Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Spring Hill Care And Rehab during CMS and state inspections, most recent first.
A CNA verbally and physically abused a resident during an overnight room interaction. Video showed the CNA arguing with the resident over the call light and recliner remote, forcefully tugging at the remote and the resident’s hand, and then yelling at the resident after the resident bit the CNA. The CNA rapidly pushed her forearm toward the resident’s head, causing the resident’s head and neck, while in a cervical collar, to bounce off the recliner headrest. Witnesses described the CNA as frustrated and verbally aggressive, and the resident later said she felt scared and abused.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
The facility did not ensure that a resident received both routine and 24-hour emergency dental care as required, resulting in unmet dental needs.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for 36 residents. Instead, a dietary staff member was still in training to become a CDM, and the RD visited only monthly, which did not meet the facility's policy for staffing with appropriate competencies.
The facility did not complete a thorough assessment to determine required staffing levels and resources for competent care during daily operations and emergencies. The assessment lacked details on the number of RNs, LPNs/LVNs, CMAs, and CNAs needed for each unit and shift, and did not address patient acuity or census. Staffing data showed low weekend coverage, and administrative staff confirmed the assessment was incomplete, affecting all residents.
Surveyors found that pressurized oxygen tanks were not secured in a locked area, making them accessible to cognitively impaired, independently mobile residents. Additionally, two residents with severe cognitive impairment and a history of falls did not have required fall prevention interventions in place, such as accessible call lights, fall mats, and nonskid strips, despite these being outlined in their care plans. Staff confirmed knowledge of these requirements, but interventions were not consistently implemented.
Surveyors found that several residents' respiratory equipment, including CPAP masks, a nebulizer mask, and a nasal cannula, were not stored in a sanitary manner, with items left on the floor, draped over machines, or hung on message boards. Additionally, clean linens were transported with bath blankets exposed on top of a covered cart. Staff interviews revealed inconsistent knowledge of proper procedures, and the facility lacked a policy for respiratory equipment storage.
A resident with severe cognitive impairment and incontinence was left in urine-soaked clothing after breakfast and repeatedly called out for help, but staff delayed providing incontinence care for ten minutes despite the resident's visible distress. Staff interviews confirmed that immediate assistance should have been provided to maintain dignity.
A resident with severe dementia and a history of inappropriate sexual behaviors was able to inappropriately touch another cognitively impaired resident in a common area without immediate staff intervention. Despite care plan instructions and staff awareness of the need for supervision, the resident was left unsupervised, resulting in an incident of sexual abuse.
A resident was administered Cymbalta, an antidepressant, without a documented indication for use, despite facility policy and staff expectations that all medications require an indication. The resident had intact cognition and multiple diagnoses, and staff interviews confirmed that orders lacking an indication should be clarified, but this was not done.
A resident with multiple medical conditions and significant care needs was not accurately documented as requiring a CPAP device on the MDS assessment. The resident's care plan and CAA also lacked mention of the CPAP, despite confirmation from staff and medical records of its use. This omission resulted in an incomplete reflection of the resident's status and needs.
A resident with severe cognitive impairment and dysphagia continued to have a care plan listing a therapeutic diet with pureed meat, despite a current dietary order and observed practice of providing a mechanically soft diet with chopped meat. Staff confirmed care plans should be updated to reflect changes, but the care plan was not revised to match the resident's actual dietary needs.
A resident with severe cognitive impairment and dysphagia continued to have a care plan listing a therapeutic diet that did not match the current dietary order, which specified a mechanically soft diet with chopped meat. Staff provided meals according to the updated order, but the care plan was not revised to reflect this change, resulting in a discrepancy between documented and provided care.
A resident with hemiparesis, dementia, and respiratory issues was left lying flat in bed while attempting to eat without staff assistance, and the call light was not within reach. Facility records and staff interviews confirmed that the resident required supervision and setup help with eating, and that call lights should always be accessible, but these protocols were not followed.
Two residents at risk for pressure ulcers did not receive proper use of pressure-reducing equipment and interventions. One resident's low air-loss mattress was set incorrectly and was found deflated, while another resident did not have heel protector boots applied as required, with staff failing to consistently implement these interventions according to care plans and facility policy.
A resident with multiple medical conditions and moderate cognitive impairment had a CPAP mask that was not stored in a sanitary manner, as it was found draped over the machine without a clean barrier or container. Staff interviews revealed inconsistent practices and a lack of clear policy or documentation regarding the cleaning and storage of respiratory equipment.
