Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mullican Care Center during CMS and state inspections, most recent first.
A crash cart was found with an oxygen cylinder at 0 psi, meaning it was empty, during observation. Staff including CNAs, an LVN, the ADON, the DON, and the Administrator stated oxygen should be full and readily available for emergency use, and that nursing staff were responsible for checking the crash cart. The DON and Administrator were unaware the tank was empty, and the facility had no crash cart policy.
Food service staff failed to keep kitchen food properly labeled, dated, and discarded when expired. During an observation, a pan of ground sausage was in the refrigerator with no label or date, and a container of turkey pot roast remained past its use-by date. The Dietary Manager said he was responsible for labeling and discarding expired food, but he had not done so, and the Administrator stated all food was expected to be labeled, dated, and disposed of when expired.
Hot Dining Room in Women's Secure Unit: The Women's Secure Unit dining room was observed at 87-90.7 F while a window AC unit was not working. A resident said the room had been hot, another resident appeared flushed, and a family member reported the issue had been ongoing for about 2 months. Staff said fans were used, but the Maintenance Director reported the unit needed an electrician and temperatures had been running high during the day; the DON and Administrator were not aware of the issue until interviewed.
A resident with Parkinson disease, severe cognitive impairment, and incontinence had pressure ulcers to the coccyx and right hip and was at risk for further skin breakdown. During observation, an LPN did not follow the ordered coccyx wound care steps, and a new unblanchable pressure area was found on the left hip. Staff interviews showed the resident needed regular turning, offloading, and monitoring, but the LPN was not aware of the left hip wound or a turn schedule for that area.
An unsecured hygiene supply cupboard in a memory care shower room contained shampoo, shaving cream, body wash, and disposable razors within resident reach, and a resident with Alzheimer's dementia and moderate cognitive impairment was also found with five disposable razors on his bedside table. Staff stated the shower room was unlocked, residents entered without assistance, and the razors and liquids should have been kept out of residents' reach.
Resident #4, a cognitively impaired resident with dementia and dependence in ADLs, did not have a water pitcher in her room during two observations. A CNA who cared for her on both days confirmed the pitcher was missing, and later water was seen at bedside. The DON and Administrator stated residents were expected to have water within reach, and the facility policy required fresh water to be maintained at bedside.
Medication error rate exceeded the 5% threshold after an LPN failed to prime insulin pens before administering ordered doses to two residents with diabetes. One resident received NovoLog and the other received Novolin R, and the MAR documented the doses were given as ordered, but observation showed the insulin pens were not primed before administration. The DON, ADON, and Administrator stated insulin should be administered according to manufacturer guidelines and physician orders.
Insulin pens were not primed for two residents receiving sliding-scale insulin. An LPN administered Novolog to one resident and Novolin R to another without performing the required safety test, despite both residents having diabetes and active insulin orders. The LPN stated she was unaware the pens had not been primed, and the DON, ADON, and Administrator stated insulin was expected to be given according to manufacturer instructions and physician orders.
Unattended Secure Unit Medication Cart Left Unlocked: A medication cart in the secure unit area was observed unlocked and unattended in a hallway while staff, visitors, and residents passed by it. MA F said she was responsible for the cart and that it should be locked when not in use, and the ADON, DON, and Administrator stated medication carts should be locked whenever staff were not actively administering meds. The facility policy stated medication carts and supplies are to be locked or attended to by authorized staff.
A resident with COPD, DM2, dementia, and gout had incomplete EMR documentation for the care plan conference. The record did not show evidence of an initial care plan meeting within the required timeframe, and staff could not locate documentation of attendance, meeting content, or proof that the resident's family participated, despite interviews indicating the meeting was held and discussed by the IDT.
The facility failed to coordinate hospice care and keep hospice binders current for two residents receiving hospice services. One resident with dementia had a hospice binder missing recent IDG meeting documentation and an updated care plan, while another resident with stroke, anxiety, and depression did not have the most up-to-date hospice medication list. Interviews confirmed the hospice binder was expected to contain current orders, care plans, IDG notes, and medication information for continuity of care.
A facility failed to maintain infection control practices for two residents. One resident on contact isolation for ESBL had no linen or trash disposal containers in the room, and a CNA entered the room without gown or gloves after handling linen in a regular trash bag. Another resident receiving wound care under EBP precautions had treatment performed by an LVN who wore gloves but did not wear a gown. The DON and Administrator stated staff were expected to follow the posted PPE precautions and facility infection control policy.
A resident with dementia and other comorbidities was facility-initiated for discharge to an inpatient psychiatric hospital, but the facility failed to complete the ombudsman notification section of its discharge protocol and did not send the required written notice to the State LTC Ombudsman. Although documentation on an eTransfer form indicated that the physician and resident representative were notified, the local ombudsman and the resident’s responsible party both reported they were not informed of the actual discharge. Interviews with the Administrator, DON, ADON, Social Worker, and an RN showed unclear roles and missed communication, and the Social Worker was unaware of the requirement to notify the ombudsman, despite facility policy requiring written notice to the resident, representative, and ombudsman for facility-initiated transfers and discharges.
Surveyors found that the facility failed to properly label, date, and dispose of expired food items, and did not maintain safe holding temperatures for food on the steam table. Multiple expired and unlabeled items were observed in the kitchen, and several foods were held below the required temperature. Both the Dietary Manager and Administrator were unaware of these issues until informed by surveyors.
Surveyors found that the facility failed to provide palatable, attractive, and properly heated food during a lunch meal, with food temperatures below recommended levels and bland taste reported. Two residents expressed dissatisfaction with the food's appearance and texture. Additionally, the cook did not follow the prescribed puree recipe, using water instead of recommended liquids, and did not consult the recipe book. The Dietary Manager and Administrator were unaware of these deviations and lacked oversight regarding recipe adherence and staff training.
The facility did not serve meals at the posted times, with observations confirming that lunch service was delayed and a resident reporting consistent lateness for breakfast and lunch. Staff interviews acknowledged the issue and attributed delays to staff performance, despite prior in-services on timely meal service.
A resident with a history of schizoaffective disorder and major depressive disorder did not receive quarterly PASRR IDT meetings as required, due to a lapse in Medicaid coverage and lack of coordination by facility staff. Documentation showed only two IDT meetings over more than a year, despite the resident's need for specialized services. Staff interviews confirmed the missed meetings and a lack of awareness regarding the requirement.
