Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Sullivan Healthcare & Senior Living during CMS and state inspections, most recent first.
Missed and Delayed Resident Showers: Staff failed to provide showers to residents who were dependent on assistance for ADLs. Several residents reported long gaps without showers, and shower records showed repeated 7- to 10-day gaps or longer between showers. The affected residents included individuals with significant medical conditions such as dementia, CHF, DM2, morbid obesity, quadriplegia, and chronic respiratory failure.
A resident with paroxysmal atrial fibrillation, RVR, and hypertension, who was moderately cognitively impaired, had a provider order for daily Warfarin Sodium 4 mg for stroke prevention. After the resident was sent to the hospital and then readmitted with orders to continue Warfarin, facility staff failed to transcribe the readmission Warfarin order into the physician orders, and the IDT and nursing staff did not double-check the orders. As a result, Warfarin was omitted from the POS and MAR, and the resident did not receive Warfarin for multiple consecutive days, which the Regional Clinical Nurse identified as a significant medication error consistent with facility policy defining a drug ordered but not administered as a medication error.
Surveyors found that the facility failed to initiate and update fall care plans, implement ordered fall interventions, and thoroughly investigate falls for two high‑risk residents. One resident with moderate cognitive impairment and a documented need for supervision with transfers and toileting fell and sustained a scalp laceration after being unable to reach his urinals or call light, despite care plan directives for a “Call Don’t Fall” sign and urinal placement within reach; observations showed the sign was missing, the urinals and call light were out of reach, and the fall investigation lacked key details such as last toileting offer and footwear. Another resident with severe dementia, multiple neurologic diagnoses, and a need for maximum assistance with transfers had no fall‑focused care plan from admission through the date of an unwitnessed fall in which the resident self‑transferred from a wheelchair to bed, resulting in a nasal fracture and skin tears; the fall investigation again omitted documentation of last assistance offered and footwear. An APN and the DON acknowledged that staff depend on fall care plans to know what interventions to use, that all residents should have an at‑risk fall care plan from admission, and that these residents’ injuries could have been prevented.
The facility failed to follow its call system policy requiring staff to answer call lights within five minutes, resulting in multiple cognitively intact residents reporting prolonged waits for assistance. A resident with significant physical impairments and a sacral pressure ulcer stated she often waits over an hour for help with toileting, sometimes leading to incontinence episodes. Another resident reported similar long delays for her roommate’s call light, and a third resident described frequent waits of over 30 minutes, particularly on night shift. CNAs acknowledged that residents regularly complain about long call light response times and attributed delays to insufficient CNA staffing on evening and night shifts. The Administrator confirmed that residents rely on the call system for toileting assistance and that staff are expected to respond promptly, and acknowledged that delayed responses can negatively affect resident care.
A resident with severe dementia and significant cognitive impairment was being assisted into bed by two CNAs when the resident grabbed one CNA’s head. According to a witness CNA, the involved CNA responded by striking the resident’s hand and verbally telling the resident not to grab her head, while the involved CNA’s written statement claimed she only removed the resident’s hand. The resident was later assessed for injuries and vital signs, and was observed to be unable to answer questions due to cognitive impairment. The facility’s abuse prevention policy affirms residents’ rights to be free from physical abuse and commits to protecting residents from abuse by staff and others.
Failure to protect a resident from physical abuse by another resident. A moderately cognitively intact resident who needed assistance with toileting and transfers was using a shared bathroom when another resident with severe cognitive impairment entered and punched him in the face, causing lacerations to the face, lip, and ear and requiring ER evaluation. The resident reported being scared and shocked, and an LPN stated staff tried non-pharmacological de-escalation before giving PRN Haldol IM to the aggressive resident.
No Dietary Manager or CDM was onsite, and the facility could not provide documentation of employment for either role. Surveyors observed dietary staff receiving verbal guidance from V9, the Administrator serving meals from the kitchen because a CDM was not onsite, and the Regional CDM stating she had not been onsite for at least ten days and was not the interim Dietary Manager.
Kitchen sanitation and food temp monitoring were not maintained. Temperature logs for coolers, freezers, and meal service were incomplete or unavailable, and a cook did not check temps on multiple menu items before service. Surveyors also observed a reach-in cooler, vegetable freezer, and meat freezer with spilled pink liquid and food debris on the bottom shelf. A test tray later showed sliced pork, mashed potatoes with gravy, and green beans below proper serving temp, and the ADM and CDM acknowledged the foods were not up to temp and that temp checks were not being completed.
Failure to provide timely grooming and hygiene care resulted in three residents being observed with untrimmed facial hair, uncombed hair, food on clothing, and grime under fingernails. The residents were documented as cognitively impaired and dependent on staff for ADLs, and their care plans directed staff to provide hygiene, grooming, facial hair care, and nail care per preference. CNAs confirmed the conditions, and the DON stated residents should be groomed per their preference and acknowledged ongoing issues with personal hygiene and ADL care.
Incomplete incontinence care and delayed toileting assistance were observed for three residents who were dependent on staff for toileting and personal hygiene, with two residents also severely cognitively impaired. Staff did not provide complete perineal care for one resident, another resident was not changed until after breakfast and was typically left until after lunch, and a third resident sat for hours in the dining room and resident lounge without being offered toileting or assistance. The DON stated dependent residents should receive incontinence care at least every two hours.
Failure to Report Resident Abuse Allegation: A cognitively intact resident accused staff of abuse after being told to wait while staff cared for another resident. The resident was also documented as yelling, cursing, throwing objects, and making a threat toward night shift. The AIT spoke with the resident, who denied the allegation, but did not interview other residents or staff and did not report the abuse allegation to the State Agency, despite the facility policy requiring investigation and reporting of all abuse allegations.
The facility did not ensure RN coverage for eight consecutive hours on a specific day, with only partial coverage documented and no evidence that the remaining hours were staffed by an RN. Staffing records were inconsistent, and administrative staff could not confirm or document that the required RN services were provided, potentially affecting all residents.
The facility did not employ a clinically qualified Director of Food and Nutrition Services, with dietary operations supervised by a cook lacking required credentials or training. The dietician was only present one day per month, and surveyors observed multiple food safety and sanitation issues, including improper food scooping, a can opener with metal shavings, and unsanitary cooler floors, potentially affecting all residents.
Surveyors found that kitchen staff failed to maintain sanitary conditions, with soiled walk-in cooler floors, an unclean can opener with food residue and metal shavings, and a disposable foam cup used as a scoop in a bulk flour container, all of which could affect all residents.
The facility did not ensure the DON attended required quarterly QAA committee meetings, as evidenced by a sign-in sheet for a meeting that the DON could not have attended due to being on vacation. The DON confirmed she had not participated in any official QAA meetings since her employment began, despite facility policy requiring her attendance. This deficiency potentially affects all 70 residents.
Two residents were found using bed linens that were stained and excessively worn, with some sheets so thin that the mattress was visible. One resident, who was cognitively intact, reported receiving stained sheets and expressed dissatisfaction, while a CNA confirmed that most linens were in poor condition and that complaints had been made to management. The laundry supervisor acknowledged the issue and noted that inadequate linens may have been used during her absence.
