ice chest was to be cleaned.
Incontinent Care Performed Without Proper Hand Hygiene or Clean Technique
Penalty
Summary
The facility failed to have an effective infection control program to prevent the development and transmission of disease and infection for 1 of 2 residents reviewed for incontinent care/peri care, Resident #30. Resident #30 was an elderly female admitted with diagnoses including diabetes, dementia, wedge compression fractures of the 4th and 5th thoracic vertebrae, cognitive communication deficit, high blood pressure, and heart disease. Her most recent quarterly MDS indicated she required partial assistance of 1 staff with transfers, dressing, toileting, and personal hygiene, and she was frequently incontinent of bladder and bowel. During an observation, CNA A performed incontinent care while the resident was lying on her left side with her brief undone and her buttocks exposed. The CNA had the package of wipes on the bed, no setup on the overbed table, and no sanitizer bottle in use. She wiped only the right hip and top part of the right buttock, flipped the wipe toward the rest of the buttocks without actually cleaning the buttocks or opening the anal area, discarded the wipe, rolled up the old brief, and placed it in the trash. Using soiled gloves, she placed a fresh brief under the resident and, without changing or removing her gloves, turned the resident to her back, pulled the brief through, and fastened it. After removing her gloves, CNA A did not wash her hands and proceeded to remove clothes from the closet, dress the resident, help transfer her to the wheelchair, and brush her hair without gloves and without hand hygiene. She stated she did not come prepared to do incontinent care in front of the surveyor and said she did extra things when surveyors watched. The DON stated she had completed CNA proficiency training and return demonstration on incontinent care in January 2026 and expected staff to bring no less than 5 pairs of gloves, wash hands before setting up supplies, place equipment on a clean overbed table, cleanse the front area, remove gloves and perform hand hygiene, then use fresh gloves to clean the back area from front to back, remove gloves and wash hands before placing the clean brief, and wash hands again after finishing other care.
Failure to Protect Residents During Call-Light Neglect and Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to take appropriate steps to prevent further potential abuse or neglect and to implement corrective action while investigations into alleged neglect and verbal abuse were in progress. Multiple grievances were filed on 02/02/26 by a CNA reporting that another CNA had been switching out working call lights with non-functioning "dummy" call lights or placing call lights out of reach for several residents. These grievances identified concerns that one CNA was switching out call lights for three residents during evening/weekend shifts, and that another CNA had given a resident a dummy call light that was not plugged in. The grievances were assigned to the Administrator/DON, but no meetings were held with the complainant or residents, and the facility’s documented follow-up consisted of maintenance checking call lights and noting they were working, with the grievances then marked as resolved. Resident #1, who had severe cognitive impairment, cervical spinal cord injury, Parkinson’s disease, dementia, neurogenic bowel, and neuromuscular bladder dysfunction, was care planned to have his call light within reach and to use it to request assistance. A grievance reported that his call light was being switched with a dummy one that did not work. An internal document dated 02/05/26 shows the Administrator learned on 02/02/26 of grievances about a fake call light and that staff had heard of dummy call lights but were unsure who was responsible. The Administrator interviewed Resident #1 and his roommate, who reported delays in call light response and identified a CNA as unplugging call lights. The Administrator later found Resident #1’s call light tangled in his wheelchair and pulled from the wall. Other staff, including the HR Director and another CNA, reported previously finding two call lights on Resident #1’s side of the room, with one plugged in and one coiled on the floor or in the resident’s hand, and turned the extra light in to nursing/HR without further action being taken at that time. Resident #3, who had intact cognition and a history of falls, was also care planned to have her call light within reach and to use it for assistance. A grievance reported that a night-shift CNA had put her call light out of reach and placed another, unplugged call light in her room as a dummy light, and that the same CNA had done this to two other residents. Resident #4, who had dementia, repeated falls, and was care planned to have her call light within reach and to be redirected to use it instead of calling out, was similarly named in a grievance alleging her call light was possibly being switched with a dummy one during shifts worked by the same CNA. Despite these specific allegations and identification of involved staff, the Administrator and DON did not immediately suspend the named CNAs when they became aware of the allegations on or about 02/02/26–02/03/26, and one CNA continued to work on the affected hall and care for the involved residents. The facility also failed to prevent verbal abuse of Resident #2 after an allegation of neglect