Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Sulphur Springs Health And Rehabilitation during CMS and state inspections, most recent first.
Food was not consistently palatable, attractive, or served at an appetizing temperature for all residents reviewed. During lunch service, the test tray and resident trays were observed moving from the kitchen to the dining areas and halls, and residents reported cold trays. The Dietary Manager confirmed several items were cold or room temperature, and surveyors observed an unappealing tray with hair on the plate. The food temperature log also showed some items, including rolls and pudding, were served at room temperature or below hot-holding temperatures.
Kitchen sanitation and equipment cleanliness deficiencies: Surveyors observed a dusty air vent, a light fixture filled with dirt and bugs, sticky floors, a skillet and baking sheets with brown buildup, trash on the ground outside the dumpster, and no liner in the hand hygiene trash can. The Dietary Mgr said the Maintenance Dir was responsible for cleaning the vent and light and that it had not been done in 2 months, while staff reported the floor had remained sticky after spilled tea and the pans had been in that condition for as long as they could remember.
Pest Control Program Not Maintained: Surveyors observed live and dead water bugs in the secure dining area, kitchen light fixtures, dry storage room, food prep area, and hall near the front entrance. The Maintenance Director said he was responsible for cleaning bugs from light fixtures and ensuring the pest control program, and reported that pest control had been coming monthly but was not completing required duties when live bugs increased, including in resident rooms. The DON was aware pest control was coming every 2 weeks, and the only inspection report provided showed 0 of 1 insect light trap and 0 of 1 rodent bait stations were inspected.
Incomplete Care Plans and Missed Ordered Interventions: The facility failed to include Eliquis and related monitoring interventions in the care plans for two residents receiving anticoagulants, and staff failed to consistently follow a resident’s ordered right palm protector intervention. Records showed the affected residents had significant medical and cognitive needs, while interviews confirmed the DON, MDS Nurse, and Administrator expected the anticoagulant and palm protector needs to be reflected in care plans and carried out by staff.
Missed Wound Care for Residents With Pressure Ulcers: A resident with a stage 4 ankle ulcer, a resident with multiple pressure ulcers including stage 4 wounds, and a resident with heel pressure ulcers and a surgical wound did not receive ordered daily dressing changes. Observations found one resident’s ankle wound left uncovered with swelling and drainage, while two others had outdated dressings still in place. The DON and Administrator stated wound care was expected to be completed according to physician orders.
A facility failed to maintain infection control practices during incontinent care, dialysis-related care, and meal tray delivery. A CNA did not clean the full peri area or change gloves and perform hand hygiene when moving from dirty to clean care for a resident, staff did not recognize or implement EBP for a resident with dialysis access, and two CNAs passed meal trays to multiple residents without hand hygiene between contacts.
A resident with bipolar disorder, depression, and anxiety received Abilify 10 mg daily, but the chart did not contain the required HHSC Form 3713 consent for the ordered dose. The resident said she was not aware of her meds and trusted the nurses, while the LVN and DON acknowledged that consent should be obtained before psychotropic meds are given and that the dose change was missed, leaving the form not updated to the correct dosage.
Failure to Report Alleged Abuse During Shower Care: Staff did not immediately report an allegation of abuse when a resident with Alzheimer’s disease and a history of sexual trauma stated the word “rape” during shower care provided by a CNA. The allegation was discussed among CNAs and an LPN, but the Administrator/Abuse Coordinator was not notified right away as required by policy. The resident’s care plan noted trauma triggers related to care, and the PIR documented the event as an abuse allegation.
Failure to Timely Report Alleged Abuse: A resident with Alzheimer’s disease and a history of sexual abuse stated “rape” during a shower while a CNA was providing perineal care. Staff discussed the allegation among themselves, but the Abuse Coordinator/Administrator was not notified immediately and the report was not made to the state agency within the required 2-hour timeframe. The resident was non-interviewable due to cognitive loss, and the facility policy required immediate reporting of abuse allegations.
A resident receiving hospice care had a hospice POC and facility medication orders that did not match. The hospice record listed Bisacodyl and Levsin directions that differed from the facility order summary, and staff from hospice, RN C, the DON, MA F, and the Administrator each described gaps in reviewing, reconciling, and updating the medication list in the hospice binder and EMR.
A resident with dementia and severe cognitive impairment, who required extensive help with personal hygiene and bathing, was observed with jagged fingernails and brown material under and across her hand. Staff noted the substance appeared to be fecal material and said the resident often put her hands in her brief. The resident had only received a partial bed bath because she was resistant, and the bath was not completed later that shift. Facility staff stated nail care was part of the routine cleaning schedule and that CNAs and nurses were responsible for keeping nails clean and trimmed.
