Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Physical Rehabilitation And Wellness Center Of Spa during CMS and state inspections, most recent first.
A resident with muscular dystrophy, paraplegia, and severe mobility dependence was transferred with a Hoyer lift using a blue sling sized for much heavier residents than her documented weight. During a shower transfer with 2 CNAs, she slipped through the sling, fell to the floor, and sustained a hematoma to the back of her head; EMS was called and a CT later showed a small scalp hematoma.
A resident with dysphagia, functional quadriplegia, memory problems, and an active NPO order, dependent on enteral nutrition, was able to receive and consume a cereal bar and water provided by visiting church members. A CNA and an LPN later found the resident with part of the cereal bar in the mouth and an empty cup, and the resident could not identify who had given the items. After ingestion, the resident developed vomiting, sweating, clamminess, and gurgling, with critically elevated BP, and was sent to the hospital, where records documented vomiting, intubation for airway protection, and suspected aspiration pneumonia. Surveyors determined this lack of supervision and control over outside food and drink constituted Immediate Jeopardy related to accident hazards and supervision requirements.
Failure to Protect Resident from Sexual Abuse: The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident who had documented hypersexual and sexually inappropriate behaviors, including entering rooms of residents of the opposite sex. The abused resident also had dementia and other psychiatric diagnoses, and the survey cited the issue as an IJ under F600 for failure to ensure freedom from abuse.
Dietary staff were observed plating residents’ breakfast trays without proper beard nets, and one aide handled food without gloves. In the Unit 100 snack/nourishment room, the refrigerator was found at an improper temperature, the temperature log was incomplete, and an unlabeled milkshake was stored inside. Staff gave differing accounts of who was responsible for checking temperatures and labeling items, while the ADM stated dietary staff were expected to check the refrigerator daily and report issues immediately.
Unsecured Medication Cart Computer Exposed Resident PHI: A medication cart computer screen was left unlocked and unattended in a hallway, displaying a resident's allergies, medication use, and the names and code statuses of several residents. An RN acknowledged the screen was not within her line of sight and that staff were required to lock or log off the computer when stepping away, and the UM, DON, and ADM all stated screens must be secured to protect resident PHI.
Failure to Maintain a Clean and Comfortable Bed for an Incontinent Resident: A resident with vascular dementia, moderate cognitive impairment, and frequent urinary incontinence was observed in bed with a visible urine stain under the pad, and the stained pad and sheets remained unchanged across multiple observations. Staff interviews showed the CNA did not notice the urine stain, while the UM said the condition was unacceptable and that the resident should have been cared for earlier.
A resident with osteoarthritis, repeated falls, intact cognition, and high fall risk status fell during a shower when a CNA did not lock the shower chair wheels before the resident tried to sit down. The chair rolled backward, and the resident fell on the back and buttocks without injury. The resident, CNA, and LPN all confirmed the chair was not locked, and the DON and Administrator stated staff were expected to lock the shower chair wheels.
A facility failed to provide a written bed hold policy to a resident during a hospital transfer, as required by their policy. The resident, who had no cognitive impairment, was not given the notification prior to discharge. Interviews revealed confusion among staff about who was responsible for providing the policy, with the BOM and Admissions Director both unclear on their roles. The Administrator confirmed the policy should have been reviewed with the resident, but it was not completed.
A facility failed to update a comprehensive care plan for a resident with aggressive behaviors following an incident. The resident, with conditions including aphasia and moderate cognitive impairment, did not have new psychosocial interventions added to their care plan. Staff interviews revealed that the responsibility to update the care plan was overlooked due to miscommunication and the absence of a full-time MDS nurse.
The facility failed to implement proper infection control measures during wound care and medication administration, leading to potential cross-contamination. A resident with a stage 4 sacral wound did not receive care under Enhanced Barrier Precautions, and several LPNs did not follow hand hygiene and PPE protocols during medication administration. Additionally, the facility did not complete yearly reviews of its infection control policies.
A resident experienced increased anxiety during a dressing change when two male ambulance attendants entered the room, despite the situation not being an emergency. The LPN held the privacy curtain but proceeded with the report to the attendants, causing the resident discomfort. The DON later confirmed the transport was urgent, not emergent, and the attendants could have waited.
