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 Waters Of Sullivan Nursing Facility, The during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow food safety and sanitation standards, including improper use of beard restraints while working over food, inadequate hot-holding temperatures for items such as baked chicken, mashed potatoes, and vegetables, and visibly soiled hall tray carts with heavy brown debris on rails and wheels. Several cognitively intact residents reported poor food quality, including cold or lukewarm meals, dry and overcooked items, and rubbery eggs, particularly for trays delivered to rooms. Grievance records documented repeated complaints about cold and poor-quality food, while facility policies required proper hair restraints, correct cooking and holding temperatures, and regular cleaning and sanitizing of carts and equipment.
A resident with diabetes, heart failure, and HTN, who was cognitively intact and on a consistent carb, regular texture diet, repeatedly received oatmeal on meal trays despite stating multiple times that he did not like it. Review of the care plan and nutrition assessment showed no documented food preferences, and the daily menu for the resident lacked any notation of likes or dislikes, even though the facility’s policy and the DM’s process required recording such information on nutritional assessments and menus.
A resident with Type II DM had a standing order for mealtime Lispro insulin without any parameters for holding doses, yet nursing staff repeatedly held scheduled insulin at various times for blood glucose values ranging from the 50s to just over 100, and on some occasions failed to document any blood glucose value or whether insulin was given. The clinical record did not show MD notification or new orders for these held doses, and interviews with a QMA and the DON confirmed that no physician parameters for holding insulin had been provided and that staff did not contact the prescriber as required by facility policy.
The facility required CNAs and nursing staff to cover laundry duties in addition to resident care, resulting in longer call light response times, increased staff workload, and delays in meal tray delivery. The Administrator did not seek additional staffing or external support, and the actual staffing levels did not match the facility's assessment plan. Staff reported running out of linens and increased stress, with no additional staff scheduled to address the shortage.
The Administrator failed to address ongoing gnat infestations, unsafe environmental conditions, and staffing shortages, resulting in residents experiencing contaminated food, injuries from unrepaired fixtures, and inadequate laundry and housekeeping services. Staff and residents reported that the Administrator was not present on the floor and did not communicate about these issues, leading to unresolved problems affecting all residents.
A gnat infestation persisted throughout the facility, affecting all residents and multiple areas such as resident rooms and the dining room. Residents reported gnats contaminating food and beverages, and one developed maggots between her toes. Staff repeatedly reported the issue to administration, but responses were delayed and insufficient, with pest control measures failing to resolve the problem in a timely manner.
Meals were not consistently palatable during breakfast and lunch observations. A CNA served a resident a waffle that was hard and crunchy, and residents reported overcooked waffles, biscuits, French fries, and eggs that were not cooked right. One resident also reported pizza with only cheese and a crust that was too hard to chew. Resident council minutes showed ongoing concerns about food palatability, and the RDO stated the kitchen was not preparing food properly.
Food safety and sanitation lapses were observed during meal preparation and service. A cook with a full beard prepared breakfast food without a beard restraint, the high-temp dish machine did not reach the required rinse temperature for sanitizing, and drink carts were left in hallways with open ice buckets, uncovered ice, and a scoop left in the ice. Staff also used a drinking cup to scoop ice for a resident’s beverage, and the DON and RNC acknowledged the improper handling of the ice and carts.
Call Light Not Kept Within Reach: A resident with vascular dementia, anxiety, and a history of falls was observed twice with the call light out of reach while lying in bed. The resident stated she could use the call light if it were available, and both an LPN and the DON said it should have been kept within reach. The resident's record showed severe cognitive impairment, moderate assist with transfers, and care needs for ADLs and fall risk.
Resident Council Grievances Not Timely Addressed: The facility failed to provide prompt responses to resident council concerns documented across multiple meetings. A resident council president reported that the daily menu was not posted, a chosen monthly meal was not served, snacks were not consistently available for residents including those with DM, and grievances were not being answered. Review of council minutes showed grievances were raised, but there was no evidence of follow-up responses.
Failure to notify resident representative of contact isolation order: A resident with dementia and a UTI was placed on contact isolation for E. coli in the urine, but the record lacked documentation that the resident's representative was informed of the new isolation order. The representative stated they were unaware the resident was on isolation or why it was in place, and the DON could not provide documentation showing the notification occurred.
Failure to provide an ABN with the NOMNC for two residents. Records showed Medicare Part A stays ended before benefit days were exhausted, and NOMNCs were signed by the resident and a representative, but there was no documentation that ABNs were issued with those notices. The BOM stated ABNs were not given because detailed NOMNCs were provided and she was unaware an ABN was still required.
Failure to Immediately Report Abuse Allegation to Administrator: A cognitively intact resident with a trauma history reported that another resident touched her shoulders and made a sexual advance. The report went from the resident to a QMA and then to an RN, who left a note for the SSD instead of calling the DON/Administrator. The Administrator stated the allegation was not reported immediately as required by facility policy.
A resident with hypertensive heart disease and CHF was receiving hospice services, but the quarterly MDS was coded incorrectly for prognosis and lacked documentation of a terminal prognosis. The MDS Coordinator acknowledged the coding error, and the DON provided the CMS RAI guidance stating J1400 Prognosis should be coded yes when the record shows the resident is receiving hospice services.
The facility failed to document that two residents were invited to and attended quarterly care plan meetings, despite one resident with dementia and limited cognition stating she was never asked to attend and another cognitively intact resident not remembering attending. Records lacked quarterly meeting documentation for multiple quarters, although some notes indicated attendance. The facility also had conflicting care plans for a resident with severe cognitive impairment and a POST form indicating CPR, with one plan calling for full intervention and another for comfort measures and natural death.
Two residents had delayed UTI treatment after UA C&S results were received. One resident’s culture showed Proteus mirabilis susceptible to Bactrim DS, but an NP ordered ciprofloxacin even though it was not listed on the C&S, and the antibiotic was later changed by the physician. Another resident’s culture showed E. coli, but the record lacked documentation of timely antibiotic treatment after the results were faxed to the physician, and the MAR showed multiple changing Macrobid orders over several days. The DON stated results should have been reported and addressed immediately.
