Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Chadwick Community Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was discharged after going on therapeutic leave with family, but neither the resident nor their representative received a required bed-hold notice or clear communication about discharge status, appeal rights, or the process for returning. Facility staff confirmed that bed-hold notifications were not provided for therapeutic leave, and the resident's family experienced confusion regarding medication, discharge, and the removal of a wander guard.
A resident with significant neurological impairments and total dependence for ADLs did not receive perineal care according to the care plan, which required two-person assistance. Instead, a CNA provided care alone, contrary to the documented interventions. Facility leadership and nursing staff confirmed that the care plan was not followed during this incident.
A CNA failed to provide perineal care according to policy for a resident with neurological impairments, neglecting to clean all required areas and improperly handling a feeding pump, which only nurses are authorized to operate. Facility staff confirmed the care was not performed correctly and that the resident was unable to participate in a mental status interview.
A resident on Enhanced Barrier Precautions did not receive perineal care in accordance with infection control protocols. A CNA failed to wear a gown, perform hand hygiene, use a barrier for supplies, or change gloves as required, and did not properly clean the perineal area. Facility staff confirmed these actions did not meet established infection prevention standards.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised through a kitchen door that lacked a wander guard alert system. Despite wearing a wander guard bracelet, the resident was able to leave undetected, as staff did not immediately notice the absence and the door was not properly secured. The resident was found approximately one mile away after crossing a busy highway, highlighting a failure in supervision and environmental safety controls.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and untimely incontinent care for residents. A resident experienced frequent delays, with observations noting a strong odor of urine and saturated briefs. Another resident reported long wait times for call light responses, with staff often failing to return. A third resident reported long wait times, particularly during the night shift, and a CNA confirmed staffing shortages. The DON and Administrator stated expectations for timely care, but observations indicated systemic staffing issues.
The facility failed to honor the rights of two residents who requested bedrails for assistance with mobility. Despite their requests, the facility removed all bedrails, citing state regulations and a restraint-free policy. The residents' needs and choices were not assessed, leading to a violation of their rights.
A resident receiving oxygen therapy at 2 L/min was found without a dated tubing and a humidifier, contrary to facility policy and physician orders. The resident, with a history of respiratory issues, had been hospitalized twice for shortness of breath. Staff interviews confirmed the oversight, highlighting the risk of infection and dryness due to non-compliance with weekly tubing changes and humidifier use.
A resident with moderate cognitive impairment and a history of stroke, diabetes, and heart disease experienced delays in receiving incontinent care. Despite activating the call light, staff either turned it off without providing care or delayed in responding. Observations showed the resident's brief was often saturated with urine, and the wheelchair was wet due to leakage. The facility had only one CNA for 12 residents, contributing to the delay, despite expectations for timely care set by the DON and Administrator.
Failure to Provide Bed-Hold Notice and Discharge Communication
Penalty
Summary
The facility failed to provide a required bed-hold notice to a resident and their representative when the resident went out on therapeutic leave, as required for Medicaid beneficiaries. The facility did not have a policy for issuing bed-hold notifications for therapeutic leave, and staff interviews confirmed that such notices were only given when a resident was admitted to a hospital for more than 24 hours, not for therapeutic leave with family. The Executive Director, Business Office Manager, and other staff acknowledged that bed-hold notifications were not provided in these circumstances, and the Executive Director later recognized this as an oversight. The resident involved had a history of schizophrenia and wandering, with a severely impaired cognitive status as indicated by a BIMS score of 03. The resident frequently went on therapeutic leave with family, as documented in progress notes and facility records. On the date in question, the resident left with family for therapeutic leave and did not return. The family and resident representative were not informed of a discharge at the time of departure, nor were they provided with information about bed-hold policies, appeal rights, or the resident's ability to return to the facility. Interviews with the resident's representative and family revealed confusion and lack of communication regarding the resident's discharge status, medication supply, and the process for returning to the facility. The representative reported not understanding the appeal process and not receiving timely or adequate notification about the resident's discharge or bed-hold rights. Additionally, the facility did not remove the resident's wander guard upon discharge, and there was no follow-up from the social worker regarding the resident's care after leaving the facility.
