Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Park Village Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident's quarterly MDS assessment failed to document wandering behavior and incorrectly omitted a dementia diagnosis, despite multiple Elopement Wandering assessments listing dementia. The DON acknowledged errors in selecting diagnoses and stated that staff are responsible for assessment accuracy, while the administrator recognized that inaccurate records could affect assessment outcomes.
A resident with severe cognitive impairment and a history of wandering was not provided with a care plan addressing wandering behaviors until these behaviors increased and the resident was moved to memory care. Despite staff and leadership being aware of the resident's wandering, the care plan lacked measurable objectives and interventions for this issue until it escalated.
A resident with severe cognitive impairment and multiple medical conditions had routine and increased wandering behaviors that were not documented in the medical record or progress notes. Multiple elopement risk assessments incorrectly listed dementia as a diagnosis, despite the resident not having this diagnosis. The DON and Administrator confirmed these documentation errors, which were inconsistent with facility policy requiring accurate and comprehensive records.
Two residents with cognitive and psychiatric impairments were left unsupervised, resulting in one resident engaging in inappropriate sexual contact with another. Staff had previously documented escalating intrusive and aggressive behaviors by the resident, but did not implement effective supervision or interventions. The incident was not properly documented or reported to medical providers or family, and facility leadership failed to take immediate protective actions, leaving other residents at risk.
Two residents with cognitive impairment were found alone in a dining room, where one was observed by a CNA engaging in inappropriate sexual contact with the other, who was found without a brief. The facility's investigation was inconsistent and incomplete, with the Administrator and DON failing to report the incident as abuse, not notifying the medical provider, and not following the facility's abuse and neglect policy for investigation and resident protection.
Facility staff did not immediately notify a resident, the resident's physician, or the designated representative after a significant change in condition involving sexual abuse. A female resident with severe cognitive impairment was found by a CNA in a compromised state with a male resident present. The CNA reported the incident to an LVN, who notified the Administrator and performed an assessment, but no documentation or notifications to the physician or representative were made as required by facility policy. The NP was also not informed of the incident, and the designated representative confirmed they were not notified.
The facility did not report an incident where one resident was found massaging another resident's breast after removing her adult brief, despite clear evidence and policy requirements. The event was not documented in progress notes, nor was it reported to authorities or the resident's representative, and the Administrator determined it was not reportable, contrary to regulations. Both residents had significant cognitive impairments and care plans indicating vulnerability.
Two residents with severe cognitive impairment were involved in a physical altercation after one entered the other's room to retrieve personal belongings, leading to a physical assault and a scratch injury. Despite care plans addressing behavioral risks and staff training on abuse prevention, the incident was not prevented, and staff intervened only after being alerted by a vendor.
Staff failed to sanitize the food thermometer between checking different food items and did not check the temperatures of certain foods before serving them to residents. The Dietary Manager and DON confirmed that these actions could result in cross-contamination and serving undercooked food, contrary to facility policy and FDA guidelines.
Surveyors found unlocked Hoyer lifts, bed frames, and beds left in hallways, as well as a pallet with boxes stored upright near a storage closet, creating fall and injury concerns. Interviews with CNAs, an LVN, the DON, and other staff revealed inconsistent practices and unclear responsibility for securing and storing equipment, contrary to the facility's stated commitment to a safe and comfortable environment.
A medication cart on one hall was left unlocked and unattended for several minutes, with no staff present and the drawers facing the hallway. An LVN acknowledged not locking the cart before leaving to assist a resident, and staff interviews confirmed that carts should be locked when not in use. Facility policy requires all drugs and biologicals to be stored in locked compartments accessible only to authorized personnel.
A resident with moderate cognitive impairment and multiple diagnoses was unable to file grievances anonymously due to the facility's process requiring forms to be obtained from the receptionist, limiting access. Staff interviews revealed confusion about the grievance process, and observations confirmed that anonymous filing was not possible, contrary to facility policy.
A facility failed to maintain an effective infection control program, resulting in a gastrointestinal outbreak affecting numerous residents. Symptomatic individuals were not isolated, participated in group activities, and shared rooms with non-symptomatic residents. Staff did not consistently use proper PPE or follow hand hygiene protocols during care, and the outbreak was not reported to local authorities. These failures led to the spread of infection among residents, including those with cognitive impairments and high care needs.
A resident with a history of stroke and communication difficulties experienced ongoing tooth pain that was managed with pain medications, but there was a significant delay in arranging a dental referral and appointment. Despite documentation of pain and a care plan addressing communication barriers, the referral process was not initiated promptly due to lapses in communication between nursing staff and the social worker. The resident was not seen by dental services until more than a month after the initial complaint.
Three residents with cognitive and physical impairments did not receive necessary nail care, resulting in long and dirty fingernails despite care plans and facility policy requiring regular cleaning and trimming. Staff interviews confirmed that CNAs and nurses were responsible for this care, but it was not provided as needed.
Surveyors found that two medication carts contained controlled medications with broken blister pack seals, and staff failed to report or discard the affected pills as required by facility policy. Both a CMA and an LVN were unaware of when the seals became broken, and the DON confirmed that such medications should have been discarded to prevent errors or diversion.
Surveyors found that two residents' bathroom call light systems were either inaccessible or missing, with one pull string wrapped around a grab bar and another missing entirely, leaving residents unable to call for assistance if needed. Interviews with the maintenance supervisor, DON, and Administrator confirmed awareness of the issue and the facility's policy requiring accessible call systems.
