Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Estates Of Spanish Lake, The during CMS and state inspections, most recent first.
The facility did not have an RN on duty for at least 8 hours each day, 7 days a week, as required. The DON was the only RN and was only available on-call, with no RNs scheduled on daily assignment sheets. This affected a census of 140 residents.
The facility did not immediately intervene when a resident with a history of suicidal ideation expressed a desire to commit suicide, resulting in a delay in assessment and supervision. Staff failed to remain with the resident or promptly notify a nurse, and there were gaps in behavioral health follow-up and documentation. Additionally, another resident exhibiting agitation and elopement risk was not appropriately redirected or engaged, contrary to their care plan.
A resident with a history of suicidal ideation and multiple recent suicide attempts did not receive consistent or documented psychosocial support or medically related social services. After returning from hospitalizations, the resident expressed ongoing distress and a desire for counseling, but staff responses were delayed and uncoordinated. Social Services Designees lacked qualifications and training, and the facility had no qualified social worker or outside behavioral health services, resulting in unmet psychosocial needs.
Surveyors found that multiple opened vials and pens of insulin and PPD were not properly labeled or dated, with some medications being expired or improperly stored. Medication refrigerator temperature logs were incomplete, and an Environmental Aide was able to access the medication room unsupervised using keys kept in the nurses' station. These findings indicate failures in medication labeling, storage, and access control.
The facility did not ensure that two residents' code status was properly documented and accurately reflected in their medical records. One resident had no code status or physician's order documented at admission due to the absence of a social worker, while another had conflicting information in the electronic record and code status form regarding DNR status. The DON confirmed that code status should be completed and accurate for all residents, but this was not done in these cases.
Three residents did not receive the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter when their Medicare Part A skilled services ended. Medical record reviews confirmed the absence of these notifications, and staff interviews revealed confusion over who was responsible for issuing them.
The facility did not repair damaged ceilings and water stains in two residents' bathroom, leaving plaster and paint hanging down and a large water stain unaddressed for several days, despite residents and staff being aware of the issue. Additionally, a resident's bedroom door repeatedly slammed shut and would not stay open, causing disturbances, with staff aware of the malfunction but not reporting it to maintenance in a timely manner.
A resident with a history of mental health conditions reported to a CNA that another resident had entered their room and touched their genitalia while they were sleeping. The CNA reported the allegation to a nurse, who documented the resident's account, which included some uncertainty and changes in the details. The facility did not notify the State Survey Agency within the required two-hour timeframe after the allegation was made, as the report was not submitted until several hours later.
A resident with depression and schizophrenia, who was receiving psychotropic medications, did not have a required PASRR Level II evaluation completed after the Level I screening indicated it was necessary. Only the Level I documentation was found in the medical record, and facility leadership confirmed the Level II assessment was missing.
The facility did not update care plans to reflect the current needs of three residents, including one with recent suicide attempts, one receiving dialysis, and one requiring discharge planning. Care plans failed to include recent hospitalizations, dialysis care, and discharge planning, despite staff acknowledging these omissions.
Staff did not transcribe a physician's order for a urine analysis and culture for a resident with a history of UTIs, resulting in the tests not being performed. Additionally, another resident received continuous oxygen therapy without a physician order, despite multiple documented episodes of respiratory distress and staff acknowledgment that an order was required.
Staff failed to consistently assess and document dialysis access sites and vital signs for two residents receiving dialysis, did not complete required communication forms, lacked a physician order for dialysis for one resident, and did not have contracts with dialysis providers. Interviews with nursing staff and the DON confirmed these lapses in following facility policy and documentation procedures.
Two residents did not receive or have properly documented administration of medications, pain and behavior monitoring, weekly skin assessments, and blood pressure checks as ordered. Records showed multiple missed or undocumented doses and assessments, with blanks on the MAR and TAR and no corresponding explanations in progress notes. Staff interviews confirmed that all care should be documented at the time of administration, but facility policies were not followed, resulting in incomplete records.
A facility failed to report an alleged abuse incident involving two residents, leading to a delayed investigation. The Social Service Designee did not inform her supervisor or the Administrator after being told by a CNA about witnessing an inappropriate interaction between the residents, who are siblings with mental health diagnoses. The Director of Social Services assumed the incident was reported, and the Administrator was unaware until questioned by surveyors.