A resident with severe dementia and a history of falls was not provided with proper supervision or accident prevention measures, as required by her care plan. The call light was found out of reach, and the resident was involved in an incident of inappropriate contact with another resident. Staff confirmed that residents with dementia should have call lights within reach and be frequently monitored, but these measures were not consistently implemented.
A consultant pharmacist did not identify or report missing indications for administration on several medication orders and failed to note the lack of required heart rate monitoring for an antihypertensive medication for a resident with multiple diagnoses. Nursing staff confirmed that all medications should have indications and that physician-ordered monitoring should be followed, but these requirements were not met or reported as irregularities by the pharmacist.
A resident was administered antihypertensive and other medications without documented indications, and required heart rate monitoring was not consistently performed as ordered by the physician. Pharmacy reviews and facility documentation failed to identify or address these issues, and staff interviews confirmed that medication indications and monitoring parameters were not followed as required.
A resident with severe cognitive impairment and multiple diagnoses was receiving hospice services, but the facility failed to document the medications and equipment provided by hospice in the care plan. Staff interviews confirmed that this information should have been included and accessible, but it was missing, contrary to facility policy and expectations.
The facility did not post its updated daily nurse staffing sheet as required, with the most recent form displayed being several days old. Staff interviews confirmed that nursing staff and the charge nurse were responsible for this task, but the daily update was not completed according to facility policy.
The facility did not submit accurate weekend staffing coverage hours to CMS through Payroll Based Journaling, despite internal records showing no staffing gaps. Staff interviews revealed mixed perceptions about weekend staffing adequacy, and administrative staff acknowledged occasional gaps and the use of incentives for shift coverage. The facility's assessment also lacked specific staffing requirements for each unit and shift.
CNA verbally and physically abused resident during overnight care interaction
Penalty
Summary
The facility failed to ensure a resident remained free from staff-to-resident abuse when a CNA verbally, mentally, and physically abused the resident during an overnight interaction in the resident’s room. The resident had diagnoses including a displaced fracture of the first cervical vertebra, bilateral hearing loss, dementia, and Parkinson’s disease. Records showed the resident had intact cognition on MDS assessments, moderate hearing difficulty, and required assistance with transfers and most ADLs. The care plan addressed the resident’s communication needs related to hearing loss and her need for assistance with transfers. Video reviewed by the facility showed the CNA entering the resident’s room while the resident sat in a recliner wearing a cervical collar. The CNA told the resident they were done with her pushing the call light, argued with her when she said it was her right, and repeatedly attempted to control the resident’s recliner remote and movement. The resident resisted by holding the remote and tugging on it, and the CNA continued to pull at the remote and the resident’s hand while telling her to stop and that they had the right to do what they were doing. The resident then leaned forward and bit the CNA’s shoulder. After being bitten, the CNA yelled at the resident, jerked upward, and rapidly pushed her forearm toward the resident’s head while the resident’s head and neck, still in the cervical brace, bounced off the recliner headrest. The CNA continued yelling at the resident, including calling her a two-year-old, while holding the resident’s hand and speaking loudly into her face. Witness statements and interviews described the CNA as frustrated, forceful, and verbally aggressive, and staff reported that no one immediately reported the incident to administrative staff. The resident later stated she felt scared, felt the CNA acted abusively, and cried while recounting the event.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for each resident as required. This deficiency indicates that residents did not have access to necessary dental services, both for regular care and urgent dental needs, as stipulated by regulations. No additional details about specific residents, their medical history, or the circumstances at the time of the deficiency are provided in the report.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its census of 36 residents who received meals from the kitchen. At the time of the survey, the dietary staff member responsible for managing food and nutrition services was still in training to become a Certified Dietary Manager (CDM), and the Registered Dietician (RD) only visited the facility monthly. The facility's own policy required sufficient staff with appropriate competencies and skill sets to carry out food and nutrition service functions, but this standard was not met as there was no full-time certified dietary manager on staff.
Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by administrative staff was last updated in December 2024 and did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details on staffing requirements for each shift, day, and weekend. A review of the facility's Payroll Based Journaling (PBJ) staffing data revealed excessively low weekend staffing during two consecutive quarters. Interviews with administrative staff confirmed that the assessment was recently updated but still did not include the necessary staffing requirements as outlined by CMS. The facility's own policy, revised in January 2017, requires a documented assessment to determine resources needed for care during all operational periods, including evenings, nights, and weekends. This deficiency affected all 36 residents in the facility.
