Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Gate Rehab & Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired, ventilator-dependent resident who required two-person assistance for bed mobility fell from an elevated bed and sustained a fatal head injury after a CNA attempted to provide care alone, contrary to the resident's care plan. The resident was unable to reposition independently, and the CNA's failure to follow the required two-person assist protocol led to the fall and subsequent death.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility and transfers, was repositioned by a CNA without help, contrary to the care plan. The CNA was unaware of the two-person assist requirement and did not seek assistance, resulting in the resident falling from the bed to the floor. The DON confirmed the care plan was not followed.
A resident with multiple complex medical conditions, including a tracheostomy, was found unresponsive and without a pulse. Facility staff initiated CPR and used an AED, but there was no detailed documentation of the CPR event, including which staff performed interventions, the steps taken, or the timing. Staff interviews revealed that the tracheostomy had been dislodged and replaced, but this was not documented or communicated to other staff or emergency responders. The Director of Nursing confirmed that such documentation and reporting are required but were not completed.
A resident with multiple chronic conditions did not receive three scheduled doses of Clonazepam 2 mg via PEG tube as ordered. The RN responsible failed to administer the medication, did not retrieve it from the emergency drug cart, and did not contact the pharmacy, despite the medication being available. The DON confirmed the medication should have been given as ordered.
A resident with cognitive impairment and multiple medical conditions rolled out of bed and fractured her arm after being left unattended by a CNA. The incident was not reported immediately, and the resident was moved without proper assessment, violating facility protocols. The resident required a two-person assist for bed mobility, which was not provided.
The facility failed to secure catheter tubing for two residents, leading to actual harm for one resident who developed a pressure ulcer due to improper catheter positioning. Staff interviews and observations confirmed that catheter care policies were not followed, resulting in unsecured tubing and potential harm.
The facility failed to provide proper care for residents with PEG tubes, as staff did not ensure enteral feedings and flush solutions were labeled correctly for three residents. Additionally, one resident did not receive necessary PEG site care, and the facility did not obtain a physician's order for this care upon admission. These deficiencies indicate a failure to adhere to the facility's policy on feeding tubes.
The facility failed to ensure timely physician visits for several residents, as required by its policy. Despite the policy mandating physician visits within 30 days of admission and every 60 days thereafter, records showed significant gaps in visits for residents with various medical conditions. The Administrator acknowledged the requirement but the facility did not alternate physician visits with those by nurse practitioners, leading to non-compliance.
The facility failed to maintain sanitary conditions in the kitchen, leading to a significant risk of foodborne illness outbreaks. Observations revealed dirty floors, broken ice machines, and improper sanitation practices. Unsafe food handling was noted, with staff preparing food on dirty surfaces and failing to perform hand hygiene. The facility's cleaning schedules were incomplete, and numerous areas were not cleaned as scheduled, resulting in Immediate Jeopardy for 109 residents.
A long-term care facility failed to maintain an effective infection prevention and control program, resulting in unsanitary conditions affecting numerous residents. Observations revealed dried substances on bed frames, feeding pumps, and floors, along with dirty oxygen concentrators and HVAC units. The housekeeping department lacked sufficient cleaning supplies, and structural issues were noted. Additionally, two nurses failed to properly clean reusable equipment, increasing infection risks. Vulnerable residents, including those with tracheostomies, were exposed to these conditions, and staff interviews indicated unclear cleaning responsibilities.
The facility failed to maintain a sanitary and safe environment, with observations of black build-up, missing tiles, and damaged privacy curtains in resident rooms and shared bathrooms. Residents with severe cognitive impairments and those dependent on staff for ADLs were affected. The facility's hallways also had loose handrails and visible openings to the outside, compromising safety and comfort.
A resident reported missing perfume to the Unit Manager, but the facility failed to document or investigate the grievance as per their policy. The resident, who was cognitively intact, did not receive any follow-up, and the Social Services Director confirmed the oversight in documentation.
A resident with specific dietary preferences, including no pork and a requirement for finger foods, was served meals that did not adhere to these preferences. Despite being cognitively intact and having communicated these preferences, the resident received a ham sandwich and non-finger foods, which were against the documented dietary instructions. The errors were acknowledged by facility staff, including a CNA and the Unit Manager.
The facility failed to inform 10 residents about their right to formulate an advance directive, as required by its policy. Medical records lacked documentation of advance directives for residents with varying cognitive abilities. Interviews with staff revealed inconsistencies in the process, with the Admissions and Marketing Director and Social Services Director acknowledging the oversight.
