Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring River Rehabilitation And Care Center during CMS and state inspections, most recent first.
Failure to Accurately Assess and Track a Worsening Pressure Ulcer: A resident with MS, dementia, malnutrition, incontinence, and poor mobility had a sacral/coccyx wound that was repeatedly documented with inconsistent descriptions such as abrasion, excoriation, small opening, and pressure ulcer. The wound was not consistently measured, staged, or tracked, and the DON stated the facility did not identify or document the wound’s characteristics before it was later diagnosed as an infected Stage 4 pressure ulcer with exposed bone, purulent drainage, cellulitis, and osteomyelitis.
The facility failed to maintain infection control for multiple residents. A resident with a worsening sacral wound and antibiotic orders was not tracked in the antibiotic stewardship or infection control programs and did not have EBP signage posted. Two other residents with sepsis, a stage 4 PU, ESBL, and E. coli also lacked EBP signs, and staff observed providing high-contact care without PPE.
A resident with MS, dementia, and CKD began hospice care, but the facility did not complete a significant change MDS to reflect the hospice status. The DON confirmed the resident was admitted to hospice and that no significant change MDS was completed.
A resident with hypertensive heart disease with heart failure had an order for diltiazem 120 mg daily, to be held if SBP was below 110, DBP below 60, or HR below 60. Staff administered the medication even though the resident's BP was 127/50 and HR was 52. The DON stated staff did not follow the physician's order and that the medication should not have been given outside the ordered parameters.
Incomplete Care Plans for Oxygen, Bed Rails, and Secured Unit Placement: The facility failed to develop and implement care plan interventions for a resident receiving continuous oxygen, a resident using quarter-sized bed rails for positioning, and three residents admitted directly to the secured/locked unit. An LPN confirmed the oxygen and bed rail use should have been addressed in care plans, and the DON confirmed the secured-unit residents lacked care plans addressing whether they continued to meet criteria for that placement and whether the interventions met their needs.
An infection prevention and control deficiency was cited after an LPN handled a resident’s charger and bedside table while wearing soiled gloves, an RN failed to sanitize a BP cuff and did not perform hand hygiene before and after med administration, and an LPN touched a resident and then handled the resident’s plate without washing or sanitizing hands. CDC guidance and the facility’s med administration policy both required hand hygiene and proper equipment sanitation.
Call Lights Not Within Reach: The facility failed to keep call lights within reach for 5 of 6 residents reviewed. A resident was observed with the call light on the floor under the bed, another had it on the floor at the head of the bed, two residents had call lights on the floor beside the bed, and another resident in a recliner had the call light on the floor under the bed. A CMA and CNAs confirmed the call lights were not within reach.
A resident on hospice with osteomyelitis, ESBL, severe PUs, and other comorbidities had chosen a hospice physician to manage her care, but the facility refused to accept that physician’s orders for PU treatment. Instead, due to the lack of an in-house wound care nurse, the facility arranged repeated out-of-town wound clinic visits for wound care, as confirmed by the POA, the hospice executive director, and the ADON, and documented in multiple progress notes.
The facility failed to provide written notification with an explanation before changing a resident’s room. Review of the room change communication form showed that neither the resident nor the representative was informed in advance. The resident’s representative later reported arriving for a visit, finding the resident no longer in the original room, and having to ask staff where the resident had been moved.
A resident with multiple complex conditions, including osteomyelitis, ESBL infection, stage 4 sacral PU, and an attention and concentration deficit, experienced a 22% weight loss over several months while under facility care. The care plan required staff to assist with meals, monitor intake, and offer alternate food choices when less than 50% of a meal was consumed, yet documentation showed numerous days when the resident ate under 50% of all meals with no recorded alternatives offered. Observation showed the resident eating only a small portion of a meal without assistance, and staff removed the tray without assessing hunger or offering substitute food, demonstrating failure to follow the ordered nutritional interventions.
A resident’s PASARR Level I screen incorrectly stated that the resident had no diagnosis or suspected mental illness, even though the resident’s record included depression and the administrator confirmed the PASARR was wrong. The resident was admitted with multiple diagnoses, including UTI, surgical aftercare, hypothyroidism, HTN, depression, and hyperlipidemia.
Failure to Administer Ordered Pain Medication: A resident with ESRD, DM2, a stage 3 PU, chronic respiratory failure, epilepsy, and mental health diagnoses sustained pelvic and sacral fractures after a fall and reported ongoing pain because she had not received her pain pill for several days. The MAR showed ordered oxycodone was not administered as prescribed, and an LPN stated she could not access the medication from the Pyxis and did not report the issue because the resident received the rest of her pain medication.
A resident with COPD, morbid obesity, fluid overload, SOB, DM2, and HF received a breakfast tray that did not match the menu provided to her. She was served oatmeal, hashbrowns, a small portion of egg, milk, and juice instead of biscuits with sausage and gravy, and stated that alternative meals were not offered and resident preferences were not asked about.
Failure to provide ordered weighted eating equipment for a resident during meals. During dining observation, a resident was seen trying to eat oatmeal with only a weighted fork available, and the resident stated she rarely gets a weighted spoon unless she asks for one. Record review showed a physician order for a weighted utensil during meals.
The facility failed to post the required daily nurse staffing information at the beginning of the shift, including the facility name, current date, RN, LPN, and CNA hours, and resident census. An observation at the main entrance showed the staffing sheet was dated the prior day, and the HRD confirmed it should be posted daily but was not.
Lunch Menu Not Posted: Surveyors observed that no lunch menu was posted in the dining room, and the DM confirmed the menu was not posted. The deficiency affected all 110 residents on the census and involved the facility’s failure to ensure menus were updated and posted correctly for residents’ nutritional needs and preferences.
The facility failed to provide sufficient nursing personnel and could not verify staffing compliance because PPD records, schedules, and timecards were missing for the period before the change of ownership. For the records available after the ownership change, the DON confirmed the reported RN staffing totals were inaccurate, with two 12-hour RN shifts documented as 36 hours instead of 24 hours.
Improper hand hygiene and food handling occurred during meal service when CNAs touched chairs, a resident's arm, and other dirty surfaces, then served drinks and lunch without washing or sanitizing their hands. Staff also handled residents' cups and bowls by the top rim while placing them on the table. The DS confirmed that staff should wash or sanitize hands after touching dirty surfaces and handling food items and trays.
Failure to report incidents, submit follow-up reports, and maintain administrative oversight: The DOO and ADM did not ensure serious injury incidents were reported to the State Survey Agency on time, and multiple reportable incidents had completed investigations with no evidence the required five-day follow-up results were submitted. The DOO also had not notified the state licensing office of the ADM's extended leave, there was no interim ADM in place, and the DOO attempted to limit surveyors' access to the facility and resident records beyond the original complaint scope.
The facility failed to ensure the governing body appointed a properly licensed administrator responsible for facility management. A license for the listed ADM was observed behind the reception area, but the DOO stated the ADM was on leave and not available, there was no interim administrator, and she was not licensed as an administrator in the state. A CNA stated she had not seen anyone acting in an administrative capacity since before the change in ownership.