involving call lights had already been reported. Resident #2, who had intact cognition and was the roommate of Resident #1, reported that a CNA moved Resident #1’s call light out of reach and that he had repeatedly reported this to the ADON, Administrator, and HR Director. He later reported an incident in which, after he demanded that the CNA get his roommate up, he used profanity toward the CNA and the CNA responded by telling him to "shut the [F-word] up" and to mind his business. The facility’s Provider Investigation Report documented Resident #2’s account that he was offended by the CNA’s language. Although the DON left a voicemail for Resident #1’s family member stating that one CNA was off the schedule and the other would be suspended as of that day, video and time records show that the CNA identified in both the call light allegations and the verbal abuse allegation continued to work that day and was not suspended until later that evening for the verbal abuse incident. The DON later acknowledged to the family member that she "dropped the ball" and that the identified CNAs should have been suspended when the allegations were known, and the Administrator acknowledged that the allegations could constitute neglect or seclusion and that the two aides should have been suspended immediately but were not.
Failure to Protect Residents From Call Light Tampering and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect several residents from abuse and neglect by ensuring access to functioning call lights and freedom from verbal abuse. Multiple residents with significant physical and cognitive impairments were care planned to have call lights within reach and to use them to request assistance, yet staff allegedly removed or disabled this means of communication. One male resident with severe cognitive impairment, cervical spinal cord injury, Parkinson’s disease, dementia, neurogenic bowel, and bladder dysfunction was dependent on staff for most ADLs and incontinent of bowel and bladder. His care plan required that his call light be kept within reach and that he be encouraged to use it. A grievance reported that a CNA had been switching out this resident’s working call light with a dummy call light that did not function, particularly on evening and weekend shifts. The Administrator later found this resident’s call light tangled in his wheelchair and unplugged from the wall, and the HR Director and another CNA each separately reported previously finding two call lights on his side of the room, with one plugged in and the other coiled on the floor or in the resident’s hand but not plugged in. Two additional female residents with dementia, fall risk, incontinence, and varying levels of assistance needs were also implicated in the dummy call light allegations. One resident with intact cognition, diabetes, dysphagia, and a history of falls was care planned to have her call light within reach and to use it for assistance. A grievance stated that a night-shift CNA had placed this resident’s working call light out of reach and provided another call light that was not plugged in as a dummy. An LVN reported that a day-shift aide relayed this resident’s statement that the night aide had done this and that the aide had done the same to two other residents. Another resident with dementia, a displaced femur fracture, major depressive disorder, repeated falls, and total incontinence was care planned both for falls and for redirection to use the call light instead of calling out loudly. A grievance reported concern that a CNA had possibly been switching this resident’s call light with a dummy one that did not work, believed to occur on evening and weekend shifts. The Social Worker stated she was told that an aide was moving the good light out of reach and using an extra one for three residents. The facility also failed to protect a cognitively intact male resident from verbal abuse by staff. This resident, who shared a room with the dependent male resident described above, reported that when he instructed a CNA to get his roommate up immediately, the CNA delayed and he began using profanity toward her. He stated that the CNA responded by telling him to “shut the [F-word] up and mind your business,” and he reported feeling offended by her cursing. A nurse reported overhearing the resident yelling and using profanity but did not hear the CNA yell or curse. This same resident also reported that the CNA had been moving his roommate’s call light out of reach and plugging in a fake call light, and he stated that he had been returning the working call light to his roommate for at least a month. Facility leadership, including the DON and Administrator, acknowledged being informed of allegations that two CNAs were involved in using extra or dummy call lights and that such conduct could constitute neglect or seclusion, but the residents continued to experience delayed responses to call lights and ongoing concerns about call light access and staff behavior. Family and staff interviews further described the pattern of inaction and inconsistent response to the abuse and neglect allegations. The family member of the dependent male resident reported that she had been told by several people that two CNAs were taking residents’ call lights away and giving them non-functioning call lights, and she described finding her family member without water and with saturated sheets on multiple visits. She reported the call light issue to