Baptist Nursing Home-Calhoun, INC

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 93.0 residents a day — about 78% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.12 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.11 hrs/resident/day on weekends vs 5.43 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 16 most serious are shown; the remaining 6 are one tap away and print in full.

• Immediate jeopardy · J2025-07-30 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, record reviews, observations, policy and procedure reviews, local county sheriff's report and interview, and review of the social media video, the facility failed to ensure that the rights of Resident #1 to have respect and dignity were honored when two Certified Nursing Assistants (CNAs) taunted, threatened and abused Resident #1 and posted the videos to social media. Resident #1 was one (1) of three (3) residents that were reviewed for Resident Rights. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident.The facility's failure to ensure the right to be treated with dignity placed Resident #1 and other residents at risk in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-07-30 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, observations, resident interviews, record reviews, policy and procedure reviews, video review, and sheriff's arrest report review, the facility failed to protect Resident #1's right to be free from abuse when staff created a video during care of the resident, of verbal and physical abuse, of the resident and posted it to social media. Resident #1 was one (1) of three (3) residents reviewed for Abuse and Neglect. The evening of 07/22/25 two (2) facility Certified Nursing Assistants (CNA)'s posted a video to social media in which they taunted, threatened and abused Resident #1. The video was seen by the community and the family of the resident.The facility's failure to ensure the right to be free from abuse placed Resident #1 and other residents at risk for abuse and neglect in a situation that has caused and is likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-05 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for 1) for Resident #16 who was a known risk for sexual behaviors towards others, to prevent the resident from entering Resident #56's room and sexually assaulting her while she lay in her bed, 2) transfer assistance for a dependent resident (Resident #5), and 3) assistance with Activities of Daily Living (ADL) (Resident #40, #90, and #92) for five (5) of 22 resident care plans reviewed. Resident's # 5, #16, #40, #90 and #92. This facility failed to implement the sexual behavior care plan for Resident #16 which led to Resident #56 being sexually assaulted in her room on 4/24/25 at approximately 3:00 PM, when a Certified Nursing Assistant (CNA) observed Resident #16 in the bed on top of Resident #56, with his hand inside her incontinence brief, performing jabbing motions. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-05-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review and facility policy review, the facility failed to protect the resident's right to be free from sexual abuse for one (1) of 20 residents on the Special Care Unit. Resident #56. Resident #56 was found on 4/24/25 at approximately 3:00 PM, by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to prevent the sexual abuse of Resident #56 placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 11/05/24 when Resident #16 began to exhibit sexual behaviors towards staff and the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-05-05 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interviews, and facility policy review, the facility failed to report alleged violations of sexual abuse that occurred within the two (2) hour timeframe to the proper authorities for one (1) of one (1) allegations of sexual abuse. Resident # 56 On 4/24/25 at approximately 3:00 PM, Resident #56 was found by a Certified Nursing Assistant (CNA) with Resident #16 in the bed and on top of her, with his hand inside her incontinence brief, performing jabbing motions. Resident #16 became violent with the staff when they tried to remove him from Resident #16's room where he hit a staff member with his fist. The facility's failure to report sexual abuse of Resident #56 to the proper authorities within prescribed timeframes placed Resident #56 and other residents at risk for sexual assault, in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death. The SA identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 4/24/25 when Resident #16 was found in the bed and on top of Resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-05-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, and facility policy review the facility failed to ensure a resident was free from accident hazards when the facility failed to ensure staff transferred the resident with the proper assistive devices for one (1) of three (3) residents reviewed for accidents. Resident #5. Findings Include: Record review of the facility policy Falls Management revealed It is the goal of [Proper Name of Facility] to assure that our residents remain free of accident hazards as possible and that each resident receives adequate supervision and assistive devices as needed to prevent accidents. Record review of the facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two (2) Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. She was assisted from the floor without difficulty and the Registered Nurse (RN) assessment