Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Healthcare And Rehabilitation - Paris during CMS and state inspections, most recent first.
Failure to Notify Physician of Critical Blood Glucose Readings: Two residents with DM had repeated blood glucose readings over 400, and the physician orders required the doctor to be called for 400+ results. MARs showed multiple elevated readings, but the nurses' notes did not document physician notification, new orders, or related symptoms. Interviews with an RN, an LVN, the physician, the DON, and the Administrator confirmed the expectation to notify the MD and document the communication.
Medication administration errors exceeded the allowed rate after surveyors found insulin, IV antibiotic, and gout medication errors involving multiple residents. An LVN failed to prime insulin pens before giving Humalog and Novolin R, one LVN infused IV vancomycin at a much faster rate than ordered, and a CMA gave only half of an ordered allopurinol dose. The residents involved had diabetes, endocarditis, dementia, and gout, and staff acknowledged the errors during observation and interview.
Significant medication errors occurred during insulin and IV medication administration. An LPN administered Humalog without priming the pen and a second LPN administered Novolin R without properly priming the pen, both contrary to manufacturer instructions. Another LPN infused vancomycin at 400 mL/hr instead of the ordered 100 mL/hr, causing the dose to run much faster than prescribed. The DON and Administrator stated they expected insulin and IV medications to be given according to manufacturer instructions and physician orders.
Personal food and drink items were observed on the kitchen food prep counter, including an open soda, an uncovered cup with dark liquid, an open energy drink, and an open plastic container with tan liquid. The Dietary Supervisor, Dietary Aide, DON, and Administrator all stated that staff personal food items are not allowed in the kitchen and should be kept in the breakroom or office, but the facility did not have a policy for staff personal food or drink items.
Facility assessment was not reviewed and updated to reflect enteral feeding needs or bariatric care needs. A resident with a G-tube had an active enteral feeding order and care plan for tube feeding, and another resident had morbid obesity with dependence for multiple ADLs and Hoyer lift use; the Administrator also identified 4 bariatric residents, but the assessment still showed zero enteral feeding and did not address bariatric residents.
Failure to Use PPE and EBP for Residents With Wounds: Staff did not wear gowns during wound care and other high-contact care for residents with wounds, and two residents who required EBP did not have signage or a PPE cart outside their rooms. One resident had a stage 3 pressure ulcer and a surgical wound, another had a deep tissue pressure injury to the heel, and a third had a venous leg ulcer/ruptured abscess with daily wound care orders. Staff interviews showed they knew gowns and gloves were expected for EBP, but the required PPE and room setup were not in place.
Missing pacemaker and defibrillator documentation: The facility failed to ensure that residents with pacemakers and an implantable cardiac defibrillator had specific maintenance, precaution, and care information documented in the EMR. Two residents had pacemaker-related care plans and orders for pulse monitoring and signs of malfunction, but one resident’s EMR lacked key defibrillator details such as the make, model, last check date, and cardiologist information. The DON stated she did not think the device make/model was important and confirmed the facility had no specific pacemaker policy.
A resident with morbid obesity, intact cognition, and dependence for toileting and dressing missed dialysis because the facility did not have the correct size briefs she wore. CNA D confirmed the resident could not go, checked with other aides and the charge nurse, and found no 3XL briefs available; the dialysis social worker also recalled the resident saying she did not come to dialysis for that reason.
A resident with depression and intact cognition received Prozac 40 mg daily after a dose increase, but the chart initially contained only a consent for the prior 30 mg dose. RN A later produced a backdated consent for the 40 mg dose, while the resident stated she did not sign it when the dose changed and was given the paperwork later. The DON and Administrator stated consents were expected before administration, and the facility policy required informed consent before starting a new psychoactive medication order.
Failure to Ensure Smoking Apron Use During Supervised Smoking: A resident with Tourette's disorder and severe cognitive impairment was observed smoking under 1:1 supervision without the required smoking apron. Her care plan and smoking evaluation identified the need for a smoking apron during smoking, and the supervising maintenance staff member stated he normally placed it on her but forgot. The DON and Administrator confirmed the resident was expected to wear the apron and that the staff member taking her out was responsible for ensuring it was on.
Controlled medications were not properly reconciled in the narcotic box for two residents. One resident’s Diazepam and another resident’s Pregabalin were found wrapped in the narcotic count sheet in the med cart even though the orders and MAR did not reflect those discontinued doses. Staff stated the meds should have been removed and given to the DON, and the pharmacist expected controlled meds to be reconciled each shift and removed when no longer prescribed.