the DON, who later left a voicemail stating that both implicated CNAs were being taken off the schedule, but the family member subsequently observed one of the CNAs working on the unit and caring for the same resident. In recorded conversations, the DON admitted she “dropped the ball,” acknowledged that the family had reported specific rooms and staff names, and stated that she believed the situation could be neglect or seclusion because the dependent resident’s means of communication had been taken away. The Administrator acknowledged receiving grievances about fake call lights, being told the names of the two CNAs, and understanding that the allegations could constitute neglect or seclusion, yet also stated that the aides were not immediately suspended and that the issue was not reported to the state agency. These actions and inactions resulted in residents not being consistently provided with functioning, accessible call lights and one resident being subjected to alleged verbal abuse by a CNA. Additional staff accounts corroborated the presence of extra call lights and concerns about delayed responses. The HR Director described finding two call lights on the dependent male resident’s side of the room in late December, with one plugged in and draped between the bed and bedside table and another coiled on the floor and not plugged in, which she took to the ADON without notifying the Administrator. A CNA who routinely cared for this resident reported finding an extra, unplugged call light in his hand while the working call light was plugged in and draped over his bedside drawers; she believed the extra light had been given because the resident used his call light frequently and staff did not want him to call. Another resident reported that his roommate became upset and hollered when he did not have his call light and that he himself would return the call light to his roommate when it had been moved. The DON and Administrator each stated that the allegations of dummy call lights and the identified staff should have been treated as potential neglect or seclusion and reported, but acknowledged that this did not occur and that one of the implicated CNAs continued to work on the affected hall after the allegations were known.
Failure to Timely Report Alleged Neglect Involving Dummy Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report allegations of neglect related to the use of non-functioning or inaccessible call lights, and to report these allegations to the state agency within required timeframes. On 02/02/26, the Social Worker received grievances from a CNA alleging that another CNA had been switching out working call light cords/buttons with dummy ones that did not work for three residents. These grievances identified that the alleged conduct occurred on evening/weekend shifts and involved residents who were care planned to have call lights within reach and to use them to request assistance. The Administrator acknowledged receiving grievances about fake call lights on 02/02/26 and understood that residents were being given call lights that did not function or were pulled from the wall. Resident #1 was an older male with cervical disc disorder with myelopathy, Parkinson’s disease, dementia, cervical spinal cord injury, neurogenic bowel, and neuromuscular bladder dysfunction. He had severe cognitive impairment, significant functional limitations in all extremities, was dependent or required substantial assistance for most ADLs, and was always incontinent of bowel and bladder. His care plan for falls required that his call light be placed within reach and that he be encouraged to use it for assistance. Multiple staff and a family member reported or described situations in which his call light was out of reach, unplugged, or replaced with an extra call light. The HR Director and a CNA each described finding two call lights on his side of the room, with one plugged in and draped over furniture and another coiled on the floor or in his hand and not plugged in. His roommate reported that a CNA moved his call light out of reach and that he had to return it to him, and that this had been ongoing for at least a month. Resident #3, an older female with type 2 diabetes, dementia, a thoracic vertebral compression fracture, and dysphagia, had intact cognition and required supervision or assistance with transfers, toileting, and bathing. Her falls care plan included education on use of the call light and placement of the call light within reach. A grievance documented that a CNA reported Resident #3 stated that a night aide had put her call light out of reach and placed another light in her room that was not plugged in as a dummy light. Resident #4, an older female with a displaced right femur fracture, major depressive disorder, dementia, and repeated falls, had moderate cognitive impairment and required substantial assistance with transfers and ADLs. Her care plan noted that she would call out loudly instead of using the call light and directed staff to redirect her to use the call light, with interventions to keep the call light within reach. A grievance documented that a CNA reported concerns that another CNA had possibly been switching out Resident #4’s call light with a dummy one that did not work. Despite these allegations, the facility did not treat them as reportable abuse/neglect events and did not report them to the state agency within the required 24-hour timeframe. The Social Worker stated she