Failure to Secure Oxygen Tanks and Implement Fall Interventions
Penalty
Summary
Surveyors identified that the facility failed to secure pressurized supplemental oxygen tanks in a locked area, leaving 35 oxygen cylinders accessible in an unsecured storage room. The room had a key lock, but it was not secured at the time of observation, making the tanks accessible to 22 cognitively impaired, independently mobile residents. Staff interviews confirmed that facility policy required oxygen tanks to be stored in a locked room, and all interviewed staff acknowledged this expectation. Additionally, the facility did not ensure that fall prevention interventions were in place for two residents with severe cognitive impairment and significant physical limitations. One resident, with diagnoses including dementia, major depressive disorder, and a history of hip fracture, was found in bed with her call light on the floor and her fall mat folded and not in use. Her care plan required the call light to be within reach and the fall mat to be in place. Another resident, also with severe cognitive impairment and a history of falls, was observed with her call light on the floor, her fall mat folded at the head of the bed, and no nonskid strips in her bathroom, despite these being specified interventions in her care plan. Staff interviews revealed that all nursing staff had access to care plans and were responsible for ensuring fall interventions were in place before leaving a resident's room. Facility policy required staff to implement individualized fall prevention measures based on each resident's risk factors. Despite these policies and staff awareness, required interventions were not consistently implemented for the residents reviewed.
Failure to Maintain Sanitary Storage of Respiratory Equipment and Linens
Penalty
Summary
Surveyors identified that the facility failed to store respiratory equipment for four residents in a sanitary manner. Specifically, one resident's CPAP mask was draped over the CPAP machine without a clean barrier or sanitary container, another resident's CPAP mask was found on the floor next to the bed, and a third resident's nebulizer mask was hung from a thumb tack on a message board. Additionally, a fourth resident's nasal cannula was draped over a wheelchair without proper containment. These observations were made during a facility walkthrough and were confirmed by staff interviews, which revealed inconsistent knowledge and practices regarding the proper storage of respiratory equipment. The facility also failed to transport linens in a sanitary manner, as observed when laundry staff moved a covered linen cart with bath blankets placed on top, exposing them to potential contamination. Staff interviews indicated uncertainty and lack of clarity regarding the correct procedures for both respiratory equipment storage and linen transport. Furthermore, the facility did not provide a policy for respiratory equipment storage, although a policy for handling clean linen was available, which required clean laundry to be handled in a way that prevents contamination.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with severe cognitive impairment, dementia, benign prostatic hyperplasia, dysphagia, and anxiety disorder was dependent on staff for all activities of daily living, including toileting and personal hygiene. The resident was always incontinent of bowel and bladder and had a care plan in place requiring staff to provide incontinence care every two hours and as needed, as well as to respond promptly when the resident was found to be incontinent. The resident also required cueing and set-up assistance during meals and was at risk for nutritional impairment. On the morning of the incident, the resident was observed in the dining room with urine-soaked pants extending down to the knees after breakfast. The resident approached staff, repeatedly stating he was sticky and needed help, but was asked to sit and wait next to the nurses' cart. Multiple staff members walked past as the resident continued to call out for assistance and stood up several times while waiting. It was not until ten minutes later that the resident was finally escorted to his room for care. Interviews with staff confirmed that incontinence care should have been provided immediately to maintain dignity and prevent discomfort, in accordance with the facility's dignity policy.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse involving two cognitively impaired residents. One resident, who had a diagnosis of dementia, severe cognitive impairment, and a history of inappropriate sexual behaviors, was observed by a licensed nurse groping another severely cognitively impaired resident in a common area. The care plan for the resident with a history of sexual behaviors included instructions for staff to supervise him, monitor his behaviors, and intervene as necessary to protect others, but these interventions were not effectively implemented at the time of the incident. Staff interviews confirmed that residents with behavioral concerns were not to be left unsupervised with others, and that the resident in question required supervision due to his history. Despite documented behavioral risks and care plan interventions, the resident was able to access and inappropriately touch another resident without immediate staff intervention. Both residents involved were unable to recall the incident due to their cognitive impairments. The facility's abuse prevention policy required staff to recognize and report abuse and to manage behavioral symptoms in residents at risk, but the failure to supervise the resident as outlined in his care plan resulted in an episode of preventable abuse.