A resident with severe cognitive impairments was moved to a different room without prior notification to their family, contrary to facility policy. The notification occurred only after the room change, as confirmed by the Unit Manager.
A resident with severe cognitive impairment and multiple diagnoses experienced an anterior dislocation of the left shoulder. Despite the facility's policy requiring immediate reporting of injuries of unknown origin, the incident was not reported within the required 2-hour timeframe. The DON confirmed the reporting failure during an interview.
The facility failed to thoroughly investigate and report abuse allegations for four residents. For one resident, bruises and fractures were not properly investigated, and the follow-up report was delayed. Another resident's shoulder dislocation investigation was incomplete, with missing witness statements and a misunderstanding of previous injuries. Bruises on a third resident were inadequately investigated, and a fourth resident's abuse threat by a family member was not fully documented. These deficiencies show a lack of comprehensive investigations and timely reporting.
The facility failed to complete accurate MDS assessments for four residents, as their BIMS scores were not assessed and marked with dashes. These residents had various medical conditions requiring precise assessments. The Social Services Director confirmed that the BIMS scores should be completed by the ARD, but were not, leading to incomplete assessments.
A facility failed to update a PASRR after a resident received a new mental health diagnosis and was prescribed Seroquel. The resident, admitted with multiple diagnoses, was later diagnosed with a Psychotic Disorder and Depression. The PASRR Nurse was unaware of the new medication order and acknowledged that the PASRR should have been updated, resulting in non-compliance with the required PASRR process.
A facility failed to conduct quarterly care conference meetings for a cognitively intact resident with multiple diagnoses, as required by their policy. The resident reported not being invited to any care plan meetings, which was confirmed by the Social Services Worker.
A facility failed to assist a resident with personal grooming, as required by their care plan. The resident, dependent on staff for all ADLs and with multiple health conditions, was observed with matted and knotted hair. Despite the facility's policy and the resident's cognitive awareness, the resident reported infrequent showers and minimal attempts to brush her hair. A CNA confirmed that hair care should occur with each shower, highlighting a lapse in care.
The facility failed to follow physician orders for medication administration and vital sign monitoring for three residents. A resident did not receive required blood glucose monitoring, another had multiple missed medication doses, and a third had no documented vital sign checks before antihypertensive medication administration. These deficiencies were confirmed by facility staff.
A facility failed to change a resident's oxygen tubing weekly as per policy and did not adhere to the physician's order for oxygen administration. The resident, with multiple health issues, was observed receiving oxygen at 2.5 L/min instead of the prescribed 1 L/min. LPNs and the DON confirmed these discrepancies, indicating non-compliance with both facility policy and physician orders.
The facility failed to post accurate and current nurse staffing information for several days, as required by their policy. Observations showed outdated staffing sheets, and interviews revealed a lapse in the process of updating and posting the information. The Staffing Coordinator and DON confirmed the deficiency.
The facility failed to properly store and secure medications for two residents, leaving them unattended in their rooms. Additionally, an opened and undated vial of Tubersol was found in the medication storage room. The DON confirmed these lapses in following the facility's medication storage policy.
A resident with a broken tooth experienced pain affecting their ability to eat and drink, but was not added to the dental list for evaluation. Despite reporting the issue to staff, the resident's need for dental services was overlooked due to communication failures within the facility.
A facility failed to ensure a resident's legal representative understood the binding arbitration agreement, as required by policy. The agreement was emailed without explanation, and the representative had no recollection of signing it. Interviews revealed that the Admissions Director often handled the process electronically, providing only brief explanations unless questions were asked, which was acknowledged as insufficient by the Administrator.
A resident's request for a room change to a private room was denied by the DON, despite the facility's policy supporting such requests. The resident, who was cognitively intact, reported the denial, and the SSD, responsible for coordinating room changes, failed to follow up on the request, leading to a violation of the resident's rights.
Failure to Follow Care Plan for Bed Mobility Results in Fatal Fall
Penalty
Summary
A cognitively impaired resident with a tracheostomy, who was dependent on staff for all activities of daily living and required two-person assistance for bed mobility and transfers, fell from an elevated bed and sustained a fatal head injury. The resident's care plan and medical record clearly indicated the need for two-person assistance with bed mobility and transfers, as well as the use of a mechanical lift. The resident was also noted to be unable to follow commands, was nonverbal, and was totally dependent on staff for repositioning. On the night of the incident, a certified nursing assistant (CNA) entered the resident's room alone to provide care and prepare for repositioning. Despite the care plan's requirement for two-person assistance, the CNA proceeded without additional help. While the CNA was gathering supplies and standing behind the resident, the resident rolled off the bed and fell face down onto the floor, resulting in a laceration to the forehead. The CNA did not attempt to reposition the resident or provide hands-on care prior to the fall, and the bed was elevated to the CNA's hip level at the time of the incident. The resident's ventilator tubing became disconnected during the fall, and emergency assistance was called. Interviews with facility staff, including the DON, RN, and Nurse Practitioner, confirmed that the resident was completely dependent on staff for movement and could not reposition herself. The CNA failed to follow the care plan instructions, which directly contributed to the resident's fall and subsequent death. The facility was cited for failing to provide an environment free from accident hazards and for not ensuring adequate supervision and assistance as required by the resident's care plan.
