Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Panola County Nursing & Rehabilitation during CMS and state inspections, most recent first.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident admitted with schizoaffective disorder, bipolar type, was not properly assessed through the PASRR process. The PASRR Level 1 screening failed to indicate mental illness, and no Level II evaluation was completed, despite the resident's diagnosis and use of psychotropic medication. Staff interviews confirmed the oversight, and facility policy requiring such screenings was not followed.
Two residents did not have comprehensive, person-centered care plans implemented as required. One resident's care plan lacked interventions for the use of a self-releasing seat belt on a motorized wheelchair, despite staff needing to prompt the resident to release it. Another resident's care plan and orders did not specify the correct settings for a low air loss mattress based on her weight, and the mattress was found set incorrectly. Staff interviews confirmed that these omissions meant the residents' needs were not fully addressed.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to consider residents' trauma histories or cultural backgrounds as required.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by pest infestations and water-damaged ceiling tiles in residents' rooms. Observations revealed dead roaches, dust, and water bugs, while staff interviews confirmed ongoing issues with cleanliness and maintenance. The administration acknowledged the problems and noted efforts to address roof leaks and pest control, but deficiencies persisted, affecting residents' quality of life.
The facility failed to implement comprehensive care plans for three residents, leading to unmet needs and safety risks. One resident missed scheduled smoke breaks, another had an incomplete care plan lacking documentation for ADL dependence and medical conditions, and a third experienced falls due to missing fall mats and unaddressed contractures. Staff interviews confirmed lapses in following care plan interventions.
The facility failed to provide meaningful activities for residents in the memory care unit, as observed during multiple visits. Despite a scheduled activity plan, residents were often found without engaging activities, leading to potential boredom and behavioral issues. Staff interviews revealed a lack of sufficient dementia-focused activities and a need for more structured engagement, with the Activity Director expressing a need for additional staff to support these efforts.
A facility failed to ensure a safe environment and adequate supervision, resulting in incidents involving three residents. One resident with Alzheimer's was left unsupervised, leading to ambulation without a wheelchair. Another resident with Parkinson's suffered a skin tear during an improper transfer without a gait belt. A third resident experienced multiple falls and skin tears due to inadequate supervision and improper transfer techniques, including a fall when fall mats were not in place.
The facility failed to provide sufficient nursing staff on the secured unit, resulting in multiple falls and injuries among residents with cognitive impairments. Observations and interviews revealed that only one CNA was assigned to care for 16-20 residents, leading to periods of unsupervised care. This staffing shortage contributed to unwitnessed falls and injuries, as staff struggled to meet the residents' needs.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies affecting four residents. Wash basins were improperly stored, and wipes with feces were left on the floor, posing infection risks. Staff interviews confirmed these issues, and the facility's policies were not effectively implemented.
The facility did not implement an effective antibiotic stewardship program from January to June 2024, failing to conduct 72-hour antibiotic time-out reviews and maintain complete documentation on infection resolution. The Infection Preventionist was unable to keep up with tracking due to additional CNA duties, and antibiotics were sometimes prescribed without culture results. The Administrator acknowledged the nursing department's responsibility to ensure compliance with facility policy and state guidelines.
A resident with severe cognitive impairment and a history of wandering was improperly restrained by a CNA who locked her wheelchair brakes, preventing her from moving freely. Despite the facility's policy against restraints, the CNA's actions restricted the resident's mobility, contrary to her care plan. Staff interviews confirmed that such actions could be considered restraints and were not in line with the facility's practices.
The facility failed to maintain the dignity of two residents during care activities. A CNA pushed a resident backwards in a wheelchair, and an LVN stood while feeding another resident, both actions against facility policy. The residents had severe cognitive impairments and required assistance, highlighting the importance of maintaining dignity in care.
The facility failed to develop baseline care plans within 48 hours for two residents admitted with various medical conditions, including cellulitis, diabetes, and deep vein thrombosis. The DON admitted to not completing any baseline care plans in the past 4-6 weeks due to working as a night CNA, which hindered her ability to fulfill her duties. The ADM acknowledged the importance of these plans in guiding care until comprehensive care plans are developed, but the facility's policy was not followed.
A facility failed to update a resident's care plan to reflect changes in diet and transfer needs. The resident, with dementia and dysphagia, required a pureed diet and dependent assistance for transfers, but the care plan was not revised accordingly. Staff interviews revealed that the MDS Coordinator did not update the care plan, and the DON acknowledged the oversight, highlighting the risk of unmet resident needs.