An unlocked, unattended medication cart was observed in a hall while staff and residents passed by, and an LPN later stated he thought he had locked it when he walked away. In a separate observation, a narcotic refrigerator containing a resident’s lorazepam drops was found unlocked; the LPN said he thought he had locked it during shift count. The DON, pharmacist, and Administrator all stated medication carts and controlled medications must be kept locked when unattended.
Food was not consistently palatable or served at an appetizing temperature for two residents who said meals were cold, bland, or did not taste good. During meal observation, the Dietary Manager and surveyors found the sampled tray items were warm but could have been hotter, despite temperature checks being documented before service and the use of plate warmers. The Dietary Supervisor, DON, and Administrator stated they relied on temperature monitoring and resident feedback, and the facility policy required hot foods to remain above 135 degrees Fahrenheit during holding and plating.
Smoking materials were not handled per facility policy. An observation found numerous cigarette butts in a galvanized outdoor trash can and on the ground in the smoking area, with no metal ash tray present. Maintenance staff gave conflicting statements about where cigarette butts should be disposed of, and the Administrator stated the prior metal container with a self-closing lid had broken. The facility policy required safety code approved ashtrays as the only approved receptacle for smoking materials.
A resident with moderate cognitive impairment sustained second-degree burns after spilling hot coffee served by a CNA without a temperature check. The facility lacked a specific policy on hot liquid management, contributing to the incident. The coffee was brewed in the breakroom, bypassing the kitchen's temperature control procedures.
The facility failed to complete timely MDS assessments for two residents, with both assessments being finalized 3 days late. The MDS Coordinator Resource Nurse, who took over after the previous nurse went on leave, acknowledged the delay, citing the assessments were part of overdue tasks. The facility follows the RAI Manual guidelines, and the Administrator expects timely completion of assessments.
The facility failed to complete quarterly MDS assessments within the required time frame for four residents, including those with syncope, Alzheimer's, hypertension, and diabetes. The MDS Coordinator Resource Nurse, who assumed duties after the regular nurse went on leave, acknowledged the late completions. The facility followed RAI Manual guidelines but lacked a specific policy for MDS assessments.
A facility failed to provide scheduled hygiene care to three residents, resulting in missed baths and inadequate personal hygiene. One resident with diabetes and pressure ulcers reported strong body odor and unshaven facial hair, while another with Alzheimer's disease received fewer baths than scheduled, affecting her mood. A third resident with cognitive impairment felt unclean due to infrequent bathing. Interviews revealed challenges in completing scheduled baths and lack of documentation for refusals.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications by administering Humulin R insulin without a documented diagnosis of diabetes mellitus. Despite the resident's medical records lacking this diagnosis, insulin was prescribed and administered. Interviews with staff revealed a lack of responsibility and clarity in verifying diagnoses and medication orders, leading to this oversight. The facility's policy requires medications to align with the resident's service plan, which was not adhered to in this case.
The facility failed to attempt gradual dose reductions or document contraindications for three residents on psychotropic medications. A resident with severe cognitive impairment was on Risperdal without GDR attempts. Another resident with paranoid personality disorder continued Risperdal despite a failed GDR attempt. A third resident received Ativan and Risperidone without appropriate diagnoses, and the Ativan lacked a 14-day stop date, risking unnecessary medication use.
A facility failed to maintain an effective infection control program when an LVN did not perform hand hygiene after taking a blood sugar reading from a resident with diabetes, congestive heart failure, and Alzheimer's. Despite the facility's policies requiring hand hygiene before and after resident contact, the LVN admitted to not washing hands, which staff agreed could lead to infection risks.
A resident treated for a urinary tract infection with Ciprofloxacin was not included in the facility's Tracking and Trending Log for antibiotic use, as required by the antibiotic stewardship program. Despite the resident's treatment being administered as ordered, the oversight was acknowledged by the Infection Preventionist, who noted the potential impact on monitoring accuracy and staff training. The DON and Administrator expected the resident to be monitored, indicating a lapse in following established procedures.