A resident with an indwelling Foley catheter was found to have the catheter unsecured for several days, despite physician orders and care plan interventions requiring securement. The resident reported the issue to staff, but it was not addressed, and interviews with nursing staff and leadership confirmed the responsibility to ensure securement was not met.
A nurse failed to properly reconcile and dispose of a controlled medication for a resident with severe cognitive impairment and a feeding tube. The nurse disposed of a clonazepam tablet without a witness and did not follow facility policy, resulting in a discrepancy in the narcotic log and incomplete accountability for the controlled drug.
A resident with a seizure disorder and on Keppra therapy did not have the required Keppra level lab drawn as ordered, due to a miscommunication between facility staff and the lab company. The lab requisition to discontinue routine labs did not specify that the Keppra level should continue, resulting in the cancellation of all labs. The DON and lab staff confirmed the omission and lack of follow-up, and there was no facility policy in place for laboratory services.
Staff failed to follow enhanced barrier precautions during wound care for a resident with dementia and peripheral vascular disease, as both an LVN and a CNA wore gloves but did not don gowns as required by the care plan and facility policy. Both staff members acknowledged forgetting to use the gowns, despite the PPE being available and the resident's care plan specifying the need for these precautions.
A resident reported missing $250 from her room, but the facility did not file a grievance form or keep the resident informed about the resolution process. Although the resident was cognitively intact and able to communicate, staff did not follow the required grievance procedures, resulting in a lack of documentation and communication about the incident.
The facility failed to accurately code the use of restraints for three residents in their MDS assessments. The residents were noted to use bed rails as restraints, but observations and care plans indicated the use of grab bars for repositioning and transfers. Interviews revealed that the coding errors were due to a misunderstanding of the meaning of restraints.
The facility failed to maintain a safe environment on the C hall, where the flooring was raised and split, creating a trip hazard. The ADON, DON, Maintenance Director, and Administrator were unaware of the severity of the issue until it was pointed out, and the facility lacked a policy for maintaining a safe and homelike environment.
The facility failed to refer a resident with serious mental disorder for a PASARR evaluation. The resident, with diagnoses including bipolar disorder and schizophrenia, was admitted without a proper PASARR Level II screening. The MDS nurse lacked knowledge about PASARR requirements, leading to the oversight.
The facility failed to include a resident's PTSD diagnosis in her care plan, despite her severe cognitive impairment and the importance of addressing PTSD triggers. Staff members, including an LVN, ADON, DON, and the Administrator, acknowledged the oversight and its potential impact on the resident's care.
The facility failed to update care plans for three residents, leading to discrepancies between their current conditions and documented care plans. One resident frequently removed his Foley catheter leg strap, another no longer needed a wander guard, and a third was inaccurately listed as a smoker. These oversights could result in inappropriate care and potential harm.
The facility failed to ensure proper respiratory care for two residents. One resident did not have documented oxygen orders despite using oxygen, and another resident's oxygen concentrator filter was not cleaned as required. These deficiencies were confirmed through staff interviews and observations.
The facility failed to maintain accurate documentation in the MAR for a resident, leading to incomplete and inaccurate medical records. Despite being at high risk for elopement, the resident did not have a wander guard bracelet, and staff signed the MAR without verifying its presence. Interviews revealed systemic issues in monitoring and documentation processes for wander guards.
A CNA failed to follow proper hand hygiene protocols while providing peri care to a resident with multiple diagnoses, including diabetes and epilepsy. The CNA did not use hand sanitizer between glove changes, which was observed and confirmed through interviews with facility staff. The resident required substantial assistance with daily activities and had moderate cognitive impairment.
The facility failed to report a resident's allegations of abuse within the required timeframe. The resident, who has multiple medical conditions, made repeated allegations against the DON and ADON. Interviews revealed a lack of clarity and communication regarding the reporting process, leading to the incident not being reported to the state agency as mandated.
The facility failed to report a resident's allegations of abuse to the state agency within the required timeframe. Despite the resident's repeated allegations against the ADON, the incident was not reported as mandated by law. Interviews revealed a lack of clarity and adherence to the facility's policy on reporting abuse.
The facility failed to notify the Office of the State LTC Ombudsman of a resident's discharge to a psychiatric hospital, violating regulatory requirements. The resident, who was cognitively intact and had multiple diagnoses, was not allowed to return to the facility, and the necessary paperwork was not properly managed.
The facility failed to re-admit a resident after psychiatric hospitalization and did not issue the required 30-day discharge notice, violating their own policy. The resident, with multiple diagnoses, was left feeling emotionally drained and homeless.
Empty Oxygen Cylinder Found on Crash Cart
Penalty
Summary
The facility failed to ensure the emergency crash cart was equipped with a readily available oxygen supply when an empty oxygen cylinder was found attached to the crash cart during observation on 07/22/2026 at 1:30 p.m. The cylinder registered 0 psi, indicating it was empty, and this was identified on 1 of 1 crash carts reviewed. During interviews on 07/23/2026, CNA C, CNA B, LVN A, the ADON, the DON, and the Administrator all stated that oxygen should be full and readily available on the crash cart for emergency use. Staff stated the nurse was responsible for checking the crash cart, that the crash cart was checked daily or every night, and that the night shift nurse was responsible for verifying the oxygen supply. The DON and Administrator stated they were unaware the oxygen tank was empty. Record review showed an oxygen policy dated 02/2007 with the goal that the resident maintain safe and effective prescribed oxygen delivery, and the facility did not have a crash cart policy.
Food items left unlabeled, undated, and expired in kitchen refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for dietary services. During an observation with the Dietary Manager, a pan of ground sausage was found in the refrigerator with no label or date, and a container of turkey pot roast was found with a use-by date of 07/16/2026. The Dietary Manager stated that all food in the refrigerator should be labeled and dated and that expired food items were to be discarded on Mondays and Fridays, but he had not been in the facility on Friday and did not discard expired items. He also stated he had placed the pan of ground sausage in the refrigerator while preparing breakfast and had not labeled or dated it because he was in a hurry. During interview, the Dietary Manager said he was responsible for discarding expired food items and ensuring food was labeled and dated, and he acknowledged that food should be labeled and dated and expired items discarded because residents could get sick. The Administrator stated that all food items in the refrigerator were expected to be labeled, dated when opened, and dated with an expiration date, and that expired food was to be disposed of. Record review showed the facility's Food Safety policy stated opened food shall be labeled, dated, and stored properly, and the Left-Over Foods policy stated spoiled, contaminated, or suspect food shall not be served and shall be discarded immediately.