Failure to Perform Ordered Wound Care: A resident with a non-pressure wound on the right second toe did not receive ordered daily wound care on two days, and the TAR was not signed off as completed. The resident had a care plan and physician order for cleansing, dressing, and covering the wound daily, but the assigned LVN stated the usual wound care person did not show up and she forgot to do it. The ADON, DON, and Administrator all stated the wound care was expected to be performed as ordered.
Mechanical Lift Not Locked During Resident Transfer: A resident with severe cognitive impairment, cerebrovascular disease, a history of TBI, and dependence for transfers was observed being moved from his wheelchair to his bed with a mechanical lift. A CNA failed to lock the lift wheels before lifting and lowering the resident, and the CNA stated the lift moved when the transfer began. The DON and Administrator stated the CNAs were expected to use the lift correctly, and the facility did not have a mechanical lift policy.
A resident with ESRD and dialysis did not receive ordered Sevelamer Carbonate with lunch when an LPN responsible for the dose left due to a family emergency without notifying the charge nurse. In a separate finding, an expired Novolog insulin vial was found on the west med cart for a resident with DM, and RN P stated she only checked the open date and did not verify the expiration date. The DON and Administrator stated the medication should have been given with meals and that expired meds should not be available for use.
Two residents receiving Eliquis had no documented anticoagulant monitoring in their care plans or MARs. One resident was cognitively intact with multiple chronic conditions, and the other had AFib, Alzheimer's disease, parkinsonism, TIA history, and severe cognitive impairment. The ADON, DON, and Administrator stated the monitoring should have been in place and entered for nursing review.
Failure to Obtain Ordered Labs for Two Residents: A resident with diabetes, bipolar disorder, chronic respiratory failure, and dementia had ordered CMP, CBC, and HgA1c labs that were never drawn, and another resident with ESRD, cirrhosis, heart disease, diabetes, and cognitive decline did not receive an ordered magnesium lab. The DON and NP said the labs were expected to be completed as ordered, but the facility could not explain why they were missed.
Surveyors observed that the facility did not dispose of expired food items, failed to label and date all food in the refrigerator and freezer, and did not clean the deep fryer weekly as required. The fryer was found with dirty oil and food debris, and multiple food items lacked proper labeling or were expired. Staff did not consistently document cleaning tasks, and the Dietary Manager and Administrator were not fully aware of these lapses.
A resident with chronic conditions requiring substantial assistance for ADLs fell and fractured her tibia due to inadequate supervision during a bed bath. The facility failed to provide the necessary two-person assistance, and staff were unaware of where to find information on required assistance levels, contributing to the incident.
The facility failed to properly store and label food items in accordance with professional standards, as observed in one of the kitchens. A zip lock bag of flour tortillas was not sealed, and a boiled egg lacked an expiration date. Despite recent in-services on labeling, the Dietary Manager acknowledged the oversight. The facility's policy and FDA guidelines require proper labeling to prevent foodborne illnesses.
The facility failed to maintain effective infection control practices, as evidenced by a CNA not performing proper hand hygiene during incontinent care for a resident, and a CNA and LVN not following Enhanced Barrier Precautions for another resident with a wound. These lapses occurred despite clear facility policies and signage indicating the need for such precautions.
The facility failed to provide scheduled activities for residents on multiple days, affecting their physical, mental, and psychosocial well-being. Residents, including those with heart failure, multiple sclerosis, dementia, and bipolar disorder, reported a lack of activities since December 5th, leading to feelings of boredom. The absence of the Activity Director and lack of a substitute contributed to this deficiency, as confirmed by staff observations and interviews.
A facility failed to include a resident's weight-bearing status on a fractured arm in the baseline care plan, risking increased pain and worsening of the fracture. Staff interviews revealed a lack of awareness and communication about the resident's needs, and the facility's policy on person-centered care plans was not adequately followed.
A facility failed to update a resident's care plan to include a diagnosis of staph dermatitis and the corresponding antibiotic treatment. The oversight was discovered during a record review, which showed a prescription for Bactrim DS without care plan updates. Interviews with staff revealed a lack of communication and awareness about the resident's condition, with the DON and Administrator acknowledging the risk and impediment to care quality.
The facility failed to obtain ordered lab tests for two residents, leading to deficiencies in care. A resident with COPD, heart failure, and high blood pressure did not have a lipid panel drawn as ordered due to a nurse's error and lack of follow-up. Another resident with diabetes did not receive an Hgb A1C test due to a clerical error by the lab provider and the absence of a lab tracking system.
A resident with Parkinsonism, Major Depressive Disorder, and dementia was not assisted out of bed as per his preference, despite activating his call light and communicating his desire to a transport aide. The aide claimed to have informed a CNA, but the CNA denied receiving this information. Facility staff acknowledged the expectation to meet residents' needs promptly, highlighting a failure to uphold the resident's right to self-determination.
A facility failed to provide a resident's legal representative with timely access to medical records, violating the resident's rights. The resident, with multiple health conditions, had a legal representative who requested the records. The facility's process involved several steps, including corporate approval, which delayed the release. Staff interviews revealed confusion about the timeframe for releasing records, and the facility's policy was not followed.