Improper Storage of Nebulizer Equipment: Two residents receiving nebulizer therapy were repeatedly observed with unbagged nebulizer masks left on chairs or bedside tables, and one resident’s equipment was even found with the medication chamber detached and touching the floor. One resident had COPD and chronic respiratory failure with hypoxia and reported staff did not always bag the mask after treatments; the other resident had CHF and no cognitive deficit. An LPN and the DON stated nebulizer equipment should be cleaned and placed in a dated or labeled bag when not in use, consistent with the facility’s aerosolized medication therapy policy.
A resident with stage IV CKD and dependence on renal dialysis had a Permacath to the right upper chest, but the MAR included an order to assess for a fistula thrill and staff documented those assessments twice daily. The resident stated she did not have a fistula, an LPN confirmed the access was a Permacath, and the DON said the fistula order was entered by mistake and should not have been documented.
A resident with severe cognitive impairment, Parkinson’s disease, hallucinations, and hospice services had an order for every-shift behavior monitoring, but facility nursing staff did not document the resident’s hallucinations on the TAR or in progress notes. Hospice RN and aides reported frequent visual hallucinations to facility staff, yet the record lacked corresponding behavior documentation and did not show what interventions were attempted when behaviors were recorded.
An undated, opened multi-use vial of Tubersol was found in the East wing med storage room. An LPN stated the vial should have been dated when opened and discarded if it had been in use for 30 days, and the DON provided facility policies stating meds and biologicals must be stored per manufacturer recommendations and that Tubersol in use for 30 days should be discarded.
Failure to Post Daily Nursing Staff Hours: The facility did not ensure the required daily nursing staff hours posting was displayed for the weekend and the current day. During an observation, no staff posting was seen at either nurse's station or in the main lobby. The DON later stated she posted the current day's sheet when she arrived and was unsure why the weekend and current day postings had not been hung up earlier, despite the facility policy requiring daily posting at the beginning of each shift.
A resident admitted with orders for enoxaparin, Humalog, and Lantus did not receive scheduled doses because the required medications were unavailable in the Emergency Drug Kit and not obtained in time from the pharmacy. The Director of Nursing confirmed that staff should have used the EDK or arranged for emergency delivery, but the EDK was out of stock for the needed insulins and did not have the correct enoxaparin dose, resulting in missed medication administration.
Three residents, including those with cognitive impairments and special dietary needs, reported that their meals were frequently served cold and unappetizing. Observations confirmed that food was delivered on unheated carts without adequate warming devices, resulting in meal temperatures below the facility's policy requirements. The Dietary Manager acknowledged insufficient warming equipment, and complaints were noted about both food temperature and appearance.
The facility failed to manage food safety and storage, with incomplete temperature logs, expired food items, and improper storage practices. Bread lacked expiration dates, and sanitizer concentration levels were not properly tested or logged. Staffing shortages contributed to these deficiencies.
The facility did not conduct quarterly care plan meetings for two residents, as required by policy. One resident reported not attending a recent meeting, and records showed only one meeting in the past year. Another resident's records indicated only two meetings over a year, despite the quarterly requirement. The facility lacked a Social Service Director, which may have contributed to these oversights.
A resident with a history of prostate cancer and atrial fibrillation experienced edema in his feet and ankles, but the facility failed to notify the physician of this change in condition. Despite the resident's significant weight gain and the care plan's directive to monitor for edema, the facility did not document notifying the physician, resulting in a deficiency.
A resident was observed self-administering medications without supervision, contrary to facility policy requiring licensed nursing staff to administer medications or have physician authorization for self-administration. The resident's records lacked necessary assessments and orders, and staff interviews confirmed non-compliance with supervision protocols.
A facility failed to properly store and obtain physician orders for a resident's CPAP equipment. Observations showed the CPAP mask and tubing were unbagged and undated, and the resident's medical record lacked specific CPAP settings or humidification orders. An LPN confirmed the equipment should have been bagged and dated, and the facility's policy required a written physician's order for CPAP therapy, which was missing.
A facility failed to ensure proper physician documentation for a resident's continued use of Vesicare, despite a pharmacy recommendation to discontinue it. The resident, diagnosed with neuromuscular dysfunction of the bladder, had no documented rationale from the physician for continuing the medication, contrary to facility policy. This deficiency was confirmed by the Regional Nurse Consultant during an interview.
A facility failed to complete physician-ordered lab tests for a resident with multiple medical conditions, including heart failure and diabetes. Despite orders for various tests such as Digoxin levels, Hemoglobin A1C, and CBC, the records lacked documentation of their completion. The Regional Nurse Consultant confirmed the absence of lab results, highlighting a deficiency in following the facility's policy for nursing actions related to physician orders.
The facility failed to maintain infection prevention measures during meal service and medication administration. A CNA did not sanitize hands after touching her ear and hair while serving ice, and an LPN did not wash hands between checking blood sugar for two residents. Staff also did not follow hand hygiene guidelines, washing hands for less than 20 seconds and turning off faucets with bare hands.