Failure to Follow Care Plan for Dependent Resident During Perineal Care
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who was observed for activities of daily living (ADL) care, specifically during perineal care. The resident's care plan, initiated on 10/2/24, indicated that the resident was incontinent of bladder and bowel and required incontinent checks and care every two hours and as needed, with two-person assistance due to total dependence. However, during an observation on 9/16/25, a CNA provided perineal care to the resident without the required two-person assistance as specified in the care plan. Interviews with the CNA, Executive Director, and Director of Nursing confirmed that the care plan was not followed during the provision of care. The CNA acknowledged not using two-person assistance, and both the Executive Director and Director of Nursing stated that the expectation is for CNAs to follow the care plan and provide proper care. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview, indicating a high level of dependency and vulnerability.
Failure to Provide Proper Perineal Care and Unauthorized Handling of Feeding Pump
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide perineal care according to the facility's policy and accepted standards for a resident with significant neurological impairments, including hemiplegia, hemiparesis, dysphasia, and aphasia. During the observed care, the CNA used wipes to clean the resident's groin area but did not separate the labia or clean each side and the center thoroughly, nor did he clean the rectal area. The CNA also placed the resident's feeding pump on hold, an action that facility policy reserves for nurses only. The CNA acknowledged not following proper procedure and attributed the lapse to nervousness. Interviews with facility staff, including the RN Unit Manager, Executive Director, and Director of Nursing, confirmed that the CNA did not perform perineal care correctly and was not authorized to operate the feeding pump. The facility's policy requires thorough cleaning of the entire perineal area and mandates that only nurses handle feeding pumps. The resident involved was unable to participate in a mental status interview, as indicated by a BIMS score of 00, and had been admitted with multiple neurological diagnoses.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to provide perineal care in accordance with infection prevention and control protocols for one of two residents observed. During the observation, a CNA gathered supplies and entered the resident's room, which was under Enhanced Barrier Precautions (EBP), without donning a gown as required. The CNA placed supplies directly on the table without a barrier, did not perform hand hygiene before, during, or after care, and did not change gloves during the procedure. The CNA also failed to separate the labia to clean each side and the center individually, did not clean the rectal area, and placed soiled wipes and briefs on the bed instead of in a designated bag. After completing care, the CNA removed gloves and exited the room without washing or sanitizing hands. Interviews with facility staff, including the CNA, RN Unit Manager, Executive Director, DON, and Infection Preventionist, confirmed that the CNA did not follow established protocols for EBP, hand hygiene, and perineal care. Staff acknowledged that the CNA's actions constituted cross-contamination and did not meet the facility's expectations for infection control. The CNA admitted to not wearing a gown, not washing hands, and not following proper perineal care procedures, attributing the lapse to nervousness and oversight. The resident involved had a history of significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview. Facility records and policy reviews indicated that staff were trained and expected to follow EBP and hand hygiene protocols, but these were not adhered to during the observed incident.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement and wandering risk, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of Schizophrenia and severe cognitive impairment as indicated by a BIMS score of 4, was last seen in the dining room by staff. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility through a kitchen door that was not equipped with a wander guard alert system, unlike other facility exits. The door had a keypad lock, but it was accessible from the dining area and not properly secured to prevent resident exit. Staff did not immediately notice the resident's absence. The resident's walker was left in the dining room, and staff initially assumed the resident had returned to his room. It was only after a phone call from the resident's family and subsequent checks that staff realized the resident was missing. A facility-wide elopement alert was then announced, and staff began searching the premises and surrounding area. The resident was located approximately one mile from the facility, having crossed a busy four-lane highway, and was returned after being unsupervised for about two hours. Interviews with staff and family confirmed that the resident had a history of exit-seeking behavior and had previously expressed a desire to go home. Staff had observed the resident attempting to open exit doors on multiple occasions. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but in this instance, the resident was able to leave undetected due to the lack of a wander guard system on the kitchen door and insufficient supervision in the dining area.
Removal Plan
- RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries.
- A 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings.
- All the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly.
- Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly.
- Head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings.
- Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident.
- Upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1:1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status.
- A keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff.
- The Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility.
- Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning.
- The Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director.
- Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement.
- The Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye.
- Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen.
- The facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services.
- We had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility.
- Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place.
- A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by delayed responses to call lights and untimely incontinent care for three residents. Resident #48 experienced frequent delays in receiving care, with observations noting a strong odor of urine and saturated briefs. The resident reported that CNAs often turned off call lights without returning promptly, and the facility was observed to have only one CNA attending to 12 residents on the hall. The Director of Nurses and an LPN acknowledged the delay, attributing it to staffing shortages. Resident #87 also reported long wait times for call light responses, with staff often failing to return after initially acknowledging the call. This resident, who was cognitively intact, expressed frustration with the consistent delays across all shifts. Similarly, Resident #23 reported long wait times, particularly during the night shift, and a CNA confirmed that the facility was often short-staffed, with nurses not assisting CNAs. The Director of Nurses and the Administrator both stated expectations for timely care, but the observations and interviews indicated a systemic issue with staffing levels and response times.
Failure to Honor Resident Choice for Bedrails
Penalty
Summary
The facility failed to honor the rights of two residents, who expressed a desire to have bedrails for assistance with turning and bed mobility. Resident #54, who was cognitively intact, reported wanting bedrails to maintain some independence, but was informed by staff that state regulations prohibited their use. Similarly, Resident #78, who had moderate cognitive impairment and required assistance with mobility, expressed frustration over the removal of his bedrails, which he used for turning assistance. Both residents were told that the state regulations were the reason for the removal of bedrails, and their requests for bedrails were not assessed or honored. The facility's management confirmed that all bedrails were removed from residents' beds, citing state regulations and the facility's restraint-free policy as reasons. However, it was acknowledged that the removal of bedrails without assessing individual resident needs or choices was a violation of residents' rights. The facility did not have a specific bedrail policy in place, only a restraint policy, which contributed to the oversight in addressing the residents' requests and needs for bedrails.
Failure to Follow Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper oxygen therapy for a resident, as evidenced by not following physician orders or facility policies. During an observation, it was noted that a resident was receiving oxygen at 2 liters per nasal cannula without a date on the tubing and without a humidifier attached. The resident had a history of shortness of breath and acute respiratory failure with hypoxia, and had been hospitalized twice due to shortness of breath. The facility's policy required oxygen tubing to be changed and dated weekly, and a humidifier to be used if needed to prevent dryness in the nasal area. Interviews with staff, including an LPN and the Director of Nurses, confirmed the oversight. The LPN acknowledged the absence of a date on the tubing and the lack of a humidifier, stating that these omissions could lead to infection issues. The Director of Nurses also confirmed that the resident should have had a humidifier attached to the oxygen delivery system to maintain moisture in the nasal area and that the tubing should be changed weekly to prevent bacterial growth. The physician's orders for the resident specified continuous oxygen at 2 L/min and weekly tubing changes, which were not adhered to.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident, leading to a deficiency in care. The resident, who has a history of cerebral infarction, type 2 diabetes mellitus, and hypertensive heart disease, was observed to have a moderate cognitive impairment and required substantial assistance with toileting and personal hygiene. On multiple occasions, the resident's call light was activated, indicating a need for assistance, but staff either turned off the light without providing care or delayed in responding. The resident expressed frustration over the long wait times for care, which occurred across different shifts. Observations revealed that the resident's incontinent brief was often soiled and saturated with urine, and the resident's wheelchair was also wet due to leakage. Interviews with staff, including CNAs and the DON, confirmed that there was only one CNA available for 12 residents on the hall, which contributed to the delay in care. Despite the facility's policy and the expectations set by the DON and the Administrator for timely care, the resident continued to experience delays in receiving necessary assistance, resulting in a strong odor of urine in the resident's room and hallway.
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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 Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Hills Community Living Center | 0.4 mi | — | 2 | 1 |
| Woodlands Rehabilitation And Healthcare Center | 4.3 mi | — | 3 | 0 |
| Methodist Sepcialty Care Center | 4.5 mi | — | 1 | 0 |
| Willow Creek Retirement Center | 4.9 mi | — | 9 | 0 |
| Compere Nh Inc | 5 mi | — | 0 | 0 |
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