Failure to Follow Care Plan for Two-Person Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to follow its own comprehensive care plan policy for a resident with significant medical and cognitive impairments. The resident, who was admitted with multiple diagnoses including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, tracheostomy and gastrostomy status, and dependence on a respirator ventilator, was assessed as requiring two-person assistance for bed mobility and transfers, as well as mechanical lift use. The care plan and nursing admission evaluation both documented the need for two-person assistance due to the resident's inability to move independently, cognitive impairment, and high risk for falls. Despite these documented needs, a CNA provided care to the resident without the required two-person assistance. The CNA repositioned the resident alone during a shift and did not seek help from other staff, stating she was unaware of the two-person assist requirement. As a result, the resident, who was severely cognitively impaired and nonmobile, fell from the bed to the floor when repositioned by only one staff member. The DON confirmed that the care plan was not followed and that the CNA should have requested assistance.
Failure to Document and Record CPR Event for Resident in Cardiac Arrest
Penalty
Summary
The facility failed to provide adequate clinical documentation that continuous Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) were administered to a resident who was found unresponsive and without a pulse. According to the facility's policy, staff are required to initiate CPR following American Heart Association guidelines and document the event in the medical record. However, the facility was unable to produce a code sheet or detailed documentation specifying which staff performed CPR, the steps taken during the event, or the timing of those steps. The resident involved had significant medical conditions, including cerebral infarction, acute respiratory failure, aphasia, dysphasia, epilepsy, diabetes mellitus, and a tracheostomy. The resident was found unresponsive in her room by a respiratory therapist, who noted the absence of a pulse and initiated a code. Progress notes indicated that CPR was started and an AED was applied, with emergency services arriving shortly thereafter. Despite these actions, there was no comprehensive documentation in the medical record detailing the sequence of events, staff roles, or interventions performed during the code. Interviews with staff, including the respiratory therapist, LPNs, and the Director of Nursing, revealed inconsistencies and gaps in the documentation and communication regarding the CPR event. The respiratory therapist acknowledged starting CPR and replacing a dislodged tracheostomy but did not document the tracheostomy incident or report it to other staff or emergency personnel. The Director of Nursing confirmed that documentation of CPR events and reporting of tracheostomy dislodgement are expected but were not found in this case.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, tracheostomy, gastrostomy, and ventilator dependence, did not receive Clonazepam 2 mg as ordered via PEG tube for three scheduled doses. Medical record review showed that the medication was not administered on three occasions despite being prescribed twice daily. The registered nurse responsible confirmed that the medication was not in the medication cart, did not retrieve it from the emergency drug cart, and did not contact the pharmacy to obtain it. The DON later confirmed that the medication was available in the emergency drug cart and should have been administered as ordered.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for Resident #77, a cognitively impaired individual with a history of multiple cerebrovascular accidents and other significant medical conditions. On the day of the incident, the resident rolled out of bed and sustained a fracture to the right humerus. This occurred after a Certified Nursing Assistant (CNA) left the resident unattended on her side while changing her linens. The CNA did not notify the nurse of the incident and attempted to return the resident to bed with the help of another CNA, without following proper protocol. The facility's policies on falls and incidents require staff to report and investigate any accidents or incidents immediately. However, in this case, the incident was not reported until days later when a bruise was noticed on the resident's arm. The initial failure to report the fall and the subsequent lack of documentation in the medical record on the day of the incident contributed to the delay in addressing the resident's injury. The facility's policy also mandates the use of mechanical lifts for heavy lifting, which was not adhered to in this situation. Interviews with staff revealed that the CNAs involved did not follow the facility's protocol for handling falls, which includes notifying a nurse and not moving the resident until assessed. The Director of Nursing confirmed that the resident required a two-person assist for bed mobility, which was not provided. The incident highlights a breakdown in communication and adherence to established safety protocols, resulting in harm to the resident.
