Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springs Village Care Center during CMS and state inspections, most recent first.
A resident with dementia, respiratory failure, diabetes, and asthma, who was dependent on staff for ADLs, was transferred to the hospital at family request and later hospitalized with pneumonia and hyponatremia. After the hospitalization, facility leadership decided not to allow the resident to return, citing concerns about a family member’s verbally and physically abusive behavior toward staff, even though staff reported no problematic behaviors by the resident and confirmed the facility could meet the resident’s medical needs. An expedited discharge notice was created citing safety concerns but was not completed or provided to the resident or family prior to discharge, and the record lacked evidence that the resident was reassessed at the hospital once she returned to baseline before the immediate discharge decision was made.
The facility did not ensure prompt action or follow-up on group grievances raised by the resident council, specifically regarding missing and misdelivered laundry items. Although individual grievances were sometimes addressed, group concerns were not formally documented or resolved, and updates were not provided to residents in subsequent meetings, as confirmed by both resident interviews and review of meeting minutes.
A resident independently emptied her indwelling catheter bag without performing hand hygiene or using a privacy cover, and staff did not assess, educate, or monitor her for proper infection control practices. Additionally, multiple staff members provided high-contact care to residents on Enhanced Barrier Precautions without wearing required gowns, despite facility policy and CDC guidelines mandating both gown and glove use for such activities.
A resident with anemia and other chronic conditions was not informed of her critical lab values or the specific reason for her hospital transfer for a transfusion, nor was she updated on her lab results after returning. Although staff and policy indicated residents should be kept informed, there was no documentation or evidence that the resident or her representative received this information.
A resident with dementia and other diagnoses was allowed to self-administer Visine eye drops without a documented assessment or a physician's order authorizing self-administration. The resident kept multiple bottles of the medication unsecured at her bedside and used them daily, despite being unable to state the correct usage frequency. Facility policy required an IDT assessment and secure storage, but these steps were not followed.
Three residents received psychotropic medications without individualized care approaches, as the facility used generic, non-person-centered interventions and failed to document specific target behaviors or the effectiveness of interventions. For each resident, care plans and physician's orders did not reflect their unique behavioral history or interests, and there was no documented physician rationale for continued medication use, despite minimal or no documented behaviors. Staff interviews confirmed a lack of awareness of individualized interventions and reliance on standard documentation.
A resident with Parkinson's disease and significant hand tremors did not receive consistent staff assistance with eating, despite observable difficulties in cutting food and consuming meals. The care plan lacked specific interventions for meal assistance, and staff only provided help when directly asked, which was not always effective. The resident experienced unplanned weight loss, and the root cause was identified as difficulty eating due to tremors, yet no therapy referral or dietary adjustments were made.
Two residents experienced deficiencies related to environmental safety and medication security. One resident with a history of falls and multiple health conditions had a loose bathroom grab bar that was not repaired and did not receive an additional grab bar as recommended by OT, despite a work order being submitted. Another resident with severe cognitive impairment had a bottle of Dakin's solution left unsecured at the bedside, contrary to facility policy. These issues were identified through observations, record reviews, and interviews, revealing failures to follow safety protocols and secure treatments.
A resident with a history of major depressive disorder, suicidal ideations, and previous suicide attempts did not receive appropriate monitoring or individualized interventions for worsening depression. Despite documented symptoms such as increased sleep, decreased appetite, and expressions of hopelessness, staff failed to follow up or adjust monitoring, and key staff members were unaware of the resident's mental health history and triggers.
Controlled medications, including liquid lorazepam, were found in a locked narcotic box inside an unlocked medication storage refrigerator, and the narcotic box was not permanently affixed as required. Nursing staff confirmed that both the refrigerator and the narcotic box should be locked at all times, and the DON was unaware of the requirement for permanent affixation.
A resident in a LTC facility did not receive timely incontinence care, remaining soiled for nearly four hours despite facility policy requiring checks every two hours. The resident, who was cognitively intact and dependent on staff for toileting, preferred to be checked before or after meals, but this was not reflected in her care plan. Staff interviews indicated a lack of communication and adherence to the facility's incontinence care policy.
A facility failed to manage a resident's pain according to physician's orders and did not provide non-pharmacological interventions before administering PRN pain medication. The resident, diagnosed with quadriplegia and unspecified pain, received Tramadol for a pain level outside the prescribed parameters, and there was no documentation of non-pharmacological interventions. The DON confirmed the need to follow physician-ordered parameters.
