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 Spring Valley Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, unsteadiness, repeated falls, and HTN had multiple falls with pain, confusion, and decreased mobility, but the chart did not show complete post-fall documentation, including ongoing neurochecks and 72-hour monitoring. Staff also did not include all assessment findings when reporting to the MD and did not transcribe ordered x-ray and blood test orders onto the POS.
Improper Disposal of Blood-Contaminated Glucose Testing Supplies: An LPN obtained a resident’s blood glucose level and then placed a blood contaminated glucose strip, contaminated lancet, swabs, and gloves into a plastic cup before throwing the cup into a regular trash bin at the nurses’ station. The resident had dementia, diabetes, and HTN and received injections seven times a week. The LPN stated blood contaminated test strips and lancets were usually discarded in regular trash, while the RN, CNA, ADON, DON, Administrator, and Infection Preventionist stated these items should go in the sharps container and not regular trash.
The facility failed to complete and document required neurological assessments after multiple falls with potential head injury or unwitnessed falls. One resident with a history of stroke and fall risk had neuro checks started after a fall with head impact, but required time-interval checks and shift-based monitoring were missing, and staff gave conflicting accounts about whether checks were done and where the form was. Another resident with COPD, diabetes, obesity, gait problems, and repeated falls had several incidents where neuro checks were either partially documented, missing for required intervals, or referenced in notes without corresponding neuro logs, including falls with manual or Hoyer lifts used and one with bleeding from the foot. A third resident with cancer and other comorbidities, care-planned for fall risk and delayed reporting, self-reported multiple unwitnessed falls with hip pain; neuro checks were initiated but only partially completed and documented, and some falls were not contemporaneously charted. Staff and leadership interviews confirmed that neuro checks were expected for 72 hours after unwitnessed or head-impact falls, but revealed inconsistencies in understanding duration, responsibility, and documentation practices, resulting in incomplete adherence to the facility’s neuro-check protocol.
A resident with an order for boric acid vaginal suppositories did not receive the medication as prescribed due to unavailability and documentation errors. Staff failed to accurately record administration or non-administration on the MAR, did not consistently notify the physician of missed doses or refusals, and did not update the care plan to address the medication use or refusals. Interviews revealed confusion among staff about medication procurement, documentation, and notification procedures.
A resident dependent on tube feeding did not consistently receive the ordered nutrition due to staff confusion and errors in documenting intake, failure to record variances from physician orders, and lack of physician notification when discrepancies occurred. Staff interviews revealed misunderstandings about MAR documentation and inconsistent practices, resulting in inadequate monitoring and care for the resident at nutritional risk.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Several residents with cognitive and physical impairments did not receive showers as preferred, with some only receiving bed baths or experiencing long gaps between bathing. Staff interviews revealed confusion about shower schedules, documentation, and honoring resident preferences, resulting in unmet requests and a lack of support for resident self-determination.
Surveyors found that the facility failed to maintain clean and homelike conditions, with multiple residents experiencing unclean rooms, persistent odors, damaged furniture and fixtures, and uncomfortable temperatures. Staff and residents reported ongoing issues with cleanliness, odor control, and delayed maintenance, affecting both cognitively intact and impaired individuals.
The facility did not provide or document scheduled group and one-on-one activities for several residents, including those with cognitive impairment and chronic illnesses. Activities listed on the calendar were not conducted as scheduled, and staff failed to record activity participation or offer meaningful engagement, especially on the dementia unit. Some residents reported not being informed about available activities or receiving one-on-one visits, while staff interviews confirmed inconsistent documentation and lack of instruction regarding activity provision.
The facility failed to ensure proper documentation of medication administration or refusal on the MAR for multiple residents, including those with complex medical needs. In several cases, staff did not record whether medications were given or refused, and did not follow up on new prescriptions from outside providers, resulting in residents not receiving ordered treatments. Staff and leadership interviews confirmed that these actions did not meet facility policy or expectations.
Staff failed to administer medications as ordered, resulting in a medication error rate of 20%. Errors included giving incorrect doses of folic acid and iron supplements to multiple residents, as well as administering the wrong type of iron supplement. Additionally, insulin pens were not primed before use for two residents with diabetes, contrary to manufacturer and facility guidelines. Staff interviews confirmed a lack of adherence to medication administration protocols and insufficient knowledge regarding insulin pen priming.
Staff failed to document insulin administration and blood glucose checks for two residents with diabetes, leaving multiple MAR entries blank despite active orders. Additionally, two other residents received insulin via prefilled pens that were not primed before use, contrary to facility policy and manufacturer instructions. Interviews revealed staff were unaware of the need to prime insulin pens with each use, and leadership confirmed this was required. These actions resulted in significant medication errors.
Three of seven stove burner control knobs were missing in the kitchen, and staff continued to use the stove despite the deficiency. Dietary staff and management were aware of the missing knobs, but replacements had not yet been obtained. The facility lacked a policy for kitchen appliance upkeep.
Surveyors observed unsanitary conditions in the kitchen, including dirty floors, food debris, mold-like substances, and grease on walls and baseboards. Staff interviews revealed inconsistent cleaning practices and uncertainty about responsibilities, resulting in the kitchen not being kept clean and free of debris as required by facility policy.
Surveyors found that the facility did not maintain an effective pest control program, with multiple residents experiencing flies and gnats in their rooms. Observations included flies landing on residents and their food, dirty rooms with food debris, and pest control equipment not in use. Staff interviews revealed inconsistent pest control practices and a lack of a documented policy.
The facility failed to ensure written transfer notices were provided when residents were sent to the hospital. Three residents were transferred for events including a fall with head injury, altered mental status, and unresponsiveness with severe hypoxia; although bed hold acknowledgements were completed and family or NOK were notified, the records did not show hospital transfer letters were given. Staff, including an RN, SSD, DON, and Administrator, were not aware of transfer letters being sent.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors found that necessary interventions were lacking for both treatment and prevention.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including inadequate catheter care and insufficient measures to prevent UTIs.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
Missing Door Name Tag for Resident Led to Staff Confusion: A resident with intact cognition and diagnoses including lung cancer and dermatophytosis did not have a name tag on the room door during multiple observations, while the roommate's name remained posted. Staff were unsure of the resident's identity, and one staff member addressed the resident using the roommate's name. Interviews showed staff and leadership recognized that correct door name tags were important for identifying residents and providing care.