A facility failed to honor a resident's preference for showers, providing only two showers over two months instead of the scheduled two per week. The resident, who was cognitively intact, expressed dissatisfaction with receiving bed baths instead. The Social Service Director confirmed the discrepancy, highlighting a lapse in adhering to the facility's policy on resident dignity and self-determination.
The facility failed to issue necessary SNFABN and NOMNC forms to two residents, leading to a lack of information about Medicare coverage and potential liability. One resident was not given a SNFABN due to no appeal being filed, and another was informed of their last covered day by phone but did not receive a SNFABN. The SSD misunderstood the requirements, believing SNFABNs were only needed if an appeal was filed.
A facility failed to provide a written baseline care plan to a resident within 48 hours of admission, as required by policy. The resident, who was cognitively intact, did not receive the care plan despite it being documented and signed by staff. Interviews revealed that the Social Services Director sometimes forgot to deliver the plan if the resident was not easily found, and the DON indicated that the Social Worker should seek help if needed.
A facility failed to include a resident's religious preferences in their care plan, despite the resident being a Muslim and the care plan listing Christian-based activities. Staff were unaware of the resident's religious preferences, which were documented in the profile. Additionally, the facility did not develop a care plan for another resident's stage four pressure ulcer, despite having physician orders and a wound management summary. These deficiencies indicate a lack of person-centered care.
A facility failed to obtain a physician's order before administering oxygen to a resident with conditions including diabetes, asthma, and atrial fibrillation. The resident, who was cognitively intact, was observed receiving oxygen at two liters per minute without an order, contrary to the facility's policy. Both the ADON and DON confirmed the absence of the required order.
A facility failed to ensure proper communication with a dialysis center for a resident with end-stage renal disease, leading to incomplete documentation of dialysis sessions. The resident's records lacked information on shunt site, lab values, medications, and other critical observations. The DON stated that nurses should obtain verbal reports and assess residents upon return, but this was not consistently done.
A facility failed to maintain a medication error rate below five percent, resulting in an 11.54% error rate. Errors included an LPN initially setting an incorrect insulin dose, another LPN administering a chewable aspirin without instructing the resident to chew, and an LPN attempting to administer unsecured medication not prepared by herself. These incidents were discussed with the DON and Administrator.
The facility failed to properly label and store medications, as observed during a survey. An LPN administered insulin without open and discard dates, and another LPN found unsecured medication meant for a resident. The DON acknowledged these issues, emphasizing the need for proper medication management.
A resident undergoing dialysis found her breakfast tray left in her room for several hours, resulting in cold and unappetizing food. Despite staff reheating the meals, the resident expressed dissatisfaction. Facility staff were unaware of the potential food safety issues, with the Registered Dietician acknowledging the risk of foodborne illness. The Dietary Manager initially did not see a problem, while the Administrator and DON later agreed that a fresh, hot meal should be provided upon the resident's return.
The facility failed to ensure proper handling of ready-to-eat foods, as staff were observed preparing plates without gloves, potentially risking foodborne illness transmission to residents. The Dietary Manager and Administrator acknowledged the need for gloves when handling such foods, highlighting a compliance gap with FDA regulations.
The facility failed to document consent or refusal for flu and pneumonia vaccinations for two residents. One resident's record showed no documentation of vaccination or refusal, while another had outdated vaccination records with no further documentation. Interviews revealed a lack of awareness and responsibility among staff regarding vaccination documentation.
The facility failed to ensure a clean and safe environment, with observations of dirty baseboards, chipped doors, patched walls, sticky floors, and grime-covered kitchen mats. The Administrator was unsure of the last floor cleaning, and the Housekeeping Director followed a routine cleaning schedule, while the Maintenance Director mentioned hiring help for special projects.