A shared bathroom used by two residents had an ongoing water leak from under the toilet, with water spreading across the floor to the shower drain. The Maintenance Director and other staff were unaware of the leak, and required procedures such as reporting the hazard and placing wet floor signage were not followed, resulting in unsanitary and unsafe conditions.
A resident with severe cognitive impairment was struck in the right eye by another cognitively impaired resident, resulting in bruising. The incident occurred in front of the nursing station and was witnessed and interrupted by a CNA. Both residents were assessed, and the event was reported to facility leadership, but not further reported due to lack of perceived intent. Facility policy addresses abuse prevention and monitoring of aggressive behaviors.
Two residents with severe cognitive impairment were involved in an altercation resulting in a bruise, which was witnessed and internally reported by staff but not reported to the State Survey Agency as required by facility policy. The DON and Administrator determined not to report the incident externally due to lack of intent and memory of the event by the residents, leading to a deficiency in abuse reporting procedures.
A resident with severe cognitive impairment and multiple medical conditions was found with the call light out of reach, contrary to facility policy. Staff interviews confirmed the importance of ensuring call light accessibility to prevent risks such as falls and injuries. The facility's policy requires the call device to be within reach before staff leave the room.
A resident with severe cognitive impairment and an indwelling suprapubic catheter was found with their catheter drainage bag resting on the floor, contrary to facility guidelines. Staff interviews confirmed the importance of keeping the bag off the floor to prevent infections, highlighting a lapse in catheter care that posed a risk to the resident.
A resident with a suprapubic catheter was not provided care in accordance with Enhanced Barrier Precautions (EBP) due to a failure by an LVN to wear the required PPE, specifically a gown. The facility lacked proper signage and PPE supplies, despite policies requiring these measures for residents with indwelling devices to prevent the spread of infections. Interviews confirmed the oversight, highlighting a lapse in infection control practices.
The facility failed to maintain a safe environment for five residents due to an ant infestation in their rooms. Despite reports of ants on residents and in their beds, there was inconsistent documentation and follow-up. The pest control measures were inadequate, leading to recurring ant sightings and a lack of coordination among staff to address the issue effectively.
A facility failed to maintain a safe environment by not adequately addressing an ant infestation in resident rooms, affecting five residents. Despite reports of ants on residents and in their rooms, there was inconsistent documentation and follow-up. Staff interviews revealed a lack of awareness and communication about the issue, and the facility lacked a clear incident policy.
The facility failed to document incidents involving black ants found in the rooms and beds of five residents, leading to incomplete medical records. Despite reports from residents and family members, the nursing staff did not complete incident reports, skin assessments, or progress notes. Interviews revealed inconsistencies in reporting practices, with some staff unaware of the incidents and others not following documentation procedures.
A deficiency in the pest control program at a facility led to black ants infesting several residents' rooms. Despite reports and some treatments, there were inconsistencies in documentation and communication among staff. Residents experienced ants on their bodies and in their beds, but follow-up actions like skin assessments were not consistently performed. Maintenance and housekeeping staff attempted to address the issue, but challenges in communication and procedure implementation persisted.
A treatment cart was found unlocked and unattended in a hallway, containing various medical supplies. Nurse A, responsible for the cart, indicated it was left unlocked by the previous shift. Interviews with staff, including the ADON, DON, and Administrator, acknowledged the risk of residents accessing unauthorized medications. The facility's policy requires all drugs to be stored in locked compartments, accessible only to authorized personnel.
A facility failed to administer medications properly to a resident with dementia, depression, and diabetes. Observations revealed pills on the floor, indicating the resident did not receive all prescribed medications. The MA responsible did not verify if the resident swallowed the pills, and the DON acknowledged the risk of worsening conditions due to missed doses.
A resident with multiple medical conditions requiring Enhanced Barrier Precautions (EBP) did not receive care in accordance with infection control protocols. Two CNAs failed to wear the necessary PPE, such as gowns, during high-contact care activities, despite signage indicating the requirement. The Director of Nursing acknowledged the risk of infection spread due to non-compliance, and the facility's infection prevention policy lacked guidance on EBP.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically regarding wandering behavior and dementia diagnosis. The quarterly Minimum Data Set (MDS) assessment did not document wandering behaviors in Section E, despite other records, such as the quarterly Elopement Wandering assessments, repeatedly listing dementia as a diagnosis for the resident. The resident's face sheet did not include dementia as a diagnosis, and the resident had a BIMS score indicating severe cognitive impairment. The discrepancy between the MDS and other assessments, as well as the inconsistent documentation of dementia, was identified during record review and interviews. During interviews, the DON acknowledged that dementia was incorrectly selected as a diagnosis on multiple Elopement Wandering assessments and admitted to not being aware of her own error in selecting dementia on one of the assessments. The DON also stated that whoever completed the assessment was responsible for its accuracy and recognized that incorrect documentation could affect assessment outcomes. The administrator, lacking a clinical background, also noted that inaccurate information in the electronic record could impact assessment results. Facility policy requires comprehensive and accurate assessments, but this was not followed in this instance.