Inconsistent DNR Code Status List: The facility failed to keep a clear and consistent DNR code status process when two residents with documented DNR orders/directives were not listed on the purple-folder DNR list kept on the crash cart. One resident had atrial fibrillation and HTN, and the other had diabetes, COPD, fluid overload, syncope, and hospice status. Staff gave conflicting accounts of where to find code status, including the computer, MAR, face sheet, and the purple folder, and the DON and unit manager acknowledged the residents should have been on the DNR list.
Missed Dialysis Refusals Not Documented or Reported: A resident with ESRD and kidney failure had repeated dialysis refusals, but the chart did not document the refusals, resident education, or physician notification. The resident was cognitively intact, had orders for hemodialysis 3 times weekly, and staff interviews showed uncertainty about notifying the MD and documenting monitoring when dialysis was missed. The resident also had episodes of chest pain while en route to dialysis and later was sent to the hospital after being seen by the NP.
Incomplete documentation of a resident's AMA departure and return. An RN documented that a resident left with family after signing out AMA, and another note stated EMS picked the resident up in the parking lot after the family could not get the resident into the car. However, the chart did not include the time or date the resident returned, nor notification to the physician, even though staff stated that discharge and return/readmission should be documented.
A resident with a chronic indwelling catheter did not consistently receive or have documented catheter care, output monitoring, or assessment for infection as required by physician orders and care plans. Staff failed to document catheter care and output on multiple occasions, did not always transcribe or update orders, and did not revise the care plan to reflect changes in catheter management or involvement by urology. Interviews revealed confusion among staff about documentation and order requirements, and there was a lack of coordination with urology providers.
A resident with multiple chronic conditions experienced a change in mental status, prompting a provider to order a stat urinalysis with culture and sensitivity. Despite this, staff did not obtain the urine sample for ten days, with inconsistent documentation and no evidence of timely provider notification or explanation for the delay. Staff interviews confirmed confusion about the process and acknowledged the delay was excessive, resulting in a failure to meet professional standards of care.
A resident with significant medical needs reported to an LPN that a CNA had jerked and broken their leg during a transfer. The LPN assessed the resident and discussed the incident with the involved CNAs, but did not consider it an abuse allegation and failed to report it to the Administrator or state agency within the required timeframe. Multiple staff interviews indicated that such statements should be reported as abuse, but the required self-report to the state was not made.
Staff did not immediately investigate or take protective measures after a resident with multiple medical conditions alleged that a CNA was rough and broke their leg during a transfer. Despite the facility's abuse prevention policy requiring immediate action, the accused CNA continued working, and no written investigation was completed. Interviews with staff confirmed that the incident was not reported as abuse to administration, and both the DON and Administrator were unaware of the specific allegation, resulting in no formal investigation.
The facility failed to provide care according to standards of practice, resulting in deficiencies in wound care and medication administration for several residents. Wound care orders were not obtained or documented for all wounds, and medication administration was inconsistently documented, suggesting potential non-administration. Interviews with staff revealed that undocumented medications might not have been given, highlighting a significant deficiency in care.
The facility failed to ensure residents were free from significant medication errors due to staff not documenting the administration of multiple medications for three residents. This included critical medications for conditions such as CHF, diabetes, and schizophrenia. Interviews confirmed that undocumented medications were possibly not given, highlighting a significant lapse in medication management.
A facility failed to maintain effective infection control practices, as staff did not sanitize multi-use equipment, use barriers for supplies, or perform hand hygiene while managing diabetes care for residents. Observations revealed that an LPN did not adhere to hand hygiene protocols or clean equipment between uses, increasing the risk of cross-contamination. Interviews with staff confirmed a lack of adherence to infection control policies.
A facility failed to provide pressure ulcer care per standards of practice for a resident with a sacral pressure ulcer. Despite physician orders to cleanse and dress the wound every three days, staff did not document treatment completion on multiple occasions. The resident's care plan also lacked updates regarding the pressure ulcer. Interviews confirmed that staff should have followed orders and documented wound changes, leading to a deficiency in care.
The facility failed to properly store and administer medications, as a resident was found with medication left at their bedside without a physician's order, and medication carts were observed unlocked and unattended. Staff interviews confirmed these practices were against facility policy.
The facility failed to maintain a sanitary environment, with observations of unclean conditions in shower rooms and resident areas. Used towels, plastic gloves, and fecal matter were found in various locations, and staff were unaware of priority cleaning needs. Housekeeping staff followed a checklist but faced interruptions, and there was no written policy for cleanliness.
Incomplete post-fall assessment and order transcription
Penalty
Summary
The facility failed to provide care according to orders, resident preferences, and goals when a resident with dementia, unsteadiness on feet, repeated falls, and hypertension experienced multiple falls and the post-fall assessments were not fully documented. Facility policy required injury evaluation before moving the resident, neurological evaluation as applicable, notification of the physician and others, and documentation in the medical record with post-fall evaluations for 72 hours. The record showed that after the falls, staff documented some assessments and notifications, but did not document initiation or continuation of neurological checks after the falls, and did not document the required ongoing monitoring for 72 hours. The resident’s record showed several fall-related events in which staff noted pain, confusion, and changes in mobility, including inability to bear weight, but the documentation did not consistently include full follow-up assessments such as neurological checks, range of motion, or deformity checks. In one instance, staff documented a slight protrusion on the forehead and pain in the left knee; in another, staff documented a bump on the forehead, confusion, and inability to acknowledge the fall or location; in another, staff documented a bump on the forehead and inability to bear weight on the left leg. The medical record also showed that staff did not document continued monitoring after the falls, including neurochecks. The facility also failed to provide all assessed information to the physician and failed to transcribe physician orders after the falls. An SBAR communication form documented that the resident fell and had pain, but did not include fall evaluation details, neurological checks, or inability to bear weight. The physician ordered blood tests, an x-ray, and medication changes, but the Physician Order Sheet did not show the x-ray and blood test orders transcribed. A later physician order for an x-ray was also not transcribed. Staff interviews confirmed that after a fall, the expectation was to assess neurological status, obtain vital signs, notify the physician and family, document for 72 hours, and transcribe new orders, but these steps were not fully reflected in the resident’s record.