Incorrect Hoyer Sling Size Used During Transfer
Penalty
Summary
The facility failed to properly secure a resident for transfer using a Hoyer lift when staff used an incorrect sling size. Facility policy required staff to validate the resident’s weight, evaluate sling size, and choose the correct sling based on manufacturer recommendations, noting that slings that are too large may allow a person to slip out. The manufacturer’s sling chart showed that the blue XL sling used for the transfer was recommended for residents weighing 275 to 500 lbs, while the resident’s documented weight was 120.9 lbs, with prior weights of 116.4 lbs and 114.8 lbs, which aligned with the red sling recommended for 75 to 150 lbs. The resident had diagnoses including muscular dystrophy, low back pain, age-related physical debility, displaced fracture of the second cervical vertebra, cognitive communication deficit, muscle weakness, severe protein-calorie malnutrition, and paraplegia. MDS assessments showed intact cognition with BIMS scores of 15 out of 15, and the care plan directed staff to provide a Hoyer lift with 2 staff for all transfers. The resident’s care plan also identified a fall risk related to decreased mobility, weakness, deconditioning, and paraplegia. During a shower transfer, two CNAs used the blue crisscross sling, and the resident slipped through the bottom opening where her butt sat, fell to the floor, and struck her back and head. Staff documented that the resident was found lying on her back underneath the Hoyer lift with her legs still over one of the lift legs, and a hematoma formed to the right occipital area of the head. EMS was called, spinal precautions were initiated, and a CT scan later showed a small right posterior scalp hematoma. The DON stated the resident preferred that sling, and observation of the sling in the room showed it was blue with no serial number or identifiable marking.
Failure to Supervise NPO Resident Receiving Food and Fluids from Visitors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an NPO (nothing by mouth) resident was adequately supervised and protected from receiving food and fluids by mouth. The resident had an active physician’s order for NPO status and a care plan identifying high nutrition risk related to dysphagia and dependence on enteral nutrition for 100% of nutrient and energy needs, along with functional quadriplegia, history of subarachnoid hemorrhage, and epilepsy. The resident’s MDS indicated memory problems and use of a feeding tube as the nutritional approach. Despite these documented needs and restrictions, the resident was able to obtain and consume a cereal bar and water provided by visitors from a church group. On the day of the incident, a CNA observed the resident in his room with a cereal bar in his mouth and removed it from his hand, then notified the nurse. Another LPN later observed a cereal bar in a blue wrapper and a Styrofoam cup, noting that the resident had some of the bar in his mouth and some in his hand, with about half of the bar already in his mouth and all of the water gone. The resident could not identify who had given him the items. Staff interviews and the medical director’s account indicated that the food and drink were given by an unknown church member or group visiting the facility, and that such missionary visits were common on weekends. Following ingestion of the cereal bar and water, the resident developed symptoms including vomiting, sweating, clamminess, and gurgling, as documented in an Interact SBAR completed by an LPN. The SBAR noted that the event started with these symptoms after the resident ate a cereal bar from a church member, and recorded a blood pressure of 184/108. The NP reported being called by the nurse and informed that the NPO resident had received a cereal bar and water earlier that day and was now experiencing projectile vomiting and clamminess, and she ordered the resident to be sent to the hospital. Hospital records show the resident was admitted for vomiting, with a history of intracerebral hemorrhage, stroke, and schizophrenia, and was intubated for airway protection with suspected aspiration pneumonia, later requiring a tracheostomy. The state agency determined that the facility’s non-compliance with accident hazard and supervision requirements constituted Immediate Jeopardy at F689, effective as of an earlier date.
Removal Plan
- Assess the identified resident following the incident and implement provider orders.
- Discharge the resident to the hospital.
- Assess residents with nothing-by-mouth orders for change in condition, including changes in vital signs, respiratory distress, and gastrointestinal distress.
- Place a sign at the entrance of the facility instructing visitors and delivery drivers to consult with a nurse prior to delivering or providing food or drink to a resident.
- Post signs in rooms of residents with nothing-by-mouth orders identifying the resident as nothing by mouth and instructing staff/visitors to contact the nurse prior to providing any food or drink.
- Reeducate facility staff on the policy for food brought in from outside sources, including instructing staff to question visitors providing food/drink and to request visitors notify the nurse prior to providing food/drink to a resident.
- Complete audits of food distributed from outside sources to validate proper distribution.
- Hold an ad hoc QAPI meeting.