A resident with a history of pressure ulcers and paraplegia did not receive proper wound care due to the absence of a physician's order and failure to follow the care plan. The RN did not moisten the old dressing before removal, potentially damaging the wound bed, and used an inappropriate dressing. The resident was also found without necessary offloading interventions, contrary to the care plan. The RN relied on previous notes due to missing documentation in the EMR, leading to inadequate care.
A facility failed to manage a resident's pain according to professional standards by not conducting a thorough pain assessment and not offering non-pharmaceutical interventions before administering as-needed pain medication. The resident, with severe cognitive impairments, was observed in pain without a completed pain assessment or a documented pain management plan.
A facility failed to maintain proper infection control during wound care for a resident with a history of osteomyelitis. An RN did not use barrier pads, neglected hand hygiene between glove changes, and reused sponges on multiple wound sites, contrary to facility policies. The DON and RN acknowledged these lapses, emphasizing the importance of infection prevention.
The facility failed to report an allegation of sexual abuse made by a resident to the State Survey and Certification Agency. The resident, who had mild cognitive impairment, reported inappropriate touching by a male staff member. The Director of Nursing notified the Nursing Home Administrator, but there was no documentation that the allegation was reported to the State Agency.
A resident reported inappropriate touching by a CNA, but the facility failed to document an investigation. The DON suspended the CNA and notified the NHA, who later allowed the CNA to return to work without informing the DON of the investigation's outcome. The OM confirmed no documentation of an investigation could be found.
Failure to Allow Resident to Return After Hospitalization Due to Family Behavior
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge/transfer by refusing to allow a resident to return from the hospital, despite being able to meet the resident’s medical needs and in the absence of problematic resident behaviors. The resident, over age 65, had dementia, respiratory failure, diabetes, and asthma, and was dependent on staff for eating, personal hygiene, dressing, and transferring. The resident was transferred to the hospital at the family’s request and was hospitalized with pneumonia and hyponatremia. While the facility later issued an Expedited Notice of Transfer citing that the safety of individuals in the facility would otherwise be endangered, the record did not show that the resident had exhibited behaviors that endangered others, nor did it show that the facility reassessed the resident once she returned to baseline at the hospital prior to issuing the immediate discharge notice. Interviews with facility staff confirmed that the decision not to readmit the resident was based on the behavior of a family member, not on the resident’s condition or conduct. The admissions director stated the resident was not permitted to return and that the situation required an immediate discharge, but could not specify the reason beyond family dynamics. The DON reported there had been no issues with the resident’s care or behavior and acknowledged that a facility could not refuse readmission based on a family member’s behavior, further stating the resident should have been allowed to return. The NHA described the resident as a great resident with no mistreatment of staff or other residents, and admitted the decision to deny readmission was made quickly due to concerns about the abusive behavior of a family member and its impact on staff. The NHA also acknowledged that the resident had the right to return, that the facility could manage the resident’s medical needs, and that the Expedited Notice of Transfer was not completed or provided to the resident or family prior to discharge from the hospital. A RN corroborated that the resident had no significant behavior issues and was friendly toward staff, while noting that a family member often directed care decisions in conflict with the resident’s wishes.
Failure to Address Group Grievances Raised by Resident Council
Penalty
Summary
The facility failed to ensure prompt action was taken upon the filing of a group grievance, specifically regarding missing clothing, as brought up by the resident council. According to the facility's own policy, all grievances or recommendations from resident or family groups concerning resident care are to be considered and responded to in writing, including a rationale for the response. However, interviews with alert and oriented residents who regularly attended resident council meetings revealed that group grievances, such as the ongoing issue of laundry items being delivered to the wrong residents, were not followed up on or resolved. Residents reported that while individual grievances were sometimes addressed, group grievances raised in council meetings did not receive updates or resolutions in subsequent meetings, and the facility did not communicate how or when these issues would be resolved. Review of resident council meeting minutes over several months confirmed that concerns about missing or misdelivered laundry were repeatedly raised but not documented as addressed or resolved by the facility. Staff interviews further revealed that while there was a process for handling individual grievances, there was no established process for following up on group grievances from resident council meetings. Grievances discussed in meetings were not formally documented on facility grievance forms, and there was no system to ensure department managers provided updates or resolutions to the resident council, resulting in unresolved group concerns.