A resident with multiple health issues experienced a significant change in condition, including confusion and drowsiness, but the facility failed to immediately notify the physician. Attempts to contact the physician and nurse practitioner were unsuccessful, and the resident's condition worsened the following day. The telehealth physician was eventually contacted, and the resident was sent to the ER. The facility's policy for immediate physician notification was not followed, impacting continuity of care.
A facility failed to protect a resident's medical record privacy when an LVN left a computer screen unlocked, displaying the resident's MAR. The resident, who was moderately cognitively impaired and had multiple diagnoses, had her information exposed to passersby. The DON and Administrator confirmed the expectation for MARs to be closed when unattended, aligning with the facility's policy on privacy and confidentiality.
The facility failed to administer oxygen therapy as prescribed for two residents, one with COPD and another with respiratory failure. Observations showed incorrect oxygen settings, with one resident receiving less and another more than prescribed. Staff interviews revealed a lack of awareness and oversight, leading to potential risks for the residents' respiratory health.
A medication cart in the facility was left unlocked and unattended by an RN, allowing unauthorized access to medications. The RN admitted responsibility, and both the DON and Administrator emphasized the importance of keeping carts locked to prevent unauthorized access. The facility's policy mandates that all drugs be stored in locked compartments accessible only to authorized personnel.
A facility failed to ensure a nursing assistant was certified according to state laws. The assistant, who had completed a CNA training course but was not certified, provided resident care, including bathing and transfers. The DON and Administrator were aware of the situation, with the DON mistakenly believing hospitality aides could work with certified CNAs. Despite being informed not to provide care, the assistant continued working in a non-care capacity due to the holiday season, leading to a deficiency in compliance.
A resident with a right arm fracture did not have a follow-up appointment scheduled with an orthopedic specialist, as required by hospital discharge orders. The resident was cognitively intact and required the appointment to assess the healing process. Facility staff interviews revealed that the admitting nurse was responsible for scheduling the appointment, but it was not done, leading to potential quality of care issues.
A facility failed to coordinate hospice care and maintain necessary documentation for a resident receiving hospice services. The resident, with dementia and other conditions, was on hospice due to a terminal prognosis. The hospice binder lacked essential documents like the care plan and physician certification. Interviews revealed poor communication between the facility and hospice provider, with staff acknowledging the need for updated documents to ensure proper care coordination.
Two residents in an LTC facility were not treated with dignity and respect by a CNA, who spoke to them in a rude tone. One resident, with severe cognitive impairment, was told she could manage bathroom activities herself, while another resident, with no cognitive impairment, reported the CNA's disrespectful tone. Both residents' care plans lacked provisions for ensuring respectful treatment.
Food Served Cold and Unappealing
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for 8 of 8 confidential residents and for 1 of 1 meal reviewed. During observation of the lunch meal, surveyors noted the meal service sequence from the warming table to the assisted dining area, main dining room, and halls, with the test tray leaving the kitchen preparation area and later arriving in the work room after trays had been passed to residents. A confidential group interview found that 11 of 11 residents said the food trays served on the halls were cold. During the test tray interview, the Dietary Manager stated the turkey stew was warm and had good flavor, but the mixed vegetables were cold, the roll was room temperature, and the lemon pudding was room temperature; overall, the food was good but cold. Surveyors observed the tray was unappealing and had hair on the plate. Record review showed the food temperature log documented regular meat at 188 degrees Fahrenheit, cooked vegetables at 187 degrees Fahrenheit, rolls at room temperature, and lemon pudding at 40 degrees Fahrenheit; mechanical soft and puree items also included room temperature rolls and vegetables below hot-holding temperatures. The Dietary Manager, Dietary Aid S, [NAME] T, the DON, and the Administrator all stated their roles included ensuring food was hot, good tasting, and served in a timely manner, and the Resident Council Meeting Form documented residents voiced that their food was cold.