- Notify the Medical Director and provide updates on interventions completed.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident’s rights to be free from sexual abuse by another resident. The deficiency involved one of seven residents reviewed for abuse and was cited under F600, with the survey team determining that the failure had the likelihood of causing physical, mental, and psychosocial harm. The report states that the issue was identified as an Immediate Jeopardy related to freedom from abuse, neglect, and exploitation. The resident involved in the allegation had diagnoses including vascular dementia, psychosis, anxiety, and cognitive communication deficit, and had a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident’s care plan reflected impaired decision-making related to vascular dementia. The other resident involved had diagnoses including dementia, depression, anxiety disorder, a history of TIA and stroke without residual deficits, and a cognitive communication deficit, with a BIMS score of 11 out of 15 indicating moderate cognitive impairment. The record showed that staff had reported sexually inappropriate behavior by the resident accused of the abuse, including frequently entering rooms of residents of the opposite sex. The psychiatric follow-up addendum noted that there had been no witnessed incidents or assaults and that the resident had been easy to redirect. Despite these reports of hypersexual and sexually inappropriate behavior, the facility failed to protect the vulnerable resident from sexual abuse.
Improper Food Handling and Refrigerator Monitoring
Penalty
Summary
Dietary staff failed to follow proper personal hygiene practices while plating and arranging residents’ breakfast trays in the kitchen. During observation, two dietary aides were seen with facial hair and without beard nets while working with food, and one of them was also observed arranging food on residents’ plates without gloves. The facility policy required infection control and sanitation practices to be followed to minimize contamination of food and prevent food borne illness, and both aides later stated that beard nets should be worn whenever staff were in the kitchen and gloves should be worn when touching food. The facility also failed to ensure proper labeling and temperature control in the Unit 100 snack/nourishment room refrigerator. During observation, the refrigerator thermometer showed 50 degrees F, and an unlabeled fast-food milkshake with a straw was found in the refrigerator door. The temperature log for the unit refrigerator was incomplete, including an incomplete PM entry and an AM entry that did not document the month or year. Later in the day, an Out of Order sign was observed on the refrigerator, and the refrigerator temperature was still observed at 42 degrees F during interview. Facility staff gave differing accounts of responsibility for monitoring and labeling items in the unit refrigerator. An LPN stated kitchen staff were responsible for monitoring refrigerator temperatures and nursing staff were responsible for dating and labeling resident items, while the CDM stated dietary staff were responsible for completing temperature logs and ensuring food items they delivered were labeled and not expired. The DON stated nursing staff were responsible for dating and labeling resident items and that dietary and nursing staff should have monitored and completed the temperature logs. The Administrator stated dietary staff were responsible for checking refrigerator temperatures in snack/nourishment rooms and expected them to do so daily and notify a supervisor immediately if there was an issue.
Unsecured Medication Cart Computer Exposed Resident PHI
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when a medication cart computer screen was left unlocked and unattended in the hallway with resident protected health information displayed. Observation on 12/16/25 at 8:31 AM showed the unlocked screen on the medication cart displaying personal and medical information for Resident 107, including allergies and medication use, along with the names and code statuses of Residents 78, 121, 107, 70, and 27. During the observation, Unit Manager 3 saw the deficient practice, entered Resident 107's room, and verbally instructed RN 9 to step away and lock the computer screen. At 8:42 AM the screen was still unlocked, and Unit Manager 3 again instructed RN 9 to correct the issue. At 8:45 AM, RN 9 locked the screen and stated it was not within her line of sight and acknowledged staff were required to lock the screen or log out when stepping away to protect residents' PHI. RN 2, Unit Manager 3, the DON, and the Administrator all stated that computer screens on medication carts must be locked or otherwise secured when unattended to protect residents' PHI.
Failure to Maintain a Clean and Comfortable Bed for an Incontinent Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident with vascular dementia, disorientation, muscle weakness, moderate cognitive impairment, and frequent urinary incontinence. The resident’s care plan identified a risk for skin breakdown and complications related to bowel/bladder incontinence and directed staff to provide toileting and incontinence care as needed. The resident also required partial to moderate assistance with ADLs and toileting hygiene, and was observed wearing an incontinent brief while lying in bed with a visible urine stain under the bed pad. During observations, the resident’s bed pad and bed sheets remained visibly stained with urine over multiple checks, including while the resident was awake in bed, later sleeping in the same bed, and then sitting at the bedside eating lunch. The resident stated they were unsure when the bed had last been changed. Staff interviews showed the CNA assigned to the resident stated she had checked on the resident but did not notice urine stains, while the UM stated CNAs were expected to check residents every two hours and more often as needed and agreed the urine stain was unacceptable. The DON and ADM stated rounding frequency was based on the care plan and that staff should have observed and addressed the resident’s needs, but the resident’s bed remained unchanged during the observations.
