Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Cypress Springs Wellness & Rehabilitation during CMS and state inspections, most recent first.
Insufficient Nursing Coverage During Required Lunch Breaks: The facility repeatedly had only one nurse on duty on multiple shifts, and that nurse was required to clock out for a 30-minute lunch break even when no other nurse was present to cover the unit. Staff interviews confirmed that nurses were told to take lunch breaks by the DON/Administrator, including overnight shifts, and that the only available coverage at times came from administrative nurses or no nurse at all.
The facility failed to follow its policy requiring daily temperature monitoring and documentation for residents’ personal in-room refrigerators and freezers used to store food brought by families and visitors. Several residents with multiple chronic conditions and varying cognitive status had personal refrigerators containing perishable items such as milk and ice cream, but temperature logs showed entries on only some days, with gaps where no temperatures were recorded. Although observed temperatures were within acceptable ranges at the time of survey, logs for multiple refrigerators were incomplete, and staff interviews revealed confusion over which department was responsible for daily temperature checks and that existing rounding tools did not instruct staff to verify refrigerator and freezer temperatures as required by policy.
A resident receiving scheduled nebulizer treatments for acute respiratory failure with hypoxia had a nebulizer mask and tubing left on a recliner rather than stored in a protective, labeled, and dated bag as required. Staff interviews revealed uncertainty about who was responsible for proper storage and when nebulizer equipment should be changed. The DON and Administrator indicated that equipment should be stored in a clean, dated bag with routine change orders, and facility policy required weekly changes and bedside bag storage for oxygen-related equipment, which was not followed.
Surveyors observed an open can of an energy drink stored in the kitchen walk-in cooler alongside residents’ food, despite facility policy prohibiting personal belongings in food preparation or storage areas. The FSS reported that staff had been previously in-serviced that personal drinks were not allowed near residents’ food due to infection control, and a dietary staff member admitted the drink was hers and that she knew it should not have been in the cooler. The Administrator confirmed that personal food and drink items are not permitted near food preparation or storage areas and that the FSS is responsible for preventing this practice.
The facility did not obtain ordered laboratory tests for three residents, including missed CMP, CBC, and urinalysis collections, despite physician orders and care plan requirements. Staff interviews revealed confusion about active lab orders after a change in medical directors and inconsistent communication and follow-up regarding outstanding lab collections.
A resident with a seizure disorder had a lab result showing an elevated Keppra level, which was above the therapeutic range. The medical director questioned the current Keppra dosage, but nursing staff did not respond or document any follow-up. The resident continued to receive the medication as ordered, and the facility's required process for addressing high medication levels was not followed.
A resident with hemiplegia and dementia did not have a comprehensive admission MDS assessment completed within the required 14-day timeframe. The assessment was signed 8 days late due to coordination issues between the MDS Coordinator, who was not an RN and worked at multiple sites, and the DON, who was unaware of the required deadlines and unable to sign assessments daily.
Surveyors identified that two residents did not have complete, up-to-date care plans reflecting their assessed needs. One resident's care plan required a fall mat to be in place while in bed, but observations showed the mat was not used as directed, and there was no documentation explaining its absence. Another resident was prescribed an antidepressant, but this was not included in the care plan, contrary to facility policy. These omissions were confirmed by staff interviews and record reviews.
A resident with moderate cognitive impairment and multiple medical conditions was found to have a bottle of meyer's cleaner left on his bedside table, brought in by a family member. Staff and administration acknowledged that hazardous items should not be present in resident rooms, but the facility lacked a policy addressing this issue. The cleaner remained in the room over multiple days, and staff did not remove it, creating a risk for injury.
Two residents were found with medications and biologicals left unsecured at their bedsides, including wound cleanser, non-prescribed powder, and artificial tears, despite facility policy requiring locked storage and staff administration. Neither resident had been assessed for self-administration, and staff were unclear about authorization, resulting in medications being accessible in resident rooms.
The facility did not obtain or maintain the most recent hospice plan of care and nursing visit notes for a resident with multiple medical conditions receiving hospice services. Required hospice documentation was not delivered to the facility as expected, resulting in outdated records and a lack of coordination between facility staff and hospice representatives.