A resident dependent on staff for hygiene did not receive timely incontinence care or scheduled showers. The resident reported long waits for staff assistance after using the call light and received only three showers in 55 days, despite being scheduled for two per week. Staff confirmed the resident's dependence and reliability in reporting these issues, and resident council minutes documented ongoing concerns about delayed responses to call lights and inadequate bathing.
A resident with severe cognitive impairment and total dependence on staff was observed multiple times in common areas with visible white mucous on her mouth and lips, indicating a lack of adequate oral care by staff despite facility expectations for daily and as-needed assistance.
A resident reported missing jackets to staff and the Ombudsman, who notified the Administrator, but the grievance was not documented or acted upon for nearly two months. Facility policy requiring prompt reporting and investigation of grievances was not followed, and the Social Service Director was not informed until the issue was raised during survey.
A resident with moderate cognitive impairment experienced a witnessed fall from a wheelchair, resulting in a skin tear, which was documented in facility records but not accurately reflected in the most recent MDS assessment. Both the DON and administrator confirmed the omission, noting that the fall event was missed during MDS coding due to staff changes.
A resident who was severely cognitively impaired and fully dependent on staff developed Stage I and II pressure ulcers on the lower legs due to the facility's failure to implement prescribed preventative measures, such as floating heels and using cushions. Despite care plan interventions and physician orders for daily skin checks, staff did not provide the required skin protection, and the wounds were not assessed or documented in a timely manner.
A resident with multiple medical conditions, including quadriplegia and diabetes, experienced deterioration of buttock wounds due to the facility's failure to assess, monitor, and notify the physician for treatment orders. The resident's care plan, which required checking and changing incontinence briefs every two hours, was not followed. Additionally, a CNA cross-contaminated the resident's wounds during care, and the facility lacked a policy for turning and positioning. The resident's mattress was also in poor condition, contributing to the issue.
A resident with multiple medical conditions did not receive timely incontinence care, leading to cross-contamination of open wounds during care. CNAs failed to adhere to the care plan, and there was a lack of communication and responsibility among staff. The DON acknowledged the importance of regular care but found no policy for preventing cross-contamination.
A resident in cardiac arrest did not receive adequate ventilation during CPR due to the absence of a functional bag valve mask (BVM) in the facility's emergency crash cart. Despite staff efforts to provide manual ventilation with an Ambu bag, the lack of a BVM mask led to insufficient life-sustaining ventilation. The resident, who had a POLST indicating a wish for full treatment, subsequently expired.
The facility failed to implement post-fall interventions for two residents and did not adequately recognize, document, or investigate falls from bed for one resident. One resident with severe cognitive impairment was observed with numerous bruises and an unsafe bed height, while another resident frequently rolled out of bed onto a mattress without these incidents being documented as falls. The facility did not adhere to its fall prevention policy, failing to assess, document, and report these occurrences.
A facility failed to protect residents from abuse when a verbal altercation between two residents escalated into physical violence in the dining room. One resident verbally abused another, leading to a third resident intervening and striking the abuser. Staff intervened to separate the residents, but the incident caused distress among other residents present. The involved residents have various cognitive and mental health issues, contributing to the incident.
The facility did not ensure residents were informed of their rights, as several residents reported not having their rights communicated during Resident Council meetings. They received a booklet upon admission, but it had been some time since then. Meeting minutes from several months showed no discussion of resident rights, and the Activity Director confirmed this omission. The facility houses 71 residents.
The facility failed to deliver mail to residents on Saturdays, affecting all 71 residents. During a resident group meeting, several residents reported not receiving mail on Saturdays. The administrator claimed the post office does not deliver on Saturdays, but a local mail clerk confirmed that mail is delivered and placed in the facility's mailbox. Facility documentation states that mail must be delivered promptly.
The facility failed to employ a qualified Director of Food and Nutrition Services, affecting nearly all 71 residents who consume food prepared in the facility kitchen. The Administrator confirmed the absence of a Dietary Manager, and a Cook was observed managing dietary activities without the necessary qualifications. The Cook only held a Food Service Sanitation certificate and lacked formal training required for the role. Issues with food storage, sanitation, and equipment cleanliness were also identified. Four residents were noted to be NPO and did not receive meal trays.
The facility failed to properly implement food storage and leftover tracking processes, maintain bulk food cleanliness, and ensure kitchen equipment cleanliness, potentially leading to food contamination. Observations revealed undated food items, unsanitary kitchen conditions, and non-compliance with facility policies on food storage and cleanliness.
The facility failed to provide adequate ADL assistance and hygiene care to several residents. A resident with cognitive impairment and total dependence on staff was not given necessary oral care, with staff confirming a lack of supplies and documentation. Additionally, multiple residents reported not receiving scheduled showers, with documentation showing missed baths/showers and no record of actions taken if a resident refused care.
The facility failed to implement enhanced barrier precautions for residents with medical devices and open wounds, affecting five residents. Staff, including CNAs and the DON, were observed providing care without wearing gowns, despite the facility's policy requiring gowns and gloves during high-contact care activities. The lack of signage and PPE setup contributed to this deficiency.
A resident's family was not informed of a decrease in the dosage of Risperdal, an antipsychotic medication, leading to noticeable changes in the resident's behavior. The facility's policy requires notifying family representatives of significant medical changes, but staff did not inform the family, believing a gradual dose reduction was mandatory.
A resident with moderate cognitive impairment and mobility needs did not receive a timely resolution to a grievance filed by their family representative for a specialized wheelchair. Despite the grievance being unresolved for several months, the facility did not provide an adequate temporary solution, and the resident continued to use uncomfortable and unsuitable wheelchairs. An occupational therapy evaluation confirmed the need for a custom wheelchair, but it was conducted months after the grievance was filed.
A resident with quadriplegia and neurological issues was found with hand mitten restraints that were not removed as per the care plan, which required removal every two hours. Staff confirmed the mittens were only removed on shower days, contrary to the facility's policy. The resident's inability to remove the mittens and the condition of her fingernails indicated infrequent removal.
A facility failed to include a urinary catheter in a resident's care plan, despite the resident having a diagnosis of urine retention and an unspecified UTI. The physician's orders required a 16 French catheter with a 10-milliliter bulb, to be changed every 28 days or as needed. The care plan lacked any interventions for the catheter until the issue was identified and corrected by the MDS/Care Plan Coordinator after being informed by the Administrator.
A resident with multiple health conditions developed new Stage II pressure ulcers that were not assessed or documented in a timely manner by the facility. Despite CNAs notifying the DON about the ulcers, there was an eight-hour delay in assessment and documentation, contrary to the facility's policy.
A resident with a tracheostomy, who was documented as NPO, experienced a significant medication error when the DON administered a sublingual Hyoscyamine tablet instead of using the prescribed G-tube route. This resulted in the resident coughing violently and struggling to breathe, highlighting a failure to adhere to the correct medication administration route as per the facility's policy.
