Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Three Springs Sr Living & Rhab during CMS and state inspections, most recent first.
A facility failed to keep shower/restroom areas clean and stocked with paper towels for most residents reviewed. Staff reported repeatedly running out of supplies and sometimes buying items from local stores or taking paper towels from resident bathrooms to fill dispensers. Observations found empty paper towel dispensers, a dirty toilet, feces on the shower floor, loose toilet paper on the floor, and a rusted shampoo holder with dried residue. A resident stated her bathroom had been without paper towels for a while and that the shower room was typically not clean or sanitary.
Delayed incontinence care and toileting assistance were identified for two residents who required help with ADLs. One resident with CHF, CKD, weakness, edema, UTI history, and moderate cognitive deficit required toileting support and q2h incontinence checks, but reported waiting longer for care and having incontinence episodes when care was delayed. Another resident with BKA, PVD, obesity, reduced mobility, and frequent bowel/bladder incontinence required substantial/maximal toileting help, but reported waiting up to 30 minutes for bed pan assistance; CNAs and the DON described short staffing and delayed call light response.
A resident with a long history of seizures had ordered anticonvulsant medications and methocarbamol scheduled for 8:00 AM, but the doses were administered about 2 1/2 hours late. The resident and his wife reported that he is sensitive to late seizure meds, and the next day he had seizure activity and was sent to the ER; the ED note stated EMS reported the meds were given late.
RN coverage was not provided for at least 8 consecutive hours a day, 7 days a week. Review of the staffing schedule showed multiple days when no RN was on duty for the required time. The IP stated she scheduled whatever staff was available and that the facility only had 1 RN. The DON stated she had been covering on her off days when RN coverage could not be found, and the Administrator stated the facility had been unable to find RNs willing to travel to the area.
Improper labeling and dating of refrigerated foods was observed in the main kitchen refrigerator. Surveyors found tartar sauce, banana pudding, and cranberry juice containers with dates that did not align with staff expectations, along with two containers of individual cups of colored liquids that were not labeled or dated. A Dietary Aid and the Administrator gave different statements about how long leftovers should be kept, while the facility policy required covered, labeled, and dated storage of prepared foods.
Insufficient food was prepared and served to residents. A Cook was scraping the bottom of a pan of chili on the steam table, and staff discussed giving a resident a grilled cheese with a little chili because the kitchen was running low. Residents later reported the facility often ran out of food and items like sugar, that one resident did not receive chili as promised, and that another asked for more food at meals but did not get it. A Dietary Aid said the kitchen sometimes ran out of food because of the budget and that items were often removed from food orders.
Failure to Remove Old Fentanyl Patch: A resident with chronic pain diagnoses was found with three Fentanyl patches on the back/shoulders, including two patches that had not been removed before a new patch was applied. The DON confirmed the extra patches should have been removed first, and the physician noted the resident had not experienced negative outcomes.
A facility failed to provide the required minimum floor space per bed for 53 of 53 residents reviewed. Multiple Medicaid-certified rooms in several halls measured only 75 to 77 square feet per bed, and a Housekeeper verified that the affected residents were living in waivered rooms. Resident interviews noted no complaints about room size, and the Administrator stated there had been no changes to the room sizes.
A resident with a recent ankle fracture and non-weight bearing status was discharged home without a physician order or proper discharge planning. The care plan did not address discharge, and staff provided conflicting information to the resident and her family. Despite therapy recommendations against discharge and the primary physician's refusal to authorize it, a new RN and the Social Service Director facilitated the discharge, relying on home health services and a friend's assistance at home.
A resident with a history of stroke, hemiplegia, cognitive impairment, and high fall risk was left unsupervised outside in a wheelchair after being taken out for a cigarette. The resident, unable to communicate effectively and requiring total assistance for transfers, was observed rocking and moaning before slipping from the wheelchair and sustaining significant injuries, including a head hematoma and abrasions. Staff interviews revealed confusion about supervision requirements, and facility policies for direct supervision during smoking were not followed.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to ensure a licensed nurse was in charge on each shift, as required.
