Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Quitman Wellness & Rehabilitation during CMS and state inspections, most recent first.
Baseline care plans were not completed within 48 hours for multiple new admissions, and one resident’s plan was not signed off by an RN. Records showed incomplete or late baseline care plans for residents with significant needs such as a PICC line, urinary catheter, oxygen use, IV antibiotics, dementia, and other complex diagnoses. Staff interviews confirmed the plans were intended to guide initial resident care and should have been completed and RN-reviewed within the required timeframe.
A resident with an indwelling urinary catheter and severe cognitive impairment was observed multiple times with her catheter drainage bag hanging at the bedside without a privacy cover, making the urine visible from the hallway. A CNA said she had tried to keep the bag in a pillowcase and had reported the missing cover, but therapy staff did not replace it after returning the resident to her room. The DON and Administrator stated staff were expected to ensure catheter drainage bags had privacy covers to maintain dignity.
A resident with depression and severe cognitive impairment received fluoxetine before a psychotropic consent form was properly obtained. The MAR showed the antidepressant was administered on multiple days, while the consent form was not completed until later and was manually backdated by the ADON. Staff stated the consent was not obtained from the resident, and the DON and Administrator said consent was expected before the medication was given.
A resident’s room had damaged window blinds with missing pieces, allowing sunlight to shine in even when the blinds were closed. The resident, who had dementia and moderate cognitive impairment, said the light bothered her when it shined in her eyes. A family member said the blinds had been damaged since the resident moved into the room, and CNA, ADON, DON, Maintenance, and the Administrator all acknowledged the blinds were not functional and should have been replaced.
The facility failed to accurately code two residents’ admission MDS assessments. One resident’s MDS did not reflect current tobacco use even though her smoking assessment, care plan, and observation showed she smoked during scheduled smoking times. Another resident’s MDS did not reflect an indwelling urinary catheter even though her care plan identified the catheter and observation showed the catheter bag in place with urine present. The Regional MDS Coordinator stated the MDS should accurately reflect resident status.
A resident with Parkinson’s disease, dementia, chronic pain, and mobility problems required moderate help with bathing and personal hygiene, but she did not receive her scheduled showers and reported going over a week without one. Her shower schedule was changed because the shower aide had too many residents, and staff said the Tuesday/Thursday/Saturday shower aide was out while only two aides were caring for about 37 to 40 residents. Interviews confirmed the resident kept asking for her shower, staff knew showers were being missed, and the facility’s policy was to bathe residents at least weekly and schedule showers three times a week.
A resident with dementia, COPD, and chronic respiratory failure was observed multiple times with Mentholatum ointment in her room while she was on continuous O2 via nasal cannula. The ointment had no MD order, and the resident said she used it for nasal dryness from the cannula. The DON, ADON, and Administrator all acknowledged that petroleum-based ointment used with oxygen is a fire hazard, and the facility’s O2 policy prohibited oil, alcohols, and petroleum products around the resident’s face.
A resident with dementia, COPD, and chronic respiratory failure had Mentholatum ointment left on her bed in her room on multiple observations while she was on continuous O2, and no MD order was present for the ointment. The resident said she used it for nasal dryness from the cannula. Surveyors also observed an unlocked nurse med cart at the nurses' station, and the LVN acknowledged responsibility for the cart. The DON stated nurses were expected to keep med carts locked when not in use.
The facility's kitchen failed to meet food safety standards, with expired food items found in storage and improper storage of raw meat. A mixing bowl with an unlabeled substance was also noted. Staff interviews revealed a lack of adherence to the facility's food storage policy, which requires proper labeling, dating, and storage of food items.
A facility failed to update a resident's care plan to reflect her DNR status, instead listing her as a full code. Despite having a DNR order and an out-of-hospital DNR form, the care plan was not updated due to communication lapses among staff, including the MDS nurse and SW. The DON acknowledged the error, noting that other records correctly indicated the DNR status, but the care plan documentation was incorrect.
A resident was injured during transport when a CNA failed to properly secure the resident in a wheelchair, leading to a fall and minor injuries. The resident, who was cognitively intact and required supervision for mobility, was not secured with a shoulder strap, resulting in a fall when the CNA made a sudden stop. The facility's policy required proper securing of wheelchairs and use of seatbelts, which was not followed in this instance.
A resident with a recent change in mental status and diagnosed with a UTI was able to leave the facility in her wheelchair without staff knowledge. Despite expressing a desire to leave, staff did not increase supervision, leading to her being found 800 feet away, attempting to cross a highway.
