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 Avir At Carthage during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, paralytic syndrome, traumatic brain injury, and hypothyroidism had a care plan intervention to monitor thyroid function tests per MD order, with a TSH lab ordered every six months. The last TSH was drawn in March, and no further TSH results were documented, meaning the ordered lab due six months later was missed. The DON acknowledged the lab was not obtained and attributed the failure to a change in lab services and incorrect transcription of the order, while facility policy required establishment and implementation of care and services to support each resident’s highest practicable quality of life.
Kitchen Stove Burners Not Functioning Properly: Multiple burners on the gas stove did not light during separate observations, including the left front burner and other burners on the stove. The DM, Maintenance Director, and Administrator each described staff responsibility for reporting and repairing the issue, and the Maintenance Director stated dietary staff had not notified him that the burners were not lighting. The facility policy required all equipment to be kept in operable condition and in good working order.
Call Light Not Kept Within Reach: A resident with severe cognitive impairment, hemiplegia, weakness, visual impairment, and dependence for ADLs had a call light that was repeatedly observed out of reach. The resident stated he could use the call light if it were reachable, but he could not reach it from the nightstand and wanted it on his bed. CNA, LVN, DON, and ADM interviews confirmed staff were responsible for keeping the call light within reach, and the facility policy required it to be within easy reach when the resident was in bed.
A resident with schizophrenia and autistic disorder was care planned to wear a roam alert bracelet for elopement risk, with placement checked every shift and function checked daily. However, the quarterly MDS did not code the wander/elopement alarm even though staff observed the resident wearing the bracelet and confirmed it was monitored and used routinely. The MDS Nurse and leadership acknowledged the omission as an inaccurate MDS.
Failure to Maintain Nail Hygiene: A resident with severe cognitive impairment, diabetes, and right-sided hemiplegia was dependent on staff for ADLs, including personal hygiene. Staff documentation indicated nail care was completed, but repeated observations showed long fingernails and black debris under the nails, including on a contracted hand with nails pressing into the palm. The RP raised concerns about hygiene, and staff described nail care responsibilities and occasional refusal, but the resident’s nails remained untrimmed and uncleaned during survey observations.
Inadequate supervision during a mechanical lift transfer. A resident with severe cognitive impairment, right-sided flaccid hemiplegia, and dependence for transfers required a mechanical lift with two staff members. During the transfer, one CNA lifted the resident while the second CNA stood across the room holding the Geri-chair instead of staying with the resident throughout the move. Both CNAs later stated the second person should have remained next to the resident during the full transfer, and the DON and ADM confirmed that two staff members were expected to stay with the resident during the entire process.
A resident with COPD ordered continuous oxygen at 4 LPM was observed with an empty oxygen tank while wearing a nasal cannula. Staff later found the tank still empty, had trouble getting a replacement regulator to work, and had to place the resident on his concentrator. The nurse said she was responsible for checking that the resident’s oxygen tank had oxygen and that he was receiving oxygen as ordered, but she had not checked the tank earlier because he was using his concentrator.
Medication Left Unsecured at Bedside: A resident with moderate cognitive impairment and diagnoses including muscle weakness, ataxia, and asthma had a medication cup containing white powder left on the bedside table. The powder was identified as nystatin used for a yeast rash under the breast. Staff interviews confirmed the medication should have been stored on the med cart or in the med room, and the resident was not approved to keep medication at bedside.
Failure to follow EBP during peri care for a resident with klebsiella pneumoniae, MRSA history, a wound, and a feeding tube. CNA G and CNA M provided peri care without gowns even though the resident’s care plan and order summary indicated EBP, and staff interviews showed confusion about whether the resident was still on EBP and that PPE was not set up outside the room. The DON stated staff were expected to follow the MD order and use the door signage, orange sticker, and PPE placement as indicators.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental hazards and insufficient staff monitoring.
The facility failed to maintain RN coverage for at least 8 consecutive hours daily, as required, on multiple occasions in early 2024. Despite hiring two RNs for weekend coverage, one RN was unable to work due to personal issues, leading to gaps in coverage. This deficiency was confirmed through staffing reports and interviews with facility staff.
The facility failed to ensure accurate MDS assessments for two residents, leading to unrecorded falls, incorrect medication coding, and missing dementia diagnosis. These inaccuracies could impact care plans and safety measures. Staff interviews revealed a lack of oversight and potential for human error in completing assessments.
The facility failed to develop comprehensive care plans for three residents, omitting critical medical and psychosocial needs such as hearing impairments, vision issues, and medication management. Observations and interviews with staff highlighted the lack of individualized care planning, potentially impacting residents' well-being.
The facility failed to maintain proper food service safety standards, with issues including a malfunctioning ice machine causing a trip hazard, significant carbon buildup on the kitchen stove, and improper labeling and storage of food in a resident's refrigerator. Staff interviews revealed confusion over responsibilities for cleaning and maintaining resident refrigerators, and the facility's policies on kitchen sanitation and personal refrigerators were not consistently followed.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in PPE use and hand hygiene. Staff did not wear N95 masks or change masks between rooms when dealing with COVID-19 positive residents. Additionally, proper hand hygiene and glove-changing practices were not followed during incontinent care, increasing the risk of cross-contamination.