Failure to Secure Catheter Tubing Results in Harm
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, resulting in actual harm to two residents. Resident #30, who was admitted with paraplegia and a pressure ulcer, was found to have a deep purple area of trauma on the left labia due to improper positioning of the catheter tubing. The catheter tubing was not secured with a clip, as required by the physician's orders, leading to the resident laying on the tubing and developing a pressure ulcer. Interviews with staff confirmed that the catheter tubing was not properly positioned or secured, which contributed to the injury. Resident #304, who was admitted with respiratory failure and acute kidney failure, was observed with a catheter anchor clip attached to the indwelling catheter tubing but not secured to the resident's leg. This observation was confirmed by the Infection Control Nurse, indicating a failure to adhere to the facility's policy of securing catheter tubing to prevent movement and potential harm. The facility's policy on catheter care requires that catheters be secured to prevent pulling and damage, but this was not followed for the residents reviewed. The Director of Nursing and other staff acknowledged the importance of securing catheter tubing to prevent injury, yet the deficiency in care resulted in actual harm to Resident #30 and a potential risk for Resident #304.
Deficiencies in PEG Tube Care and Labeling
Penalty
Summary
The facility failed to provide proper care and services for residents with percutaneous endoscopic gastrostomy (PEG) tubes. For three residents, the staff did not ensure that enteral feedings and flush solutions were properly labeled. Specifically, Resident #58's water bottle used for the PEG was not labeled with a date, rate for delivery, or initials, and similar labeling issues were observed on multiple occasions. Resident #72's enteral feeding and water bottle also lacked proper labeling, including the date, rate of delivery, and nurse's initials, as confirmed by a Licensed Practical Nurse (LPN). Resident #304's enteral feeding was observed without a date or time label, which was acknowledged by LPN B. Additionally, the facility failed to administer site care for Resident #498, who was admitted with a PEG tube. There was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicating that PEG site care was provided. Furthermore, the facility did not obtain a physician's order for PEG site care upon the resident's admission, which was later confirmed by the Director of Nursing (DON). The resident confirmed receiving feedings through a PEG tube and showed the site, which had no dressing, indicating a lack of site care. These deficiencies highlight the facility's failure to adhere to its policy on feeding tubes, which requires proper labeling and maintenance according to physician orders and clinical standards. The lack of labeling and site care poses potential risks for complications, as the facility did not follow established protocols to ensure the safety and well-being of residents with PEG tubes.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted according to its policy for nine out of eleven residents reviewed. The facility's policy requires that a physician see a resident within 30 days of initial admission, at least once every 30 days for the first 90 days, and at least every 60 days thereafter. However, the medical records for residents with various diagnoses, including hepatic failure, cerebral infarction, multiple sclerosis, Parkinson's disease, dementia, and others, showed significant gaps in physician visits. For instance, Resident #8 was only seen by a physician on two occasions over several months, and similar patterns were observed for other residents, indicating non-compliance with the facility's policy. The deficiency was further highlighted during an interview with the Administrator, who acknowledged the requirement for physician visits every 60 days after the initial 90-day period. Despite this understanding, the facility did not ensure that physician visits were alternated with visits by a nurse practitioner or other qualified healthcare professionals, as allowed by state law. This oversight resulted in residents not receiving the required frequency of medical supervision, as evidenced by the lack of documentation for physician visits every other 60 days, as stipulated by the facility's policy.