The facility failed to ensure call lights were accessible to residents, affecting five residents who were unable to reach their call lights due to mobility or cognitive impairments. Observations and interviews revealed that call lights were often out of reach, leading residents to yell for help. The facility lacked a call light policy, and staff acknowledged the issue but did not consistently ensure call lights were within reach.
A resident with chronic pain and other conditions did not receive prescribed Lidocaine patches on multiple occasions due to unavailability. Staff failed to reorder the medication or notify the PCP, despite the facility's emergency kit containing the patches. The deficiency in care was identified through interviews and record reviews.
A resident at high risk for pressure ulcers did not receive proper care and documentation, leading to deficiencies in weekly skin and wound assessments and treatment applications. The facility's wound reports were inaccurate, and staff failed to adhere to policies, putting the resident at risk for complications.
A resident with a colostomy experienced complications due to the facility's failure to provide proper care and documentation. Despite the resident's complaints of pain and improper fitting of colostomy bags, the facility lacked a documented care plan and failed to apply prescribed treatments. The resident had to call 911 for assistance, leading to multiple emergency department visits. Interviews revealed that the resident was changing their own colostomy apparatus, contrary to the facility's expectations.
Failure to Provide RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by policy. Review of the daily assignment sheets over a period of more than a month showed that no RNs were scheduled during this time. The Director of Nursing (DON) confirmed in an interview that she was the only RN on staff and was only available on-call as needed, rather than being present in the facility for the required hours. The facility census at the time was 140 residents. The Administrator also acknowledged the expectation to have an RN present for at least eight hours daily, seven days a week, but this was not being met.
Failure to Immediately Intervene for Suicidal Ideation and Behavioral Health Needs
Penalty
Summary
The facility failed to immediately intervene when a resident with a recent history of suicidal ideation and multiple suicide attempts expressed a desire to commit suicide. Despite the facility's policy requiring that residents expressing suicidal tendencies not be left unattended and that staff immediately notify a nurse, there was a significant delay in response. On one occasion, the resident was observed crying and stating a wish to kill themselves, but staff did not remain with the resident or promptly assess their condition. The environmental aide informed the nurse, who was on a phone call and did not immediately check on the resident. The resident remained alone, crying and expressing suicidal thoughts, for over fifteen minutes before a nurse arrived and eventually arranged for hospital transport. The resident had a documented history of depression, anxiety, schizophrenia, and previous suicide attempts, including overdosing and attempting to strangle themselves. The care plan indicated the need for close monitoring and immediate intervention if the resident posed a threat to themselves. However, documentation showed gaps in psychosocial follow-up and a lack of consistent behavioral health services. Staff interviews revealed uncertainty about the frequency and type of behavioral health services provided, and the social services designee admitted to not documenting therapy sessions and being unsure of their own qualifications to provide therapy or assess safety for discontinuing one-on-one monitoring. Additionally, the facility failed to address the behavioral needs of another resident who became agitated and left a secured unit. Staff did not offer alternative activities or explanations, and the resident was left pacing and expressing agitation after being redirected back to the unit. The care plan for this resident identified them as an elopement risk and required interventions to distract and redirect, but these were not implemented during the observed incident. Interviews with the administrator and DON confirmed that staff did not follow expected procedures for managing agitation and supervision.
Failure to Provide Medically Related Social Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to support a resident with a known history of suicidal ideation, resulting in a lack of appropriate person-centered care to meet the resident's highest practical psychosocial well-being. The resident had a documented history of suicide attempts, including overdosing and attempting to strangle themselves, and was diagnosed with anxiety and schizophrenia. The care plan identified suicide risk and outlined interventions such as monitoring, notification of the physician and power of attorney, and redirection to activities. Despite these documented needs, there were significant lapses in the provision and documentation of social services and psychosocial support. After returning from multiple hospitalizations for suicide attempts, the resident did not receive consistent or documented social services follow-up. Progress notes showed gaps in psychosocial or social services documentation, with no entries between key incidents. The resident expressed ongoing distress, including crying, stating a desire to harm themselves, and reporting a lack of access to group or individual counseling. During an observation, the resident was found in bed, crying, and expressing suicidal ideation, but staff response was delayed and uncoordinated. The Social Services Designee present did not check on the resident and deferred to nursing staff, who also did not provide immediate support or intervention. Interviews with staff revealed that Social Services Designees were not qualified to provide medically related social services and had not received formal training in managing residents with suicidal ideation. The facility had been without a qualified social worker for several months, and outside behavioral health services were no longer available. Staff were unclear about the interventions in place for the resident and did not consistently document or provide the required psychosocial support, resulting in a failure to meet the resident's psychosocial needs as outlined in their care plan.
