Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Lakin during CMS and state inspections, most recent first.
Infection Control Program Not Maintained: A resident on Contact Isolation was observed outside the room and received care from a CNA without PPE, despite MRSA of the skin and a posted isolation sign. In addition, two residents had damaged wheelchair and Geri-chair arm pads with exposed inner padding that could not be cleaned effectively.
The facility failed to provide staff education on the benefits and risks of the COVID-19 vaccine and failed to offer staff the vaccine or information on how to obtain it. During interview, the ED stated the COVID vaccine was seasonal and they were out of season. Facility census was 60.
Failure to notify the resident's MPOA when a wanderguard was applied. Facility records and staff interview showed the resident's treatment was changed with an order for a wanderguard, but the resident's representative was not notified at the time the change occurred. The Administrator later provided documentation of notification after the surveyor requested it.
A resident's wheelchair was observed with dirt and food debris buildup under the seat cushion, and another resident's geri-chair had broken plastic on and around the arm rests. The facility admin confirmed both conditions during the tour.
A resident’s MDS was coded for substantial/maximal assistance with sit-to-stands, chair/bed-to-chair transfers, and toilet transfers, but the ADL task documentation showed only independent, supervision, or partial/moderate assistance. Survey observation found the resident transferring with supervision/touching assistance, and both a NA and PTA stated the resident typically needed only supervision or stand-by assistance. The MDS Coordinator confirmed the MDS was not coded based on the NA task documentation.
A resident reported having an eye appointment several months earlier and being told she needed cataract surgery, but she had not heard anything further. Record review showed the resident had an eye visit with an order to refer her to an ophthalmologist for cataract surgery, and the DON stated there were no upcoming cataract surgery appointments.
A resident with heart failure had an order for continuous O2 at 2 L/min via nasal cannula, but was observed twice without oxygen outside her room. An RN confirmed the order and checked the resident’s pulse ox, which was 81%, and the Administrator later confirmed the saturation returned to normal after oxygen was applied.
Incomplete and incorrect resident documentation was identified for two residents. For one resident, behavior task entries marked yes for false beliefs, delusions, or hallucinations were not supported by progress note documentation describing the behaviors or how they were addressed. For another resident, a psychiatric provider note used female pronouns and appeared to describe the wrong resident, while the resident was male, and the DON confirmed the note may have been written for the incorrect resident.
Multiple deficiencies occurred when a resident requiring two-person assist was transferred by a single aide without the required device, another resident was transported in a van without a seatbelt and slid to the floor, two residents eloped through inadequately alarmed doors, and a resident who smoked did not receive an annual safety assessment as required by policy.
Three residents with dysphagia and orders for thickened liquids were found to have unthickened water at their bedsides, despite clear care plans and physician orders specifying the required liquid consistency. Staff, including an LPN and a Unit Charge Nurse, confirmed that the water was not thickened as required and acknowledged routinely providing ice water to these residents. This failure was identified through observation and record review, affecting residents with a history of aspiration risk.
Multiple residents were subjected to abuse and neglect, including two who were sexually assaulted by another resident who was inadequately supervised despite known risks. Several residents did not receive their prescribed medications or neurological checks due to an LPN neglecting duties, while two RNs were involved in the misappropriation of a resident's medication. Additional deficiencies included unsafe transfers performed by a single aide against care plan instructions and a resident transported without a seatbelt, resulting in a fall, with staff failing to follow established safety protocols.
Residents were unable to access or identify grievance forms to file anonymous concerns, as forms were either not readily available or were displayed in a manner that made them inaccessible. Staff interviews and observations confirmed that residents did not know how to file grievances, and the facility's grievance log showed no recent entries.
The facility failed to report allegations of abuse and neglect to state agencies and did not implement effective interventions to prevent further abuse. Staff did not follow care plans for resident transfers, failed to ensure resident safety during transport, and did not provide required supervision or documentation for a resident with a history of sexually predatory behavior, resulting in repeated incidents of sexual abuse against vulnerable residents.