Two residents did not receive care in accordance with infection control protocols: a nurse failed to wear required PPE during wound care for a resident with a Foley catheter, and a CNA did not perform hand hygiene between glove changes during incontinent care for another resident. Both staff members acknowledged the lapses, and facility leadership confirmed these actions were not consistent with policy.
A resident alleged rough handling and verbal mistreatment by a CNA during care, which was witnessed by another CNA who did not report the incident promptly. The DON and ADON were notified of the allegation via text but did not inform the abuse coordinator, allowing the alleged perpetrator to continue working. Additionally, several CNAs had not received required abuse training before providing care, as confirmed by personnel records and staff interviews.
A resident with rheumatoid arthritis and PTSD, who was cognitively intact and dependent on staff for care, experienced disrespectful treatment from CNAs. One CNA provided care while wearing earbuds and was inattentive, while another spoke to the resident in a disrespectful manner, making the resident feel awful. Witness statements and staff interviews confirmed these actions, which violated facility policy and resident rights.
The facility failed to maintain food safety standards as Cook K used malfunctioning thermometers to check food temperatures, and the Maintenance Supervisor entered the kitchen without performing hand hygiene or wearing a hair restraint. Despite reheating, food temperatures remained inconsistent, posing a risk of foodborne illness.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies. Staff did not perform hand hygiene or change gloves during care, did not clean equipment between uses, and were unaware of a resident's contact isolation precautions, placing residents at risk for infection.
The facility failed to assist a resident with severe cognitive impairment in removing facial hair, despite the resident being dependent on staff for all ADLs. Staff interviews and observations confirmed that the resident did not refuse care, and it was the responsibility of CNAs and nurses to ensure grooming was completed during bathing.
The facility failed to ensure that a medication cart was locked and secure, posing a risk of unauthorized access to medications. An unlocked cart was found in the hallway near the dining room, with multiple residents around. Staff interviews confirmed that medication carts should always be locked when unattended, as per facility policy.
Insufficient Nursing Coverage During Required Lunch Breaks
Penalty
Summary
The facility failed to provide sufficient nursing staff on a 24-hour basis to meet resident needs and failed to have a licensed nurse in charge on each shift. Record review of the monthly staffing schedules and time cards for April and May 2026 showed multiple shifts in which only one nurse was on duty, including overnight, evening, and day shifts. On those dates, the only nurse on duty was required to take a 30-minute or longer lunch break, and during that break there was no other nurse in the facility to cover resident care. The staffing records showed this occurred repeatedly on 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/7/26, 4/8/26, 4/10/26, 4/11/26, 4/18/26, 4/22/26, 4/24/26, 4/25/26, 4/28/26, 4/29/26, 5/2/26, 5/3/26, 5/5/26, 5/7/26, 5/11/26, 5/12/26, 5/13/26, 5/14/26, 5/16/26, and 5/18/26. Examples included RN A as the only 10:00 p.m. to 6:00 a.m. nurse on duty while taking lunch breaks, LVN B as the only 2:00 p.m. to 10:00 p.m. nurse on duty while taking lunch breaks, LVN C as the only 10:00 p.m. to 6:00 a.m. nurse on duty while taking lunch breaks, and RN D as the only nurse on duty during certain shifts while taking lunch breaks with no other nurse present. During interviews, LVN E said she was the only floor nurse on the 6:00 a.m. to 2:00 p.m. shift and that the ADON or MDS nurse covered her during lunch. LVN B said nurses were required to clock out for a 30-minute lunch break every shift, even on 10:00 p.m. to 6:00 a.m. shifts when no other nurse was available, and that the directive came from the Administrator. RN A said staff were told during in-service meetings that they must take a 30-minute lunch break and that she usually clocked out and sat in the conference room or break room because there was no other nurse on the overnight shift. The Administrator stated she had not thought about the nurse not being in the facility, but later said staff should not leave the facility or clock out if they were the only nurse and that nurses would not clock out unless there were 2 nurses in the facility.