Improper Disposal of Blood-Contaminated Glucose Testing Supplies
Penalty
Summary
The facility failed to implement a complete and effective infection control program when staff did not properly discard blood contaminated glucose test strips and sharps for one resident. The resident had diagnoses including dementia, diabetes, and high blood pressure, and the care plan directed administration of diabetic medications as ordered. The resident’s most recent MDS showed injections seven times a week. During observation, an LPN obtained the resident’s blood glucose level and then placed a used alcohol swab, cotton swab, blood contaminated glucose strip, and contaminated lancet into a plastic cup carried on a tray. The LPN then brought the tray to the open-door nurses’ station, placed it on top of the medication cart, removed gloves, placed them into the plastic cup, and threw the cup containing the contaminated items into the trash bin on the side of the medication cart. The LPN stated he/she discarded the blood contaminated test strip, lancet, alcohol swab, cotton swab, and gloves into the trash bin and usually discards blood contaminated test strips and lancets in regular trash bins. Other staff, including an RN, CNA, ADON, DON, Administrator, and the Infection Preventionist, stated that glucose test strips and lancets should be discarded in the sharps container and that blood contaminated items and/or lancets should not be placed in regular trash bins.
Failure to Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document complete neurological assessments after falls with potential for head injury, contrary to its own Fall Management and Neurological Evaluation policies. Those policies required a licensed nurse to perform a structured neuro evaluation for 72 hours after a potential head injury or unwitnessed fall, with checks every 15 minutes for one hour, every 30 minutes for one hour, every hour for two hours, every two hours for eight hours, every four hours for 12 hours, and then every shift for 48 hours. Staff interviews confirmed that nurses and aides understood that neuro checks were required after unwitnessed falls or when a resident hit their head, and that checks were to be completed in full and documented on a neurological evaluation form. Despite this, surveyors found multiple instances where neuro checks were either not initiated as described, not carried out for the full required duration, or not documented as required. For one resident with a history of stroke, hemiplegia, impaired mobility, and a care plan identifying fall risk, staff documented that the resident slipped on melting snow, hit the back of the head and bottom, and that neuro checks were initiated. The neurological evaluation log showed checks were completed through the 15‑minute, 30‑minute, and hourly phases, but there were no documented checks every two hours for eight hours, missing entries in the four‑hour phase, and no documentation of shift‑based checks for 48 hours. Staff interviews reflected confusion and inconsistency: one LPN believed the resident was near the end of neuro checks and completed only one set, another did not believe neuro checks had been initiated, and another reported starting the checks but later could not find the sheet and was told by another nurse they were unaware the resident was on neuro checks. The NP stated the resident should have received neuro checks for 72 hours, while the ADON was unaware of the circumstances of the fall and unsure if neuro checks were done. For a second resident with COPD, diabetes, morbid obesity, gait problems, muscle weakness, and a care plan noting fall risk and history of falls, surveyors identified several falls with incomplete or inconsistent neurological monitoring. After a fall over oxygen cords, staff documented that neuro checks were started, but the log showed missing entries in the two‑hour phase, no four‑hour checks, and incomplete shift‑based checks, followed by another fall with new neuro checks initiated. On another date, staff documented a fall with neuro checks within normal limits and stated that neuro checks were restarted and leadership notified, but there were no further progress notes or fall follow‑up/neuro assessments that day. A subsequent neuro log showed a full 72‑hour sequence starting the next evening, yet there was no progress note documenting a fall on that date, and another fall the following day had neuro checks ordered in the progress note but no corresponding neuro documentation. Additional falls later in the month showed neuro logs with missing entries in the 15‑minute, two‑hour, four‑hour, and shift‑based phases, and another fall with bleeding from the foot where neuro checks were said to be initiated but no documentation of restarted neuro assessments was found. For a third resident with malignant neoplasm of the head/face/neck, anxiety, depression, esophageal obstruction, chronic kidney disease, and a care plan noting fall risk, history of falls, and delayed reporting of unwitnessed falls, staff documented that the resident reported having fallen twice and complained of right hip pain. Neuro checks were initiated, but the log showed completion of the 15‑minute and 30‑minute checks only, with no documented hourly or two‑hour checks, and only sporadic four‑hour entries and no shift‑based checks for 48 hours. Later, the resident reported another fall that had occurred on a prior night, with staff documentation of hip pain and the resident’s written report of being given morphine and helped back to bed, but there was no progress note documenting a fall on those dates. A new neuro log was started, but the 15‑minute checks were not documented, and subsequent phases were only partially completed. Interviews with CNAs, CMTs, LPNs, the NP, DON, ADON, UM, and Administrator showed that while staff generally described a consistent fall and neuro‑check protocol, there were discrepancies in understanding of duration (two days vs. three days vs. 72 hours), who completed checks, and where forms were kept and filed, and some staff were unaware that certain residents were on neuro checks at the time of survey. Across these three residents, the surveyors determined that the facility did not ensure neurological assessments were consistently initiated, completed, and documented according to its policies and professional standards after falls with potential for head injury or unwitnessed falls. The medical records and neuro logs contained multiple gaps and missing entries in the required time intervals, and in some instances, falls were referenced by residents or in late entries without corresponding timely fall documentation or neuro‑check records. Leadership interviews confirmed expectations that neuro checks be completed in full for the required duration, that CNAs could obtain vitals but nurses must perform the neurological assessment, and that completed forms should be turned in to nursing leadership or medical records, yet the documentation reviewed did not reflect that these expectations were met for the residents involved.
Failure to Document, Administer, and Notify Regarding Ordered Medication
Penalty
Summary
Facility staff failed to provide care in accordance with accepted standards of practice for a resident who had an order for boric acid vaginal suppositories. The staff did not accurately document the administration or non-administration of the medication, with inconsistencies noted in the Medication Administration Record (MAR) and a lack of corresponding progress notes. There were instances where the medication was marked as refused or held, but staff interviews revealed that these entries may have been inaccurate, as the medication was not available in the facility at the time. Additionally, staff did not consistently notify the physician of missed doses or refusals as required by facility policy. The medication was not available for administration for several days after the order was written, and there was confusion among staff regarding the procurement and location of the boric acid suppositories. Central supply did not have the medication in stock and had to order it from an outside supplier, resulting in a delay. During this period, staff documented refusals or held doses on the MAR, but did not make explanatory notes or notify the physician in a timely manner. Interviews with nursing and supply staff indicated a lack of clarity about the process for obtaining over-the-counter medications and the appropriate documentation and notification procedures when medications are unavailable or refused. The resident's care plan did not address the use of or refusals related to the boric acid suppository, despite multiple missed doses and documentation issues. Staff interviews revealed uncertainty about who was responsible for updating care plans in such situations. The facility's policies required accurate documentation, timely physician notification, and care planning for medication refusals, but these procedures were not followed in this case.