informed the Administrator on 02/02/26 of allegations that an aide was moving working call lights out of reach and using extra dummy call lights for three identified residents. The DON stated she became aware of someone doing this with call lights during a clinical meeting on 02/03/26 and that she informed the Administrator that day, and she acknowledged that this could be considered neglect or seclusion and should have been reported to the state. The Administrator confirmed she received a grievance about fake call lights on 02/02/26, learned the names of the two potentially involved CNAs by 02/03/26, and acknowledged that the situation could be considered neglect or seclusion and should have been reported to the state, but it was not. The facility’s handling of the grievances as internal complaints without timely reporting to HHSC constituted the failure to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, or within 24 hours when not involving abuse or serious bodily injury, to the administrator and appropriate state officials. Additional interviews and observations further supported that the facility had information suggesting possible misuse of call lights but did not initiate required external reporting. The HR Director described finding two call lights on Resident #1’s side of the room in late December, with one unplugged on the floor, and she took the unplugged light to the ADON but did not notify the Administrator. Another CNA reported finding an extra call light in Resident #1’s hand that was not plugged in while his regular call light was plugged into the wall and draped over his bedside drawers, and she reported this to the DON and gave the extra light to the HR Director. A family member of Resident #1 reported to the DON and Administrator that she had been told by several people that two CNAs were unplugging his call light and giving him a fake one, and she provided recordings showing that the DON and Administrator were aware of these allegations. The Administrator later acknowledged that the two identified aides should have been suspended immediately and that the failure to do so and the failure to report the allegations to HHSC put residents at risk for further neglect, seclusion, and mistreatment.
Improper Manual Transfer Performed Instead of Required Mechanical Lift and Two-Person Assist
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance devices during transfers. Resident #1, a male with cervical disc disorder with myelopathy, Parkinson’s disease, dementia, cervical spinal cord injury, neurogenic bowel, and neuromuscular bladder dysfunction, had severe cognitive impairment with a BIMS score of 03 and functional limitations in all four extremities. His MDS and care plan documented that he was dependent for transfers and required a total/mechanical lift with two-person assistance for chair/bed and tub/shower transfers. The Kardex also reflected that he required total assist with a mechanical lift and two staff for transfers. On 02/10/26, Resident #1 experienced a fall during a transfer when CNA DD attempted to manually transfer him from his wheelchair to his bed without using the required mechanical lift and without a second staff member. The incident form documented that CNA DD reported his grip was slipping during the manual transfer, so he lowered the resident to the floor and then sought help. The post-fall evaluation and CNA DD’s statement indicated that he did not check the Kardex prior to providing care and that he attempted a manual transfer because the resident did not have a mechanical lift pad under him. The DON later stated that it was possible to place a sling on someone while in the wheelchair, and that CNA DD acknowledged he had not checked the Kardex. Interviews corroborated that the mechanical lift and two-person assist were the usual and expected method for transferring Resident #1 and that this was not followed during the incident. Resident #1 reported that the CNA initially said something was wrong with the mechanical lift, did not explain what was wrong, and then tried to lift him by hand, ultimately dropping him to the floor. Resident #2, the roommate, stated he heard a loud noise, a scream, and then heard the CNA call for help, and confirmed that typically a mechanical lift was used for Resident #1’s transfers and that the lifts were working at the time. RN O stated that CNA DD told her, “I dropped him,” and confirmed that Resident #1 was normally a mechanical lift transfer and that the CNA did not use the lift. A family member’s video-recorded conversation with a nurse further reflected that the nurse acknowledged the CNA should have had two people and that a mechanical lift was available at the time of the transfer. The facility’s mechanical lift policy, last revised 09/08/23, stated that the purpose of the lift was to move immobile patients for whom manual transfer poses potential for resident injury and noted that, although one person can operate most models, it is advisable to have two staff members present to stabilize and support the resident. Despite this, CNA DD attempted a manual, one-person transfer of Resident #1 without the mechanical lift and without a second staff member, contrary to the resident’s care plan, Kardex instructions, and the facility’s policy. This sequence of actions and inactions led to Resident #1 being lowered to and found on the floor next to his bed, constituting the accident event underlying the cited deficiency.