A facility failed to implement physician orders for a resident's immediate care, including wearing a knee brace and maintaining a non-weight bearing status on the right knee. The attending nurse did not thoroughly review the ER discharge paperwork, leading to the omission of critical care instructions. This lapse in procedure placed the resident at risk for not receiving appropriate care and treatment.
Baseline Care Plans Not Completed or RN-Reviewed Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a Baseline Care Plan within 48 hours of admission for 5 of 12 residents reviewed for new admissions. The deficiency involved Resident #15, Resident #64, Resident #47, Resident #67, and Resident #69. Surveyors reviewed records and interviewed staff and found that the baseline care plans were either incomplete, not signed, or completed after the required timeframe. Resident #15 was admitted with diagnoses including NSTEMI, bacteremia, muscle weakness, urinary retention, hypertension, COPD, and acute and subacute infective endocarditis. Her admission MDS showed moderate cognitive impairment, dependence for most ADLs, an indwelling catheter, bowel incontinence, shortness of breath when lying flat, a mechanically altered diet, pressure ulcer risk, continuous oxygen use, IV antibiotics, and a PICC line. Her baseline care plan, dated 04/25/26, had no care areas completed and was not signed. The ADON stated that items such as a urinary catheter, PICC line, and incontinence should have been included in the baseline care plan. Resident #64 was admitted with ataxic cerebral palsy, hypertension, hypercholesterolemia, major depressive disorder, and dementia. Her baseline care plan was signed as completed approximately 96 hours after admission. Resident #47, admitted with zoster without complication and a BIMS score of 5 indicating severe cognitive impairment, had a baseline care plan signed as completed 11 days after admission. Resident #67, admitted with ventricular tachycardia, had a baseline care plan signed as completed approximately 72 hours after admission with no RN signature. Resident #69, admitted with lung transplant status, squamous cell carcinoma of the face, and COPD, had baseline care plan sections signed by the DON and an LVN approximately 96 hours and 72 hours after admission, respectively. During interviews, the ADON, DON, Administrator, and nursing staff stated that baseline care plans were to be completed within 48 hours of admission and were used to guide continuity of care and provide a starting point for resident care. The DON stated the baseline care plan had to be signed off by an RN, and the Administrator stated she expected the plan to be opened, completed, and reviewed by an RN within 48 hours. The facility policy stated that a licensed nurse would initiate the care plan and that a person-centered baseline care plan would be developed for each resident within 48 hours of admission.
Catheter Drainage Bag Left Without Privacy Cover
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring her indwelling urinary catheter drainage bag was kept in a privacy bag. Resident #47 was an elderly female admitted with diagnoses including shingles and urinary retention. Her admission MDS reflected clear speech but a BIMS score of 5, indicating severe cognitive impairment. Her baseline care plan documented that she had an indwelling urinary catheter. During observations, the resident was found in bed with her catheter drainage bag hanging on the side of the bed without a privacy cover, and the urine in the tubing and bag was visible from the hallway. This was observed multiple times while she remained in bed. A CNA stated she had been trying to keep the drainage bag in a pillowcase and had reported the missing privacy cover to the nurse, but therapy staff had not replaced it after returning the resident to her room. An LVN stated she was unaware the privacy cover was missing and that everyone was responsible for ensuring catheter drainage bags had a privacy cover. The DON and Administrator both stated staff were expected to ensure catheter drainage bags had privacy covers to maintain dignity, and the Administrator stated therapy staff had been in-serviced after believing a privacy cover was not needed while residents were in their rooms.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure Resident #47 was informed in advance and gave informed consent before receiving fluoxetine, an antidepressant ordered for depression. Resident #47 was an older female admitted with shingles and major depressive disorder. Her admission MDS reflected clear speech and that she could understand others, but also showed a BIMS score of 5, indicating severe cognitive impairment, and she had little interest or pleasure in doing things and felt down, depressed, or hopeless during the look-back period. The order for fluoxetine 40 mg daily began on 04/24/26, and the MAR showed the resident received the medication on multiple days in late April and early May. The baseline care plan stated psychotropic medications were being used and that a current list was provided and reconciled with the representative. However, the psychotropic medication consent form was not completed until 05/06/26, and it was printed that day by the Regional MDS Coordinator. The ADON manually signed the form and dated it 04/24/26, stating she signed it on 05/06/26 and was asked to date it earlier. During observation on 05/04/26, Resident #47 was lying in bed and unable to answer questions appropriately due to confused conversation. The ADON stated the consent was not obtained from the resident and she could not remember whether the family was spoken to. She also stated the admitting nurse was responsible for obtaining psychotropic consent before the medication was given, and nurse management was responsible for monitoring that the forms were obtained. The DON and Administrator both stated they expected psychotropic consent forms to be completed before administration of the medication. The facility policy stated the licensed nurse would not administer psychotherapeutic medication until informed consent had been obtained and documented by the attending physician from the resident and/or surrogate decision maker, unless it was an emergency.