The facility failed to timely report incidents involving serious bodily injury to the State Agency for two residents. One resident sustained a compression fracture of L2 after a fall, and another resident sustained a rib fracture after a fall, but both reports were submitted days after the incidents instead of within the required 2-hour timeframe. The DOO stated the DON completes the reporting process and believed it was being done correctly.
Failure to Submit Investigation Results to State Survey Agency: The facility completed investigations for multiple reportable incidents involving five residents, but there was no evidence the results were submitted to the State Survey Agency within the required timeframe. The DOO confirmed the facility was responsible for sending the five-day follow-up reports but could not verify that the investigation results had been submitted.
A resident with respiratory failure, emphysema, heart failure, and dementia was served lunch without a drink and asked twice for something to drink before finishing the meal. Her care plan and MD order directed staff to encourage fluids during meals, and an LPN confirmed she ate without a drink available. Another resident with lumbar fractures, osteoporosis, morbid obesity, weakness, reduced mobility, and moderate cognitive impairment was dependent on staff for toileting and was left on the toilet for an undetermined extended period, causing pain; the DOO could not produce the complete record, and the ADM stated a resident should never be left on the toilet that long.
The facility failed to provide timely access to a resident’s complete EHR when the State Agency requested it. The DOO stated the prior owners were not providing full access to records for residents admitted before the ownership change, and the resident’s EHR was not fully available until 36 days after the initial request.
Call lights were not within reach for several residents in their rooms. Four residents were observed in bed with call lights hanging on a wall fixture near the ceiling, and another resident had a call light wrapped around the bed rail and resting near the floor. An LPN confirmed that residents not having accessible call lights did not meet expectations.
A resident was observed in a wheelchair moving through multiple common areas with a urine bag that was about one-quarter full and not covered. The SSD later confirmed the bag was uncovered and stated it should have been covered.
Failure to provide appropriate foot care occurred for a resident with osteomyelitis, pressure ulcers, a T1 compression fracture, and a cognitive communication deficit. The resident had MD orders for podiatry wound care and toenail care, but the EHR contained no podiatry notes or visits, and a photo showed long, overgrown toenails. An LVN stated staff may do nail care unless nails are too thick and hard, but could not confirm when the resident’s nails were last trimmed.
Failure to provide ordered continuous oxygen: A resident with acute and chronic respiratory failure with hypoxia, emphysema, heart failure, and dementia had an order for continuous O2 at 5 L/min via NC. During observation, the resident was in the dining room without an O2 tank or concentrator nearby and was not wearing a nasal cannula. An LPN confirmed the resident did not have access to supplemental oxygen despite the continuous O2 order.
Failure to Post Daily Nurse Staffing Data: The facility did not post the required nurse staffing information at the beginning of the shift. An observation at the main entrance showed the staffing sheet was dated the prior day, and a receptionist confirmed the sheet should be posted daily but was not.
An LPN left a pre-poured medicine cup containing Nystatin powder on a resident's dresser instead of securing it. During observation, surveyors found the medication in the room, and the LPN stated it should not have been left there.
A resident with paraplegia, cellulitis, and diabetes was discharged without confirmation that home health services were arranged, despite physician orders and a care plan indicating the need for such services. Facility staff could not verify that the referral to the home health agency was sent or received, and the agency had no record of receiving the referral or admitting the resident.
Two residents with significant medical needs did not have access to a functioning call light system in their rooms, as confirmed by both staff and direct observation. The facility's policy requires working call lights or alternative communication devices, but these were not provided or maintained for the affected residents.
The facility failed to maintain complete and accurate medical records for two residents. One resident's records lacked documentation of a change of condition and the reason for hospital transfer due to shortness of breath. Another resident's records did not describe events leading to a change in condition and death, despite a hospice referral. The DON confirmed the absence of necessary documentation.
A resident with a complex medical history developed a fever, and the facility failed to notify the physician as required by the resident's care plan. Despite orders to contact the physician before administering acetaminophen for fever, nursing staff gave the medication without notification. Documentation confirmed the oversight, and interviews with the DON and medical director acknowledged the failure to follow physician orders.
A resident with dementia and other health issues was administered acetaminophen for a fever without notifying the physician, contrary to medical orders. The facility's staff documented the administration and effectiveness of the medication but failed to follow the order to contact the provider when the resident developed a fever. The medical director confirmed that the staff should have adhered to the physician's instructions.
The facility did not ensure that the consultant pharmacist's recommendations from monthly drug regimen reviews were reviewed by the physician. The DON and Administrator confirmed the lack of documentation and completion of these reviews before November 2024, potentially affecting all 96 residents.
The facility failed to provide adequate support staff for food and nutrition services, leading to delayed meal services. Observations showed meals were served significantly later than scheduled, causing frustration among residents. One resident vocalized and banged on the table due to delays, while another fell asleep waiting for assistance. The Administrator acknowledged the issue of late meal service.
The facility did not have a QAPI plan in place, affecting all 96 residents. The Administrator confirmed the absence of a QAPI plan, records, and monitoring system since July 2024. Despite a policy commitment to QAPI principles, the facility failed to implement these across care and service areas.
The facility failed to implement an effective infection prevention and control program, as observed by surveyors. A Unit Secretary entered rooms with special precautions without PPE, and PPE disposal containers were incorrectly placed outside rooms. The DON confirmed the absence of necessary documentation and program implementation due to previous management lapses.
The facility did not implement a comprehensive antibiotic stewardship program, affecting all 96 residents. The DON admitted to the lack of documentation for the program, which was not in place before November 2024. The facility's policy requires an ASP with protocols and monitoring, with the IP responsible for the program and the Administrator accountable for compliance.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented care needs. One resident's MDS inaccurately stated bedrails were not in use, another's was not updated after returning to the facility, and a third's incorrectly indicated dialysis treatment. These inaccuracies were confirmed by the DON.
The facility failed to complete comprehensive care plans for three residents, affecting the implementation of preventative measures. One resident's care plan omitted prescribed medications, another's lacked focus, goals, and interventions, and a third's did not include Foley Catheter care. The DON confirmed these deficiencies.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their care needs. One resident's plan lacked interventions for pain management, another's was incomplete for anti-depressant use, a third's did not reflect a left ankle fracture, and a fourth's was not updated for Foley Catheter use. The DON confirmed these omissions, indicating care plans were not updated as required.
A facility failed to provide proper Foley catheter care for a resident with chronic urinary issues, leading to a deficiency. The resident's catheter care orders were incomplete, lacking details such as catheter and balloon size, and necessary maintenance orders were not documented. The DON confirmed the oversight, highlighting the importance of proper documentation and care for residents with chronic conditions.
A medication error occurred when an RN mixed Guaifenesin and Lamotrigine in a single cup for a resident's feeding tube, contrary to the facility's policy requiring separate administration. This resulted in a medication error rate of 6.45%, exceeding the acceptable threshold.