A resident with a history of falls and cognitive impairment was not provided with care planned fall prevention interventions, including non-skid socks and a non-skid mat for the wheelchair. The resident was observed without these interventions in place and experienced two falls in the dining room. The facility administrator confirmed that the required interventions were not implemented as specified in the care plan.
The facility failed to ensure staff encouraged COVID-19 positive residents to wear masks and that staff donned proper PPE. A resident with severe cognitive impairment was observed without a mask in common areas, and two CNAs provided care to another COVID-19 positive resident without appropriate PPE. The facility's DON confirmed the expectation for full PPE use during the ongoing COVID-19 outbreak.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Staffing schedules showed no RN coverage on five days, and the administrator acknowledged a misunderstanding of coverage requirements. The Director of Nursing confirmed only two RNs are employed, with efforts to hire more. This deficiency potentially affects all 66 residents.
The facility failed to conduct proper infection control surveillance for residents with vomiting and diarrhea, affecting all 66 residents. The infection control specialist, who was uncertified, did not implement contact isolation or notify the health department. Despite testing for flu and COVID, no surveillance or tracking of affected rooms and staff was conducted. The medical director and hospital infection control specialist were not informed of the outbreak, and the facility's infection control policy was not followed.
The facility failed to provide scheduled showers to several residents, as confirmed by interviews and record reviews. A resident reported not receiving showers twice a week as per their care plan, and the DON confirmed the inconsistency. Another resident's family expressed dissatisfaction with the care, noting the resident often appeared unkempt. The facility's policy requires documentation of showers, but this was lacking, and the DON acknowledged the issue.
The Facility did not have an RN on duty for at least eight consecutive hours a day, seven days a week, as required. This was confirmed through interviews and record reviews, with the Administrator and DON citing staffing challenges and recruitment difficulties in a rural setting. The absence of an RN on specific dates affected all 70 residents.
A resident with a DNR order was mistakenly resuscitated due to conflicting code status documentation. Despite having a POLST form indicating DNR, the resident's records listed them as Full Code, leading an LPN to perform CPR when the resident was found unresponsive. The error occurred after the resident's orders were incorrectly reinstated following a brief discharge and return to the facility.
The Facility failed to adhere to proper food storage and labeling practices, potentially affecting all 66 residents. Observations revealed unlabeled and undated food items in various refrigerators and freezers, sticky oven handles, and improperly stored sanitizer. These actions violated the Facility's policies, which require all food items to be labeled and dated, and discarded after a certain period.
A facility failed to attempt Gradual Dose Reductions (GDR) on psychotropic medications for a resident with Alzheimer's and other conditions, despite policy requirements. The resident was cognitively intact and showed no behavioral symptoms, yet was on multiple psychotropic medications. No behavior monitoring or GDR attempts were documented, and pharmacy consults resulted in no new orders.
The facility failed to provide the required 80 square feet of floor space per resident bed for 50 residents. Rooms in various halls, all Medicaid certified, only provide 75 to 77 square feet per bed. This was confirmed by the Maintenance Director, and no resident complaints were noted. The VP of Operations stated no changes have been made to room measurements or certifications.
Unsanitary Shower/Restroom Areas and Missing Paper Towels
Penalty
Summary
The facility failed to ensure that residents had clean and sanitary shower/restroom areas and paper towels available in resident rooms and shower/restrooms for 51 of 55 residents reviewed. Staff reported that when supplies ran low, they often obtained items from local stores themselves, sometimes without reimbursement, and in some cases paper towels were taken from resident bathrooms to refill dispensers. Multiple staff members confirmed that paper towels had been out in the C Hall shower room for several days, and the laundry/housekeeping manager stated that supplies were ordered monthly and that paper towels were currently out, with delivery expected later. The administrator stated there was no par level for products and that ordering was based on prior month usage. During observation, both the men’s and women’s shower rooms on C Hall had no paper towels in the dispensers. The men’s shower room also had loose toilet paper on the floor behind the toilet, a toilet bowl dirty from a bowel movement, feces on the shower floor, and a rusted shampoo holder with an orange/red dried trail running down the shower wall and floor to the drain. A resident who was alert and oriented stated that her bathroom had been without paper towels for a while and that she had been air drying her hands, and she described the shower room as typically not clean or sanitary when she used it. The laundry/housekeeping manager stated that bathroom and shower rooms should be cleaned daily, while shower rooms should be deep cleaned monthly, and that A, B, and C Hall residents used the C Hall shower/restroom areas.
