Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Big Meadows during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, dependent on staff for daily care, was subjected to disrespectful and derogatory language by staff, including age-related remarks and suggestions that she belonged on the dementia unit. The facility's investigation confirmed that inappropriate comments were made, constituting verbal abuse as defined by facility policy.
A resident with dementia experienced an unwitnessed fall resulting in a head injury and right hip pain. Although staff attempted some assessments, there was no documentation of a neurological assessment or range of motion check in the medical record, despite the resident being sent to the ER and later diagnosed with a hip fracture. Staff interviews confirmed that required assessments were not documented as expected.
A resident with dementia and anxiety fractured a finger after becoming agitated and hitting a wall during care. The facility failed to implement care plan interventions to manage the resident's behaviors, and communication lapses between CNAs contributed to the incident.
The facility failed to provide meaningful activities for dementia residents, as observed in four cases. One resident wandered aimlessly without engagement, while another sat unengaged in a common area. A third resident expressed a desire for activities but was not invited to participate, and a fourth resident paced without staff engagement. The Activity Director was the only staff member responsible for activities during weekdays, leaving weekends without structured activities, contrary to the facility's policy.
The facility did not follow the prescribed pureed menu for residents on pureed diets. The cook prepared and served meals without the required pureed cornbread, as confirmed by the Dietary Manager. This resulted in residents not receiving the complete meal as per their dietary needs.
A facility failed to include a bed hold policy in the packet of information for a resident transferred to the hospital. The resident experienced a drop in oxygen saturation, necessitating an emergency room transfer. The Registered Nurse was unsure if the bed hold policy was included, and the Administrator confirmed it was not, citing packet thickness as the reason for its exclusion. The facility's policy requires written notification of the bed hold policy to accompany the resident to the hospital.
A resident with moderate oral/pharyngeal dysphagia did not receive the recommended diet modifications due to a communication lapse in the facility. Despite speech therapy's advice for a mechanical soft diet and nectar thick liquids, the resident continued on a regular diet, as the recommendations were not relayed to the nursing staff. This oversight contradicts the facility's dysphagia management policy.
A facility failed to maintain a resident's adaptive equipment, impacting his range of motion. The resident, with a history of stroke and hemiplegia, had a broken arm trough on his wheelchair, which had been reported but not repaired for months. The restorative staff was unaware of the issue, and the facility lacked a policy on adaptive equipment care.
The facility failed to implement enhanced barrier precautions for two residents, leading to deficiencies in infection control. One resident with an open pressure ulcer did not have proper signage or gown use by staff, while another resident with a urinary catheter had inconsistent gown use despite posted precautions. The facility's policy requires clear signage and PPE for high-contact care, which was not consistently followed.
Resident Subjected to Verbal Abuse by Staff
Penalty
Summary
A resident with moderate cognitive impairment, dependent on staff for activities of daily living and mobility, reported being subjected to disrespectful and derogatory language by facility staff during care. The resident recalled staff making age-related disparaging remarks, including comments such as, 'Well, if you weren't so old,' and, 'I don't know why they send you (old) people here.' The resident stated that when she asked the staff to stop, her request was ignored. Documentation from a Certified Nursing Assistant (CNA) indicated that the resident reported being hurt by two aides and that one aide admitted to making a comment suggesting the resident belonged on the dementia unit if she continued certain behaviors. The facility's investigation substantiated the occurrence of verbal abuse, as defined by their Abuse Program Policy, which prohibits the use of disparaging or derogatory language toward residents. The involved staff members denied the events, but the investigation included written statements and interviews that confirmed inappropriate comments were made within the resident's hearing. The incident was reported to facility administration, and an investigation was initiated following the resident's complaint.
Failure to Document Post-Fall Assessment After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to conduct and document a comprehensive assessment for a resident following an unwitnessed fall. The resident, who had a diagnosis of unspecified dementia and resided on the dementia unit, was found on the floor with a pool of blood at his head and was yelling for help. Although the incident report included vital signs, it did not document a range of motion (ROM) or neurological assessment, despite the presence of an obvious head injury. The resident complained of right hip pain and was unable to bear weight on the right hip before being sent to the emergency room, where a closed right hip fracture was diagnosed. Interviews with staff revealed that while some assessment attempts were made, such as checking vital signs and attempting to assess ROM and pupils, these were not documented in the medical record. The RN involved acknowledged that the assessments should have been documented, especially given the resident's complaints of pain and visible injuries. The Director of Nursing confirmed that the required assessments, including ROM and neuro checks, were missing from the documentation. The facility did not have a specific policy for post-fall assessments, but staff agreed that documentation of these assessments was expected.
Failure to Implement Dementia Care Interventions
Penalty
Summary
The facility failed to implement care planned interventions to manage a resident's dementia-related anxiety and aggressive behaviors, resulting in the resident fracturing a finger after punching a wall. The resident, who had diagnoses of anxiety and dementia with behavioral disturbances, became agitated during care and swung at a CNA, hitting the wall in the process. The care plan for the resident included interventions such as offering a soda or calling the resident's son to de-escalate behaviors, but these were not implemented during the incident. On the night of the incident, the CNA assigned to the resident did not inform the covering CNA about the resident's ongoing aggressive behaviors before taking a break. The covering CNA attempted to change the resident without giving him a break, despite his agitation, leading to the resident's aggressive response. The facility's Behavioral Management policy emphasizes the use of non-pharmacological interventions and staff awareness of de-escalation strategies, which were not effectively communicated or executed in this case.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide meaningful activities to dementia residents, as observed in four residents. One resident, diagnosed with dementia, was seen wandering the hallways aimlessly on multiple occasions without being engaged in any activities. Despite having a care plan that included preferences for individual and group activities, the resident was not offered any engagement, particularly on weekends when no activities were scheduled. Staff acknowledged the resident's behavior but did not attempt to involve him in any activities. Another resident, also with dementia, was observed sitting in a common area without any engagement or activities offered. The resident's care plan indicated a preference for fresh air and religious activities, but no such activities were provided. Staff members, including CNAs, confirmed that they were not conducting activities on weekends, and the activity calendar showed a lack of scheduled activities during the observed times. A third resident, with dementia and COPD, expressed a desire for activities but reported that no one invited him to participate. The Activity Director admitted to being the only staff member responsible for activities during weekdays, leaving weekends without structured activities. A fourth resident, with a care plan emphasizing the importance of music and outdoor activities, was observed pacing and expressing a desire to go outside, yet no staff engaged him in any activities. The facility's policy on activities was not adhered to, as staff failed to provide a comprehensive program that met the residents' needs.