A facility failed to provide proper respiratory care for a resident with COPD and emphysema. The resident's nebulizer mask was not stored in a bag, labeled, or dated, as required by the facility's policy. Observations showed the mask improperly placed on a bedside table and floor. Interviews with staff revealed that the night shift LVNs were responsible for labeling and dating, but this was not done, potentially risking infection.
The facility did not update the daily nurse staffing information for three consecutive days, posting outdated data instead. The DON admitted the oversight, and the ADM confirmed the lack of a policy on staff posting, which was expected to be updated daily by the DON or ADON.
A resident with severe dementia was prescribed Seroquel without an appropriate diagnosis or behavior and side effect monitoring. The facility did not document a medication review or plan, and staff interviews revealed that monitoring should have been ordered but was not. The facility's policy required a specific condition for psychotropic drug use, which was not met.
A resident with Alzheimer's and mild malnutrition struggled to eat due to the lack of a scooped plate, despite staff recognizing the need for such an assistive device. Observations showed food spillage and difficulty during meals, but no action was taken to provide the necessary equipment, contrary to the facility's policy on assistive devices.
A resident's personal refrigerator contained expired and decomposing food, posing a risk for foodborne illness. The resident, with moderately impaired cognition, was unaware of the need to check expiration dates. Interviews revealed confusion among staff about who was responsible for cleaning the refrigerators, and the facility lacked a policy on this matter.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Failure to Coordinate PASRR Assessment for Resident with Serious Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident who was admitted with a diagnosis of schizoaffective disorder, bipolar type. Upon admission, the resident's PASRR Level 1 screening form indicated no evidence or indicator of a mental illness, and no PASRR Level II screening was completed. The admission Minimum Data Set (MDS) assessment also reflected that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite documentation of an active diagnosis of schizoaffective disorder and the resident being on psychotropic medication. The comprehensive care plan noted a mood problem related to this diagnosis. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for obtaining and reviewing PASRR documentation, acknowledged that the resident's PASRR Level 1 screening should have been positive for mental illness due to the diagnosis. The MDS Coordinator was not working full time at the facility during the resident's admission period. The Administrator confirmed that the correct PASRR documentation was expected to be on file and that inaccuracies in the screening should have been corrected to allow for a Level II evaluation. Facility policy required all new admissions to be screened for mental disorders per the Medicaid PASRR process, but this was not followed in this case.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of a self-releasing seat belt for one resident and the correct settings of a low air loss mattress for another. For the first resident, who had diagnoses including cerebral palsy, paraplegia, contractures, and impaired cognitive skills, the care plan did not include specific interventions or services for the use of a self-releasing seat belt on his motorized wheelchair. Observations showed that staff placed the seat belt on the resident and required multiple prompts before he could release it himself. Interviews with facility staff, including the MDS Coordinator, LVNs, DON, and Administrator, confirmed that the use of the seat belt should have been care planned with interventions to ensure safety and proper monitoring, but this was not done. For the second resident, who had contractures, dementia, severe malnutrition, and was nonverbal and dependent for all ADLs, the care plan included the use of a low air loss mattress for pressure relief due to a history of deep tissue injury. However, the mattress was observed to be set incorrectly, and staff interviews revealed that the settings were not based on the resident's current weight and there was no physician order specifying the correct settings. The ADON and other staff acknowledged that incorrect settings could lead to increased pressure and potential skin injury, and that the care plan and orders should have included specific mattress settings based on the resident's weight. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet each resident's needs, derived from thorough assessments. In both cases, the lack of specific interventions and failure to implement or update care plans as required led to the deficiencies identified by surveyors. Staff interviews consistently indicated that the absence of these care plan details could result in unmet needs and safety concerns for the residents involved.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Environment and Adequate 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.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or address the trauma histories or cultural backgrounds of residents when delivering care or services, as required. The report does not provide specific details about the residents involved or the exact circumstances, but it documents the lack of trauma-informed and culturally competent approaches in the care provided.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its established policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified through surveyor observation and documentation review.