Failure to Address Resident Wandering in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for a resident with multiple complex diagnoses, including heart failure, schizoaffective disorder, insomnia, dysphagia, repeated falls, type 2 diabetes, hypertension, muscle weakness, and cognitive communication deficit. Despite a history of wandering behavior, the resident's care plan did not address wandering until a significant increase in wandering was observed, at which point the resident was moved to memory care and the care plan was updated. Prior to this, the care plan lacked measurable objectives and timeframes to address the resident's wandering, even though staff and leadership were aware of the behavior. Interviews with the DON, Administrator, and staff confirmed that the resident had a longstanding pattern of wandering within the facility, which had recently escalated to include entering other areas such as resident rooms and administrative offices. The omission of wandering from the care plan meant that staff may not have been fully informed of the resident's behaviors or the best interventions to use. Facility policy required that assessment information be used to develop and revise comprehensive care plans, but this was not followed in the case of this resident until the behavior became more pronounced.
Failure to Accurately Document Resident Wandering and Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including heart failure, schizoaffective disorder, insomnia, dysphagia, repeated falls, type 2 diabetes, essential hypertension, muscle weakness, and cognitive communication deficit. Despite the resident exhibiting routine wandering behaviors since admission and an increase in wandering 2-4 weeks prior to a specific date, these behaviors were not documented in the resident's electronic medical record or progress notes. The care plan did not address wandering until a later date, and incident logs did not reflect any wandering incidents. Quarterly Minimum Data Set (MDS) assessments consistently indicated severe cognitive impairment but did not document wandering behaviors or a diagnosis of dementia. However, multiple quarterly elopement risk assessments incorrectly listed dementia as a diagnosis, despite the resident not having this diagnosis according to the MDS and statements from the DON. The DON acknowledged that the incorrect selection of dementia could affect the outcome of risk assessments and that wandering behaviors should have been documented in all relevant assessments and progress notes. Interviews with the DON and Administrator confirmed that the lack of documentation regarding the resident's wandering was an oversight, with the DON attributing it to staff possibly not paying attention or accidentally selecting the wrong diagnosis. Both acknowledged that the responsibility for accurate documentation lay with the staff completing the assessments and that the facility's policies required comprehensive and accurate documentation of resident care, assessments, and behaviors.
Failure to Prevent and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to prevent inappropriate sexual behavior between them. One resident with severe cognitive impairment and another with moderate cognitive impairment and a history of psychiatric issues were left unsupervised in the dining room, where a certified nursing assistant (CNA) observed one resident massaging the breast of the other over her clothing. The CNA also noted that the female resident's bra was around her waist and she was not wearing a brief. Prior to this incident, the male resident had been documented as exhibiting increasingly erratic and intrusive behaviors, including entering other residents' rooms, being verbally aggressive, and being difficult to redirect. These behaviors were noted by multiple staff members and documented in progress notes, but no effective interventions or increased supervision were implemented to address the escalating risk. Despite clear documentation of the male resident's behavioral changes and repeated incidents of him entering other residents' rooms, staff did not provide adequate supervision or take preventive measures. The incident in the dining room was not properly documented in the residents' progress notes, and there was no notification to the physician or the designated representative regarding the sexual abuse incident. The facility's incident reports for the relevant period did not include this event, and the initial internal investigation discounted the CNA's account due to perceived inconsistencies, leading to a determination that no abuse had occurred. As a result, both residents remained on the same locked unit without additional monitoring or safeguards in place. Interviews with staff and review of facility records revealed a lack of immediate protective actions and failure to follow abuse prevention policies. The administrator and DON did not take action after being notified of the incident, and the male resident was not placed under increased supervision until after the event was identified by surveyors. The nurse practitioner was not informed of the potential sexual abuse, and there was no evidence of timely or appropriate notification to medical providers or family members. This series of inactions and failures to document, report, and intervene placed other residents at risk of abuse and neglect.
Failure to Investigate and Respond to Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of inappropriate sexual behavior between two residents. One resident with severe cognitive impairment and another with moderate cognitive impairment and a history of psychiatric illness were found alone in the dining room, where a certified nursing assistant (CNA) observed one resident massaging the other's chest and discovered that the cognitively impaired female resident's brief was removed. The CNA intervened, removed the female resident from the situation, and notified the nurse. The incident was reported to the Director of Nursing (DON) and the Administrator, but the subsequent investigation was inconsistent and incomplete. The facility's investigation did not include a thorough review of the incident. The CNA's written and verbal statements were inconsistent, and the Administrator and DON determined that nothing had happened between the residents based on this discrepancy, despite physical evidence such as the removed brief and the residents being alone together. The Administrator described the investigation as a "soft investigation" and did not report the incident as abuse, nor did they notify the nurse practitioner of the potential sexual abuse. The medical provider was not informed of the incident until after state surveyors were present in the facility. Additionally, the facility did not separate the residents or provide increased supervision immediately following the incident, as required by their own abuse and neglect policy. The facility's policy required immediate and thorough investigation of all allegations of abuse, including interviews, medical assessments, and documentation. However, the investigation lacked key elements such as interviews with all relevant staff, timely notification of the medical provider, and adequate protection of the alleged victim. The failure to follow policy and thoroughly investigate the incident placed residents at risk for abuse and neglect, and led to the identification of Immediate Jeopardy by surveyors.
