Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring City Care And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Dignity During Meal Assistance: CNA A and CNA B were observed standing while feeding three residents instead of sitting at the bedside, despite facility policy stating residents who need meal assistance are to be fed with dignity. The residents had diagnoses including dementia, Alzheimer's disease, bipolar disorder, feeding difficulties, contractures, and protein-calorie malnutrition, and one resident stated she preferred staff to sit at her eye level.
The facility failed to accurately code MDS assessments for several residents. Four residents with PASRR Level II findings for serious mental illness, including Bipolar Disorder, were coded as not having that status on admission or annual MDSs, and an MDS Coordinator confirmed the assessments were inaccurate. Another resident with Cerebral Palsy, Down Syndrome, and Epilepsy had documented chipped and missing teeth, was observed with multiple missing teeth, and was noted by staff to eat a puree diet, yet the MDS recorded no dental concerns.
Failure to provide ADL assistance for grooming: A resident with dementia, stroke, and schizophrenia had severe cognitive impairment and needed substantial to maximal help with personal hygiene. Staff observed the resident with a large amount of facial hair, and the CNA, RN, and DON confirmed it had not been removed despite the resident being scheduled for showers and no documented refusal of grooming care.
An LPN left medication cups at a resident’s bedside for about an hour, including Ativan, Keppra, and lactulose, even though the resident had severe cognitive impairment and no order to self-administer medications. The DON confirmed this was against facility policy.
The facility failed to protect a cognitively impaired female resident from sexual abuse by a male resident and did not provide adequate supervision to prevent physical altercations between other residents. The incidents caused harm and distress to multiple residents, highlighting the need for better monitoring and management of residents with cognitive impairments and behavioral disturbances.
A resident reported a sexual assault by a male CNA, but the Behavioral Health Nurse Practitioner did not report the incident within the required 2-hour timeframe due to the resident's request for privacy. The facility's investigation did not substantiate the claim, and the Behavioral Health Nurse Practitioner has been barred from the facility for not following the reporting policy.
A resident with Parkinson's Disease and Epilepsy did not receive several prescribed medications on the evening of admission. The facility failed to administer available medications from the emergency drug kit (EDK) as ordered, resulting in a delay of approximately 24 hours before the medications were delivered from the pharmacy.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain dignity for 3 residents during meal assistance by having CNA A and CNA B stand while feeding residents instead of sitting at the bedside. Facility policy titled, "Assistance with Meals," dated 1/31/2025, stated residents shall receive assistance with meals in a manner that meets individual needs and that residents who cannot feed themselves will be fed with dignity. During observations, CNA A stood while feeding Resident #25, who had diagnoses including Alzheimer's Disease, Mood Disorder, and Unspecified Protein-Calorie Malnutrition and had an annual MDS showing severe cognitive impairment with independence in eating. CNA A also stood while feeding Resident #45, who had diagnoses including Dementia, contractures of the left hand and elbow, and feeding difficulties, and whose annual MDS showed severe cognitive impairment and substantial maximal assistance with eating. CNA B was observed standing while feeding Resident #62, who had diagnoses including Bipolar Disorder, Unspecified Protein-Calorie Malnutrition, Schizophrenia, and Feeding Difficulties, and whose admission MDS showed cognitive intactness and dependence with eating. CNA A stated he stood at times when assisting residents with eating and said he did not think he could get a chair in Resident #45's bedside area. CNA B stated staff are supposed to sit to assist a resident with eating and said she was getting ready to pull a chair up to Resident #62's bedside. The DON observed CNA A standing while assisting Resident #45 and confirmed the facility policy was for staff to sit while feeding a resident. Resident #62 stated staff stood at times to assist her with eating and that she preferred staff to sit at her eye level.
Inaccurate MDS Coding for PASRR Status and Dental Findings
Penalty
Summary
The facility failed to accurately complete MDS assessments for 5 residents by not reflecting required PASRR serious mental illness status for 4 residents and by not accurately documenting oral/dental status for 1 resident. Review of the RAI Manual showed that A1500 requires coding yes when PASRR Level II determined a resident has a serious mental illness, and Section L requires documentation of dental problems such as obvious broken natural teeth. Medical record review showed that Residents #32, #62, #2, and #59 each had diagnoses including Bipolar Disorder, and each had a PASRR Level II outcome indicating approval for nursing facility services and that the resident met criteria for serious mental illness. Despite this, their annual or admission MDS assessments were coded as no for whether the resident was currently considered by the state level II PASRR process to have serious mental illness. The MDS Coordinator later confirmed the assessments were inaccurate and did not reflect these residents' serious mental illness. For Resident #27, the record showed diagnoses including Cerebral Palsy, Down Syndrome, and Epilepsy, along with a dental note documenting a chipped tooth and multiple missing teeth. The resident was observed lying in bed smiling with multiple missing upper and lower teeth, and staff stated the resident had multiple missing teeth, ate a puree diet, ate 100% of meals, and had not had weight loss. However, both the annual and quarterly MDS assessments documented no dental concerns. The MDS Coordinator confirmed the MDS was inaccurate for dental status.