Delayed Incontinence Care and Toileting Assistance
Penalty
Summary
The facility failed to ensure timely incontinence care for 2 of 3 residents reviewed for ADL assistance. One resident was admitted with diagnoses including heart failure, chronic kidney disease, weakness, edema, history of urinary tract infections, pain, and unsteadiness on feet. The resident’s MDS documented a BIMS score of 12, indicating a moderate cognitive deficit, and the resident required partial/moderate assistance with toilet hygiene and toilet transfer. The care plan identified the resident as at risk for self-care deficit and included interventions to assist with toileting and to check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas. During interview, the resident stated that staff sometimes did not have enough time to meet needs timely and that incontinence episodes occurred when care was delayed. A second resident was admitted with diagnoses including acquired absence of the right leg below the knee, peripheral vascular disease, obesity, pain, constipation, acute kidney failure, reduced mobility, muscle weakness, and need for assistance with personal care. The resident’s MDS documented a BIMS score of 15, indicating cognitive intactness, and the resident required substantial/maximal assistance with toilet hygiene and was frequently incontinent of bowel and bladder. The care plan included a self-care deficit focus area with interventions to assist with toileting and showers/bath, but it did not include a focus area or intervention related to toileting assistance needs. The resident stated staff did not have enough time to meet needs timely and reported waiting up to 30 minutes for bed pan assistance. Multiple CNAs and the DON described short staffing, delayed call light response, and delayed incontinence care, and the Administrator stated the facility operated at minimum staffing and denied complaints about timely incontinence care.
Delayed seizure medications led to seizure activity
Penalty
Summary
The facility failed to ensure that medication errors did not occur for one resident who had orders for carbamazepine ER 400 mg twice daily, phenytoin sodium 100 mg two capsules twice daily, and methocarbamol 750 mg three times daily. The resident’s records documented a diagnosis of unspecified convulsions on the POS, while the MDS identified seizure disorder or epilepsy and the care plan addressed seizure activity with medication administration as ordered and monitoring for effectiveness and side effects. The resident stated that seizure medication had been given about 2 1/2 hours late and that this caused a seizure, and the resident’s wife reported that he has had seizures his whole life and that he does not have issues when his medication is given on time. The August MAR showed that on 8/27/2025 the resident’s methocarbamol, carbamazepine, and phenytoin sodium were all scheduled for 8:00 AM but were not administered until 10:24 AM to 10:25 AM. The next day, the resident was noted to have small seizure activity and requested transfer to the ER for evaluation; EMS was called and the resident was sent out. The ED note documented that the resident was sent due to seizures lasting less than 10 seconds and that EMS reported the medications were given late. The facility’s medical policy stated medications shall be administered in a safe and timely manner as prescribed.
RN Coverage Not Provided for Required Hours
Penalty
Summary
The facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility schedule dated August 11, 2025 through September 11, 2025 showed that on 8/9/25, 8/27/25, 8/29/25, 9/1/25, 9/3/25, 9/6/25, 9/7/25, and 9/8/25, the facility did not have an RN providing resident care for 8 consecutive hours. During interviews on 9/12/25, the Infection Preventionist stated she completed the working schedules and scheduled whatever staff was available, and that the facility only had 1 RN at the time. The DON stated she was new to the facility and understood the facility had been unable to provide RN coverage in the past, but she had been covering on her off days when RN coverage could not be found. The Administrator stated the facility had been unable to find RNs willing to travel to the area and that the facility was doing the best it could; the facility policy stated RN coverage would be provided 8 hours per day, 7 days per week.