Failure to Notify Physician and Representative After Resident Sexual Abuse Incident
Penalty
Summary
Facility staff failed to immediately inform a resident, the resident's physician, and the designated representative following a significant change in the resident's condition involving an incident of sexual abuse. The incident involved a female resident with severe cognitive impairment and a history of senile degeneration of the brain, who was found by a CNA in the dining room with her bra around her waist and without a brief, while a male resident with moderate cognitive impairment and a history of brain compression and schizophrenia was present. The CNA observed the male resident massaging the female resident's breast over her blouse and holding her undergarments. The CNA reported the incident to an LVN, who then notified the Administrator and performed a skin assessment on the female resident, finding no injuries or distress at that time. Despite the incident, there was no documentation in the progress notes regarding the event, nor was there any notification to the physician or the designated representative of the female resident. The LVN stated she was instructed by the DON to wait for clarification from the Administrator before documenting the incident or notifying the physician and family. The Administrator later acknowledged that the nurse was supposed to notify medical staff, the designated representative, the DON, and Administration, but this did not occur due to improper education of the nurse. The DON was uncertain about who made the decision not to notify the designated representative, and the designated representative confirmed they had not been informed of the incident. The nurse practitioner (NP) for the residents was also not notified of the potential sexual abuse and only became aware of a significant event when informed that state surveyors were present in the facility. The facility's policy required licensed nurses to inform family or responsible parties of changes in condition and to document all nursing actions, physician contacts, and resident assessments in the nursing progress notes. These steps were not followed in this case, resulting in a failure to meet notification and documentation requirements after a significant change in a resident's condition.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made. Specifically, the facility did not report an incident involving two residents, where one was found massaging the breast of another after removing her adult brief, to local law enforcement or the State Survey Agency as required. The incident was observed by a CNA, who found the two residents alone in the dining room, with one resident's bra around her waist and her brief missing, while the other resident was holding the brief. The CNA intervened, ensured the resident was dressed, and notified the nurse, who then informed the Administrator. Record reviews revealed that there was no documentation of the sexual incident in the progress notes, nor was there any documentation of notification to the doctor or the designated representative. The Administrator conducted what he described as a "soft investigation" and determined that the incident was not reportable, despite the circumstances and the facility's own abuse and neglect policy, which requires immediate reporting of such allegations. The Administrator stated that he could not assume anything had happened between the residents because there were no witnesses, even though the CNA's account and the video evidence indicated otherwise. The residents involved had significant cognitive impairments and care plans that identified risks such as impaired mobility, self-care deficits, and potential for aggressive behaviors. The facility's failure to report the incident as required by policy and regulation resulted in a deficiency, as it did not follow established procedures for reporting suspected abuse, neglect, or exploitation to the appropriate authorities within the mandated timeframe.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when an altercation occurred between two residents, resulting in one resident sustaining a scratch on his nose. Both residents involved had severe cognitive impairment and a history of dementia and cerebrovascular accidents, with one resident also experiencing hemiplegia. The incident took place when one resident entered the other's room, reportedly to retrieve personal belongings he believed were left there, as it had previously been his room. The resident occupying the room was asleep, became startled upon awakening to find someone going through his belongings, and responded by physically assaulting the other resident, including punching and overturning his wheelchair. Prior to the incident, both residents had been roommates and reportedly got along well, but one had requested a room change, which was accommodated. There was no documented history of aggression between the two residents before this event. The care plans for both residents included interventions for managing physical behaviors and aggression, such as 1:1 monitoring, psychiatric consults, and de-escalation techniques. However, at the time of the incident, these interventions did not prevent the altercation from occurring, and the staff were alerted to the situation by a vendor who witnessed the fight. Upon arrival, staff found one resident on the floor and the other actively hitting him. The staff separated the residents and assessed the injured resident, who was found to have a bleeding scratch on his nose. Interviews with staff and review of records confirmed that the residents had not previously exhibited aggressive behavior toward each other or other residents. The facility's policy required separation of residents involved in altercations and ongoing assessment, but the incident demonstrated a failure to protect the resident from abuse as required.
Failure to Sanitize Thermometer and Check Food Temperatures in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen operations. During breakfast service, the cook did not sanitize the food thermometer between checking different food items, instead wiping it with a rag that was sitting on a cart. The cook also did not check the temperatures of certain foods, including cinnamon rolls, biscuits, and fried eggs, before serving them to residents. The cook stated that alcohol swabs were not available at the time, and the Dietary Manager confirmed that swabs should have been present in the kitchen. The Dietary Manager also acknowledged that not sanitizing the thermometer between uses could expose residents to bacteria and infection, and that not checking food temperatures could result in serving undercooked food. Record review showed that the facility's policy requires prevention of food contamination to avoid foodborne illness, and FDA guidelines emphasize the importance of using a food thermometer to ensure food safety. Interviews with the Dietary Manager and DON confirmed that these lapses in procedure could lead to cross-contamination and serving inadequately cooked food. The report also referenced a recent incident involving undercooked chicken being served to a resident, further highlighting the failure to follow safe food handling practices.