The facility did not report multiple allegations of abuse and neglect to state agencies as required, including a resident with severe disabilities being transferred by a single staff member against care plan instructions, a cognitively intact resident's report of receiving an unauthorized injection, and a resident transported without a seatbelt who subsequently fell. Staff were aware of relevant policies but failed to follow reporting protocols.
Three residents did not have complete or properly implemented care plans: one lacked a dietary goal, another's care plan did not address a known behavior of unbuckling a seatbelt during transport, and a third continued to receive weights and vitals despite being on comfort care, contrary to facility policy. Staff interviews and record reviews confirmed these deficiencies.
The facility did not revise or update activity care plans for four residents, resulting in discrepancies between documented participation in activities and the interventions listed in their care plans. In several cases, residents received one-on-one activities or experienced significant changes in condition, but their care plans were not updated to reflect these changes, as confirmed by the Activity Director during interviews.
Surveyors found that the facility did not maintain an ongoing, individualized activity program to meet residents' interests and support their well-being. Several residents were observed with minimal engagement, and care plans were outdated or not reflective of current needs. The Activity Director confirmed that care plans had not been updated to address changes in residents' conditions or preferences.
Multiple residents did not receive medications, neurological checks, observation checks, or skin assessments as ordered, with some medications missed entirely and others administered late. A resident on comfort care continued to receive interventions that should have been discontinued per orders and policy, and the family was not notified of significant weight loss. Another resident did not receive scheduled dressing changes, and documentation was falsified to indicate care was provided when it was not, with no related nursing notes or assessments in the record.
The facility did not provide enough nursing staff to meet resident needs, resulting in lapses in supervision for residents requiring close observation, including one with aggressive sexual behavior who was able to assault another resident while on line of sight observation. Staff assigned to supervise high-risk residents were also tasked with other duties, leading to inadequate monitoring. Additionally, a high fall risk resident was left alone in the bathroom, resulting in an unwitnessed fall. Staffing records showed the facility did not meet its own target staffing levels on multiple occasions.
A resident expressed dissatisfaction with unannounced menu changes, noting that the posted menu did not match the meal served. The dietary manager confirmed that a last-minute change to serve soup and a sandwich, due to a flu outbreak, was not communicated to residents or reflected on the posted menu. The administrator acknowledged that residents were not notified of the change.
A resident on enhanced barrier precautions for MRSA did not receive proper infection control during incontinence care, as a nurse aide failed to wear PPE, placed soiled items on the shower room floor, and wore soiled gloves while handling clean supplies and moving through the unit. Clean linen was improperly stored in the shower room, and during an influenza outbreak, a staff member entered a unit under contact/droplet precautions without PPE and left the door open, with residents unmasked at the entrance.
Two nurse aides did not complete their required annual education, as post-test materials were photocopied with answers already filled in and only required staff to add their names and dates. Both the Nurse Educator and Administrator confirmed that the education records were not completed by the staff themselves.
A resident's family member, serving as MPOA, was not permitted to visit in the resident's room and was restricted to the lobby, a practice in place since Covid. Staff, including an LPN and a social worker, confirmed that in-room visits were generally not allowed except for end-of-life or very ill residents, citing infection control and behavioral concerns.
A resident with a history of intellectual disabilities, PTSD, and major depression was not referred for a Level II PASARR evaluation after being newly diagnosed with a psychotic disorder in the schizophrenia spectrum. The last PASARR did not reflect the updated diagnoses, and staff were unaware of the most recent mental health diagnosis, resulting in the required referral not being completed.