Failure to Revise Care Plan for Resident with Exploitation History and Changing Needs
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of exploitation, cognitive impairment, and multiple medical conditions, including dementia, diabetes, and COPD. Despite documentation on the resident's face sheet indicating that only a specific family member with power of attorney was authorized to take the resident out of the facility, the care plan did not address the resident's history of exploitation, potential for elopement, or include interventions to reduce the risk of future exploitation. There were also no instructions regarding visitor restrictions or interventions to address concerns of elopement, and the resident's mental health needs and feelings about his restrictions were not included in the care plan. The care plan contained a discharge plan with a goal for the resident to return to the community, which was not updated or revised to reflect the family's clear communication that the resident's placement was intended to be permanent. Multiple quarterly and comprehensive MDS assessments were completed, but the care plan was not updated following these assessments to reflect the resident's current needs or changes in discharge planning. Progress notes documented incidents where unauthorized individuals attempted to remove the resident from the facility, and the family member reiterated the need for strict visitor and outing restrictions due to the resident's vulnerability and history of exploitation. Interviews with facility staff, including the BOM, LVNs, SW, Administrator, DON, and MDS Coordinator, revealed a lack of awareness regarding the resident's history of exploitation, visitor restrictions, and discharge plans. Staff were either unaware of where such information would be documented or unfamiliar with the resident's specific needs. The facility's policy required comprehensive, person-centered care plans to be reviewed and revised after each MDS assessment, but this was not followed in the resident's case, resulting in the failure to address and communicate critical safety, mental health, and nursing needs.
Failure to Administer and Document Ordered Eye Drops
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with multiple diagnoses, including dry eye syndrome, anxiety, dementia, and quadriplegia. The resident was ordered to receive 0.5% Carboxymethylcellulose Ophthalmic Solution in both eyes at bedtime, but three scheduled doses were not administered as documented in the Medication Administration Record (MAR). There was no documentation in the progress notes or risk management reports explaining the missed doses, and no Medication Error Reports were completed for these omissions. Interviews revealed that medication aides did not use all available resources to obtain the eye drops, despite the medication being available in other medication carts and the medication room. The aides failed to notify the appropriate nursing staff or document the reasons for the missed doses, as required by facility policy. The resident reported not receiving the eye drops for several days and experienced mild irritation and burning in her eyes as a result. The Director of Nursing confirmed that the missed doses were not properly documented and that the process for obtaining over-the-counter medications was not followed.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these fundamental rights were upheld for the resident, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations related to the resident's experience.