Damaged Window Blinds Left Unreplaced in Resident Room
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, clean, comfortable, and homelike environment for 1 of 19 residents reviewed for environment because Resident #3’s window blinds were damaged and missing pieces were not replaced. Resident #3 was a [AGE]-year-old female with diagnoses including anxiety disorder, muscle wasting and atrophy not elsewhere classified, right shoulder muscle weakness, need for assistance with personal care, cognitive communication deficit, and dementia. Her MDS assessment dated 3/23/26 showed a BIMS score of 9, indicating moderate cognitive impairment, and her care plan noted an ADL self-care performance deficit related to left hemiplegia weakness and incontinence. During observations on 5/4/26, 5/5/26, and 5/6/26, the blinds in Resident #3’s room remained damaged, and sunlight continued to shine into the room even when the blinds were closed. Resident #3 stated the damaged blinds bothered her when the sun shined into her eyes. A family member stated the blinds had been damaged ever since the resident had been in the room and that light shined in even when the blinds were closed. CNA C stated she usually closed the curtain so the resident would not get too much sunlight and said maintenance was responsible for replacing the blinds. The ADON, DON, Maintenance Director, and Administrator all stated the blinds should be functional and that maintenance was responsible for replacing them; the Maintenance Director stated he was just notified about the blinds about 10 minutes before his interview.
Inaccurate MDS Coding for Tobacco Use and Indwelling Catheter
Penalty
Summary
The facility failed to ensure an accurate admission MDS assessment was completed for Resident #11 by not coding current tobacco use. Resident #11’s record showed diagnoses including benign neoplasm of the meninges and tobacco use, and a smoking assessment documented that she smoked and was safe to smoke with minimal supervision. The admission MDS, however, did not code her for current use of tobacco products. Her care plan identified that she used tobacco products, and during observation she was seen smoking in the facility smoking area and stated that she smoked during scheduled smoking times. The facility also failed to ensure an accurate admission MDS assessment was completed for Resident #47 by not coding an indwelling catheter. Resident #47’s record showed diagnoses of zoster without complication and urinary retention, and her baseline care plan identified an indwelling urinary catheter. The admission MDS did not code the catheter, even though observation showed a urinary catheter drainage bag hanging on the side of her bed with a large amount of clear yellow urine in the tubing and bag. During interview, the Regional MDS Coordinator stated she was unsure why the catheter was missed and acknowledged that MDS assessments needed to accurately reflect resident status for continuation of care and to ensure an accurate representation of residents.
Missed Scheduled Showers and Incomplete Personal Hygiene Care
Penalty
Summary
The facility failed to provide the necessary services to maintain personal hygiene for one resident who required moderate staff assistance with showering and personal hygiene. The resident had diagnoses including Parkinson’s disease, right knee pain, difficulty walking, dementia, chronic pain syndrome, and osteoarthritis. Her annual MDS indicated she understood others, was understood by others, had a BIMS score of 13, did not reject care, and required moderate assistance with shower/bathing and most ADLs, including personal hygiene. The resident’s care plan identified an ADL self-care deficit related to weakness and directed partial or moderate assistance by one staff member with showering and personal hygiene. The facility’s shower schedule listed the resident for showers on Tuesdays, Thursdays, and Saturdays before breakfast. CNA shower forms showed the resident refused showers on two scheduled days, and there was no shower form for one scheduled day. A later shower form showed she was showered on a subsequent date. During observations and interviews, the resident stated she had not had a shower in over a week and said she had asked for one on her scheduled days but still did not get it. She reported that her shower schedule had been changed because there were too many showers for the shower aide to give on the prior schedule. She later stated she still had not received her shower when it was due and asked whether she would get one that day. Staff interviews confirmed that the Tuesday/Thursday/Saturday shower aide had been out, that there were only two aides for approximately 37 to 40 residents, and that residents on those days sometimes did not receive showers when the shower aide was unavailable. The DON and ADM stated the facility’s policy was to bathe residents at least once weekly and that residents were scheduled for showers three times a week, but the resident did not receive her scheduled showers during the week in question.