Food Safety, Temperature Control, and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The deficiency involves multiple failures in food safety and sanitation practices in the facility’s dietary services. Surveyors observed contracted dietary staff working in the kitchen food preparation area without properly using beard restraints, despite a facility policy requiring hair and beard coverings at all times. One dietary aide with facial hair repeatedly entered and worked in the food preparation and tray assembly areas with his beard restraint either not in place or pulled down below his mouth, leaving his beard and mustache uncovered, including while standing directly over the steam table and loading trays into hall tray carts. Another dietary aide was observed serving trays over open plates of food with long sideburns exposed because his beard restraint did not fully cover his facial hair. The Dietary Manager acknowledged understanding the policy requirement for hair and beard restraints. Surveyors also identified problems with food temperatures and resident complaints about food quality and temperature. A test tray taken during the noon meal service showed a piece of baked chicken at 112°F, mashed potatoes with gravy at 119°F, and mixed vegetables at 105°F, which the Dietary Manager acknowledged were below the correct holding temperatures and inconsistent with the facility’s policies on cooking and holding food, including poultry at 165°F. Several cognitively intact residents reported that food was often cold or lukewarm, dry, overcooked, rubbery, tough, or otherwise of poor quality. Residents who typically ate in their rooms and received hall trays specifically reported that their food was sometimes or usually cold by the time it reached them. Grievance forms documented prior complaints that food quality was poor, food was cold, often late, and that items were sometimes unavailable. In addition, the surveyors observed that the hall tray food delivery carts used for the East and another hall at the noon meal were visibly soiled. The carts, which contained individual meal trays, cups with liquids, and eating utensils, had a heavy coating of brown debris along the bottom rails and on the wheels. This condition existed despite a facility policy requiring that trays and carts used to carry clean tableware and utensils be cleaned and sanitized daily or as often as necessary. The Dietary Manager stated that the carts were cleaned after every meal service and that the outside was wiped down as needed. The Administrator reported that dietary staff were contracted employees and stated she was aware of kitchen issues but believed she did not have authority over them.
Failure to Document and Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that a resident’s food preferences were documented and honored, resulting in the resident repeatedly receiving an undesired food item. During an interview, Resident B, who was cognitively intact per a 5-day MDS assessment, reported that he did not like oatmeal and had continued to receive it on his meal tray despite telling staff several times not to send it. Review of his medical record showed he was admitted with diagnoses including diabetes, heart failure, and hypertension, and had a physician’s order for a consistent carbohydrate, regular texture diet. However, his care plan contained no specific food preferences, and his nutrition assessment only stated that food preferences were on the tray card, with no additional information recorded. The DON stated that food preferences were recorded on nutritional assessments, while the DM explained that residents were given daily menus and asked to indicate what they wanted, and that she would include likes and dislikes if residents informed her. Neither the DON nor the DM reported being told of any food preferences by this resident. The DM provided a copy of the daily menu for the resident, which lacked any notation of likes or dislikes at the bottom where such information was supposed to be recorded. The facility’s policy, “Clinical Nutrition documentation,” stated that residents have the right to make their own food choices related to individual differences and cultural and ethnic preferences, but the documentation and meal service for this resident did not reflect his stated dislike of oatmeal.
Failure to Follow Insulin Orders and Obtain Parameters for Holding Doses
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin as ordered by the physician and to obtain physician parameters or orders for holding insulin doses for a resident with Type II diabetes mellitus. Resident B had a current signed order for Lispro insulin, 25 units subcutaneously with meals, dated 12/4/25, with no parameters for when to hold doses. The eMAR showed multiple instances where scheduled insulin doses were held without corresponding physician orders or documented parameters: the 7:30 a.m. dose was held on several dates for blood sugar (BS) values of 46, 90, and 116; the 11:30 a.m. dose was held on multiple dates for BS values ranging from 54 to 80; and the 5:30 p.m. dose was held on one date for a BS of 105. The clinical record also lacked documentation of any BS value, progress note, indication of the resident being out of the facility, or indication that insulin was administered for certain scheduled doses. The record further lacked documentation that the physician was notified regarding the held insulin doses. A QMA reported obtaining BS values prior to insulin administration and stated that, on one occasion when the BS was 77 at 11:30 a.m., the nurse instructed her to document in the eMAR that the insulin was held due to that BS value. During interview, the DON confirmed that the physician had not provided parameters for holding mealtime insulin, that the hospital discharge records did not include such parameters, and that the facility physician had not added any. The facility’s medication administration policy stated that if a dosage is believed to be inappropriate or excessive, or associated with potential adverse consequences, the person administering the medication will contact the prescriber or attending physician, but the documentation did not show that this occurred for the held insulin doses.
Nursing Staff Shortage Due to Laundry Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet resident needs while also requiring nursing assistants to cover laundry services since the end of October. Certified Nursing Assistants (CNAs) reported that they were assigned to laundry duties during their shifts, which resulted in them leaving the floor and being less available for direct resident care. Multiple CNAs and an LPN indicated that this dual responsibility led to longer call light response times, increased workload, and delays in meal tray delivery and pick-up. Staff also noted that there were occasions when only two aides, a nurse, and a QMA were present on night shift to care for all residents while also handling laundry, and that no additional staff had been scheduled to compensate for the increased workload. The Administrator acknowledged that only one full-time housekeeper/laundry person was employed after the termination of the Housekeeping Supervisor, and that CNAs had picked up extra hours to cover laundry. The Administrator had not reached out to regional leadership or considered external sources for laundry coverage, nor had she discussed the impact of the staffing shortage with residents or staff in detail. The Facility Assessment Tool indicated a staffing plan that included more housekeeping/laundry staff than were actually present. Staff reported running out of linens on night shift, necessitating laundry to be done during evenings and nights. One resident noted that staff appeared more stressed, though did not observe increased call light response times.
Failure to Address Bug Infestation, Staffing Shortages, and Unsafe Conditions
Penalty
Summary
The Administrator failed to manage the facility in a manner that ensured effective use of resources and quality of life for residents, as evidenced by ongoing issues with bug infestation, inadequate direct care staffing, and unsafe living conditions. Multiple confidential interviews with staff and residents revealed that the Administrator was not present on the floor, did not engage with staff or residents, and was perceived as indifferent to the facility's challenges. Staff morale was reported to be low, and concerns about vacancies and pest infestations were largely ignored by the Administrator. One resident reported sustaining a cut on his arm from a damaged bathroom door frame, which had not been repaired for over a month due to the absence of a Maintenance Director. The Administrator acknowledged the delay in repairs and indicated that the new Maintenance Director would address the issue when possible. The same resident described severe gnat infestations in his room and the dining area, with gnats contaminating food and beverages. Staff and residents reported that the gnat problem persisted for several weeks, and staff requests to use pest control devices were denied by the Administrator. Another resident reported developing maggots between her toes, which she attributed to the insect infestation in her room. The facility also experienced significant staffing shortages, particularly in housekeeping and laundry. The Administrator had terminated the Housekeeping Manager, leaving only one full-time housekeeper/laundry staff member, and CNAs were required to cover laundry duties, leading to frequent shortages of linens, especially during night shifts. The Administrator admitted to not seeking additional support or outside services to address the laundry staffing gap and had not communicated with staff or residents about the impact of these shortages. The Administrator was aware of the gnat issue but did not fully grasp its extent and did not escalate the problem to higher management or seek alternative pest control solutions.