The facility failed to ensure that medications and medical supplies in the North Medication Storage room were not expired. Observations revealed expired laxative enemas, Ibuprofen, and needless connectors. A registered nurse confirmed that these items should have been discarded.
The facility failed to ensure that two residents had completed and signed consent or refusal forms for the pneumococcal vaccine. One resident had not been offered the vaccine since 2019, and another resident's records lacked evidence of the vaccine being offered. The facility's policy requires offering the vaccine after education but does not specify the frequency.
The facility failed to offer COVID-19 vaccinations to three residents, as their EHRs showed no evidence of offers after their last vaccinations in 2021 and 2022. This was confirmed by the DON, despite the facility's policy requiring adherence to CDC guidelines for vaccination in LTC settings.
A facility failed to ensure a resident was free from unauthorized physical restraints, specifically bed rails, which were used without orders, consent, or documentation. The resident's records indicated a preference against bed rails, and the MDS assessment did not document their use. The DON confirmed the lack of authorization for the bed rails.
A resident with multiple health conditions, including MS and anxiety disorder, was found smoking in his room despite requiring supervision. The facility's care plan stated smoking materials should be kept at the nurses' station, but the resident had access to them, leading to unsupervised smoking. The facility had previously allowed residents to hold their smoking supplies, contributing to this deficiency.
Failure to Accurately Assess and Track Worsening Pressure Ulcer
Penalty
Summary
The facility failed to accurately identify, assess, measure, stage, monitor, document, report, and adjust care for a resident’s coccyx/sacral pressure ulcer. The resident had multiple sclerosis, dementia, protein-calorie malnutrition, bowel incontinence, poor mobility, and a history of a sacral pressure ulcer on admission. The care plan identified the resident as at risk for skin impairment and included interventions such as pressure-relieving devices, frequent repositioning, keeping skin clean and dry, and weekly skin checks, but the wound documentation did not consistently reflect the wound’s location, characteristics, or progression. Record review showed the resident’s sacral/coccyx skin issue was repeatedly described in inconsistent terms, including abrasion, excoriation, small opening, and pressure ulcer, with several entries stating that the wound was stable, improved, or resolved. One skin check noted a pressure ulcer on the coccyx with no measurements documented and a note that the wound nurse would measure it. Later documentation described the wound as an excoriation with a small opening, then as a wound measuring 3.5 cm by 5.5 cm with 50% epithelial tissue and light clear drainage. The facility’s records did not show consistent staging or accurate tracking of the wound’s worsening condition before it was later identified as a Stage 4 pressure ulcer with exposed bone, purulent drainage, cellulitis, and concern for osteomyelitis. The resident’s hospice and wound clinic records documented a large, non-healing sacral wound with purulent drainage, odor, necrotic tissue, and progressive deterioration. The wound clinic measured the wound as a Stage 4 pressure ulcer with exposed bone and cellulitic surrounding tissue and sent the resident to the emergency department. The emergency department documented a Stage 4 decubitus ulcer with purulent drainage, foul odor, exposed bone, erythema, tachycardia, hypotension, high white blood cell count, and osteomyelitis. During survey interviews, the DON stated the facility did not identify or document any characteristics of the wound prior to the hospital physician diagnosing it as an infected Stage 4 pressure ulcer, and there was no documented evidence that staff notified the physician of the wound’s progression.
Infection Control and Enhanced Barrier Precautions Not Followed
Penalty
Summary
The facility failed to maintain an effective, comprehensive infection prevention and control program for three residents. For one resident with a sacral wound that progressed from excoriation to a stage 4 pressure injury, the record showed orders for Bactrim and later Doxycycline, but the resident was not included in the antibiotic stewardship monitoring program and was not tracked in the facility’s infection control program for February, March, and April 2026. The facility also did not have enhanced barrier precautions in place for this resident during those months, and a CNA confirmed there was no EBP sign posted on the resident’s door. For another resident admitted with sepsis, a stage 4 sacral pressure ulcer, and need for assistance with personal care, an OT observed providing high-contact care and confirmed she was not wearing PPE, and there was no EBP sign posted. For a third resident admitted with ESBL resistance and unspecified E. coli, the physician ordered enhanced barrier precautions with a sign on the door and gown and gloves for all high-contact care, but a CNA confirmed there was no EBP sign posted and that she performed high-contact care during a brief change without PPE.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change MDS within 14 days after a resident began hospice care. Record review showed the resident was admitted with diagnoses of MS, dementia, and CKD. The Hospice Election Form was dated 03/26/26 and showed hospice care began on 03/27/26, but the most recent MDS assessment indicated the resident was not on hospice. During an interview on 05/14/26 at 4:10 pm, the DON stated that the resident was admitted to hospice on 03/27/26 and did not have a significant change MDS to reflect hospice care.
Medication Given Outside Ordered Blood Pressure and Heart Rate Parameters
Penalty
Summary
The facility failed to administer medication according to physician orders for one resident with hypertensive heart disease with heart failure. The resident had an order for diltiazem 120 mg once daily, with instructions to hold the medication if systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60. The MAR showed staff administered diltiazem even though the resident's blood pressure was 127/50 and heart rate was 52, which was outside the ordered parameters. During interview, the DON stated staff did not follow the physician's order when they gave the medication and that it was expected the medication would not be administered when the resident's blood pressure and heart rate were outside the parameters.
Incomplete Care Plans for Oxygen, Bed Rails, and Secured Unit Placement
Penalty
Summary
The facility failed to develop and implement accurate, comprehensive care plans for multiple residents. For one resident with an order for oxygen at 3 liters per minute continuously via nasal cannula, the care plan last revised on 02/25/26 did not include any interventions for oxygen therapy. During observation on 03/22/26, the resident was in bed with oxygen in place, and an LPN confirmed the resident wears oxygen and should have a care plan with interventions for its use. For another resident, the care plan did not include interventions for the use of quarter-sized bed rails, even though the medical record contained an order for quarter-sized bed rails as an enabler for turning and repositioning in bed, and an LPN confirmed the resident uses them and should have a care plan in place. The facility also failed to include care plan interventions for placement in the secured/locked unit for three residents. One resident with diagnoses including vascular dementia with psychotic disturbance, GERD, fibromyalgia, hyperlipidemia, and psychosis had no care plan addressing secured/locked unit placement. Another resident with ESRD, DM2, insomnia, dementia with agitation, and major depressive disorder also had no care plan for secured/locked unit placement. A third resident with COPD, depression, muscle wasting/atrophy in both legs, and dementia with agitation likewise had no care plan for secured/locked unit placement. The DON confirmed that each of these residents was admitted directly to the secured/locked unit and did not have a care plan that was implemented and reviewed to address whether they continued to meet criteria for remaining there or whether the interventions continued to meet their needs.