Unsecured Shower Chair Led to Resident Fall
Penalty
Summary
The facility failed to ensure that the safety locks on a shower chair were properly locked and secure for one resident who was reviewed for accident hazards. The resident was admitted with diagnoses including osteoarthritis and repeated falls, had a BIMS score of 15 indicating intact cognition, required set up or clean-up assistance with showers/bathing, and was identified as a high fall risk on the Morse Fall Scale. The care plan documented a history of falling related to debility, osteoarthritis, and poor safety awareness, as well as self-care deficits related to poor activity tolerance and weakness. During a shower, the resident attempted to sit down on the shower chair and fell when the chair rolled backward because the wheels were not locked. The incident investigation documented that the resident sustained no injury and that the CNA was educated about ensuring the shower chair was locked before residents got up or sat down. In interviews, the resident stated the shower chair was not locked, the CNA acknowledged she did not lock it, and the LPN confirmed the CNA reported the chair was not locked when the resident fell. The DON and Administrator both stated their expectation was that staff lock the shower chair wheels.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident and/or their representative in a timely manner during a transfer to the hospital. According to the facility's policy, the bed hold policy should be provided at the time of admission and each time a resident leaves the facility for hospitalization or therapeutic leave. However, there was no documentation of a bed hold notification given to the resident or responsible party prior to the transfer. The resident, who had no cognitive impairment, was discharged to the hospital, but the facility did not follow its own procedures to ensure the bed hold policy was communicated. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for providing the bed hold policy. The Social Services Director indicated that the Business Office Manager (BOM) and Admissions were responsible for completing bed holds. However, the BOM, who was new to the role, believed that the admissions department was responsible for making contact. The Admissions Director, who had been at the facility for three months, stated she had never been instructed to handle bed holds and was unaware of the requirement to provide the policy at the time of transfer. The Administrator confirmed that the policy should have been reviewed with the resident upon leaving, regardless of the payor source, and acknowledged the task was not completed as there was no signed document available.
Failure to Update Care Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with aggressive behaviors. The resident, identified as R02, was admitted with diagnoses including aphasia, hemiplegia, and diabetes mellitus, and was moderately cognitively impaired. The care plan for R02, which was supposed to be updated following an incident on 11/29/24, did not include new psychosocial interventions or address the aggressive behavior. The existing care plan focused on monitoring the resident's mood and response to antidepressant medication but lacked specific interventions related to the incident. Interviews with facility staff revealed a breakdown in communication and responsibility. The Director of Social Services indicated that her assistant was supposed to update the care plan but failed to do so. Additionally, the Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's behaviors and necessary interventions. The absence of a full-time MDS nurse, who had recently quit, contributed to the oversight, as the part-time MDS nurse was not present to ensure the care plan was updated appropriately.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during wound care and medication administration, leading to potential cross-contamination. For Resident 25, who was cognitively intact and had a stage 4 sacral wound, the Wound Care Nurse did not adhere to Enhanced Barrier Precautions (EBP) by failing to wear a gown and gloves during dressing changes. The nurse also did not wait for the appropriate dry time after using a Sani Cloth on the overbed table and used the same 4x4 gauze to pat the wound dry multiple times. Additionally, the nurse used the same gloves to open a Medi Honey container and apply it to the wound, which was stored with supplies for other residents. During medication administration, several Licensed Practical Nurses (LPNs) did not follow proper hand hygiene and personal protective equipment protocols. One LPN did not wear a gown while administering tube feeding to a resident with a PEG tube, despite the presence of an EBP sign. The LPN also failed to perform hand hygiene after removing gloves and touched various surfaces with contaminated gloves. Another LPN reused gloves and did not perform hand hygiene between tasks, while a third LPN did not clean the rubber septum of an insulin pen before use and failed to perform hand hygiene after glove removal. The facility also failed to complete yearly reviews of its infection control policies and procedures, with the last revision occurring in July 2023. The Director of Nursing and the Administrator acknowledged that the policies should have been reviewed annually but were not. These lapses in infection control practices and policy reviews had the potential to spread infections among the vulnerable population in the facility.