Failure to Control Gnat Infestation Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment by not controlling a gnat infestation that affected multiple areas, including resident rooms and the dining room. Residents reported significant issues with gnats over a period of several weeks to months, with gnats found in beverages and food, and residents taking measures such as covering drinks and personal items to avoid contamination. One resident described counting multiple gnats in his coffee, while another mistook gnats for pepper on her food. Staff interviews confirmed that the infestation was widespread and persistent, with reports that the issue was communicated to administration multiple times. Resident interviews revealed that the infestation caused considerable discomfort and annoyance, with one resident covering her face at night to avoid gnats and another developing maggots between her toes, which was documented in a Skin Integrity Issue report. The report noted that this resident had predisposing factors such as a preference for independence, incontinence, fragile skin, improper footwear, and resistance to care. Staff described the infestation as severe, with gnats present in food, beverages, and throughout the facility, and expressed concerns that the facility's response was insufficient and not timely. The Administrator acknowledged being aware of some gnats in her office but was not aware of the extent of the infestation throughout the facility. She had not spoken directly to residents or staff about the issue and relied on department heads for information. The pest control company was called for additional visits, but staff felt these measures were inadequate. The facility's pest control policy outlined responsibilities for prevention, monitoring, and control, but the actions taken did not prevent or resolve the infestation in a timely manner.
Meals Not Served in a Palatable Manner
Penalty
Summary
The facility failed to provide meals that were palatable during 2 of 2 mealtime observations. During breakfast service in the main dining room, the first tray was not served until 8:23 a.m. even though the menu indicated trays were to be served at 7:45 a.m. A CNA served a male resident a breakfast tray and stated she was unable to cut the waffle easily because it was hard and crunchy; the waffle was noted to be dark brown and hard on half of it. The resident stated he was unable to eat the waffle because it was overcooked and too hard to cut with a butter knife. Another resident stated the waffles or biscuits on her table mate’s plate appeared overcooked and too hard to cut, and a resident later reported her lunch was difficult to eat because the French fries were overcooked and too crunchy, the pizza crust was too hard to chew, and the pizza had only cheese with no protein. Additional resident interviews reflected ongoing concerns with food quality. One resident stated the facility food was not good, that waffles and biscuits were hard when served, and that eggs were never cooked right, describing the yolk as gel-like. Review of May, June, and July resident council meeting minutes showed residents had raised concerns about food palatability each month. The Regional Director of Operations stated the facility was aware of ongoing kitchen concerns and that the food was not being prepared properly, describing that it may have been cooked together and left out too long, resulting in hard and crunchy food. The Administrator also stated the facility was aware of the kitchen concerns and was working on getting new cooks and a Dietary Manager.
Food Safety and Sanitation Lapses During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure a male cook with a full beard wore a beard restraint while preparing breakfast food. During the kitchen tour, the cook was observed working without any beard restraint, and the Dietary Manager stated the facility knew beard restraints were not available and had ordered them. The Administrator later stated she was not aware the cook had been working without a beard restraint, and the Regional Director of Operations confirmed the cook was the first male kitchen staff member with a beard and that beard restraints were on order. The facility also failed to ensure the high temperature dish machine reached the proper rinse temperature during the sanitizing cycle. The dish machine was observed reaching only 174 degrees Fahrenheit, while the Dietary Manager stated it should reach at least 180 degrees Fahrenheit to sanitize dishes. The Dietary Manager reported a problem with the machine’s booster to Maintenance, and the Administrator stated she had not been made aware that the dish machine was not reaching the proper rinse temperature. In addition, improper handling of food and beverages was observed during lunch tray service on the hallways. A drink cart was left in the hallway and at the nurses’ station with an open metal ice bucket, no lid, and a scoop left in the ice. On another cart, plastic cups of ice were left open to air on the cart, and an activity aide used a plastic drinking cup to scoop ice from the bucket before serving lemonade to a resident with a lunch tray. The DON stated she was not aware the ice bucket should be covered while in the hallway, and the Regional Nurse Consultant stated ice should be covered when leaving the kitchen and staff should not leave the scoop in the ice bucket or use drinking glasses to scoop ice.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was kept within reach for 1 of 24 residents reviewed for call lights. Resident 7 was observed lying in bed on 7/28/25 with the call light lying on the recliner next to the bed and out of reach, and the resident stated it was not within reach. On 8/1/25, the resident was again observed in bed with the call light under the pillow and out of reach, and the resident stated she did not know where it was and was unable to find it. The resident said she would yell for help if needed but would have used the call light if she had it. Resident 7's record showed diagnoses including moderate vascular dementia with anxiety and a history of falling. The quarterly MDS dated 7/6/25 indicated severe cognitive impairment and moderate staff assistance was required with transfers. The care plan identified the resident as needing staff assistance with ADLs and being at risk for falls. During interviews, an LPN and the DON both stated the resident was able to use her call light and that it should have been kept within her reach. The DON also provided the facility policy stating call lights should be positioned conveniently for residents and placed on the bed at all times, never on the floor or bedside stand.