Missed and Delayed Resident Showers
Penalty
Summary
The facility failed to administer showers to residents who were dependent on staff for assistance with activities of daily living. During interview and record review, four residents identified in the sample reported or had documentation showing missed or delayed showers. R4, who was cognitively intact and dependent on staff for showers, stated staff were not giving showers as they were supposed to and reported a 2-week gap between showers. R4’s shower records showed a 10-day gap between 4/24/26 and 5/4/26, followed by a 7-day gap between 5/4/26 and 5/11/26. R5, who had acute neurologic encephalopathy, anxiety, dementia, and muscle weakness and required moderate staff assistance with showers, stated she had only received three showers the previous month; her shower sheets showed an 8-day gap between 4/7/26 and 4/15/26. R6, who was cognitively intact and required maximum staff assistance for showers, stated staff were slack on giving showers like they were supposed to be; shower sheets documented a 10-day gap between 4/28/26 and 5/8/26. R9, who was cognitively intact and dependent on staff for showers, stated he had gone 8 or 9 days without a shower; his shower sheets documented a 7-day gap between 5/1/26 and 5/8/26. The report also notes R4 had multiple chronic conditions including CHF, DM2, morbid obesity, atrial fibrillation, bilateral lower-extremity amputations, CAD, anxiety, bradycardia, HTN, and ischemic cardiomyopathy; R6 had cellulitis, chronic respiratory failure, epilepsy, anemia, morbid obesity, depression, lumbago with sciatica, spondylosis, fracture right foot, fibromyalgia, polyneuropathy, myalgia, tachycardia, shoulder pain, amblyopia, and chronic fatigue; and R9 had quadriplegia, DM2, polyneuropathy, CAD, spinal stenosis, obesity, polyosteoarthritis, cervical spondylosis with radiculopathy, atrial fibrillation, depression, and anxiety.
Failure to Transcribe Readmission Order Resulting in Missed Warfarin Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when Warfarin Sodium, ordered for stroke prevention, was not administered for multiple days following readmission. The resident had medical diagnoses of paroxysmal atrial fibrillation with rapid ventricular rate and hypertension and was documented as moderately cognitively impaired. A provider progress note dated 2/23/26 showed a physician order for Warfarin Sodium 4 mg daily starting 2/18/26 with no end date. However, the February Physician Order Sheet documented that Warfarin 4 mg was discontinued on 2/21/26 when the resident was sent to the hospital, and the February MAR showed no administration of Warfarin from 2/22/26 through 2/28/26. Upon the resident’s return to the facility on 2/22/26, hospital discharge orders included continuation of Warfarin Sodium 4 mg daily, but this readmission order was not transcribed into the facility’s physician orders and was not double-checked by the IDT or any nurse. As a result, the March Physician Order Sheet did not list Warfarin from 3/1/26–3/2/26, and the March MAR documented no administration of Warfarin on those dates. A Medication Error Report dated 4/15/26 confirmed that the resident missed Warfarin doses from 2/22/26 through 3/2/26 because the readmission order was not entered. The Regional Clinical Nurse acknowledged that this constituted a significant medication error and stated that the resident’s INR had been subtherapeutic prior to the error. The facility’s policy defined a medication error to include a drug that is ordered but not administered.
Failure to Implement and Update Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and provide adequate supervision and fall prevention for two residents identified as high fall risk. One resident (R7) was documented as moderately cognitively impaired, requiring supervision with transfers and toileting, and had a fall risk evaluation identifying him as high risk. His care plan included interventions such as a “Call Don’t Fall” sign and placement of his urinal next to his chair, and his physician orders included daily aspirin. Despite these documented needs and interventions, he experienced an unwitnessed fall after standing from his recliner and falling backward, resulting in a scalp laceration that required four staples. Following this fall, the facility’s fall investigation for R7 did not document when staff last offered toileting assistance or what footwear he was wearing at the time of the fall. On observation, two urinals labeled for him were placed on a portable table out of his reach, there was no “Call Don’t Fall” sign posted in his room, and his call light was attached to his roommate’s call light, also out of his reach. The resident reported that on the day of the fall he could not reach his urinals or his call light, and that he attempted to stand to reach his urinal, which required him to lean forward significantly. The APN later confirmed that his urinals were not within reach and that there was no precautionary sign posted, and stated that staff rely on fall care plans to know what interventions to implement. A second resident (R3) was admitted with multiple medical diagnoses including severe dementia, TIA, and cerebral infarction, and was assessed as a high fall risk. His MDS documented severe cognitive impairment and a need for maximum assistance with transfers, and his physician orders included daily Plavix for stroke prevention. Despite these risk factors, his care plan from admission through the date of his fall did not include a focus area, goal, or interventions for falls. He had an unwitnessed fall in his room while attempting to self‑transfer from his wheelchair to his bed, resulting in a nasal fracture and skin tears. The fall investigation did not document when staff last offered assistance to lie down or what footwear he was wearing. An LPN stated that the resident, who had dementia and poor safety awareness, was found on the floor by his bed after apparently self‑propelling from the sunroom to his room and attempting to transfer himself, with his pull alarm sounding at the time. The DON later acknowledged that all residents should have an at‑risk fall care plan from admission and that residents who fall should have their fall care plans updated the same day, and stated that both residents’ injuries could have been prevented.
