Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Cass Valley Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, bipolar disorder, severe cognitive impairment, and total ADL dependence, who was known to be resistive to care and potentially physically aggressive, was subjected to verbal and physical abuse by a CNA during incontinence care. Video showed the CNA entering while the resident appeared asleep, raising the bed, turning on the light, and attempting to change the brief without calm explanation, then swatting and pushing the resident’s arms down, physically holding his arms and legs, pushing him into the mattress, and lifting his legs above their heads and against the wall as he thrashed, kicked, and pushed. The CNA did not stop care or seek assistance despite the escalation, contrary to the resident’s care plan interventions for resistance and aggression. The CNA later told an LVN she had given the resident a push and placed his hands on his chest so he would hit himself instead of her. The facility’s review of the video and statements determined that the CNA’s actions constituted inappropriate physical contact and were inconsistent with the abuse prohibition policy and staff training.
Two residents with severe cognitive impairments and care plans requiring in-room activities did not receive these services for a three-week period. Both had documented needs for individualized activities due to their inability to participate in group programs, but participation records and staff interviews confirmed the activities were not provided as required.
A dietary staff member failed to change gloves or wash hands after wiping her nose while preparing pureed biscuits, then continued to handle food and utensils. Both the Administrator and Dietary Manager confirmed that this action was against facility policy and could result in contaminated food being served.
Two residents with severe cognitive impairment and mental health conditions did not have their care plans updated to reflect their current need for in-room activities, despite documented changes in their activity preferences and participation. Staff interviews confirmed that care plans were not revised as required when residents' needs changed, resulting in a lack of specific interventions to guide staff in meeting these residents' activity needs.
A resident's insulin was found stored in a zip lock bag labeled for a different medication, with the actual medication inside not matching the prescription label or the resident's physician orders. The medication was not from the facility's pharmacy, and staff confirmed that the resident was not prescribed the medication found. Nursing staff and the DON acknowledged that medications should only be stored in their original packaging and that expired or discontinued medications should be removed, in accordance with facility policy.
A resident with severe cognitive impairment and a history of falls was injured when a CNA moved an unlocked bed during peri-care, causing the resident to fall from the bed. The resident sustained multiple injuries, including a hip fracture and lacerations. Staff interviews confirmed that peri-care assistance was not documented in the Kardex prior to the incident, and that the CNA did not follow established protocols for bed movement and resident safety.
A resident with multiple health conditions was discharged to a psychiatric facility without proper discharge planning from the LTC facility. The facility failed to coordinate a new placement for the resident after psychiatric evaluation, leading to a deficiency. Staff interviews revealed a lack of communication and responsibility in the discharge process, contrary to the facility's policy requiring a 30-day notice for transfers or discharges.
A resident's urinal was not emptied appropriately, leading to a failure in maintaining a clean and homelike environment. The resident, who required substantial assistance due to medical conditions, reported that the urinal was only emptied during the night shift and had not been emptied the previous night. Observations confirmed the urinal contained urine throughout the day. Staff interviews indicated that CNAs should ensure urinals are emptied during rounds, and the facility's policy stressed the importance of frequent checks to prevent discomfort and infection control issues.
A resident with Alzheimer's disease was physically abused by a CNA from a staffing agency, as captured on video surveillance. The resident, who has severe cognitive impairments, was struck multiple times during a night shift. The facility's abuse prohibition policy was not effectively enforced, leading to Immediate Jeopardy. The incident was reported by the resident's family, and law enforcement was involved.
The facility failed to ensure call bells were within reach for five residents, potentially placing them at risk for being unable to call for assistance. Observations revealed that residents with varying levels of cognitive impairment and physical assistance needs had call bells out of reach. Staff interviews indicated it was their responsibility to ensure accessibility, but the deficiency suggests inconsistent implementation of this practice.
The facility failed to provide adequate nail care and hygiene for four residents, leading to unclean and rough nails with blackish substances, indicating a lack of proper assistance. Residents with cognitive impairments and medical conditions were dependent on staff for personal hygiene, but staff confusion about responsibilities resulted in inadequate care.