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as observed during a survey. Specifically, the rooms of two residents were found to have dead roaches and dust, indicating a lack of cleanliness. Additionally, another resident's room had water-damaged ceiling tiles with visible water spots, which the resident reported had been an ongoing issue. The facility's maintenance staff acknowledged the problem, noting that the roof was leaking and causing the ceiling tiles to become wet and potentially hazardous. Further observations revealed that another resident's room was infested with roaches, which the resident described as unsanitary and potentially harmful. The presence of water bugs was also reported by another resident, who expressed discomfort with the infestation. Interviews with staff, including a CNA, housekeeper, and LVN, confirmed the presence of pests and water damage throughout the facility. The maintenance man and DON acknowledged the issues, with the maintenance man noting that pest control services were conducted monthly, but the effectiveness was questioned by staff. The facility's administration was aware of the pest and water damage issues, as indicated by interviews with the ADM and DON. They confirmed that pest control services were performed recently, but the presence of bugs persisted. The ADM emphasized the expectation for housekeeping to maintain cleanliness, akin to the standards of a presidential residence. The facility was in the process of addressing the roof leaks, which were recognized as a potential hazard due to the risk of mold and falling ceiling tiles. Despite these efforts, the deficiencies in maintaining a safe and clean environment were evident, impacting the residents' quality of life.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to unmet medical, nursing, mental, and psychosocial needs. For one resident, the facility did not adhere to the scheduled smoke breaks, despite the resident's care plan indicating a desire to smoke. Observations revealed that the resident was often found sitting near the designated smoking area without being taken outside, and staff interviews confirmed that there was no designated staff to assist with smoking breaks, leading to potential distress for the resident. Another resident's care plan was incomplete, lacking documentation for activities of daily living (ADL) dependence, dietary needs, vision impairment, bowel/bladder status, and several medical diagnoses, including anemia and gastroesophageal reflux disease. Observations showed the resident was sometimes unresponsive and required assistance with eating and personal hygiene, yet these needs were not adequately addressed in the care plan. The MDS Coordinator acknowledged the care plan's deficiencies, indicating that important care areas were missing. The third resident experienced issues related to contractures and fall interventions. The care plan did not address the resident's muscle contractures or limited range of motion, and there were incidents where fall mats, a critical fall intervention, were not placed as required. This oversight resulted in falls, one of which caused injury. Staff interviews highlighted a lack of adherence to care plan interventions, with the DON admitting to leaving the resident unsupervised without fall mats in place, leading to a fall with injury.
Lack of Meaningful Activities for Memory Care Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs of residents in the memory care unit, as observed during multiple visits. On several occasions, residents were found in the dining and sitting areas without engaging in meaningful activities, despite the presence of a television playing music, which did not capture their interest. The activity schedule indicated planned activities, but these were not observed during the surveyor's visits. Interviews with staff revealed that the Activity Director (AD) was responsible for activities outside the unit and only conducted one structured activity per day on the secured unit. The AD expressed a need for additional staff to provide more structured activities. Staff interviews highlighted a lack of sufficient dementia-focused activities, with some residents experiencing boredom due to inadequate engagement. A CNA mentioned that activities were scheduled at specific times, but there was a shortage of staff to conduct sensory activities. An LVN noted that while the facility provided dementia-centered care, more individualized activities could benefit residents, particularly those with a history of homemaking. The DON acknowledged the need for more structured activities and the challenges in finding suitable activities that are safe and infection control compliant. The ADM emphasized the importance of using care plans to tailor activities to residents' needs, noting that a lack of activities could lead to agitation and falls.
Inadequate Supervision and Unsafe Transfers Lead to Resident Injuries
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for residents, leading to several incidents involving three residents and three staff members. One incident involved a resident with Alzheimer's disease and severe cognitive impairment who was left unsupervised by a CNA, resulting in the resident ambulating without her wheelchair. This resident was at high risk for falls due to her medical conditions and required supervision or assistance for mobility, which was not provided at the time of the incident. Another incident involved a resident with metabolic encephalopathy and Parkinson's disease who suffered a skin tear during a transfer. The CNA responsible for the transfer did not use a gait belt, which is required for safe transfers, and the resident, who had severe cognitive impairment and was dependent on assistance for transfers, pulled away during the process, resulting in the injury. The resident's care plan indicated the need for caution during transfers to prevent such injuries, but this was not adhered to. A third resident, with a history of falls and severe cognitive impairment, experienced multiple incidents due to inadequate supervision and improper transfer techniques. This resident required two-person assistance for transfers, but was often transferred by a single CNA, leading to skin tears and falls. Additionally, the resident's fall mats, a critical intervention to prevent injury, were not consistently placed at the bedside, resulting in a fall with injury. The DON also failed to provide adequate supervision during incontinent care, leaving the resident unsupervised, which led to a fall.