Improper Labeling and Dating of Refrigerated Foods
Penalty
Summary
The Facility failed to store foods in a manner that prevents foodborne illness. During an observation of the standing refrigerator in the main kitchen, surveyors found a container of tartar sauce labeled 8/29, a container of banana pudding labeled 9/2, and a pitcher labeled CB (cranberry) juice labeled 9/2. Surveyors also observed two containers holding 28 individual cups of various colored liquids that were not labeled or dated. A Dietary Aid stated leftover food items should be thrown out after three days, while the Administrator stated she expected staff to follow dietary policies regarding labeling, dating, and discarding items after 7 days. The Facility’s policy required food to be stored using appropriate methods to ensure food safety and stated that leftover contents of cans and prepared food must be stored in covered, labeled, and dated containers.
Insufficient food prepared and served to residents
Penalty
Summary
The Facility failed to ensure adequate food was prepared for 5 of 5 residents reviewed for food and nutrition services. On 9/9/25 at 12:40 PM, a Cook was scraping the bottom of the pan of chili on the steam table and asked whether a resident was going to eat it. The Infection Preventionist stated they would see when it was taken to the resident in her room, and the Cook continued scraping the pan until only about half a bowl could be filled. The Infection Preventionist also stated the resident had wanted a grilled cheese the day before, so they might give her that with a little chili. The Cook stated that sometimes the kitchen runs out of food and has to offer residents something else. Later that day, meal service was complete and there was not enough remaining chili or peas to obtain temperatures. During the Resident Council Group Meeting on 9/11/25, residents reported the Facility did not provide enough food and was often out of items such as sugar and pink sugar. One resident stated her sister had to bring in snacks so the Facility would have something to give out during Bingo, and that none of the residents were getting enough calories each day. Another resident stated the Facility ran out of chili the night before and she did not receive any, despite being told a tray would be saved for her; she instead received two pieces of ham. A third resident stated he asks for more food at meals but does not get it. The Dietary Aid stated the kitchen sometimes runs out of food because of the budget and that the Facility is always removing items from the food order after it is placed. The Administrator stated that if there is ever a concern about not having enough food, dietary staff should go to the local store and buy it, and also stated the Facility does not have a policy specific to dietary adequacy.
Failure to Remove Old Fentanyl Patch
Penalty
Summary
The facility failed to ensure that Fentanyl patches were removed from one resident as ordered by the physician. The resident had diagnoses including unspecified acquired deformity of the right lower leg and unspecified osteoarthritis, and the physician order summary listed Fentanyl transdermal patch 37.5 mcg/hour along with other pain medications. The resident's granddaughter reported that while the resident was in physical therapy, she found three Fentanyl patches on the resident's back, with two on the right shoulder and a third on the left shoulder. The DON stated that two patches were removed from the resident's shoulder and that the third patch should have been removed before the new patch was applied. The physician stated the hospital had placed two patches because the prescribed dosage was not available, and that the additional patch was not viewed as significant because it had been on longer than 72 hours and the resident had not experienced negative outcomes. The resident's eMAR documented that the scheduled Fentanyl patch was placed on the resident's shoulder at 12:38 AM, and the facility policy on administering topical medications states to remove the old patch.
Insufficient Room Space for Residents
Penalty
Summary
The facility failed to provide at least 80 square feet of floor space per resident bed for 53 of 53 residents reviewed for room size in a sample of 61. Observation and interview showed that multiple Medicaid-certified rooms in A Hall, B Hall, C Hall, and D Hall provided only 75 square feet per bed or 77 square feet per bed, rather than the required minimum. On 09/16/25 at 9:36 AM, V18 (Housekeeper) measured the rooms and verified that the listed residents were living in rooms that were waivered. Interviews conducted from 09/09/25 through 09/12/25 documented no resident concerns or complaints about room size, and on 09/11/2025 at 12:10 PM, V1 (Administrator) stated that there had been no changes to the room sizes.