Infection Control Lapses During Care, Medication Pass, and Meal Service
Penalty
Summary
Provide and implement an infection prevention and control program was cited after record review and interview showed multiple lapses in infection control practices. During ADL care for R #1, an LPN donned clean gloves and a gown, performed peri-care, then handled the resident’s phone charger and moved a bedside table while still wearing soiled gloves. CDC hand hygiene guidance reviewed in the record stated that if gloves become soiled with blood or body fluids after a task, the gloves should be removed, hands sanitized, and clean gloves put on. For R #42, an RN did not sanitize a blood pressure cuff before using it and did not cleanse it after use during medication administration observations. The record also showed the RN failed to sanitize hands before preparing medications and after administering medications, despite the facility’s medication administration policy stating that staff will wash hands prior to and after medication administration. For R #27, during lunch dining services, an LPN touched the resident’s leg, moved the resident and wheelchair closer to the table, and then touched the resident’s plate without washing or sanitizing hands. The LPN later confirmed that staff should sanitize or wash hands after touching dirty surfaces and handling food items and trays.
Call Lights Not Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for 5 of 6 residents reviewed for call lights, including R #6, R #30, R #39, R #54, and R #100. During observations on 03/21/26, R #39 was lying on her bed with the call light on the floor underneath the bed, R #6 was lying in bed with the call light on the floor at the head of the bed, R #30 and R #100 were both lying in bed with their call lights on the floor next to the bed, and R #54 was lying in a recliner next to her bed with the call light on the floor underneath the bed. CMA #1 and CNA #1 and CNA #2 each confirmed that the call lights were not within reach and should have been.
Failure to Honor Hospice Physician Choice for Wound Care Management
Penalty
Summary
The facility failed to honor a resident’s right to choose her attending physician by refusing to accept medical orders from her selected hospice physician for treatment of her pressure ulcers. The resident was admitted with multiple serious conditions, including osteomyelitis, ESBL, an unstageable right heel pressure ulcer, a stage 4 sacral pressure ulcer, hypertensive heart disease without heart failure, a cutaneous abscess of the buttock, and an attention and concentration deficit. Her record showed an order for admission to hospice care, and the resident’s Power of Attorney reported that hospice had been chosen so that the hospice physician would manage her care. However, the POA stated that the facility would not accept the hospice physician’s orders for pressure ulcer care and instead required the resident to attend appointments at an out-of-town wound clinic. The Hospice Executive Director confirmed that the facility contacted her to obtain permission to send the resident to a wound clinic because they did not have anyone in-house to provide the needed wound care. She explained that facility nurses are responsible for providing continuous wound care, with a hospice nurse providing wound care and measurements once weekly, yet the facility continued to send the resident to the wound clinic despite her being on hospice. The ADON stated that the resident was going to the wound clinic because the facility did not have a wound care nurse. Progress notes documented multiple dates on which the resident had out-of-town wound clinic appointments, demonstrating the facility’s ongoing reliance on the clinic rather than accepting and implementing the hospice physician’s orders for pressure ulcer management.
Failure to Provide Required Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notification with an explanation prior to a room change for one resident, identified as R #7. Record review of the facility’s communication form for room change notification dated 02/02/26 showed that neither R #7 nor her representative was informed in advance of the room change. During an interview on 03/24/26 at 1:47 p.m., R #7’s representative reported that the facility did not notify him before moving the resident to a new room and that, upon arriving for a visit, he went to the resident’s former room, found it empty, and had to ask facility staff where the resident had been moved. The report notes that, as a result of the facility’s failure to notify the resident and representative in writing, the resident and/or representative could experience confusion and frustration.
Failure to Follow Nutrition Care Plan Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident by not following the resident’s diet order and nutritional care plan, resulting in significant weight loss. The resident was admitted with multiple serious medical conditions, including osteomyelitis, ESBL infection, unstageable right heel PU, stage 4 sacral PU, hypertensive heart disease without heart failure, a cutaneous abscess of the buttock, and an attention and concentration deficit. The resident’s weight log showed a decline from 100.8 pounds to 78.6 pounds over six months, a 22.02% weight loss. The resident’s POA reported that the resident had lost about thirty pounds in the last few months. The resident’s care plan, revised on 01/08/26, directed staff to assist with meals using verbal and/or physical assistance, encourage the resident to come out of her room for meals, monitor intake at all meals, and offer alternate food choices if 50% of a meal was not consumed. The Nutrition – Amount Eaten log showed fourteen days in a one‑month period when the resident did not eat more than 50% of any meal that day. The electronic health record contained no documentation that alternative meal choices were offered on days when intake was less than 50%. During an observation, the resident received a breakfast tray and ate only a small portion of the meal without assistance, and staff later removed the tray without asking if she was still hungry or if she wanted an alternative food option.
Inaccurate PASARR Screening for Mental Illness
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for one resident reviewed. The resident was admitted with diagnoses including UTI, surgical aftercare, hypothyroidism, HTN, depression, and hyperlipidemia. Record review of the resident’s PASARR dated 03/04/26 showed that the Level I Identification Screen stated the resident did not have a diagnosis or suspected mental illness. During an interview on 04/01/26 at 12:21 pm, the administrator confirmed the resident did have a diagnosis of mental illness and that the PASARR was incorrect.
Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to effectively manage pain for a resident who had multiple diagnoses including ESRD, dependence on renal dialysis, DM2, a stage 3 pressure ulcer of the left buttock, chronic respiratory failure with hypoxia, epilepsy, generalized anxiety disorder, major depressive disorder, and bipolar disorder. After the resident fell while walking with her walker, she was sent to a local emergency department for evaluation after complaining of excruciating hip pain. Hospital discharge paperwork dated 03/08/26 showed she sustained a closed fracture of the right inferior pubic ramus and a closed fracture of the sacrum. Record review of the MAR showed an order dated 03/09/26 for oxycodone 10 mg every 4 hours as needed for moderate pain for 10 days, and the resident received one dose on 03/18/26 at 4:41 pm. She did not receive the medication on 03/19/26, had no order for it on 03/20/26, and after a new order dated 03/21/26 for oxycodone 5 mg every 6 hours as needed for pain for 14 days, she did not receive the medication on 03/21/26. During interview on 03/22/26, the resident stated she was in pain because she had not been given her pain pill for the past three days. An LPN stated she had not been able to access the oxycodone for the resident over the past few days and that another nurse would be pulling it from the Pyxis, and she did not report it because the resident got the rest of her pain medication.
Resident Meal Did Not Match Menu and Preferences Were Not Honored
Penalty
Summary
The facility failed to ensure that resident preferences were honored for R #106 when the breakfast tray provided did not match the menu given to the resident and alternative meals were not offered. R #106 was admitted with COPD, morbid obesity, fluid overload, shortness of breath, DM2, and heart failure. During observation and interview, R #106 received oatmeal, hashbrowns, a small portion of egg, milk, and juice, but stated the menu she had been given listed biscuits with sausage and gravy and that she did not receive any of that. R #106 also stated that residents are not asked about preferences, they just eat what is served, and that the menu rarely matches what is served. Record review of the March 2026 menu provided to R #106 showed biscuit with sausage gravy as the main course.