Kitchen sanitation and equipment cleanliness deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its kitchen. During surveyor observations, the air vent above the preparation area was dusty, the light fixture above the preparation area contained brown dirt and bugs, the kitchen floor was sticky, a skillet used to cook a grilled cheese had brown buildup around the entire edge, baking sheets had brown residue on the top and bottom, trash was laying on the ground outside the garbage receptacle, and there was no trash can liner in the hand hygiene trash can. On interview, the Dietary Manager stated the Maintenance Director was responsible for cleaning the light fixture and air vent and that it had not been done in two months, although the kitchen was part of his daily rounds. She also stated she was aware of the dirty light and vent, that there was a risk of dirt and dust getting into food, and that the residents were at risk of foodborne illness and cross contamination due to the dirty equipment, kitchen floor, vent, light, trash on the ground outside, and no trash can liner. She stated the staff cleaned the hand hygiene trash can but could not provide documentation. The Maintenance Director stated he was responsible for cleaning the lights and air vent and had done so two months earlier when he replaced the light bulbs. Other staff stated the air vents and lights did not get cleaned very often and that the floor remained sticky from spilled tea a few weeks earlier despite repeated mopping. Staff also stated the skillet and sheet pans had been in that condition for as long as they could remember, and that they were unaware why there was trash on the ground outside the garbage can or why there was no liner in the hand hygiene trash can.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of pests and rodents. During observations, surveyors found 2 live water bugs in the secure dining area crawling on the floor, dead water bugs in a kitchen light fixture and on the floor of the dry storage room, and dead water bugs with dark brown particles in light fixtures above the food preparation area. Large brown bugs were also observed in the hall near the front entrance. The report stated the facility failed to eradicate cockroaches in the building. During interviews, the Maintenance Director stated he was responsible for cleaning bugs out of the light fixtures and for ensuring the pest control program. He reported that pest control had been coming monthly but was not completing required duties when the facility noticed an increase in live bugs, including bugs in resident rooms. He stated he contacted the pest control company supervisor, who performed a full inspection and identified the problem as water bugs, after which the company increased visits to every 2 weeks. The DON stated she was aware pest control was coming every 2 weeks but did not report any issues with bugs, and the Administrator stated the Maintenance Director was responsible for communicating with and ensuring pest control services. The only pest control inspection report provided, dated 3/23/2026, showed 0 of 1 insect light trap and 0 of 1 rodent bait stations were inspected, and no other pest control logs were provided.
Incomplete Care Plans and Failure to Follow Ordered Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents whose assessments identified ongoing medical and nursing needs. For Resident #15, the record showed diagnoses including COPD, ventricular tachycardia, diabetes mellitus, major depressive disorder, and hypertension. Her MDS indicated she was cognitively intact, required extensive assistance with several activities of daily living, and was receiving an anticoagulant medication. However, her comprehensive care plan revised 01/15/26 did not include Eliquis or related interventions, and the order summary and MAR did not indicate monitoring for side effects related to the anticoagulant. For Resident #4, the record showed diagnoses including atrial fibrillation, Alzheimer’s disease, parkinsonism, history of TIA, and cerebral infarction. Her MDS indicated severe cognitive impairment and that she was taking an anticoagulant. Her physician orders included Eliquis 5 mg by mouth twice daily, but the comprehensive care plan dated 3/25/2026 did not include any focus, goals, or interventions for anticoagulant use or monitoring. During interviews, the DON, MDS Nurse, and Administrator stated the Eliquis should have been included in the care plan and that the omission left staff without awareness of the residents’ bleeding risk. For Resident #10, the record showed diagnoses including dementia, right hand contracture, muscle weakness, and depressive disorder. Her physician order directed that a right palm protector be worn during waking hours as tolerated, and her care plan included an intervention for staff to apply the palm protector and notify the charge nurse if she refused. During observations, Resident #10 was found in bed without the palm protector on her right hand. CNA B said she was not aware of a palm protector and could not locate one in the room, RN C said she was unaware of the order or where the device was located, and the Rehab Director later obtained a new palm protector and placed it in the resident’s hand. The DON and Administrator stated the resident should have been wearing the palm protector and that staff were responsible for placing and ensuring it was on.
Missed Wound Care for Residents With Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received wound care according to physician orders for 3 of 5 residents reviewed for pressure ulcers: Resident #45, Resident #37, and Resident #19. Record review showed each resident had active wound care orders requiring daily dressing changes, but the treatment administration records showed missed wound care on multiple dates. The facility’s wound care guidelines stated that evidence-based treatments in accordance with current standards of practice would be provided for all residents with pressure injuries. Resident #45 was admitted with lymphedema, obesity, and a stage 4 pressure ulcer to the right lateral ankle. His order required daily cleansing, xeroform, and rolled gauze, but wound care was not documented as completed on 3/22/26. During observation, he was found without a dressing on the right lateral ankle, and he stated the wound care nurse had removed the bandage for provider assessment and it had been left off after his bed bath. Later observations showed the wound still uncovered, with swelling, yellow drainage seeping onto the sheet, and blood on the heel protectors while he remained lying on his back. Resident #37 was admitted with cellulitis and pressure ulcers to the heels, back, left lateral ankle, and left lateral foot, including multiple stage 4 wounds. Orders required daily wound care, including calcium alginate and gauze to the left upper back, but treatment was not completed on 3/8/26 and 3/22/26. Resident #19 was admitted with osteomyelitis of the right ankle and foot and cellulitis of the right lower limb, had a surgical wound, and was care planned for pressure ulcer and wound care. Orders required daily cleansing, hydrogel, and border dressings to both heels, but wound care was not documented as completed on 3/22/26. Observations showed both residents with outdated dressings dated 3/20/26 and without heel protectors while in bed.