Resident Discharged Without Physician Order or Safe Discharge Planning
Penalty
Summary
A deficiency occurred when a resident was discharged home without a physician's knowledge, order, or consent. The resident had a recent history of right ankle trimalleolar fracture with open reduction internal fixation (ORIF), was non-weight bearing, and required partial to moderate assistance with ambulation and transfers. The care plan identified risks for falls and orthopedic complications but did not address discharge planning or the resident's preferences regarding discharge. There was no documentation in the care plan or progress notes indicating that the resident had expressed a desire to leave the facility or that discharge planning had been discussed with her. On the day of discharge, conflicting information was provided to the resident and her family regarding whether she could be released, with staff initially stating she could go home, then later retracting this due to the absence of a physician's order, and finally stating she could be discharged. The resident was ultimately discharged with the assistance of a friend, who provided care at home, including help with mobility, wound care, and daily activities. Occupational therapy had recommended continued stay in the facility due to environmental barriers at home and the need for physical assistance with stairs, and the primary physician had explicitly stated that discharge was not safe due to ongoing therapy needs and uncertainty about the resident's support system at home. Interviews with facility staff revealed that a new RN was instructed to obtain a discharge order but did not actually secure one from the physician. The Social Service Director believed an order had been obtained, and home health services were arranged, but the discharge proceeded without proper physician authorization. The primary physician later confirmed that he had denied the discharge request due to safety concerns, and the Medical Director stated he would not have approved discharge against therapy recommendations or the primary physician's wishes. The facility's discharge policy requires physician authorization and appropriate planning, which was not followed in this case.
Failure to Supervise Resident with Impaired Mobility and Cognition Resulting in Fall
Penalty
Summary
A deficiency occurred when a moderately cognitively impaired resident with a history of stroke, hemiplegia, hemiparesis, muscle weakness, and impaired mobility was left unsupervised outside the facility in her wheelchair. The resident required total assistance for transfers and had documented risks for falls, as well as impaired visual function and cognitive deficits. Despite these needs, the resident was left unattended after being taken outside for a cigarette, with no staff present to supervise her, even though her care plan and facility policies indicated the need for supervision. While outside, the resident was observed by a surveyor rocking back and forth in her wheelchair, moaning, and slumped in the chair, with no staff monitoring her or other residents in the area. The resident was unable to communicate her needs effectively and was not alert when approached. She subsequently leaned forward, slipped out of her wheelchair, and fell onto the concrete, sustaining abrasions to her knees, a large swelling on her forehead, and a black eye. The surveyor had to alert staff to the incident, and the resident was sent to the hospital for evaluation and treatment. Interviews with staff revealed a lack of clarity regarding the supervision requirements for the resident while outside, despite her documented need for assistance and supervision, especially during smoking. The staff member who took the resident outside did not remain with her and was unsure if supervision was necessary beyond smoking. Facility policies required direct supervision for residents with restricted privileges, such as supervised smoking, but these were not followed, resulting in the resident being left unsupervised and subsequently experiencing a fall with injury.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for one resident with a history of falls and multiple medical diagnoses, including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, and cognitive impairment. The resident was assessed as moderately cognitively impaired and required supervision or assistance with transfers. Despite being care planned for non-skid socks and a non-skid mat on and below the wheelchair pad, the resident was observed wearing socks without non-skid material and without the required non-skid mat in place during multiple observations. The absence of these interventions was confirmed by the facility administrator. The resident experienced two falls in the dining room, one of which was witnessed and triggered an alarm, and another where the resident was found sitting on the floor in front of her wheelchair. The facility's policy requires staff to implement individualized fall prevention interventions based on resident risk, and the administrator acknowledged that the interventions specified in the care plan were not in place at the time of the observations.
Failure to Enforce PPE and Mask Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that staff were encouraging COVID-19 positive residents to wear masks and that staff donned proper personal protective equipment (PPE) to prevent the spread of COVID-19. This deficiency was observed in the case of two residents, both of whom were COVID-19 positive. One resident, identified as R6, was noted to be severely impaired for cognition and had a history of wandering due to dementia. Despite being on isolation precautions, R6 was observed multiple times without a mask while ambulating in the hallway and sitting near the dining room, with no staff intervention to encourage mask-wearing. Another resident, R8, who also tested positive for COVID-19, was observed in her room with staff providing care without wearing the appropriate PPE. Two certified nursing assistants (CNAs) were seen transferring R8 using a mechanical lift while only wearing surgical masks, without N95 masks, eye protection, or gowns, as required by the facility's COVID-19 guidance. The CNAs admitted to not noticing the PPE requirements posted on the door and not being aware of R8's COVID-19 status. The facility's Director of Nursing (DON) confirmed that staff should have been wearing full PPE when providing care to COVID-19 positive residents. The facility was experiencing a COVID-19 outbreak, with several residents testing positive. The facility's COVID-19 guidance and CDC guidelines require healthcare personnel to use proper PPE, including N95 respirators, gowns, gloves, and eye protection, when exposed to residents with suspected or confirmed COVID-19.