Failure to Notify Physician of Critical Blood Glucose Readings
Penalty
Summary
The facility failed to immediately consult the resident's physician when two residents had blood glucose readings above 401 and the physician order required the doctor to be called for 400+ readings. Resident #4 had diagnoses including diabetes, stroke, and kidney failure, was cognitively intact, and was ordered Novolin R sliding scale insulin with instructions to call the doctor for blood sugars of 400 or higher. His January 2026 MAR showed multiple blood sugars above 400, including 406, 425, 408, 422, 449, and 420, but the nurses' notes did not show that the physician was notified on those occasions, and there were no documented new orders, symptoms of hyperglycemia, or hospitalization related to those readings. Resident #30 had diagnoses including diabetes, dementia, and high blood pressure, with a BIMS score of 12 indicating moderately impaired cognition. His physician order also required Novolin R sliding scale insulin and to call the doctor for blood sugars of 400 or higher. His January 2026 MAR showed blood sugars of 412, 506, 405, and 475, but the nurses' notes did not document physician notification for the elevated readings, and there were no documented signs or symptoms of hyperglycemia, new orders, or hospitalization related to those events. During interviews, RN P said he could not tell whether the doctor had been notified for the elevated blood sugars and acknowledged the importance of notifying the physician. LVN Q said she did not remember whether she called the doctor and stated that if it was not documented, then she did not call. The facility physician said he expected staff to notify him of blood sugars below 60 and above 400, and the DON and Administrator stated that charge nurses were expected to notify the doctor when blood sugars were over the ordered parameters and document the notification and any new orders.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Surveyors identified a 10% medication error rate, based on 4 errors out of 40 opportunities, involving four residents reviewed for medication administration. The errors involved insulin administration for two residents, IV vancomycin administration for one resident, and allopurinol administration for one resident. One resident with type 1 diabetes mellitus and a BIMS of 14 was ordered Humalog KwikPen by sliding scale and also had a separate order for 10 units before meals. During observation, an LVN dialed 22 units of Humalog and administered it in the left arm without priming the insulin pen first. The LVN stated she had not been taught to prime the pen before injection and acknowledged the resident was at risk for not receiving the correct dose of insulin. A second resident with type 2 diabetes mellitus and a BIMS of 14 had an order for Novolin R FlexPen 4 units subcutaneously before meals. During observation, an LVN dialed 6 units and administered the full dose without priming the pen with 2 units to remove air from the needle. The LVN stated she intended to remove air and that this was how the DON had taught her. A third resident with endocarditis and a BIMS of 12 had an order for vancomycin 500 mg/100 mL IV twice daily at 100 mL/hr, but an LVN administered the medication at 400 mL/hr, causing the 100 mL bag to infuse in 15 minutes. A fourth resident with dementia and gout had an order for allopurinol 100 mg, 2 tablets by mouth daily, but a CMA administered only 1 tablet. The CMA stated she made a mistake and did not give 2 tablets.
Significant Medication Errors During Insulin and IV Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for three residents reviewed for pharmacy services. Resident #74 had type 1 diabetes mellitus with hyperglycemia and was ordered Humalog KwikPen before meals and by sliding scale. During observation, LVN E administered 22 units of Humalog to the resident and did not prime the insulin pen before injection. LVN E stated she had not been taught to prime the insulin pen and explained that priming was to get the air out. Resident #46 had Alzheimer’s disease with late onset and was ordered Novolin R FlexPen 4 units subcutaneously before meals. During observation, LVN F dialed 6 units of Novolin R FlexPen and administered the full dose without priming the pen with 2 units to remove air from the needle. LVN F stated that although she could not see the 2 units come through the needle, her intention was to remove air and that this was how her DON taught her. Resident #40 had endocarditis and was receiving IV vancomycin 500 mg/100 mL twice daily. During observation, LVN E administered the vancomycin at 400 mL/hr instead of the ordered 100 mL/hr, and the infusion completed in 15 minutes rather than the ordered 60 minutes. LVN E stated she thought the medication was in a 400 mL bag and that this was the first dose of the new order, and she misread the order. The DON and Administrator stated they expected residents to be free from significant medication errors and that insulin and IV medications should be administered according to manufacturer instructions and physician orders.
Personal drinks found on kitchen food prep counter
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation on 02/02/2026 at 9:40 a.m., an open can of soda and an uncovered Styrofoam cup containing approximately 4 ounces of dark liquid believed to be coffee were observed on the food prep counter. During a later observation on 02/03/2026 at 7:15 a.m., an open 16-ounce energy drink and an open 16-ounce plastic container with tan liquid that appeared to be iced coffee were also observed in the kitchen on the food prep counter. During interviews, the Dietary Supervisor stated personal food items are not allowed in the kitchen and should be kept in the office or break room, and the Dietary Aide stated the drink items did not belong to him and that personal food items should be consumed in the breakroom. The DON stated personal food items are not allowed on nursing carts or in kitchen areas, and the Administrator stated she expected dietary staff to follow instructions about not having personal drink items in the food prep area and to keep them in the staff breakroom. The facility requested a policy for personal food items and was provided a policy titled Resident Personal Food storage, but it did not have a policy for staff personal food or drink items.