Hot Dining Room in Women's Secure Unit
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the Women's Secure Unit dining room when the temperature was documented between 87 and 90.7 F. During observation, residents in the dining area were noted to have water within reach, and some residents appeared flushed but were not sweating. One resident was unable to describe how she felt because of her cognitive status, while another resident said the dining room had been hot. A family member also reported that the dining room had been extremely hot for about 2 months and said she had reported the issue to administration and the ADON. Staff interviews showed that the window air conditioning unit in the Women's Secure Unit had been broken for about a month to about 2 weeks, depending on the staff member interviewed. CNA G said fans had been placed in the dining room but were not helping. The Maintenance Director said he had replaced the plug in the unit, but it still did not work and needed an electrician. He said he had been checking the temperature in the dining area every other day and it had been between 81 and 90 F at the peak of the day. The ADON said a CNA had reported the area was hot and that she notified the Maintenance Director, who ordered a part and placed fans in the area. The DON and Administrator both stated they were not aware of the temperature issue until interviewed. The Administrator said anything above 81 degrees would require evacuation of residents to another area of the facility and that temperatures above 81 were dangerous and could cause heat stroke, heat exhaustion, and heat-related illness. Record review of the facility's discharges for the past 6 months did not show any residents hospitalized related to heat exposure. The Administrator also stated the facility did not have a policy on temperature for the environment.
Failure to Follow Wound Care Orders and Monitor New Pressure Injury
Penalty
Summary
The facility failed to ensure a resident with pressure ulcers received wound care according to physician orders. Resident #25, a male with Parkinson disease, severe cognitive impairment, and bowel and bladder incontinence, had a care plan for pressure ulcer risk and wounds to the coccyx and right hip. The record showed physician orders for daily wound care to the coccyx and wound care to the right hip on Monday, Wednesday, and Friday, and the resident was identified as at risk for pressure ulcers on the quarterly MDS. During observation on 07/22/2026, a previously unidentified pressure injury was noted on the resident’s left hip, described as a reddened unblanchable area measuring 0.5 cm x 0.7 cm x 0.35 cm. During the same observation, LVN A did not follow the physician order for coccyx wound care when she sprayed the wound with wound cleaner and skipped the ordered step of cleaning the wound and patting it dry. The wound care report also documented the coccyx wound measurements as 8.5 cm x 3.5 cm x 1.5 cm. Interviews showed CNA C and CNA B were responsible for checking and changing the resident, repositioning him, and offloading pressure, and both stated the resident was at risk for skin breakdown. CNA B stated the left hip area had been red for a couple of days and had been reported to the nurse. LVN A stated she was aware of the coccyx and right hip wounds but was not aware of the left hip wound and was not aware the resident needed a turn schedule to reduce pressure to the left hip. The ADON, DON, and Administrator stated they expected wound care orders to be followed and the resident to be turned every two hours, and the DON stated the resident frequently lay on his right side, increasing risk for skin breakdown.
Unsecured hygiene supplies and razors accessible to memory care residents
Penalty
Summary
The facility failed to keep the resident environment free from accident hazards in the men's memory care unit common shower room and in Resident #40's room. On observation, the hygiene supply storage cupboard in the shower room was unsecured and contained an opened gallon of shampoo about half full, five cans of shaving cream, four disposable razors, one hairbrush, and six bottles of body wash. CNA D stated she knew the cupboard was not secured and said residents could get sick if they drank the shampoo or soap or could cut themselves on the razors. CNA E stated the shower room was always unlocked and residents on the memory care unit often entered without assistance. The ADON later stated hygiene items should be kept out of residents' reach, especially on the memory care unit, and that the cupboard should have a lock. Resident #40 was observed with five disposable razors on the bedside table next to his bed. He was an older male resident with diagnoses including Alzheimer's dementia, major depressive disorder, hypertension, left eye blindness, and long-term anticoagulant use. His MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and he required supervision with bathing, dressing, transfers, and bed mobility. His care plan addressed impaired cognition, impaired vision, and self-care deficits, with assistance needed for personal hygiene including shaving. CNA D stated she had not given him razors and was not sure how they got into his room, while CNA E stated disposable razors were not safe for residents to have in their rooms and should have been kept in a locked area.
Resident Lacked Water at Bedside
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for Resident #4, who was re-admitted to the facility with diagnoses including dementia, muscle weakness, anxiety, and depression. Her quarterly MDS reflected that she rarely made herself understood, was sometimes understood by others, had severe impairment in cognitive skills for daily decision making, and was dependent on ADLs such as eating and personal hygiene. Her care plan also identified a history of falls and directed staff to keep needed items, including water, within reach. During observations, Resident #4 did not have a water pitcher in her room on 07/20/26 and again on 07/21/26. She was unable to answer questions about the pitcher during an attempted interview because of impaired cognition. A CNA who cared for her on both days verified the pitcher was not in the room and stated she had not noticed it was missing. Later that day, water was observed at the resident's bedside. Interviews with an LVN, the DON, and the Administrator reflected that they expected residents to have water at bedside and within reach, and the facility policy stated that fresh water would be maintained at bedside.
Medication Error Rate Exceeded Threshold Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors determined the facility had an 8% medication error rate, based on 2 errors out of 25 opportunities, involving two of five residents reviewed for medication administration. The errors involved insulin administration for two residents with diabetes mellitus: one resident with dementia and type 2 diabetes, and another resident with type 2 diabetes and moderate cognitive impairment. For one resident, the order summary showed NovoLog FlexPen was prescribed per sliding scale, and the MAR documented 7 units were administered for a blood sugar of 336. During observation, LVN A did not prime the insulin pen before giving the dose. For the second resident, the order summary showed Novolin R was prescribed per sliding scale, and the MAR documented 2 units were administered for a blood sugar of 154. During observation, LVN A also did not prime that insulin pen before administering the dose. During interview, LVN A stated the DON had shown her how to prime the insulin pen when she was checked off on her skills, but she was unable to recall the exact date of the checkoff. She later stated she was unaware she had not primed the insulin pens for either resident and acknowledged she was supposed to prime the insulin and administer it according to manufacturer instructions. The ADON, DON, and Administrator stated they expected insulin pens to be primed and medications to be administered according to manufacturer guidelines and physician orders.