Failure to Ensure Accurate Tube Feeding Documentation and Physician Notification
Penalty
Summary
The facility failed to ensure that all residents with tube feedings received sufficient nutrition due to staff misunderstanding and inconsistent documentation practices. Staff did not consistently document tube feeding intake accurately, failed to record when the amounts administered varied from the physician's orders, and did not notify the physician when such variances occurred. Multiple staff interviews revealed confusion regarding where and how to document tube feeding intake and output in the Medication Administration Record (MAR), with some staff documenting anticipated amounts rather than actual amounts administered, and others mistakenly recording oral intake or water flushes as tube feeding intake. There were also discrepancies in the timing of documentation, with the MAR not aligning with the actual start and end times of tube feedings as ordered by the physician. A resident with a history of nontraumatic intracerebral hemorrhage and dysphagia was identified as being at nutritional risk and dependent on tube feeding for adequate nutrition. The resident's care plan and physician orders specified the required tube feeding regimen, including the amount and timing of feedings. However, review of the MAR showed multiple instances where the documented intake did not match the ordered amount, including days with significantly less or more than the prescribed volume, and days with no intake recorded. Staff interviews confirmed that these discrepancies were not consistently explained in the resident's record, and physician notification was not documented when variances occurred. Further, staff expressed confusion about the documentation process, with some admitting to not being trained on the specific unit or not understanding the MAR system. There was also a lack of clarity regarding when to notify the physician about deviations from the ordered tube feeding amounts, with some staff believing notification was only necessary if the variance persisted over several days. The facility's policies required documentation of changes in condition and physician notification, but these were not followed in practice, leading to a failure to provide appropriate care and monitoring for the resident receiving tube feedings.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Bathing Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not providing timely bathing in the form preferred by several residents. Multiple residents with varying degrees of cognitive impairment and physical limitations reported not receiving showers as requested, with some only receiving bed baths or going extended periods without any form of bathing. Documentation and interviews revealed inconsistencies in offering showers, lack of clarity on whether showers or bed baths were provided, and gaps of several days between bathing opportunities. One resident with a history of stroke, hemiplegia, and depression expressed a preference for showers over bed baths, but records showed reliance on family-provided bed baths and infrequent staff-provided bathing. Another resident with a leg fracture and impaired mobility reported receiving only occasional sponge baths, despite a care plan indicating the need for bathing or showering twice weekly. A third resident, with altered mental status, kept a personal calendar and noted significant gaps between showers, sometimes waiting up to eleven days, and reported feeling unclean and having requests for showers unmet. Staff interviews indicated confusion regarding shower schedules, documentation practices, and the process for handling refusals or preferences. Some staff were unaware of the frequency with which residents should be offered showers, and there was no consistent system for ensuring residents' bathing preferences were honored. The Director of Nursing and other staff assumed that showers were being offered as scheduled, but documentation and resident reports did not support this, leading to unmet resident preferences and a failure to support resident choice in personal care.
Failure to Maintain Cleanliness, Odor Control, and Comfortable Environment
Penalty
Summary
Multiple deficiencies were identified in the facility's ability to maintain a safe, clean, comfortable, and homelike environment for its residents. Surveyors observed unclean conditions in resident rooms and bathrooms, including strong urine odors, brown and black substances on floors and walls, sticky floors, and the presence of ants. Several rooms had peeling paint, damaged drywall, and holes in doors, while some bathrooms had loose or broken fixtures. In one case, a resident's over-bed table was left soiled after a meal, and a recliner in the dementia unit's sunroom was found with dried brown substances on multiple surfaces. These issues persisted over several days and were acknowledged by housekeeping and maintenance staff, who were sometimes unaware of the duration or cause of the problems. Odors were a recurring issue in several resident rooms and hallways, with strong urine smells noted both inside and outside rooms. Staff interviews confirmed awareness of these odors, and in some cases, staff attributed them to factors such as resident incontinence, pets, or infrequent cleaning due to resident preferences. Despite daily cleaning routines, staff reported ongoing complaints about sticky floors and persistent odors. Maintenance logs revealed delays or lack of documentation regarding repairs, such as broken lights, damaged doors, and malfunctioning air conditioning units. Temperature control was also problematic, with observations of resident rooms and common areas measuring above 80 degrees Fahrenheit, despite thermostats being set lower. Residents and staff reported discomfort due to excessive heat, and temporary solutions such as mini-air conditioners and fans were provided. However, temperature logs did not always reflect the higher temperatures observed during the survey. The facility census at the time was 149, and the deficiencies affected multiple residents with varying levels of cognitive impairment, including those who were cognitively intact and those with severe cognitive deficits.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide activity programs that met the needs of all residents, as evidenced by missed scheduled activities, lack of documentation of activity participation, and failure to offer or complete meaningful activities for several residents. Observations showed that activities listed on the Special Care Unit (SCU) calendar, such as music and craft sessions, were not conducted at the scheduled times. Additionally, staff did not document attendance or the offering of group, independent, or one-on-one activities for multiple days for several residents. For one resident with severe cognitive impairment and osteoarthritis, records indicated that activity participation was unknown, and there was no documentation of activities being offered or attended over several days. Another resident with cognitive communication deficits, schizophrenia, and bipolar disorder had a care plan specifying preferred activities and the need for assistance to attend, but staff failed to document any activity participation or offerings during multiple periods. A third resident with multiple chronic conditions, including COPD, CKD, and CHF, preferred independent activities such as using a computer and reading, but there was no documentation of activity involvement, and the resident reported not seeing activity staff for one-on-one visits or being informed about available activities. Interviews with staff revealed inconsistent practices regarding the provision and documentation of activities, particularly on the dementia unit. Some staff admitted to not documenting one-on-one visits or not being instructed to provide such activities. The Activity Director and DON both acknowledged gaps in documentation and the need for one-on-one activities, while residents expressed a lack of engagement and awareness of available options. These findings demonstrate a failure to implement and document an activity program that supports the physical, mental, and psychosocial well-being of all residents as required by facility policy.