Failure to Provide Ordered Weighted Utensil During Meals
Penalty
Summary
The facility failed to provide assistive eating equipment for 1 of 5 residents reviewed during dining observation. During an observation and interview on 03/25/26 at 9:25 am, Resident #106 was seen trying to eat oatmeal with a weighted fork, and no other utensils were available to the resident. The resident stated that she rarely gets a weighted spoon unless she asks for one. Record review showed a physician order dated 01/26/26 for Resident #106 to use a weighted utensil during meals.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis at the beginning of the shift, including the facility name, current date, total number and actual hours worked by RN, LPN, and CNA staff directly responsible for resident care, and resident census. During observation on 03/21/26 at 10:57 am, the main entrance staffing data sheet was found dated 03/20/26. During an interview at 10:58 am, the Human Resources Director confirmed that the nursing staffing data sheet should be posted daily and that it was not. The deficiency was identified for a facility census of 110 residents.
Lunch Menu Not Posted
Penalty
Summary
The facility failed to ensure that menus were updated and posted correctly for all 110 residents on the census provided by the DON on 03/21/26. During a random observation of the dining room at 12:11 pm, surveyors found that no lunch menu was posted. In an interview at 12:18 pm, the Dietary Manager confirmed that the lunch menu was not posted. The report states that menus must meet residents’ nutritional needs, be prepared in advance, be followed, be updated, and be reviewed by a dietician, and that the facility did not ensure the nutritional needs and preferences were met because the correct menu was not posted.
Inaccurate staffing records and missing PPD documentation
Penalty
Summary
The facility failed to provide sufficient nursing personnel to meet residents’ individualized care needs and failed to maintain accurate PPD documentation to show compliance with federal staffing standards. The deficiency affected all 87 residents in the facility. Record review showed that the facility did not have PPD documentation available for the period from 06/01/25 to 11/30/25, which was before the change of ownership on 12/01/25, and the facility also had no schedules or timecards available for that period. For the records that were available after the change of ownership, the facility’s PPD documentation was inaccurate. On 12/03/25, two RNs were scheduled for two 12-hour shifts totaling 24 hours, but 36 hours was reported. The same discrepancy was found on 12/10/25, when two RNs were scheduled for two 12-hour shifts totaling 24 hours, but 36 hours was reported. The DOO confirmed she could not provide PPD, schedules, or timecards from before 12/01/25, and the DON confirmed the staffing totals reported for 12/03/25 and 12/10/25 were not accurate.
Improper Hand Hygiene and Food Handling During Meal Service
Penalty
Summary
The facility failed to serve food under sanitary conditions when staff did not use proper hand hygiene and handling techniques while distributing meals in the dining room. During lunch service, CNA #1 moved a chair, moved a table, touched another chair at a different table, and then served drinks to residents without washing or sanitizing her hands. CNA #2 touched a resident's arm and chair while assisting the resident to sit, then served another resident lunch without sanitizing or washing her hands, and handled the resident's cup and bowl by the top rim when placing them on the table. CNA #3 pushed one resident's sleeve up her arm and then served another resident lunch without washing or sanitizing her hands, and also touched the resident's bowl by the top rim when placing it on the table. The Dietary Supervisor confirmed that staff should sanitize or wash their hands after touching dirty surfaces and handling food items and trays.
Failure to Report Incidents, Submit Follow-Up Reports, and Maintain Administrative Oversight
Penalty
Summary
The facility's DOO and ADM failed to manage the facility when they knew or should have known that incidents of abuse and significant injury were not being reported to the State Survey Agency within the required time. Record review showed that R #13 had an incident resulting in serious bodily injury on 01/12/26, but the report was not submitted until 01/21/26, about nine days later. R #14 had an incident resulting in serious bodily injury on 12/28/25, but the report was not submitted until 01/09/26, about 12 days later. During interview, the DOO stated the DON completes the reporting process and she thought it was being done correctly. The facility also failed to ensure or know whether five-day follow-up reports were submitted to the State Survey Agency after reportable incidents. Record review showed reportable incidents for R #12 on 12/04/25, 12/22/25, 01/07/26, and 01/11/26, and the five-day reports showed the investigations were completed, but there was no evidence the results were submitted to the State Survey Agency. Similar findings were noted for reportable incidents involving R #13, R #14, R #15, and R #16, where the investigations were completed but there was no evidence the results were submitted. The DOO confirmed it was the facility's responsibility to submit the five-day follow-up report and stated she could not confirm whether the reports had been submitted or how they were supposed to be submitted. The facility further failed to notify the state licensing office of the ADM's extended leave of absence and did not have a current interim ADM in place. The DOO confirmed she had not contacted the state licensing office about the ADM's leave and stated she was not aware the facility needed to do so. She also confirmed the ADM had not been acting in the administrator role due to leave and that there was no current interim administrator at the facility. In addition, during the survey, the DOO had a staff member search for and bring the surveyors to the conference room and stated the surveyors did not have authority to walk through the facility or review resident charts unless related to the original complaints, even though the facility had been unable to provide surveyors access to view documents related to the complaint and had to reenter the facility to conduct a thorough investigation.
No Licensed Administrator Managing the Facility
Penalty
Summary
The facility failed to ensure the governing body appointed an administrator who was responsible for managing the facility. During observation, a license for the listed Administrator was seen hanging on the wall behind the reception area. In interviews, the Director of Operations stated the administrator was on vacation and not available, later confirmed the administrator was not available and that she was handling things, and then stated she was not and had not been the acting administrator. She also confirmed the listed Administrator had not been acting in the administrator role due to being on leave of absence, that there was no current interim administrator at the facility, and that she was not licensed as an administrator in the state. A CNA stated she had not seen any other person acting in an administrative capacity in the building since before the change in ownership occurred on 12/01/25.
Failure to Timely Report Serious Injury Incidents
Penalty
Summary
The facility failed to report allegations of abuse and incidents resulting in serious bodily injury to the State Agency within 2 hours for 2 of 5 residents reviewed for abuse and neglect. For R13, a facility incident report dated 01/12/26 documented a fall that resulted in a compression fracture of L2, and the report was not submitted to the State Survey Agency until 01/21/26, about 9 days later. For R14, a facility incident report dated 12/28/25 documented a fall that resulted in a rib fracture, and the report was not submitted to the State Survey Agency until 01/09/26, about 12 days later. During interview on 02/04/26, the DOO stated that the DON completes the reporting process for the facility and thought it was being done correctly.
Failure to Submit Investigation Results to State Survey Agency
Penalty
Summary
The facility failed to report the results of completed investigations to the State Survey Agency within five working days for five residents reviewed for abuse or neglect. Record review showed reportable incidents for one resident on 12/04/25, 12/22/25, 01/07/26, and 01/11/26; for a second resident on 01/12/26; for a third resident on 12/28/25; for a fourth resident on 01/15/26; and for a fifth resident on 12/07/25. For each of these incidents, the facility’s five-day reports showed the investigations were completed, but there was no evidence that the results of the investigations were submitted to the State Survey Agency. During an interview on 02/04/26 at 2:18 PM, the Director of Operations confirmed it was the facility’s responsibility to submit a five-day follow-up report with the results of the investigation to the state survey agency. She could not confirm that the results of the investigations had been submitted for the incidents involving the five residents listed above.