Resident Council Grievances Not Timely Addressed
Penalty
Summary
The facility failed to ensure prompt response to resident council grievances for 3 of 3 resident council meetings reviewed. During an initial observation on 7/28/25, the daily menu posted in the facility was dated 7/11/25, and subsequent daily survey observations noted that the daily menu had not been posted. During the resident council meeting on 7/31/25 at 1:00 p.m., the Resident Council President reported that residents had asked for the daily meal menu to be posted, but it had not been done. He also stated that residents were supposed to choose a meal of their choice once a month, but the chosen meal was not served. The Resident Council President further reported that residents had asked for snacks to be available, but he was told the budget did not allow the facility to purchase snacks. He stated he was diabetic and kept snacks in his room, but other diabetic residents had reported not receiving snacks. He also stated that grievances were not responded to for him or other residents. During interview on 7/31/25 at 1:45 p.m., the Administrator stated grievances were addressed in daily stand up and stand down meetings and that responses should be written on the grievance form. Review of resident council minutes from 5/27/25 to 7/29/25 showed grievances were presented, but the documentation lacked evidence of follow-up responses to complaints.
Failure to Notify Resident Representative of Contact Isolation Order
Penalty
Summary
The facility failed to ensure a resident's representative was notified of a new order for contact isolation precautions. Resident 7 had diagnoses including moderate vascular dementia with anxiety and a UTI, and a quarterly MDS dated 7/6/25 indicated severe cognitive impairment. On 7/21/25, a nursing progress note documented that the physician ordered Macrobid for seven days for a UTI, and the resident's representative was notified of the antibiotic order, but there was no documentation that the representative was told about isolation precautions. A physician's order dated 7/23/25 directed contact isolation precautions for E. coli in the urine until 7/29/25, but the order did not document that the resident's representative was notified. During interview, the resident's representative stated they were not aware the resident was on isolation precautions or why they were in place. The DON provided an NP progress note dated 7/23/25 stating the patient/family was made aware the visit was being performed using remote telephonic technology, but it did not document notification of the contact isolation order. The DON also provided the facility policy stating the resident representative is to be notified of changes in the resident's medical condition or status, including significant changes, within 24 hours except in medical emergencies.
Failure to Provide ABN With NOMNC
Penalty
Summary
The facility failed to ensure an Advance Beneficiary Notice (ABN) was provided for 2 of 3 residents reviewed for beneficiary notices, Residents 62 and 19. For Resident 62, the record showed a Medicare Part A stay that began on 3/1/25, with the last covered day listed as 4/30/25. The facility initiated discharge from Medicare Part A services before benefit days were exhausted, and a Notice of Medicare Non-Coverage (NOMNC) was signed by the resident on 4/28/25, but the record lacked documentation that an ABN was provided with the NOMNC. For Resident 19, the record showed a Medicare Part A stay that began on 1/27/25, with the last covered day listed as 3/24/25. The facility initiated discharge from Medicare Part A services before benefit days were exhausted, and a NOMNC was signed by the resident's representative on 3/18/25, but the record lacked documentation that an ABN was provided with the NOMNC. During interview, the BOM stated ABNs were not provided to Residents 62 and 19 because they were provided a detailed NOMNC and she was not aware an ABN still needed to be issued. The Administrator later provided an undated document titled Form Instructions Advance Beneficiary Notice of Noncoverage, which stated the ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case.
Failure to Immediately Report Abuse Allegation to Administrator
Penalty
Summary
The facility failed to ensure staff immediately reported an abuse allegation to the Administrator for 1 of 1 reportable incidents reviewed involving Resident 23. Resident 23’s admission MDS dated 7/9/25 indicated she was cognitively intact and did not have behaviors during the look-back period. Her care plan noted a history of significant trauma and identified her as a trauma survivor. The incident involved Resident 23 reporting that another resident touched her shoulder inappropriately and made a sexual advance toward her, with the resident also describing that the male resident had been massaging her back and shoulders and saying she was the perfect height for him to do what he needed. The resident reported the concern to the evening/night shift QMA, who told the evening/night shift nurse. The nurse left a note for the SSD but did not call the Administrator, and the Administrator stated the staff did not report the incident to her immediately. An undated handwritten note stated the writer was unsure what to do because they were working nights and did not know if the SSD would be there before they left. During interviews, the Administrator stated any abuse allegation should have been reported to her immediately, or if she was not in the facility, staff should have called her. The facility policy titled Abuse Prevention Program stated employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or mistreatment to the Administrator or an immediate supervisor who will immediately report it to the Administrator.
Incorrect MDS Prognosis Coding for a Resident Receiving Hospice
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for Resident 46 by incorrectly coding the resident's prognosis on a quarterly MDS dated 6/17/25. The resident's record showed diagnoses including hypertensive heart disease and congestive heart failure, and the census indicated hospice services began on 3/13/25. The care plan reflected the resident's wish for hospice services, with interventions including hospice services as ordered. However, the quarterly MDS indicated the resident received hospice services but lacked documentation of a terminal prognosis. During interview, the MDS Coordinator stated the resident's prognosis had been coded incorrectly. The DON later provided the CMS RAI Manual Section J and indicated it was the facility policy being used, which stated that J1400 Prognosis should be coded yes if the medical record includes physician documentation that the resident is receiving hospice services.
Care Plan Meetings Not Documented and Conflicting POST Care Plans
Penalty
Summary
The facility failed to ensure residents were invited to attend quarterly care plan meetings for 2 of 3 residents reviewed. Resident 19, who was admitted with hypertension and dementia and had limited cognition on an MDS assessment, stated in interview that she had not attended a care plan meeting and had not been asked to attend one. The medical record lacked documentation of quarterly care plan meetings or of the resident attending quarterly meetings for 3/2024, 9/2024, 12/2024, and 6/2025, although one care plan note indicated the resident attended a care plan meeting. The Social Service Director stated residents were invited to care plan meetings and attendance was documented in the meeting record. Resident 8, who was admitted with diabetes and hypertension and was cognitively intact on an MDS assessment, stated she did not remember attending a care plan meeting to discuss care needs and concerns. The medical record lacked documentation of quarterly care plan meetings or of the resident attending quarterly meetings for 7/2024, 10/2024, 1/2025, and 7/2025, although care plan meeting notes dated on two occasions indicated the resident attended a care plan meeting. In addition, Resident 7’s record showed a quarterly MDS assessment with severe cognitive impairment, a POST form indicating CPR if found in cardiac arrest, and two conflicting care plans: one for POST form-full intervention including life support measures and another for POST form-comfort measures, allow natural death. The DON stated she was not sure why there were two conflicting care plans and that the care plan should have been consistent with what the resident indicated in the POST form.