Failure to Maintain Infection Control Procedures for Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies related to both staff and resident practices. One deficiency involved a resident with an indwelling urinary catheter who independently managed her catheter care. The resident was observed emptying her catheter bag without performing hand hygiene before or after the procedure, touching both the toilet seat and the catheter bag with bare hands, and leaving the catheter bag on the floor without a privacy cover. The resident reported not recalling any education on proper catheter care, and her care plan did not address her self-management of the catheter or include steps for staff to ensure proper infection control practices. There was also no documentation of assessment, education, or monitoring to ensure the resident adhered to infection control guidelines. Another deficiency was identified in the staff's failure to follow Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Multiple staff members, including CNAs, were observed providing high-contact care activities such as incontinence care and transfers to residents on EBP without donning the required gowns, although gloves were used. Staff interviews revealed inconsistent awareness and adherence to EBP protocols, with some staff citing reasons such as not noticing signage or being in a hurry. The facility's policy and CDC guidelines require both gown and glove use for high-contact care activities for residents on EBP, but these were not consistently followed. The report documents that the facility's infection control failures occurred across more than one unit and involved both direct care staff and the lack of appropriate care planning and assessment for residents managing their own medical devices. The observations and interviews confirm that the facility did not ensure adherence to established infection control procedures, as required by both facility policy and professional guidelines.
Failure to Inform Resident of Laboratory Results and Treatment Decisions
Penalty
Summary
The facility failed to ensure that a resident was fully informed of her laboratory bloodwork values and the reasons for her transfer to the hospital for a transfusion, as well as her lab results after returning from the hospital. Despite facility policy requiring residents to be notified of their medical condition and any changes, there was no documentation that the resident or her legal representative was informed of her critically low hemoglobin (HGB) levels or the specific reason for her hospital transfer. Nursing progress notes indicated that the physician and family were notified of the transfer, but did not mention informing the resident herself about her lab results or the rationale for the transfer. The resident, who was cognitively intact and had diagnoses including anemia, chronic heart failure, and chronic respiratory failure, reported that she was not told her bloodwork values either before being sent to the hospital or after her return. Staff interviews confirmed that it was the responsibility of nursing staff to inform residents of significant changes in their condition, but there was no evidence in the medical record that this communication occurred. The DON also could not recall specifically discussing the resident's HGB levels with her.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the self-administration of Visine eye drops, as required by facility policy. The resident, who had diagnoses including bipolar disorder, unspecified dementia, and anxiety disorder, was found to have three bottles of Visine eye drops at her bedside and reported using them daily. However, she was unable to state how often she should use the drops. The physician's order for the eye drops did not specify that the resident was permitted to self-administer the medication, and there was no documentation in the medication administration record indicating that staff had administered the drops. Additionally, the resident's electronic medical record did not contain an assessment for self-administration of the eye drops. Staff interviews confirmed that the resident was allowed to keep the eye drops unsecured at her bedside and self-administer them without a documented assessment or a physician's order authorizing self-administration. The facility's policy required an interdisciplinary team assessment to determine if self-administration was clinically appropriate and safe, as well as secure storage of medications. Despite these requirements, the resident was permitted to self-administer the medication without the necessary assessment or authorization, and the medication was not securely stored.
Failure to Individualize Psychotropic Medication Use and Documentation
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraint and that the use of psychotropic medications was properly justified and documented. For each of these residents, the facility did not document resident-specific care approaches, including medication-specific target behaviors and person-centered interventions. The care plans and physician's orders relied on generic, non-personalized interventions for behavior monitoring, and did not incorporate individualized strategies or interests identified in assessments such as the Level II PASRR. Additionally, there was a lack of documentation regarding the effectiveness of interventions used, and in some cases, no interventions were documented at all when behaviors occurred. For one resident with a diagnosis of disorganized schizophrenia, the care plan and behavior monitoring orders listed the same non-person-centered interventions for all behaviors, regardless of the specific issue. The resident's history of psychiatric symptoms, self-harm, and interests were not reflected in the care plan or orders. Documentation in the medication administration and treatment records showed minimal or no behaviors, and when behaviors were noted, the effectiveness of interventions was not recorded. There was also no documentation of a physician's rationale for the continued use of antipsychotic medications, despite quarterly reviews indicating no recent behaviors. Another resident with diagnoses including Parkinson's disease, anxiety, OCD, and depression had behavior monitoring orders that did not specify non-pharmacological interventions. The care plan did not reflect the resident's specific behaviors or interests as identified in the PASRR evaluation. Documentation showed minimal behavioral incidents, with no evidence of non-pharmacological interventions being attempted. Similarly, a third resident with depression, intellectual disability, and TBI had no non-pharmacological interventions indicated in the orders, and the care plan did not address specific behaviors or interests. Despite concerns documented by the psychiatrist regarding the rationale for increased medication dosage, the medication was not adjusted, and there was no documentation justifying its continued use. Staff interviews confirmed a lack of awareness of individualized interventions and reliance on generic documentation.