revealed no injuries. On 1/28/25 at approximately 4:00 PM, Resident #5 complained of pain to her right leg, the physician was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-25 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and policy and procedure reviews, the facility did not follow established infection control procedures for the transportation, handling, and disturbing of dirty and clean linens. The facility used the public laundry and transported the dirty and clean linens in the facility van that was for resident use without cleaning the van/bus before and after each use. The facility also used public washing machines without cleaning them before and after each use and for not using hot water temperatures in accordance with infection control policies and procedures. The deficient practice had the potential to affect 93 of 93 residents living in the facility and all staff.Findings Include:The facility policy titled: Laundry Services undated, read: To assure a clean supply of linens and to protect employees who handle and process the laundry. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-05-05 · tag F0868 — widespread
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interviews, record review, and facility policy review, the facility failed to ensure quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings were held at least quarterly with the mandatory staff present for two (2) of the most recent four (4) quarters. November 2024 and February 2025 Findings include: Record review of facility policy titled Quality Assurance and Performance Improvement, with revision date of October 2024, revealed, All QAPI (Quality Assurance and Performance Improvement) activities will be unified across all areas of care and services at our facility. There will be a representative of each area of service on the QAA Committee. Each area will be discussed regardless of whether the representative is present or not. All areas will work together to combine care and services across our continuum of care to better meet the needs of the elders living in our facility. Record review of Monthly Quality Assurance/Improvement Meeting sign-in sheets revealed the facility had not had a Quality Assurance meeting since 08/2024. During an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-05 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on resident and staff interview, record reviews, and facility policy review, the facility failed to promptly resolve grievances regarding cold food for four (4) of six (6) residents present in Resident Council. (Resident #34, # 37, #47, and #84) Findings Include: Review of facility policy titled, Patient Complaint and Grievance Policy effective date 3/18, last review date 1/22, revealed, Policy: Providing quality services is the primary objective .Feedback and comments received by patients or their representatives provide the organization with opportunities for improvement and enhancements of services. Patients and/or their representatives have the right to voice concerns verbally or in writing when their expectations are not met . During the Resident Council meeting held on 4/30/25 at 2:00 PM, Residents #34, #37, #47, and #84 expressed ongoing concerns regarding cold food, specifically highlighting that eggs served at breakfast were consistently cold. Resident #34 mentioned that she was often the last to receive her food tray and recalled that previously a brick was placed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-05 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, and facility policy review, the facility failed to carry out a physician ordered gradual dose reduction (GDR) for one (1) of five (5) residents reviewed for medication. Resident #64 Findings Include: Review of the facility policy titled Resident's Rights and Privileges with no revision date revealed, 21. Freedom from Chemical and Physical Restraints: Residents in the proper name of the facility shall enjoy freedom from chemical or physical restraints . Record review of the Consultant Pharmacist Recommendation dated September 3, 2024, revealed the physician ordered a decrease in Resident #64's Effexor (antidepressant) from 75 milligrams daily to 37.5 milligrams daily. Additionally, review of the Consultant Pharmacist Recommendation dated 3/21/25 revealed the physician ordered a decrease in Zyprexa (antipsychotic) 5 milligram to 2.5 milligrams at bedtime. Record review of the 4/2025 Medication Administration Record for Resident #64 revealed the residents continued to receive Olanzapine (Zyprexa) 5 milligrams nightly and Venlafaxine (Effexor-XR)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-05 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and record review, the facility failed to accurately complete section P of the Minimum Data Set (MDS) for one (1) of 22 sampled residents. Resident #19 Findings Include: The facility provided a statement on letterhead that revealed, MDS (Minimum Data Set) at proper name of the facility follows the RAI (Resident Assessment Instrument) Guidelines. Record review of the MDS with an Assessment Reference Date (ARD) of 4/03/25 revealed under section P, a bed rail was coded as a physical restraint that was used daily. An observation on 4/29/25 at 11:27 AM revealed Resident #19 with no type of restraint in use. Record review of Resident #19's Restraint Usage Evaluation dated 4/03/25 revealed under, Has any type of restraint been used in the past 7 days? No was indicated. During an interview on 4/30/25 at 1:51 PM