Insulin Pens Not Primed During Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors when insulin pens were not primed according to manufacturer instructions during administration. Resident #10 had a diagnosis of dementia and type 2 diabetes, and the record showed an order for Novolog Flex Pen to be given by sliding scale. On 07/22/2026, the Nursing MAR documented a blood sugar of 336 and 7 units were administered. During observation at 11:23 a.m., LVN A was observed administering the insulin pen without priming it. Resident #42 had a diagnosis of type 2 diabetes mellitus and an annual MDS showing a BIMS of 11, indicating moderate cognitive impairment. The resident had an order for Novolin R solution to be given by sliding scale. On 07/22/2026, the Nursing MAR documented a blood sugar of 154 and 2 units were administered. During observation at 11:30 a.m., LVN A was observed administering the insulin pen without priming it. During interview, LVN A stated she was unaware she had not primed the insulin pens for either resident and stated she was supposed to prime the insulin and administer it according to manufacturer instructions. The ADON, DON, and Administrator stated they expected insulin pens to be administered according to manufacturer guidelines and physician orders. The facility policy stated medications are to be administered in accordance with physician orders, and the insulin pen policy required performing a safety test before each injection by selecting 2 units, holding the pen upright, tapping the reservoir, and pressing the injection button to confirm insulin comes out of the needle tip.
Unattended Secure Unit Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 medication carts reviewed, specifically the Secure Unit Medication Cart. During an observation on 07/21/2026 at 10:27 AM, the Secure Unit Medication Cart was found unlocked and unattended in the hallway before entering the secured units, with multiple staff, visitors, and residents passing by it. At 11:50 AM, the State Surveyor notified the Administrator of the unlocked cart, and the Administrator stated it should not have been unlocked and locked it. During an interview on 07/21/2026 at 12:02 PM, MA F said she was responsible for the Secure Unit Medication Cart and stated the cart should be locked at all times when not in use and out of sight. MA F said residents could open an unlocked, unattended medication cart and take the medications. The ADON, DON, and Administrator later stated that the person responsible for the cart was expected to keep it locked whenever staff were not actively administering medications, and the facility policy titled, Medication Storage in the Facility, dated 03/2025, stated that medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.
Incomplete Care Plan Conference Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical record documentation for Resident #46, specifically related to the care plan conference record. Resident #46 was admitted on 05/28/2026 and had diagnoses including COPD, type II diabetes mellitus, dementia, and gout. The comprehensive MDS documented moderately impaired hearing, a BIMS score of 9 indicating moderate cognitive impairment, use of a walker for mobility, independence with eating, and supervision needed for toileting, bathing, dressing, bed mobility, and transfers. Record review showed the care plan was initiated on 05/28/2026 with a next review date of 09/01/2026, but the EMR did not contain evidence of an initial care plan conference completed within 21 days of admission. The care plan conference assessment file contained only one assessment dated [DATE], and staff were unable to locate documentation showing that the meeting occurred, who attended, or what was discussed. During interviews, the ADON, SW, MDS Nurse, DON, Administrator, and the resident's responsible party each described involvement in care plan meetings, but the MDS Nurse could not locate documentation confirming the initial meeting or attendance, and the DON and Administrator stated that the assessment should reflect the meeting content and attendees.
Hospice Documentation and Care Coordination Lapses
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services, including communication with the hospice medical director, the attending physician, and others involved in care. For Resident #4, who was re-admitted with diagnoses including dementia, muscle weakness, anxiety, and depression, the quarterly MDS indicated severe cognitive impairment and that the resident was on hospice services. The care plan identified a terminal prognosis and hospice services, with interventions focused on comfort and adjusting ADLs to the resident’s changing abilities. Record review of Resident #4’s hospice binder showed that it did not contain the last two IDG meetings or an updated care plan. The hospice RN stated the binder should contain supporting documentation such as the face sheet, election form, code status, certification of terminal illness, plan of care, and medications, and that documentation should be updated after IDG meetings. She reviewed the binder and noted the last IDG meeting in the binder was from 06/18/26 and the last care plan was from 02/22/26, while an IDG meeting from 07/02/26 was not in the binder. She stated she did not know why the updated care plan or IDG meeting was missing. For Resident #3, who was re-admitted with diagnoses including stroke, anxiety, and depression, the quarterly MDS showed severe impairment in cognitive skills for daily decision making and that the resident was receiving hospice services. The care plan indicated hospice services for stroke and cooperation with the hospice team to meet the resident’s needs. Record review showed a physician order for sertraline and a hospice medication list printed on 06/29/26 that listed sertraline 50 mg daily for depression, but the facility failed to obtain the resident’s most up to date hospice medication list. Interviews with the hospice nurse, LVN, DON, and administrator confirmed that the hospice binder was expected to contain current hospice documents and that updated information was to be provided by hospice for continuity of care.
Infection Control PPE and Isolation Practices Not Followed
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents reviewed for infection control. One resident was on contact isolation for ESBL and had a physician order for contact isolation every shift, along with a care plan noting contact isolation. During observation, the resident was in bed with an isolation sign and PPE cart outside the room, but there were no containers in the room for linen or trash disposal. The resident stated she was not sure why she was in isolation. During an interview, an LVN stated that anyone entering the contact isolation room should wash hands, apply a gown and gloves, and rewash before leaving the room. However, during observation, a CNA exited the room with linen in a normal trash bag and placed it in the hallway linen barrel, then re-entered the room without gown or gloves. The CNA stated she had been told by the DON that she did not have to wear PPE just to go into the room and did not have to dispose of linen or trash in any special container. A laundry aide stated she knew resident clothing from the resident should be washed separately, but if staff used towels or other linen, she would not know to wash them separately because there were no identifying markings. A second resident had a wound on the right lateral ankle and a physician order for daily betadine treatment and leaving the area open to air. The resident’s room had an EBP sign and cart inside. During wound care, an LVN applied gloves but did not wear a gown while performing the treatment. The LVN later stated she was supposed to wear gown and gloves while performing wound care and said she forgot to wear a gown. The DON and Administrator stated staff were expected to wear PPE according to the posted precautions and facility policy, including gown and gloves for contact isolation and EBP care.