Delayed Treatment of UTI After Culture Results
Penalty
Summary
The facility failed to ensure urinary tract infections were treated in a timely manner after urine culture and sensitivity results were received for two residents. One resident was cognitively intact on admission and later had increased sleeping and confusion noted by the daughter, prompting a UA C&S. The urine culture was finalized with greater than 100,000 Proteus mirabilis, and the report showed susceptibility to Bactrim DS, but ciprofloxacin was not listed as tested against the organism. The results were faxed to the physician, but no antibiotic order was documented at that time. When the NP reviewed the results, ciprofloxacin was ordered for UTI without documentation explaining why it was selected despite not being included on the culture report. Several days later, the physician changed the antibiotic to Bactrim DS after reviewing the results. A second resident with severe cognitive impairment also had a UA C&S finalized showing greater than 100,000 E. coli in the urine. The culture report did not include Macrobid as an antibiotic tested for efficacy against the bacteria. The results were faxed to the physician, but the record lacked documentation of an antibiotic order at that time. The MAR then showed multiple changing Macrobid orders over several days, with administrations beginning after the culture results were received, but the record lacked documentation that the UTI was treated prior to the first Macrobid order. The care plan reflected isolation precautions for E. coli in the urine and that the resident received an antibiotic for a UTI. During interview, the DON stated the physician should have been notified immediately of UA C&S results requiring an antibiotic and that if an antibiotic ordered was not included on the C&S, the nurse should have informed the physician to ensure the correct order. The DON also stated she could not find additional information explaining why the second resident’s antibiotic was not ordered until several days after the culture results were received. Facility policies provided by the DON stated that lab results were to be tracked and reported timely and that UTIs should be identified and addressed with treatment implemented immediately.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for 2 residents receiving nebulizer treatments. Resident 51, who had diagnoses including COPD and chronic respiratory failure with hypoxia and was cognitively intact, was observed multiple times with an unbagged nebulizer mask sitting on a chair next to the bed, on top of blankets and linens, and once with the medication chamber detached and in contact with the floor. The resident stated she received breathing treatments several times a day and had noticed staff did not always place the nebulizer mask in a bag after treatment was completed. Her record showed an order for albuterol sulfate nebulization solution 1.25 mg/3 ml four times daily, and an LPN stated that after treatment the nebulizer equipment was to be rinsed and placed in a plastic bag for storage while not in use. Resident 46, who had diagnoses including CHF and no cognitive deficit, was also observed with an unbagged nebulizer mask sitting on the bedside table on multiple occasions when the resident stated she had not had a treatment that day and that the last treatment had been the day prior. The resident’s record showed an order for albuterol sulfate nebulization solution 2.5 mg/3 ml every 24 hours as needed for shortness of breath, and the July 2025 MAR showed nebulizer treatments were given on 7/5/25, 7/7/25, and 7/31/25. An LPN and the DON both indicated nebulizer equipment should be cleaned and placed in a dated bag when not in use, and the facility policy titled Aerosolized Medication Therapy stated that when finished, the nebulizer should be placed in a labeled bag with the patient name and date.
Dialysis Access Site Assessed Incorrectly
Penalty
Summary
The facility failed to ensure that Resident 42’s dialysis access site was accurately assessed. The resident was admitted with stage four chronic kidney disease and dependence on renal dialysis, and the admission MDS indicated the resident was cognitively intact. The MAR contained an order to maintain the resident’s dialysis access site by checking for a thrill on the access site, with documentation showing the assessment was completed twice daily from 7/7/25 through 7/31/25. However, the resident’s current care plan identified a Permacath to the right upper chest and dialysis three times weekly, not a fistula. During interview, the resident stated she had a Permacath in her chest/neck area for dialysis access and that dialysis staff provided care for the access site, while facility staff did not normally do anything with it or look at it. The resident stated she did not have a fistula. An LPN confirmed the resident had a Permacath and stated the fistula assessment order should not have been in place because the resident did not have a fistula. The DON stated the resident had a Permacath, the fistula assessment order was entered by mistake, and nurses should not have documented that they assessed a fistula because the resident did not have one.
Failure to Document and Monitor Hallucination Behaviors
Penalty
Summary
The facility failed to ensure behavior monitoring was completed for a resident with diagnoses including metabolic encephalopathy, Parkinson’s disease, hallucinations, severe cognitive deficit, and hospice services. The resident’s care plan identified risk for hallucinations and delusions, and a physician’s order dated 11/15/23 directed staff to monitor for hallucinations and delusions every shift. Hospice documentation throughout March, April, May, June, and July 2025 repeatedly noted that the resident continued to have frequent daily hallucinations, but the facility’s TAR did not document behaviors for entire months and did not reflect the behaviors noted by hospice on multiple dates. Review of the resident’s progress notes from March 2025 through July 2025 showed no documentation by facility nursing staff of hallucinations, and interdisciplinary team notes from July 2024 through July 2025 also lacked documentation of hallucinations or delusions. When interviewed, an LPN stated nurses were responsible for completing behavior tracking on the TAR each shift. Hospice RN and hospice aides reported witnessing visual hallucinations and said they informed facility nursing staff, but they were unsure whether the facility documented or followed up on those reports. CNAs stated they reported behaviors to nurses and were not responsible for documenting them, and the DON stated CNAs were not responsible for documentation and nurses were to document the behaviors they witnessed.