Inadequate Staffing Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the safety and well-being of residents, particularly on the secured unit. Observations, interviews, and record reviews revealed that the facility did not have enough staff to meet the needs of residents, resulting in multiple falls and injuries. For instance, Resident #50, who had severe cognitive impairment and was at high risk for falls, experienced two falls resulting in injuries due to inadequate supervision. The Director of Nursing (DON) admitted to working alone on the night shift and leaving the resident unattended, which contributed to the fall. Similarly, Resident #32, who also had severe cognitive impairment and required extensive assistance, experienced multiple falls with injuries over a three-month period. The care plan for this resident included interventions such as answering call lights promptly and frequent visual checks, but these were not adequately implemented due to staffing shortages. The lack of sufficient staff to monitor and assist residents contributed to the occurrence of unwitnessed falls and injuries. Resident #31, with a moderate cognitive deficit and a history of falls, also suffered multiple falls, some of which were unwitnessed and resulted in injuries. The facility's staffing records indicated that only one CNA was assigned to the secured unit, which had an average census of 16-20 residents. Interviews with staff, including the DON and CNAs, highlighted the challenges of managing resident care with limited staff, leading to periods when residents were left unsupervised. The facility's staffing pattern, dictated by corporate policies, did not allow for adequate supervision and care, increasing the risk of falls and injuries among residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which resulted in several deficiencies affecting four residents. Specifically, the facility did not ensure that wash basins for two residents were stored properly with names and in bags, which could lead to cross-contamination and infection control issues. Observations revealed that three wash basins were found in a bathtub without names and not in bags, indicating a lack of adherence to proper infection control practices. Additionally, the facility failed to properly discard wipes with feces, which were left on the bedroom floor of two other residents. This oversight resulted in a foul odor in the room and posed a risk of exposure to communicable diseases and infections. Interviews with staff, including a CNA and the maintenance man, confirmed the presence of these issues and highlighted a lack of proper disposal practices for contaminated materials. The Director of Nursing (DON) and the Administrator acknowledged the deficiencies, noting that the CNA's were expected to label wash basins and dispose of trash correctly. The facility's Infection Prevention and Control Program Policy, dated October 2018, and the Homelike Environment Policy, dated February 2021, were not effectively implemented, as evidenced by the observed deficiencies. These failures compromised the safety, sanitation, and comfort of the residents, as outlined in the facility's policies.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program over a six-month period from January 2024 to June 2024. The program lacked adherence to established protocols, including the absence of a 72-hour antibiotic time-out review and incomplete documentation on the Tracking and Trending Logs regarding the resolution of infections. The facility's policy required prescribers to document the dose, duration, and indication for all antibiotic usage, but this was not consistently followed. Additionally, there were instances where antibiotics were prescribed prior to obtaining culture results, contrary to the facility's guidelines. The Infection Preventionist (IP) acknowledged during an interview that the tracking and trending for infection control were not completed and were behind schedule. The IP had been working additional shifts as a Certified Nursing Assistant (CNA) on the secured unit, which impacted her ability to maintain the logs. The IP emphasized the importance of minimizing antibiotic usage to prevent resistance and stated her intention to incorporate the 72-hour antibiotic time-out into the tracking log. She also mentioned encouraging the medical doctor to adhere to the guidelines of culturing before prescribing broad-spectrum antibiotics unless symptoms were severe. The Administrator (ADM) confirmed that it was the responsibility of the nursing department to ensure the antibiotic stewardship program was conducted correctly. The ADM noted that the IP had been stretched thin due to additional floor duties, but ultimately, it was their responsibility to ensure compliance with facility policy and state guidelines. The ADM acknowledged that failure to follow these protocols could lead to more serious infections among residents who are already vulnerable to infections.