The facility failed to ensure call lights were within reach for two residents, potentially placing them at risk for unmet needs. One resident with hemiplegia had her call lights on the floor, while another with a history of falls was unable to locate her call light. Staff interviews revealed a lack of adherence to the facility's policy requiring call lights to be within easy reach.
A facility failed to submit a resident's MDS discharge assessment within the required 14 days after completion. The resident, an 85-year-old female with a non-ST elevation myocardial infarction, was discharged home, but her MDS assessment was not submitted on time. The MDS Coordinator was responsible for this task, and the corporate MDS Coordinator was expected to monitor submissions. Despite the facility's policy and CMS guidelines, the submission was missed, and the MDS Coordinator was unaware of how this occurred.
A facility failed to ensure an RN signed and certified the MDS assessment for a resident discharged with a myocardial infarction diagnosis. The MDS Coordinator was responsible for notifying the RN, but the DON was still learning the requirements. The Administrator expected timely signatures for service payments. Facility policy and the MDS 3.0 RAI Manual require RN certification of assessment completion.
A resident on antidiabetic medication did not receive the required daily blood sugar checks, as their care plan did not reflect the need for such monitoring. Interviews with staff revealed a lack of adherence to monitoring protocols, and the facility's policy on diabetes management was not followed, leading to a deficiency in care.
Two residents in an LTC facility did not receive appropriate incontinence care, leading to potential risks of UTIs and skin breakdown. One resident was found excessively wet, and another did not receive complete perineal care, leaving feces in the perineal area. Staff interviews revealed inconsistencies in adhering to care standards, placing residents at risk for infections and skin issues.
A CNA failed to report a change in a resident's urine color, delaying physician notification and treatment. The resident, with a history of chronic UTIs, was found with pink-tinged urine during care. Despite training on reporting changes, the CNA did not inform the LVN immediately, highlighting a lapse in competency.
A facility failed to document the administration of a controlled substance for a resident with a history of seizures. The medication aide did not sign the narcotic drug record for the last dose of lacosamide, despite administering it. Interviews confirmed the oversight, and the facility's policy requires proper documentation of controlled substances.
A resident received Minocycline and Acidophilus without proper indications and for excessive durations. The resident was prescribed Minocycline prophylactically without a confirmed infection and continued to receive it beyond the necessary duration. Acidophilus was also administered without a stop date. Facility staff failed to follow up with the prescribing physician to confirm the necessity of these medications, contrary to the facility's antibiotic stewardship policy.
The facility failed to store wound cleansers in locked compartments, as required by regulations. Observations revealed that wound cleansers for two residents were improperly stored in their rooms. Interviews with staff, including the ADON, indicated a lack of awareness regarding the facility's storage policy. The DON and ADM confirmed that wound care supplies should be securely stored to prevent unauthorized access and potential harm.
A resident with a history of stroke and seizure disorder was found unresponsive in the dining room. Despite being a full code, facility staff did not initiate CPR until EMS arrived 12 minutes later. The resident was later pronounced deceased at the hospital, with solid food found in his airway. Staff confusion and inexperience contributed to the delay in providing life-saving measures.
Two residents were verbally and physically abused by an LVN, who used foul language and threw objects at them. One resident with severe cognitive impairment was subjected to verbal abuse and had ice thrown at him, while another resident with schizoaffective disorder was verbally abused and had a note thrown at him. The facility failed to prevent these incidents, placing residents at risk for emotional distress and further abuse.
The facility failed to implement its abuse prevention policies, resulting in two residents being subjected to inappropriate behavior by an LVN. The LVN used foul language and threw objects at the residents, and staff failed to report these incidents immediately as required by policy.
A facility failed to report an alleged abuse incident involving a resident and an LVN within the required 24-hour timeframe. The LVN used inappropriate language and behavior towards the resident, who had a history of mental health conditions and cognitive impairment. The incident was reported internally but not to the state agency as required, placing residents at risk for continued abuse.
Failure to Implement Care Plan Interventions for Thyroid Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with hypothyroidism and severe cognitive impairment. The resident, an older male with diagnoses including paralytic syndrome, traumatic brain injury, and hypothyroidism, required dependent assistance with all ADLs and had a BIMS score of 03, indicating severe cognitive impairment. His comprehensive care plan, dated 06/12/2025, identified hypothyroidism and included an intervention to monitor thyroid function tests per MD order and notify the MD of abnormal lab values. Physician orders dated 09/21/2024 required a TSH lab to be drawn every six months, and the last documented TSH result in the EHR was from 03/17/2025. No subsequent TSH labs were documented after that date, meaning the ordered lab due in September 2025 was not obtained. During interview, the DON acknowledged that the resident should have had a TSH drawn in September 2025 and that it had not been done, attributing the lapse to a change in lab services and incorrect transcription of the order. The Administrator stated her expectation that all care plan interventions be followed and acknowledged that not following the care plan could lead to lack of individualized care. The facility’s policy on comprehensive care planning stated that the facility will establish, document, and implement care and services to assist each resident in attaining or maintaining their highest practicable quality of life.