Undated Open Tubersol Vial in Medication Storage Room
Penalty
Summary
The facility failed to ensure medication was labeled properly for 1 of 2 medication storage rooms reviewed. On 7/30/25 at 1:45 p.m., the East wing medication storage room contained an undated and opened multi-use vial of Tubersol, a clear, colorless solution for injection used as an aid in the diagnosis of tuberculosis. During interview, an LPN stated that Tubersol is good for 30 days once opened and that the vial should be discarded because it was not labeled with an open date and she was unsure how long it had been in the refrigerator. Another LPN stated that Tubersol is good for 30 days once opened and should be dated when opened. The DON provided the facility’s medication storage policy stating that medications and biologicals are stored safely, securely, and properly following manufacturer or supplier recommendations, and a Tuberculin Purified Protein Derivative policy stating that a vial of Tubersol entered and in use for 30 days should be discarded.
Failure to Post Daily Nursing Staff Hours
Penalty
Summary
The facility failed to ensure the required daily nursing staff hours posting was posted for Saturday, Sunday, and Monday during 1 of 5 staff posting observations. During a continuous observation on 7/28/25 from 7:30 a.m. to 7:59 a.m., no daily staff hours posting was observed in the facility, and there was no posting from the weekend or the current day at either nurse's station or in the main lobby. During interviews on 7/31/25, the DON stated she hung up Monday's daily staff posting when she arrived at the facility and was not present between 7:30 a.m. and 7:59 a.m. She also stated she was not sure why the weekend and Monday posting sheets were not hung up prior to her arrival, explaining they were left for staff over the weekend and the nursing supervisor or floor staff should have hung them up. The DON provided the facility's staffing posting policy, which stated that SNFs and NFs must post daily, at the beginning of each shift, the facility-specific shift schedule for the 24-hour period and the number and category of nursing staff employed or contracted for each 24-hour period, as well as the total number of hours worked by licensed and licensed nursing staff directly responsible for resident care.
Failure to Timely Obtain and Administer Ordered Medications After Admission
Penalty
Summary
The facility failed to ensure that medications were obtained and administered in a timely manner for a newly admitted resident. Upon admission, the resident had physician orders for enoxaparin (an anticoagulant), Humalog (short-acting insulin), and Lantus (long-acting insulin). The Medication Administration Records (MAR) showed that scheduled doses of these medications were not administered as ordered, with documentation indicating to see nurse's notes for the reason. However, progress notes lacked documentation regarding the missed enoxaparin doses, and notes for the missed insulin doses indicated that Humalog and Lantus were not available in the Emergency Drug Kit (EDK) at the time they were needed. The Director of Nursing (DON) confirmed that if residents did not arrive with their medications, staff were expected to use the EDK, which is restocked with regular pharmacy runs. On the dates in question, the EDK was out of stock for Humalog and Lantus, and the available enoxaparin doses did not match the physician's order. The DON was unsure if staff should have contacted the physician regarding alternative dosing with the available enoxaparin. Facility policy required prompt initiation of therapy from the EDK or emergency delivery if needed, but this did not occur, resulting in the resident not receiving ordered medications as scheduled.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature for three residents reviewed for dietary services. Resident C, who was cognitively intact and ate all meals in his room, reported that the food was always cold and not good. Observations revealed that meal trays were delivered on an unheated metal cart, with plates covered only by plastic covers and lacking warming pieces. The Dietary Manager checked the temperature of a test tray after all meals were served and found the barbeque sandwich meat at 107.3°F and baked beans at 117.4°F, both below the facility's policy requirement of 135°F. The Dietary Manager acknowledged there were not enough warming pieces for all trays, especially since most residents preferred to eat in their rooms, and none of the trays on the east wing had warming pieces during the observed lunch service. Additionally, the barbeque meat was noted to be an unnatural bright red color, and there had been complaints about the food's appearance. Resident B, who had moderate cognitive impairment and was on a mechanical soft diet, was reported by a family member to have poor food intake due to the food not being good, with meals also taken in her room. Resident G, cognitively intact, stated that the food was often cold when it arrived. The facility's policy required hot food to be held at 135°F or greater throughout service, which was not met during the observed meal service. These findings were based on interviews, observations, and record reviews, and were related to a specific complaint investigation.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to properly manage food storage and safety protocols, as observed during a kitchen tour. Temperature logs for the walk-in refrigerator and freezer were incomplete, lacking documentation for specific dates. The responsibility for maintaining these logs typically fell to the cook, but due to staffing shortages, this task was neglected. Additionally, thawed raw chicken was found with an outdated label, indicating it should have been discarded. The facility's policy required food to be labeled and dated, with expired items discarded, but this was not consistently followed. Further observations revealed that bread items in dry storage lacked manufacturer expiration dates or received dates. The Dietary Director was unaware of the specific policy regarding this issue, although bread shipments were received weekly and stored in the freezer for up to two weeks. Additionally, boxes of broccoli cuts and sheet cakes were found on the floor of the walk-in freezer, contrary to the facility's policy that required food to be stored at least six inches off the floor. The facility also failed to maintain a testing log for sanitizer concentration levels. A Dietary Assistant demonstrated incorrect testing procedures, initially holding the test strip in the solution for too long and repeating the process multiple times. The Dietary Director acknowledged the absence of a sanitation chemical testing log, although testing was believed to occur throughout the day. The facility's policy required adherence to the manufacturer's recommendations for sanitizer concentration, but this was not consistently monitored or documented.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for two residents, as required by their policy. Resident 19, who was cognitively intact, reported not being invited to or attending a care plan meeting recently. A review of Resident 19's records showed that only one care plan meeting was documented over the past year, despite the requirement for quarterly meetings. The Regional Nurse Consultant confirmed the absence of additional quarterly care plan meetings for Resident 19 and noted the facility's lack of a Social Service Director, which may have contributed to this oversight. Similarly, Resident 30, also cognitively intact, indicated he had not participated in a care plan meeting. His medical records showed only two care plan meetings were conducted from May 2023 to June 2024, failing to meet the quarterly requirement. The facility's policy mandates that comprehensive care plans be reviewed and updated every quarter, but this was not adhered to for Resident 30. The Regional Nurse Consultant provided the facility's policy, which outlines the procedures for scheduling and documenting care plan meetings, highlighting the facility's failure to follow its own guidelines.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to notify a physician of a resident's change in condition related to edema. Resident 46, who has a history of malignant neoplasm of the prostate and atrial fibrillation, was observed multiple times with edema in his bilateral feet and ankles. Despite the resident's observations of swelling and attempts to manage it by elevating his legs, there was no documentation of the physician being notified of this change in condition. The resident's care plan included monitoring for signs of atrial fibrillation, such as edema, but the facility did not follow through with notifying the physician as required. The resident's weight had increased significantly over the last 30 days, yet there was no record of the physician being informed of this weight gain, which was a critical indicator of the resident's condition. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to in the case of Resident 46. Interviews with staff revealed that some were aware of the swelling but did not take appropriate action to notify the physician, leading to a deficiency in the care provided to the resident.