Untimely Call Light Responses Lead to Delayed Assistance With Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to meet its own policy requirement that resident call lights be answered as soon as possible and no later than five minutes. The facility’s Call System, Residents policy dated September 2022 states that each resident is provided a means to call staff for assistance and that calls should be answered promptly, with urgent requests addressed immediately. During interviews on 3/11/26, a cognitively intact resident with chronic kidney disease, severe protein calorie malnutrition, adult failure to thrive, rheumatoid arthritis, malaise, and a Stage II sacral pressure ulcer reported often waiting over an hour for staff to respond to her call light. This resident, who has upper and lower extremity impairments and requires maximal assistance for personal/toilet hygiene and transfers, stated she knows when she needs to use the bathroom but must wait for staff to transfer her, and that the delays sometimes result in her urinating in her incontinence brief, which makes her feel terrible. Another cognitively intact resident, diagnosed with Type II diabetes, muscle weakness, anxiety, and major depression, and requiring supervision and touching assistance for personal/toilet hygiene and transfers, stated it often takes staff over an hour to answer her roommate’s call light and that she feels badly because she knows it bothers her roommate when she has an accident. A third cognitively intact resident with COPD, lymphedema, obesity, and peripheral vascular disease, who uses a cane and requires supervision and touching assistance for personal/toilet hygiene and transfers, reported that it often takes staff over a half hour to answer call lights, especially on night shift. Two CNAs stated that residents frequently complain about long call light wait times and reported there is not enough CNA staff on evening and night shifts, resulting in residents waiting extremely long for assistance and their needs not being met timely. The Administrator confirmed that the resident who uses the call light for toileting knows when she needs to use the bathroom and that staff should respond to call lights quickly and within a reasonable time frame, and acknowledged that not answering call lights in a timely manner can negatively affect resident care.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during care. On the evening of December 9, 2025, two CNAs were assisting resident R2 into bed when R2, who has severe dementia with anxiety and behavioral disturbances and is documented as having severe cognitive impairment on the MDS, reached out and grabbed one CNA’s head. According to a witness statement from the assisting CNA, the primary CNA responded by striking R2’s hand and telling R2 not to grab her head. The alleged perpetrator CNA’s written statement in the facility’s investigation file differs, indicating that she only removed R2’s hand from her head. The facility’s investigation report documents that R2 grabbed the CNA’s head and that the CNA immediately responded by grabbing and redirecting R2’s hand away from her head. R2’s EMR includes a health status note from the date of the incident indicating that a CNA reported an alleged incident during a transfer in R2’s room and that R2 was assessed for injuries and vital signs were obtained. Subsequent observation on January 15, 2026, showed R2 lying in bed, unable to respond to questions due to severe cognitive impairment. Interviews conducted later revealed that the CNA alleged to have struck R2’s hand was no longer employed at the facility and declined to discuss details of the incident, citing concern about self-incrimination. The Administrator/Abuse Coordinator later stated that the CNA had instinctively moved R2’s hand away from her long hair and confirmed there was no injury to R2. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy states that residents have the right to be free from physical abuse and that the facility is committed to protecting residents from abuse by anyone and to maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional challenges.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. R2, who was documented as moderately cognitively intact and required moderate assistance with toileting, dressing, personal hygiene, and transfers, was involved in an altercation with R3 while using the restroom in a shared bathroom. According to the record, R3 entered the bathroom and punched R2 in the face, causing lacerations to R2’s left face, left upper lip, and left ear. R2 was sent to the emergency room for further evaluation, and the hospital record listed the chief complaint and diagnosis as assault and abrasion. R2 also received treatment for pain, including Tramadol, and stated he was scared and shocked by the incident. R3 was documented as severely cognitively impaired and required maximum assistance with bed mobility and transfers. Facility staff separated both residents, and R3 was given PRN Haldol IM for agitation and sent to the emergency room. During interview, R2 stated he was on the toilet when R3 came charging in, hit him in the jaw, and made comments about his appearance and girlfriends. An LPN stated staff attempted non-pharmacological de-escalation measures without success before administering Haldol, and the Administrator confirmed the incident was abuse. The facility policy stated residents have the right to be free from abuse and that staff are to protect residents from abuse by anyone, including other residents.
No Dietary Manager or CDM Onsite
Penalty
Summary
Failure to employ sufficient food and nutrition service staff with the appropriate competencies and skill sets, including a qualified dietician, was identified when the facility could not provide documentation of employment of a Certified Dietary Manager (CDM) and/or Dietary Manager. The Daily Midnight Census dated 11/23/25 documented 71 residents in the facility. During the survey timeframe of 11/23/25 through 11/25/25, surveyors observed that there was no CDM or Dietary Manager onsite on first and second shifts. On 11/23/25 at 9:00 AM, V9 was providing verbal guidance to dietary staff and stated the facility did not have a CDM or Dietary Manager. On 11/24/25 at 12:15 PM, the Administrator was serving resident meals from the kitchen and stated she was helping because a CDM was not onsite. On 11/25/25 at 3:25 PM, the Regional CDM stated she splits her time between this facility and another facility, had not been onsite for at least ten days, was not the interim Dietary Manager, and that the facility had not had a Dietary Manager for about six months.
Kitchen sanitation and food temperature monitoring failures
Penalty
Summary
Kitchen sanitation was not maintained, and temperatures of cold stored foods and foods prepared for meal service were not obtained. The facility could not provide any temperature logs for meal service. The temperature logs dated November 2025 only documented temperatures taken on 11/8 and 11/10-14/25 for the walk in cooler, reach in vegetable freezer, third door reach in cooler, and reach in meat freezer, with no other temperatures recorded on the logs. On 11/23/25 at 12:15 PM, V9 did not obtain temperatures of country fried steak, mashed potatoes/gravy, mixed vegetables, spaghetti, or green beans before meal service. At 12:20 PM, the reach in cooler, reach in vegetable freezer, and reach in meat freezer had an unknown pink sticky liquid spilled on the bottom shelf with dozens of pieces of food debris. On 11/24/25 at 12:35 PM, V1 obtained temperatures on a test tray of sliced pork, mashed potatoes and gravy, green beans, and cornbread; the sliced pork was 108 degrees F, the mashed potatoes with gravy were 120 degrees F, and the green beans were 86 degrees F. V9 stated the kitchen was a mess because there were not enough staff, that the temperature logs on the coolers and freezers were not completed as they should be, and that hot food service temperature logs had not been completed since she started a year ago. V9 also stated she had never checked food temperatures for food service. V1 confirmed the test tray foods were not warm enough to be palatable, and V6 stated the facility should be checking temperatures of coolers, freezers, dishwashing cycles, and food service temperatures.
Failure to Provide Timely Grooming and Hygiene Care
Penalty
Summary
The facility failed to maintain the dignity of three residents by not providing timely ADL care, including grooming, hygiene, and nail care. R10 was documented as severely cognitively impaired and dependent on staff for oral hygiene, toileting, dressing, personal hygiene, transfers, bathing, and bed mobility. His care plan directed staff to provide hygiene and grooming per his preferences, keep his hair in place before meals, and keep his facial hair trimmed or shaved. During observations, R10 was seen in the resident lounge and dining room with an overgrown, unkempt mustache, long facial hair stubble, hair sticking up, and a piece of egg on his shirt after breakfast. R10 stated he preferred to be clean shaven, did not get help cleaning himself up after breakfast, and could not see when he had spilled food on himself. R11 was documented as moderately cognitively impaired and dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. Her care plan directed staff to provide bathing, hygiene, dressing, and grooming per her preferences, including keeping facial hair trimmed or shaved and providing fingernail care as needed. She was observed sitting in her wheelchair with chin hair showing and dark grime underneath her fingernails on two separate occasions. R12 was documented as severely cognitively impaired on the BIMS and moderately cognitively impaired on the MDS, and dependent on staff for eating, oral hygiene, bathing, dressing, toileting, personal hygiene, bed mobility, and transfers. Her care plan directed staff to provide oral care morning and evening, along with bathing, hygiene, dressing, grooming, facial hair care, and fingernail care. She was observed in the hallway and resident lounge with multiple chin hairs, mustache hairs, and dark grime under her fingernails. A CNA confirmed the facial hair and grime under the fingernails for R11 and R12, and stated residents should be shaved every day if needed. Another CNA confirmed R10 preferred to be clean shaven, in clean clothes, and have his hair combed down, but stated she had not gotten around to doing that yet.