Failure to Provide Required Transfer/Discharge Notices to Representative and Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer or discharge to a resident, the resident’s representative, and the State LTC Ombudsman, and to send a copy of the notice to the Ombudsman. The resident involved was an elderly male with dementia, diabetes mellitus, hypertension, and depression, who had a BIMS score of 2 indicating severe cognitive impairment and required supervision for ADLs. Record review showed a facility-initiated discharge protocol dated 01/09/2026 for this resident, with the ombudsman notification portion left incomplete. The discharge MDS dated 01/16/2026 documented that the resident was discharged to an inpatient psychiatric facility. Further record review of an eTransfer form dated 01/16/2026 at 3:00 PM, completed by the ADON, indicated the resident was transferred to an inpatient psychiatric hospital in a non-emergent transfer, and that the facility physician and resident representative were documented as notified at 9:00 AM the same day. However, the local facility ombudsman stated in interview that she was never notified of the resident’s discharge and only learned of it several days later. The resident’s responsible party reported receiving a 30‑day discharge notice on 01/09/2026 but stated that no one from the facility notified her when the resident was actually discharged on 01/16/2026, and that even during a conversation with the Administrator on the day of discharge, she was not informed that the resident had been discharged. Multiple staff interviews revealed inconsistent involvement and a lack of clarity regarding who was responsible for notifications. The ADON stated the resident received a 30‑day notice but did not know when, was not involved in the discharge to the behavioral health unit, and did not verify that the family had been contacted, though she acknowledged the family should be notified prior to discharge. The Administrator stated he had discussed the facility’s inability to meet the resident’s needs with the family and believed he had provided a 30‑day notice, but he acknowledged that he forgot to notify the family when the resident was sent to the behavioral hospital and that he did not complete the ombudsman notification section of the facility-initiated discharge protocol. The DON and Social Worker each reported limited or no direct involvement in the actual discharge notifications on the day of transfer, with the Social Worker stating she was unaware of the requirement to notify the ombudsman. RN A reported that, to his knowledge, the discharge process had been completed before his shift and that he was not involved in notifying the responsible party or physician. The facility’s own undated policy stated that for facility-initiated transfers and discharges, including emergent transfers and discharges decided while a resident is hospitalized, notices must be provided to the resident and resident representative and copies sent to the State LTC Ombudsman, which did not occur in this case.
Deficiencies in Food Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to the storage, labeling, dating, and disposal of food items. During observations in the kitchen's refrigerators and freezers, several food items were found to be expired, including BBQ beef, celery seed seasoning, ground red pepper seasoning, and sugar seasoning. Additionally, some items such as jelly, ketchup, diced tomatoes, and hamburger meat were either missing expiration dates or were not labeled and dated as required. These issues were observed in the presence of the Dietary Manager, who stated that all items should be labeled, dated, and discarded if expired, but was unaware of the expired items found during the survey. Further observations revealed that the facility failed to maintain safe holding temperatures for food on the steam table. Several food items, including regular chicken parmesan, spaghetti sauce, and various pureed foods, were recorded at temperatures below the required 135°F for hot holding, with some items as low as 54.3°F. These findings were documented during meal service observations and confirmed by staff present at the time. Interviews with the Dietary Manager and Administrator indicated that both were unaware of the expired food items and improper labeling until informed by surveyors. The Dietary Manager reported conducting daily walk-throughs and stated that staff had recently completed in-services on labeling and dating food items. The Administrator also reported conducting daily walk-throughs but was not aware of the deficiencies until notified. Review of facility policy and FDA guidelines confirmed the requirements for proper food labeling, dating, and temperature control, which were not met during the survey.
Deficient Food Palatability, Temperature, and Recipe Adherence
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for one of three meals observed during a survey. During the lunch meal, food temperatures were recorded as being below recommended levels, with the regular chicken parmesan measured at 87°F and the puree chicken parmesan at 109°F, both of which are below the standard for hot food service. Observations and interviews revealed that the green beans were bland and cool, and the chicken parmesan was described as warm but not hot by both the Dietary Manager and surveyors. Residents interviewed expressed dissatisfaction with the food, noting issues such as tough meat, unappetizing appearance, and insufficient quantity. Further investigation found that the facility did not follow the prescribed puree recipe for the lunch meal. The cook was observed adding water and food thickener to green beans instead of using the recommended liquids such as broth, juice, milk, gravy, or sauce, as specified in the recipe book. The cook admitted to not consulting the recipe book prior to preparing the meal and stated that he relied on his own experience. The Dietary Manager was unaware that staff were not following the recipe book and confirmed that the last in-service training on following the menu was completed a month prior. Interviews with the Dietary Manager and Administrator indicated a lack of oversight and communication regarding adherence to recipes and food preparation standards. The Dietary Manager stated he was responsible for ensuring staff followed the recipe book but was not informed of deviations. The Administrator, who oversees the Dietary Manager, was also unaware of staff not following recipes and was unsure about the completion of in-service training. Both acknowledged the importance of providing palatable and appetizing food but did not identify recent complaints or issues prior to the survey findings.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve meals at the specific times posted in the main dining room, resulting in residents not receiving meals at regular times comparable to normal mealtimes in the community. The posted meal service times were 7:00 AM for breakfast, 12:00 PM for lunch, and 5:00 PM for dinner. Observations showed that lunch service had not begun by 12:42 PM, and a resident reported that both breakfast and lunch were always served late. Record review indicated that the last staff in-service on time management was completed on 4/29/25. Interviews with the Dietary Manager and Administrator confirmed awareness of the late meal service, with the Dietary Manager attributing the delay to the cook's inability to handle pressure. Both the Dietary Manager and Administrator acknowledged the importance of serving meals on time to maintain residents' routines and support their nutritional needs. Despite previous in-services on timely meal service, the deficiency persisted, as evidenced by the late lunch service and resident complaints.