The facility failed to provide resident-centered activity programs for three residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being. A resident with depression and cognitive deficits did not receive her preferred activities, such as listening to music. Another resident with dementia and depression expressed loneliness and a lack of activities, while a third resident with cognitive impairment and anxiety did not receive the in-room activities outlined in his care plan. The Activity Director admitted to the lack of activity records and visits, which could lead to depression and loneliness.
The facility failed to follow professional standards for food safety and sanitation. Frozen hamburger meat was improperly thawed, and food storage in the walk-in refrigerator was not maintained correctly, with boxes on the floor and debris present. Additionally, Dietary Aide P did not follow proper hand hygiene practices, risking cross-contamination. These actions were against the facility's policies and could potentially lead to foodborne illness.
The facility failed to maintain an effective infection prevention and control program, with lapses in equipment sanitation and hand hygiene. An LVN did not clean a blood pressure cuff between residents, and another LVN did not follow aseptic techniques during a catheter irrigation procedure. Additionally, an LVN failed to practice proper hand hygiene while delivering meal trays and feeding residents, potentially leading to cross-contamination.
The facility failed to maintain a safe and sanitary environment, with observations revealing large holes in walls, exposed drywall, and debris in resident rooms. Staff interviews highlighted challenges in maintaining cleanliness and repairing damage, with the maintenance supervisor acknowledging ongoing issues since March 2023. The administrator was unaware of the damage's severity and noted plans to address the issues.
Resident Abuse During Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by a CNA during incontinence care. The resident was an elderly male with Alzheimer’s disease, dementia, bipolar disorder, diabetes mellitus, severe cognitive impairment, and significant ADL dependence. His MDS documented that he was rarely/never understood, had severe cognitive impairment, short- and long-term memory problems, severely impaired decision-making, continuous inattention and disorganized thinking, and was short-tempered and easily annoyed. His care plan identified ADL self-care performance deficits related to dementia, fluctuating ADL abilities, resistance to care including refusal of glucose checks, ADL and incontinence care, medications, and showers, and a potential for physical aggression such as hitting, pushing, biting, or slapping staff. Interventions in the care plan directed staff to allow the resident to make decisions to provide a sense of control, give clear explanations of treatment, leave and return in 5–10 minutes if he resisted ADLs, communicate to alleviate anxiety, give choices about care when agitated or distressed, and for staff to walk away calmly and re-approach later. On the date of the incident, an additional intervention was added for two-person staff to slowly approach the resident when providing care and to reattempt care later if he escalated. Video footage from the resident’s in-room camera on the date of the incident at approximately 5:30 AM showed CNA A entering the resident’s room while he appeared to be asleep, raising the bed, and turning on the light before attempting to change his incontinence brief. As soon as the resident responded with his arms up, CNA A swatted and pushed his arms down onto his body, after which he began thrashing in bed. Audio from the video captured CNA A telling the resident that if he did not stop, she would act. During the interaction, CNA A physically pushed down and held the resident’s arms and legs while he kicked and pushed at her. The video showed CNA A pushing the resident down into the mattress, lifting his legs up above both of their heads and against the wall, and repeatedly pushing him around, picking him up, and pushing him down into the mattress while attempting to control his movements and change his brief. The footage showed that CNA A did not approach the resident in a calm manner, did not explain what she was doing, and did not stop care or seek assistance when the resident became aggressive, contrary to his care plan interventions and facility expectations. Following the incident, a nurse (LVN B) reported that at the end of the shift, CNA A told her that the resident had become combative, punching and kicking, and that she had given him a push and put his hands on his chest so he would hit himself instead of her. LVN B stated she did not witness the event and only knew what CNA A told her. She observed the resident afterward walking around the area and not appearing injured, and later documented a head-to-toe skin/wound assessment that showed no bruising, skin alterations, or discoloration. A subsequent skin check by the ADON also noted no new skin issues and that the resident was cooperative with staff. The facility’s abuse prohibition policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and physical abuse as including hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment, with verbal abuse defined as the use of disparaging or derogatory language. Based on review of the video and statements, the Administrator and facility investigation concluded that CNA A reacted inappropriately to the resident’s behavior, engaged in aggressive and inappropriate physical contact inconsistent with training, expectations, and the abuse prohibition policy, and that the allegation of abuse was substantiated.