Kitchen Stove Burners Not Functioning Properly
Penalty
Summary
The facility failed to maintain the kitchen gas stove in safe operating condition when multiple burners did not light during separate observations. On 09/15/25, three of ten burners did not light when turned on, including the left front burner, the back stove second burner to the left, and the far right burner, and no gas smell was noted. On 09/16/25, two of ten burners did not light, including the left front burner and the back middle burner, and no gas smell was noted. The staff member responsible for the kitchen said she had been educated to notify the DM and Maintenance Director if the burners did not light, and she stated the burners lit that morning. During interview, the DM said the cooks were responsible for notifying her and the Maintenance Director if the burners did not light, and she was responsible for notifying the Maintenance Director if the stove burners did not light. The Maintenance Director said dietary staff were responsible for notifying him if the burners did not light, and if he could not fix the stove, a technician would be called. He stated the dietary staff did not notify him that the burners did not light. The Administrator said the cooks or Dietary Manager were responsible for notifying the Maintenance Director, and she was ultimately responsible for ensuring the stove and all kitchen equipment were working properly. Record review of the facility maintenance policy stated that all equipment, building, spaces, and fixtures are to be kept in operable condition and properly maintained in good working order.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #34 had a call light within reach. Resident #34 was a [AGE]-year-old male admitted to the facility with diagnoses including paralytic syndrome, hemiplegia, weakness, muscle wasting atrophy, alternating exotropia, and age-related nuclear cataract. His MDS reflected that he was sometimes understood and sometimes understood others, had a BIMS score of 3 indicating severe impaired cognition, and required substantial or maximal assistance with all ADLs. His care plan identified him as at risk for falls related to lack of coordination and visual impairment, with interventions to keep the call light within reach and orient him to objects in the room. Observations showed Resident #34's call light was not within reach multiple times, including on 9/15/25 at 11:00 A.M., 1:33 P.M., and 2:53 P.M., and on 9/17/25 at 7:45 A.M. and 8:51 A.M. During interview, the resident stated he could push the button if the call light was in reach, but he could not reach it from his nightstand and felt it should be on his bed. CNA K, LVN L, the DON, and the ADM all stated the call light should be within reach and that staff were responsible for ensuring it was accessible. The facility's policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Inaccurate MDS Coding for Wander Bracelet Use
Penalty
Summary
The facility failed to ensure Resident #40’s assessment accurately reflected her status by not coding her wander/elopement alarm use on the quarterly MDS assessment. Resident #40 was a [AGE]-year-old female admitted and readmitted to the facility with diagnoses including schizophrenia and autistic disorder. Her care plan, initiated on 06/13/25, identified her as at risk for elopement and directed that she wear a roam alert bracelet at all times, with the device checked daily for function and placement verified every shift. Record review showed the 08/09/25 quarterly MDS did not mark Resident #40 for wander/elopement alarm use during the assessment period. At the same time, the MAR dated 09/16/25 documented that her wander bracelet was assessed every shift for placement and daily for function. During observation on 09/15/25, Resident #40 was seen sitting in her wheelchair wearing a wander bracelet on her left wrist, and she stated she wore a special bracelet all the time and staff checked it every day. During interviews, the LVN, MDS Nurse, Regional Reimbursement Coordinator, DON, and Administrator all confirmed that Resident #40 wore a wander bracelet and that it was monitored and care planned. The MDS Nurse stated the bracelet should have been marked on the MDS and was overlooked, and the Regional Reimbursement Coordinator, DON, and Administrator each described the omission as an inaccurate MDS and human error. The facility’s reference to the RAI User’s Manual stated that wander/elopement alarms, including bracelets worn by the resident, should be coded in P0200E when used during the look-back period.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for one resident who was unable to perform ADLs independently. Resident #2 had diagnoses including heart failure, diabetes, lack of coordination, flaccid hemiplegia on the right side, and cerebral infarction. The quarterly MDS indicated severe cognitive impairment with a BIMS score of 6, and the resident was dependent on staff for most ADLs, including personal hygiene. The care plan documented nail care tasks in POCareAssist on a scheduled basis. During observation, Resident #2 was seen sitting in the dining area with long fingernails on both hands and a black substance under the fingernails of the left hand. The resident’s right hand was contracted with the nails pressing into the palm area, though the skin was not broken. These same conditions were observed again on later dates, including while the resident was waiting to go smoke and while seated in the dining room. The resident stated he did not mind his nails being long, did not know what was black under his nails, and said staff cleaned under his fingernails and trimmed them sometimes. Record review showed CNA documentation indicating nail care had been performed, but the observations showed the nails remained long and dirty. The resident’s RP stated concerns about hygiene, including clipping and cleaning dirty nails and bathing. CNA A stated nail care included cutting, cleaning under the nails, and handwashing, but also said she did not cut the resident’s nails and that the resident sometimes refused care. The DON stated CNAs were responsible for nail care and nurses were to follow up, and the ADM stated she would expect staff to ensure fingernails were trimmed and cleaned if the resident allowed.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision during a mechanical lift transfer for a resident who was readmitted with chronic diastolic heart failure, cerebral infarction, flaccid hemiplegia affecting the right dominant side, hyperlipidemia, type II diabetes, schizophrenia, and morbid obesity. The resident’s MDS indicated a BIMS score of 6, wheelchair use, dependence for toileting hygiene, bathing, dressing, personal hygiene, and transfers. The care plan identified impaired physical mobility related to paralysis and contractures to the right extremities and directed that the resident required a mechanical lift for transfers from chair to bed, with two people assisting to prevent injury. During observation, one CNA wheeled the mechanical lift into the resident’s room, secured the sling, and used the remote to lift the resident while the second CNA stood across the room holding the Geri-chair in place. The first CNA then spread the lift legs and lowered the resident into the chair. The second CNA later stated she was supposed to stand behind the resident once he was secured in the lift, but she was not standing behind him during the transfer and was instead behind the Geri-chair. She said she should have been right with the other CNA and the resident and acknowledged that both CNAs were responsible during the transfer. The first CNA stated the transfer went well until she spoke with the other CNA and said she should have remained with the resident until he was moved across the room into the Geri-chair. She acknowledged the resident could have fallen out of the sling and that she could have assisted if there was an issue. The LVN and DON both stated that the second person should remain with the resident during the full transfer, and the ADM said the two-person transfer should be next to the resident during the transfer. The facility policy required two staff members for mechanical lift transfers and stated staff members are expected to maintain compliance with safe handling and transfer practices.