A resident's PASARR did not include documentation of several psychiatric diagnoses, including anxiety disorder, depressed mood, PTSD, and hallucinations. The missing information was confirmed by the Director of Social Services, who stated the PASARR received from an acute psychiatric facility lacked these diagnoses.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection control program to provide a sanitary environment and help prevent the transmission of communicable diseases and infections. During observation, Resident #60 was seen outside of the room despite a Contact Isolation sign posted outside the door. The resident requested oxygen, and a nurse aide entered room A-10, brought an oxygen concentrator into the hallway, moved the resident to the other side of the hallway, and provided care without wearing PPE. The nurse aide later stated that she did not put PPE on because she did not think about it, and confirmed that Resident #60 had MRSA of the skin. The Infection Preventionist confirmed that residents on Contact Isolation were to remain in their rooms. The facility also had two pieces of personal care equipment with damaged surfaces that could not be cleaned effectively. During a tour, Resident #1's wheelchair right arm pad was observed with rips and tears exposing the inner padding, and Resident #39's Geri-chair had tears in the right arm rest with exposed inner padding. The administrator acknowledged that both items had rips and tears and confirmed they could not be cleaned.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure staff were offered education regarding the benefits and risks associated with the COVID-19 vaccine and were offered the vaccine or information on how to obtain it. During record review and staff interview, the executive director stated that the COVID vaccine was seasonal and that they were out of season. The facility census was 60.
Failure to Notify MPOA of Treatment Change
Penalty
Summary
The facility failed to notify the resident's Medical Power of Attorney when a wanderguard was applied as a change in treatment. A policy titled Change in Condition/Physician Notification stated that the nurse will notify the physician/NP/PA and the resident/patient representative when there is a need to alter medications or treatment or when there is a significant change in the resident's physical, mental, or psychosocial status. For Resident #59, an order dated 06/29/26 at 7:00 PM directed that the wanderguard be checked for placement on the right arm/wrist every shift. Review of eInteract Change in Condition forms and progress notes showed that the facility did not notify the resident's MPOA that the wanderguard was being applied. During interview on 06/30/26 at 3:45 PM, the surveyor asked the Administrator for documentation of the notification, and at 4:00 PM the Administrator provided a note dated 06/30/26 at 3:57 PM documenting that the MPOA had been notified.
Dirty Wheelchair and Broken Geri-Chair Observed
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when surveyors observed Resident #1's wheelchair with a buildup of debris, including dirt and food, underneath the seat cushion. During the same tour, Resident #9's geri-chair was observed with broken pieces of plastic on and around the arm rests. The facility administrator confirmed both conditions during the observation and stated that the geri-chair and wheelchair would be repaired and cleaned up.
Incorrect MDS Coding for Transfer Assistance
Penalty
Summary
Resident #44’s MDS was not accurately coded for functional abilities in Section GG. The record review showed the MDS dated [DATE] indicated the resident required substantial/maximal assistance with sit-to-stands, chair/bed-to-chair transfers, and toilet transfers. However, the 30-day task documentation completed by nurse aides during the three-day look-back period did not support that level of assistance. The documented care showed sit-to-stands ranging from independent to supervision and partial/moderate assistance, chair/bed-to-chair transfers ranging from supervision to partial/moderate assistance, and toilet transfers ranging from independent to supervision and partial/moderate assistance. The resident’s documented care and the survey observations were consistent with less assistance than what was coded on the MDS. The resident had no documentation in the ADL tasks showing a need for substantial or maximum assistance. During observation, the resident transferred from a recliner to a wheelchair with supervision/touching assistance. A NA stated the resident usually required supervision or touching assistance with transfers and had never seen the resident require maximum assistance. A PTA stated the resident required stand-by assistance with all transfers. The MDS Coordinator confirmed the MDS was not coded based on the task documentation completed by the nurse aides providing care.
Failure to Arrange Timely Cataract Surgery Referral
Penalty
Summary
The facility failed to ensure Resident #60 received timely treatment to maintain vision. During interview, Resident #60 stated she had an eye appointment several months earlier and was told she needed cataract surgery, but she had not heard anything about it since then. Record review showed the resident had an eye appointment with 360 Eye Care on 02/05/26, and the order from that visit was to refer her to an ophthalmologist for cataract surgery. During interview, the DON stated there were no upcoming appointments for cataract surgery.