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents and staff. During observation, CNA B provided incontinent care to a resident with gloves on, cleaned the pubic area, but did not clean both crease areas between the resident’s legs. CNA B then turned the resident onto his left side and wiped the buttocks without changing gloves or performing hand hygiene. CNA B also handled a clean brief, the resident’s bed remote, clothing, bed controls, and covers before performing hand hygiene. During interview, CNA B stated she should have changed gloves and performed hand hygiene after cleaning the crease areas, after turning the resident, and after cleaning the buttocks. Resident #5 was a male with end stage renal disease who received dialysis treatment and had a BIMS score of 10, indicating moderately impaired cognition. His care plan identified dialysis-related risks, and the physician order summary reflected an order to remove the dialysis dressing from the left upper arm in the evening for prophylaxis. The facility’s Enhanced Barrier Precautions policy stated residents with indwelling medical devices should have an order for enhanced barrier precautions, but the order summary did not address EBP. During interviews, Resident #5 stated staff did not wear PPE when providing care, and CNA D, RN C, the ADON, the DON, and the Administrator all discussed that PPE was not being used or was not understood to be required for this resident. During meal service observations, CNA Q passed trays to four residents on the North Hall without performing hand hygiene, and CNA R also passed trays to four residents on the North Hall without performing hand hygiene between resident contacts. Both CNAs acknowledged they forgot to use sanitizer and stated hand hygiene was needed to prevent cross contamination. The facility’s hand hygiene policy required staff involved in direct resident contact to perform hand hygiene between resident contacts, and the DON and Administrator stated they expected hand hygiene to be performed between tray passes.
Missing Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident #1 was fully informed in advance of the risks and benefits of proposed psychoactive treatment and that written consent was obtained on HHSC Form 3713 for Abilify 10 mg (aripiprazole) before administration. Resident #1 was a re-admitted female with diagnoses including bipolar disorder, depression, and anxiety. Her quarterly MDS indicated she was cognitively intact with a BIMS score of 14, and she required assistance with several activities of daily living. Her care plan identified psychotropic medication use related to bipolar disorder, and the physician ordered Abilify 10 mg daily for bipolar and depression. Record review showed Resident #1 received Abilify daily from 03/01/26 through 03/25/26, but the chart did not contain consent for the use of the psychotropic medication at the ordered dose. During interview, the resident stated she was not aware of her medications and trusted what the nurses gave her. The LVN stated consent should be obtained before psychotropic medications are given and said she was not aware that a change in medication strength required a new consent. The DON stated consent should be signed before administering any psychoactive medication and acknowledged that the Abilify order change in October 2025 was missed, leaving HHSC Form 3713 not updated to the correct dosage. The Administrator stated she expected nurses and the DON or designee to ensure the psychotropic consent form was completed correctly.
Failure to Report Alleged Abuse Involving a Resident During Shower Care
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents when an allegation of abuse involving a resident was not reported to the Abuse Coordinator immediately after it was made. The facility policy required alleged violations involving abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately, but not later than 2 hours after the allegation is made if the events involve abuse or serious bodily injury. Resident #11 was an elderly female with Alzheimer’s disease, long-term and short-term memory problems, and a quarterly MDS indicating she rarely or never made herself understood and rarely or never understood others. Her care plan reflected a history of trauma, including sexual abuse, with interventions to identify triggers that could re-traumatize her, such as male staff providing care. The record review showed that during a shower provided by CNA L, Resident #11 stated the word “rape.” The PIR documented the allegation as an abuse incident, with the date of the incident unknown, and noted that no staff witnessed the incident. Interviews showed that the allegation was discussed among staff, but it was not immediately reported to the Administrator or Abuse Coordinator when first heard. CNA L stated she did not report the incident because it slipped her mind and she was busy. CNA K stated she did not report it because CNA L said she would. LVN H stated she learned of the allegation later from staff discussion and then reported it to the DON and Administrator. The Administrator stated she was notified after the fact and that this was the first time she had ever heard Resident #11 say the word rape. The DON stated she had no knowledge of the allegation before 03/23/26 and that prior to that incident she was not aware of sexual abuse allegations related to Resident #11 during showers.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident with Alzheimer’s disease and significant cognitive impairment was reported immediately, but no later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency. Resident #11’s record showed a history of sexual abuse, and the care plan included interventions to identify triggers that could re-traumatize her, including male staff providing care. Her quarterly assessment reflected that she rarely or never made herself understood and rarely or never understood others. The allegation arose when a CNA was providing a shower and the resident stated the word “rape” while the CNA was washing her private area. The CNA stopped the shower, dried the resident, and returned her to her room. Multiple staff later discussed that the resident had previously made similar statements during showers, but the incident was not reported immediately to the nurse, administrator, or state agency. One CNA stated she did not report it because she believed another CNA would do so, and another CNA stated she did not report it because it slipped her mind and she was busy. The Abuse Coordinator, who was also the Administrator, was notified by an LVN on 03/23/26 at about 8:30 p.m. to 9:00 p.m. that an allegation of possible abuse had been reported. The Administrator stated she did not learn of the resident saying the word “rape” until later and reported the incident to the state agency on 03/24/26 at 2:23 p.m. The facility policy required allegations involving abuse to be reported immediately, but no later than 2 hours after the allegation was made.