Psychotropic Medication Administered Without Indication
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication, specifically Cymbalta (an antidepressant), had an appropriate indication for administration as required. Review of the resident's electronic medical record showed an active order for Cymbalta without a documented reason for its use. The resident's diagnoses included hypertension, major depressive disorder, gallbladder calculus, and diabetes mellitus. Both annual and quarterly Minimum Data Set (MDS) assessments indicated the resident had intact cognition and was receiving multiple classes of medications, including psychotropics. The care plan documented staff education on proper medication administration, but did not address the lack of indication for the psychotropic medication order. Interviews with facility staff confirmed that every medication order should include an indication for use, and that orders lacking this information should be clarified. The facility's policy on chemical restraints and unnecessary psychotropic medications required that such medications only be used to treat specific medical symptoms and not for staff convenience or discipline. Despite these policies and staff expectations, the resident continued to receive Cymbalta without a documented indication, constituting a failure to comply with regulatory requirements for medication management.
Failure to Document CPAP Use on MDS Assessment
Penalty
Summary
The facility failed to accurately document a resident's use of a continuous positive airway pressure (CPAP) device on the comprehensive Minimum Data Set (MDS) assessment. The resident, who had a history of acquired absence of the right foot, sacral pressure ulcer, hematogenous osteomyelitis, lack of coordination, muscle weakness, and anxiety, was admitted with multiple care needs and required significant assistance with activities of daily living. The MDS assessment did not indicate the resident's need for a CPAP, despite the resident's medical record and staff interview confirming its use. Further review of the resident's care plan and Care Area Assessment (CAA) showed no mention of the CPAP device, even though the resident was dependent on staff for most care and had complex medical conditions. The facility's comprehensive assessment policy required accurate and timely assessments reflective of the resident's status, but this was not met in the case of the CPAP documentation. An administrative nurse confirmed that all CPAPs should be indicated on the MDS, highlighting the omission.
Failure to Update Care Plan to Reflect Current Dietary Orders
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple medical diagnoses, including BPH, anxiety disorder, dysphagia, and dementia, to accurately reflect his current dietary needs. The resident's care plan, initiated in 2022, indicated a regular, mechanically soft diet with pureed meat texture and thin liquids due to swallowing difficulties. However, the active dietary order in the electronic medical record, dated later, specified a regular, mechanically soft diet with chopped meat texture. During observation, the resident was provided a meal with chopped meat consistency and consumed it without swallowing concerns, but the care plan was not updated to match this change. Interviews with nursing staff and administrative personnel confirmed that care plans are intended to be updated quarterly or as changes occur, and should accurately reflect each resident's current care needs, including diet type and consistency. The facility's policy requires comprehensive assessments and individualized interventions, with care plans reviewed and updated to reflect any changes. Despite these procedures, the resident's care plan was not revised to remove the therapeutic diet, resulting in a discrepancy between the care plan and the actual dietary order provided.
Failure to Update Care Plan for Dietary Changes
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple medical diagnoses, including benign prostatic hyperplasia, anxiety disorder, dysphagia, and dementia, to accurately reflect his current dietary needs. The resident's care plan, initiated in 2022, continued to indicate a regular, mechanically soft diet with pureed meat texture and thin liquids, despite an active dietary order from May 2025 specifying a regular, mechanically soft diet with chopped meat texture. Observations confirmed that the resident was provided and consumed a chopped meat consistency meal without swallowing concerns, but the care plan was not updated to match this change. Interviews with nursing staff and administrative personnel revealed that care plans were intended to be updated quarterly or as changes occurred, and that all staff had access to view and review these plans. The facility's policy required care plans to be individualized and updated to reflect any changes in the resident's goals and care needs. However, the failure to revise the care plan to remove the therapeutic diet and accurately document the current dietary order resulted in a discrepancy between the resident's actual care and the documented plan.