Resident Restrained by Locked Wheelchair Brakes
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as observed in the case of a resident who was unable to move freely due to the actions of a CNA. The resident, who had severe cognitive impairment and was known to wander, was observed being pushed in her wheelchair by CNA A, who then locked the wheelchair brakes and walked away. This action restricted the resident's ability to self-propel and move around the secured unit, which was contrary to the facility's policy of not using restraints. The resident, who had Alzheimer's disease, dementia, and a history of wandering, was at risk for falls and required assistance for various daily activities. Despite this, the facility's care plan did not include the use of physical restraints, and the resident was supposed to be free to move around the unit. The MDS assessment indicated that the resident was understood and usually understood others, and she normally used a wheelchair for mobility. However, the locking of the wheelchair brakes by CNA A was not in line with the resident's care plan or the facility's policy. Interviews with various staff members, including the MDS Coordinator, CNA H, LVN G, the DON, and the ADM, confirmed that the facility did not use restraints and that locking a resident's wheelchair could be considered a restraint. The staff acknowledged that such actions could lead to injury or harm to the resident. The facility's policy on the use of restraints emphasized that they should only be used for the safety and well-being of residents and not for staff convenience or to prevent falls, highlighting the inappropriate nature of the CNA's actions.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during care activities. For one resident, a CNA was observed pushing the resident backwards in his wheelchair from his room to the dining room. This resident, who had severe cognitive impairment due to conditions such as metabolic encephalopathy and Parkinson's disease, was dependent on staff for daily activities. The CNA acknowledged that pushing a resident backwards could make them feel degraded and was against facility policy. In another instance, an LVN was observed standing while feeding a resident his lunch. This resident had severe dementia with agitation and dysphagia, requiring setup assistance for eating. The LVN admitted to feeding the resident while standing, despite knowing that feeding should be done at the resident's eye level to maintain dignity. Both the DON and the ADM confirmed that staff were expected to sit at the resident's level during feeding to ensure dignity and proper care. The facility's policy on resident rights emphasized treating all residents with kindness, respect, and dignity.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents within 48 hours of their admission, as required by their policy. Resident #110, a male with cellulitis, diabetes mellitus, and hypertension, was admitted without a baseline care plan. His admission MDS assessment indicated moderate cognitive impairment and required supervision for transfer, bathing, and toileting. Despite his plans to return home, no one discussed his medications or discharge plan with him, leaving him uncertain about his stay. Similarly, Resident #111, a male with deep vein thrombosis, anxiety, and hyperlipidemia, was admitted without a baseline care plan. His MDS assessment showed severe cognitive deficit and dependency for bathing, transfer, and toileting. The Director of Nursing (DON) admitted that no baseline care plans had been completed for new admissions in the last 4-6 weeks due to her working as a night CNA, which prevented her from fulfilling her responsibilities. The Administrator (ADM) expected staff to complete baseline care plans, acknowledging their importance in guiding care until comprehensive care plans are developed. The facility's policy mandates that baseline care plans be developed by RNs and other healthcare team members within 48 hours of admission, but this was not adhered to, resulting in the deficiency.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that Resident #50's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team following each assessment. Specifically, the care plan was not updated to reflect a change in diet order from regular to pureed, nor did it address the resident's swallowing disorder, which included coughing or choking during meals or when swallowing medications. Additionally, the care plan did not reflect the resident's need for dependent assistance with transfers, as indicated by the MDS assessment. Resident #50, a male with dementia and dysphagia, was admitted with a regular diet order that was later changed to pureed texture due to swallowing difficulties. Despite this change, the care plan continued to list a regular diet and did not include interventions for the resident's swallowing disorder. The MDS assessment highlighted the resident's severe cognitive impairment and dependence on assistance for daily activities, including eating and transferring, yet these needs were not accurately reflected in the care plan. Interviews with facility staff revealed that the MDS Coordinator was responsible for updating care plans but failed to do so in this case. The DON acknowledged that the resident's transfer needs had changed and should have been updated to require a two-person assist or mechanical lift. The failure to update the care plan could result in the resident not receiving appropriate interventions to meet their current needs, as staff rely on these plans to provide proper care.