Facility Assessment Not Updated for Enteral Feeding and Bariatric Care
Penalty
Summary
The facility failed to ensure its facility assessment was reviewed and updated as necessary, and at least annually, for 1 of 1 facility. Record review of the facility assessment, reviewed on 06/17/25, showed zero enteral feeding and did not address bariatric residents. During interview, the Administrator stated she was responsible for completing and updating the facility assessment annually or whenever there was a major change in the facility, and that these items would be updated in the assessment annually. The facility policy titled Facility Assessment, revised 04/2025, stated the facility would conduct and document a facility-wide assessment that includes the resident population and the resources needed to care competently for residents during day-to-day operations and emergencies, and that the assessment would be reviewed and updated at least annually and as necessary when substantial changes occur. Record review showed Resident #38 had a diagnosis including gastrostomy, an active enteral feeding order for Jevity 1.5, and a comprehensive care plan reflecting the need for a feeding tube related to dysphagia. Resident #38's quarterly MDS reflected that eating was not attempted due to medical condition or safety concerns and that she had feeding while a resident of the facility within the last 7 days. Record review also showed Resident #44 had a diagnosis including morbid obesity due to excess calories, was dependent for multiple ADLs, and required a Hoyer lift with two-person assist at times depending on fatigue level. An undated sheet provided by the Administrator reflected the facility had 4 bariatric residents, but the facility assessment did not include care of bariatric residents.
Failure to Use PPE and EBP for Residents With Wounds
Penalty
Summary
The facility failed to ensure PPE was worn during wound care and other high-contact resident care activities for residents with wounds and enhanced barrier precautions (EBP). During an observation, RN P performed wound care for a resident with a stage 3 pressure ulcer to the left lower lateral leg and a left hip surgical incision with a wound vacuum, but RN P did not wear a gown while providing the care. The resident’s record showed intact cognition, assistance needs with multiple activities of daily living, and physician orders for daily wound treatment and EBP related to the surgical incision. The facility also failed to ensure PPE was worn when CNA S provided care to another resident with wounds. CNA S entered the resident’s room to allow the surveyor to view the resident’s buttock and noted a wound to the left heel. CNA S stated she was supposed to wear a gown and gloves when providing care for residents on EBP, but she did not wear PPE because there was no EBP sign or cart outside the room. The resident’s record showed intact cognition, assistance with ADLs, a deep tissue pressure injury to the right heel, and an order for daily povidone-iodine treatment. The facility further failed to have PPE, EBP signage, and a cart outside the rooms of two residents who had wounds and required EBP. One resident had actual impairment to skin integrity related to a ruptured abscess/venous leg ulcer and an active order for daily wound care to the left lower leg. The other resident had a stage 3 pressure ulcer and a wound care order for the left lower lateral leg. Staff interviews indicated they expected gowns and gloves to be used for residents with wounds, and the infection preventionist, DON, and Administrator all stated that residents with wounds should have signage and a cart outside the room. The facility policy stated that EBP includes gowns and gloves during high-contact resident care activities for residents with wounds, including chronic wounds, pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.
Missing pacemaker and defibrillator documentation
Penalty
Summary
The facility failed to ensure that residents with pacemakers and an implantable cardiac defibrillator had specific guidelines for maintenance, precautions, and care documented in the EMR for 3 of 13 residents. Resident #5 had diagnoses including an automatic implantable cardiac defibrillator, atrial fibrillation, chronic kidney disease, hypertension, cardiomyopathy, and congestive heart failure, and had a BIMS score of 9 indicating moderate cognitive impairment. Resident #6 had a cardiac pacemaker, atrial fibrillation, cerebral infarction, and hypertension, and also had a BIMS score of 9. Resident #15 had a pacemaker and the DON stated the facility was able to obtain and document the make and model of the pacemaker and the name of the cardiologist in the EMR. Record review showed Resident #5 had a care plan addressing pacemaker use related to atrial fibrillation with interventions to monitor apical pulse daily and monitor for signs and symptoms of pacemaker malfunction, and physician orders dated 10/21/2025 directed staff to monitor the apical pulse daily and for signs and symptoms of pacemaker malfunction. However, the EMR contained no specific information regarding the defibrillator, including the make, model, last date checked, or name of cardiologist. Resident #6's care plan also addressed pacemaker use related to atrial fibrillation with interventions to monitor and document/report signs or symptoms of altered cardiac output or pacemaker malfunction, dizziness, syncope, difficulty breathing, pulse rate lower than programmed rate, lower than baseline BP, and to monitor vital signs as ordered/per facility protocol and record. During interview, the DON stated she did not feel that knowing the make and model of the pacemaker or defibrillator was important and expected nursing staff to monitor the pulse and pacemaker checks. She stated the ADON was responsible for ensuring the information was present in the orders and the MDS Nurse was responsible for ensuring the device was annotated in the care plan, while she was ultimately responsible for accuracy of the record. The Administrator stated it was important to gather the necessary information regarding a resident's pacemaker and that nursing staff were responsible for obtaining the pacemaker date and ensuring a cardiology follow-up appointment was completed. When a policy for monitoring pacemakers/defibrillators was requested, the DON stated the facility did not have a specific policy for pacemakers.