Empty Oxygen Tank During Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD who was ordered continuous oxygen at 4 LPM via nasal cannula. Resident #47 had diagnoses including COPD, weakness, and anxiety, and his care plan identified him as at risk for hypoxemic and hypercarbic respiratory failure due to impaired gas exchange, chronic lung disease, and increased oxygen needs. His physician orders and MAR indicated continuous oxygen at 4 LPM, and the facility’s policy required oxygen to be administered under physician orders with ongoing assessment and monitoring for complications. On 9/16/25, the resident was observed in the dining room wearing a nasal cannula attached to an oxygen tank on the back of his wheelchair. The tank regulator dial was at the bottom of the red area, indicating the tank was empty. The resident was later observed in front of the nurse’s station asking for help with his oxygen, and his nasal cannula was found positioned between his hip and chair while the tank remained empty. A nurse attempted to replace the tank and tried several regulators, but they did not work. The resident’s nurse stated she was responsible for ensuring oxygen tanks had oxygen and that the resident was receiving oxygen as ordered. She said she had checked the resident’s oxygen saturation earlier and it was 93%, but she did not check the tank because he was using his concentrator at that time. She later acknowledged the tank was empty and that the resident had been new to continuous oxygen after returning from the hospital. Other staff confirmed the tank was empty and that there were problems getting the regulator to work, and the DON stated nurses were responsible for ensuring oxygen tanks were not empty and that residents were receiving the ordered amount of oxygen.
Medication Left Unsecured at Bedside
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for 1 of 18 residents reviewed for drug storage. During an observation and interview, a white powder substance was found in a medication cup on Resident #14’s bedside table. Resident #14 stated the substance was medication staff had used on her breast for a rash. Record review showed Resident #14 was admitted with diagnoses including chronic inflammatory demyelinating polyneuritis, muscle weakness, ataxia, and mild intermittent asthma, and the quarterly MDS indicated a BIMS score of 10, showing moderate cognitive impairment. Record review showed Resident #14 had a care plan for redness under the breast related to a yeast rash and a MAR for nystatin powder 100,000 units/gram administered topically. During interviews, an LVN stated medications should be stored on the medication cart or in the medication room and that nystatin should not be left on a resident’s bedside table. The DON stated residents should not have medication on their bedside table and that Resident #14 was not approved to self-administer or keep medication at bedside. The Administrator stated medication at bedside would require an order, care plan, and assessment for self-administration, and that the medication would need to be out of sight.