Failure to Perform Daily Temperature Monitoring of Residents’ Personal Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to implement its policy for monitoring and documenting temperatures of residents’ personal in-room refrigerators and freezers used to store food and beverages brought in by families and visitors. The written policy, dated 01/01/2025, required that a temperature monitoring log be maintained, that a designated staff member document refrigerator temperatures daily, and that a thermometer be kept in the refrigerator to maintain a temperature of 41 degrees or below. Surveyors found that temperature checks were not being performed and documented daily as required, despite residents having personal refrigerators containing perishable items. For one resident with COPD, deep vein thrombosis, schizophrenia, and depression, who had intact cognition with a BIMS score of 13, observation showed a personal refrigerator containing a gallon of milk with a valid expiration date. The temperature log taped to the side of the refrigerator showed entries only on four dates, rather than daily, and all recorded temperatures were 32 degrees. The thermometer inside the unit read 32 degrees in the refrigerator and 22 degrees in the freezer at the time of observation, which were within acceptable parameters, but the monitoring was not done every day. The resident stated he did not know who checked the thermometer and did not recall having spoiled food. For another resident with cervical disc degeneration, cerebral infarction, aphasia, hypertension, and chronic kidney disease, and a BIMS score of 3 indicating severe cognitive impairment, observation revealed a personal refrigerator with three pints of ice cream in the freezer, all with future expiration dates. The temperature log showed checks on only three dates, with refrigerator and freezer temperatures within acceptable ranges, but again not documented daily. A third resident with diabetes type II, unspecified chronic bronchitis, and spinal cord disease, and intact cognition with a BIMS score of 15, had a personal refrigerator log with missing temperature entries for two consecutive days, indicating temperatures were not obtained daily. This resident reported that staff did not always keep up with temperature checks, though they looked at the refrigerator daily. Interviews with the DON, Housekeeping Supervisor, and Administrator confirmed that nursing staff were not responsible for monitoring these temperatures, that housekeeping had not been clearly informed of this responsibility until after the survey date, and that the Ambassador Round sheet used by staff did not direct them to check refrigerator and freezer temperatures, resulting in the failure to carry out the facility’s policy.
Improper Storage and Lack of Dating for Nebulizer Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice for a male resident with intracerebral hemorrhage, hypertension, hyperlipidemia, and dysphagia. The resident had a physician’s order for Ipratropium-Albuterol inhalation solution via nebulizer three times daily for acute respiratory failure with hypoxia, and the MAR showed the treatment was administered as ordered. During observation, the resident’s nebulizer mask and tubing were found lying on a recliner chair in his room, not stored in a protective bag. Although a storage bag was present, it was neither labeled nor dated, and there was no physician’s order specifying when to change or date the nebulizer mask and tubing. In interviews, an RN reported being unsure who was responsible for ensuring nebulizer masks were properly stored, labeled, and dated, and stated she did not know when the nebulizer equipment should be changed. The DON stated that nebulizer masks and tubing should be stored in a clean bag, with both the equipment and bag dated, and that the tubing and mask were typically changed on Sundays with an order in place for routine changes. The Administrator stated that nursing staff were responsible for ensuring nebulizer equipment and oxygen tubing were properly stored in a bag with a date and that each resident should have an order addressing respiratory supply changes. The facility’s Oxygen Administration policy required that oxygen tubing, humidifiers, masks, and cannulas be changed weekly and when visibly soiled, and stored in a plastic bag at the bedside when not in use, which was not followed in this case.
Personal Beverage Stored in Walk-In Cooler with Residents’ Food
Penalty
Summary
Surveyors identified a deficiency in food storage practices when, during observation of the kitchen’s walk-in cooler, they found an open 16-ounce can of an energy drink that was more than two-thirds full stored inside with residents’ food items. The Food Service Supervisor (FSS) acknowledged during interview that staff had been in-serviced that personal drinks were not allowed in kitchen areas near residents’ food items due to infection control. A dietary staff member admitted the drink belonged to her, stated she knew she was not supposed to have the open drink in the walk-in cooler, and acknowledged that this practice could result in contamination. The Administrator confirmed that no personal food or drink items should be near food preparation or storage areas due to risk of contamination and stated that the FSS was responsible for ensuring this practice did not occur. Review of the facility’s “Nutrition Services Personnel Guidelines” policy, dated 01/01/2026, showed that all personal belongings may not be kept in food preparation or food storage areas. This deficiency reflects the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own policy by allowing personal beverages to be kept in the walk-in cooler used for residents’ food.