Failure to Document Medication Administration and Follow-Up on Prescriptions
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents by not ensuring proper documentation of medication administration or refusal on the Medication Administration Record (MAR) for multiple residents. For one resident with complex medical conditions including acute kidney failure, diabetes, and pressure ulcers, staff did not document the administration or refusal of several prescribed medications, such as anticoagulants, antidepressants, pain medications, gastrointestinal treatments, potassium supplements, and muscle relaxants, over several days. Interviews with staff revealed uncertainty about the reasons for missing documentation, with some staff indicating the resident was noncompliant or out of the facility, but these events were not properly recorded on the MAR as required by facility policy. Another resident, who had diagnoses of diabetes and morbid obesity, attended an outside dermatology appointment and reportedly received a new prescription for a topical medication. The resident reported discomfort and lack of access to the prescribed cream, stating that staff had not applied it and were unaware of its status. Interviews with nursing staff indicated a lack of follow-up with the outside provider and pharmacy to obtain the prescription, and there was no documentation of these follow-up attempts in the resident's progress notes. The Director of Nursing and other staff confirmed that the expected process was not followed, and the medication was not obtained or administered in a timely manner. A third resident with diagnoses including acute post-hemorrhagic anemia, diabetes, colon cancer, and atrial fibrillation also experienced multiple instances where staff failed to document the administration or refusal of several medications, including blood thinners, diabetes medications, gastrointestinal treatments, nerve pain medications, antidepressants, and antihypertensives. Staff interviews consistently indicated that all medications administered or refused should be documented on the MAR, and that blank areas on the MAR are not acceptable. The Director of Nursing and Administrator both confirmed that lack of documentation means the medication was not given, and that staff are expected to document all medication administration or refusals.
Medication Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as required, resulting in a 20% error rate based on 5 errors out of 25 observed opportunities. Staff administered incorrect medication doses and wrong medications to several residents. Specifically, one resident with severe cognitive impairment was prescribed folic acid 1 mg daily but was given 800 mcg instead, as the correct dose was not available. Another resident with kidney failure and iron deficiency, who was ordered folic acid 400 mcg daily, received 800 mcg. Additionally, a resident with diabetes and vitamin D deficiency was ordered ferrous sulfate 325 mg daily but was given ferrous gluconate 27 mg instead. Staff interviews confirmed that medications and doses were not administered as ordered, and staff acknowledged that they should have sought clarification from the physician or ensured the correct medication was available before administration. The DON and Administrator both stated that staff should follow physician orders and not substitute medications or doses. The facility's policy required adherence to the five rights of medication administration, including the right drug and right dose, and staff failed to comply with these requirements in the observed cases. Further deficiencies were observed in the administration of insulin using prefilled pens. Two residents with diabetes were administered insulin without the required priming of the pen before each use, contrary to manufacturer guidelines and facility policy. Staff interviews revealed a lack of knowledge regarding the need to prime insulin pens before every injection, with some staff believing priming was only necessary for new pens. The DON, Administrator, and Corporate Nurse Consultant all confirmed that insulin pens should be primed before each use to ensure accurate dosing, but this was not consistently practiced by staff.
Failure to Document and Properly Administer Insulin Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration and documentation of insulin for residents with diabetes. Staff did not document the administration of insulin or the checking of blood sugar levels for two residents over multiple days, as evidenced by blank entries in the Medication Administration Records (MARs) despite active physician orders for both blood glucose monitoring and insulin administration. Interviews with staff and leadership confirmed that if the MAR is blank, it is assumed that the medication or task was not completed, which constitutes a medication error. The Medical Director also confirmed that undocumented insulin administration is considered a significant medication error. Additionally, staff failed to follow manufacturer guidelines for insulin pen use by not priming the pens prior to each administration for two residents. Observations showed that registered nurses administered insulin using prefilled pens without priming them, contrary to both facility policy and manufacturer instructions, which require priming before every use to ensure accurate dosing. Interviews with nursing staff revealed a lack of awareness regarding the need to prime insulin pens with each use, with some staff believing priming was only necessary for new pens. Leadership, including the DON, Administrator, and Corporate Nurse Consultant, stated that priming is required every time, as per manufacturer guidelines. The residents involved had diagnoses of Type 2 diabetes and were cognitively intact or severely cognitively impaired, depending on the individual. Their care plans and physician orders required regular blood glucose monitoring and insulin administration, including sliding scale dosing. The failure to document administration and to properly prepare insulin pens directly contradicted facility policy and physician orders, resulting in significant medication errors for multiple residents.
Failure to Maintain Safe Kitchen Equipment Due to Missing Stove Knobs
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as evidenced by three out of seven stove burner control knobs being missing on the kitchen cook stove. Observations on two separate dates confirmed the missing knobs, and interviews with dietary aides and the Dietary Manager revealed that staff were aware of the issue but continued to use the stove by turning the burners on and off without the knobs. The Dietary Manager acknowledged the missing knobs and indicated a need to order replacements. The Administrator also confirmed awareness of the deficiency, stating that all knobs should be present. The facility did not provide a policy regarding the upkeep of kitchen appliances.
Failure to Maintain Sanitary Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as evidenced by multiple observations of unclean floors and walls. Surveyors noted black and white substances on the kitchen floors, particularly under sinks and the dishwasher, as well as food debris in these areas. The baseboards were observed to be black with dirt. Additional observations revealed a mold-like substance and brown stains along the backsplash above the sink, large brown splatters on the wall under the sink, a black substance under the dishwasher, and grease drops on the wall behind the stove. These conditions were present despite the facility's policy requiring a clean and sanitary work environment in nutritional services. Interviews with dietary aides and the dietary manager revealed inconsistencies and uncertainty regarding cleaning responsibilities and schedules. Staff reported that floors were swept and mopped each shift, with deep cleaning of walls occurring two to three times weekly, but there was a lack of clarity about the frequency and thoroughness of these tasks. The dietary manager and administrator both stated that floors and walls should be clean, but acknowledged that there should not be visible dirt, mold, or food debris. The dietary manager also indicated that maintenance and housekeeping were involved in cleaning, but was not aware of the presence of mold or the extent of the dirt observed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement and maintain an effective pest control program, as evidenced by multiple observations of flies and gnats in several resident rooms affecting five residents. Surveyors observed flies landing on residents and their belongings, including pillows and food, and noted that residents found the flies to be bothersome. In one instance, a resident's pillow had a black substance on it, and flies were seen landing on it repeatedly. Another room had eight to ten live flies, gnats, and an unplugged pest control light, along with an uncovered bedside commode containing urine and debris on the floor. Additional observations revealed rooms with unpleasant odors detectable from the hallway, dirty floors with food debris, full trash cans, and personal items scattered about. In one room, a sticky fly trap was completely full of flies, and several live and dead flies were present. Residents reported that housekeeping cleaned their rooms every other day, but some did not want their belongings moved. Staff interviews confirmed the presence of flies, with some staff using fly swatters and others unsure about the frequency of pest control treatments. The facility did not provide a pest control policy for review, and staff interviews indicated inconsistent knowledge and practices regarding pest control measures. The maintenance director stated that pest control services were provided at least monthly or more often if needed, but had not received complaints about flies. The administrator described various methods used to address flies but was not aware of an ongoing issue. The lack of a documented pest control policy and the presence of pests in resident rooms contributed to the deficiency.