Failure to Provide Correctly Sized Briefs for Dialysis
Penalty
Summary
The facility failed to treat Resident #44 with respect and dignity when it did not ensure she had the correct size briefs to go to dialysis. Resident #44 was a readmitted female resident with morbid obesity, intact cognition, and dependence for toileting, bathing, dressing, and footwear. Her care plan identified an ADL self-care performance deficit related to self-care deficit and morbid obesity, and she required extensive assistance with transfers at times depending on fatigue level. Record review showed there were no 3XL briefs in the supply room on multiple dates in December 2025. Resident #44 stated she missed dialysis because the facility did not have briefs that fit her and said she wanted to go that day but was told by CNA D that the facility was out of the briefs she needed. CNA D confirmed the resident missed dialysis because the facility did not have the correct size briefs and said she checked with other aides and the charge nurse, but none were available. The dialysis social worker also recalled a conversation with Resident #44 about not coming to dialysis because the facility did not have the correct size briefs for her.
Missing Informed Consent for Prozac Dose Change
Penalty
Summary
The facility failed to ensure Resident #44 was informed in advance and had a valid consent for Prozac 40 mg before the medication was administered. Resident #44 was a readmitted female with a diagnosis of depression, had an intact BIMS score of 15, and was able to make herself understood and understand others. Her record showed an order for Prozac 40 mg daily starting 01/29/26, and the MAR documented that she received the medication daily from 01/29/26 through 02/04/26. Record review showed the electronic chart contained a signed consent for Prozac 30 mg, not 40 mg. During interview, the DON initially provided the 30 mg consent when asked for the most recent Prozac consent. RN A stated she completed a consent for the 40 mg dose and placed it in a folder at the nurse’s station, then later produced a signed consent for Prozac 40 mg that was back dated 01/29/26. Resident #44 stated the paperwork for Prozac 40 mg was brought to her to sign on 02/04/26 while she was playing bingo and that she did not sign a consent on 01/29/26. The DON and Administrator stated consents were expected to be signed prior to administration, and the facility policy stated informed consent was to be obtained prior to medication use and prior to initiation of a new psychoactive medication order.
Failure to Ensure Smoking Apron Use During Supervised Smoking
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for one resident reviewed for accident hazards and supervision. Resident #60, a [AGE] year-old female with Tourette's disorder and a BIMS score of 00 indicating severe cognitive impairment, had an undated care plan identifying a potential for injury related to smoking. The care plan interventions included a smoking assessment, 1:1 observation while smoking, and use of a smoking apron during smoking activities. Record review showed Resident #60's smoking evaluation dated 02/03/26 reflected that she required a smoking apron. During an observation on 02/03/26 at 9:30 a.m., Resident #60 was being supervised by Maintenance B while smoking two cigarettes without wearing a smoking apron. Her hands were shaking and not steady while holding the cigarettes. During interviews, Maintenance B stated he normally placed an apron on her but forgot, and the DON and Administrator both stated the resident was expected to wear an apron while smoking and that the staff member taking her out was responsible for ensuring it was on.