Failure to Coordinate Quarterly PASRR IDT Meetings for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program to the maximum extent practicable, resulting in missed quarterly PASRR Interdisciplinary Team (IDT) meetings for a resident with a serious mental illness. Record review showed that the resident, who had diagnoses including schizoaffective disorder and major depressive disorder, was identified as PASRR positive and required specialized services. Although the care plan indicated that the local authority would be invited annually to care plan meetings, documentation revealed that quarterly IDT meetings were not consistently conducted as required. The resident's PASRR Level 1 Screening and evaluation confirmed the need for specialized services, but recommended services were not listed, and only two IDT meetings were documented over a period exceeding one year. Interviews with facility staff, including the MDS Coordinator and PASRR Coordinator, revealed that the missed meetings were attributed to a lapse in the resident's Medicaid coverage. Staff stated that when Medicaid lapsed, IDT meetings were not scheduled, and there was a lack of awareness regarding the missed quarterly meetings. The facility's policy did not specify the required frequency for PASRR IDT meetings. The administrator confirmed the expectation for quarterly meetings and identified the MDS Coordinator as responsible for coordination, but acknowledged the deficiency in meeting this requirement.
Failure to Secure Foley Catheter as Ordered
Penalty
Summary
A deficiency was identified when a male resident with a history of prostate cancer and benign prostatic hyperplasia, who had an indwelling Foley catheter, was found to have his catheter unsecured to his leg. The resident reported that the catheter had been unsecured for several days and that he had informed staff, but the issue was not addressed. The resident's care plan and physician orders required the catheter to be secured to prevent trauma and infection, and the facility's policy instructed staff to minimize friction or movement at the insertion site, although it did not specifically address securement. Interviews with nursing staff and facility leadership confirmed that the responsibility for ensuring the catheter was secured rested with the nurses and other care providers. Despite this, the catheter remained unsecured, and staff were unable to provide a reason for the lapse. The deficiency was observed during a survey, and documentation supported that the required interventions to secure the catheter were not followed as ordered.
Failure to Accurately Reconcile and Dispose of Controlled Medication
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically for one resident who was prescribed clonazepam for anxiety. On the observed date, a registered nurse (RN) removed a tablet of clonazepam from the medication card, crushed it, and prepared it for administration via the resident's gastrostomy tube. The RN then signed off the administration in the narcotic log. However, the narcotic record indicated there should have been two tablets remaining, but only one was present. The RN explained that she had disposed of a tablet after recalling that a state surveyor wanted to observe the administration, but did so without obtaining a witness, as required by facility policy. The RN admitted she was unfamiliar with the facility's policy, having only recently started working there, and did not secure a witness during the disposal process. The resident involved was a female with severe cognitive impairment, dependent on staff for all activities of daily living, and received medications via a feeding tube. Facility policy and interviews with the Director of Nursing (DON) and Administrator confirmed that a witness is required when disposing of controlled medications, and failure to do so could lead to discrepancies in drug accountability. The lack of a witness and improper reconciliation of the narcotic log resulted in an inability to accurately account for all controlled drugs, as required by federal and state regulations.
Failure to Obtain Ordered Keppra Level for Resident on Anticonvulsant Therapy
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for a resident with a seizure disorder who was receiving Keppra, an anticonvulsant medication. The resident's care plan and hospice admission orders specified that routine labs were to be discontinued except for the Keppra level, which was to be monitored every three months. Despite these orders, the Keppra level was not obtained for the month of May. Record review showed that the last Keppra level was within therapeutic range in February, and the resident continued to receive Keppra as prescribed. However, a lab requisition to discontinue routine labs did not specify that the Keppra level should continue, leading to the cancellation of all labs, including the required Keppra level. Interviews with facility staff and the lab company revealed a miscommunication regarding which labs were to be discontinued, resulting in the Keppra level not being drawn as ordered. The Director of Nursing (DON) acknowledged that the omission occurred when the lab requisition was filled out and that nursing staff were responsible for ensuring labs were obtained as ordered. The lab company also indicated that both the facility and the lab were responsible for ensuring the correct labs were drawn, and the failure to do so was due to a lack of clarification and follow-up. There was no policy in place at the facility regarding laboratory services.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that staff followed enhanced barrier precautions (EBP) during wound care for a resident with significant medical needs. Specifically, during an observed wound care procedure, an LVN and a CNA donned gloves but did not wear gowns as required by the resident's care plan and facility policy. Both staff members acknowledged in interviews that they were aware of the EBP requirements, which included wearing both gloves and gowns for wound care, but stated they forgot to put on gowns during the procedure. The necessary personal protective equipment (PPE) was available, but not utilized as directed. The resident involved had a history of dementia and peripheral vascular disease, with a severely impaired cognitive status and ongoing pressure ulcer care. The care plan for this resident specifically indicated the need for EBP, including the use of gloves and gowns during high-contact care activities such as wound care. Facility policy also required EBP for residents with wounds, regardless of known infection status. Despite these documented requirements, staff did not adhere to the established precautions during the observed care event.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Money
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance for one resident who reported missing $250 from her room. The resident, who was cognitively intact and able to communicate her needs, informed the Administrator about the missing money. Despite this report, no grievance form was filed, and the resident was not appropriately apprised of the progress toward a resolution. The facility's grievance log did not contain any entry for this incident, and staff interviews confirmed that the required grievance process was not followed. The resident had a history of making negative statements and allegations, but the facility's policy required that all grievances be documented and investigated. The Social Worker and DON both acknowledged that a grievance form should have been completed, and the Administrator admitted that the usual process was not followed in this case. The failure to document and address the grievance as per policy meant that other staff were not made aware of the incident, and there was no formal record of the steps taken to resolve the resident's concern.
Inaccurate MDS Assessment Coding for Restraints
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for three residents reviewed for MDS assessment accuracy. Specifically, the facility did not accurately code the use of restraints for these residents. Resident #17, a male with diagnoses including seizures, bipolar disorder, schizophrenia, and generalized anxiety, was noted to use bed rails daily as a restraint in his MDS assessment. However, his physician's orders and care plan indicated the use of a U-shaped grab bar for repositioning and transfers, not as a restraint. Observations confirmed the use of grab bars for transfers, not restraints. Resident #4, a male with diagnoses including epilepsy, dementia, high blood pressure, and heart failure, was also inaccurately coded as using bed rails daily as a restraint in his MDS assessment. However, his order summary and care plan did not indicate the use of side rails, and observations confirmed that he did not have side rails on his bed. Similarly, Resident #11, a male with diagnoses including complete traumatic amputation, muscle wasting, and abnormal posture, was coded as using bed rails in his MDS assessment. His care plan and order summary indicated the use of a grab bar for repositioning, and observations confirmed the use of the grab bar for transfers. Interviews with the MDS nurse, ADON, DON, and Administrator revealed that the coding errors were due to a misunderstanding of the meaning of restraints. The MDS nurse acknowledged the incorrect coding and the importance of accurate MDS assessments for reflecting resident care. The ADON, DON, and Administrator emphasized that the facility is restraint-free and that the grab bars were not used as restraints. They also highlighted the need for accurate MDS coding to ensure proper care and billing.