Sanitation Deficiency in Kitchen Due to Inadequate Water Temperature
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, specifically in the dishwashing process. During an observation, the Dishwasher was not wearing a hairnet while working in the kitchen, which is a breach of sanitary protocols. Additionally, the Dishwasher was observed running dishes through the dish machine while the temperature gauge indicated the water was at 106 F, below the required 120 F for proper sanitization. This discrepancy in water temperature was acknowledged by the Dishwasher, who stated that the dishes appeared clean and did not need to be rewashed, despite the posted requirement for a higher temperature. The issue of insufficient hot water was linked to the simultaneous use of laundry machines, which depleted the hot water reserves needed for dishwashing. The facility had previously identified this problem in January 2025, and repairs were made to the water heater. However, the Dishwasher and other staff members indicated that the problem persisted, as the laundry machines consumed a significant amount of hot water, leaving insufficient reserves for the kitchen. Despite the Maintenance Supervisor's belief that the issue had been resolved, the Dishwasher's actions demonstrated ongoing challenges with maintaining the required water temperature for dish sanitization.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed of their right to file grievances, as evidenced by interviews and record reviews. During a review of resident council meeting minutes from the past four months, it was revealed that a grievance form had not been explained to the residents, nor were they informed of how to use the form. Eight confidential interviewees confirmed that they did not know how to file a grievance, and the Assistant Director (AD) admitted to never reviewing or explaining the grievance form to the residents. Furthermore, the AD was unable to locate grievance forms at the nurses' station and acknowledged that residents were not informed of their location. The Administrator also confirmed that residents could express concerns to any staff member, who would then document it on a grievance form. However, the Administrator had not reviewed or explained the grievance form to the residents, nor had she informed them of their right to complete a grievance form independently or where the forms were located. The facility's grievance policy, revised in 2016, states that residents and their families have the right to file grievances orally or in writing, and that residents should be made aware of this right through individual communication or postings throughout the facility. This lack of communication and failure to inform residents of their rights and the grievance process constitutes a deficiency in the facility's operations.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, specifically in the coding of the Preadmission Screening and Resident Review (PASRR) on their Minimum Data Set (MDS) assessments. Resident #3, who was admitted with diagnoses including bipolar disorder and major depressive disorder, had a PASRR Form 1012 indicating a primary diagnosis of dementia, which would not qualify her for specialized services. However, her MDS assessment inaccurately indicated that she was not considered by the state level II PASRR process to have a serious mental illness. During an interview, the MDS RN acknowledged that a PASRR Level 1 screening was not completed for Resident #3, and the form was filled out based on her primary diagnosis of dementia. Similarly, Resident #41, admitted with bipolar disorder and schizophrenia, had a PASRR Level 1 screening and evaluation indicating a positive result for mental illness, but she did not meet the PASRR definition for specialized services. Her MDS assessment incorrectly indicated that she was not considered to have a serious mental illness. The MDS RN admitted to not realizing the connection between Section I Active Diagnoses and Section A PASRR screening documentation, leading to the incorrect coding. The RN was under the impression that if residents did not qualify for PASRR services, they should be marked as negative, despite having a positive diagnosis for mental illness.
Failure to Document Hemodialysis Orders in EHR
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who was reviewed for medical records accuracy. The deficiency involved the absence of physician's orders for hemodialysis treatment for a resident with End Stage Renal Disease, among other diagnoses. Despite the resident being scheduled for hemodialysis three times a week, the orders were not documented in the Electronic Health Record (EHR) following her readmission to the facility from the hospital. The resident, who was cognitively intact, had been receiving hemodialysis for seven years and was scheduled for treatment on specific days each week. During an observation, the resident expressed satisfaction with her care and confirmed her dialysis schedule. However, a review of her physician's active orders revealed that the necessary orders for hemodialysis were missing, although her care plans indicated the need for dialysis three times a week. Interviews with facility staff, including an LVN and the Assistant Directors of Nursing (ADONs), revealed that the responsibility for entering and reviewing physician orders into the EHR fell on the ADONs. It was noted that the dialysis orders were not re-entered into the EHR upon the resident's readmission, which was a lapse in the facility's procedure for maintaining accurate and complete electronic clinical records. The facility's policies on maintaining electronic clinical records and following physician orders were reviewed, highlighting the requirement for accurate documentation to ensure appropriate care delivery.