Medication Labeling, Storage, and Access Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices, specifically regarding the labeling and storage of drugs and biologicals. Observations revealed that several opened vials and pens of insulin (Levemir, Lantus, Lispro) and Tuberculin Purified Protein Derivative (PPD) were found in medication carts and rooms without proper labeling or dating. In some cases, staff were unable to identify the owner of the medication or when it had been opened, and some medications were found to be expired. Additionally, an opened and unlabeled bottle of an over-the-counter antifungal medication was found, and a Lispro insulin pen was improperly stored on a shelf instead of in the refrigerator or medication cart as required. Temperature monitoring of medication refrigerators was also deficient. The temperature log for the medication refrigerator showed multiple dates with missing documentation of temperature readings and staff signatures. The Assistant Director of Nursing (ADON) stated that housekeepers were responsible for monitoring refrigerator temperatures, but acknowledged that they may not have had pens to record the readings, resulting in incomplete logs. This practice deviated from the facility's policy, which required daily temperature documentation by nursing staff. Access to medication rooms was not restricted to authorized personnel. An Environmental Aide (EA) was observed obtaining keys from a nurses' station drawer and entering the medication room unsupervised to retrieve residents' cigarettes. The EA reported that this had been standard practice since employment, with keys always accessible in the nurses' station. The Director of Nursing (DON) confirmed that only nurses and Certified Medication Technicians (CMTs) should have access to medication rooms, and non-licensed staff should not enter these areas.
Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to ensure that residents' code status was properly documented and accurately reflected in their medical records, as required by facility policy. For one resident, who was cognitively intact and had multiple diagnoses including high blood pressure, hemiplegia, traumatic brain injury, and psychiatric conditions, there was no code status indicated in the electronic medical record and no physician's order for code status at the time of admission. The Director of Nursing confirmed that the social worker was responsible for completing the initial code status sheet, but since there was no social worker present during the resident's admission, the code status was not completed. Staff were expected to treat the resident as full code until the code status was clarified and completed. For another resident, also cognitively intact and with significant medical conditions such as heart failure, renal insufficiency, diabetes, and chronic lung disease, there was a discrepancy between the code status documented in different parts of the medical record. The computer system and care plan indicated the resident was full code, while the code status decision form, signed and dated, indicated the resident was DNR (Do Not Resuscitate). An LPN confirmed the inconsistency and stated that, in the event of an emergency, the resident would be treated as DNR based on the form, but also acknowledged the need to clarify the code status order due to the conflicting documentation. The facility's policy requires that code status be determined and documented upon admission, with communication to the interdisciplinary team and regular review during care plan conferences. The Director of Nursing stated an expectation that code status should be completed and accurate for all residents. The failure to complete and accurately document code status for these residents represents a deficiency in honoring residents' rights to make informed decisions about their care.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide required written notification to residents regarding the initiation, reduction, or termination of Medicare Part A benefits. Specifically, three residents who remained in the facility after their Medicare Part A skilled services ended did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter, as mandated by CMS guidelines. Medical record reviews confirmed that for each of these residents, there was no documentation of the SNFABN form being issued at the appropriate time. Interviews with facility staff revealed a lack of clarity regarding responsibility for issuing the SNFABN. The MDS Nurse stated that Social Services previously handled the notifications, but she had since assumed responsibility and was unaware that the forms had not been completed for all applicable residents. The Administrator and DON both indicated that they expected the SNFABN to be completed after a resident's discharge from Medicare Part A, but this was not consistently done.