Controlled medications left unreconciled in narcotic box
Penalty
Summary
The facility failed to establish a system for the receipt, disposition, and reconciliation of controlled medications in sufficient detail to show that drug records were in order and that all controlled drugs were accounted for and periodically reconciled. During observation and record review, two discontinued controlled medications were found wrapped in the back of the narcotic box in the medication cart rather than being reflected in the medication records or otherwise reconciled: Diazepam for one resident and Pregabalin (Lyrica) for another resident. One resident was a cognitively intact male with cerebral palsy, impulsive disorder, and hypertension, and his records showed an order for Diazepam 2.5 mg at bedtime for anxiety. However, the Diazepam 5 mg tablet that had been dispensed for bedtime use was still in the narcotic lock box, wrapped in the narcotic count sheet, and the physician order summary and MAR did not address that medication. The last documented administration was signed out with an illegible signature. A staff member stated the medication had last been administered on 01/14/26 and said she had no idea it was still there, adding that discontinued medications should have been given to the DON. The other resident was a cognitively intact female with low back pain and neuropathy, and her records showed an order for Pregabalin 150 mg at bedtime for pain. However, Pregabalin 75 mg capsules that had been ordered twice daily were still in the narcotic lock box, wrapped in the narcotic count sheet, and were not addressed by the physician orders or MAR. The last documented administration was signed out with an illegible signature. The pharmacist stated controlled medications were expected to be reconciled each shift and removed from the cart and given to the DON for destruction when no longer prescribed, while the DON and Administrator stated discontinued narcotics were expected to be brought to the DON and that all narcotics in the cart were to be reconciled.
Unlocked Medication Cart and Narcotic Refrigerator
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards in 2 of 4 medication storage areas observed. During an observation on 02/02/2026, an unlocked and unattended medication cart was found at the beginning of the 400 hall, with multiple staff and residents passing by it. The DON later observed the cart, locked it, and stated medication carts should not be left unlocked when unattended because anyone could get into them and residents could take medications. MA H stated she thought she had locked the 300 hall Medication Cart when she walked away from it, but later learned it had been left unlocked while she went down the hall and outside to take a call. The Administrator stated staff should ensure medication carts are locked when unattended. During an observation on 02/04/26, LVN L was found with the narcotic refrigerator unlocked while Resident #14's lorazepam drops were stored inside. LVN L stated he thought he had locked the refrigerator when he counted at shift change and said he was responsible for ensuring it was locked. The pharmacist stated controlled medications should be locked with 2 locks and that the medication refrigerator was required to be locked. The DON stated she expected nurses to ensure the refrigerator was locked during count and at all times, and the Administrator stated the DON was responsible for ensuring medications were locked, stored, and distributed according to professional standards and pharmacist recommendations.
Food Served Cold and Unappetizing
Penalty
Summary
Food was not consistently palatable or served at an appetizing temperature for two residents who reported that meals were cold and did not taste good. During observation, the Dietary Manager completed temperature checks for all food textures and meal items before tray line service and documented acceptable temperatures in the logbook, and stated temperatures were checked again about halfway through meal service. However, during lunch meal observation, the sampled tray served on a plate warmer was described by the Dietary Manager and surveyors as warm but could have been hotter, including chicken parmesan, barbecue sausage, and white beans. Resident #43 stated the food was terrible, cold, and bland. Resident #62 stated the food was not seasoned enough. The Dietary Supervisor stated she had not received complaints about cold food and said the cook monitored temperatures throughout meal service, while she completed spot checks of temperature logs and actual temperatures weekly. The DON stated the facility used plate warmers on all trays to keep food as warm as possible, and the Administrator stated she expected staff to notify the kitchen and obtain a new item if a resident complained of cold food. The facility policy required temperatures of all food items to be taken and recorded prior to service and hot foods to stay above 135 degrees Fahrenheit during holding and plating.
Smoking materials not disposed of in approved receptacle
Penalty
Summary
The facility failed to follow its established smoking policy by not providing a metal container with a self-closing cover device and by not ensuring smoked cigarettes were extinguished in a fire-retardant receptacle. During an observation on 02/03/26 at 9:30 a.m., a 31-gallon galvanized removable lid outdoor trash can contained numerous cigarette butts, and numerous cigarette butts were also observed on the ground. No metal ash tray was observed in the smoking area. During interviews, Maintenance B stated it was acceptable to dispose of cigarette butts in the outdoor trash can because it was a metal container, and he did not notice the cigarette butts on the ground. Maintenance C stated cigarette butts should be disposed of in the metal ash tray and that he was responsible for monitoring the smoking area by rounding every morning. The Administrator stated the metal container that had been out there last month had a self-closing lid that had broken and was supposed to be replaced, and she expected cigarette butts to be disposed of in the ash tray rather than on the ground. The facility policy titled Smoking and Safety Measures, revised 10/2022, stated that safety code approved ashtrays are provided and are the only approved receptacle for disposing of smoking materials.