Incomplete Incontinence Care and Delayed Toileting Assistance
Penalty
Summary
Timely and complete incontinence care was not provided for three residents who were documented as dependent on staff for toileting and personal hygiene, with two of the residents also documented as severely cognitively impaired and one as moderately cognitively impaired. R9’s care plan directed staff to check for incontinence and wash, rinse, and dry the perineum, but on observation R9 was not provided complete perineal care because the CNA did not open the resident’s legs to visualize the front perineal area. R9 was incontinent of both bladder and bowel, had been up since early morning, and the CNA stated R9 had not been offered or assisted with incontinence care since getting up. R9 also had multiple dark red lines on the buttocks from sitting on a total body mechanical lift sling. R10 was observed receiving perineal care after having been up before breakfast, and staff confirmed the resident had not been provided care since then. Staff stated residents should be changed at least every two hours, but also stated R10 was not usually changed until after lunch because he did not like to be laid down until then. R10 stated he wanted to be clean if he had an accident and did not want to sit for hours because it made his back hurt. R13, who was dependent for toileting and required total dependence of one staff member for toileting per the care plan, was observed with R9 and R10 sitting in the dining room and then the resident lounge for about four hours without being offered drinks, toileting, or assistance from staff. The DON stated dependent residents should receive incontinence care at least every two hours and that staff should not assume bladder and bowel habits, and confirmed the three residents had been sitting in the resident lounge for four hours without attention from staff.
Failure to Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident’s allegation of staff-to-resident abuse to the State Agency. The resident was documented as cognitively intact on the MDS, and the care plan directed staff to allow time for the resident to express feelings and frustrations, provide empathy and validation, and approach in a calm, non-threatening manner. On 10/13/25, a nurse progress note documented that the resident had been cursing and throwing objects at staff, was asked to wait a couple of minutes while staff finished caring for another resident, and then accused staff of abusing him when staff entered his room to provide care. The same note documented that after pain medication was given, the resident continued yelling and cursing at staff, and an LPN told the resident that if he kept treating staff that way, he would be sent to the hospital for behaviors. The note also documented the resident stated he wanted to take a gun and kill all of night shift. The resident’s initial report to the State Agency documented the abuse allegation from 10/13/25. On 11/25/25, the AIT stated she was aware of the allegation, spoke with the resident on 10/13/25, and the resident denied the allegation at that time, but she did not speak with any other cognitively intact residents or staff and did not report the allegation to the State Agency. The Administrator stated the AIT should have reported the incident and that any allegation of abuse requires the facility abuse policy to be followed, including a full investigation and reporting the finding to the State Agency. The facility policy stated staff are to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report allegations within required federal timeframes.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for eight consecutive hours a day, seven days a week, as required. On August 2, 2025, the only RN scheduled was the Assistant Director of Nursing, who was documented to work from 2:00 am to 6:00 am, resulting in four hours of RN coverage instead of the required eight. There was no corresponding timecard to confirm that the RN actually worked those hours. Another RN was initially listed on the schedule but was later confirmed not to have worked due to illness. The Administrator, who is also an RN, believed she may have covered the remaining hours but could not provide documentation or medical record entries to confirm this. The Director of Nursing also could not confirm that the Administrator worked as a floor nurse on that date. The Director of Nursing reported ongoing difficulties in hiring RNs due to non-competitive wages, leading to reliance on agency staff and the hiring of additional CNAs to maintain direct care staffing. The facility's records indicated that only one RN shift was covered on the date in question, and there was no evidence of RN coverage for the required eight consecutive hours. At the time of the survey, the facility had 70 residents, all of whom were potentially affected by the lack of required RN coverage.
Lack of Qualified Dietary Manager and Food Safety Deficiencies
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, as required by federal and state regulations. During the survey, it was observed that a cook was actively supervising dietary operations without the necessary credentials or training. The cook confirmed not being a certified dietary manager, dietician, or having completed any of the required educational programs or certifications. The facility did not have a full-time designated manager for dietary services, and the dietician only worked on-site one day per month. The cook also reported only completing a one-day food service sanitation course, which did not include clinical nutrition instruction. Additionally, throughout the survey period, the facility failed to maintain proper food safety and sanitation practices. Surveyors observed the use of an unapproved food scoop in bulk flour, a can opener with accumulated metal shavings, and unsanitary floor surfaces in the walk-in cooler. These deficiencies had the potential to affect all 70 residents residing in the facility, as documented in the facility's application for Medicare and Medicaid.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the walk-in cooler and food preparation areas. On two separate dates, the walk-in cooler floor was found soiled with food debris, including a decomposed tomato, onion skins, and spilled beverages, with no evidence of cleaning between observations. Additionally, a table-mounted can opener and its receiver were noted to have dark, sticky food accumulations and metal shavings, and remained uncleaned over multiple days, despite staff acknowledging that cleaning should occur after each use. Furthermore, a disposable foam cup was being used as a scoop in a bulk flour container, with the entire cup in direct contact with the flour. These unsanitary practices were observed in areas where food is prepared and stored for all 70 residents in the facility.
Failure to Ensure DON Attendance at QAA Meetings
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON), a required member, attended the quarterly Quality Assessment and Assurance (QAA) committee meetings. According to the facility's QAPI Plan and supporting documents, the QAA meeting is to be conducted every three months and must include key personnel, including the DON. However, review of the QA meeting sign-in sheet for a meeting dated July 15, 2025, showed the DON's signature, but upon interview, the DON confirmed she was on vacation in Hawaii on that date and could not have attended the meeting. The DON further stated that she was given the sign-in sheet to sign as part of the QA meeting team, but the date and quarter reviewed were handwritten on the sheet after she signed it, and she had not attended any official QA meeting since her start date of May 27, 2025. The Administrator also confirmed that the DON was on vacation on the date of the alleged meeting and could not have been present. The facility's records indicate that there are currently 70 residents residing in the facility. The deficiency centers on the lack of required participation by the DON in the QAA committee meetings, as mandated by facility policy and federal regulations.
Failure to Provide Clean and Homelike Bed Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the use of stained and excessively worn bed linens. One resident, who was cognitively intact, was observed on multiple occasions lying directly on a fitted sheet that had several brown stains and was worn through to the point that the mattress was visible. This resident reported that staff provided her with clean sheets that were still stained and expressed a preference for linens without stains from previous users. A certified nurse aide confirmed that most resident bed linens were stained or worn to the point of being nearly transparent and stated that residents had complained about the condition of the linens. The aide also reported having informed management about the need for new linens. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was repeatedly observed lying on a fitted sheet with brown and grey stains, which was also worn through to the mattress. The laundry supervisor acknowledged that the facility had linens with tears, stains, and excessive wear, and stated that she attempts to remove inadequate linens during the laundry process. However, she noted that during her absence, some stained and worn linens may have continued to be used by residents. The facility's own pamphlet on resident rights specifies the obligation to provide services that maintain residents' physical and mental health and satisfaction.
Failure to Provide Timely Incontinence Care and Scheduled Bathing
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically bathing and timely incontinence care, for a resident who was dependent on staff for hygiene. Resident council meeting minutes over several months documented ongoing concerns from residents about staff not answering call lights promptly and issues with receiving showers. One resident, who was admitted with multiple diagnoses including muscle weakness, Parkinsonism, severe obesity, and was dependent on staff for all mobility and hygiene needs, reported waiting several hours for staff assistance after activating the call light for incontinence care. The resident also reported receiving only three showers over a 55-day period, despite being scheduled for two showers per week. Staff interviews confirmed the resident's reliability in reporting care issues and acknowledged the resident's dependence on staff for bathing and toileting hygiene. The resident expressed frustration with the delays, noting that staff often cited being busy with other residents as the reason for the lack of timely assistance. Documentation in the resident's care plan and assessments further supported the resident's need for substantial or maximal staff assistance for hygiene, which was not consistently provided as required.