Failure to Provide Ordered Continuous Oxygen
Penalty
Summary
The facility failed to ensure Resident #6 received oxygen as ordered. The resident had an order dated 05/07/26 for oxygen at 2 liters per minute via nasal cannula continuously and had a diagnosis of heart failure. On 07/01/26, a state surveyor observed the resident outside of her room at 8:35 AM without oxygen and again at 10:05 AM without oxygen. During an interview at 10:05 AM, RN #86 confirmed the resident was ordered continuous oxygen at 2 liters per minute via nasal cannula and then checked the resident’s oxygen saturation, which measured 81%. The Administrator later confirmed that the resident’s oxygen saturation returned to normal after oxygen was applied.
Incomplete and Incorrect Resident Documentation
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents. For one resident, the 14-day behavior task sheet showed three dates marked "yes" for false beliefs, delusions, or hallucinations, but there was no corresponding progress note documentation describing what the behaviors were or how they were addressed. Two NAs stated that when they document a yes on the behavior task sheet, they inform the nurse so the nurse can document, and the DON confirmed there was no progress note documentation related to the behaviors marked on the task sheet. For another resident, a psychiatric provider note documented symptoms and statements using female pronouns and described the resident sitting in the common area, but the resident was male, and the DON stated the facility had contacted the provider to determine whether the note had been written for the correct resident.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
A facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident, who required a two-person assist and a specific transfer device for all transfers due to severe intellectual disabilities and cerebral palsy, was observed being transferred by a single nurse aide on two occasions without the required assistance or device. The aide had access to the resident's Kardex, which clearly indicated the need for two-person assistance and the use of a transfer device, but did not consult it. Other staff members were unfamiliar with the term 'brief type transfer device,' and documentation showed a pattern of single-person transfers for this resident on night shifts, despite care plan requirements. This pattern was not identified or addressed by facility staff prior to surveyor intervention, and no reeducation or reporting for neglect occurred before the immediate jeopardy situation was identified. Another resident experienced an unsafe transport incident when staff allowed the resident to be transported in a facility van without a seatbelt, resulting in the resident sliding to the floor during a sharp turn. Staff involved did not ensure the seatbelt was fastened and assumed the other had done so. The resident had a known history of unbuckling the seatbelt, but this behavior was not documented in the care plan, and no special instructions were provided to staff. The facility's policy required seatbelts to be worn at all times, but there was no evidence of specific training for staff on this requirement, and no statements were obtained from the staff involved after the incident. Two additional residents eloped from the facility by manipulating a metal slide on a day room door and exiting through a fire door. In both cases, the exit door alarm could not be heard from the nurses' station, and after the first elopement, no additional alarms were added to the door until after a second elopement occurred. Another resident who smoked did not have an updated annual smoking assessment as required by facility policy, with the most recent assessment being over a year old. The responsible social worker confirmed that assessments were only completed if an issue arose, contrary to the policy's annual requirement.
Failure to Provide Thickened Liquids as Ordered for Residents with Dysphagia
Penalty
Summary
Surveyors identified that the facility failed to provide thickened liquids as ordered for three residents with dysphagia and a history of aspiration risk. Medical record reviews for these residents showed clear physician and care plan orders for specific thickened liquid consistencies, such as level 4 extremely thick or level 3 moderately thick liquids, due to their impaired swallowing abilities and high risk for aspiration and pneumonia. Despite these orders, observations revealed that unthickened water pitchers were present at the bedsides of these residents. During observations, staff confirmed that the water provided to these residents was not thickened according to their dietary requirements. For example, an LPN and a Unit Charge Nurse both acknowledged that the water in the residents' rooms was not thickened, even though they had access to the water pitchers and were aware of the residents' dietary restrictions. Staff interviews indicated a routine practice of passing ice water to residents, regardless of their thickened liquid orders, with the assumption that the residents would not drink it. The failure to provide thickened liquids as ordered was found during random observations and record reviews, and it was determined to be an Immediate Jeopardy situation by the State Agency. The deficiency was identified for three residents with documented swallowing difficulties and specific dietary orders, and the facility census at the time was 61.