Sanitation Deficiencies in Kitchen Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to a significant risk of foodborne illness outbreaks. Observations during the survey revealed numerous sanitation issues, including dirty kitchen floors with standing water from leaking pipes, broken ice machines with mold, and a lack of sanitation logs for the three-compartment sinks. Staff were observed to be unaware of proper sanitizer use, and there was a significant build-up of carbon and dried food particles on pots, pans, and utensils. Additionally, the drying rack for dishes was dusty, and the warming oven and flat grill had carbon build-up and food particles. Unsafe food handling practices were also noted, such as the preparation of macaroni and cheese on a dirty two-compartment sink and the Certified Dietary Manager (CDM) failing to perform hand hygiene during tray line service. The facility's failure to ensure sanitary conditions posed a potential source of pathogen exposure for 109 of 138 residents, resulting in Immediate Jeopardy. The kitchen staff were observed using improper methods to turn on stove eyes due to missing knobs, and the warming oven was missing a handle. The ice machine used by the kitchen was out of order, forcing staff to use an alternative machine outside the kitchen. Further observations revealed that the facility's cleaning schedules were incomplete, with multiple blank areas and missing dates. The kitchen was not regularly cleaned, with numerous areas such as the coffee maker, tea maker, utility carts, and dish room not being cleaned as scheduled. The facility's policies on kitchen sanitation, food receiving and storage, and emergency food storage were not adhered to, contributing to the unsanitary conditions. The facility's noncompliance with these standards resulted in a citation for Immediate Jeopardy at F812 with a scope and severity of K.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in unsanitary conditions that affected 24 out of 38 residents reviewed. Observations revealed dried dark brown and tan substances on bed frames, side rails, enteral feeding pumps, poles, walls, window blinds, and floors. Additionally, oxygen concentrators were found to be dirty with dusty filters, and HVAC units were covered in dust. The housekeeping department lacked sufficient cleaning disinfectants, and structural issues such as a hole in a wall and a gap around an HVAC unit were noted, exposing the facility to the outside environment. The facility's failure extended to the improper cleaning and disinfection of reusable equipment by two nurses, which increased the risk of infection transmission. Specific residents, including those with tracheostomies and ventilator dependencies, were exposed to these unsanitary conditions. For instance, in one shared room, brown smears were found on bed frames and side rails, and a suction canister was left uncovered with brown mucus. In another room, a cracked vanity mirror had brown smears beneath it, and the feeding pole was rusted with orange residue. Residents with severe cognitive impairments and those dependent on staff for all activities of daily living were particularly vulnerable. The facility's infection control lapses were highlighted by multiple instances of dried substances on floors and equipment, overflowing trash, and clogged sinks. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities, with some staff indicating that cleaning was only performed if they were directly responsible for the mess. These deficiencies were observed across multiple rooms and units, including those housing high-risk residents with respiratory conditions.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as evidenced by numerous observations of black build-up and missing tiles in resident rooms and shared bathrooms. The facility's policies on routine cleaning, daily cleaning, and deep cleaning procedures were not effectively implemented, leading to unsanitary conditions in multiple areas. Observations revealed black build-up on floors, baseboards, and around bathroom fixtures, as well as missing tiles and cracked surfaces, which were not addressed in a timely manner. Several residents, including those with severe cognitive impairments and those dependent on staff for activities of daily living (ADLs), were affected by these deficiencies. For instance, residents with diagnoses such as dementia, muscle weakness, and Alzheimer's disease were observed living in rooms with significant black build-up and missing tiles, which could potentially impact their health and safety. Additionally, shared rooms and bathrooms were found to have similar issues, indicating a widespread problem throughout the facility. The facility also failed to maintain privacy curtains in resident rooms, with numerous instances of missing hooks and holes in the curtains. This issue was confirmed by the Maintenance Director during interviews and observations. Furthermore, the facility's hallways were found to have loose handrails and visible openings to the outside, further compromising the safety and comfort of residents, staff, and visitors. These deficiencies highlight a lack of adherence to the facility's preventive maintenance program and cleaning policies, resulting in an environment that does not meet the required standards for long-term care facilities.
Failure to Address Resident's Missing Personal Possession
Penalty
Summary
The facility failed to ensure a resident's right to retain and use personal possessions, as evidenced by the case of a resident who reported missing perfume. The facility's policy on Quality Assistance Procedure allows residents to file grievances concerning treatment and theft of property without fear of reprisal. However, a review of the facility's grievance log for August and September 2024 showed no documentation of a grievance form related to the resident's missing perfume, indicating a lapse in following the established procedure. The resident, who was cognitively intact with a BIMS score of 15, reported the missing perfume to the Unit Manager but did not receive any follow-up. Interviews with the Social Services Director confirmed that the missing item should have been documented on the Quality Assistance Forms when reported. Despite the resident's report, there was no evidence of an investigation or resolution, highlighting a deficiency in addressing the resident's grievance and ensuring their right to personal possessions.