Failure to Secure Equipment and Maintain Safe Hallways
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of three halls reviewed. On multiple occasions, surveyors observed unlocked Hoyer lifts, bed frames, and beds left in the hallways of Halls 100 and 400. Additionally, a pallet with boxes was found upright against a wall near a storage supply closet. These items were not properly secured or stored, creating potential fall and injury concerns for residents. Interviews with CNAs, an LVN, the DON, the Central Supplies Coordinator, the Maintenance Director, and the Administrator revealed inconsistent understanding and practices regarding responsibility for securing and storing equipment. Staff members variously stated that CNAs, nursing staff, or everyone was responsible for locking and storing Hoyer lifts and other equipment after use. The Central Supplies Coordinator and Maintenance Director described their roles in removing pallets and boxes, but acknowledged that these items were sometimes left in hallways. The facility's admission packet indicated residents have a right to a safe, clean, comfortable, and homelike environment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency occurred when a medication cart on Hall 400 was left unlocked and unattended for approximately five minutes in front of the nurse's station. The drawers of the cart faced the hallway, and no staff were present in the area during this time. LVN A was observed walking by the cart, pressing the lock closed, and then leaving the hall with a resident, but the cart remained unlocked. No residents or visitors were in the immediate area at the time of the observation. Interviews with staff confirmed that the medication cart should be locked when not in use to prevent unauthorized access. LVN A acknowledged that she should have locked the cart before leaving to check on a resident who had returned from dialysis. The DON also stated that medication carts must be locked to prevent drug diversion and unauthorized access. Review of the facility's policy indicated that all drugs and biologicals are to be stored in locked compartments, accessible only to authorized personnel.
Failure to Provide Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to ensure that a resident had access to file grievances anonymously, as required by policy. Record review showed that all grievances for the resident were not filed anonymously, and the resident reported not knowing where grievance forms were located or how to file a grievance anonymously. The resident, who had a history of stroke and diabetes and was moderately cognitively impaired, kept a personal notebook of complaints and relied on staff to make copies, but felt her concerns were not addressed. Interviews with staff revealed uncertainty about whether grievances had been filed for the resident and indicated that grievance forms were only available through the receptionist, limiting anonymous access. Further interviews confirmed that there was no established process for residents to file grievances anonymously, and the social worker, who served as the grievance official, stated that residents could only report concerns directly to her or through staff. Observations showed that blank grievance forms were kept at the receptionist desk and were not freely accessible to residents without staff assistance. The facility's policy required making information on filing grievances available to residents, but this was not effectively implemented, resulting in the deficiency.
Failure to Implement and Maintain Infection Control Program During GI Outbreak
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in an outbreak of suspected norovirus among residents. Surveyors found that the facility did not identify the outbreak in a timely manner, did not isolate symptomatic residents, and allowed residents with gastrointestinal symptoms to participate in group activities and dine with others who were not ill. Additionally, symptomatic residents were housed in rooms with non-symptomatic residents, and proper cleaning and decontamination of infected rooms was not performed. The facility also failed to report the outbreak to local authorities and did not have a system in place to evaluate or screen employees for symptoms such as nausea, vomiting, and diarrhea. Direct observations and record reviews revealed multiple instances where staff did not follow standard infection control practices. For example, a CNA failed to change gloves and perform hand hygiene during incontinence care for a resident, and another CNA did not wear appropriate PPE when providing care to a resident on enhanced barrier precautions. During wound care for a resident on enhanced barrier precautions, the ADON did not don the required PPE. These lapses in infection control were observed despite the presence of signage and available supplies for PPE outside resident rooms. Staff interviews indicated a lack of awareness or adherence to infection control protocols, with some staff denying the presence of symptoms among residents despite documentation to the contrary. The outbreak affected a significant number of residents, with documentation showing multiple cases of nausea, vomiting, and diarrhea over several days. Physician orders for symptomatic treatment were given, but isolation and transmission-based precautions were inconsistently implemented. Residents with cognitive impairments and those dependent on staff for care were among those affected. The facility's failure to implement and train staff on transmission-based precautions, as well as to maintain surveillance and reporting systems, contributed to the spread of infection and placed residents at risk for further complications.
Delay in Dental Referral and Care for Resident with Tooth Pain
Penalty
Summary
The facility failed to provide timely routine and 24-hour emergency dental care for a resident who began experiencing tooth pain. The resident, a male with a history of stroke, cognitive communication deficit, and unspecified pain, reported tooth pain starting on 02/11/25. Despite ongoing complaints of tooth pain, which were documented in the medical record and managed with pain medications such as acetaminophen and tramadol, there was a significant delay in arranging a dental referral and appointment. The resident's care plan included monitoring for nonverbal indicators of discomfort due to expressive aphasia and slurring, and staff documented multiple instances of tooth pain and administration of pain medication. Although the nurse practitioner was notified and a dental referral was ordered, the referral process was not completed in a timely manner. The social worker, responsible for dental referrals, was not made aware of the resident's dental pain in February and only initiated the referral process after being informed in March. The dental referral was faxed on 03/14/25, and the resident was seen by dental services on 03/21/25, more than a month after the initial complaint of tooth pain. Interviews with nursing staff and the social worker confirmed that communication lapses contributed to the delay in the referral process. The facility's policy required timely arrangements for outside services, but the resident did not receive prompt dental care as required. The delay in providing dental services was acknowledged by both the social worker and the administrator, who stated that referrals should typically be completed within a few days.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for three residents who were dependent on staff for care. Observations and interviews revealed that these residents had excessively long and dirty fingernails, with dark or black substances underneath, indicating a lack of routine nail care. Staff interviews confirmed that nail care, including cleaning and trimming, was the responsibility of CNAs unless the resident had diabetes, in which case nurses were responsible. However, the required care was not provided as needed. Resident assessments showed that all three residents had significant cognitive and/or physical impairments, requiring extensive or maximal assistance with personal hygiene. Care plans for these residents included interventions for staff to provide the necessary level of physical assistance with ADLs, but these interventions were not consistently implemented. Observations on multiple dates confirmed that the residents' fingernails were not maintained according to facility policy or care plan expectations. Interviews with CNAs, an LVN, and the DON confirmed that nail care should be performed regularly and as needed, and that failure to do so could pose risks such as infection or skin breakdown. The facility's own policy required routine cleaning and inspection of nails during ADL care, with additional care provided as needed, but this was not followed for the residents in question.