Failure to Provide Assistance with Eating and Ensure Call Light Accessibility
Penalty
Summary
A deficiency was identified when a resident with a history of hemiparesis following a cerebrovascular accident, pulmonary edema, dementia, and other significant medical conditions did not receive appropriate assistance with eating and did not have their call light within reach. The resident was observed lying flat in bed while attempting to eat oatmeal without staff assistance, despite physician orders to keep the head of the bed elevated due to respiratory failure and pulmonary edema. The call light was found wrapped around the trapeze arm, out of the resident's reach, and no staff were present to monitor or assist during the meal. Facility records indicated that the resident required supervision and setup or cleanup assistance with eating, and was dependent on staff for all other activities of daily living. Interviews with nursing staff confirmed that call lights should always be within reach and that residents should not be laid flat while eating. The facility's policy also required staff to assist residents unable to perform activities of daily living. Despite these requirements, the resident was left unattended, in a flat position, and without access to the call light during mealtime.
Failure to Implement and Monitor Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure proper use of pressure-reducing equipment and interventions for two residents at risk for pressure ulcers. One resident, with a history of pressure ulcers, limited mobility, and a low body weight, was observed with her low air-loss mattress set incorrectly at a much higher weight than her actual weight and, on one occasion, with the mattress deflated and the control panel turned off. Staff interviews revealed uncertainty about why the mattress was off and inconsistent practices regarding checking and setting the mattress according to the resident's weight, despite facility policy requiring these checks each shift. Another resident, who was dependent on staff for all activities of daily living and had multiple medical conditions including hemiparesis, dementia, and a history of skin breakdown, was observed multiple times lying in bed with his heels directly on the mattress, despite care plan instructions and physician orders for the use of heel protector boots to offload pressure. The boots were found on the bed or bedside table rather than on the resident. Staff interviews indicated that both nurses and CNAs were aware of the need to float the resident's heels or apply boots, but the intervention was not consistently implemented. The facility's policies required identification and implementation of preventative interventions for residents at risk for pressure injuries, as well as ongoing monitoring to ensure effective prevention and care. However, the observed failures to use pressure-relieving devices as intended and to follow care plan interventions for both residents constituted deficiencies in pressure ulcer prevention and care.
Failure to Store CPAP Mask in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the continuous positive airway pressure (CPAP) mask for a resident was stored in a sanitary manner. The resident had multiple medical conditions, including an acquired absence of the right foot, pressure ulcer, osteomyelitis, muscle weakness, and moderately impaired cognition. The resident was dependent on staff for most activities of daily living and used a wheelchair. Despite the resident's complex medical needs, the care plan and electronic medical record did not include instructions for the use, cleaning, or sanitary storage of the CPAP device. During observation, the CPAP mask was found draped over the CPAP machine without a clean barrier or sanitary container. Interviews with nursing staff revealed inconsistent knowledge and practices regarding the proper storage of respiratory equipment, with some staff stating the mask should be placed in a plastic bag or drawer, and others indicating it was the responsibility of nursing staff to ensure sanitary storage. The facility did not have a respiratory storage policy available.
Failure to Provide Adequate Supervision and Accident Prevention for Resident with Dementia
Penalty
Summary
A resident with a diagnosis of dementia, severe cognitive impairment (BIMS score of zero), history of falls, muscle weakness, and other comorbidities was not provided with appropriate supervision and accident prevention services. The resident's care plan required that the call light be kept within reach and the door remain open for easier monitoring due to a history of unassisted walking and falls. However, observations revealed that the call light was found on the floor and not within the resident's reach, contrary to the care plan and facility policy. Staff interviews confirmed that call lights should always be accessible to residents with dementia and that such residents require frequent monitoring. Additionally, an incident occurred in which the resident was found in a common area with another resident who was observed groping her breast. Both residents were immediately separated, and neither recalled the incident when interviewed. The facility's documentation and staff statements indicated that the resident with dementia was severely impaired and unable to understand or communicate effectively, further emphasizing the need for close supervision. The failure to ensure the resident's call light was accessible and to provide adequate supervision placed the resident at risk for preventable accidents and incidents.
Consultant Pharmacist Failed to Identify and Report Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in a resident's medication regimen. Specifically, the CP did not note the absence of indications for administration on physician orders for several medications, including Ursodiol, Tamsulosin, and Cymbalta. Additionally, the CP did not identify or report that the physician's order for Metoprolol, an antihypertensive medication, required heart rate monitoring prior to administration, and that this monitoring was not documented as completed for 61 out of 100 days reviewed. The Monthly Medication Reviews (MMRs) over a one-year period did not reflect that these irregularities were identified or reported by the CP. The resident involved had diagnoses including hypertension, major depressive disorder, gallbladder calculus, and diabetes mellitus, and was receiving multiple classes of medications such as anticoagulants, antidepressants, antianxiety agents, antiplatelets, diuretics, opioids, and hypoglycemics. Interviews with nursing staff confirmed that all medications should have an indication for administration and that specific monitoring parameters ordered by the physician should be followed. The facility's policy required the CP to review medication regimens and report irregularities, but this was not done in the case reviewed.