Hospice Medication List Did Not Match Facility Orders
Penalty
Summary
The facility failed to ensure services provided, as outlined by the comprehensive care plan, met professional standards of quality for one resident receiving hospice services. Resident #13 was a female admitted with CAD, had a quarterly MDS showing severe cognitive impairment with a BIMS score of 3, and was documented as having a life expectancy of less than 6 months and receiving hospice care. Her comprehensive care plan identified that she had a terminal illness and was receiving hospice or palliative care, with interventions to monitor for signs and symptoms of increased pain or discomfort and to give medications and treatments as ordered while monitoring for relief. Record review of the hospice binder and EMR showed the hospice administration record and the facility physician orders did not match. The hospice medication record listed Bisacodyl 10 mg rectally twice daily as needed for constipation and Levsin 0.125 mg 1 to 2 tablets by mouth or sublingually every 4 hours as needed for secretions, while the facility order summary listed Bisacodyl 10 mg rectally every 24 hours as needed for constipation and Levsin 1 tablet by mouth as needed for increased secretion. The Hospice RN Case Manager stated she should review the facility medication list monthly but could not remember the last review. RN C stated she coordinated with hospice weekly but was unaware the medication list was not updated and did not review the binder because documentation would be in PCC. The DON stated she was not aware of the medication difference until the survey date and that MA F was responsible for reviewing medication orders monthly, while MA F stated she had never been told to reconcile hospice and facility medication orders. The Administrator stated she expected the hospice and facility medication lists to match and that the DON/designee was responsible for ensuring the information was updated.
Dirty and Jagged Fingernails Not Maintained
Penalty
Summary
The facility failed to ensure Resident #10, a female with dementia, muscle weakness, depressive disorder, severe cognitive impairment, and dependence for extensive assistance with personal hygiene and bathing, received needed grooming and nail care. Her care plan identified an ADL self-care performance deficit and directed staff to provide showers, shave, oral care, hair care, and nail care per schedule and when needed. During observation, Resident #10 was found lying in bed with jagged fingernails and a brown substance under several fingernails and scattered across her hand, and she was unable to state how long her hand had been dirty or when her nails were last trimmed. Later the same day, Resident #10 was again observed in bed with jagged fingernails and brown material on her right hand and under several fingernails. A CNA stated the substance looked like fecal material and reported that the resident often placed her hands in her brief. The CNA said the resident had only received a partial bed bath the prior day because she became resistant and the bath was not completed later during the shift. Facility staff, including an LVN, the DON, and the Administrator, stated that nail care was part of the routine cleaning schedule and that CNAs and nurses were responsible for ensuring nails were clean and trimmed; they also acknowledged that jagged and dirty nails could lead to injury and infection control issues.
Failure to Perform Ordered Wound Care
Penalty
Summary
The facility failed to ensure that Resident #43 received wound care in accordance with physician orders, the comprehensive care plan, and professional standards of practice for a non-pressure wound on the right second toe. Resident #43 was a male resident with hypotension and moderately impaired cognition, with a BIMS score of 8. His care plan identified the wound and directed staff to provide wound care per physician's order and keep the dressing clean, dry, and intact. The physician order required cleansing the right second toe with normal saline or wound cleanser, drying with gauze, applying xerofoam gauze, and covering with a border dressing once daily and as needed for wound healing. The TAR for the resident's wound care was not signed off as completed on 03/21/26 and 03/22/26. During observation, the dressing on the right foot was dated 03/20/26, and the ADON stated the wound should be changed daily. The LVN assigned to the resident stated she was responsible for wound care on those days, but the usual wound care person did not show up and she forgot to perform the care, describing the days as chaotic. The DON stated she expected wound care orders to be followed, including weekends, and said the nurses were responsible when no dedicated wound care person was available. The Administrator also stated all wound care treatment was expected to be done as ordered.