Failure to Obtain Ordered Laboratory Services for Multiple Residents
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for three residents. One resident with diagnoses including cerebrovascular disease, hypertension, hypothyroidism, and prediabetes had a physician's order for a Comprehensive Metabolic Panel (CMP) on admission and every three months, but the last CMP was collected several months prior to the review, and there was no care plan addressing lab collection. Another resident with Parkinson's disease, hyperlipidemia, and chronic kidney disease had orders for a CBC and CMP every three months, but these labs were also not collected as ordered, with the last collection occurring months earlier. The care plan for this resident did mention monitoring labs, but the orders were not followed. A third resident, admitted with Parkinson's disease and benign prostatic hyperplasia, had an order for a urinalysis upon admission. Documentation showed repeated notations over several days that the urinalysis was needed, but the specimen was not collected until more than a week after the order. Nursing staff interviews revealed that attempts to collect the specimen were unsuccessful, and alternative collection methods were not pursued. Communication about the outstanding lab order was inconsistent, and the need for the urinalysis was not consistently documented in the 24-hour report. Interviews with nursing leadership indicated confusion regarding lab order discontinuation following a change in medical directors, with some staff believing the orders were no longer active. Leadership also acknowledged that lab collection should have been monitored and communicated more effectively among staff. The facility's policy required the team to process and arrange for lab tests as ordered by the physician, but this was not consistently followed for the residents in question.
Failure to Notify Physician and Follow Up on Elevated Keppra Level
Penalty
Summary
The facility failed to promptly notify and follow up with the ordering physician regarding a laboratory result that was outside the clinical reference range for one resident. The resident, an elderly female with a history of cerebrovascular disease, seizures, and dementia, had a physician's order for a Keppra level to be drawn and monitored. The lab result, received and electronically signed by the medical director, showed a Keppra level above the therapeutic range. The medical director specifically questioned the resident's current Keppra dosage in response to the elevated result. Despite the physician's inquiry, there was no documented response from the nursing staff regarding the resident's current Keppra dose. Review of the facility's 24-hour reports and progress notes revealed no indication that the lab result was addressed or that the physician's question was answered. The resident continued to receive her prescribed Keppra dosage, and there was no documentation of any changes to her medication or further follow-up regarding the elevated lab value. Interviews with the DON and nursing staff confirmed that the elevated Keppra level and the physician's inquiry were not followed up on or documented. The DON acknowledged that the lab result was not written on the 24-hour report for follow-up and that the process for addressing such results was not completed. The facility's policy required prompt physician notification and withholding of the next dose in the event of a high or toxic medication level, but this procedure was not followed in this instance.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 calendar days after admission, as required. Specifically, the admission Minimum Data Set (MDS) assessment for a female resident with hemiplegia, hemiparesis following a stroke, and dementia was not completed on time. The resident was admitted on 03/04/2025, but the MDS assessment, which had an Assessment Reference Date (ARD) of 03/11/2025, was not signed as completed until 03/25/2025, making it 8 days late. Interviews with facility staff revealed that the MDS Coordinator, who was not an RN and worked at two different buildings, relied on the DON to sign off on MDS assessments. The MDS Coordinator attempted to notify the DON via email about assessments needing signatures, but the DON was not always able to check or sign them daily due to other responsibilities and was unaware of the required timeframes. The Administrator expected timely completion but was not aware of the clinical implications. Facility policy required a registered nurse to coordinate and sign each assessment within the specified timeframes, which was not followed in this instance.
Failure to Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interviews, and record reviews. For one resident, who had diagnoses including dementia, chronic kidney disease, anxiety, and hypertension, the care plan required a fall mat to be in place while the resident was in bed due to a recent fall. However, during multiple observations, the fall mat was found folded and not in use while the resident was in bed. Staff interviews revealed that the resident had previously moved the mat herself and sometimes requested its removal, but there was no documentation explaining why the intervention was not in place as required by the care plan. For another resident with diagnoses of dementia, urinary retention, heart failure, and hypertension, the care plan did not include the use of an antidepressant medication, despite the resident having an active order for citalopram for depression. The resident's medication administration record confirmed ongoing use of the antidepressant, but this was not reflected in the care plan. Interviews with the DON and Administrator confirmed that the care plan should have included this medication and the associated diagnosis. The facility's policy requires that care plans be comprehensive, person-centered, and updated to reflect all relevant diagnoses, medications, and interventions based on ongoing assessments. The failures identified in these two cases resulted in care plans that did not accurately reflect the residents' needs or the interventions required to address those needs, as evidenced by the lack of a fall mat in use and the omission of an antidepressant medication from the care plan.