Failure to Maintain Homelike Environment Due to Unrepaired Ceiling Damage and Malfunctioning Door
Penalty
Summary
The facility failed to maintain a homelike environment for its residents by not repairing damaged ceilings and water stains in resident bathrooms over a period of several days. Specifically, two residents' shared bathroom had a damaged ceiling with plaster and paint hanging down, as well as a large water stain on the wall. Both residents reported that the ceiling had been in disrepair for months, and although staff had acknowledged the issue and stated it would be fixed, no repairs had been made. One resident also reported that the ceiling sometimes leaked, and maintenance staff had inspected it but had not completed any repairs. Additionally, the facility did not ensure that a resident's bedroom door was in proper working condition. The door would not remain open and slammed shut loudly, disturbing the resident and their roommate. The resident stated that the door had been malfunctioning for a while, causing sleep disturbances, and staff were aware of the issue but had not addressed it. Staff interviews confirmed awareness of the malfunctioning door, and maintenance leadership stated they had only recently become aware of the problem, despite staff being expected to report such issues.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to notify the State Survey Agency within the required two-hour timeframe after an allegation of sexual abuse was made by a resident. According to the facility's policy, all allegations or suspicions of abuse, neglect, or exploitation must be reported immediately to the Administrator and the State Agency. In this incident, a resident reported to a CNA that another resident had entered their room and touched their genitalia while they were sleeping. The CNA promptly reported the allegation to the nurse, who then documented the resident's account, which included some uncertainty about the details due to the resident's confusion and distress. The resident involved was cognitively intact and able to express themselves clearly, with a history of mental health diagnoses including anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The incident was described as causing the resident significant distress, particularly because it resembled a previous event at another facility. The nurse's documentation noted inconsistencies in the resident's account, as the resident changed details about the incident multiple times before and after emergency services were contacted. Despite the facility's policy requiring immediate reporting, the self-report to the State Agency was not made until the following morning, several hours after the initial allegation was brought to staff attention. The DON confirmed that the report was made within two hours of her being notified, but the initial delay in escalating the allegation to the DON resulted in the facility failing to meet the required reporting timeframe.
Failure to Complete Required PASRR Level II Evaluation for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder received a required DA-124 Level II evaluation (PASRR Level II) after a Level I screening indicated the need for further assessment. The facility's policy states that prior to admission, the DA-124 is completed, and if a Level II is triggered, the assessment should be completed and reviewed to determine if the facility can meet the resident's needs. The Level II/PASRR is then to be placed in the resident's medical record and used to develop an individualized care plan. For the resident in question, who had diagnoses of depression and schizophrenia and was receiving antidepressant and antipsychotic medications, the DA-124 Level I screening indicated a Level II was required. However, upon review, only the Level I documentation was available in the resident's record, and the Administrator confirmed that the Level II evaluation was not present. Both the Administrator and the DON acknowledged that the Level II should have been completed as required.
Care Plans Not Updated to Reflect Resident Needs
Penalty
Summary
The facility failed to ensure that resident care plans were updated and accurate to reflect the current needs of three residents. For one resident with a history of suicide attempts, the care plan did not include information about recent hospitalizations for suicide ideation and self-harming behaviors, despite documented incidents where the resident attempted to harm themselves and required emergency intervention and hospitalization. The care plan remained unchanged after these significant events, and staff interviews confirmed that these incidents should have been reflected in the care plan. Another resident, who was cognitively intact and diagnosed with end stage renal disease, received regular dialysis treatments as ordered by a physician. However, the resident's care plan did not address dialysis care, monitoring of the access site, or emergency procedures related to dialysis. Staff responsible for care plan updates acknowledged that dialysis should have been included as a focus area but was omitted due to oversight. A third resident, with moderate cognitive impairment and multiple diagnoses including schizophrenia and COPD, had no documentation in the care plan regarding discharge planning, despite the need for such planning. Staff interviews confirmed that care plans are expected to be updated quarterly and with significant changes, and that information regarding dialysis, discharge planning, and suicide ideation should have been included for these residents. The care plans in use at the time of the survey did not accurately reflect these residents' current needs.
Failure to Transcribe Physician Orders and Obtain Required Orders for Oxygen Therapy
Penalty
Summary
Staff failed to ensure that services provided met professional standards of care in two separate instances. For one resident with a history of urinary tract infections (UTIs), a physician ordered a urine analysis (UA) and culture and sensitivity (C/S) test after the resident complained of pelvic pain and dysuria. However, the order was not transcribed into the computer system, and there was no documentation that the urine was collected or that the physician was notified of any results. The resident's care plan indicated ongoing antibiotic therapy and monitoring for UTIs, but the required diagnostic tests were not obtained as ordered. In a second instance, another resident who was cognitively intact and had diagnoses including chronic lung disease was observed receiving continuous oxygen therapy via nasal cannula at varying flow rates. Despite this, there was no physician order for oxygen therapy in the resident's medical record. Progress notes documented multiple episodes where the resident experienced respiratory distress and received oxygen, but staff confirmed that no physician order was present for this intervention. Both the LPN and DON acknowledged that a physician order should have been in place for the oxygen therapy.