Failure to Follow Pureed Menu for Residents
Penalty
Summary
The facility failed to adhere to the prescribed pureed menu for eight residents who were on pureed or liquidized pureed diets. On the specified date, the cook, identified as V20, was observed preparing the pureed meal but did not include pureed cornbread as required by the menu. Instead, only pureed BBQ turkey, creamed corn, and dessert were prepared and served. This omission was confirmed by the Dietary Manager, V21, who acknowledged that the menu should have been followed. As a result, residents did not receive the complete meal as indicated by their dietary requirements, specifically lacking the pureed cornbread component.
Failure to Include Bed Hold Policy in Hospital Transfer Packet
Penalty
Summary
The facility failed to ensure that a bed hold policy was included in the resident's packet of information for a resident who was transferred to the hospital. The deficiency was identified during a review of the facility's procedures for handling hospital transfers. The resident, identified as R33, experienced a change in condition with oxygen saturation levels dropping to 86 percent, prompting a transfer to the emergency room. The nurse practitioner was notified, and the resident's power of attorney was informed, with necessary paperwork faxed to the hospital. During the investigation, it was revealed that the facility's bed hold policy was not included in the packet of information sent with the resident to the hospital. The Registered Nurse, V17, was unsure if the bed hold policy was included, and the Administrator, V1, confirmed that the policy was not sent with the resident. The Administrator explained that the bed hold policy used to be included in the packet but was removed due to the packets becoming too thick. The facility's undated Bed Hold Policy and Readmission document states that written notification of the bed hold policy should be provided to the family or legal representative within 24 hours of transfer, and a copy should accompany the resident to the hospital.
Failure to Implement Speech Therapy Recommendations for Dysphagia
Penalty
Summary
The facility failed to implement speech therapy recommendations for a resident with moderate oral/pharyngeal dysphagia, leading to a deficiency in care. The resident, who was on droplet/contact precautions, was observed on two separate occasions with meals that did not align with the recommended diet for her condition. Despite having a regular diet listed on her diet card, the speech therapy evaluation recommended a downgrade to a mechanical soft consistency and nectar thick liquids due to new onset of coughing and choking during oral intake. The Licensed Practical Nurse was unaware of any swallowing problems, and the Administrator acknowledged that the speech therapy recommendations were not communicated to the nursing staff. The Physician Order Sheets confirmed the resident was still on a regular diet, contrary to the speech therapy's recommendations. The facility's Management of Dysphagia Policy emphasizes the importance of appropriate management to prevent complications, yet the necessary dietary adjustments and swallowing strategies were not implemented for the resident.
Failure to Maintain Resident's Adaptive Equipment
Penalty
Summary
The facility failed to ensure that a resident's adaptive equipment was functioning properly, which affected the resident's ability to maintain or improve range of motion. The resident, who had a history of stroke and hemiplegia, was observed sitting in a wheelchair with a broken arm trough that was supposed to support his left arm. The resident reported that the arm trough had been broken for several months, and although he had informed the staff, it had not been repaired. This lack of functioning equipment led to the resident's left arm dangling by his side, potentially impacting his comfort and positioning. The restorative staff member, upon being informed of the issue, was unaware that the adaptive device was broken and confirmed that the arm trough was not correctly positioned for use. Further inspection revealed that the trough did not fit the wheelchair properly. The facility did not have a policy on the use and care of adaptive equipment, which contributed to the oversight and delay in addressing the resident's needs. This deficiency highlights a lapse in ensuring that necessary equipment is maintained and functional for resident care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents, leading to deficiencies in infection control. For one resident, there was no sign posted on the door indicating the need for enhanced barrier precautions, and a CNA provided incontinence care without wearing a gown, despite the resident having an open pressure ulcer on the coccyx. The Assistant Director of Nursing confirmed that the resident should have been on enhanced barrier precautions due to the wound, but the Physician Order Sheets did not reflect this requirement. In another instance, a resident with a urinary catheter had an Enhanced Barrier Precaution sign posted inside the room, but a CNA assisted with the resident's leg bag without wearing a gown. The RN confirmed that the resident was on enhanced barrier precautions due to the urinary catheter, and staff were required to use gowns and gloves for catheter care. The facility's policy mandates clear signage and the use of personal protective equipment for high-contact resident care activities, which was not consistently followed in these cases.
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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 Savanna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Mt Carroll | 7.9 mi | — | 0 | 0 |
| Eagle Point Nursing And Rehabilitation | 15.3 mi | — | 7 | 0 |
| The Alverno Health Care Facility | 16.7 mi | — | 8 | 0 |
| Allure Of Stockton | 18.7 mi | — | 0 | 0 |
| Mill Valley Care Center | 18.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.