RN Coverage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of staffing schedules for the past 14 days, which revealed that there was no RN coverage on five specific days: Wednesday 10/30/2024, Thursday 10/31/2024, Saturday 11/2/2024, Sunday 11/3/2024, and Monday 11/4/2024. The facility's administrator acknowledged the issue, noting a misunderstanding regarding the RN coverage requirements, particularly concerning the Director of Nursing's role. The Director of Nursing confirmed that the facility currently employs only two RNs, including herself, and that efforts are underway to hire more RNs. The facility's staffing policy, dated 10/2017, states that sufficient numbers of staff with the necessary skills and competencies are to be provided to meet the needs of all residents. However, the staffing schedules did not reflect compliance with this policy, as evidenced by the lack of RN coverage on the specified days. This deficiency has the potential to impact all 66 residents living in the facility.
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to ensure proper infection control surveillance for residents experiencing vomiting and diarrhea, potentially affecting all 66 residents. The administrator acknowledged that a few residents had these symptoms a few weeks prior, but claimed they were now resolved. The infection control specialist, who started working at the facility on October 25, 2024, had not yet completed the necessary certification course. They reported that 11 residents experienced symptoms, with three being hospitalized. Despite testing all residents for flu and COVID, which returned negative results, no contact isolation was implemented, nor was the health department notified. Surveillance and tracking of affected rooms and staff were not conducted, even though staff members also experienced similar symptoms. The facility's infection control policy, revised in September 2017, requires ongoing surveillance for healthcare-associated infections and other significant infections. However, the infection control specialist did not perform any surveillance or tracking, and the medical director and infection control specialist for the hospital were not informed of the outbreak. The facility provided an undated floor plan that did not identify residents or document interventions, except for COVID and flu vaccinations. The lack of proper surveillance and communication with relevant health authorities contributed to the deficiency in infection control practices.
Deficiency in Providing Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents received their scheduled showers, which is a part of their activities of daily living care. This deficiency was identified for four out of five residents reviewed in a sample of thirteen. Resident 2, who is cognitively intact and uses a wheelchair, reported not receiving the scheduled showers twice a week as per their care plan. The Director of Nursing confirmed that Resident 2 was supposed to receive showers on Wednesdays and Saturdays, but this was not consistently happening. Similarly, Resident 6, who is also cognitively intact, reported only receiving one shower per week over the past 14 days, despite being scheduled for two showers per week. Resident 3's family expressed dissatisfaction with the inconsistent care, noting that Resident 3 often appeared unkempt and had not received the scheduled showers. The Director of Nursing was unable to provide documentation to confirm that Resident 3 received the showers as scheduled. Resident 12 also reported issues with not receiving showers, which was a topic of discussion in the resident council meetings. The facility's policy requires documentation of showers, including any refusals and the condition of the resident's skin, but this documentation was lacking. The Director of Nursing acknowledged the complaints and stated efforts were being made to address the issue.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The Facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by federal regulations. This deficiency was identified through interviews and record reviews, which revealed that the Facility's Nurse's Schedule did not document an RN being scheduled for the required hours on specific dates. The Administrator confirmed the absence of an RN for the required hours on these dates, citing staffing challenges due to call-offs and recruitment difficulties in a rural setting. The Director of Nursing also acknowledged the staffing issues and the ongoing efforts to recruit staff. The Facility does not have a specific policy on RN staffing and follows federal regulations, impacting all 70 residents living in the Facility.