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to honor the dietary preferences of a resident, identified as Resident #70, who was admitted with multiple diagnoses including cerebral infarction, diabetes, visual loss, stage 5 end-stage renal disease, and quadriplegia. The resident was cognitively intact and had clearly communicated a preference against consuming pork. Despite this, the resident was served a meal containing pork, specifically a ham sandwich, which was against the documented dietary preferences. This incident was observed during a meal service when a CNA delivered the incorrect meal, and the resident had to inform the CNA of the mistake. The CNA then reported the issue to the kitchen, and a replacement meal was provided. Further observations revealed another instance where the resident's dietary preferences were not followed. The resident was supposed to receive finger foods, but was instead served pudding and fruit cocktail, which do not qualify as finger foods. This was confirmed by the Unit Manager, who acknowledged the error. The Lead Dietician also confirmed that the facility should honor the resident's dietary preferences and allergies. These incidents highlight the facility's failure to adhere to the resident's documented dietary preferences, as outlined in the care plan and meal ticket.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information to residents regarding their right to formulate an advance directive, affecting 10 out of 32 residents reviewed. The facility's policy, titled 'End of Life,' mandates that residents and their families be informed and educated about end-of-life decisions, including advance directives, which should be documented in the medical record. However, the review of medical records revealed a lack of documentation for several residents, indicating whether they had an advance directive or if they wished to formulate one. Among the residents affected, some were cognitively intact, while others had varying degrees of cognitive impairment. For instance, Resident #34, who was cognitively intact with a BIMS score of 13, had no documentation regarding an advance directive. Similarly, Resident #57, with a moderate cognitive impairment and a BIMS score of 12, also lacked documentation. Other residents, such as Resident #71 and Resident #72, were severely cognitively impaired, yet there was no record of advance directive discussions or documentation. Interviews with facility staff, including the Admissions and Marketing Director and the Social Services Director, confirmed that the process for handling advance directives was not consistently followed. The Admissions and Marketing Director stated that a copy of a living will or power of attorney should be made upon admission, with Social Services responsible for follow-up. However, the Social Services Director acknowledged that information should be provided to residents to formulate an advance directive, indicating a gap in the facility's adherence to its policy.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to notify the resident representative in advance of a room change for Resident #305, which is a violation of their policy. The policy requires that all persons involved in a room change, including residents and their representatives, be given advance notice. Resident #305, who has severe cognitive impairments and multiple diagnoses such as Ventricular Tachycardia and Severe Hypoxic Ischemic Encephalopathy, was moved to a different room without prior notification to the family. The notification to the resident's son occurred only after the room change had been completed, as confirmed by the Unit Manager during an interview. This oversight was documented in the progress notes, indicating the son was informed and agreed to the change post-factum.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse and neglect related to an injury of unknown origin within the required 2-hour timeframe for a resident. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of such incidents to the appropriate authorities, including the state survey agency, within 2 hours if the allegation involves abuse or results in serious bodily injury. However, in this case, the injury was not reported as per the facility's policy. The resident involved was admitted with multiple diagnoses, including cerebral infarction and severe cognitive impairment, requiring assistance with daily living activities. An X-ray revealed an anterior dislocation of the left shoulder, and the resident was transferred to an emergency room for further evaluation. Despite the abnormal X-ray results and the resident's complaints of left arm pain, there was no documentation that the injury of unknown origin was reported within the specified timeframe. The Director of Nursing confirmed during an interview that such injuries should be reported within 2 hours.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and did not report the results of their investigations to the appropriate government agency within the required five working days for four residents. The facility's policy mandates the protection of residents' health, welfare, and rights by preventing abuse, neglect, and exploitation, and requires thorough investigations and timely reporting. However, the facility did not adhere to these policies in several instances. For Resident #58, the facility did not complete a thorough investigation after the resident was found with bruises and fractures of unknown origin. The incident was reported, but the follow-up report was not submitted within the required timeframe. Similarly, for Resident #248, the facility's investigation into a shoulder dislocation was inadequate, with witness statements missing or improperly dated, and a misunderstanding of the resident's previous injuries by the former DON. Resident #298 was found with bruises on her breasts, attributed to her holding her hands tightly against her chest, but the investigation lacked thoroughness, with insufficient witness statements. In the case of Resident #300, the facility began an investigation after the resident's daughter threatened her, but failed to obtain necessary witness statements. These deficiencies highlight the facility's failure to conduct comprehensive investigations and timely reporting as required by regulations.
Incomplete MDS Assessments Due to Missing BIMS Scores
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were complete and accurate for four residents. Specifically, the Brief Interview for Mental Status (BIMS) scores were not assessed and were marked with a dash for Residents #6, #41, #84, and #105. These residents had various diagnoses, including Chronic Obstructive Pulmonary Disease, Dementia, Hemiplegia, and Cognitive Impairment, which necessitate accurate assessments to ensure appropriate care. The absence of BIMS scores on the MDS assessments indicates a lapse in the facility's assessment process. During an interview, the Social Services Director (SSD) confirmed that the BIMS scores were the responsibility of the social services department and should be completed by the Assessment Reference Date (ARD). The SSD explained that when the BIMS scores are not completed by the ARD, dashes are used to allow the MDS Coordinator to complete the assessment on time. The SSD acknowledged that both she and the Social Service Assistant had access to the MDS assessments and their due dates, confirming that the BIMS should be completed without dashes.
Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a PASRR after a resident received a new mental health diagnosis. The facility's policy requires a Level I PASRR screen for all residents prior to or upon admission, and a Level II screen notification to the State's PASRR program if indicated. Additionally, a review is required upon a change in the resident's condition. However, the facility did not adhere to this policy for one resident who was admitted with multiple diagnoses, including Multiple Sclerosis, Respiratory Failure, Paraplegia, and Cognitive Communication Deficit. The resident was later diagnosed with a Psychotic Disorder and Depression, and was prescribed Seroquel, a medication used to treat schizophrenia, which was not listed in the PASRR dated May 2024. The deficiency was identified during a phone interview with the PASRR Nurse, who acknowledged that a new PASRR should have been completed when the resident received a new order for Seroquel. The nurse admitted to being unaware of the new medication order and confirmed that the PASRR should have been updated prior to September 2024. This oversight resulted in the facility's failure to comply with the required PASRR process, as the resident's change in condition and new medication were not properly documented and communicated to the State's PASRR program.
Failure to Conduct Quarterly Care Conference Meetings
Penalty
Summary
The facility failed to conduct quarterly care conference meetings for a resident, as required by their policy on comprehensive care plans. The policy mandates the development and implementation of a person-centered care plan for each resident, which should be prepared by an interdisciplinary team and include the resident and their representative. Despite this, the facility was unable to provide documentation that a quarterly care conference was conducted for the resident in question. The resident, who was admitted with diagnoses including a fracture of the right femur, dysphagia, and chronic obstructive pulmonary disease, was found to be cognitively intact based on their BIMS score. However, during an interview, the resident stated they had not been invited to or attended any care plan meetings. This was confirmed by the Social Services Worker, who acknowledged that the facility had not conducted a meeting with the resident since January 2024.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to ensure that a resident was assisted with activities of daily living (ADLs) related to personal grooming. The facility's policy on ADLs, revised on December 28, 2022, mandates that residents who are unable to perform ADLs independently should receive necessary services to maintain grooming and personal hygiene. However, the facility did not adhere to this policy for a resident who was dependent on staff for all ADL care. The resident, who was admitted with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, cerebral infarction, muscle weakness, and tracheostomy, was observed with matted and knotted hair on multiple occasions. The resident, who was cognitively intact, reported receiving showers only once or twice a week and confirmed that only one staff member had attempted to brush her hair. During interviews, a certified nursing assistant (CNA) acknowledged that residents' hair should be washed and combed every time they have a shower. Despite this, the resident's hair remained unkempt, indicating a failure to provide adequate personal grooming assistance as required by the resident's care plan.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for blood glucose monitoring, medication administration, and vital sign checks before administering antihypertensive medication for three residents. Resident #12, who was severely cognitively impaired and diagnosed with multiple conditions including hypertension and diabetes, did not receive the required blood glucose monitoring on a specified date, as confirmed by the Unit Manager. Resident #68, also cognitively impaired and diagnosed with conditions such as diabetes and hypertension, had multiple instances of missed medication doses. These included critical medications like Hydralazine and Metoprolol, which were not administered as ordered on specific dates. Additionally, Metoprolol was administered outside of the prescribed blood pressure parameters on several occasions, as confirmed by the Director of Nursing. Resident #70, with severe cognitive impairment and a history of hypertension, had no documented blood pressure or heart rate checks before the administration of antihypertensive medication over several months. This was confirmed by an LPN who admitted to not recording the necessary vital signs, and the DON confirmed that staff should follow physician orders for such medications.