Failure to Follow Enhanced Barrier Precautions During Peri Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control practices. Resident #3 was a [AGE]-year-old female with diagnoses including klebsiella pneumoniae, a personal history of infectious and parasitic diseases, carrier or suspected carrier of MRSA, and contact with and suspected exposure to other viral communicable diseases. Her quarterly MDS indicated she was usually able to make herself understood, had a BIMS score of 10, required dependent assistance with ADLs, and was always incontinent of bladder and bowel. Resident #3’s care plan identified enhanced barrier precautions due to colonization or infection with a multi-drug organism, a feeding tube, and a wound. The plan directed staff to wear PPE during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens, incontinent care, wound care, and device care, and to keep a sign on the door and PPE available outside the room. Her order summary also indicated Enhanced Barrier Precautions were in place due to klebsiella pneumoniae. During observation, CNA G and CNA M provided peri care to Resident #3 without applying gowns, even though she was on enhanced barrier precautions. Interviews showed the ADON initially stated the resident should not be on enhanced barrier precautions and would clarify it, while the DON stated the resident should remain on enhanced barrier precautions and staff should follow the MD orders. CNA G, LVN C, and CNA M each stated they were not aware the resident was still on enhanced barrier precautions, and they noted PPE was not set up outside the room. The DON and ADM stated staff should know which residents were on enhanced barrier precautions by the door signage, orange sticker, and PPE placement, and that staff were expected to follow the precautions.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have RN coverage on multiple specific dates in January, February, March, and July 2024. The absence of RN coverage was confirmed by the facility's PBJ Staffing Data Report and staff schedules, which showed no RN hours recorded on the specified dates. Interviews with the facility's administration and nursing staff indicated that the facility faced challenges in maintaining consistent RN coverage, particularly on weekends. The facility had initially hired two RNs to cover weekend shifts, but one RN was unable to fulfill their duties due to a family issue. As a result, RN M had to adjust her hours to cover the gaps. The lack of RN coverage was acknowledged by the Director of Nursing (DON) and was noted to potentially affect resident care and nursing supervision.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #8's falls on two occasions were not coded on her Minimum Data Set (MDS), despite her being at risk for falls due to hemiparesis and personal preferences. Her care plan indicated a risk for falls, yet the MDS did not reflect these incidents, which could impact her care and safety measures. Resident #15's MDS also contained inaccuracies, as it failed to code her falls on three separate occasions, her diagnosis of dementia, and the correct medication type. Although she was receiving an anticoagulant, the MDS incorrectly listed her as receiving an antiplatelet. These omissions could affect her care plan and the management of her conditions, including dementia and a history of falls. Interviews with facility staff revealed a lack of oversight and accuracy in completing MDS assessments. The MDS Coordinator acknowledged the potential for human error and the importance of accurate assessments for care planning. The Director of Nursing and Administrator also emphasized the significance of accurate MDS assessments for billing and insurance purposes, highlighting a systemic issue in ensuring the accuracy of resident assessments.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, addressing their medical, nursing, mental, and psychosocial needs. Resident #15, a female with hearing impairments and moderately impaired cognition, did not have her hearing problems and use of hearing aids included in her care plan. Observations noted that she was hard of hearing and her hearing aids were not visible, indicating a lack of proper documentation and planning for her auditory needs. Resident #23, a male with Type 2 diabetes, impaired vision, and chronic respiratory failure, also had deficiencies in his care plan. His care plan did not address his hearing difficulties, impaired vision, shortness of breath on exertion, use of antidepressant and oral antidiabetic medications, or dental issues. Observations showed that he was sitting close to a high-volume television, suggesting unaddressed hearing or vision issues. His medical records indicated regular administration of medications for diabetes and depression, yet these were not reflected in his care plan. Resident #35, a male with dry eye syndrome and impaired vision, had his visual impairments and use of corrective lenses omitted from his care plan. Interviews with facility staff, including the LVN, RN, MDS Coordinator, and DON, revealed a shared responsibility for care plans, yet a lack of inclusion of critical care areas. The staff acknowledged the importance of individualized care plans and the potential impact on residents' mental and physical well-being when care plans are incomplete or inaccurate.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper food service safety standards in its kitchen, as observed during a survey. The ice machine in the dining hall was malfunctioning, causing ice to spill onto the floor, which was absorbed by a beige/brown blanket placed directly in front of the machine. This setup was identified as a potential trip hazard by the Dietary Manager and other staff members. Additionally, the kitchen's gas stove had a significant black carbon buildup, which was not adequately cleaned, despite the Dietary Manager's assertion that the kitchen staff were responsible for maintaining cleanliness. In a resident's personal refrigerator, a green, moldy, undated, and unlabeled sandwich was found, indicating a failure to properly label, date, and store food. Interviews with various staff members, including dietary aides, the Dietary Manager, and the Director of Nursing (DON), revealed confusion and lack of clarity regarding responsibilities for cleaning and maintaining resident refrigerators. Some staff believed that housekeeping or maintenance was responsible, while others thought it was the duty of the nursing aides or night nurses. The facility's policies on kitchen sanitation and personal resident refrigerators were not consistently followed. The kitchen sanitation policy required routine cleaning and sanitization of all surfaces and equipment, while the personal refrigerator policy mandated weekly temperature checks and cleaning. However, interviews with staff indicated a lack of adherence to these policies, with no clear schedule or assignment of responsibilities for these tasks. This lack of coordination and adherence to policies could potentially lead to food-borne illnesses among residents.