Resident Kept Petroleum-Based Ointment in Room While Using Oxygen
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident. Resident #14 was an 82-year-old female with dementia, COPD with acute exacerbation, and chronic respiratory failure with hypoxia. Her quarterly MDS indicated a BIMS score of 5, showing severe cognitive impairment, and her care plan noted that over-the-counter medication could sometimes be found in her room from family and that she had altered respiratory status related to COPD. She was ordered oxygen at 2-4 liters via nasal cannula continuously. Record review and observations showed Mentholatum original ointment in Resident #14’s room on multiple occasions, including on her bed while she was not in the room and while she was sitting up in a wheelchair with oxygen in place. During an interview, Resident #14 stated she used the Mentholatum ointment for her nose because the nasal cannula made her nose dry and hard. There was no physician order for the ointment. Staff interviews confirmed they were aware that medications should not be in residents’ rooms and that medications should be administered by the nurse. The DON, ADON, and Administrator all acknowledged the concern with the ointment being in the resident’s possession while she used oxygen. The DON stated petroleum in the ointment with oxygen could be a fire hazard, the ADON stated petroleum ointment and oxygen used together is flammable, and the Administrator stated the resident could not use it with oxygen because it could cause a fire. The facility’s oxygen administration policy stated that oil, alcohols, and petroleum products are not to be used around the resident’s face.
Unlocked medication cart and unauthorized ointment found in resident room
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments when Resident #14 had Mentholatum original ointment in her room on multiple observations. Resident #14 was an 82-year-old female with diagnoses including dementia, COPD with acute exacerbation, and chronic respiratory failure with hypoxia. Her quarterly MDS showed a BIMS score of 5, indicating severe cognitive impairment. Record review also showed she had continuous oxygen ordered at 2-4 liters via nasal cannula, and there was no physician order for Mentholatum ointment. On 5/4/26, 5/5/26, and 5/6/26, surveyors observed Mentholatum ointment on Resident #14's bed while she was either out of the room, sitting in a wheelchair with oxygen in place, or lying in bed asleep with oxygen in place. During interview, Resident #14 stated she used the ointment for her nose because the nasal cannula made her nose dry and hard. The care plan noted that over-the-counter medication would sometimes be found in the room and had been provided by family, with education provided to the resident and family. The facility also failed to keep the Front Halls nurse medication cart locked. During observation, the cart was found unlocked in front of the nurse's station. LVN B stated she was responsible for the cart and acknowledged it was unlocked. The DON stated nurses were expected to keep medication carts locked when not in use, and the facility policy stated medication carts must remain locked and secured unless under direct and continuous supervision during medication administration.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Several deficiencies were noted, including the presence of expired food items in both the walk-in refrigerator and freezer. Specifically, a container of peas and a container of pinto beans in the freezer were past their expiration dates, as well as a container of cottage cheese in the refrigerator. Additionally, a mixing bowl containing a pink and white substance was found in the freezer without any labeling or dating, which is against the facility's policy. Furthermore, the facility did not properly store raw meat, as a pan of raw bacon was found on the top shelf of the refrigerator above bags of bread and cooked meat, which poses a risk of cross-contamination. Interviews with staff revealed a lack of awareness and adherence to the facility's food storage policy, which requires labeling, dating, and proper storage of food items. The Dietary Manager and Administrator both acknowledged the expectations for food safety, but the deficiencies indicate a failure to consistently implement these standards.
Failure to Update Care Plan for DNR Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timetables to meet the resident's highest practicable physical, mental, and psychosocial needs. Specifically, the care plan for a resident with a DNR order was not updated to reflect this status, instead indicating the resident was a full code. This discrepancy was identified during a review of the resident's records and interviews with facility staff. The resident in question was an elderly female with a history of cerebral infarction, heart failure, and vascular dementia with behaviors. Despite having a DNR order documented in the physician's orders and an out-of-hospital DNR form, the care plan continued to list her as a full code. Interviews with various staff members, including an LVN, ADON, MDS nurse, SW, and DON, revealed that the care plan had not been updated to reflect the DNR status due to communication lapses and oversight. The staff acknowledged the error, with the MDS nurse and SW indicating they were not informed of the change in the resident's advance directive. The DON admitted responsibility for ensuring the care plan was correct and noted that the error was not perceived as a risk to the resident because other records, such as the crash cart book and electronic chart, correctly indicated the DNR status. However, the care plan documentation was incorrect, highlighting a failure in the facility's process for updating care plans in response to changes in residents' conditions.