Unsafe Flooring on C Hall
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on the C hall. The flooring on the C hall was observed to be raised and split across the hallway, creating a trip hazard. This issue was identified during an observation on 04/09/24 and confirmed through subsequent observations and interviews with the ADON, DON, Maintenance Director, and Administrator on 04/10/24. The ADON and DON acknowledged the potential risk for falls but were not previously aware of the severity of the floor's condition. The Maintenance Director admitted that the floor had been shaved three times since 2009 and had deteriorated significantly, posing a risk for falls. He stated that regional maintenance would be responsible for fixing the floor due to an upcoming remodeling project. The Administrator was also unaware of the raised floor until notified on 04/10/24. He recognized the fall risk and planned to prioritize the issue by marking the area with yellow tape to alert residents and staff. The facility did not have a policy for maintaining a safe and homelike environment, which contributed to the oversight. The lack of immediate corrective action and awareness among the staff and administration led to the deficiency, placing residents at risk of falls and injuries due to the unsafe environment.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with possible serious mental disorder for a PASARR evaluation. The resident, a male with diagnoses including seizures, bipolar disorder, schizophrenia, and generalized anxiety, was admitted to the facility without a proper PASARR Level II screening. The resident's records indicated he was cognitively intact and required extensive assistance with daily activities. Despite having a diagnosis of schizoaffective disorder and being prescribed Quetiapine Fumarate, the initial PASARR Level I screening did not reflect his mental illness diagnosis, leading to a failure in triggering a necessary Level II evaluation. During interviews, the MDS nurse admitted to lacking knowledge about PASARR requirements and only sought guidance from the regional nurse after the deficiency was identified. The MDS nurse then filled out the necessary 1012 form for a mental illness/dementia resident review and planned to submit it for review to the local authority. The facility's administrator and DON confirmed that the MDS nurse was responsible for completing the PASARR evaluations and acknowledged the oversight in Resident #17's case. The facility's policy on PASARR screenings mandates obtaining a PL1 screening form from the referring entity before or on the day of admission. The policy emphasizes the importance of accurate and timely submission of these forms to ensure residents receive appropriate services. However, in this case, the facility did not adhere to its policy, resulting in a delay in identifying and addressing the resident's mental health needs through the PASARR process.
Failure to Include PTSD in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had severe cognitive impairment and a BIMS score of 0 out of 15, did not have her PTSD diagnosis included in her care plan. This omission was discovered during a record review and confirmed through interviews with various staff members, including an LVN, the ADON, the DON, and the Administrator. The staff members acknowledged the importance of including PTSD in the care plan to prevent potential triggers and provide appropriate care, but it was missed during the care planning process. The deficiency was highlighted by the fact that the resident's PTSD diagnosis was not communicated to the staff, as evidenced by the LVN's lack of awareness. The ADON and DON both admitted that the care plan should have included the PTSD diagnosis and that the failure to do so could result in the resident not receiving the necessary care. The Administrator also confirmed that the interdisciplinary team meeting should have ensured the inclusion of all relevant diagnoses in the care plan. The facility's policy on comprehensive care planning mandates the inclusion of measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Update Care Plans for Three Residents
Penalty
Summary
The facility failed to review and revise the person-centered care plan to reflect the current condition for three residents. For Resident #17, the care plan did not include his removal of the Foley catheter leg strap, despite multiple observations and interviews indicating that he frequently removed it. The nursing staff was aware of his behavior, but it was not documented in his care plan, and the MDS nurse and ADON were not informed. This oversight could lead to inappropriate care and potential harm to the resident. Resident #15's care plan was not updated to remove her wander guard, even though her MDS assessment indicated no wandering behavior. The medication administration record still showed checks for the wander guard, which were being signed off by the nurse. This discrepancy between the resident's current condition and the care plan could result in unnecessary interventions and a lack of appropriate care. Resident #25's care plan still listed him as a smoker, although he had not smoked in a long time. The MDS assessment did not indicate that he was a smoker, and interviews with staff confirmed that his smoking status had changed. The failure to update his care plan could lead to inappropriate interventions and a lack of accurate care. The facility's policy on comprehensive care plans emphasizes the importance of ongoing discussions and updates to reflect changes in residents' preferences and goals, which was not adhered to in these cases.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that Resident #8 had proper oxygen orders. Despite the resident being observed with oxygen set at 4.5 liters per mask, there were no corresponding physician orders documented. Interviews with staff revealed that the resident had been using oxygen for almost two weeks due to an upper respiratory infection, but the necessary orders were not written or communicated properly. This oversight was acknowledged by the CNA, LVN, ADON, DON, and the Administrator, all of whom confirmed the importance of having documented orders to ensure correct oxygen administration and prevent potential respiratory issues. The facility also failed to maintain the oxygen concentrator filters for Resident #31. Observations showed that the resident's oxygen concentrator filter had a thick grey, fuzzy material, indicating it had not been cleaned. Interviews with staff, including an LVN, ADON, DON, and the Administrator, confirmed that the filters were supposed to be cleaned weekly and as needed, but this had not been done. The staff acknowledged the importance of clean filters for proper ventilation and preventing respiratory complications. Both deficiencies highlight a lack of adherence to professional standards of practice for respiratory care. The failure to document oxygen orders for Resident #8 and to clean the oxygen concentrator filters for Resident #31 could lead to significant respiratory complications and a decreased quality of care for the residents involved.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate documentation in the Medication Administration Record (MAR) for a resident, leading to incomplete and inaccurate medical records. Specifically, the MAR for April 2024 indicated that the resident had a wander guard in place, which was not the case. Interviews with staff revealed that the resident did not have a wander guard bracelet on his chair or body, despite the MAR being signed off as if it were in place. This discrepancy was confirmed by multiple staff members, including CNAs and LVNs, who admitted to signing the MAR without verifying the presence of the wander guard bracelet. The resident in question was a male with a history of seizures, bipolar disorder, schizophrenia, and generalized anxiety. His quarterly MDS assessment indicated that he was cognitively intact but required extensive assistance with daily activities. The resident was also identified as being at high risk for elopement, with an elopement risk assessment score of 15. Despite this high risk, the resident's care plan did not include any interventions related to a wander guard, and staff failed to monitor and document the presence of the wander guard as required. Interviews with the ADON, DON, and Maintenance Supervisor revealed systemic issues in the monitoring and documentation processes for wander guards. The ADON and DON acknowledged that the nurses were responsible for checking the wander guards but failed to do so. The Maintenance Supervisor confirmed that he did not handle the wander guard system, focusing instead on door alarms. The Administrator admitted that it was an oversight on the part of the nurses to sign the MAR without verifying the presence of the wander guard bracelet. The facility's policies on wandering and elopement prevention were not adequately followed, leading to the deficiency in maintaining accurate medical records for the resident.