Failure to Properly Store and Label Nebulizer Mask
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD) and emphysema. The resident's nebulizer mask was not stored in a bag after use, nor was it labeled and dated, as observed on two separate occasions. The resident's care plan indicated that respiratory tubing and masks should be changed every seven days, but there was no physician order specifying the frequency of changing oxygen equipment. The facility's policy required nebulizer masks to be stored in a plastic bag, marked with the date and resident's name, and changed weekly. Interviews with facility staff revealed that the nebulizer mask was not stored correctly or labeled/dated, which could lead to infection. The Licensed Vocational Nurse (LVN) stated that the night shift LVNs were responsible for labeling and dating the equipment. The Director of Nursing (DON) confirmed that the nebulizer masks should be stored in a bag and changed weekly, with the responsibility falling on the Sunday night LVNs. The Administrator acknowledged that the nursing department was responsible for respiratory equipment. The facility's policy on infection prevention for respiratory therapy tasks was not followed, leading to the deficiency.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for three consecutive days. Observations revealed that the staffing information posted on 06/03/2024 was from 05/30/2024, and the information on 06/04/2024 and 06/05/2024 was from 06/03/2024. During an interview, the Director of Nursing (DON) acknowledged the oversight and stated that it was her responsibility to update the staffing information daily, which would later be delegated to the Assistant Director of Nursing (ADON) once trained. The Administrator (ADM) confirmed that there was no policy on nurse staff posting, but it was expected to be updated daily by the DON or ADON. The failure to update the staffing information could result in the public receiving inaccurate information about the staffing levels caring for residents.
Failure to Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic drugs, specifically Seroquel, without adequate behavior and side effect monitoring. The resident, a male with severe dementia and other conditions, was prescribed Seroquel without an appropriate diagnosis for its use. The medication was intended to address unspecified dementia without behavioral disturbance, psychotic disturbance, or mood disturbance, which did not align with the facility's policy requiring a specific condition for psychotropic drug use. Additionally, the facility did not implement behavior and side effect monitoring for the resident's prescribed Seroquel. The lack of monitoring meant that there was no documentation to assess whether the medication was necessary, effective, or causing any adverse effects. Interviews with facility staff revealed that behavior and side effect monitoring should have been ordered upon admission or when the medication was prescribed, but this was not done. The Director of Nursing (DON) acknowledged the oversight, stating that the resident was admitted from the community already on Seroquel and that there were plans to discontinue the medication. However, no documentation of a medication review or facility plan was available at the time of the survey. The facility's policy on psychotropic drug use emphasized the need for a specific condition and documentation of target symptoms, which was not adhered to in this case.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide special eating equipment and utensils for Resident #19, who required assistance during meals. Observations revealed that Resident #19, who has Alzheimer's disease and mild protein-calorie malnutrition, struggled to eat using a flat plate, resulting in food spillage. Despite the resident's need for a scooped plate to prevent food from being pushed off, no assistive device was provided, and there was no physician order for such equipment. Interviews with staff indicated a lack of awareness and assessment regarding the resident's need for assistive devices. LVN D and CNA H acknowledged Resident #19's difficulties during meals, with CNA H specifically noting that a scooped plate would benefit the resident. However, there was no communication or action taken to provide the necessary equipment. The staff's failure to assess and provide the required assistive device contributed to the resident's challenges in consuming meals independently. The facility's policy on assistive devices and equipment, revised in January 2020, mandates the assessment and provision of such devices based on comprehensive evaluations documented in the resident's care plan. Despite this policy, the interdisciplinary team, including the nurse, CNA, dietary staff, and DON, did not adequately assess Resident #19's needs, resulting in the resident's continued struggle with meal consumption and potential risk for weight loss and diminished independence.
Failure to Maintain Safe Food Storage in Resident's Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in a resident's personal refrigerator, which could place the resident at risk for foodborne illnesses. Specifically, the refrigerator of a male resident with Parkinson's Disease, Hypomagnesemia, and Dysphagia contained expired and decomposing food items, including a blackened banana, a container of watermelon with an unidentifiable clear white slime, and expired bologna lunch meat. The resident, who had moderately impaired cognition, was unaware of the need to check for expiration dates and did not recall when the refrigerator was last cleaned. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning residents' personal refrigerators. A housekeeper stated she was not informed that cleaning these refrigerators was part of her duties, while the DON indicated it was the housekeeping staff's responsibility. The Administrator mentioned that all staff were responsible for this task but acknowledged the absence of a specific policy regarding personal refrigerators. This lack of clear responsibility and policy led to the oversight of spoiled food in the resident's refrigerator.
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 31 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 | 0.9 mi | ★★★★★ | 9 | 1 |
| Avir At Carthage | 1.5 mi | ★★★★★ | 19 | 0 |
| Heritage House Of Marshall Health & Rehabilitation | 23.3 mi | ★★★★★ | 3 | 0 |
| Garrison Nursing Home & Rehabilitation Center | 25 mi | ★★★★★ | 0 | 0 |
| Marshall Manor West | 25.4 mi | ★★★★★ | 18 | 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.