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which resulted in several deficiencies related to the use of personal protective equipment (PPE) and hand hygiene practices. Specifically, staff members did not adhere to the required protocols for wearing N95 masks and changing masks between resident rooms, particularly when dealing with COVID-19 positive residents. For instance, a medical assistant entered the rooms of two COVID-19 positive residents without wearing an N95 mask and failed to change her mask before entering a non-isolation room. This was against the expectations set by the facility's Director of Nursing (DON) and Director of Clinical Operations, although it was noted that the policy was not clearly documented. Additionally, the facility did not ensure that staff members wore appropriate PPE when entering the room of a COVID-19 positive resident. A certified nursing assistant (CNA) and a housekeeper entered a COVID-19 positive resident's room without wearing N95 masks or face shields, despite the presence of signage indicating the requirement for full PPE. The DON was unaware of the specific mask policy, and the staff had been under the impression that N95 masks and face shields were optional, leading to inconsistent practices. The facility also failed to ensure proper hand hygiene and glove-changing practices during incontinent care. Observations revealed that a CNA and a licensed vocational nurse (LVN) did not change gloves or perform hand hygiene after handling soiled linens and before touching clean items or residents. This lack of adherence to hand hygiene protocols was acknowledged by the staff involved and highlighted by the facility's Infection Control Preventionist as a risk for cross-contamination and infection spread. Despite having competencies in hand hygiene and peri-care, the staff did not consistently apply these practices during care activities.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences, specifically regarding the placement of call lights within reach. This deficiency was observed in two residents, Resident #8 and Resident #15, who were both unable to access their call lights, potentially placing them at risk for unmet needs. Resident #8, who had hemiplegia and used a wheelchair, was found with her call lights on the floor behind her bed, and she reported that staff told her she did not need her call light as they would assist her at the right times. Resident #15, who had difficulty walking and a history of falls, was observed with her call light on the floor on multiple occasions. She was unable to locate her call light and expressed that she could get herself up if needed. Interviews with staff, including a CNA and the DON, revealed that it was the responsibility of all staff to ensure call lights were within reach of residents. However, the CNA assigned to Resident #15 did not recall the call light's location, and the call light was not within reach during observations. The facility's policy on answering call lights, revised in March 2021, indicated that call lights should be within easy reach of residents when they are in bed or confined to a chair. Despite this policy, the observations and interviews indicated a failure to adhere to these guidelines, resulting in the deficiency noted in the report. The ADM and RN M both acknowledged the importance of having call lights within reach to prevent falls and ensure residents receive the assistance they need.
Failure to Timely Submit MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment for a resident was electronically completed and transmitted to the CMS System within the required 14 days after completion. The resident in question was an 85-year-old female who had been admitted with a diagnosis of non-ST elevation myocardial infarction and was discharged home with services. The discharge MDS assessment was not submitted within the required timeframe, as indicated by the lack of submission on the MDS document. Interviews with the MDS Coordinator and the Administrator revealed that the MDS Coordinator was responsible for completing and submitting the MDS assessments, and the corporate MDS Coordinator was expected to monitor these submissions. The MDS Coordinator acknowledged the importance of timely submission to ensure proper documentation prior to discharge but was unaware of how the oversight occurred. The facility's policy on MDS Completion and Submission Timeframes, as well as the CMS RAI Manual, both emphasize the necessity of adhering to federal and state guidelines for timely submission, which was not followed in this instance.
Failure to Ensure RN Signature on MDS Assessment
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) signed and certified the Minimum Data Set (MDS) assessment for a resident, which is a requirement for accurate documentation of the resident's status. The resident in question was an elderly female who had been admitted with a diagnosis of non-ST elevation myocardial infarction and was discharged home with services. The discharge MDS assessment for this resident did not have the RN's signature in section Z, which is necessary to verify the completion of the assessment. Interviews revealed that the MDS Coordinator was responsible for notifying the RN when an MDS assessment needed to be signed, and the RN was expected to sign the assessment within 14 days of discharge. However, the Director of Nursing (DON) admitted to still learning about the MDS requirements and relied on the MDS Coordinator to complete most sections. The Administrator expected the RN or DON to sign the MDS assessments within the specified timeframe to ensure timely payment of services. The facility's policy and the MDS 3.0 RAI Manual both require the RN assessment coordinator to sign and certify the completion of the assessment.
Failure to Monitor Blood Sugar Levels for Resident on Antidiabetic Medication
Penalty
Summary
The facility failed to ensure that a resident, who was on antidiabetic medication, received daily blood sugar glucose checks as required. This oversight was identified for one resident who was being treated for Type 2 diabetes. The resident's care plan did not reflect the use of hypoglycemic medication or the diagnosis of Type 2 diabetes, which contributed to the lack of proper monitoring. Interviews with facility staff revealed a lack of awareness and adherence to the necessary blood sugar monitoring protocols. Licensed Vocational Nurse (LVN) L and Registered Nurse (RN) M both assumed that blood sugar checks were being conducted, but acknowledged that sometimes the order for such checks was missed. The Director of Nursing (DON) confirmed that daily blood sugar checks should have been ordered and performed for residents on oral diabetic medication, but this was not consistently done. The facility's policy on managing diabetes in older adults indicated that blood glucose levels should be monitored at least twice weekly for residents on oral medication who are well-controlled, and more frequently for those who are poorly controlled. However, this policy was not followed in the case of the resident in question, leading to a deficiency in care and placing the resident at risk for undetected hypo or hyperglycemic episodes.