Failure to Provide Drinks at Meals and Timely Toileting Assistance
Penalty
Summary
The facility failed to provide quality of care for a resident with acute and chronic respiratory failure with hypoxia, emphysema, heart failure, and dementia when she was not assisted with a drink during mealtime. During a dining observation, the resident was served lunch and asked a CNA for something to drink when her meal was placed on the table. She asked again several minutes later, but the CNA walked by and began serving other residents without giving her a drink. Her care plan directed staff to encourage her to consume all fluids during meals and to offer and encourage fluids of choice, and a current medical order directed her to increase fluids as tolerated. An LPN later confirmed the resident was not served a drink with her meal and had finished eating without having a drink available. The facility also failed to provide timely assistance for another resident's toileting needs. That resident had diagnoses including wedge compression fractures of the lumbar spine, osteoporosis, morbid obesity, muscle weakness, reduced mobility, need for assistance with personal care, and abnormalities of gait and mobility. His MDS showed moderate cognitive impairment and that he was dependent on staff for toileting and hygiene. A progress note documented an incident in which he was assisted to the restroom, placed on the toilet, and left there for an undetermined and extended period of time; the nurse's evaluation noted he was experiencing pain due to staying on the toilet too long, but the location of the pain was not documented. During interview, the DOO stated she could not produce the resident's complete record and could not explain why he was left on the toilet, while the ADM stated a resident should never be left on the toilet for an extended period of time.
Failure to Provide Timely Access to Resident EHR
Penalty
Summary
The facility failed to ensure medical records were readily accessible for 1 resident, R #7, when staff did not provide timely access to the State Agency for the resident’s entire Electronic Health Record (EHR). Record review showed that the complete EHR was unavailable and inaccessible. During an interview, the Director of Operations stated she was unable to produce R #7’s record in its entirety and explained that the previous owners were not providing complete access to records for residents who were in the facility before the 12/01/25 change of ownership. In a later interview, the Director of Operations confirmed that the facility was then able to provide access for the State Agency to view R #7’s EHR, 36 days after the initial request.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents while they were in their rooms for 4 of 6 residents reviewed for call lights. During observations, R17, R18, R19, and R20 were each lying in bed with their call lights hanging on the light fixture attached to the wall near the ceiling. R21 was observed lying in bed with her call light wrapped around the bed rail several times and resting approximately two inches from the floor. During an interview, an LPN confirmed that it did not meet her expectations for residents not to have their call lights accessible.
Uncovered Urine Bag Observed on Resident in Common Areas
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when staff did not cover the resident’s urine bag. During a random observation on 02/03/26 at 11:43 am, R #15 was seen in a wheelchair traveling down the North hallway, across the lobby, up the South hallway, and into the activity area with a urine bag that was approximately one-quarter full and uncovered. During an interview on 02/03/26 at 11:56 am, the Social Services Director confirmed that R #15’s urine bag was not covered and stated that it should be.
Failure to Provide Ordered Podiatry and Toenail Care
Penalty
Summary
Provide appropriate foot care was not met for one resident who had orders for podiatry wound care and toenail care. The resident’s face sheet showed diagnoses including osteomyelitis, a pressure ulcer of the right heel, a stage 4 pressure ulcer of the sacral region, a wedge compression fracture of T1, and a cognitive communication deficit. Physician orders dated 09/23/25, 10/09/25, and 12/03/25 included podiatry for wound care and toenail care. A photo dated 11/17/25 showed the resident’s toenails were long and overgrown. The electronic health record did not contain any podiatry notes or visits. During interview on 12/31/25, an LVN stated staff can provide nail care unless the nails are too thick and hard, in which case residents are sent to podiatry for nail care, but she was unable to confirm when the resident’s nails were trimmed.
Failure to Provide Ordered Continuous Oxygen
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident who had diagnoses of acute and chronic respiratory failure with hypoxia, emphysema, heart failure, and dementia. The resident’s MDS indicated she used oxygen therapy, and her care plan directed staff to cue and remind her to wear her oxygen because she frequently forgot to keep it in, with oxygen ordered at 5 L/min via nasal cannula. The resident’s medical order required continuous oxygen at 5 L/min by nasal cannula. During a random observation in the dining room, the resident was seated in a wheelchair near the main entrance without an oxygen tank or concentrator in her immediate area and was not wearing a nasal cannula. An LPN later confirmed the resident did not have access to any type of supplemental oxygen in the dining room and that the resident had an order for continuous oxygen.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post nurse staffing data daily at the beginning of the shift with the required information, including the facility name, current date, total number and actual hours worked by RN, LPN, and CNA staff directly responsible for resident care per shift, and resident census. On 12/31/25 at 9:02 AM, an observation at the main entrance showed the nurse staffing data sheet was dated 12/30/25. During an interview at 9:21 AM the same day, the facility receptionist confirmed that the nursing staffing data sheet should be posted daily and was not.
Medication Left Unsecured in Resident Room
Penalty
Summary
The facility failed to ensure medications were administered and secured for 1 resident when staff left a pre-poured medication on the resident's dresser in the room. During a random observation on 02/03/26 at 10:00 am, surveyors found a medicine cup approximately halfway full of a white powder. During an interview at 10:23 am, an LPN identified the white powder as Nystatin powder, a medication used to treat skin infections, and stated the medication should not have been left on the resident's dresser.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were in place prior to the discharge of a resident who required ongoing care. The resident, who was admitted with paraplegia, cellulitis of the left lower limb, type 2 diabetes, and a need for assistance with personal care, had a documented goal to return to the community. The care plan and physician's note indicated that home health services were to be arranged upon discharge. However, the facility's records show that the referral to the home health agency (HHA) and the physician's orders were both dated on the day of discharge, with no confirmation that the HHA received or accepted the referral. Interviews with the facility's Social Services staff revealed that the resident initiated the discharge the day before leaving, and although the staff encouraged the resident to stay an additional day to allow time to arrange services, the resident agreed but was still discharged the following day. The Social Services staff could not provide evidence that the referral to the HHA was successfully sent or received. Additionally, the HHA representative confirmed that there were no records of the resident being admitted to their services or of receiving any orders for care.