Failure to Provide Adequate Meal Assistance for Resident with Parkinson's Disease
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically meal assistance, to a resident diagnosed with Parkinson's disease, anxiety, OCD, and depression. Although the resident was assessed as cognitively intact and independent with eating on the most recent MDS, direct observations revealed significant difficulty with eating due to persistent hand tremors. The resident struggled to cut food and consume beverages, often losing food or being unable to eat without help. On multiple occasions, the resident attempted to get staff assistance but did not receive timely help, and at times, another resident had to intervene to assist with cutting food. Interviews with the resident confirmed that he was supposed to receive help with eating due to his tremors but only received assistance if he specifically asked, and even then, help was not always provided. The resident reported that adaptive utensils were not effective when his tremors were severe, and he often had trouble getting staff attention during meals. Staff interviews indicated a belief that the resident only needed help when requested, but observations contradicted this, showing that staff did not consistently provide the necessary assistance even when the resident attempted to ask for help. A review of the care plan and interdisciplinary team notes revealed that while the resident was at risk for decreased nutritional status and had experienced unplanned weight loss, the care plan did not specify the need for meal assistance such as cutting food. The root cause analysis identified the resident's tremors as a likely cause of weight loss due to incomplete meal consumption. Despite this, there was no referral for therapy evaluation or adjustment to the diet order to provide pre-cut meals, and the registered dietitian had not observed the resident eating or considered additional interventions to facilitate meal intake.
Failure to Address Environmental Hazards and Secure Medications
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two of five residents reviewed for accident hazards. In one instance, a resident with a history of falls and multiple medical conditions, including spinal stenosis and chronic pain, reported that the grab bar in his bathroom was loose and that an additional grab bar recommended by the occupational therapist (OT) had not been installed. Despite a work order being submitted and marked as completed, the grab bar remained unrepaired and the additional bar was not installed. The resident expressed fear of using the bathroom due to the loose grab bar and stated that the lack of proper grab bars contributed to a fall incident. Staff interviews confirmed that the maintenance department did not routinely check grab bars and that there was a lack of communication and follow-up regarding the work order. In another case, a resident with severe cognitive impairment and total dependence on staff for activities of daily living was found to have a bottle of Dakin's solution, a topical antiseptic, left unsecured on his bedside table. The solution was used for wound care, and nursing staff stated it was left in the room to avoid contamination. However, facility policy required all medications and treatments to be stored securely and not left in resident rooms. The unsecured Dakin's solution was observed during a room check, and staff confirmed it should not have been left accessible to the resident. Both deficiencies were identified through observations, record reviews, and staff and resident interviews. The facility's failure to repair and install necessary safety equipment and to properly secure medications and treatments directly contradicted its own policies and procedures, as well as recommendations from clinical staff. These lapses resulted in an environment that was not free from accident hazards and did not provide adequate supervision to prevent accidents for the residents involved.
Failure to Monitor and Address Worsening Depression in Resident with History of Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorders, including major depressive disorder, suicidal ideations, and previous suicide attempts, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The resident, who was moderately cognitively impaired, reported worsening depression due to declining health and loss of abilities, and had a documented history of multiple hospitalizations related to depression. Despite these risk factors, the care plan and physician's orders did not include specific monitoring for suicidal ideations, nor did they incorporate resident-specific triggers and non-pharmacological interests identified in the Level II PASRR evaluation. Behavior monitoring orders were in place for increased sleep, decreased appetite, and verbalizations of sadness, but there was no documentation of behaviors despite the resident consistently sleeping 10-11.5 hours per day and expressing symptoms of depression during assessments. Progress notes indicated the resident reported feeling more depressed and hopeless, with PHQ-9 scores reflecting mild depression and symptoms such as decreased appetite and increased sleep. However, there was no evidence that staff followed up on these findings or increased monitoring for worsening depression or suicidal ideation. Interviews with staff revealed a lack of awareness regarding the resident's history of depression and suicidal ideations. Certified nurse aides and a registered nurse were unaware of the resident's mental health history, and the social services director did not recall the resident's identified triggers from the PASRR. The director of nursing was also unaware of the resident's history and acknowledged that monitoring for resident-specific signs and symptoms of depression was not being conducted as required.