Failure to Remove Hazardous Cleaner from Resident Room
Penalty
Summary
A deficiency occurred when a resident's environment was not kept free from accident hazards, as evidenced by a blue bottle of meyer's cleaner being left on the bedside table in the resident's room. The resident, a male with diagnoses including heart failure, diabetes, glaucoma, kidney failure, anxiety, and high blood pressure, had moderate cognitive impairment and required total assistance with most activities of daily living. Observations on two separate days confirmed the presence of the cleaner in the room. Staff interviews revealed that the cleaner had been brought in by a family member, and both the RN and DON acknowledged that such items should not be present in resident rooms due to the risk of ingestion by the resident or others. Further review showed that the facility did not have a policy addressing hazardous items or the storage of cleaners in resident areas. The administrator confirmed that staff were expected to ensure hazardous items were not left in resident rooms, but acknowledged that there was no formal policy in place. The lack of staff action to remove the cleaner and the absence of a relevant policy contributed to the deficiency, placing residents at risk for injury.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by policy. For one resident with moderate cognitive impairment and multiple diagnoses, including heart failure and diabetes, a bottle of wound cleanser and a container of non-prescribed buttocks powder were observed left on the bedside dresser on multiple occasions. The resident's care plan required staff to administer medications as prescribed, and there was no order for the buttocks powder. Despite previous discussions with the resident's family, these items remained accessible at the bedside. Another resident, who was cognitively intact and at risk for substance abuse, was found with artificial tears on his bedside table. There was no physician order for these eye drops, and the resident reported self-administering them as needed. Nursing staff were unsure if this resident was authorized to self-administer medications, and the DON confirmed that neither resident had been assessed for self-administration. Facility policy required that only authorized staff have access to medications, and that medications be stored in locked areas, but these procedures were not followed for the two residents.
Failure to Maintain Updated Hospice Documentation and Coordination
Penalty
Summary
The facility failed to collaborate and coordinate with hospice representatives to ensure the hospice care planning process was properly managed for a resident receiving hospice services. Specifically, the facility did not obtain the most recent updated hospice plan of care and hospice nursing visit notes for a female resident with a history of cerebrovascular disease, seizures, and dementia. The resident was moderately cognitively impaired and was receiving hospice care as indicated in her care plan and medical orders. However, the hospice binder at the facility only contained outdated documents, with the most recent RN visit note and hospice plan of care update both over a month old. Interviews with the Hospice Director of Nursing (DON), facility DON, and Administrator revealed that hospice documents were expected to be delivered to the facility every two weeks following the hospice interdisciplinary team (IDT) meeting. Due to the absence of the hospice Assistant Office Manager, the updated documents had not been delivered as required, and the responsible staff had not realized the lapse. The facility's contract with the hospice provider required the provision of the most recent hospice plan of care and clinical notes after each visit, but these were not present in the resident's records at the time of the survey.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during direct care activities. For one resident with a history of heart failure, diabetes, kidney failure, and other chronic conditions, who had a Foley catheter and required wound care, a registered nurse provided wound care without donning an isolation gown as required by the facility's enhanced barrier precautions policy. The nurse acknowledged during an interview that she should have worn a gown and gloves prior to providing care, and that the resident required enhanced barrier precautions for both catheter and wound care. In a separate incident, a certified nursing assistant provided incontinent care to another resident with a history of cerebrovascular disease, seizures, and dementia, who was dependent on staff for all activities of daily living and was always incontinent of urine and bowel. During the care process, the CNA failed to perform hand hygiene after removing soiled gloves and before applying clean gloves. The CNA admitted to forgetting to sanitize her hands between glove changes, which she recognized as a lapse in proper infection control practice. Interviews with the Director of Nursing and the Administrator confirmed that staff are expected to use appropriate personal protective equipment and perform hand hygiene according to facility policy. Both acknowledged that failure to follow these protocols could place residents and staff at risk for infection, and that the individuals providing care are responsible for adhering to infection control procedures.