Failure to Supervise Resident Medication Administration
Penalty
Summary
The facility failed to ensure adequate supervision for a resident self-administering medications, leading to a deficiency in accident prevention. During observations, the resident was seen taking medications without a nurse present, and the resident confirmed that nurses often left her medications in her room for her to take alone. The resident's records lacked documentation of an assessment for self-administration of medications, and there was no physician order authorizing self-administration. The resident's medical conditions included nonrheumatic aortic valve stenosis, congestive heart failure, chronic kidney disease, and a need for assistance with personal care. The facility's policy required medications to be administered only by licensed nursing staff and allowed self-administration only when authorized by a physician. Interviews with staff revealed that the nurses were aware of the policy but did not adhere to it, as one nurse left the resident to meet a pharmacy representative. The Regional Nurse Consultant confirmed that medications should not be left with residents without supervision. The facility's failure to follow its own policy and ensure proper supervision resulted in the deficiency.
Deficiency in CPAP Equipment Management and Physician Orders
Penalty
Summary
The facility failed to ensure proper storage and physician orders for a resident's CPAP equipment. During multiple observations, the CPAP machine of a resident with Parkinson's disease and obstructive sleep apnea was found with unbagged and undated tubing and mask. The resident indicated that staff assistance was required for using the CPAP, and the equipment had not been bagged since her admission. The resident's medical record lacked documentation of a physician order specifying the CPAP settings or humidification, despite a care plan indicating the need for CPAP use at bedtime and during naps. Interviews with facility staff revealed a lack of adherence to the facility's policy on CPAP equipment management. An LPN confirmed that the CPAP tubing and mask should have been bagged and dated, and acknowledged the absence of a storage bag in the resident's room. The LPN also noted that the CPAP machine was set at a different level than the resident believed it should be, and the electronic medical record did not include specific settings or humidification orders. The facility's policy required a written physician's order for CPAP therapy, including the level of CPAP and humidification if needed, which was not present in the resident's records.
Lack of Physician Documentation for Medication Continuation
Penalty
Summary
The facility failed to ensure proper physician documentation to justify the continuation of a medication against a pharmacy recommendation for a resident diagnosed with neuromuscular dysfunction of the bladder. The pharmacy had recommended discontinuing Vesicare, a medication used to treat overactive bladder symptoms, but the physician disagreed and simply noted 'Continue med' without providing further justification. This lack of documentation was confirmed during an interview with the Regional Nurse Consultant, who was unable to find any additional physician notes explaining the decision. The facility's policy requires that if a physician disagrees with a pharmacy recommendation, they must document the rationale in the resident's medical record, which was not adhered to in this case.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident with multiple medical conditions, including congestive heart failure, atrial fibrillation, type 2 diabetes, hypertension, hyperlipidemia, and gastro-esophageal reflux disease. The resident's medical record indicated several physician-approved lab tests, such as Digoxin levels, Hemoglobin A1C, BMP, Magnesium levels, Lipid profiles, and CBC, were recommended and ordered at various intervals. However, the record lacked documentation that these tests were completed as ordered. During an interview, the Regional Nurse Consultant confirmed the absence of documentation for the lab results within the specified time frame. The facility's policy, as provided by the Regional Nurse Consultant, indicated that the Director of Nursing was responsible for following up on any nursing actions needed in response to the physician's orders. Despite this policy, the necessary lab tests were not documented as completed, leading to a deficiency in the facility's compliance with physician orders for lab testing.
Infection Control Deficiencies During Meal and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection prevention measures during meal service and medication administration. During meal service observations, a Certified Nurse Aide (CNA) was seen touching her ear and hair and then continuing to pass ice to residents without sanitizing her hands. Additionally, the CNA placed the ice scoop back into the ice bucket instead of the designated container. The CNA also failed to sanitize her hands after adjusting oxygen tubing for one resident before assisting another. The facility's policy required staff to wash their hands before serving food and after assisting residents, which was not followed. During medication administration, a Licensed Practical Nurse (LPN) did not wash her hands between checking the blood sugar of two residents. The facility's policy required hand cleansing before contact with each resident, which was not adhered to. Furthermore, random observations revealed that staff did not wash their hands for the required 20 seconds and turned off the water faucet with bare hands, contrary to the facility's hand hygiene guidelines. These actions were inconsistent with the facility's policies on hand hygiene and infection control.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 130 citations issued within 25 miles in the last 12 months — including the 4 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Envive Of Sullivan | 1.3 mi | ★★★★★ | 3 | 0 |
| Serenity Spring Senior Living At Jasonville | 13 mi | ★★★★★ | 7 | 0 |
| Health Center At Glenburn Home | 13.5 mi | ★★★★★ | 4 | 0 |
| Oak Village | 15.9 mi | ★★★★★ | 15 | 0 |
| Freelandville Community Home | 17.3 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.