Failure to Promote Resident Dignity During Dressing Change
Penalty
Summary
The facility failed to promote dignity during a dressing change for a resident, identified as R25, which resulted in increased anxiety for the resident. R25, who was cognitively intact with a BIMS score of 15 out of 15, was undergoing a dressing change for a skin tear with MASD and was at risk for developing a pressure ulcer. During the dressing change, LPN5 entered the room and informed R25 that her roommate was being transported to the hospital. Despite the situation not being an emergency, LPN5 allowed two male ambulance attendants to enter the room while holding the privacy curtain together, which caused R25 to become anxious and attempt to cover herself. The Wound Care Nurse later apologized to R25 for the presence of the male attendants during the dressing change. In an interview, R25 expressed discomfort with the timing of the attendants' entry, stating that the dressing change could have been completed in about five minutes. LPN5 justified her actions by stating that she prioritized emergencies, while the Director of Nursing later confirmed that the transport was urgent but not emergent, indicating that the attendants could have waited for the dressing change to be completed.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident's preference for showers was respected, thereby denying the resident the right to self-determination. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was supposed to receive showers twice a week as per physician orders. However, the resident reported not receiving the showers as scheduled and instead was given bed baths. The resident expressed dissatisfaction with the lack of showers, indicating a preference for showers over bed baths. Upon review, it was found that the resident had only received two showers over a two-month period, despite the care plan and physician orders specifying two showers per week. The Social Service Director confirmed the discrepancy after checking the shower book for October and November. The facility's policy emphasizes the importance of maintaining resident dignity and self-determination, yet the failure to adhere to the resident's shower schedule indicates a lapse in following these guidelines.
Failure to Issue Required Medicare Notices
Penalty
Summary
The facility failed to issue accurate Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) and Notices of Medicare Non-Coverage (NOMNC) to residents, which are essential for informing them about their Medicare coverage and potential liability for services not covered. Specifically, Resident 74 was admitted for Medicare A services and was issued a NOMNC on 09/19/24, but was not given a SNFABN because the resident did not appeal. This oversight indicates a lack of proper procedure in issuing necessary notices regardless of whether an appeal is filed. Similarly, Resident 75, who was admitted for Medicare A skilled services, was informed by phone that their last covered day for skilled services was 07/19/24. However, the resident received services through a managed care plan, and the facility failed to issue a SNFABN, again due to the absence of an appeal. During an interview, the Social Services Director (SSD) revealed a misunderstanding of the requirements, believing SNFABNs were only necessary if a resident appealed a NOMNC. This misunderstanding led to the failure to provide residents with all necessary information to make informed decisions about their care.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required by their policy. The resident in question, identified as R25, was admitted with diagnoses including diabetes mellitus, asthma, and atrial fibrillation. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the baseline care plan being documented and signed by staff members, there was no evidence that the written plan was given to the resident. Interviews conducted during the investigation revealed that the Social Services Director (SSD) sometimes forgot to provide the written care plan if the resident was not easily found in their room. The Director of Nursing (DON) acknowledged that the Social Worker was responsible for ensuring the resident received the written care plan and suggested that assistance should be sought if difficulties arose in completing this task. The resident, R25, confirmed not receiving any information from the staff regarding the care plan.