Resident Burned by Hot Coffee Due to Lack of Temperature Check
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents and injury from hot liquid spills for a resident. The incident involved a resident who sustained a thermal burn from spilling hot coffee on her leg. The coffee was served by a CNA without checking the temperature of the liquid, which was against the facility's policy of not serving liquids above 140 degrees. The resident, who had moderate cognitive impairment and required supervision for eating, was able to manage hot liquids independently according to her assessment. However, on the day of the incident, the CNA brewed coffee in the employee breakroom and served it to the resident without verifying the temperature. The resident spilled the coffee while adding sugar and creamer, resulting in second-degree burns on her thigh. Interviews with staff revealed that the facility did not have a specific policy on hot liquid management or accidents and hazards related to hot liquid spills. The DON was unaware of the incident until after it occurred, and the ADM acknowledged the lack of a policy addressing such incidents. The facility's oversight in ensuring that all hot liquids were served at a safe temperature and the absence of a comprehensive policy contributed to the deficiency.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to conduct timely and comprehensive assessments for two residents, leading to deficiencies in identifying and meeting their needs. Resident #13's Annual Minimum Data Set (MDS) assessment was not completed within the required 14 days of admission, being finalized 3 days late. Similarly, Resident #28's Admission MDS assessment was also completed 3 days past the required timeframe. These delays in completing the MDS assessments could potentially place residents at risk of not having their needs properly identified and addressed. The MDS Coordinator Resource Nurse, who assumed the role after the previous MDS nurse went on maternity leave, acknowledged the delay in completing the assessments. The nurse admitted that the assessments were part of the end-of-month tasks that were either due or overdue when she took over. Despite the absence of a specific facility policy on MDS assessments, the facility followed the Resident Assessment Instrument (RAI) Manual guidelines. The Administrator expressed an expectation for timely completion of MDS assessments according to facility policies.
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for four residents. Resident #9, a [AGE]-year-old with syncope and collapse, had an MDS assessment with an Assessment Reference Date (ARD) of 10/23/24, which was completed 3 days late. Resident #16, a [AGE]-year-old with Alzheimer's, had an MDS assessment with an ARD of 10/18/24, completed 3 days late. Resident #26, a [AGE]-year-old with hypertension, had an MDS assessment with an ARD of 10/16/24, completed 5 days late. Resident #31, a [AGE]-year-old with diabetes, had an MDS assessment with an ARD of 10/17/24, completed 4 days late. The MDS Coordinator Resource Nurse, who took over the duties on 10/22/24, acknowledged the late completion of assessments, attributing it to the transition period after the regular MDS nurse went on maternity leave. The facility did not have a specific policy related to MDS assessments but followed the Resident Assessment Instrument (RAI) Manual guidelines. The Administrator expected timely completion of MDS assessments per facility policies. The RAI guidelines require that the MDS completion date must be no later than 14 days after the ARD.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain personal hygiene. This deficiency was observed in three residents who did not receive scheduled showers or bed baths at least three times per week. The lack of proper hygiene care was evident in the residents' conditions and their reports of missed bathing schedules. Resident #173, a female with diabetes mellitus type II, COPD, and stage III pressure ulcer, required maximal assistance for personal hygiene. Despite her needs, she missed several scheduled baths over a two-month period. During an interview, she expressed dissatisfaction with her hygiene care, noting a strong body odor and unshaven facial hair. She stated that she never refused baths and emphasized the importance of hygiene for her skin healing and personal dignity. Resident #16, diagnosed with Alzheimer's disease and blindness, also required maximal assistance for bathing. She reported receiving fewer baths than scheduled, which affected her mood and sense of cleanliness. Similarly, Resident #61, with moderate cognitive impairment and incontinence issues, received inadequate bathing assistance, leading her to feel unclean and embarrassed. Interviews with CNAs and the DON revealed challenges in completing all scheduled baths, with some residents' refusals not being documented or communicated to families.
Failure to Document Necessary Diagnosis for Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of Humulin R insulin. The resident, a 76-year-old male, was admitted with diagnoses including malignant neoplasm of the colon, hypothyroidism, and unspecified protein-calorie malnutrition. However, there was no documented diagnosis of diabetes mellitus, which is necessary to justify the use of Humulin R insulin. Despite the absence of this diagnosis in the resident's face sheet, quarterly MDS assessment, and hospital history, the resident was receiving insulin treatment. Interviews with facility staff revealed a lack of clarity and responsibility in ensuring that the resident's medical records accurately reflected the necessary diagnoses for prescribed medications. The Director of Nursing (DON) acknowledged that the resident came from the hospital with insulin orders but without a diabetes diagnosis. The Medical Doctor (MD) admitted to only glancing over hospital orders and assumed the hospital should have provided the diagnosis. Various staff members, including the Assistant Directors of Nursing (ADONs), Registered Nurses (RNs), and Licensed Vocational Nurses (LVNs), described a process where multiple individuals were responsible for entering and verifying diagnoses and medication orders, but there was a breakdown in ensuring the accuracy of these records. The deficiency was further highlighted by the facility's policy on medication administration, which requires medications to be given in accordance with the resident's service plan. The lack of a documented diabetes diagnosis for the resident receiving Humulin R insulin indicates a failure to adhere to this policy, potentially placing the resident at risk for adverse drug reactions and unnecessary medication use.