Failure to Prevent and Report Resident Abuse Due to Policy and Training Lapses
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse and neglect of residents, as evidenced by an incident involving a resident who alleged that a CNA was rough during incontinent care, pushing her left shoulder and nearly causing her to hit her head on the bed rail. Another CNA witnessed the alleged abuse but did not report it promptly to the abuse coordinator, citing discomfort and fear of repercussions as a new employee. The incident was instead relayed to another CNA during shift report, who then sent a text message to the DON and ADON, but the abuse coordinator was not notified until much later by the surveyor. The DON and ADON did not immediately notify the abuse coordinator upon receiving the allegation of abuse via text message. Both later stated they did not recall receiving or responding to the message until it was brought to their attention by the surveyor. As a result, the alleged perpetrator was allowed to continue working their shift and provide care to residents after the allegation was made. The administrator confirmed that if he had been notified in a timely manner, the CNA in question would not have worked the subsequent shift. Additionally, the facility failed to ensure that CNAs received abuse training upon hire and prior to providing care. Personnel files revealed that several CNAs did not complete abuse training until weeks or months after their hire dates. The business office manager acknowledged delays in training completion and stated there was no specific policy regarding the timing of abuse training. These failures were identified during interviews and record reviews, and the lack of timely reporting and training placed residents at risk of unreported abuse and neglect.
Removal Plan
- ADON, MDS coordinator and Administrator will conduct 100% resident rounds to determine if further allegations of abuse are alleged.
- Safe surveys will be conducted by Social Worker, Human Resources and Activity Director for all cognitive residents.
- C.N.A. A was educated on Abuse, neglect and reporting by DON.
- C.N.A. B and D were suspended and terminated.
- DON and ADON were given a final written warning stating any further failures would result in termination and were re-educated by Administrator.
- The Abuse Coordinator was educated by the Regional Director of Clinical Services on how to investigate allegations of abuse, reporting of abuse and the importance of a thorough investigation and written documentation of statements and in-services.
- In-servicing was initiated by Administrator on Abuse investigation, notification, and immediate removal of the perpetrator for the DON and ADON.
- In-service will be provided to all staff on Immediate Notification of Allegations to Facility Abuse Coordinator or designee when not in facility or available, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities by DON and ADON.
- Agency staff that work in the facility or staff on PTO or LOA will have in-servicing completed prior to working the floor by the DON/ADON.
- Abuse and Neglect training will be a part of the new hire orientation and no staff will be allowed to work until the Administrator has verified that training has occurred. This training will include all aspects of Reporting Abuse, Investigating Abuse and resident protection from abuse and will be completed at time of hire by HR/DON and verified by Administrator.
- Any staff member who is an alleged perpetrator for any allegation will be suspended immediately pending investigation and will be escorted out of the facility immediately by the senior staff member on duty or law enforcement and will not be allowed to return to the building until the investigation is complete.
- The police were notified of the allegation of abuse by the Administrator.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
The facility failed to ensure that staff treated a resident with respect and dignity, as required by resident rights regulations. One incident involved a CNA providing care to a resident while wearing earbuds, which was confirmed by a witness statement and staff interview. The CNA was reportedly inattentive and did not engage with the resident during care, which was identified as a respect issue by both the witness and the Director of Nursing (DON). Facility policy and staff expectations prohibit the use of earbuds or cell phones during resident care, and random spot checks are conducted to monitor compliance. Another incident involved a different CNA speaking to the same resident in a disrespectful manner. According to a witness statement and staff interviews, the CNA told the resident she would no longer be friendly because the resident was allegedly trying to get staff in trouble. This interaction made the resident feel awful, as reported during an interview. The DON and Administrator both acknowledged that such behavior constitutes a failure to treat residents with respect and dignity, and emphasized the importance of staff treating residents as they would their own family members. The resident involved had a history of rheumatoid arthritis and PTSD, with intact cognition and dependence on staff for various activities of daily living. The care plan noted a history of the resident making complaints about staff, and interventions included having two staff present during care when possible. Despite these measures, the facility did not prevent the incidents of disrespectful behavior and inattentive care, as documented in staff and resident interviews and witness statements.