Failure to Secure Controlled Medications in Locked, Permanently Affixed Storage
Penalty
Summary
The facility failed to ensure that controlled medications and biologicals were stored in accordance with accepted professional standards. Specifically, during an observation of the medication storage room, a locked narcotic medication box containing two vials of liquid lorazepam was found inside a medication storage refrigerator that was unlocked. Furthermore, the narcotic medication lock box itself was not permanently affixed to the inside of the refrigerator, contrary to facility policy and professional standards that require controlled substances to be stored in a separately locked, permanently affixed compartment. Interviews with nursing staff confirmed that the medication storage refrigerator and the narcotic medication lock box should both be locked at all times to prevent unauthorized access. The registered nurse present acknowledged forgetting to lock the refrigerator, and the DON was unaware that the narcotic lock box needed to be permanently affixed inside the refrigerator. The LPN also stated that controlled medications should always be secured in the lock box with the refrigerator locked, emphasizing the importance of restricted access to these medications.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was unable to carry out activities of daily living independently. The resident, who was cognitively intact and dependent on staff for toileting hygiene, was observed to be visibly soiled for an extended period of time without being checked or changed. The facility's policy required residents to be checked and changed every two hours, but the resident was not attended to for nearly four hours. The resident, who had a history of urinary incontinence due to impaired mobility, expressed a preference to be checked for incontinence care before or after meals. However, the care plan was updated to indicate that the resident preferred to alert staff when she wanted to be changed, which contradicted her stated preference. The resident's representative also expressed concerns about the lack of timely incontinence care, noting that the resident often went through multiple pairs of pants daily due to being left wet. Staff interviews revealed that the facility's expectation was for residents to be checked every two hours to prevent risks such as pressure ulcers. However, there was a lack of communication and awareness among staff regarding the resident's preferences and needs. The social services director was not informed of any noncompliance with care, and the director of nursing reiterated the expectation for regular checks, highlighting a disconnect between policy and practice.
Failure to Manage Pain According to Physician's Orders
Penalty
Summary
The facility failed to manage pain for a resident in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility did not administer the correct pain medication per the physician's orders and failed to provide non-pharmacological interventions before administering PRN pain medication. The resident, who was under 65 years old and diagnosed with quadriplegia, unspecified muscular dystrophy, and unspecified pain, was cognitively intact and dependent on staff for all activities of daily living. The resident's pain care plan included providing pain medication as ordered and utilizing non-pharmacological pain approaches. The review of the resident's medication administration records revealed that Tramadol was administered on several occasions for a pain level of 5, which was outside the physician-ordered parameters of moderate to severe pain (6 to 10). Additionally, there was no documentation of non-pharmacological interventions being attempted or provided before administering the PRN pain medication. The Director of Nursing confirmed that the physician-ordered parameters for pain medications needed to be followed and that a separate one-time physician's order should have been obtained if the parameters were not met.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident with a left knee wound, as observed during a survey. The resident, who was under 65 years old and had a history of pressure ulcers, paraplegia, and other chronic conditions, did not have a physician's order for the treatment of the left knee wound. This lack of a formal order led to improper wound care practices by the nursing staff. Specifically, the registered nurse (RN) did not moisten the old dressing before removal, potentially causing damage to the wound bed, and failed to clean the wound properly before applying a new dressing. Additionally, the facility did not adhere to the resident's care plan, which included the use of knee protectors and offloading interventions to prevent further pressure on the wound. During observations, the resident was found lying in bed without any pillows or wedges to offload pressure from the coccyx or knees, contrary to the care plan's requirements. The RN also did not use a non-adherent Telfa pad as specified in the wound care physician's progress note, instead using an abdominal pad, which was not appropriate for the resident's wound care needs. Interviews with the RN revealed that she was unable to locate a physician's order for the wound care treatment in the electronic medical record (EMR) and had to rely on the wound care physician's notes from a previous visit. This lack of proper documentation and adherence to professional standards of practice contributed to the inadequate care provided to the resident, highlighting significant deficiencies in the facility's wound care management and documentation processes.