Failure to Provide In-Room Activities as Required by Care Plans
Penalty
Summary
The facility failed to provide an ongoing program of activities based on comprehensive assessments, care plans, and resident preferences for two residents who required in-room activities. Both residents had severe cognitive impairments and were identified as needing individualized in-room activities due to their inability or unwillingness to participate in group activities. Despite care plans specifying the need for in-room activities at least three times per week, documentation and participation records showed that neither resident received these activities for a period of three weeks. One resident, a male with major depressive disorder, anxiety, lack of coordination, and moderate dementia, had a care plan indicating a need for a variety of activity types and locations, with a goal to participate in activities of choice one to three times per week. He was also identified as an elopement risk and was supposed to be provided with memory boxes. However, records indicated he did not receive in-room activities during the specified period, and he did not have a memory box as required by his care plan. The activity director confirmed that the resident was on the in-room activity program and acknowledged the failure to provide the required activities. The second resident, a female with unspecified dementia, generalized anxiety disorder, and cognitive communication deficit, also had a care plan requiring in-room activities and engagement in diversional activities. She was not physically or mentally able to attend group or community activities and was at risk for wandering. Despite these needs, participation records showed she did not receive in-room activities during the same three-week period. The activity director admitted to forgetting to provide in-room activities to both residents after adding them to the in-room activity program. The administrator confirmed the expectation that in-room activities be provided to residents who need them and acknowledged the responsibility of the activity director to ensure this occurs.
Failure to Change Gloves After Contamination During Food Preparation
Penalty
Summary
A deficiency was identified when a dietary staff member failed to follow proper hand hygiene and glove use during food preparation. While pureeing biscuits, the staff member wiped the left side of her nose with her gloved hand and did not change her gloves or wash her hands before continuing to handle the food and utensils. This action was observed by surveyors, and the staff member later confirmed in an interview that she did not change her gloves or wash her hands after touching her nose, acknowledging that her gloves were contaminated and that she may have touched the biscuits with her contaminated hand. Interviews with the Administrator and Dietary Manager revealed that both expected dietary staff to change gloves and wash hands after touching anything considered contaminated, such as their nose. Both acknowledged that failure to do so could result in contaminated food being served to residents. The facility's policy on hand hygiene, dated 2020, was reviewed and indicated that hand hygiene is considered the primary means to prevent the spread of infections.
Failure to Update Care Plans for In-Room Activities
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with severely impaired cognition and multiple mental health diagnoses. For one male resident with major depressive disorder, anxiety, lack of coordination, and moderate dementia, records showed that his care plan was not updated to reflect his current need for in-room activities, despite a documented decline in attending group activities. Although his name appeared on a list for in-room activities, there were no corresponding interventions in his care plan, and no revisions were made from June to September to address his changing activity preferences and needs. A female resident with unspecified dementia, generalized anxiety disorder, and cognitive communication deficits also had a care plan that did not accurately reflect her current activity needs. Her assessments indicated that activities such as keeping up with the news, being with groups, and going outside were important to her. However, her participation records showed she did not receive in-room activities for a three-week period, and her care plan interventions remained general, without specific updates to address her in-room activity needs. Interviews with facility staff, including the Activity Director, MDS Coordinator, and Administrator, confirmed that care plans were expected to be revised whenever there was a change in a resident's physical condition, cognition, or activity preferences. Despite this expectation and ongoing assessments, the care plans for these two residents were not updated to reflect their current needs for in-room activities, leaving staff without accurate guidance on how to meet their activity preferences.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored in accordance with professional standards for one resident. During an observation of the medication room refrigerator, a zip lock plastic bag was found with a prescription sticker for Lispro insulin, but the bag actually contained a box labeled for Novolog insulin, which was not prescribed to the resident. The Novolog medication was not from the facility's pharmacy, and the packaging indicated a different expiration date than the prescription sticker. Record review confirmed that the resident was only prescribed HumaLOG (Insulin Lispro) and not Novolog (insulin aspart) while at the facility. Interviews with nursing staff and the DON revealed that medications should only be stored in the packaging in which they are received, and that expired or discontinued medications should be removed and either destroyed or returned to the pharmacy. The staff acknowledged that placing a medication box for one drug in packaging labeled for another could lead to medication errors. Facility policy also requires that drugs with missing, incomplete, improper, or incorrect labels be returned to the pharmacy for proper labeling before storage, and that discontinued or outdated drugs be removed.