Failure to Discard Controlled Medications with Broken Seals
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the proper handling of controlled medications on two medication carts. Specifically, surveyors observed that blister packs containing controlled medications—Clobazam 20 mg for one resident and Tylenol with Codeine #4 for another—had broken seals with the pills still inside. In both cases, the medication count sheets matched the physical count, but the staff members responsible (a CMA and an LVN) were unaware of when the blister pack seals became broken. Both staff members acknowledged that the medication should have been discarded if the seal was broken, as per facility policy, but this was not done. Interviews with the staff and the DON confirmed that the expectation was for any medication with a broken seal to be discarded to prevent potential diversion or medication errors. The DON stated that charge nurses are responsible for checking medication carts daily for such issues during shift counts. The facility's policy also indicated that deteriorated or compromised drugs should not be used and must be returned or destroyed. Despite these policies, the failure to promptly identify and report the damaged blister packs resulted in the continued storage of potentially compromised controlled medications.
Inaccessible and Missing Call Light Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure the call light system was accessible in two residents' bathroom areas. In one room, the call light pull string was found entwined around a grab bar fixture, positioned two feet from the floor, making it inaccessible to a resident lying on the floor. In another room, the call light pull string was missing entirely, and the call light outlet did not have a push button, leaving no means for a resident to activate the system from the bathroom. Interviews with the maintenance supervisor confirmed that it was his responsibility to ensure the call lights were fixed and accessible, and he acknowledged that missing or inaccessible call light strings could prevent residents from calling for help. The DON and Administrator both stated that any issues with the call light system should be reported to maintenance and fixed, and recognized the risk to residents if they are unable to communicate their needs. Facility policy requires that residents have a means of communication with nursing staff, but this was not met in the observed cases.
Failure to Address Bathroom Water Leak and Maintain Sanitary Environment
Penalty
Summary
A deficiency was identified in the facility's failure to maintain a sanitary, orderly, and comfortable environment in one of the resident rooms. Specifically, a shared bathroom in room 301, used by two residents, was observed to have a water leak coming from underneath the toilet seat, with water crossing in front of the sink and going to the shower drain. The Maintenance Director confirmed the leak was from under the toilet tank after flushing the toilet and stated he was previously unaware of the issue. He also noted that his staff perform monthly water flushes and room checks but had not identified this leak. Interviews with staff, including an LVN, the DON, and the administrator, revealed that none were aware of the water on the bathroom floor prior to the surveyor's observation. The facility's policy requires staff to report such hazards, log them in the maintenance system, and place wet floor signage, but these actions were not taken. The presence of water on the floor was not reported or addressed, resulting in a failure to provide necessary housekeeping and maintenance services to ensure a clean and safe environment for the residents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was physically struck in the right eye by another resident, also with severe cognitive impairment, resulting in bruising. The incident took place in front of the nursing station, where a CNA intervened and separated the two residents. Both residents were assessed by an LVN, who noted the injury to the victim and reported the incident to the medical director, ADON, and DON. Interviews with staff revealed that the incident was not immediately recalled by the LVN until she reviewed her notes. The CNA confirmed witnessing the altercation and intervening promptly. Both residents involved were unable to recall the incident during interviews conducted the following day, and no other altercations between them were reported by staff. The DON and Administrator reviewed the incident and determined it was not reported further because they did not identify intent to injure. Facility policy defines abuse as the willful infliction of injury, and the policy includes measures for identifying and monitoring residents with behaviors that could lead to conflict, such as physical aggression. The failure to protect the resident from physical abuse by another resident was identified as a deficiency.