Failure to Address Religious Preferences and Pressure Ulcer in Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident, identified as R42, included the resident's religious preferences. R42, who was admitted with multiple diagnoses including chronic respiratory failure and chronic pain syndrome, was cognitively intact with a BIMS score of 15 out of 15. Despite this, the care plan did not accommodate R42's religious preferences, as the activities listed were Christian-based, and the resident, a Muslim, reported not being provided with appropriate religious accommodations. Interviews with facility staff, including the Activity Director, MDS Coordinator, Registered Dietician, Social Services Director, Dietary Manager, and the Administrator, revealed a lack of awareness regarding R42's religious preferences, which were documented in the resident's profile but not reflected in the care plan. Additionally, the facility failed to develop a comprehensive care plan for a stage four pressure ulcer for another resident, identified as R25. R25 was admitted with diagnoses including diabetes mellitus and atrial fibrillation and was coded as having a skin tear with MASD and at risk for developing a pressure ulcer. Despite having physician orders and a wound management summary indicating the presence of a stage four pressure wound, the care plan only addressed MASD and did not include a specific plan for the pressure ulcer. The Director of Nursing acknowledged the absence of a care plan for the pressure ulcer during an interview. These deficiencies highlight the facility's failure to provide person-centered care by not incorporating essential aspects of the residents' needs into their care plans. The lack of a comprehensive care plan for R42's religious preferences and R25's pressure ulcer had the potential to impact the residents' psychosocial and physical well-being, respectively.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order before administering oxygen to a resident, identified as R25, which was a requirement according to the facility's policy on oxygen therapy. R25 was admitted with diagnoses including diabetes mellitus, asthma, and atrial fibrillation, and was cognitively intact with a BIMS score of 15 out of 15. Observations on two separate occasions revealed that R25 was receiving oxygen at two liters per minute via nasal cannula. During an interview, the Assistant Director of Nursing confirmed that there was no order for the administration of oxygen for R25, acknowledging that an order was necessary. The Director of Nursing also confirmed that an order should have been in place for the administration of oxygen.
Lack of Communication with Dialysis Center for Resident Care
Penalty
Summary
The facility failed to ensure proper collaboration of care with the dialysis center for a resident requiring dialysis services. The resident, who was admitted with diagnoses of diabetes mellitus and end-stage renal disease, was receiving dialysis services while residing in the facility. The resident's physician orders indicated dialysis sessions on Mondays, Wednesdays, and Fridays. However, the Hemodialysis Communication Records provided by the facility showed missing documentation from the dialysis center on several dates. This included missing information about the shunt site, lab values, medications given, recommendations, food/fluid intake, and missing signatures and dates. Additionally, the communication sheets lacked documentation regarding the shunt observation, assessment of the auscultation of the bruit, palpation of thrill, and whether the resident reported pain. During an interview, the Director of Nursing stated that nurses are expected to call the dialysis center for a verbal report if the communication sheet is incomplete and to assess the resident upon their return to the facility. This lack of complete documentation and communication between the facility and the dialysis center had the potential to compromise the resident's care.
Medication Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.54% for three residents. The errors were identified during observations and interviews with staff. The first incident involved a Licensed Practical Nurse (LPN) administering insulin lispro to a resident. The nurse initially set the insulin pen to five units instead of the required four units, as per the resident's blood sugar level and physician's order. The error was corrected before administration, but it highlighted a lapse in attention to detail during medication preparation. In the second incident, another LPN administered a chewable aspirin to a resident without instructing them to chew it. The aspirin was given along with other tablets in a cup, and the nurse later acknowledged the mistake during an interview. This error demonstrated a failure to adhere to the correct administration route for the medication, as outlined in the facility's medication management policy. The third incident involved an LPN finding unlabeled and unsecured medication in a cart, which was meant for a resident who was away at therapy. The LPN attempted to administer the medication upon the resident's return, despite not having prepared it herself. This action was contrary to the facility's policy, which requires the same person to prepare, administer, and record medications. The Director of Nursing and the Administrator were informed of these errors, which were discussed during an interview.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which was observed during a survey. In one instance, an LPN was seen taking an insulin lispro pen from a plastic bag labeled with a different medication, Lantus Solostar. The insulin pen was labeled with the resident's name and medication name but lacked the open and discard dates. The LPN admitted to not knowing when the pen was first opened and intended to administer it despite the missing information, citing the resident's blood sugar levels as justification. The Infection Preventionist later confirmed that the pen should have been marked with the necessary dates and discarded if undated. In another instance, an LPN found an unlabeled and unsecured medication cup containing two tablets in the medication cart, which were meant for a resident but had not been administered at the scheduled time. The Director of Nursing and the Administrator were informed of these issues, and the DON expressed that the insulin pen should have been discarded and that medications should not be administered if not withdrawn by the administering nurse. These lapses in medication management had the potential to lead to residents receiving incorrect or contaminated medications.