Failure to Honor Resident's DNR Wishes
Penalty
Summary
The facility failed to respect the end-of-life wishes of a resident who had chosen Do Not Resuscitate (DNR) as their advanced directive. The resident, who had multiple diagnoses including diabetes mellitus type 2, chronic kidney disease stage 3, liver cirrhosis, heart failure, and chronic venous hypertension, had a POLST form completed and signed by their physician indicating no CPR should be attempted. Despite this, the resident's physician orders contained conflicting instructions for both Full Code and DNR. When the resident was found unresponsive, a Licensed Practical Nurse (LPN) checked the admission records and face sheet, which incorrectly listed the resident as Full Code, and initiated CPR. This action was taken without knowledge of the resident's POLST form indicating DNR status. The facility's administrator acknowledged the error, noting that the resident's code status was initially Full Code upon admission but was later clarified to DNR. However, after a brief discharge and return to the facility, the orders were reinstated incorrectly, leading to the confusion and subsequent failure to honor the resident's end-of-life wishes.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The Facility failed to store foods in a manner that prevents foodborne illness, potentially affecting all 66 residents. During observations, surveyors noted several deficiencies in food storage and labeling practices. Crumbs were found on the bottom shelf of the serving counter and food preparation area, and oven handles were sticky. In the standing refrigerator, a plastic bag with julienned zucchini and various colored cups of liquids were not labeled or dated. Opened containers of whipped cream were not re-wrapped or dated, and a container of unlabeled fruit was dated 6/2/24. The deep freezer contained an opened package of chicken breasts that were not resealed or labeled. Additionally, two Styrofoam containers of salad in the dry storage room refrigerator were not labeled or dated. Further issues were identified in the break room refrigerator, where three plastic bags labeled with a resident's identifier were found, with only one labeled as toffee and none dated. The freezer had brown smears on the bottom shelf, and the refrigerator had red spills. A large container of sanitizer was placed directly on the floor of the dry storage room, in close proximity to food items. The Facility's policies from 2016 require all food items to be labeled and dated, with specific guidelines for discarding food past expiration or after a certain period. However, these policies were not adhered to, as evidenced by the unlabeled and undated food items found during the survey.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt Gradual Dose Reductions (GDR) on psychotropic medications for one resident, identified as R23, out of a sample of ten. R23 was admitted with multiple diagnoses, including Alzheimer's Disease, unspecified dementia with psychotic disturbance, and major depressive disorder. Despite being cognitively intact with a BIMS score of 13 and no behavioral symptoms reported, R23 was prescribed several psychotropic medications, including Ativan, Risperidone, and Zoloft, among others. The care plan indicated the need for quarterly consultations with the pharmacy and physician to consider dosage reductions, but no new orders were made following pharmacy consults on various medications from January to June 2024. The facility's policy requires that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period and be subject to gradual dose reduction and re-review. However, there was no documentation of behavior monitoring or attempts at GDR for R23, as noted in the Medication Administration Record (MAR) for the months of January through June. The Director of Nurses acknowledged the lack of behavior monitoring and documentation and mentioned plans to start a committee to address these issues, but at the time of the survey, these actions had not been implemented.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident bed for 50 residents in a sample of 63. Observations and interviews revealed that rooms in A Hall, B Hall, C Hall, and D Hall, which are all Medicaid certified, only provide 75 to 77 square feet per bed. This deficiency was confirmed by the Maintenance Director, who measured the rooms and verified the inadequate space. Despite the deficiency, no concerns or complaints were vocalized by residents regarding the room size during the survey period. The Vice President of Operations confirmed that there have been no changes to the historical measurements and accuracy of the facility's waivered resident room numbers and certifications.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Genevieve Nursing | 13.2 mi | ★★★★★ | 6 | 0 |
| Independence Care Center Of Perry County | 13.4 mi | ★★★★★ | 9 | 0 |
| Riverview At The Park Care And Rehabilitation Cent | 13.8 mi | ★★★★★ | 1 | 0 |
| Estates Of Perryville, Llc, The | 13.8 mi | ★★★★★ | 13 | 0 |
| Randolph County Care Center | 14.4 mi | ★★★★★ | 2 | 0 |
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