Inadequate Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents who were incontinent of bowel and bladder, leading to potential risks of urinary tract infections and skin breakdown. Resident #18, a female with a history of chronic UTIs and cognitive impairment, was found excessively wet on multiple occasions. On one instance, she had to wait approximately 25 minutes to be changed, and when care was finally provided, her brief, under pad, and sheet were saturated with urine, and her mattress was also wet. The staff did not report the excessive wetness or the pink-tinged urine observed during the change, which could indicate a UTI. Resident #32, a female with Alzheimer's disease and a history of pressure ulcers, did not receive complete perineal care. During an observation, CNA C failed to inspect between the resident's legs to ensure she was completely clean before placing a new brief. Subsequent inspection by the DON revealed a moderate amount of feces remaining in the perineal area, which was not properly cleaned. This oversight in care could lead to infections or skin breakdown, especially given the resident's existing pressure ulcer risk. Interviews with facility staff, including CNAs, LVNs, and the DON, highlighted a lack of adherence to the expected standards of care for incontinence management. Staff were expected to perform incontinent care every 2-3 hours and ensure residents were clean to prevent infections and skin issues. However, the observations and interviews indicated that these standards were not consistently met, placing residents at risk for adverse health outcomes.
Failure to Report Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA B) demonstrated competency in identifying and reporting changes in a resident's condition. Specifically, CNA B did not report a change in the urine color of a resident, who had a history of chronic urinary tract infections (UTIs), to the licensed vocational nurse (LVN L) in a timely manner. This delay in reporting occurred despite the facility's training on the importance of notifying nurses about changes in residents' conditions. The resident involved was an elderly female with a history of hemiplegia and hemiparesis following a stroke, as well as chronic UTIs. During an observation, it was noted that the resident's brief, cloth under pad, and sheet were saturated with urine, and the mattress had a wet spot. CNA B observed pink-tinged urine during incontinent care but did not immediately report this to the charge nurse, which delayed physician notification and treatment. Interviews with facility staff, including the LVN, assistant director of nursing (ADON), and director of nursing (DON), revealed that CNA B was expected to report such changes immediately. The facility had provided training and in-services on reporting changes, and CNA B's proficiency audit indicated satisfactory performance in reporting changes. However, the failure to report the pink-tinged urine promptly was a lapse in following the established protocols for resident care.
Failure to Document Controlled Substance Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for Resident #9, specifically in the administration and documentation of controlled substances. Resident #9, a female with a history of pseudobulbar affect, diffuse traumatic brain injury, and convulsions, was prescribed Vimpat (lacosamide) to manage seizures. The medication was to be administered twice daily. However, the Narcotic Drug Record for Resident #9's lacosamide was not signed by Medication Aide A for the last dose on the medication card, which was the evening dose on August 1, 2024. This oversight was identified during a review of the narcotic drug record and the Medication Administration Record (MAR), which showed that the medication was administered but not properly documented. Interviews with staff, including Medication Aide A, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed the failure to sign the narcotic sheet for the last dose. Medication Aide A admitted to forgetting to sign the sheet after administering the last dose. The facility's policy on controlled substances requires the nurse administering the medication to record the quantity remaining and sign the sheet, which was not adhered to in this instance. The failure to document the administration of the controlled substance could lead to discrepancies in medication counts and potential risks for residents.
Failure to Discontinue Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving the administration of Minocycline and Acidophilus. The resident, a male with a history of local infection of the skin and subcutaneous tissue, was prescribed Minocycline prophylactically without a confirmed infection and continued to receive it beyond the necessary duration. Additionally, the resident was given Acidophilus for an extended period without a clear indication for its continued use. The records indicated that the resident was admitted with a diagnosis of local infection, but there was no confirmation of an active infection requiring antibiotic treatment. Despite this, Minocycline was prescribed and administered twice daily starting from June 25, 2024, with no specified end date. Similarly, Acidophilus was prescribed starting July 11, 2024, also without a stop date, and continued to be administered unnecessarily. Interviews with facility staff, including the ADON and DON, revealed a lack of follow-up and communication with the prescribing physician to confirm the necessity of continuing the medications. The ADON acknowledged the oversight in not discontinuing the medications and the absence of stop dates, which was against the facility's antibiotic stewardship policy. The DON also recognized the failure to ensure appropriate medication management, which could lead to antibiotic resistance and affect the quality of care provided to the resident.
Improper Storage of Wound Cleansers in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically wound cleansers, were stored in locked compartments as required by State and Federal laws. During observations, it was noted that wound cleansers for two residents were improperly stored in their rooms, rather than in a locked compartment. The Assistant Director of Nursing (ADON) placed a wound cleanser in a resident's dresser drawer after providing wound care, acknowledging that this was improper storage and that the cleanser should have been locked on the treatment cart. Interviews with the ADON and other nursing staff revealed a lack of awareness regarding the facility's policy on the storage of wound cleansers. The ADON admitted to not knowing the policy and stated that wound cleansers should be stored away from residents to prevent potential misuse. Other staff members also expressed concerns about the improper storage of wound care supplies, indicating that they should be kept in the medication room or on the medication cart to prevent harm. The Director of Nursing (DON) and the Administrator (ADM) confirmed that wound care supplies, including wound cleansers, should not be stored in residents' rooms. They emphasized that these items should be kept in a secure location, such as the supply room or locked in a resident's drawer, to prevent unauthorized access and potential harm. The facility's policy on medication storage, revised in November 2020, mandates that all drugs and biologicals be stored in locked compartments under proper temperatures, accessible only to authorized personnel.