Mechanical Lift Not Locked During Resident Transfer
Penalty
Summary
The facility failed to ensure the environment was as free of accident hazards as possible for one resident when CNA N did not lock the wheels of a mechanical lift during a transfer from the resident’s wheelchair to his bed. Resident #51 was a male re-admitted to the facility with diagnoses including cerebrovascular disease, history of traumatic brain injury, cognitive communication deficit, and glaucoma. His annual MDS indicated a BIMS score of 6, showing severe cognitive impairment, and that he was dependent on staff for transfers, bed mobility, and bathing, with moderate staff assistance needed for eating. His care plan identified an ADL self-care performance deficit and required total assistance from two staff for transfers. During an observation, CNA N and CNA O used a mechanical lift to transfer the resident from his wheelchair to his bed. CNA N failed to lock the lift wheels before lifting the resident and again before lowering him to the bed, and she stated she did not realize she had done that, although she saw the lift move when she began to lift the resident. CNA N said the failure placed the resident at risk for falling. The DON stated the CNAs should have locked the lift before lifting and lowering the resident, and the Administrator stated the CNAs were expected to use the mechanical lift correctly. The Administrator also stated the DON or designee were responsible for ensuring CNAs completed mechanical lift transfers safely. The Administrator further stated the facility did not have a mechanical lift policy.
Missed Meal-Time Medication and Expired Insulin on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when Resident #5 did not receive Sevelamer Carbonate 800 mg with his lunch meal. Resident #5 was an [AGE] year-old male admitted with end stage renal disease and received dialysis. His physician’s order required 4 tablets by mouth with meals, and his care plan identified dialysis-related risks and complications. During observation and interview, Resident #5 ate his lunch and left the dining room without receiving the medication, and he stated he normally received medication with meals but did not receive it with lunch that day. LVN A stated she was responsible for administering Resident #5’s Sevelamer Carbonate with lunch and knew it had to be given with meals, but she had a family emergency. She stated she did not leave the medication or notify the charge nurse that the resident had medications due with meals. The DON stated the medication was expected to be given with the resident’s meals and that LVN A should have notified the charge nurse if she could not administer it. The Administrator stated LVN A was responsible for timely administration and should have informed the charge nurse or DON to ensure the medication was given. The facility also failed to ensure Resident #15’s Novolog insulin vial on the west nurse medication cart was not expired before the open date was placed on the bottle. Resident #15 was a [AGE] year-old female with diagnoses including diabetes mellitus, COPD, ventricular tachycardia, major depressive disorder, and hypertension. During observation, the vial had an expiration date that had already passed, while the open date was still in use. RN P stated she did not notice the expiration date and only verified the open date. The DON and Administrator stated expired medications should not be available for use and that the charge nurses were responsible for checking insulin for expiration.
Failure to Monitor Eliquis Use
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were adequately monitored and free from unnecessary drugs in relation to Eliquis use. Resident #15, a female with diagnoses including COPD, ventricular tachycardia, diabetes mellitus, major depressive disorder, and hypertension, had a quarterly MDS indicating she was cognitively intact, required extensive assistance with several activities of daily living, and was taking an anticoagulant medication. Her care plan did not identify Eliquis, and the order summary and March 2026 MAR showed an order for Eliquis 5 mg by mouth twice daily for chronic atrial fibrillation, but no monitoring for side effects or adverse reactions was documented. Resident #4, a female with diagnoses including unspecified atrial fibrillation, Alzheimer's disease, parkinsonism, history of TIA, and cerebral infarction, had a quarterly MDS showing severe cognitive impairment and anticoagulant use. Her physician orders showed Eliquis 5 mg by mouth twice daily, but her comprehensive care plan had no focus, goals, or interventions for anticoagulant use or monitoring. During interviews, the ADON, DON, and Administrator stated that anticoagulant monitoring should have been in place and that the monitoring orders should have been entered, and the DON said she was responsible for ensuring the monitoring was in place.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain ordered laboratory services for two residents. One resident, a male with diabetes mellitus, bipolar disorder, chronic respiratory failure, and dementia, had orders for a CMP, CBC, and HgA1c in the morning and then every 3 months, but the EMR showed these labs were never drawn after the order was entered. His care plan did not address obtaining the labs. During interview, the NP said she entered the order and expected the lab to be drawn and followed up on, but could not recall why it was not completed, and the DON said she expected the labs to be drawn when ordered. Another male resident with ESRD, cirrhosis of the liver, heart disease, diabetes mellitus, and senile degeneration of the brain had an order for CBC, BMP, magnesium, and vitamin D level now and every 12 months, but the magnesium lab was not obtained as ordered. His care plan included an intervention to obtain, monitor, and report labs to the physician as ordered. During interview, the DON said she expected labs to be drawn as ordered, did not know why the magnesium was missing, and stated she was responsible for ensuring the labs were drawn. The Administrator said all labs were expected to be completed as ordered and in a timely manner.