with the MDS Nurse #2, she revealed that the facility did not have any physical restraints in the building. She confirmed the bed rails were coded as a restraint for Resident #19 and indicated this was an error. She verbalized that she reviewed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for three (3) of 95 residents in the facility. Resident #40, #90, and #92. Findings include: Review of facility policy titled, Activities of Daily Living (ADL'S) last review date 4/3/18, revealed, Policy .to assist residents in achieving maximum function with Activities of Daily Living .will provide assistance to residents as necessary . Resident #40 An observation and interview on 4/29/25 at 11:13 AM revealed Resident #40's fingernails to be approximately 3/4th (three-fourth) inch long and jagged past the tips of the fingers. Resident #40 stated she would like them to be shorter, and she wasn't sure the last time that her fingernails were trimmed. An interview and observation on 4/30/25 at 11:25 AM, Certified Nurse Aide (CNA) #1 confirmed the resident's fingernails were long and revealed that the nurses are responsible for cutting the resident's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-05 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were stored appropriately for one (1) of 95 residents residing in the facility. Resident # 32 Findings Include: Review of the facility policy titled Administration for Oral Medications unrevised, revealed under, Policy: It is the policy of proper name of the facility that all services provided or arranged by the facility must meet professional standards of quality. Record review of the Nursing Department QA (Quality Assurance) for Med Pass revised 2/15/12 revealed, Ensure that resident has taken and swallowed medication. An observation of Resident #32 on 4/29/25 at 11:40 AM revealed she was lying on her left side in bed with her eyes closed. A clear medication cup was observed sitting on the bedside table with seven (7) pills inside. An observation and interview with Licensed Practical Nurse (LPN) #2 on 4/29/25 at 11:50 AM confirmed that Resident #32's medications were left at the bedside. She revealed that the medication was the resident's morning medication and explained…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-05 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility policy review the facility failed to put infection control measures in place to prevent the possible spread of infections for one (1) of 95 residents residing in the facility. Resident #81 Findings include: Record review of facility policy titled, Contact Precautions dated 2018, revealed, It is the intent of this facility to use contact precautions for residents known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Contact Precautions shall be used in addition to Standard Precautions for residents with infections that can be easily transmitted by direct and indirect contact. Resident #81 An observation on 4/29/25 at 12:55 PM revealed an isolation cart outside of Resident #81's room. There was no signage to indicate the type of isolation or precautions to be used. During an interview on 4/30/25 at 8:45 AM, Registered Nurse #1 revealed that Resident #81 was in contact isolation for a wound infection with MRSA (Methicillin-resistant…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-05 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review and facility policy review, the facility failed to notify a Resident Representative (RR) following an accident for one (1) of three (3) residents reviewed for notifications of change. Resident #5. Cross Reference F689, F656 Findings Included: Record review of the facility policy titled Notification of Changes revealed, Policy: i. To immediately notify the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when: a. An accident involving the resident which results in injury or has the potential for requiring physician intervention . Record review of the facility investigation revealed that on 1/27/25 at approximately 1:35 PM Resident #5 was being assisted from her bed to the wheelchair by two Certified Nursing Assistants (CNA), her legs got weak, and the CNAs assisted her to the floor. She was assisted from the floor without difficulty and the Registered Nurse (RN) assessment revealed no injuries. On 1/28/25 at approximately 4:00 PM, Resident #5 complained of pain…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-05 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure food was stored and served under sanitary conditions, when staff failed to remove perishable food items, including milk, from the resident's room in a timely manner. This resulted in the potential for foodborne illness due to prolonged exposure of food to room temperature for one (1) of five (5) days of survey. (Resident #90) Findings include: Review of the facility policy titled, Dietary Services undated, revealed under, Purpose: To prevent contamination of food products and therefore prevent foodborne illness. Additionally revealed under, . VI. Proper Food Handling . P. Foods that have stood for several hours at room temperature cannot be considered safe and free from contamination . An observation on 4/29/25 at 11:08 AM revealed Resident #90's breakfast tray was still in the room located on the bedside table. The tray contained leftover contents of breakfast including half a carton of milk. An interview on 4/30/25 at 11:42 AM with Licensed Practical Nurse (LPN) #3 revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in MS