Failure to Immediately Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report an alleged act of physical abuse involving two residents with severe cognitive impairment. According to interviews and record review, an altercation occurred in front of the nursing station where one resident struck another, resulting in a bruise under the right eye of the resident who was hit. The incident was witnessed by a CNA, who separated the residents, and was subsequently assessed by an LVN. The LVN reported the incident internally to the MD, ADON, and DON, but no external report was made to the State Survey Agency as required. The DON and Administrator reviewed the incident and decided not to report it externally, citing a lack of identifiable intent to injure and the residents' inability to recall the event. Facility policy, however, requires all allegations of abuse or neglect to be reported to appropriate state or federal agencies within specified timeframes. The failure to report the incident externally constituted a deficiency in the facility's abuse reporting procedures.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light system was within reach, which is a necessary accommodation for the resident's needs and preferences. The resident, a male with severe cognitive impairment and multiple medical conditions including neurogenic bladder, multiple sclerosis, and hemiplegia, was observed lying in bed with the call light placed on top of the nightstand, out of reach. This oversight was noted during an observation and interview with an LVN, who acknowledged the call light should always be within the resident's reach to prevent risks such as falls and injuries. Interviews with the LVN, the Director of Nursing (DON), and the Administrator confirmed that it is the responsibility of all staff to ensure the call light is accessible to residents before leaving the room. The facility's policy, revised in 2007, also mandates that the call device be placed within the resident's reach. The failure to adhere to this policy could result in residents being unable to communicate their needs and receive timely assistance, as emphasized by the staff and administration during the interviews.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with severe cognitive impairment and multiple medical conditions, including neurogenic bladder and multiple sclerosis. The resident, who was totally dependent on staff for activities of daily living, had an indwelling suprapubic catheter. The facility's comprehensive care plan and physician orders required that the catheter drainage bag be kept below the level of the bladder and off the floor to prevent urinary tract infections. However, during an observation, the resident's catheter drainage bag was found resting on the floor while the resident was lying in bed. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that the catheter drainage bag should be kept off the floor to prevent infection. The LVN acknowledged the risk of infection due to the drainage bag's position and noted the challenge of maintaining the bed at a low position due to the resident's fall risk. The facility's infection control policy also emphasized the importance of keeping the catheter tubing below the bladder level. Despite these guidelines, the failure to maintain the catheter drainage bag off the floor was observed, posing a risk of infection to the resident.
Inadequate Infection Control Practices for Resident with Indwelling Device
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during the care of a resident with a suprapubic catheter. The resident, who has a history of cerebral palsy, neurogenic bladder, and mild intellectual disabilities, was on Enhanced Barrier Precautions (EBP) due to the presence of an indwelling medical device. Despite this, LVN A did not wear the required personal protective equipment (PPE), specifically a gown, while providing care. This oversight occurred even though the facility's policy mandates the use of gown and gloves for high-contact care activities to prevent the transmission of multi-drug resistant organisms (MDROs). The deficiency was further compounded by the absence of signage and PPE supplies outside or inside the resident's room, which should have indicated the need for EBP. Interviews with LVN A and the Director of Nursing (DON) confirmed the lapse in protocol, with LVN A acknowledging the failure to don the appropriate PPE and the DON emphasizing the importance of EBP for residents with indwelling devices. The facility's administrator also noted the lack of signage and supplies, despite a recent in-service training on EBP. This failure placed residents at risk of exposure to infectious agents, as the facility did not adhere to its infection control policies.
Ant Infestation in Resident Rooms
Penalty
Summary
The facility failed to provide a safe environment for five residents, as their rooms were infested with black ants over a period of several weeks. The presence of ants was noted in the rooms of these residents, with some residents reporting ants on their bodies and in their beds. Despite the residents' complaints and observations by staff and visitors, there was a lack of consistent documentation and follow-up actions to address the ant infestation effectively. Resident #1, a male with multiple health conditions including anemia, renal insufficiency, and hemiplegia, reported having ants all over him while in bed. Although the room was sprayed and cleaned, there was no documentation of a thorough assessment or notification to department heads. Similarly, Resident #2, a female with heart failure and multiple sclerosis, reported being bitten by ants, but there was no documentation of a skin assessment or follow-up actions in her nurse progress notes. The facility's pest control measures were inadequate, as evidenced by the recurring ant sightings in multiple residents' rooms. Maintenance and housekeeping staff were notified of the ant problem, but there was a lack of coordination and communication among staff members, leading to inconsistent responses to the infestation. The facility's pest control policy was not effectively implemented, resulting in a failure to maintain a safe and comfortable environment for the residents.
Ant Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, specifically concerning the presence of black ants in the rooms and beds of five residents. These residents, who were reviewed for incident accidents, were exposed to potential risks of ant bites, which could lead to skin irritation, infection, and pain. The nursing staff did not adequately address the ant infestation, as evidenced by multiple reports from residents and family members about ants in their rooms and on their bodies. Despite some actions taken, such as spraying and cleaning, there was a lack of consistent documentation and follow-up assessments. Resident #1, a male with multiple health conditions including anemia, renal insufficiency, and hemiplegia, reported ants on his body, but no bites were noted. Resident #2, a female with heart failure and multiple sclerosis, stated she was bitten by ants, yet there was no documentation of a skin assessment or notification to department heads. Resident #3, a male with cancer and cognitive impairment, had ants observed on his bed by a visitor, but no documentation was found in his progress notes. Resident #4, a male with hypertension and diabetes, reported ants from his AC unit and had a rash on his elbow, but there was no mention of ant bites in his records. Resident #5, a male with severe cognitive impairment and multiple health issues, had ants on his bed, but no bites were found upon assessment. Interviews with staff, including LVNs, RNs, and the DON, revealed a lack of awareness and communication regarding the ant problem. The DON acknowledged hearing about ants in some residents' rooms but was unaware of others. The Administrator was also not fully informed about the extent of the issue. The facility lacked a clear incident/accident policy, and there was no consistent procedure for documenting and addressing the ant sightings, leading to inadequate supervision and potential harm to residents.