Failure to Follow Dialysis Care Policy and Documentation Requirements
Penalty
Summary
Facility staff failed to follow their own policy for managing residents receiving dialysis, resulting in multiple deficiencies. Specifically, staff did not consistently assess or document the condition of dialysis catheters or arteriovenous (AV) fistula sites every shift for two residents who were receiving dialysis. Documentation on the Medication/Treatment Administration Record (MAR/TAR) and dialysis communication forms was incomplete, with missing entries for pre- and post-dialysis weights and site assessments. There was also a lack of documentation in progress notes regarding post-dialysis vital signs and site assessments, and no evidence that residents refused these assessments. For one resident, there was no physician order for dialysis, despite the resident receiving dialysis services. The care plan for this resident included monitoring for complications related to end stage renal disease (ESRD) and dialysis, but interventions such as checking for bruit and thrill were not documented as completed. The other resident had a physician order to attend dialysis but lacked documentation of required assessments and communication with the dialysis center. Additionally, the facility did not have contracts in place with the dialysis companies providing services to the residents. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that required documentation and assessments were not consistently performed or recorded, and that physician orders and care plans were not always complete or up to date for residents receiving dialysis.
Failure to Accurately Administer and Document Medications and Assessments
Penalty
Summary
The facility failed to ensure accurate administration and documentation of medications, weekly skin assessments, pain and behavior monitoring, and blood pressure checks as ordered by physicians for two residents. For one resident, who was cognitively intact and had diagnoses including anxiety, depression, asthma, and thyroid disorder, there were discrepancies between the controlled drug log and the Medication Administration Record (MAR) regarding the administration of alprazolam (Xanax). The records showed multiple instances where doses were either not signed out, marked as refused or held without corresponding documentation, or left blank, with no progress notes explaining the omissions. The resident reported not always receiving medications as prescribed, particularly during a hospital transfer, and there was no documentation to clarify whether medications were refused, held, or not administered. For another resident with severe cognitive impairment, multiple dependencies for activities of daily living, and diagnoses such as hypertension, hyperlipidemia, stroke, hemiplegia, dementia, and depression, the MAR and Treatment Administration Record (TAR) revealed several missed or undocumented opportunities for medication administration, pain assessments, skin checks, behavior monitoring, and blood pressure monitoring. Numerous entries were left blank, indicating that either the care was not provided or not documented, with no codes or progress notes to explain the omissions. Orders for artificial tears, senna-docusate, atorvastatin, and routine assessments were not consistently documented as completed. Interviews with staff, including an LPN and the DON, confirmed that all medications and treatments should be documented at the time of administration, and that blanks on the MAR or TAR indicate a failure to document or administer as required. The DON stated that the MAR and control log should match, and any refusals or omissions should be clearly coded and explained in the progress notes. The facility's policies require timely and accurate documentation of all care provided, but these were not followed, resulting in incomplete records and unverified administration of ordered care.
Failure to Report Alleged Abuse Delays Investigation
Penalty
Summary
The facility failed to adhere to its policy on reporting allegations of abuse, resulting in a delayed investigation into an alleged incident involving two residents. The facility's policy mandates that any suspicion or report of abuse must be communicated to the Administrator or a supervisor immediately, and an investigation should be initiated. However, the Social Service Designee, upon being informed by a CNA about witnessing an inappropriate interaction between two residents, did not report the incident to her supervisor or the Administrator. Instead, she only discussed it with the residents' counselor, which led to a delay in addressing the allegation. The residents involved in the incident were siblings, with one being cognitively intact and the other having moderately impaired cognition. Both residents had diagnoses including bipolar disorder and schizophrenia. Despite the serious nature of the allegation, there were no progress notes documenting the incident for either resident. The Director of Social Services only learned of the incident through a rumor and assumed it had already been reported. The Administrator was unaware of the situation until the surveyors' inquiry, and no investigation had been initiated by that time.