Failure to Maintain Infection Control During Peri Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the actions of a CNA who did not follow proper hand hygiene protocols while providing peri care to a resident. The CNA did not use hand sanitizer between glove changes during the procedure, which involved cleaning the resident's peri area and buttocks. This lapse in protocol was observed during an inspection and confirmed through interviews with the CNA, ADON, DON, and the Administrator. The CNA admitted to not having hand sanitizer in her pocket and being in a hurry, which led to the oversight. The resident involved was a male with multiple diagnoses, including diabetes mellitus type 2, epilepsy, high blood pressure, urine retention, and mood disorder. He had moderate cognitive impairment and required substantial assistance with daily activities. The facility's policy for perineal care clearly stated the need for hand hygiene before and after glove use, but this was not adhered to during the observed procedure. The ADON, DON, and Administrator all acknowledged the importance of hand hygiene and the risk posed by the failure to follow proper procedures.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit abuse and neglect for one resident. Specifically, the facility did not report allegations of abuse made by a resident within the required timeframe. The resident, a male with Parkinson's disease, Type 2 Diabetes Mellitus, cognitive communication issues, and Schizoaffective Disorder, Bipolar Type, made repeated allegations of abuse against the DON and ADON. Despite these allegations, the incident was not reported to the state agency within the mandated 2-hour window, as required by the facility's policy. Interviews with the ADON, DON, and former Administrator revealed a lack of clarity and communication regarding the reporting of abuse allegations. The ADON documented the resident's allegations but did not report them to the state, believing the incident did not constitute abuse. The DON was unaware of the written witness statement and did not consider the incident reportable. The former Administrator could not recall instructing the ADON to document the incident and was uncertain whether it should have been reported. This failure to report the allegations as required could place residents at risk of unreported abuse, neglect, and exploitation.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made. Specifically, the facility did not report Resident #1's allegations of abuse to the state agency within the required timeframe. Resident #1, a male with diagnoses including Parkinson's disease, Type 2 Diabetes Mellitus, Cognitive communication, and Schizoaffective Disorder, Bipolar Type, made repeated allegations of abuse against the ADON. Despite these allegations, the incident was not reported to the state agency as required by law. Interviews with the ADON, DON, and former Administrator revealed a lack of clarity and adherence to the facility's policy on reporting abuse. The ADON documented the incident but did not report it, following the Administrator's instructions. The DON was unaware of the written witness statement and did not consider the incident reportable. The former Administrator could not recall the specifics of the incident but emphasized that all abuse allegations should be reported to the state. The facility's policy mandates that any person with reasonable cause to believe that an elderly or incapacitated adult is suffering from abuse must report it to the DON, Administrator, state, and/or adult protective services immediately.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge of a resident and the reasons for the transfer or discharge in writing. The resident, a male with diagnoses including Parkinson's disease, Type 2 Diabetes Mellitus, cognitive communication issues, and Schizoaffective Disorder, Bipolar Type, was discharged to a psychiatric hospital for evaluation and treatment. Despite the resident being cognitively intact and able to understand and communicate effectively, the facility did not provide the required notification to the Ombudsman, which is a violation of the facility's policy and regulatory requirements. The Social Worker responsible for issuing 30-day notices and assisting with discharges stated that the resident was sent to a psychiatric unit at his request and never returned. The Administrator at the time confirmed that the facility did not allow the resident to return after the psychiatric evaluation, citing the facility's inability to meet the resident's needs. However, the Administrator admitted to being unsure of the proper discharge procedures and policies, and the necessary paperwork was not properly managed or located. The Ombudsman confirmed that she was not notified of the resident's discharge. The facility's policy requires that the Ombudsman be notified of all discharges, including emergency transfers, to ensure proper follow-up and assistance with placement if needed. The failure to notify the Ombudsman and properly manage the discharge process placed the resident at risk of not having other placement options and violated regulatory requirements for resident transfers and discharges.
Failure to Re-Admit Resident After Psychiatric Hospitalization
Penalty
Summary
The facility failed to admit a resident back after he was sent to a psychiatric hospital, violating their own policy on permitting residents to return after hospitalization. The resident, who had diagnoses including Parkinson's disease, Type 2 Diabetes Mellitus, and Schizoaffective Disorder, was sent to a psychiatric hospital at his request. Despite a physician's discharge summary indicating that the resident was to return to the facility after evaluation and treatment, the facility did not allow him to return, citing an inability to meet his needs without providing specific reasons. Additionally, the facility did not issue the required 30-day discharge notice to the resident, leaving him feeling emotionally drained and homeless. Interviews with the Social Worker and the former Administrator revealed that the facility did not follow its policy and procedure for discharges. The Social Worker confirmed that the resident was sent out and never returned, while the former Administrator admitted that the facility refused to accept the resident back and failed to issue a 30-day discharge notice. The facility's policy clearly states that residents should be allowed to return after hospitalization unless specific exemptions apply, and that proper documentation and notification procedures must be followed, which were not adhered to in this case.
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 143 citations issued within 25 miles in the last 12 months — including the 4 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 Savoy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Star Ranch Rehabilitation And Healthcare Cen | 10.4 mi | ★★★★★ | 28 | 0 |
| Seven Oaks Nursing & Rehabilitation | 11.3 mi | ★★★★★ | 2 | 0 |
| Clyde W Cosper Texas State Veterans Home | 11.4 mi | ★★★★★ | 22 | 0 |
| Cedar Hollow Rehabilitation Center | 13.8 mi | ★★★★★ | 8 | 2 |
| Denison Nursing And Rehab | 13.8 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mullican Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.