Failure to Document Ant Incidents and Assessments
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, specifically regarding incidents involving black ants found in their rooms and beds. The nursing staff did not complete incident reports, skin assessments, or nurse progress notes after these incidents, which were reported by residents and their family members. This lack of documentation was observed for residents who had various medical conditions, including anemia, renal insufficiency, diabetes, and cognitive impairments. For instance, one resident reported having ants all over him while in bed, but no incident report or skin assessment was documented. Another resident stated she was bitten by ants, yet there was no follow-up documentation in her medical records. Similarly, other residents had ants in their rooms, but the facility's records did not reflect any assessments or incident reports, despite reports from family members and staff observations. Interviews with staff revealed inconsistencies in reporting and documentation practices. Some staff members were unaware of the ant incidents, while others acknowledged the presence of ants but did not complete the necessary documentation. The Director of Nursing and other staff members indicated that incident reports were not completed unless there was an actual injury, and there was a lack of clarity on the procedures for documenting such incidents. The facility's documentation policy emphasized the importance of maintaining accurate records, but this was not adhered to in these cases.
Deficiency in Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of black ants in the rooms of several residents over a period of time. The pest control issues were documented in the facility's records, with sightings and treatments recorded for specific rooms. However, there were inconsistencies in the reporting and documentation of these sightings, as not all instances were logged or communicated effectively among staff members. Residents reported seeing ants in their rooms, with some experiencing ants on their bodies or in their beds. Despite these reports, there were gaps in the follow-up actions taken by the staff, such as conducting thorough skin assessments or notifying relevant department heads. Interviews with residents and family members revealed that while some rooms were treated for ants, there was a lack of consistent communication and documentation regarding the presence of ants and the steps taken to address the issue. The facility's maintenance and housekeeping staff acknowledged the ant problem and attempted to address it by spraying affected areas and advising staff on preventive measures. However, there were challenges in ensuring that all staff members were aware of the cleaning tools available and the procedures to follow when ants were sighted. The facility's pest control policy outlined responsibilities and preventive measures, but the implementation of these guidelines was inconsistent, leading to the deficiency in maintaining a pest-free environment for the residents.
Unlocked Treatment Cart Poses Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an observation of Treatment Cart #1 being left unlocked and unattended in the 100 Hall area. This incident occurred in the presence of four residents, with no staff having visibility of the cart. The cart contained various items, including hydrogen peroxide, saline, alcohol wipes, ketoconazole shampoo, nystatin topical powder, zinc oxide ointment, and hydrocortisone cream. Nurse A, who was responsible for the cart, stated that she had not used it since starting her shift and suggested that it was left unlocked by the nurse from the previous overnight shift. Interviews with facility staff, including Nurse A, ADON B, DON C, and Administrator D, highlighted the risks associated with leaving treatment carts unlocked and unattended. These risks included residents potentially accessing unauthorized medications or ingesting non-consumable items, which could be detrimental to their health. The facility's policy, revised in July 2023, mandates that all drugs and biologicals be stored in locked compartments and accessible only to authorized personnel. Despite this policy, the incident demonstrated a lapse in adherence, as the treatment cart was not secured as required.
Failure to Administer Medications Properly
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, as evidenced by the failure to administer all of the resident's medications. The resident, an elderly male with diagnoses including dementia, depression, and diabetes, was admitted to the facility and required assistance with all activities of daily living. During an observation, a pink and turquoise pill, identified as the resident's Fluoxetine, was found on the floor near the nurse station. The medication aide (MA-A) responsible for administering the medication admitted to placing the pills in the resident's mouth using a spoon but did not check the resident's mouth to ensure the pills were swallowed. Further observation revealed another unidentifiable white pill on the floor, which appeared to have been in a resident's mouth. The Director of Nursing (DON) acknowledged the risk of the resident not receiving his medications, which could lead to worsening depression and behavioral problems. The facility's policy on the administration of drugs requires medications to be administered according to the physician's written orders and documented if withheld, refused, or given at a different time. However, the failure to ensure the resident took his medications as prescribed was evident in this case.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA-B and CNA-C who did not adhere to the required Enhanced Barrier Precautions (EBP) when providing care to a resident. The resident, a female with a history of brain damage, cardiac arrest, and a blood clot in the lungs, was totally dependent on staff for all activities of daily living and had multiple medical conditions including a tracheostomy, pneumonia, an indwelling urinary catheter, and a feeding tube. Despite the presence of signage indicating the need for PPE, both CNAs only wore gloves and failed to use gowns during high-contact care activities, which was a requirement under EBP due to the resident's condition. The deficiency was further highlighted by the observation that CNA-B picked up a foam wedge from the floor and used it to position the resident, potentially increasing the risk of infection transmission. Interviews with the CNAs revealed a lack of compliance with the facility's infection control policy, as CNA-B did not initially intend to provide care and CNA-C did not wear PPE when assisting. The Director of Nursing confirmed that EBP was necessary to minimize infection spread among residents with infections, catheters, and other medical devices, and acknowledged the risk posed by not following PPE protocols. The facility's infection prevention policy, dated October 2022, did not address Enhanced Barrier Precautions, contributing to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 854 citations issued within 25 miles in the last 12 months — including the 36 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Desoto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Methodist Transitional Care Center-desoto Llc | 1.6 mi | ★★★★★ | 5 | 0 |
| Desoto Nursing & Rehabilitation Center | 2.2 mi | ★★★★★ | 15 | 1 |
| Windsor Gardens | 3.3 mi | ★★★★★ | 14 | 0 |
| Red Oak Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 2 | 0 |
| Five Points Nursing And Rehabilitation | 3.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.