Widespread Failure to Prevent Abuse, Neglect, and Ensure Resident Safety
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, including sexual abuse, improper medication administration, misappropriation of medications, unsafe transfers, and failure to ensure seatbelt use during transport. Two residents were sexually assaulted by another resident, who was a registered sex offender. Despite being placed on line of sight observation and 15-minute checks after the first incident, there was no documentation to support that these measures were implemented, and the resident was returned to the same room as his victim. The same resident was able to sexually assault another roommate days later, again with no documentation of required supervision, and staff admitted that supervision lapsed when they attended to other residents. Several residents experienced neglect related to medication administration. An LPN failed to administer or timely administer multiple medications and perform required neurological checks for numerous residents, instead spending hours vaping and talking on the phone in the medication room. This resulted in missed and late doses of critical medications, as well as missed neuro checks, affecting a significant number of residents. Additionally, two RNs were involved in the misappropriation of a resident's medication when one RN took a resident's Zofran for personal use, with both RNs present and complicit in the act. Other deficiencies included a resident being transferred by a single nurse aide despite care plan requirements for two-person assistance, with documentation showing this was a repeated, systemic issue that was not identified or addressed by facility staff. Another resident was transported in a facility van without a seatbelt, despite staff being aware of the policy requiring seatbelt use, resulting in the resident sliding to the floor during transit. Staff involved did not obtain statements or report the incident as neglect, and there was no evidence of prior training on this requirement.
Failure to Provide Accessible Grievance Forms for Residents
Penalty
Summary
The facility failed to ensure that residents had adequate access to file anonymous grievances or concerns. During a resident council meeting, residents reported that they did not know how or where to find grievance forms, nor were they aware of the process for filing grievances anonymously. A review of the facility's grievance log showed that no grievances or complaints had been filed since July 2024, and the facility's grievance policy, which lacked an effective date, stated that residents have the right to file grievances anonymously. Upon further investigation, it was found that grievance forms were only available behind the nurse's station and in the social worker's office, locations not easily accessible to residents without staff assistance. Observations revealed that only a single grievance form was posted on an informational bulletin board, and another board with a grievance form was covered by plastic, preventing residents from retrieving it. The Nursing Home Administrator acknowledged that the way the forms were displayed would not make it clear to residents that they were available for their use.
Failure to Report and Prevent Abuse, Neglect, and Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not reporting all allegations of abuse and/or neglect to the appropriate state agencies and by not putting effective interventions in place to prevent further abuse. In several instances, staff did not follow care plans or established procedures. For example, a nurse aide transferred a resident with severe intellectual disabilities and cerebral palsy without the required two-person assist, as specified in the resident's care plan and kardex. This incident was not reported to state agencies as required by policy until prompted by surveyors. In another case, a cognitively intact resident reported to the resident council that someone gave him a shot in the middle of the night, but this allegation was not reported to state agencies, and the social worker was unaware of the incident. The facility also failed to ensure resident safety during transportation. One resident, who refused to wear a seatbelt during a van transport, slid out of his seat when the vehicle turned sharply. Staff accompanying the resident did not ensure he was secured, and no statements were obtained from the staff involved. Despite longstanding facility practice and state policy requiring seatbelt use, the incident was not reported as neglect, and staff training on transport safety was limited to the state vehicle use policy. Additionally, the facility did not adequately identify or manage a resident with a history of sexually predatory behavior. This resident, a registered sex offender, was involved in two separate incidents of sexual abuse against other residents. Despite policy requirements for specific observation levels and documentation, the facility failed to assign staff for continuous observation and did not maintain required documentation. After the first incident, the resident was placed on line of sight observation and 15-minute checks, but documentation was incomplete or missing. The same resident was able to abuse another resident days later, again without proper supervision or documentation, and both victims had significant vulnerabilities, including nonverbal status and a history of trauma.