Failure to Follow Oxygen Administration Policy and Physician Orders
Penalty
Summary
The facility failed to adhere to its policy for changing oxygen tubing and did not follow the prescribed physician order for oxygen administration for a resident. The facility's policy, revised on 10/26/2023, mandates that oxygen is administered under a physician's orders and that oxygen tubing and masks or cannulas should be changed weekly or as needed if they become soiled or contaminated. However, observations revealed that the oxygen tubing for a resident was dated 8/6/2024, indicating it had not been changed weekly as required by the facility's policy. The resident in question was admitted with multiple diagnoses, including diabetes, heart failure, hypertension, and a stage 4 pressure ulcer. The physician's order specified that oxygen should be administered at 1 liter per minute via nasal cannula for comfort as needed for shortness of breath. However, observations on multiple occasions showed that the resident's oxygen was set at 2.5 liters per minute, contrary to the physician's order. Interviews with LPNs and the Director of Nursing confirmed these discrepancies, highlighting a failure to follow both the facility's policy and the physician's orders for oxygen therapy.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information was accurate and current for five out of fifteen days during the survey period. The facility's policy, dated March 4, 2024, requires that the Nurse Staffing Sheet be posted daily with the current date and updated at the beginning of each shift. However, observations revealed discrepancies in the dates of the posted Direct Care Staffing Hours. On multiple occasions, the posted dates were not current, with instances of the staffing information being outdated by several days. Interviews conducted during the survey highlighted a breakdown in the process of updating and posting the staffing information. The Staffing Coordinator indicated that they prepared the staffing sheet and left it for the night nurse to post in the morning, but confirmed that the schedule should be updated daily. The Director of Nursing also confirmed that the staffing schedule should be posted daily with the current date, acknowledging the failure to adhere to the facility's policy.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications for two residents. In the case of one resident, medications including Vitamin D, AZO, and Benzonatate were found unattended in a medication cup on the overbed table. The resident was cognitively intact, as indicated by a BIMS score of 15. Similarly, another resident, also with a BIMS score of 15, had several medications left unsecured and unattended in their room. These medications included Vitamin D, a Renal Vitamin, Amlodipine, Baby Aspirin, Carvedilol, and Vitamin B Complex. Both incidents were confirmed by the respective LPNs, who acknowledged that the medications should not have been left unattended. Additionally, an observation in the 100 Hall Medication Storage Room revealed an opened and undated vial of Tubersol in the medication refrigerator. The Director of Nursing confirmed that medications should not be left at the resident's bedside unattended and should be locked in the medication cart until administration. The DON also verified that the Tubersol should have been dated when opened, indicating a lapse in following the facility's medication storage policy.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was experiencing dental pain due to a broken tooth. The resident, who was cognitively intact and had no dental problems noted during their last assessment, reported having trouble eating and drinking due to the pain. Despite informing multiple staff members about the issue, the resident was not added to the dental list for evaluation and treatment. Interviews with facility staff revealed a breakdown in communication and procedure. The Certified Nursing Assistant stated that they would inform a nurse if a resident reported dental issues. However, the Social Services Director and Worker were unaware of the resident's dental pain and confirmed that the resident was not on the list for dental services. The Director of Nursing acknowledged that the resident should have been added to the consult list, but noted that sometimes it takes time to address such issues.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was properly understood by residents or their legal representatives, as evidenced by the case of one resident. The facility's policy on binding arbitration agreements, revised on November 1, 2022, states that residents should be informed of their right not to sign the agreement as a condition of admission or continued care. The policy also requires that the agreement be explained in a manner that the resident or their representative understands, and that they acknowledge their understanding. However, in the case of Resident #140, who was admitted with severe cognitive impairment and other medical conditions, the facility did not adhere to this policy. The resident's Power of Attorney reported that the admission paperwork, including the arbitration agreement, was emailed to her without any explanation, and she had no recollection of signing it. Interviews with facility staff revealed a lack of proper procedure in explaining the arbitration agreement. The Admissions Director admitted to handling much of the process electronically and only providing brief explanations, such as visiting hours, without thoroughly discussing the arbitration agreement unless questions were raised. The Director acknowledged that a layperson might not understand the agreement under the current process. The facility Administrator confirmed that the arbitration agreement should indeed be explained to families before signing, indicating a recognition of the deficiency in the current practice.
Failure to Honor Resident's Room Change Request
Penalty
Summary
The facility failed to honor a resident's right to request a room change, as outlined in their policy. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15, requested a room change to a private room from the Director of Nursing (DON). The DON denied the request, stating that the resident could not move. This incident was documented in a facility's Alleged Abuse Incident Report and confirmed during interviews with the resident and the Administrator. The Social Service Director (SSD) was responsible for coordinating room changes and was aware of the resident's request. However, the SSD did not follow up with the resident regarding the room change request, as confirmed during an interview. The facility's policy on room changes requires that requests be communicated to the Social Service Designee, but the SSD admitted to not following up on the request, which contributed to the failure to honor the resident's rights.
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 178 citations issued within 25 miles in the last 12 months — including the 8 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 Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Kings Daughters And Sons | 3.8 mi | ★★★★★ | 1 | 0 |
| Rainbow Rehab And Healthcare | 3.8 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Memphis | 4.8 mi | ★★★★★ | 4 | 0 |
| Ave Maria Home | 4.8 mi | ★★★★★ | 0 | 0 |
| Millington Healthcare Center | 7.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spring Gate Rehab & Healthcare 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 July 2026) and official state health department websites.