Resident Fall and Injury During Improper Bed Movement in Peri-Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure a resident's environment was free from accident hazards during peri-care. The resident, who had a history of falls, muscle wasting, lack of coordination, and severe cognitive impairment, was completely dependent on staff for all activities of daily living, including bed mobility and personal hygiene. The resident's care plan required a two-person assist for bed mobility and toileting, and staff were to be in-serviced on the required level of assistance and updates to the Kardex. During peri-care, the CNA encountered a situation where the resident had loose stool throughout the bed, including on the alternating air mattress, making the surface slick. The CNA cleaned one side of the resident and then attempted to move the bed away from the wall to access the other side. While the CNA was at the foot of the bed and moving it, the resident, who had been rolled to her right side, fell off the bed between the bed and the wall. The CNA confirmed that the bed was unlocked and that the slick mattress contributed to the fall. The resident was subsequently transferred to the hospital, where she was diagnosed with a right anterior superior iliac spine fracture, a forehead laceration, a right elbow soft tissue foreign body, and a right pulmonary nodule. Interviews with staff revealed that peri-care assistance was not documented on the Kardex prior to the incident, and that staff had been trained not to move beds during peri-care, but the CNA did not follow this protocol. The CNA stated she had previously been told the resident was a one-person assist for peri-care, but could not recall the details. Other CNAs and the Director of Nursing confirmed that beds should not be moved during peri-care and that if a bed needed to be moved, it should be done prior to starting care and with assistance. The facility's policy on perineal care emphasized reviewing the care plan and ensuring resident safety, but these steps were not followed, resulting in the resident's fall and injuries.
Failure to Ensure Safe Discharge Planning
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a safe and orderly transfer or discharge of a resident, leading to a deficiency. The resident, a male with diagnoses including unspecified systolic congestive heart failure, essential primary hypertension, major depressive disorder, and insomnia, was admitted to the facility and later discharged to a psychiatric facility without proper arrangements for subsequent placement. The resident required varying levels of assistance for daily activities, indicating a need for careful discharge planning. The resident was given a 30-day discharge notice on the same day he was sent to the psychiatric facility, but the facility did not assist in finding a new placement after his psychiatric evaluation and treatment. Interviews with facility staff, including the social worker (SW), business office manager (BOM), director of nursing (DON), and administrator (ADM), revealed a lack of coordination and communication regarding the resident's discharge process. The SW and BOM were not involved in securing a new facility for the resident, and the DON and ADM were either new to the facility or assumed others were handling the discharge planning. The facility's policy required a 30-day advance written notice for transfers or discharges, except in specific urgent circumstances. However, the policy was not effectively implemented in this case, as the resident was discharged without a coordinated plan for his next placement. The resident eventually found a new facility through the psychiatric facility's referral, but the lack of initial planning by the facility could have jeopardized his safety and care continuity.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the improper handling of the resident's urinal. The resident, who was cognitively intact and required substantial assistance with activities of daily living due to a history of traumatic brain injury and other medical conditions, had a urinal that was not emptied appropriately. Observations throughout the day showed that the urinal contained yellowish liquid, presumed to be urine, indicating it had not been emptied for an extended period. Interviews with the resident and staff revealed that the urinal was only emptied during the night shift, and the resident reported it had not been emptied the previous night. Staff, including an LVN, the DON, and the ADM, acknowledged that CNAs should ensure urinals are emptied during rounds and that anyone entering the room should address this issue. The facility's policy on bedpan and urinal assistance emphasized the importance of frequently checking and emptying urinals to prevent discomfort and potential infection control issues.