Failure to Ensure Food Palatability and Safety for Dialysis Resident
Penalty
Summary
The facility failed to ensure food palatability and safety for a resident undergoing dialysis, which had the potential to affect the resident's nutritional intake and cause food-borne illnesses. The resident, who was cognitively intact and had end-stage renal disease, attended dialysis three times a week, leaving the facility early in the morning and returning mid-morning. Upon return, the resident found her breakfast tray, which had been left in her room for several hours, with the food cold and unappetizing. Although staff sometimes reheated the food, the resident expressed dissatisfaction with the quality and temperature of the meals. Interviews with facility staff revealed a lack of awareness and understanding of the potential food safety issues associated with leaving the breakfast tray in the resident's room for extended periods. The Registered Dietician acknowledged the risk of foodborne illness and the unpalatability of reheated eggs, while the Dietary Manager did not initially recognize the problem, believing reheating was sufficient. The Social Service Director was unaware of the issue, and the Administrator and Director of Nursing later agreed that the practice was inappropriate, indicating a need for a fresh, hot meal upon the resident's return from dialysis.
Improper Handling of Ready-to-Eat Foods in Kitchen
Penalty
Summary
The facility failed to ensure proper handling of ready-to-eat foods in the kitchen, which could potentially lead to the transmission of foodborne illnesses to 107 of the 112 residents. During an observation, staff members were seen preparing plates without wearing gloves, despite handling ready-to-eat foods such as hamburgers and French fries. A staff member was observed adjusting food items on plates with bare hands before placing a dome on top, which is against the FDA regulations that require suitable utensils or gloves when handling ready-to-eat foods. Interviews with the Dietary Manager (DM) and the Administrator and Director of Nursing (DON) revealed a lack of adherence to proper food handling protocols. The DM acknowledged that gloves should be worn when touching ready-to-eat foods, yet staff were not required to wear gloves when checking plates and placing domes. The Administrator and DON confirmed that staff should not touch ready-to-eat food with bare hands, indicating a gap in compliance with food safety standards.
Failure to Document Vaccination Consent or Refusal
Penalty
Summary
The facility failed to offer or document consent or refusal for flu and pneumonia vaccinations for two residents, R25 and R37, out of a sample of 25. R25's electronic medical record showed no documentation of administration or refusal of the flu or pneumococcal vaccine. R37's record indicated the resident received one dose of PPSV23 in 2013, but there was no further documentation of additional pneumococcal vaccinations or refusals. This lack of documentation and action was identified during a review of the residents' immunization records. Interviews with facility staff revealed a lack of awareness and responsibility regarding vaccination documentation. The Infection Preventionist (IP) nurse acknowledged being unaware of the failure to meet vaccination requirements, while the Director of Nursing (DON) confirmed that the IP nurse was responsible for managing vaccinations. This oversight had the potential to increase the risk of flu and pneumonia for the affected residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and visitors. Observations revealed that the hallways had baseboards with a build-up of dirt and debris, and a door to a resident's room was chipped with missing pieces of wood. In one resident's room, a wall appeared to be patched with a piece of sheetrock and some white paint. Another resident's room had a sticky floor and a thick buildup of dirt and debris on the baseboard, some of which was easily wiped away. Additionally, the kitchen mats were observed to be dirty with grime build-up, with thick layers of grime between the holes of the mats. During an interview, the Administrator was unsure of the last time the floors were stripped and cleaned, and mentioned that painting was part of a special project the facility was preparing to implement. The Housekeeping Director indicated that a routine cleaning schedule was followed, with deep cleaning completed in one to two rooms a day, starting from the ceiling down. The Maintenance Director stated that someone had been hired to assist with special projects like painting, stripping, and waxing the floors.
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 65 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spartanburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Falls Terrace | 1.8 mi | ★★★★★ | 0 | 0 |
| Spartanburg Hospital For Restorative Care Snf | 1.9 mi | ★★★★★ | 1 | 0 |
| Magnolia Manor - Spartanburg | 1.9 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Spartanburg | 2 mi | ★★★★★ | 4 | 0 |
| White Oak At North Grove Inc | 2.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.