Failure to Provide ADL Assistance for Grooming
Penalty
Summary
The facility failed to provide assistance with activities of daily living for one dependent resident. Resident #42 was admitted with diagnoses including dementia, stroke, and schizophrenia. A quarterly MDS assessment showed a BIMS score of 4, indicating severe cognitive impairment, and the resident required substantial to maximal assistance with personal hygiene. The care plan stated that assistance with ADLs was to be provided as needed. During observation, Resident #42 was seen sitting in a wheelchair with a large amount of facial hair. The facility bathing schedule showed the resident was scheduled for showers on Monday and Thursday, and review of the nursing progress notes for the prior 30 days showed no documentation of refusal of shower or grooming care. A CNA stated that residents are to have facial hair removed on shower days and confirmed that Resident #42's facial hair had not been removed. An RN and the DON also observed and confirmed that Resident #42 had a large amount of facial hair that had not been removed.
Medications Left at Bedside for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure safe medication administration for one resident with severe cognitive impairment. Resident #44 was admitted with diagnoses including vascular dementia, anxiety disorder, other seizures, and unspecified cirrhosis of the liver. A quarterly MDS assessment showed a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The resident’s physician orders included levetiracetam 500 mg twice daily, lactulose solution 30 mL twice daily, and Ativan 0.5 mg twice daily, and there was no order authorizing the resident to self-administer medications. During an observation, two medicine cups were found on the resident’s overbed table, one containing two pills and the other containing a clear pale-yellow liquid. The LPN stated the cups had been left at the bedside for about an hour and identified the medications as Ativan, Keppra, and lactulose. She stated the resident was not assessed to self-administer medications and confirmed the medications should not have been left at the bedside. The DON later stated that leaving medications at the bedside with a resident who is not assessed to self-administer is against facility policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired female resident from sexual abuse by a cognitively impaired male resident. The male resident was found in the female resident's room with his pants and underpants down, and his hand inside her brief. The female resident was screaming for help, and the incident caused her mental distress. Despite the male resident's history of inappropriate sexual behavior, the facility did not provide adequate supervision or effective interventions to prevent the incident. The male resident was placed on one-on-one supervision only after the incident occurred. Additionally, the facility failed to protect other residents from physical abuse. One resident slapped another during a verbal altercation, and another resident sustained a bruise and skin tear when a fellow resident grabbed her arm. Both incidents involved residents with severe cognitive impairments, and the facility did not provide sufficient supervision to prevent these altercations. The facility's response to these incidents was inadequate, as they did not substantiate the allegations as abuse due to the cognitive impairments of the involved residents. The facility's failure to provide appropriate supervision and interventions for residents with known behavioral issues resulted in harm and distress to multiple residents. The incidents highlight the need for better monitoring and management of residents with cognitive impairments and behavioral disturbances to ensure their safety and well-being.
Failure to Report Allegation of Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required 2-hour timeframe for a resident diagnosed with Cerebral Palsy, PTSD, and other mental health conditions. The resident, who was cognitively intact, reported that a male CNA had sexually assaulted her during a brief change. The incident was initially disclosed to a Behavioral Health Nurse Practitioner, who did not report it immediately due to the resident's request for privacy. The resident later disclosed the incident to a CNA, who reported it to the facility administration. The facility's policy mandates that any abuse allegation must be reported to the state within 2 hours. However, the Behavioral Health Nurse Practitioner did not follow this policy, resulting in a delay in reporting the incident. The facility's Social Service Director and other staff members were eventually informed, but the required timely reporting was not adhered to. The facility's investigation did not substantiate the sexual abuse claim, citing a lack of witnesses and corroborating evidence. Interviews with various staff members, including the Social Service Director, CNA, and Administrator, revealed that the Behavioral Health Nurse Practitioner had not reported the incident as required. The Administrator acknowledged that the facility's abuse policy was not followed, leading to the failure to report the allegation within the federally mandated 2-hour timeframe. The Behavioral Health Nurse Practitioner has since been barred from the facility for not adhering to the reporting policy.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident. Resident #18, who had diagnoses including Parkinson's Disease, Epilepsy, and a history of falling, was admitted to the facility and had specific medication orders that were not followed. The medications included Amantadine, Carbidopa-Levodopa, Entacapone, Gabapentin, Levetiracetam, Metoprolol Tartrate, and Aspirin, among others. The resident's spouse reported that the resident had not received his medication by the morning after admission, and the resident was observed to be shaking. The Director of Nursing confirmed that several medications, which were available in the emergency drug kit (EDK), were not administered as ordered on the evening of the resident's admission. These included Levetiracetam, Metoprolol Tartrate, Aspirin, and Gabapentin. The medications were ordered from the pharmacy the morning after admission and were delivered later that day, resulting in a delay of approximately 24 hours from the time of admission. Interviews with the Medical Director and Pharmacist provided additional context. The Medical Director noted that missing a couple of doses of seizure and Parkinson's medications could potentially increase tremors but would not cause harm. The Pharmacist explained the facility's medication ordering and delivery process, indicating that medications ordered by specific times would be delivered during scheduled pharmacy runs. The facility had the option to request special deliveries or obtain medications from a backup pharmacy if needed. Despite these procedures, the facility did not administer the available medications from the EDK as ordered, leading to the deficiency in medication administration for Resident #18.
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 68 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spring City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Rhea County | 11.5 mi | ★★★★★ | 6 | 0 |
| Decatur Wellness And Rehabilitation Center | 11.7 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of Rockwood Rehab & Wellness | 17.6 mi | ★★★★★ | 0 | 0 |
| Bledsoe County Nursing Home | 18.6 mi | ★★★★★ | 7 | 0 |
| Laurelbrook Nursing Home | 18.7 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spring City Care And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.