Failure to Maintain Resident Dignity Through Adequate Oral Care
Penalty
Summary
A deficiency was identified when a resident, documented as severely cognitively impaired and fully dependent on staff for all activities of daily living, was repeatedly observed in the resident lounge with visible white mucous on her lips and mouth area. On multiple occasions, the resident was seen with either a thick line of white mucous hanging from her mouth or dried, thick white mucous on her lips and mouth corners, while in the presence of other residents and staff. The Director of Nursing confirmed that staff are expected to provide oral care at least daily and as needed, and acknowledged that this resident requires total assistance from staff for personal hygiene.
Failure to Timely Initiate and Investigate Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to initiate a grievance report in a timely manner after a resident reported missing personal items, specifically two jackets. The resident communicated the loss to multiple staff members and the Ombudsman, who then notified the Administrator on the same day. Despite this notification, the Administrator did not recall or document the grievance until nearly two months later, and no action was taken to resolve the issue during that period. The resident expressed ongoing distress and uncertainty about the missing items, stating that she had informed several staff members and the Ombudsman, but did not see any resolution or follow-up until the survey was in progress. Facility policy requires all staff to report grievances to the Social Service Director, who serves as the grievance official, and mandates that grievances be investigated and resolved within five working days. However, the Social Service Director was not informed of the grievance until the time of the survey, and the grievance was not brought to the daily Quality Assurance meeting as required. The delay in reporting and investigating the grievance resulted in a significant lapse in addressing the resident's concern in accordance with facility policy.
Inaccurate MDS Coding of Resident Fall Event
Penalty
Summary
The facility failed to accurately encode a resident's health status on the Minimum Data Set (MDS) regarding falls. Specifically, a resident with moderate cognitive impairment, as indicated by a Brief Interview of Mental Status score of 10 out of 15, experienced a witnessed fall from a wheelchair in the dining room, resulting in a skin tear to the left elbow. This fall was documented in the resident's AIMS Wellness Event Record and the facility's fall log, but was not reflected in the resident's most recent quarterly MDS assessment, which incorrectly indicated that the resident had not experienced any falls since the last assessment. Interviews with facility staff confirmed the discrepancy. The DON, who reviewed the electronic medical record, acknowledged that the MDS did not accurately reflect the resident's status at the time of assessment, citing the documented fall. The administrator, who had recently taken over MDS responsibilities due to staff turnover, also recognized that the fall may have been missed in the MDS documentation. The resident was unable to recall details of the falls due to cognitive impairment.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to identify, assess, and provide appropriate treatment for pressure ulcers for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident was assessed as high risk for pressure ulcers and had care plan interventions in place, including floating heels and using pillows or cushions to prevent skin-to-skin contact and pressure on the legs and feet. Despite these interventions and physician orders for daily skin checks and monitoring of red areas on the legs, staff did not implement the prescribed preventative measures. Observations over several days showed the resident lying in bed with bare legs directly on the fitted sheet, without heel protectors, pillows, or cushions in place. Documentation revealed that the resident developed a Stage II pressure ulcer on the right inner leg and a Stage I pressure ulcer on the left posterior leg, with no prior physician orders or assessments for these wounds before their identification. Staff interviews confirmed a lack of awareness and action regarding the need for skin protection and preventative measures, and the facility administrator acknowledged that the pressure ulcers were known but not addressed or documented as required by facility policy. The facility's policy mandated daily skin inspections and positioning according to the care plan, which was not followed in this case.
Failure to Monitor and Care for Resident's Wounds
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician to obtain treatment orders for a resident's open buttock wounds, which were documented to have deteriorated from reddened areas to open wounds. The resident, who is moderately cognitively impaired and dependent on staff for all care, including toileting and personal hygiene, was not provided with the necessary incontinence care as per the care plan. The care plan instructed staff to check and change the resident's incontinence brief every two hours, but staff failed to adhere to this schedule, leading to the resident's condition worsening. On one occasion, a CNA cross-contaminated the resident's open wounds with a soiled towel during incontinence care, which could potentially lead to infection. The CNAs involved did not consistently check on the resident or provide the necessary care, and there was a lack of communication and responsibility among the staff regarding the resident's care. The Director of Nurses acknowledged that the staff should have been asking the resident if he would like to be turned or provided with incontinence care every two hours, but this was not done. Additionally, the facility did not have a policy for turning, positioning, and preventing cross-contamination of wounds. The resident's mattress was also in poor condition, contributing to the issue. The Wound LPN noted that the resident's wounds were not assessed, monitored, or documented properly, and the necessary treatment orders were not obtained. The lack of monitoring and documentation meant that the facility could not determine the exact condition of the resident's wounds over time, leading to inadequate care and intervention.
Inadequate Incontinence Care and Cross-Contamination
Penalty
Summary
The facility failed to provide appropriate incontinence care and prevent cross-contamination for a resident with multiple medical conditions, including quadriplegia and diabetes. The resident, who is moderately cognitively impaired and depends on staff for all care, was found in his recliner chair without having received incontinence care for several hours. The care plan for the resident required staff to check and change incontinence briefs every two hours, but this was not adhered to. During an observed care session, a CNA cross-contaminated the resident's open wounds on the buttocks by using a soiled towel to provide bowel incontinence care, directly wiping over the wounds. Interviews with the CNAs revealed a lack of communication and responsibility regarding the resident's care. One CNA, who was assigned to the resident, admitted to not having been in the resident's room during her shift, while another CNA, who got the resident up in the morning, had not returned to provide further care. The Director of Nurses acknowledged the importance of regular repositioning and maintaining cleanliness to prevent infections, especially given the resident's history of open wounds. However, there was no policy found for turning/positioning and preventing cross-contamination, indicating a gap in the facility's procedures.
Failure to Provide Lifesaving Equipment During CPR
Penalty
Summary
The facility failed to provide lifesaving equipment for emergency airway management for a resident in cardiac and respiratory arrest. This deficiency was identified during a survey and affected one of 18 residents reviewed for advanced directives, with the potential to affect all 72 residents residing in the facility. The resident, who had a Physician Order for Life Sustaining Treatment (POLST) indicating a wish for full treatment, including CPR, was found without a pulse or respirations. Despite the initiation of CPR by facility staff, they were unable to locate a functional bag valve mask (BVM) to provide effective ventilation. The resident's medical history included unspecified asthma, hypertensive heart disease without heart failure, and age-related osteoporosis with a current pathological fracture. The resident had recently returned from the hospital after a right hip surgical repair. During the emergency, staff attempted to provide manual ventilation using an Ambu bag without a BVM mask, which did not create an adequate seal over the resident's mouth and nose. This inadequate ventilation was confirmed by the lead paramedic on the scene, who stated that the lack of a BVM mask led to insufficient life-sustaining ventilation during CPR. Interviews with facility staff revealed that the emergency crash cart did not contain a functional BVM mask at the time of the incident. The Director of Nursing and other staff members confirmed that the mask initially found was broken, and a replacement was not obtained before emergency medical technicians arrived. The facility's policy required that emergency equipment, including a BVM, be portable and readily available at all times, but this was not adhered to, resulting in the deficiency.