Failure to Provide Immediate CPR to Unresponsive Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who was found unresponsive in the dining room. The resident, who was a full code, was not assessed or given CPR until emergency medical services (EMS) arrived, which was 12 minutes after the resident was found unresponsive. The resident was later transported to the hospital and pronounced deceased. The report indicates that the facility staff did not follow the facility's policy on CPR, which requires immediate initiation of CPR if a resident's DNR status is unclear. The resident involved was a male with a history of stroke, cognitive communication deficit, and seizure disorder. He was on a mechanical soft diet due to his medical history and required substantial assistance with eating. On the morning of the incident, the resident was found unresponsive after breakfast, with large amounts of solid food later discovered in his airway at the hospital. Despite being a full code, CPR was not initiated by the facility staff, and the resident remained unresponsive until EMS arrived and began CPR. Interviews with facility staff revealed confusion and a lack of immediate action in response to the resident's unresponsive state. Staff members were unsure of the resident's code status and did not initiate CPR, instead opting to verify the code status before taking action. The facility's emergency procedures were not followed, and the crash cart was not utilized. The staff's inexperience and lack of immediate response contributed to the delay in providing life-saving measures to the resident.
Facility Fails to Prevent Abuse by LVN
Penalty
Summary
The facility failed to protect two residents from abuse by an LVN, who verbally and physically abused them. The incidents involved the LVN using foul language and throwing objects at the residents. One resident, a male with severe cognitive impairment and dementia, was subjected to verbal abuse and had ice thrown at him by the LVN. Witnesses reported that the LVN told the resident to 'stop fucking looking at me and go on' and threw a piece of ice at him. The resident, who had a BIMS score indicating severe cognitive impairment, did not remember the incident, but staff interviews revealed that the LVN often spoke rudely to residents and staff. Another resident, a male with moderate cognitive impairment and schizoaffective disorder, was also verbally abused by the same LVN. The LVN used inappropriate language and threw a note at the resident, telling him to go away. This resident was known to be easily agitated and had a history of making threatening statements. Staff members reported that the LVN escalated situations with this resident, leading to the resident talking aloud to himself and expressing dislike for the LVN. The facility's failure to prevent these incidents of abuse placed the residents at risk for emotional distress and further abuse. Staff interviews indicated that the LVN had a history of speaking inappropriately to both residents and staff. Despite the facility's policies on abuse prevention and reporting, the incidents were not reported immediately, and the LVN continued to work until the investigation was completed.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically affecting two residents. The incidents involved a Licensed Vocational Nurse (LVN) who used foul language and threw ice at one resident, and displayed inappropriate behavior towards another resident by using foul language and throwing a note at them. These actions were witnessed by other staff members, but the incidents were not reported immediately to the abuse coordinator as required by the facility's policy. The first resident involved was a male with severe cognitive impairment, dementia, and mood affective disorder. The incident occurred when the resident approached the nurse's station, and the LVN responded with inappropriate language and threw ice at him. Despite the resident's severe cognitive impairment, staff members witnessed the LVN's actions but failed to report the incident immediately, which is a violation of the facility's abuse prevention policy. The second resident, a male with moderate cognitive impairment and schizoaffective disorder, was also subjected to inappropriate behavior by the same LVN. The LVN used foul language and threw a note at the resident when he approached the nurse's station. This incident was also not reported immediately by the staff who witnessed it. The facility's failure to ensure immediate reporting and proper documentation of these incidents led to the deficiency identified by the surveyors.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required 24-hour timeframe to the state agency. The incident involved a Licensed Vocational Nurse (LVN) who used inappropriate language and behavior towards a resident at the nursing station. The LVN reportedly made a sign with offensive language and threw it at the resident, which was witnessed by a Medication Aide (MA). The MA reported the incident to the Administrator (ADM) immediately, but the ADM did not report the incident to the state agency within the required timeframe. The resident involved in the incident was a male with a history of anxiety disorder, Type 2 diabetes, nicotine dependence, and schizoaffective disorder, among other conditions. The resident was known to have moderate cognitive impairment and required assistance with daily activities. The resident's care plan indicated a risk for altered psychosocial well-being and mood state, with interventions to be non-judgmental and reassuring. Interviews with facility staff revealed that the ADM was responsible for investigating and reporting allegations of abuse. However, the ADM did not recall all details of the incident and may have confused it with another incident involving the same LVN. The Director of Nursing (DON) confirmed that the ADM was responsible for reporting, but the failure to report the incident in a timely manner placed residents at risk for continued abuse and neglect.
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 30 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 Carthage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcliff Skilled Nursing Facility | 0.6 mi | ★★★★★ | 9 | 1 |
| Panola County Nursing & Rehabilitation | 1.5 mi | ★★★★★ | 18 | 0 |
| Garrison Nursing Home & Rehabilitation Center | 23.8 mi | ★★★★★ | 0 | 0 |
| Heritage House Of Marshall Health & Rehabilitation | 24.7 mi | ★★★★★ | 3 | 0 |
| Focused Care Of Center | 25.6 mi | ★★★★★ | 3 | 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.