Failure to Timely Report Allegations of Abuse and Neglect to State Agencies
Penalty
Summary
The facility failed to ensure that all allegations of abuse and neglect were reported to the appropriate state agencies as required. In one instance, a nurse aide was observed transferring a resident with severe intellectual disabilities and cerebral palsy by himself, despite the resident's care plan and kardex specifying that two staff members were required for all transfers. The nurse aide admitted to transferring the resident alone and acknowledged the error after reviewing the kardex. The incident was not reported to state agencies until prompted by the surveyor. Another deficiency involved a cognitively intact resident who reported during a resident council meeting that someone had given him a shot in the middle of the night. This allegation was documented and signed by the activities representative and the Nursing Home Administrator, but it was not reported to any state agencies. The social worker confirmed that the incident was not reported because it was not brought to her attention, and the administrator acknowledged the failure to report. A third incident involved a resident who was transported to an appointment without being secured by a seatbelt, resulting in the resident sliding to the floor during a sharp turn. Staff interviews revealed that it was standard practice not to transport residents who refused to wear seatbelts, and all staff interviewed stated they were aware of this policy. Despite this, the two nurse aides involved did not ensure the resident was secured, and the incident was not reported as neglect to the state agencies. The staff involved had only received training on the state vehicle use policy, which clearly required seatbelt use at all times.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents. For one resident, the care plan addressing dietary needs lacked a specific goal, despite detailed interventions and preferences being listed. This omission was confirmed during an interview with the Nursing Home Administrator. Another resident, who had a known behavior of unbuckling his seatbelt during transport, did not have this risk or any special instructions documented in his care plan. Staff interviews revealed that this behavior was known to them, but it was not reflected in the care plan, leaving staff without guidance on how to manage the risk during transportation. A third resident, who was on comfort care status with a Do Not Resuscitate (DNR) order, continued to receive routine weights and vital sign checks despite facility policy stating these interventions should be discontinued for comfort care residents. The care plan and orders had been updated to reflect comfort care status, but the facility continued to perform and document these interventions. Additionally, the resident's Power of Attorney was not notified of a significant weight loss, consistent with the facility's practice of not notifying families about such changes for comfort care residents. These findings were confirmed through record review and staff interviews.
Failure to Revise and Update Activity Care Plans
Penalty
Summary
The facility failed to revise and update activity care plans for four residents as required, following comprehensive assessments. For each of these residents, the care plans did not reflect their current participation in activities or the interventions actually being provided. For example, one resident was documented as receiving one-on-one activities and sensory stimulation, but this was not included in the written care plan. The Activity Director acknowledged during interviews that the care plans were outdated and did not match the residents' current needs or the services being delivered. Another resident's care plan indicated participation in group activities and self-direction, but nursing progress notes documented numerous behavior-related incidents without any corresponding updates to activity interventions in the care plan. The resident had a history of anxiety, depression, PTSD, and behavioral outbursts, yet the activity care plan had not been revised for several months despite significant changes in the resident's condition and abilities. The Activity Director confirmed that the resident had experienced a decline and that the care plan had not been updated to reflect these changes. Across all four cases, the care plans listed interventions and goals that were not consistent with the residents' documented participation or current needs. The lack of timely review and revision of care plans by the interdisciplinary team resulted in discrepancies between the care provided and the care planned, as evidenced by both record reviews and staff interviews.