Resident Injury Due to Inadequate Wheelchair Securing During Transport
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident during transportation. The incident occurred when a Certified Nursing Assistant (CNA) was transporting the resident from the hospital back to the facility. The CNA did not properly secure the resident in the wheelchair with a shoulder strap, believing it would not reach across the resident. As a result, when the CNA had to make a sudden stop, the resident fell forward onto his hands and knees, sustaining a scrape on the knee and a skin tear on the finger. The resident involved was an elderly male with a history of pneumonia, left bundle-branch block, and emphysema. At the time of the incident, the resident was cognitively intact and required supervision only with bed mobility and transfers. The care plan indicated that the resident was independent in transfers and should be encouraged to participate in physical activities for strengthening and improved mobility. Interviews revealed that the CNA had been working temporarily at the facility and was not fully familiar with the transportation procedures. The facility's policy required all wheelchairs to be secured with straps, and seatbelts to be placed around all residents, including those in wheelchairs. The CNA admitted to not using the shoulder strap, which led to the resident's fall and subsequent injuries. The facility identified this as past noncompliance with Immediate Jeopardy (IJ) and took corrective actions before the survey began.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide adequate supervision to prevent avoidable accidents for a resident reviewed for quality of care. The resident, who had a change in mental status and expressed a desire to leave the facility, was able to leave the facility in her wheelchair without staff knowledge. She was found approximately 800 feet away from the facility, attempting to cross a four-lane state highway to reach a gas station. This incident occurred despite the resident's recent confusion and a diagnosis of a urinary tract infection, which had been identified during an ER visit the previous day. The resident's care plan did not indicate a history of wandering or elopement, and the facility's Wandering Risk Scale had assessed her as low risk for wandering. However, the resident had shown signs of confusion and had expressed a desire to leave the facility to multiple staff members. Despite this, the staff did not increase supervision or take additional precautions to prevent her from leaving. The facility's doors were not locked from the inside, allowing the resident to exit without difficulty. Interviews with staff revealed that they were aware of the resident's confusion and her statements about leaving the facility. However, they did not take appropriate actions to monitor her more closely or prevent her from eloping. The facility's policy on wandering and elopements was not effectively implemented, leading to the resident's unsupervised departure and subsequent hospitalization.
Failure to Implement Physician Orders for Resident's Immediate Care
Penalty
Summary
The facility failed to have physician orders for a resident's immediate care upon admission, specifically for wearing a knee brace and maintaining a non-weight bearing status on the right knee. The resident, an elderly female with a history of dementia, anxiety, and chronic obstructive pulmonary disease, was readmitted to the facility with a nondisplaced tibial plateau fracture and possible compression fractures to the spine. Despite the ER discharge instructions indicating the need for a knee brace and non-weight bearing status, these orders were not entered into the electronic health record by the attending nurse, LVN B, upon the resident's return from the ER. LVN B admitted to not thoroughly reviewing the ER discharge paperwork, which led to the omission of critical care instructions. The Director of Nursing (DON) and the Administrator confirmed that it was the responsibility of the nurse on duty to input these orders into the electronic health record. The DON also stated that she reviews admissions and ER records during weekdays, while the weekend RN is responsible for this task over the weekend. However, in this case, the necessary orders were not communicated or entered, resulting in the resident not receiving the appropriate care. Interviews with the staff revealed a breakdown in communication and procedural adherence. LVN A, who received the initial call from the ER, was unaware of the specific orders, and LVN B failed to input the orders into the system. The DON emphasized the importance of reviewing ER records for new orders and diagnoses to ensure proper treatment plans. The Administrator reiterated that charge nurses are expected to follow physician's orders to provide the required care for residents. This lapse in procedure placed the resident at risk for not receiving appropriate care and treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Quitman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Mineola | 8.8 mi | ★★★★★ | 22 | 1 |
| Mineola Gardens Wellness & Rehabilitation | 9.7 mi | ★★★★★ | 6 | 0 |
| Avir At Winnsboro | 13.4 mi | ★★★★★ | 0 | 0 |
| Lakeview Rehabilitation & Healthcare Center | 13.4 mi | ★★★★★ | 13 | 0 |
| Avir At Bradburn | 17.6 mi | ★★★★★ | 7 | 2 |
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