Failure to Implement Gradual Dose Reductions and Appropriate Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented contraindications for three residents receiving psychotropic medications. Resident #1, a female with severe cognitive impairment and diagnoses including Tourette's Syndrome and dementia, was prescribed Risperdal 4mg twice daily without any attempt at GDR or documentation of contraindications from April 2024 to November 2024. The Director of Nursing (DON) admitted reliance on the pharmacist to manage GDRs according to CMS guidelines, but no such reductions were documented. Resident #13, diagnosed with paranoid personality disorder and dementia, was prescribed Risperdal 0.5 mg twice daily since March 2023. Despite a previous suggestion by the consultant pharmacist to reduce the dose due to potential side effects, the attending physician disagreed without providing a reason. The resident's care plan included consulting with the pharmacy and medical doctor for dosage reduction when clinically appropriate, but no further GDR attempts were made after the initial failed attempt. Resident #37, a male with vascular dementia and other mental health conditions, was prescribed Ativan and Risperidone without appropriate diagnoses for antipsychotic use. The Ativan was ordered as needed without a 14-day stop date, contrary to facility policy. The DON acknowledged the lack of appropriate diagnoses for antipsychotic use and the absence of a stop date for the PRN Ativan, which could lead to unnecessary medication use. The attending physician and consultant pharmacist confirmed the inappropriate use of antipsychotics for altered mental status, which is not an approved diagnosis for such medications.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN T, who did not perform hand hygiene after taking a blood sugar reading from a resident. This incident involved a resident with a history of diabetes mellitus, congestive heart failure, and Alzheimer's disease. The resident was on a care plan that included monitoring and managing diabetes through medication and regular blood sugar checks. On the day of the incident, LVN T entered the resident's room, took her blood sugar, and administered insulin without washing or sanitizing her hands before the procedure. Interviews with various staff members, including LVN T, LVN U, ADON B, RN Q, LVN S, ADON C, the DON, and the ADM, revealed a consensus that proper hand hygiene should be performed before and after resident care, especially when dealing with bodily fluids like blood. LVN T acknowledged the importance of hand hygiene in preventing the spread of germs and infections, such as COVID-19, but admitted to feeling uncomfortable when questioned about her actions. Other staff members reiterated the necessity of hand hygiene to prevent cross-contamination and infection, emphasizing that improper practices could lead to negative outcomes for residents. The facility's hand hygiene policy, last revised in October 2022, mandates the use of alcohol-based hand rubs or soap and water before and after direct contact with residents and after contact with blood or bodily fluids. The facility's infection control policy, revised in December 2023, outlines the importance of minimizing infection spread through proper hand hygiene. Despite these policies, the failure to adhere to them in this instance placed residents at risk of exposure to communicable diseases and infections.
Failure to Monitor Antibiotic Use for a Resident
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program by not including Resident #37 in the Tracking and Trending Log for antibiotic use. Resident #37, who was treated for a urinary tract infection with Ciprofloxacin, was not monitored as required by the facility's policy. The resident, who had a BIMS score indicating no cognitive impairment, was admitted to the hospital with a urinary tract infection and discharged with a prescription for Ciprofloxacin. Despite the administration of the antibiotic as ordered, the resident's antibiotic use was not tracked, which is a critical component of the facility's antibiotic stewardship program. Interviews with the facility's staff, including the Infection Preventionist and the Director of Nursing, revealed that Resident #37 should have been included in the tracking and trending process. The Infection Preventionist acknowledged the oversight and its potential impact on the accuracy of monitoring antibiotic use and the effectiveness of staff in-services. The Director of Nursing and the Administrator both expressed that they expected the resident to be monitored for antibiotic stewardship, highlighting a lapse in following the facility's established procedures for monitoring antibiotic use.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brentwood Terrace Healthcare And Rehabilitation | 1.8 mi | ★★★★★ | 3 | 0 |
| Avir At Paris | 2.2 mi | ★★★★★ | 5 | 0 |
| Stillhouse Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Heritage House At Paris Rehab & Nursing | 2.9 mi | ★★★★★ | 13 | 0 |
| Honey Grove Nursing Center | 20.9 mi | ★★★★★ | 10 | 1 |
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.