Removal Plan
- Provided in-service training and video for Cardio Pulmonary Resuscitation and Basic Life Support. V2, Director of Nursing (DON) was in-person and V27, Registered Nurse (RN), BLS Certified, [NAME] Health Care was present via tele-monitor.
- Inspected all onsite Ambu bags. V1, Administrator/RN and V2, DON.
- Facility will maintain 2 Ambu bags on the crash cart. Confirmed with V1, Administrator/RN.
- Began a crash cart audit checklist to be completed nightly.
- In serviced licensed nurses on restocking crash cart after use.
- In serviced licensed nurses on the crash cart checklist, replacement of faulty supplies, and notification to nursing management. V2, DON.
- CPR certifications training for licensed nurses. Confirmed.
- Began daily audits to ensure the crash cart checklist is conducted nightly.
- Began random audits of the crash cart inventory supplies.
- The Quality Assurance Quality Improvement Team meeting is scheduled to further address the event. V1, Administrator confirmed.
Failure to Implement Post-Fall Interventions and Document Falls
Penalty
Summary
The facility failed to implement post-fall interventions for two residents, R2 and R3, and did not adequately recognize, document, or investigate falls from bed for R3. R2, who has severe cognitive impairment and multiple diagnoses including dementia and osteoporosis, was observed with numerous bruises on her arms and hands. Her bed was elevated to an unsafe height, which was confirmed by the facility's administrator. Despite a documented fall from her bed on 12/04/24, the intervention of a low bed was not included in her care plan. R3, also with severe cognitive impairment and quadriplegia, experienced multiple falls, including a documented incident on 12/09/24 where he tumbled out of his wheelchair. Despite having a mattress placed on the floor next to his bed, staff did not document these occurrences as falls, nor did they conduct fall reports or notify the family. The facility's Director of Nursing acknowledged that R3 consistently rolled out of bed onto the mattress, but these incidents were not considered falls, and thus, no investigations or reports were made. The facility's fall prevention policy requires immediate assessment and documentation of falls, as well as discussion in Quality Assurance meetings. However, the facility did not adhere to these procedures for R3, as his frequent changes in plane were not documented or reported as falls. This lack of documentation and investigation represents a failure to follow established protocols for fall prevention and resident safety.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by an altercation involving four residents. The incident occurred in the dining room, where one resident verbally abused another by using derogatory and offensive language. This verbal abuse escalated when another resident intervened, leading to a physical altercation where the intervening resident struck the verbally abusive resident multiple times. The staff eventually separated the residents, but the incident had already caused distress among other residents present. The residents involved in the incident have various medical diagnoses that may have contributed to their behavior. One resident, who initiated the verbal abuse, has dementia with psychotic disturbances and is moderately cognitively impaired. Another resident, who responded physically, has a history of anxiety, psychotic disorder with delusions, and other mental health issues, and is also moderately cognitively impaired. The third resident, who was the initial target of the verbal abuse, has dementia with agitation and moderate intellectual disabilities, and requires assistance with daily activities. Staff members, including a Licensed Practical Nurse and Certified Nurse Aides, witnessed parts of the altercation and intervened to separate the residents. However, the initial verbal abuse and subsequent physical altercation occurred in front of other alert and oriented residents, causing fear and distress. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as outlined in their abuse prevention policy.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to ensure that residents were informed of and understood their rights while living in the nursing home. During a resident group meeting, several residents stated that they did not have their resident rights communicated to them during Resident Council meetings. They mentioned receiving a booklet upon admission, but it had been a while since then. A review of the Resident Council meeting minutes from April to September 2024 showed no documentation that resident rights were discussed. The Activity Director confirmed that resident rights were not covered in the meetings. The facility's documentation indicates that 71 residents reside in the facility.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to deliver mail to residents on Saturdays, which has the potential to affect all 71 residents residing in the facility. During a resident group meeting, several residents reported that they do not receive mail on Saturdays. The facility administrator stated that the residents do not receive mail on Saturdays because the post office does not deliver mail to the facility on that day. However, a local post office mail clerk confirmed that mail is indeed delivered to the nursing home on Saturdays and placed in their mailbox. The facility's documentation on residents' rights indicates that mail must be delivered promptly.
Facility Lacks Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a qualified Director of Food and Nutrition Services, which has the potential to affect nearly all 71 residents who consume food prepared in the facility kitchen. On a specific date, the Administrator confirmed the absence of a Dietary Manager. A Cook was observed managing and directing dietary personnel and food preparation activities without possessing the necessary qualifications, such as a Certified Dietary Manager (CDM) certificate. The Cook only held a Food Service Sanitation (FSS) certificate, which is not managerial in nature, and lacked formal training or education required for the role of Director of Food Service. Additionally, issues related to food storage, food sanitation, and equipment cleanliness were identified in the facility kitchen. Four residents were noted to be NPO and did not receive meal trays.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to implement proper food storage and leftover tracking processes, maintain cleanliness of bulk food, and ensure kitchen equipment cleanliness, which could potentially lead to food contamination. During an observation, it was noted that food items in the dry storage area were not dated to indicate when they were received, hindering the 'first in first out' rotation process. A cook acknowledged that dating items depended on who put them away. Additionally, a bag of mixed salad in the walk-in refrigerator was not dated or labeled, and the cook admitted that leftovers were supposed to be dated, but this was not consistently done. Further observations revealed unsanitary conditions in the kitchen, including a microwave interior splattered with an unidentified dark red substance and a plastic cup left inside a bulk sugar bin. A cook mentioned that such items were frequently left in the bins, requiring daily removal. A Styrofoam bowl was also found in a bulk flour bin, used by a cook to scoop flour. The range hood had copious amounts of lint and dust hanging from the fire suppression outlets, grease track, and fire suppression supply pipes, which the administrator acknowledged had been previously noted by life safety inspectors. The facility's policies on food storage and cleanliness were not adhered to, as evidenced by these findings.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) assistance to six out of seven residents reviewed. One resident, who is non-verbal and totally dependent on staff for personal hygiene and oral care, was observed with a crusted white matter on her lips and dry, cracked mucous membranes. Despite her cognitive impairment, which prevents her from modifying her behavior, staff did not provide the necessary oral care. The resident's nurse and CNA confirmed the lack of oral care supplies and documentation of care refusal, indicating a failure to meet the resident's care needs. Additionally, several residents reported not receiving showers as scheduled, with some going up to three weeks without a shower. Documentation confirmed that multiple residents did not receive the required number of baths or showers, and there was no record of what actions were taken if a resident refused a bath or shower. The facility's policy requires notifying the charge nurse if a resident refuses a bath or shower, but this was not documented, leading to inadequate hygiene care for the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for residents with specific medical conditions, including tracheostomy airway access, gastrostomy feeding tubes, pressure ulcers, urinary catheters, and intravenous access ports. This deficiency was observed in five residents during the survey. For instance, one resident with an indwelling urinary catheter and pressure ulcers did not have Enhanced Barrier Precaution signage or personal protective equipment available in their room. Certified Nursing Assistants and the Director of Nursing were observed providing care without wearing gowns, despite handling high-contact care activities that could transfer multidrug-resistant organisms. The facility's Enhanced Barrier Precautions policy requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices and open wounds. However, during the survey, there were no signs posted to guide staff in following these precautions, and staff did not consistently wear the required personal protective equipment. The facility administrator acknowledged that implementing these precautions would affect nearly all residents, indicating a systemic issue in adhering to the policy.