Failure to Maintain Functioning Call Light System for Two Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents who required assistance. For the first resident, who had diagnoses including acute and chronic respiratory failure, major depressive disorder, epilepsy, generalized anxiety disorder, and required help with personal care, both the resident and a CNA observed that the call light in the resident's room did not activate the external light or provide any visible indication when pressed. This was confirmed during interviews and direct observation, with the CNA acknowledging the malfunction. For the second resident, who had Alzheimer's disease, dysphagia, and other medical conditions, a similar issue was observed. The CNA attempted to activate the call light in the resident's room, but it did not function. The CNA stated an intention to document and report the issue. The facility's policy requires that each resident have access to a working call light or alternative communication device in their room, bathroom, and bathing area, and that staff promptly report and address any malfunctions. However, these requirements were not met for the two residents reviewed.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents, which could result in staff being unaware of the residents' daily care events, changes, and needs. For the first resident, the records lacked documentation of a change of condition, assessment of symptoms, or progress notes indicating the need for transfer due to shortness of breath. The resident's vital signs were last recorded without any indication of elevated temperatures or breathing issues, and there was no documentation explaining the reason for the ambulance call and subsequent hospital transfer. Interviews with staff confirmed the absence of necessary documentation and the expectation for records to be accurate and complete. For the second resident, the records did not include documentation or descriptions of events leading up to the resident's change in condition and subsequent death. The resident was referred to hospice services, but the electronic health record lacked details about the change from baseline condition. The Director of Nursing confirmed the absence of documentation and reiterated the expectation for complete and accurate records, especially when a resident experiences a change in condition.
Failure to Notify Physician of Resident's Fever
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who developed a fever. The resident, who had a complex medical history including unspecified dementia, muscle weakness, and a history of myocardial infarction, was admitted with physician orders for acetaminophen to be given as needed for pain or fever. However, a subsequent physician's recommendation specified that acetaminophen should only be given for pain, and the physician should be notified if a fever occurred. Despite this order, nursing staff administered acetaminophen to the resident on multiple occasions for a low-grade fever without notifying the physician. Documentation in the resident's electronic health record confirmed the administration of acetaminophen for fever and noted its effectiveness, but failed to record the physician's notification. Interviews with the Director of Nursing and the medical director confirmed that the physician should have been contacted when the resident developed a fever, indicating a lapse in following the physician's orders.
Failure to Follow Medical Orders and Notify Provider of Resident's Fever
Penalty
Summary
The facility failed to ensure quality care that meets professional standards for a resident when it did not follow a medical order and failed to notify the provider about changes in the resident's condition. The resident, who was admitted with multiple diagnoses including unspecified dementia, cognitive communication deficit, and muscle weakness, had a physician's order for acetaminophen to be given for pain only, with instructions to notify the physician if a fever occurred. Despite this, nursing staff administered acetaminophen for a low-grade fever without notifying the physician, as documented in the progress notes. The progress notes revealed that on multiple occasions, acetaminophen was administered to the resident for a fever, and the effectiveness was noted without documenting the new temperature or the reason for administration. The medical director confirmed that staff should have followed the physician's order and contacted the provider when the resident developed a fever. This failure to implement care orders and notify the provider about changes in the resident's vital signs could likely lead to staff and the physician being unaware of changes in the resident's condition, potentially worsening the resident's condition.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations from the monthly drug regimen reviews were reviewed and responded to by the physician. This deficiency was identified during interviews with the Director of Nursing (DON) and the Administrator. The DON admitted that there was no documentation available to show that medication regimen reviews were completed before November 2024, and although the pharmacist's printed recommendations could be provided, there was no evidence of physician review. The Administrator confirmed that the pharmacist's recommendations had not been completed prior to November 2024. This oversight has the potential to affect all 96 residents in the facility, as identified by the census provided by the Administrator.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support staff to effectively carry out the functions of the food and nutrition services, resulting in delayed meal services for residents. During an initial observation, the dining room doors were found closed and locked due to insufficient staffing. The facility's posted mealtimes were not adhered to, with meals being served significantly later than scheduled. For instance, lunch was served fifty-three minutes late, and breakfast was served forty-six minutes late. Interviews with residents revealed dissatisfaction with the delays, as one resident expressed frustration with the waiting times, and another resident adjusted her schedule due to the consistent lateness of meals. Further observations highlighted the impact of these delays on residents. During a dining observation, one resident began vocalizing and banging on the table due to the delay in meal service, while another resident fell asleep waiting for assistance with dinner. The Administrator acknowledged the issue of late meal service during an interview, indicating awareness of the problem. These findings demonstrate the facility's failure to meet the dietary needs of its residents in a timely manner due to inadequate staffing in the food and nutrition services department.
Failure to Implement and Maintain QAPI Plan
Penalty
Summary
The facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) Plan, which could potentially affect all 96 residents. During an interview, the Administrator admitted to not having a QAPI plan in place, lacking records of QAPI activities, and not having a QAPI monitoring system since July 2024. A review of the facility's policy for QAPI, dated October 2022, indicated a commitment to integrating QAPI principles across all care and service areas, including clinical care, quality of life, and patient choice. However, the absence of an active QAPI plan suggests a failure to adhere to these stated commitments.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to develop and implement an ongoing infection prevention and control program, which is crucial for preventing, recognizing, and controlling the onset and spread of infections. During observations, it was noted that signs indicating special contact and droplet precautions were present on the doorways of certain rooms. However, a Unit Secretary was observed entering these rooms without using the necessary personal protective equipment (PPE), which was available on carts outside the rooms. Additionally, containers for discarding used PPE were incorrectly placed outside the rooms, contrary to the facility's protocol that requires them to be inside the rooms for proper disposal before exiting. The Director of Nursing (DON) confirmed the absence of documentation for the infection prevention and control program, acknowledging that the program had not been developed or implemented prior to November 2024 due to the previous DON's failure to complete these duties. The facility's policy on Infection Control Outcome and Process Surveillance and Reporting outlines the responsibilities of the Infection Preventionist, including conducting regular outcome and process surveillance. However, the lack of documentation and adherence to these protocols indicates a significant lapse in infection control practices, potentially affecting all 96 residents in the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program, which is essential for optimizing infection treatment and minimizing adverse events from antibiotic use. This deficiency potentially affects all 96 residents in the facility. During an interview, the Director of Nursing (DON) admitted that there was no documentation available for the surveyors to review because the program had not been implemented before November 2024. The facility's policy, revised on 08/07/23, mandates the implementation of an Antibiotic Stewardship Program (ASP) with protocols and monitoring systems, with the Infection Preventionist (IP) responsible for the program and the Administrator ultimately accountable for compliance. The DON and Medical Director are tasked with executing ASP standards. The Administrator confirmed that the program was not in place prior to November 2024.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, which could lead to inadequate services and support. For one resident, the MDS assessment inaccurately indicated that bedrails were not in use, despite a bed safety assessment showing they were safe to use with monitoring. Another resident's MDS assessment was not updated after their return to the facility, and it incorrectly stated that bedrails were not in use, even though the resident had expressed a preference against them. The Director of Nursing confirmed these inaccuracies during an interview. Additionally, a third resident's MDS assessment inaccurately documented that the resident was on dialysis, although there were no medical orders for dialysis, and the resident had never been on dialysis. This discrepancy was also confirmed by the Director of Nursing. These inaccuracies in the MDS assessments highlight a failure in the facility's processes to ensure that residents' assessments are current and reflective of their actual care needs and preferences.