Inaccessible Call Lights in Resident Rooms
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents in their rooms, affecting five sampled residents. Observations revealed that call lights were out of reach for residents who were either bedridden or in wheelchairs, making it difficult for them to call for assistance. Interviews with residents and staff confirmed that call lights were often not within reach, and residents had to resort to yelling for help, which was not always effective. Resident #5, who was cognitively intact but had impaired vision and mobility issues, reported that the call light was always out of reach, leaving them to scream for help. Similarly, Resident #11, with moderately impaired cognitive skills and mobility issues, had to lean dangerously over the bed to reach the call light, leading to falls. Resident #12, with severe eyesight impairment and cognitive issues, could not reach the call light from their wheelchair, and the Director of Nursing acknowledged the issue but could not resolve it due to the short length of the call light string. The facility lacked a call light policy, and staff interviews highlighted that call lights were made of thin strings, which could break easily. The Director of Nursing and the Administrator both expressed expectations that call lights should be within reach and functioning, but this was not consistently ensured. The Maintenance Associate noted that rooms with two residents should have two pull cords, but this was not always the case, as seen with Resident #15, who had to rely on a roommate to access the call light.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered for a resident, leading to a deficiency in care. The resident, who was cognitively intact but had an altered level of consciousness, was on a scheduled pain medication regime due to chronic pain from trauma and other conditions such as anxiety, depression, schizophrenia, PTSD, and Parkinson's disease. The Medication Administration Record (MAR) indicated that the resident did not receive the prescribed Lidocaine patch on multiple occasions in August 2024 because it was unavailable. There was no documentation that the facility ordered the missing medication or informed the Primary Care Physician (PCP) about the issue. Interviews with staff revealed that Certified Medication Technicians (CMTs) were responsible for re-ordering medications and notifying nurses if a medication was missing. However, the nurses did not document any actions taken to resolve the issue or notify the PCP. The facility's emergency kit contained Lidocaine patches, but they were not utilized. The Administrator expected staff to follow policies, ensure medications were available, and document any issues and actions taken. The failure to administer the medication as ordered put the resident at risk of increased pain.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident, leading to deficiencies in weekly skin and wound assessments, as well as the application of treatments as ordered. The resident, who was at high risk for pressure ulcers, had a history of heart failure, stroke, diabetes, and other conditions that increased their vulnerability. Despite being admitted with no unhealed pressure ulcers, the resident developed a Stage II pressure ulcer on the buttock and an unstageable ulcer on the left heel, which were not consistently documented or treated according to the facility's policies. The facility's wound reports were inaccurate, lacking essential details such as wound measurements, tissue type, and signs of infection. The Director of Nursing (DON) and other staff failed to complete weekly skin assessments and wound assessments, and there was no documentation of treatments being applied as ordered. The resident's Treatment Administration Record (TAR) showed missing entries for skin assessments and treatments, indicating a lack of adherence to physician orders and facility policies. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin issues. The DON admitted to inaccuracies in wound reports and assessments, which hindered the facility's ability to monitor wound healing effectively. The administrator acknowledged the deficiencies and the potential risks of delayed wound healing and infection due to incomplete and inaccurate documentation. The facility's failure to follow its own policies and procedures for pressure ulcer prevention and management put the resident at risk for further complications.
Failure to Provide Proper Colostomy Care
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, leading to complications and multiple emergency department visits. The resident, who was cognitively intact but had a history of psychiatric conditions, experienced irritation and redness around the colostomy site. Despite the resident's complaints of pain and improper fitting of colostomy bags, the facility did not have a documented care plan for the resident's colostomy care, and there was a lack of documentation for the application of prescribed treatments. The resident's progress notes indicated that the resident had to call 911 due to severe pain and lack of colostomy supplies, resulting in emergency department visits. The facility's staff, including the Director of Nursing, were aware of the resident's issues but attributed the problems to the resident's behavior of removing the colostomy bags. However, the facility did not have a policy on ostomy care, and the nurses failed to document the application of prescribed treatments on multiple occasions. Interviews with the resident and staff revealed that the resident was responsible for changing their own colostomy apparatus, contrary to the facility's expectations. The facility's administrator acknowledged that the nurses were responsible for providing ostomy care and documenting treatments, but there were gaps in documentation and care. The lack of a care plan and proper documentation put the resident at risk of delayed healing and increased skin irritation.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 967 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hidden Lake Health Care Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Christian Extended Care & Rehabilitation | 3.5 mi | ★★★★★ | 0 | 0 |
| Atrium Place Health And Rehabilitation | 3.8 mi | ★★★★★ | 2 | 0 |
| Stonebridge Florissant | 4.1 mi | ★★★★★ | 14 | 0 |
| Evercare Of Granite City | 4.3 mi | ★★★★★ | 3 | 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.