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Cook K was observed using three different thermometers to check the temperatures of the lunch meal on the steam table, but none of the thermometers provided consistent readings. Despite reheating the food, the temperatures remained inconsistent, with some items like pureed steak fingers and gravy not reaching the required temperature of 135 degrees Fahrenheit. The Dietary Manager (DM) instructed Cook K to serve the food, believing it was at the correct temperature, although the thermometers were not functioning properly. Additionally, the Maintenance Supervisor entered the kitchen to get ice without performing hand hygiene or wearing a hair restraint. The Maintenance Supervisor admitted to being unaware of the need for these precautions but acknowledged the potential for cross-contamination after considering the situation. The DM confirmed that the Maintenance Supervisor should have asked for ice from the kitchen staff and should have performed hand hygiene and worn a hair restraint before entering the kitchen area. Interviews with the Dietician, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator revealed that they were aware of the importance of maintaining proper food temperatures, hand hygiene, and wearing hair restraints to prevent foodborne illness and contamination. The facility's policies on food holding and service, as well as employee sanitation, were reviewed and indicated the need for serving hot foods at 135 degrees Fahrenheit or greater and the requirement for hand hygiene and hair restraints in the kitchen.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in infection control practices. One incident involved a CNA who did not perform hand hygiene or change gloves while providing perineal care to a resident, despite the resident having multiple health conditions including multiple sclerosis and herpes viral infection. The CNA admitted to not following proper procedures, and both the ADON and DON confirmed that this failure placed the resident at risk for infection. The facility's policy required hand hygiene and glove changes between clean and dirty tasks, which were not followed in this case. Another deficiency was observed when an LVN did not clean an electronic wrist blood pressure monitor between uses on two residents. The LVN also failed to perform hand hygiene after administering medications to one resident before checking another resident's blood pressure. The LVN acknowledged the importance of these practices to prevent the transfer of germs but admitted to not following them due to nervousness. The ADON and DON confirmed that the failure to clean equipment and perform hand hygiene could lead to the spread of infections. Additionally, the facility did not ensure that staff were aware of a resident's contact isolation precautions. Several staff members, including a housekeeper, an LVN, and a CNA, were observed not wearing PPE while interacting with the resident who had a staph infection. The ADON admitted to not conducting an in-service to update staff on the resident's change from enhanced barrier to contact precautions. The DON and Administrator confirmed that the lack of proper PPE use and hand hygiene placed residents at risk for the spread of infection.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide assistance with the removal of facial hair for a resident with severe cognitive impairment. The resident, who had a BIMS score of 1 indicating severe cognitive impairment, was dependent on staff for all ADLs, including bathing and grooming. Despite being scheduled for regular baths, the resident was observed with long chin hairs, and staff interviews revealed that the CNAs and nurses had not noticed or addressed the facial hair removal as part of the resident's grooming routine. Interviews with the CNA, DON, LVN, ADON, and the Administrator confirmed that the resident did not refuse care and that it was the responsibility of the CNAs and nurses to ensure the resident was shaved during bathing. The facility's policy indicated that residents unable to carry out ADLs independently should receive services to maintain good grooming and personal hygiene. However, the failure to remove the resident's facial hair was observed over multiple days, indicating a lapse in the facility's adherence to its own policies and procedures for maintaining resident dignity and appearance.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a locked compartment, accessible only by authorized personnel. During an observation, an unlocked medication cart was found in the hallway near the dining room entrance, with multiple residents around. LVN A, who was responsible for the cart, acknowledged that it should always be locked when unattended to prevent unauthorized access. The ADON and DON confirmed that medication carts should be locked when staff are away from them, emphasizing the importance of preventing residents or unauthorized individuals from accessing the medications. The facility's policy also indicated that medication carts should be kept closed and locked when out of sight of the medication nurse or aide. Interviews with the ADON, DON, and Administrator revealed that they conduct daily rounds to ensure medication carts are locked and address any lapses with the staff. Despite these measures, the unlocked medication cart posed a risk of residents or unauthorized individuals accessing medications, which could lead to misuse or overdose. The facility's failure to secure the medication cart as per their policy and regulatory requirements was identified as a deficiency.
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 100 citations issued within 25 miles in the last 12 months — including the 2 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 Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Springs Healthcare Center | 14.5 mi | ★★★★★ | 13 | 1 |
| Greenhill Villas | 14.7 mi | ★★★★★ | 5 | 0 |
| Focused Care At Mount Pleasant | 14.7 mi | ★★★★★ | 10 | 0 |
| Lakeview Rehabilitation & Healthcare Center | 16.7 mi | ★★★★★ | 13 | 0 |
| Avir At Winnsboro | 16.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.