Incomplete Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure the completion of comprehensive care plans for three residents, which could potentially affect the staff's ability to implement necessary preventative measures for the residents' health and well-being. For one resident, the care plan did not include the use of anticoagulant and psychotropic medications, despite the resident being prescribed and administered Clopidogrel Bisulfate and Trazadone. The Director of Nursing (DON) confirmed the omission of these medications from the care plan, acknowledging the requirement for their inclusion. Another resident's care plan was found to be incomplete, lacking focus, goals, and interventions, despite the resident having multiple diagnoses, including diabetes with complications, sepsis, insomnia, and depression. Additionally, a third resident's care plan failed to include Foley Catheter care, despite the resident having conditions such as a urinary tract infection and obstructive uropathy. The DON verified the incompleteness of the care plans for all three residents.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in addressing their care needs. For one resident, the care plan did not include necessary interventions for monitoring pain, non-pharmacological interventions, and the effectiveness of pain medication, despite an active order for Hydrocodone-Acetaminophen. Another resident's care plan was incomplete regarding anti-depressant medication, lacking individualized focus, goals, and interventions. Additionally, a resident with a left ankle fracture did not have their care plan revised to reflect this condition, and another resident's care plan was not updated to include the use of a Foley Catheter. Interviews with the Director of Nursing (DON) confirmed these omissions, indicating that the care plans were not updated as required for changes in conditions or on a quarterly basis. The failure to revise these care plans could result in the residents' care and needs not being adequately addressed. The report highlights the lack of timely updates and revisions to care plans, which are essential for ensuring appropriate and effective care for residents with changing medical conditions.
Deficient Foley Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate Foley catheter care for a resident, leading to a deficiency in maintaining sanitary conditions and potentially increasing the risk of urinary tract infections. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy, adult failure to thrive, and chronic urinary issues, had an indwelling catheter upon admission. However, the facility did not have complete orders for the catheter care, including the size of the catheter and balloon, and the necessary maintenance orders were not input into the computer system. During interviews, the Director of Nursing confirmed that the orders for the resident's indwelling urinary catheter were incomplete and not properly documented. The resident had a history of chronic UTIs and was a chronic catheter patient, which underscores the importance of proper catheter care. The lack of complete and accurate orders for catheter maintenance, such as changing the Foley catheter every 30 days, measuring and recording urine output, and checking for leaks, contributed to the deficiency identified by the surveyors.
Medication Administration Error via Feeding Tube
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by three medication errors occurring out of 31 opportunities, resulting in an error rate of 6.45%. This deficiency was observed during medication administration for one of the eight residents involved. Specifically, a Registered Nurse (RN) administered medications incorrectly via a feeding tube. The RN mixed Guaifenesin liquid with a crushed Lamotrigine capsule in a single cup, contrary to the facility's policy, which mandates that each medication be administered separately to avoid interaction and clumping. The incident involved a resident who was prescribed Guaifenesin syrup and Keppra solution for congestion and seizures, respectively. The RN, during an interview, indicated that she believed it was acceptable to mix medications based on their quantity. However, the facility's policy clearly states that medications should be administered separately through enteral tubes. The Director of Nursing confirmed that the expectation is for medications to be given separately, highlighting a deviation from established protocols during the administration process.
Expired Medications and Supplies Found in Storage Room
Penalty
Summary
The facility failed to ensure that all medications and medical supplies in the North Medication Storage room were not expired. During an observation, three boxes of laxative enemas and one bottle of opened Ibuprofen were found to be expired. Additionally, four needless connectors were also discovered to be expired. These findings were confirmed during an interview with a registered nurse, who acknowledged that the expired items should have been discarded.
Deficiency in Pneumococcal Vaccination Consent Process
Penalty
Summary
The facility failed to ensure that residents had completed and signed consent or refusal forms for the pneumococcal vaccine, leading to a deficiency in their immunization process. Specifically, two residents, identified as R #38 and R #74, were not offered the pneumococcal vaccination as required. For R #38, the Electronic Health Record (EHR) showed that the last pneumococcal vaccine was administered on 04/25/19, and there was no evidence of the vaccine being offered again since then, despite the Director of Nursing (DON) acknowledging that it should have been offered in April 2024. Similarly, R #74's EHR lacked evidence of the pneumococcal vaccine being offered, which was confirmed by the DON. The facility's policy, revised on 09/13/24, mandates that pneumococcal vaccinations be offered after residents receive education, but it does not specify the frequency of these offers.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to three residents, as identified in a review of their Electronic Health Records (EHRs). Resident #36's EHR showed that the last COVID-19 vaccination was received in October 2022, and there was no evidence of an offer for vaccination after that date. Similarly, Resident #38's EHR indicated the last vaccination was in November 2021, with no subsequent offer documented. Resident #74's EHR also lacked any evidence of an offer for the COVID-19 vaccination. These findings were confirmed during an interview with the Director of Nursing (DON). The facility's COVID-19 Vaccination policy, revised in February 2024, mandates offering vaccinations in line with CDC recommendations. The CDC advises that individuals in long-term care settings receive COVID-19 vaccinations, with specific guidelines for different age groups. Despite these guidelines, the facility did not adhere to its policy, as evidenced by the lack of documentation and offers for vaccination to the residents in question.
Unauthorized Use of Bed Rails as Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically bed rails, without proper authorization. This deficiency was identified for one resident, who was observed with small side rails at the head of the bed used for positioning. A review of the resident's physician orders revealed that the use of bed rails was not ordered, and the resident's consent form indicated a preference against bed rails. Additionally, the 5-day MDS assessment did not document the use of bed rails. During an interview, the Director of Nursing confirmed the absence of orders, consent, and MDS documentation for bed rail use, acknowledging that bed rails should not have been used under these circumstances.
Resident Smokes Unsupervised in Room Due to Lapse in Policy Enforcement
Penalty
Summary
The facility failed to prevent a resident from smoking in his room, which is a violation of the facility's smoking policy. The resident, who has multiple diagnoses including multiple sclerosis, anxiety disorder, and major depressive disorder, was admitted to the facility with a requirement for supervision while smoking. Despite this, the resident was found to be in possession of cigarettes and a lighter, which he kept in his bag, and admitted to smoking in his room. This was confirmed by a Certified Nursing Assistant (CNA) who stated that the resident was aware that smoking inside the building was not allowed but continued to do so. The facility's comprehensive care plan for the resident, revised in November 2024, clearly stated that the resident may smoke only with supervision and that smoking materials should be maintained at the nurses' station. However, during an interview with the Administrator, it was revealed that the facility had allowed residents to hold their smoking supplies instead of keeping them locked at the nurses' station. This lapse in policy enforcement led to the resident smoking unsupervised in his room, creating a potential hazard.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roswell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa Maria Healthcare | 4.2 mi | ★★★★★ | 17 | 0 |
| Sunset Villa Healthcare | 4.5 mi | ★★★★★ | 10 | 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 August 2026) and official state health department websites.