Failure to Conduct Pain Assessment and Offer Non-Pharmaceutical Interventions
Penalty
Summary
The facility failed to manage pain for a resident in accordance with professional standards of practice. Specifically, the facility did not conduct a thorough pain assessment for the resident, who had severe cognitive impairments and required extensive assistance for all activities of daily living. The resident was observed crying and moaning in pain on multiple occasions, yet there was no evidence of a completed pain assessment to identify the onset, presence, and characteristics of the pain since the resident's admission. Additionally, the facility's baseline care plan did not include non-pharmaceutical interventions or a scheduled pain management regimen. The facility's staff, including a registered nurse and a licensed practical nurse, acknowledged the resident's discomfort and the need for pain assessments upon admission and with changes in condition. However, the electronic medical record did not reflect any completed pain assessments, and the medication administration record showed that non-pharmaceutical interventions were not attempted before administering as-needed pain medication. The director of nursing confirmed the lack of documentation for non-pharmaceutical interventions and the absence of a documented pain goal for the resident.
Infection Control Lapses in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the area of wound care and hand hygiene. During an observation, a registered nurse (RN) did not follow proper procedures for wound care on a resident with a history of osteomyelitis. The RN did not place a barrier pad on the bedside table or under the resident during wound care, which is necessary to prevent contamination. Additionally, the RN did not perform hand hygiene between glove changes, which is a critical step in preventing the spread of infection. The RN also failed to use a clean sponge for each wound site, instead using the same sponge multiple times on different areas, increasing the risk of cross-contamination. The RN did not clean the resident's left knee wound properly, as she used a dry gauze to dab the wound multiple times without cleaning it first. These actions were contrary to the facility's policies and procedures, which emphasize the importance of hand hygiene and using clean materials for each wound site. Interviews with the RN and the Director of Nursing (DON) revealed an acknowledgment of the lapses in following the established infection control protocols. The DON confirmed that the nurse should have prepared all necessary items before starting the procedure to minimize the risk of infection. The wound care physician highlighted the importance of infection prevention for the resident, given their medical history of osteomyelitis.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse made by an 82-year-old resident to the State Survey and Certification Agency as required by state law. The resident, who had mild cognitive impairment and required assistance with daily activities, reported that a male staff member had inappropriately touched her. This allegation was discussed during an interdisciplinary team meeting, and the resident provided a detailed account of the incident. However, there was no documentation that the facility reported the allegation to the State Agency. Interviews with the facility's staff revealed that the Director of Nursing (DON) was aware of the allegation and had notified the Nursing Home Administrator (NHA) immediately. The DON did not participate in the investigation, as the former NHA was responsible for conducting all abuse investigations and reporting them to the State Agency. The Operations Manager (OM) confirmed that the former NHA, who no longer worked at the facility, was responsible for the investigation and reporting. The OM was unable to find any documentation that the allegation had been reported to the State Agency.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who reported inappropriate touching by a certified nurse aide (CNA). The resident, who had mild cognitive impairment and required assistance with daily activities, made the allegation during an interdisciplinary team meeting. Despite the report, there was no documentation of an investigation being conducted, and the CNA was allowed to return to work the same day. The Director of Nursing (DON) notified the Nursing Home Administrator (NHA) immediately and suspended the CNA, but the NHA later allowed the CNA to return to work without informing the DON of the investigation's outcome. The Operations Manager (OM) confirmed that no documentation of an investigation could be found and that the former NHA, who was responsible for conducting abuse investigations, had taken a flash drive containing facility information upon her dismissal. The DON, who was new to her position, trusted the former NHA to handle the investigation but admitted she should have followed up on the outcome.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 104 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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Healthcare Resort Of Colorado Springs | 1.1 mi | ★★★★★ | 0 | 0 |
| Center At Centennial, The | 1.5 mi | ★★★★★ | 0 | 0 |
| Colonial Rehabilitation And Nursing, Llc | 1.7 mi | ★★★★★ | 3 | 0 |
| Pikes Peak Post Acute | 2.2 mi | ★★★★★ | 2 | 0 |
| Kiowa Hills Rehabilitation And Nursing, Llc | 2.2 mi | ★★★★★ | 8 | 0 |
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