Failure to Provide Written Hospital Transfer Notice
Penalty
Summary
The facility failed to ensure that each resident or the resident’s representative received written notice of transfer when residents were sent to the hospital. The facility policy titled Discharge / Transfer – Involuntary stated that when a resident is transferred to another health care facility upon physician order, a transfer form is completed and a copy is sent with the resident. However, for three sampled residents transferred to the hospital, the medical records did not contain a copy or documentation of a hospital transfer letter being provided. Resident #39, who was cognitively intact, fell out of bed and was found with blood from a wound to the left temple, headache, and neck pain; EMS was called and the emergency contact was notified, and a bed hold acknowledgement was signed, but no hospital transfer letter was documented. Resident #65, who was severely cognitively impaired, had altered mental status and was sent to the emergency room at the family’s request after the physician was notified; a bed hold acknowledgement was completed, but no transfer letter was documented. Resident #103, who had moderate cognitive impairment, became unresponsive with oxygen saturation of 60% and increased weakness; the physician ordered hospital transfer and the next of kin was notified, a bed hold acknowledgement was signed, but the record did not show a hospital transfer letter. Staff interviewed, including an RN, the SSD, the DON, and the Administrator, were not aware of transfer letters being sent to residents or resident representatives.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing or prevent further skin breakdown. Additionally, preventive strategies for residents at risk of developing pressure ulcers were not adequately carried out, contributing to the occurrence of new ulcers.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Missing Door Name Tag for Resident Led to Staff Confusion
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect when Resident #62 did not have a name tag on the room door. Resident #62 was admitted on 02/28/25 and had diagnoses including malignant neoplasm of the upper lobe, right bronchus or lung and dermatophytosis. A significant change in status MDS dated 07/08/25 showed the resident's cognitive skills were intact. During multiple observations on 08/17/25, 08/20/25, and 08/21/25, the resident was seen in the first bed of the room while the roommate's name remained on the door and the resident's own name tag was absent. During an observation on 08/20/25, a staff member knocked on the door and stated the roommate's name to Resident #62, and the resident responded that the roommate was in the hospital. In interviews, a CNA said staff did not know who was responsible for the name tags and thought the resident was the roommate because there was no name tag for Resident #62. An LPN, a CMT, the DON, medical record staff, and the Administrator all stated that correct name tags on resident doors were important for identifying residents and providing care, and medical record staff said they were responsible for the door name tags and checked them weekly.
Inconsistent DNR Code Status List
Penalty
Summary
The facility failed to ensure there was a process in place that clearly and consistently identified each resident’s code status when two residents with DNR orders/directives were not listed on the DNR code status list kept in a purple folder on the crash cart. The survey found that the facility census was 149 and that staff used multiple sources to identify code status, including the computer, face sheet, medication administration record, and the purple folder, but the purple folder was being treated by staff as the DNR list even though it did not clearly designate code status and was not consistently updated. One resident had diagnoses including unspecified atrial fibrillation and essential hypertension. The resident’s record included an OHDNR form signed by the resident and physician, a current physician order for DNR, and a care plan revised to reflect DNR status. During record review, the resident’s name was not on the purple-folder list that staff identified as the DNR list. An LPN/unit manager stated the resident had DNR status and should have been on the list. A second resident had diagnoses including diabetes, COPD, fluid overload, and syncope and collapse, and the MDS showed the resident was on hospice. The resident’s record also included an OHDNR form, a physician order for DNR, and a care plan addressing DNR status and withholding CPR per the resident’s wishes. This resident’s name also was not on the purple-folder list. Staff interviews showed inconsistent understanding of where code status was documented and how the purple folder was used, with some staff relying on the computer and others relying on the folder, while the DON and unit manager acknowledged that residents with DNR status should be on that list.
Missed Dialysis Refusals Not Documented or Reported
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident with end stage renal disease and kidney failure. Resident #10 was cognitively intact, had a care plan addressing dialysis needs, weight fluctuations, and a history of refusing dialysis, and had physician orders for hemodialysis on Tuesday, Thursday, and Saturday. The resident’s dialysis treatment sheets showed multiple missed dialysis appointments, including refusals on 07/31/25, 08/02/25, 08/09/25, 08/14/25, and 08/16/25. For each of those refusals, the resident’s progress notes did not document the refusal, education provided to the resident about refusing dialysis, or notification of the physician. The record also showed that on 08/05/25 the resident developed chest pain while on the way to dialysis and was sent to the emergency room, and on 08/18/25 the resident was seen by the nurse practitioner and sent to the hospital. The resident told surveyors on 08/18/25 that he/she had not gone to dialysis on Thursday or Saturday because he/she did not feel well. Staff interviews showed inconsistent understanding of the process for missed dialysis appointments. CNAs and a CMT stated the resident often refused dialysis and that staff would tell the resident he/she would get sick, but they were unsure whether nursing notified the physician or provided additional monitoring. An LPN stated nursing educated residents and monitored for fluid overload and shortness of breath, but also said the doctor had not been officially notified of the times the resident missed dialysis. The DON and administrator stated they expected staff to educate the resident, notify the physician, and monitor/document the resident’s condition, while the physician stated he/she would expect to be informed when the resident refused dialysis.