Failure to Prevent Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA) employed through a staffing agency. The incident was captured on video surveillance, which showed the CNA striking the resident multiple times during a night shift. The resident, who has Alzheimer's disease and severe cognitive impairments, did not show any observable reaction to the abuse. The resident's care plan indicated a potential for physical aggression during care, but the facility did not prevent the abuse from occurring. The resident involved in the incident is an elderly male with a history of Alzheimer's disease, peripheral vascular disease, cognitive communication deficit, and amnesia. His comprehensive Minimum Data Set (MDS) indicated that he was rarely or never able to understand verbal communication and had severely impaired cognitive skills for daily decision-making. The resident was also noted to be always incontinent of bowel and bladder, requiring staff assistance for his needs. The facility's failure to prevent the abuse was identified as Immediate Jeopardy (IJ), which began and ended over a two-day period. The abuse was reported to the facility by the resident's family member, who monitored the video surveillance. The facility acknowledged the abuse and law enforcement was involved, leading to a warrant for the CNA's arrest. The facility's abuse prohibition policy was in place, but the incident highlighted a lapse in its enforcement, as the CNA was able to commit the abuse despite the policy and training provided to staff.
Failure to Ensure Call Bells Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the communication system, specifically the call bells, was within reach for five residents, which could place them at risk for being unable to call for assistance. Resident #4, a male with hemiplegia and moderate cognitive impairment, was observed with the call bell hanging out of reach, and he was unaware of its location. Similarly, Resident #21, who is cognitively intact but requires assistance with daily activities, was found with the call bell behind furniture, and he stated he never uses it, opting instead to leave the room to seek help. Resident #31, with severe cognitive impairment and dependence on staff for toileting and hygiene, was found with the call bell draped across a chair on the other side of the room. He was difficult to understand and unaware of the call bell's presence. Resident #26, with moderate cognitive impairment, was observed with the call bell across the room, out of reach, and stated he never has it within reach. Resident #20, with severe cognitive impairment, was found with the call bell hanging from the back wall onto the floor, and she was not interviewable. Interviews with staff, including a CNA, LVN, and the Interim DON, revealed that it is the responsibility of the nursing staff to ensure call bells are within reach to prevent residents from being at risk of falls or being unable to call for help. The facility had previously conducted in-service training emphasizing the importance of ensuring call bells are accessible, but the deficiency indicates a failure in consistent implementation of this practice.
Failure to Provide Adequate Nail Care and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, specifically in maintaining their personal hygiene and grooming. Residents #12, #18, #25, and #28 were observed with unclean and rough fingernails, some with blackish substances underneath, indicating a lack of proper nail care. These residents required assistance due to various medical conditions, including diabetes, lack of coordination, and cognitive impairments, which made them dependent on staff for personal hygiene. Resident #12, a male with severe cognitive impairment and a history of skin-picking behavior, was found with rough nails and a blackish substance under his nails, accompanied by a fecal odor. He reported scratching himself at night and not receiving the requested assistance to clean his fingers. Similarly, Resident #18, a female with moderate cognitive impairment, expressed a preference for long nails but was unable to maintain them herself. She reported asking staff for help to file her nails, but was told it was not their responsibility, leading to uneven and rough nails that caused a minor scratch on her arm. Residents #25 and #28 also exhibited signs of inadequate nail care. Resident #25, with moderate cognitive impairment and communication difficulties, had excessively long and rough nails with a blackish substance and fecal odor. Despite attempts to interview him, he did not respond. Resident #28, with severe cognitive impairment and diabetes, had long, rough nails and a blackish substance under his nails. He reported attempting to manage his nails himself due to lack of assistance, resulting in sharp edges. Interviews with staff revealed confusion about responsibilities for nail care, particularly for diabetic residents, and a lack of consistent monitoring and intervention to ensure proper hygiene.