Infection Control Lapses in Insulin Administration and Feeding Tube Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not cleanse the injection site before administering an insulin injection to a resident with Type II Diabetes Mellitus. The resident, who had an intact cognition, was receiving insulin injections as part of her treatment plan. The LVN admitted to forgetting to cleanse the site and acknowledged the importance of this step in reducing infection risk. The facility's policy clearly stated that the skin at the injection site should be cleaned with a sterile alcohol swab before injection. In the second incident, another LVN failed to don appropriate personal protective equipment (PPE) while administering medications via a feeding tube to a resident with severe cognitive impairment and a PEG tube. Despite the presence of Enhanced Barrier Precautions (EBP) signs indicating the need for gown and gloves during high-contact activities, the LVN only wore gloves. Additionally, the LVN used a syringe that had fallen to the floor without changing gloves or obtaining a new syringe, potentially contaminating the feeding tube. The LVN later acknowledged the oversight and the potential for spreading infection. The facility's Infection Preventionist confirmed that the nurses did not adhere to the facility's infection control policies, which are designed to prevent the transmission of communicable diseases. The Infection Preventionist emphasized the importance of following these protocols, including cleansing injection sites and using appropriate PPE during high-contact activities. The facility's policy on infection prevention and control aims to provide a safe and sanitary environment, but these lapses in protocol could compromise resident safety.
Failure to Prevent Resident Abuse in Dining Room Altercation
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse. Resident #1, a male with moderately impaired cognition, was involved in an altercation with Resident #2, who also had moderately impaired cognition. The incident occurred when Resident #1 attempted to access the coffee pot in the dining room, and Resident #2 was blocking the way. A verbal altercation ensued, during which Resident #1 threatened Resident #2, and Resident #2 responded by hitting Resident #1 on the back of the neck. Resident #1's medical history includes metabolic encephalopathy and myocardial infarction, while Resident #2 has hemiplegia and major depressive disorder. Both residents were assessed after the incident, and no injuries were found. The altercation was witnessed by the Activity Director (AD), who intervened and separated the residents. Despite the intervention, Resident #2 hit Resident #1 after the initial separation. The facility's investigation confirmed that both residents contributed to the altercation. The incident was reported to the Health and Human Services Commission (HHSC), and the facility's abuse policy was reviewed. The facility's response included separating the residents and assessing them for injuries, but the report highlights the failure to prevent the abuse from occurring in the first place.
Failure to Follow Up on Specialist Referrals
Penalty
Summary
The facility failed to ensure that a resident received care and services in accordance with professional standards of practice. Specifically, the facility did not follow up with necessary referrals to a cardiologist and neurologist for a resident who was admitted with multiple health conditions, including chronic kidney disease, hypothyroidism, Type 2 diabetes, and hypertension. The resident had been discharged from the hospital with instructions for follow-up appointments with these specialists due to stroke-like symptoms and other health concerns, but no referrals were made during the resident's stay at the facility. Interviews with the Director of Nursing (DON) and Assistant Directors of Nursing (ADONs) revealed that the responsibility for ensuring referrals were made fell on the nurse managers. However, the transportation driver, who was supposed to set up appointments, was no longer employed, and the transportation book was missing. The DON and ADONs could not confirm if any referrals were made, and the information was not documented in the resident's chart. This oversight could have resulted from a misunderstanding of the hospital's discharge instructions or a lapse in the facility's internal processes for managing referrals.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 39 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Athens | 1.7 mi | ★★★★★ | 9 | 0 |
| Park Highlands Nursing & Rehabilitation Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Cedar Lake Nursing Home | 10.5 mi | ★★★★★ | 6 | 0 |
| Chandler Nursing Center | 22.4 mi | ★★★★★ | 7 | 0 |
| Mabank Nursing Center | 22.5 mi | ★★★★★ | 15 | 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.