Failure to Ensure Physician Parameters and Indications for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not following physician parameters for a prescribed antihypertensive medication and by administering medications without documented indications. Specifically, the resident’s electronic medical record showed orders for Ursodiol and Tamsulosin that lacked indications for administration. Additionally, the order for Metoprolol succinate, an antihypertensive, included a directive to hold the medication if the systolic blood pressure was less than 110 mm Hg or the heart rate was less than 60 beats per minute, but there was no evidence that heart rate monitoring was consistently performed as ordered. Review of the resident’s Medication Administration Record and other documentation over a 100-day period revealed that heart monitoring was not documented for 61 days, despite the physician’s order requiring it prior to administration of Metoprolol. The Monthly Medication Reviews from the pharmacy also failed to identify or address the lack of indications for certain medications and the absence of required heart monitoring for the antihypertensive medication. The care plan and facility policy required staff to administer medications as ordered and to ensure every medication had an appropriate indication, but these requirements were not met in this case. Interviews with nursing staff and administration confirmed that all medications should have a documented indication and that physician parameters, such as heart rate monitoring, should be followed. Despite these expectations and policies, the facility did not ensure compliance, resulting in the administration of medications without proper indications and without following monitoring parameters as ordered by the physician.
Failure to Document Hospice-Provided Medications and Equipment
Penalty
Summary
The facility failed to provide a description of the medication and equipment supplied by hospice for a resident receiving hospice services. The resident, who had diagnoses including dementia, major depressive disorder, and cognitive communication deficit, was documented as being severely cognitively impaired and dependent on staff for mobility and personal care. The care plan indicated that hospice would provide nursing visits, a bath aide, social services, and chaplain visits, but did not specify the medications and equipment provided by hospice. Staff interviews revealed that information about hospice services should be included in the resident's care plan and accessible to all staff, but this information was missing. Observations and record reviews confirmed that the hospice provider supplied a notebook for each hospice resident, but the care plan lacked details about the specific services, supplies, and equipment provided by hospice. Staff members, including a licensed nurse and a CNA, stated that the care plan should include this information, and the administrative nurse confirmed that all staff should have access to it. The facility's policy required coordination and documentation of hospice services, but this was not followed, resulting in incomplete information in the resident's care plan.
Failure to Post Updated Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post its updated daily nurse staffing information as required. During an inspection, the Direct Care Report form displayed across from the nurse's station was found to be dated three days prior to the inspection date, indicating it had not been updated daily. Interviews with a licensed nurse and an administrative nurse confirmed that nursing staff and the charge nurse were responsible for updating and posting the staffing form each day. A review of the facility's staffing policy indicated that staffing hours must be maintained and made available upon request, but the daily posting requirement was not met at the time of the survey.
Failure to Accurately Report Weekend Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ), specifically regarding weekend staffing coverage hours. Although the facility's internal records, including working schedules, time sheets, and posted staffing hours, showed no gaps or loss of hours, the PBJ data submitted for two consecutive fiscal quarters triggered for excessively low weekend staffing. Interviews with staff indicated that while some did not perceive issues with weekend staffing, administrative staff acknowledged occasional gaps and the use of incentives or shift coverage to address open positions. The administrator noted a recent switch to a new tracking system and stated that the facility had been triggered for low weekend staffing multiple times despite being adequately staffed according to their records. Additionally, the facility's most recent Facility Assessment did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed per unit, patient acuity, or census. The assessment also lacked details on staffing levels required for each shift, day, and weekend. The facility's policy requires that staffing and census information be reported electronically to CMS and made available to residents, family members, and the public within 24 hours of a request.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 497 citations issued within 25 miles in the last 12 months — including the 16 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 Spring Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hoeger House | 7.3 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Olathe | 7.6 mi | ★★★★★ | 10 | 0 |
| The Healthcare Resort Of Olathe | 7.6 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Rehabilitation Hospital | 7.7 mi | ★★★★★ | 21 | 1 |
| Azria Health Olathe | 8.4 mi | ★★★★★ | 28 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spring Hill Care And Rehab.
100% money-back within 48 hours.
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.