Failure to Provide Resident-Centered Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the preferences and needs of three residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being. Resident #10, a female with depression, secondary parkinsonism, and cognitive communication deficit, was not provided with her preferred activities such as listening to music and participating in religious activities. Despite her care plan indicating the need for in-room visits and activities, there was no documentation of her participation in any activities during July and August 2024. Observations showed her in a dark room with no stimulation, and the Activity Director confirmed the lack of activity records for her. Resident #19, a 94-year-old female with unspecified dementia and major depressive disorder, expressed feelings of loneliness and a lack of activities. Her care plan included in-room visits and activities, but she reported not receiving any such visits or activities. She expressed a preference for listening to music and going outside, but these were not provided. The Activity Director admitted to not realizing Resident #19's needs and confirmed the absence of participation records for her during the same period. Resident #25, a male with moderate cognitive impairment and anxiety disorder, also did not receive the in-room activities outlined in his care plan. Despite being on the in-room activity program, he only received two activities in July and none in August 2024. The Activity Director acknowledged the failure to provide the expected activities and visits, which could lead to depression and loneliness. The facility's policy on activity programs emphasizes the importance of activities based on comprehensive assessments and resident preferences, but this was not adhered to for these residents.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in their kitchen operations. On one occasion, approximately 10 pounds of frozen hamburger meat was observed in a pot in the kitchen sink, with only half of it submerged in water and no running water over it, contrary to the facility's policy. Dietary Aide P acknowledged the oversight, admitting that she forgot to run water over the meat and use a larger pot, which could potentially lead to the meat being defrosted at room temperature and becoming unsafe for consumption. Additionally, the facility did not maintain proper storage practices in the walk-in refrigerator. Observations revealed four boxes of food stacked on the floor, along with paper napkins and crumbled food debris, which is against the facility's policy that requires food to be stored off the floor on crates or shelves. The Administrator and Dietary Manager both confirmed that storing boxes on the floor could lead to dampness and potential safety hazards, and that the refrigerator should be kept clean and organized. Furthermore, there was a failure in maintaining proper hand hygiene practices. Dietary Aide P was observed not washing or sanitizing her hands after removing gloves and before putting on new ones, which she admitted was against her training. This lapse in hygiene could lead to cross-contamination, especially since she touched her clothes and the outside of the new gloves before handling items that were given to a resident. The facility's policy emphasizes the importance of handwashing to prevent foodborne illness, which was not followed in this instance.
Infection Control Lapses in Equipment Sanitation and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hygiene and equipment sanitation. One incident involved a Licensed Vocational Nurse (LVN) who did not clean a reusable blood pressure cuff between uses on different residents. This oversight was acknowledged by the LVN, who admitted to not following the facility's policy of cleaning the equipment before and after use to prevent the spread of germs and infection. Another deficiency was observed during a catheter irrigation procedure for a resident with a suprapubic catheter. The LVN performing the procedure did not clean the catheter tip before attempting irrigation, nor did she sanitize her hands after handling potentially contaminated items. This failure to adhere to aseptic techniques was recognized by the LVN, who admitted that her actions placed the resident at risk for bladder infection. The facility's interim Director of Nursing (DON) confirmed that reusable medical equipment should be sanitized before each use to prevent infection. Additionally, a separate incident involved an LVN who did not practice proper hand hygiene while delivering meal trays and feeding residents. The LVN touched various potentially contaminated surfaces and objects without sanitizing her hands in between, which could lead to cross-contamination. Despite being in-serviced on the importance of hand hygiene, the LVN expressed skepticism about the feasibility of sanitizing hands frequently. The facility's policy emphasizes hand hygiene as a primary means to prevent infection, yet this was not consistently followed during meal service.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the condition of five resident rooms. Observations revealed large holes in the walls, exposed drywall, and debris on the floors in several rooms. Residents were unaware of the extent of the damage, and the housekeeping supervisor noted challenges in maintaining cleanliness due to the need for assistance in moving beds. The maintenance supervisor acknowledged the ongoing wall damage since March 2023 and identified issues with the materials used for repairs. The administrator was unaware of the severity of the damage and noted plans to address the issues. Interviews with staff highlighted the challenges faced in maintaining the environment, including the lack of a floor crew and the need for correct materials for repairs. The maintenance supervisor and administrator both recognized the potential risks posed by the damaged walls, including drywall dust and pest problems. The facility's Homelike Environment policy, dated February 2021, emphasizes the importance of providing a safe, clean, and comfortable environment, which was not upheld in this instance.
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What surveyors actually found near you
We read the 10 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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Nursing homes near Centerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madisonville Care Center | 20.9 mi | ★★★★★ | 7 | 1 |
| Avir At Madisonville | 21.4 mi | ★★★★★ | 3 | 0 |
| Houston County Nursing Home | 21.5 mi | ★★★★★ | 0 | 0 |
| Whitehall Rehab & Nursing | 32 mi | ★★★★★ | 11 | 0 |
| Winfield Rehab & Nursing | 32 mi | ★★★★★ | 14 | 0 |
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