Failure to Provide Ongoing, Individualized Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of each resident, as evidenced by observations, record reviews, and interviews. Four out of six residents reviewed for activities were found to have insufficient or outdated activity care plans, and their participation in meaningful activities was not adequately supported or documented. For example, one resident was repeatedly observed sitting alone in a recliner, either asleep or engaging in minimal self-stimulation, with no evidence of staff engagement or activity interventions despite documented preferences for group and individual activities. Record reviews revealed that activity care plans for several residents had not been updated for extended periods, even after significant changes in their condition or participation levels. For instance, one resident's care plan had not been revised despite a noted decline in her ability to participate in activities, and another resident's care plan did not reflect current interventions or preferences. Daily participation records indicated that some residents received one-on-one activities or sensory stimulation, but these interventions were not consistently aligned with their documented interests or needs. Interviews with the Activity Director confirmed that care plans were outdated and not reflective of residents' current abilities or preferences. The Activity Director acknowledged that some residents had experienced changes in their condition that were not addressed in their care plans, and that updates were needed. There was no evidence that activity interventions were implemented in response to behavioral issues or changes in residents' status, further demonstrating a lack of individualized, ongoing activity programming.
Failure to Follow Physician Orders and Provide Required Care
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate treatment and care for multiple residents, as evidenced by missed and late medication administrations, incomplete neurological checks, missed 15-minute observation checks, and uncompleted weekly skin assessments. For several residents, including those with complex medication regimens and specific monitoring requirements, medications were either not administered at all or were given significantly late. In addition, required neurological checks and frequent observation checks were not performed as ordered, and weekly skin assessments were not completed on the specified dates. These deficiencies were confirmed by the Director of Nursing upon review. One resident, who was placed on comfort care with explicit orders to discontinue certain interventions such as vital signs and weights, continued to receive these services despite the care plan and physician's orders indicating otherwise. The facility's policy for comfort care clearly stated that these interventions should not be provided, yet documentation showed that vital signs and weights were still being performed regularly after the comfort care order was in place. The facility also failed to notify the resident's family of a significant weight loss, citing the comfort care policy, even though the interventions had not actually been discontinued. Another incident involved a resident whose scheduled dressing changes for skin tears were not performed as ordered, and documentation was falsified to indicate that the treatments had been completed. The LPN responsible admitted to not performing the treatments and to initialing the treatment sheet without completing the care. The facility's investigation substantiated the allegation of neglect and falsification of documentation. Additionally, there was a lack of nursing notes or skin assessments related to the incident in the resident's record, and the Director of Nursing confirmed the absence of documentation regarding the event.
Failure to Provide Sufficient Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple incidents involving inadequate supervision and failure to follow established observation policies. One resident with a history of aggressive sexual behavior was placed on line of sight (LOS) observation and 15-minute checks after an incident of sexual assault. Despite this, the resident was able to commit another assault when staff assigned to observe him became distracted by other duties. The facility's policy required one-to-one supervision for dangerous residents, with staff maintaining constant awareness and documentation, but this was not consistently implemented or documented. Staff interviews confirmed that the assigned staff for residents on LOS observation were also responsible for assisting other residents, leading to lapses in supervision. The Director of Nursing acknowledged that staff would sometimes leave their assigned resident to help elsewhere, and that coverage was not always maintained as required by policy. Documentation showed that, during the period in question, there were numerous residents on 15-minute checks and LOS observation, but the number of available nurse aides and nurses was insufficient to provide the required level of supervision and care. Another incident involved a high fall risk resident who was left alone in the bathroom against physician orders, resulting in an unwitnessed fall. Staffing records for several dates revealed that the facility did not meet its own target staffing levels, as outlined in its HPPD report, and the administrator acknowledged that the reported targets were outdated and had not been updated. These staffing shortages directly contributed to the facility's inability to provide adequate supervision and care for residents with specialized needs.
Failure to Notify Residents of Menu Changes
Penalty
Summary
The facility failed to notify residents of changes made to the posted menu, as evidenced by both resident and staff interviews and direct observation. One resident reported dissatisfaction with the food, specifically noting that menu items were changed without informing residents, making it difficult to know if they would like the meal options. On the day in question, the posted lunch menu listed chicken fajitas and related items, but the dietary manager decided to serve chicken noodle soup and a sandwich instead due to a flu outbreak, without updating the posted menu or notifying residents of the change. The administrator confirmed that the menu was not updated and residents were not informed of the last-minute change.