Incomplete Documentation of Resident AMA Departure and Return
Penalty
Summary
The facility failed to maintain complete medical records for a resident when staff did not document full details related to the resident leaving against medical advice and later returning to the facility. The resident was admitted with diagnoses including acute kidney failure, cognitive communication deficit, Type 2 diabetes mellitus with hyperglycemia, and a pressure ulcer. The baseline care plan documented that the resident was admitted from the hospital, communicated easily with staff, understood staff, and had an initial discharge goal to return to the community. Progress notes showed an RN documented that the resident discharged AMA and that the resident's family picked up the resident and signed him/her out AMA, with the family aware they could not take any medications and that facility doctors would not sign prescriptions after departure. Another note documented that the resident left with family, but the family could not get the resident into the car and called EMS, which picked up the resident in the parking lot. The record did not include an order to discharge the resident home, and nursing progress notes did not document the time or date the resident returned to the facility or notification to the physician of the resident's return. During interviews, staff stated that nurses should document a discharge and return/readmission, and the DON said she expected nurses and social services staff to document when a resident returned to the facility.
Failure to Document and Provide Catheter Care per Standards and Orders
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received care in accordance with standards of practice and physician orders. Staff did not consistently document the completion of catheter care, monitoring of urinary output, or assessment for signs and symptoms of infection as required by the resident's care plan and physician orders. There were multiple instances across several months where documentation was missing for catheter care and output monitoring on both day and night shifts, and staff did not provide reasons for these omissions. Additionally, orders for catheter changes and care were not always transcribed or updated in the resident's records, and the care plan was not revised to reflect changes in the resident's catheter management, including involvement by urology specialists. The resident in question had a complex medical history, including chronic indwelling catheter use due to obstructive and reflux uropathy, a history of recurrent urinary tract infections, and episodes of hematuria and urinary obstruction. The resident was dependent on staff for most activities of daily living and required close monitoring and care of the catheter to prevent complications. Despite this, staff interviews revealed confusion about documentation responsibilities, with some CNAs unaware that they needed to document catheter care and others unsure about the presence of relevant orders in the electronic medical record. Nurses and administrative staff acknowledged that standard protocols required regular catheter care, output monitoring, and care plan updates, but these were not consistently followed or documented. Observations and record reviews further indicated that the facility did not maintain clear communication or coordination with the resident's urology providers regarding catheter changes and care. Orders from urology were not always incorporated into the resident's care plan, and there was a lack of documentation regarding urology visits and procedures. The failure to document catheter care, output monitoring, and care plan updates, as well as the lack of clear orders and communication with external providers, contributed to the deficiency identified by surveyors.
Delayed Urinalysis Collection Following Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice when staff did not obtain an ordered urinalysis (UA) in a timely manner. The resident, who had diagnoses including COPD, muscle weakness, heart failure, and chronic pain syndrome, was noted to have a change in mental status, including hallucinations. Following this change, a nurse practitioner ordered a stat CBC, CMP, and later a UA with culture and sensitivity, with permission to use a catheter if needed. Despite these orders, the UA was not collected until ten days after the order was received. Facility policy required that staff obtain labs as ordered, document on the lab scheduling/tracking form, and notify the physician if there were issues or delays. However, review of the resident's treatment administration record showed inconsistent documentation, with checkmarks indicating the UA was obtained on multiple occasions, but the actual collection did not occur until much later. There was no documentation in the progress notes explaining the delay, nor was there evidence that the provider was notified about the ongoing inability to obtain the sample. Interviews with staff revealed confusion about the process, with some staff indicating that a checkmark on the record did not always mean the task was completed, and others unsure why the delay occurred. The delay in obtaining the UA was confirmed by both the lab results, which showed the sample was collected ten days after the order, and by staff and provider interviews, all of whom agreed that this timeframe was excessive. The resident was known to be difficult to catheterize and sometimes refused care, but there was no documentation of refusals or provider notification during the period in question. The facility's failure to follow its own policies and ensure timely communication and documentation led to the deficiency.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency, as required by both facility policy and regulation. On the day in question, a resident with significant medical needs, including paraplegia, cancer of the larynx, and cognitive communication disorder, reported to an LPN that a CNA had jerked and broken their leg during a transfer. The LPN assessed the resident and discussed the incident with the involved CNAs, who denied any rough handling. The LPN did not consider the resident's statement to be an allegation of abuse and did not report it to the Administrator or the state agency within the required timeframe. Multiple staff interviews revealed that several employees were aware of the resident's complaint, but the information was not escalated to facility leadership or reported to the state as an abuse allegation. Staff members, including CNAs, LPNs, and the Social Service Director, indicated in interviews that such statements from a resident should be considered abuse and reported according to policy. However, the DON and Administrator both stated they were not informed that the resident had accused staff of jerking or breaking their leg, and thus no report was made to the state. Facility records and interviews confirmed that the required self-report to the Department of Health and Senior Services was not made. The failure to recognize and report the resident's statement as a potential abuse allegation resulted in non-compliance with both facility policy and regulatory requirements for timely reporting of suspected abuse.
Failure to Investigate and Protect After Allegation of Abuse
Penalty
Summary
Facility staff failed to immediately initiate an investigation and take protective measures following an allegation of possible abuse involving a resident. According to the facility's abuse prevention policy, any finding of potential abuse or neglect requires an immediate investigation and steps to protect the alleged victim. However, after a resident alleged that a certified nurse aide (CNA) was rough and broke their leg during a transfer, staff did not follow the policy. The CNA continued to work the remainder of the shift, though not with the resident, and there was no documentation of a written investigation or evidence that the accused staff was suspended pending investigation. The resident involved had significant medical conditions, including cancer of the larynx, spinal stenosis, muscle weakness, cognitive communication disorder, and paraplegia, and was dependent on staff for all activities of daily living. The incident occurred after a transfer, during which the resident reported to staff and family that the CNA had been rough and broke their leg. Despite these allegations, staff interviews revealed that the incident was not reported to administration as abuse, and no formal investigation was conducted as required by policy. Multiple staff members, including LPNs, CNAs, and the Social Service Director, indicated in interviews that such allegations should be reported and investigated, with the accused staff suspended. However, both the Director of Nursing and the Administrator stated they were not made aware of the specific abuse allegation and therefore did not initiate an investigation. Facility records and Department of Health and Senior Services records confirmed the absence of a written investigation into the allegation.
Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to provide care for residents according to standards of practice and physician orders, resulting in deficiencies in wound care and medication administration. For Resident #6, the facility did not obtain wound care orders for all wounds, specifically for the open area on the buttock and left heel. Additionally, wound care was not documented on several occasions, indicating a lack of adherence to the prescribed treatment plan. Resident #7 also experienced incomplete documentation and execution of wound care orders, with staff failing to include the full physician's order for the right leg and not documenting the reason for holding treatment on specific dates. Resident #5's medication administration was inconsistent, with multiple instances of staff failing to document the administration of various medications, including antidepressants, blood thinners, and pain medications. This lack of documentation suggests that the medications may not have been administered as prescribed, potentially impacting the resident's health and treatment outcomes. Similarly, Resident #9 experienced numerous instances where staff did not document the administration of prescribed medications, including those for anxiety, depression, and pain management, further highlighting the facility's failure to adhere to physician orders and maintain accurate medical records. Interviews with facility staff, including a Certified Medication Technician and an LPN, revealed that if a medication is not documented as given, it is possibly not administered. The facility's Administrator and DON acknowledged that staff should follow physician orders and document wound care completion or provide a note explaining why it was not done. The facility's failure to ensure proper documentation and adherence to physician orders for wound care and medication administration represents a significant deficiency in providing standard care to residents.
Significant Medication Errors Due to Lack of Documentation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the lack of documentation for the administration of multiple medications for three residents. The facility's policies require that medications be administered as prescribed and documented immediately after administration. However, staff failed to document the administration of various medications, including those for critical conditions such as congestive heart failure, diabetes, and schizophrenia, for Residents #8, #9, and #5. Resident #8, who had a complex medical history including congestive heart failure, diabetes, and schizophrenia, had multiple instances where medications were not documented as administered. These included blood pressure medications, antipsychotics, and insulin, among others. The lack of documentation spanned several days and involved critical medications that required monitoring of vital signs, such as blood pressure and blood sugar levels, which were also not documented. Similarly, Resident #9, who was cognitively intact and had diagnoses including COPD and diabetes, had numerous instances of undocumented medication administration. This included antidiabetic medications, thyroid medications, and anticonvulsants. Resident #5, with a history of bacterial meningitis and sepsis, also had several undocumented doses of antibiotics and blood pressure medications. Interviews with facility staff confirmed that if a medication is not documented as given, it was possibly not administered, indicating a significant lapse in medication management and documentation practices.
Infection Control Lapses in Diabetes Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene and equipment sanitization protocols. Specifically, staff did not sanitize multi-use resident equipment between uses, did not place appropriate barriers for supplies, and failed to perform hand hygiene according to standards of practice while checking resident blood sugar levels and administering insulin. These deficiencies were observed in the care of four residents, all of whom had diabetes mellitus and were at risk for complications related to their condition. In one instance, an LPN was observed entering a resident's room to obtain a blood sugar reading without using a barrier for supplies, potentially contaminating the resident's table. The LPN also failed to perform hand hygiene after removing gloves and did not clean the glucometer before using it on another resident. Similar lapses were noted with other residents, where the LPN did not perform hand hygiene before or after resident contact, did not use gloves, and placed used equipment on surfaces without barriers, increasing the risk of cross-contamination. Interviews with staff, including CNAs, CMTs, and LPNs, revealed a lack of adherence to the facility's infection control policies. Staff acknowledged the importance of hand hygiene, using barriers, and cleaning equipment between uses, yet these practices were not consistently followed. The facility's administrator and DON also confirmed the expectations for hand hygiene and equipment sanitization, highlighting a disconnect between policy and practice.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care according to standards of practice for one resident. The resident, who was admitted for seven weeks of chemotherapy and radiation treatment, had a diagnosis that included a pressure ulcer in the sacral region. Despite having a physician's order to cleanse the coccyx wound with normal saline, apply Mepilex border, and change the dressing every three days or as needed, the staff did not document the completion of this treatment on several occasions, specifically on 12/05/24, 12/06/24, 12/07/24, 12/08/24, and 12/09/24. Additionally, the resident's care plan was not updated to include the pressure ulcer or the redness of the coccyx, which is a critical component of managing and preventing further deterioration of the wound. Interviews with the LPN and the facility's administrative staff confirmed that the staff should have followed the physician's orders for wound treatment and documented any changes or pertinent information regarding the wound. The failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and administration protocols, as evidenced by two main deficiencies. Firstly, a resident was observed with medication left at their bedside without a physician's order, which is against the facility's policy. The resident, who is cognitively intact and dependent on staff for various activities, reported that staff routinely left potassium supplements at their bedside for them to take later. Interviews with staff, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), confirmed that medications should not be left at the bedside and that there were no physician orders permitting such practice. Secondly, multiple observations revealed that medication carts were left unlocked and unattended, with medications accessible to unauthorized individuals. Specific instances included an Ozempic pen and insulin vials left on top of an unlocked cart, and several occasions where medication carts were left with drawers open and unattended. Staff interviews, including those with a CMT and the Administrator and Director of Nursing (DON), reiterated that medication carts should always be locked when not attended by authorized personnel.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for residents, as evidenced by multiple observations of unclean and disorganized conditions in various areas. On the 200 hall, a shower room was found with used towels, plastic gloves, and a bucket containing a rusty, dirty substance. The floor was soiled with an unknown substance. Similarly, the 600 hall shower room had a dirty spa tub with discolored water residue, stains, and bits of paper, along with a smear of dried substance resembling feces on the tub's edge. Used plastic gloves and paper towels were also found on the floor. Further observations revealed unsanitary conditions in other areas. The 500 hall shower room had a dirty whirlpool tub and brown/rusty stains on the shower walls. A resident's bathroom was found with soiled clothing and fecal matter on the floor, which had not been addressed by staff despite being reported. The 400 hall shower room had feces on a shower chair and dried fecal matter on the walls, with a noticeable odor. Additionally, the 300 hall shower room had rust/black substance around the shower tiles, a missing tile section, and feces under a shower chair. Interviews with housekeeping staff and supervisors indicated a lack of awareness and communication regarding the cleaning needs. Housekeepers followed a checklist but faced interruptions and were not always informed of priority cleaning situations. The Housekeeping Supervisor was unaware of specific issues, such as stains or rust in the showers, and there was no written policy for maintaining cleanliness. The facility's failure to provide sufficient housekeeping and maintenance services resulted in unsanitary conditions in resident access areas.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 117 citations issued within 25 miles in the last 12 months — including the 1 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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springfield Villa | 0.6 mi | ★★★★★ | 10 | 1 |
| Cox Medical Centers Meyer Orthopedic And Surgical | 0.8 mi | ★★★★★ | 1 | 0 |
| Birch Pointe Health And Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Maples Health And Rehabilitation, The | 1.6 mi | ★★★★★ | 0 | 0 |
| Springfield Rehabilitation & Health Care Center | 2 mi | ★★★★★ | 0 | 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.