Failure to Notify Family of Medication Change
Penalty
Summary
The facility failed to notify a family representative of a decrease in the dosage of an antipsychotic medication for a resident with moderate cognitive impairment. The resident, who has been on Risperdal for years, experienced a reduction in the frequency of the medication from three times a day to two times a day without the family representative's knowledge. This change was documented in the resident's Medication Administration Record (MAR) for September 2024. The family representative noticed a significant change in the resident's behavior, including staring into space and being unable to talk, during visits. Upon inquiry, the family representative learned about the medication change from the facility administrator. The facility's policy requires notifying appropriate individuals, including family representatives, of significant changes in a resident's medical treatment. However, the facility staff did not inform the family representative about the medication adjustment, believing they were required to attempt a gradual dose reduction regardless of family input. The facility's administrator and director of nursing acknowledged the oversight, stating they were unaware of the need for family approval for the medication change. This lack of communication led to the family representative's dissatisfaction and concern for the resident's well-being.
Failure to Timely Resolve Grievance for Specialized Wheelchair
Penalty
Summary
The facility failed to resolve a grievance regarding the provision of a specialized wheelchair for a resident with moderate cognitive impairment and mobility needs. The resident's family representative initially filed a grievance on February 14, 2024, requesting a new wheelchair due to the resident's weight gain and the inadequacy of the current wheelchair. Despite the grievance being marked as unresolved on May 15, 2024, the facility did not take timely action to address the issue. The administrator explained that the facility's corporation would not fund a new wheelchair due to financial constraints, and the resident was left using various uncomfortable and unsuitable wheelchairs available in the facility. The resident's occupational therapy evaluation, conducted on August 28, 2024, confirmed the need for a custom wheelchair to accommodate the resident's specific physical conditions, including range of motion limitations and scoliosis. However, this evaluation occurred six and a half months after the initial grievance was filed. The facility's grievance policy mandates that investigations be completed within 15 days, but this timeline was not adhered to, resulting in the resident continuing to use inadequate wheelchairs. The family representative expressed dissatisfaction with the facility's handling of the grievance, noting the resident's discomfort and the poor condition of the temporary wheelchairs provided.
Failure to Follow Restraint Release Protocol for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as R17, who was observed with secured hand mitten restraints that were not removed according to the prescribed schedule. R17, who has a medical history of quadriplegia, traumatic brain injury, and neurological devastation, was supposed to have her mittens released every two hours as per her care plan. However, observations and staff interviews revealed that the mittens were only removed on shower days, contrary to the care plan's directives. This was confirmed by a CNA who stated that the mittens were not removed every two hours due to concerns about the resident pulling out her G-tube. Further investigation showed that the facility's policy on physical restraints required that restraints be released at a minimum of every two hours for necessary care and repositioning. Despite this policy, the resident's mittens were not removed regularly, as evidenced by the resident's long and soiled fingernails, indicating infrequent removal. The resident was unable to remove the mittens herself, as demonstrated by her unsuccessful attempts to do so when asked. The facility's failure to follow the care plan and policy resulted in the resident being restrained for extended periods without the required breaks.
Failure to Include Urinary Catheter in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident with an indwelling urinary catheter. This deficiency was identified during a review of the care plans for 20 residents, affecting one resident who had a diagnosis of urine retention and an unspecified urinary tract infection. The physician's orders specified that the resident should have a 16 French urinary catheter with a 10-milliliter bulb, to be changed every 28 days or as necessary. However, the resident's care plan, dated September 12, 2024, did not include any category plan or interventions for the urinary catheter. On September 12, 2024, the Minimum Data Set/Care Plan Coordinator acknowledged that the care plan did not cover the resident's catheter and was informed by the Administrator to correct this oversight. The facility's policy on comprehensive care planning requires that care plans be reviewed and revised as necessary to reflect the residents' current needs, but this was not initially done for the resident in question.
Delayed Assessment and Documentation of Pressure Ulcers
Penalty
Summary
The facility failed to assess and document new, facility-acquired Stage II pressure ulcers in a timely manner for a resident with multiple diagnoses, including Diabetes Mellitus II with Diabetic Polyneuropathy, Spinal Stenosis, Cervicalgia, Obesity, and Unspecified Quadriplegia. On a specific day, Certified Nursing Assistants (CNAs) discovered open pressure areas on the resident's buttocks during a transfer and peri-care. Despite notifying the Director of Nursing (DON) about the condition, the assessment and documentation of the pressure ulcers were delayed by approximately eight hours. The facility's policy requires immediate assessment and documentation of pressure ulcers upon notification, but this was not followed. The DON acknowledged the delay, attributing it to being occupied with other duties such as medication administration. The resident's medical record lacked documentation of a current pressure ulcer treatment until after the observation and interviews, indicating a lapse in the facility's adherence to its own policy for pressure ulcer care.
Failure to Maintain NPO Status Leads to Medication Error
Penalty
Summary
The facility failed to adhere to the NPO (nothing by mouth) status of a resident with a tracheostomy, leading to a significant medication error. The resident, identified as R15, had a physician order sheet indicating that medications should be administered via a G-tube due to their NPO status, which was documented in their care plan. Despite this, during a medication pass, the Director of Nursing (DON) administered a sublingual Hyoscyamine tablet by placing it under the resident's tongue, contrary to the prescribed route of administration. This action resulted in the resident experiencing distress, as they began coughing violently, appeared red, and struggled to breathe, eventually expelling the tablet from their mouth. The facility's medication administration policy emphasizes the importance of following the correct route for medication administration, which was not adhered to in this instance. The incident highlights a failure in maintaining accurate and consistent adherence to the resident's care plan and physician orders, specifically regarding their NPO status and the correct route for medication administration.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 225 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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sullivan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastview Healthcare & Senior Living | 1.4 mi | ★★★★★ | 9 | 0 |
| Arthur Home, The | 11.2 mi | — | 0 | 0 |
| Palm Garden Of Mattoon | 15 mi | ★★★★★ | 36 | 1 |
| Shelbyville Manor | 15.3 mi | ★★★★★ | 9 | 0 |
| Mattoon Rehab & Hcc | 15.5 mi | ★★★★★ | 28 | 0 |
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