Infection Control Lapses During Incontinence Care and Outbreak Precautions
Penalty
Summary
The facility failed to maintain infection control standards during incontinence care for a resident on enhanced barrier precautions due to a history of MRSA. A nurse aide did not wear the required personal protective equipment (PPE) while transferring and providing incontinence care to the resident. During care, the aide placed soiled clothing, linens, and a brief directly on the shower room floor and continued to wear soiled gloves while redressing the resident, transporting them through the unit, and handling clean incontinence supplies. The aide also failed to use appropriate containers for soiled items. Clean linen and unused briefs were observed stored inappropriately in the shower room alongside soiled items. The charge nurse was unaware of the resident's precaution status and acknowledged the infection control breaches. Additionally, clean linen was found stored in the shower room on another unit, which was confirmed by staff as inappropriate. During an influenza outbreak, an accounting specialist entered a unit under contact/droplet precautions without donning PPE and left the door open for several minutes, with multiple residents at the door not wearing masks. The specialist acknowledged not following the required precautions. These actions and inactions demonstrate multiple failures to adhere to infection prevention and control protocols as observed and confirmed by staff interviews.
Failure to Ensure Proper Completion of Yearly Nurse Aide Education
Penalty
Summary
The facility failed to ensure that required yearly education for two nurse aides was properly completed. During a review of staffing records, it was found that the post-test materials for the annual education, including topics such as dementia care and abuse prevention, had been photocopied with answers already filled in. The only action required by the nurse aides was to write their names and the date on the copied forms, rather than completing the education and post-tests themselves. The Nurse Educator acknowledged awareness of this practice, although she stated she had not personally witnessed it, and confirmed that the documents in question were indeed copies. The Administrator also confirmed that the education records were photocopies and not completed by the staff themselves. This deficiency has the potential to affect more than a limited number of residents, as the facility census at the time was 61.
Failure to Allow In-Room Visitation for Residents
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at the time and place of their choosing, specifically by not allowing family members to visit residents in their rooms. According to interviews, the Medical Power of Attorney (MPOA) for a resident reported being restricted to visiting only in the lobby since the onset of Covid, despite visiting every other day. Observations confirmed that visits were taking place in the lobby. Staff interviews revealed that this restriction was implemented due to past illness outbreaks and concerns about resident behavior, and has continued for infection control purposes, even when the facility was not experiencing an outbreak. Exceptions to this policy were only made for residents at end of life or those unable to leave their rooms due to illness.
Failure to Refer for PASARR Level II After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a Level II Preadmission Screening and Resident Review (PASARR) evaluation after the emergence of a new mental disorder diagnosis. Record review showed that the resident had multiple diagnoses, including intellectual disabilities, PTSD, recurrent major depression, and, most recently, a psychotic disorder within the schizophrenia spectrum. The last PASARR for this resident was completed in 2017 and did not reflect the more recent diagnoses of recurrent major depression or the psychotic disorder. Staff interviews confirmed that a new PASARR was not completed following the 2024 diagnosis of schizophrenia, as the Director of Social Services was unaware of the new diagnosis at the time.
Incomplete PASARR Documentation for Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) process included all relevant psychiatric diagnoses for a resident. During record review, it was found that the PASARR documentation was not available in the electronic medical record. Upon further review of the PASARR dated 02/15/22, there was no documentation of the resident's diagnoses of anxiety disorder, unspecified; depressed mood, unspecified; PTSD; and hallucinations. The Director of Social Services confirmed that the PASARR received from an acute psychiatric facility did not include these diagnoses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Overbrook Center | 3 mi | ★★★★★ | 11 | 0 |
| Pleasant Valley Healthcare Center | 5.9 mi | ★★★★★ | 3 | 0 |
| Arbors At Pomeroy | 11 mi | ★★★★★ | 7 | 0 |
| Holzer Senior Care Center | 11.1 mi | ★★★★★ | 0 | 0 |
| Abbyshire Place Health And Rehabilitation Center L | 11.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.