Failure to Properly Store, Label, and Prepare Food and Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations in the kitchen, surveyors found that expired food items were not disposed of in the refrigerator and freezer. Multiple food items, including cut-up tomatoes, pineapples, white gravy, orange juice, teas, water, salad, French fries, and diced chicken, were either missing preparation or expiration dates, or were found to be expired. The facility's policies required all food items to be labeled with preparation and expiration dates, but this was not consistently followed. Additionally, the deep fryer in the kitchen was not cleaned weekly as required by facility policy. The fryer was observed to have black cooking oil with brownish-black food crumbs floating on top, and the fryer cover had food crumbs and grease buildup. The cleaning schedule did not indicate that the fryer had been cleaned for the week in question, and staff had not initialed the cleaning log to confirm completion of cleaning tasks. The Dietary Manager acknowledged that the fryer was used daily and should be cleaned weekly, but could not confirm that this was being done consistently. Interviews with the Dietary Manager and Administrator revealed that while in-services on labeling and dating food had been conducted recently, in-services on cleaning the deep fryer had not been completed recently. The Administrator was not aware of the expired food items or the lack of fryer cleaning, and stated that she expected the Dietary Manager to report such issues. A confidential complainant described the kitchen as filthy and stated that the fryer grease was changed only once a month, despite daily use.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident that resulted in injury. A resident, who was dependent on staff for activities of daily living (ADLs) due to conditions such as chronic obstructive pulmonary disease and rheumatoid arthritis, required substantial assistance for bed mobility and bathing. Despite this, the facility did not provide the necessary two-person assistance during a bed bath, resulting in the resident falling out of bed and fracturing her right distal tibia. The incident occurred when a CNA was providing a bed bath to the resident. The CNA turned her back to the resident, who then rolled out of bed. The resident had previously expressed discomfort and resistance to the bed bath, but the CNA proceeded without the required assistance. The CNA was reportedly distracted, possibly using a phone, and did not adequately supervise the resident, leading to the fall. Interviews with staff revealed a lack of awareness and understanding of where to find information on the required level of assistance for residents. Several CNAs and nurses were unable to locate or were unaware of the electronic system (Kardex) that documented the assistance levels needed for residents' ADLs. This lack of knowledge and communication contributed to the failure to provide the necessary care and supervision, resulting in the resident's injury.
Removal Plan
- Resident #14 was assessed by charge nurse, notification to physician and X-rays obtained after the fall. Resident #14 was monitored every shift.
- The Nurse Assistance was suspended pending investigation where she was subsequently terminated due to failure to report back to work.
- The DON/Designee completed an investigation into an incident involving Resident #14.
- The DON provided in-service education to all staff on Abuse and neglect. This education was completed.
- The DON/Designee in-service education with license nurses and Nurse aide on use of PCC Kardex that determines type and amount of care residents required for all ADL's. All clinical staff are provided with training and access upon hire.
- DON/Therapy assessed all residents to determine the type and number of staff assistance required for ADL's and validated that all Kardex have been updated.
- The DON/Designee provided in-service education with all license nurses and Nurse aide on use of PCC Kardex that determines type and amount of care residents required for all ADL's, and no licensed nurse or Nurse Aide will be allowed to work until this education has been provided.
- The DON/Designee reviewed all residents requiring 2 persons bed mobility and bathing to verify that care plan and C.N.A. Kardex reflected the type of care residents require.
- DON/Designee will review 24-hour nurse report daily in the morning meeting to validate that the care plan and Kardex has been reviewed/revised for any resident that has a change in bed mobility or bed bath.
- The DON/Designee will review all Incident/Accidents daily in the morning meeting to validate those residents with falls that involved bed mobility or falls during bed baths, had the appropriate number of staff needed during the transfer.
- The Regional Nurse Consultant will provide oversight into this process weekly.
- The facility will continue to provide training to all license nurse and Nurse Aides upon hire and as need on documentation procedures for the Kardex system on PCC to identify type and amount of care a resident requires.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed in one of the kitchens. During an inspection, it was noted that a zip lock bag containing flour tortillas was not sealed properly, and a boiled egg was found without an expiration date. These observations were made in Refrigerator 1 of 3, indicating a lapse in the facility's food storage practices. Interviews with the Dietary Manager revealed that she was aware of the requirement for all food items to be labeled and dated with receive, open, and expiration dates. Despite having conducted in-services on labeling and dating recently, the Dietary Manager acknowledged the oversight in sealing the flour tortillas and dating the boiled egg. The Administrator, who also oversees the dietary staff, confirmed the importance of these practices to prevent foodborne illnesses and ensure resident safety. The facility's policy on frozen and refrigerated food storage, last reviewed in July 2022, mandates proper labeling of cooked foods with preparation and expiration dates. The FDA Food Code 2022 also requires that refrigerated, ready-to-eat foods be clearly marked with dates to ensure they are consumed or discarded within safe time frames. The failure to comply with these standards could potentially place residents at risk for food contamination and foodborne illnesses.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) did not perform proper hand hygiene between glove changes while providing incontinent care to a resident with chronic obstructive pulmonary disease, bipolar disorder, thrombocytopenia, and high blood pressure. The CNA acknowledged the lapse, attributing it to forgetting her hand sanitizer in another room. The Director of Nursing (DON) and the Administrator confirmed that this failure could lead to cross-contamination or infection, and noted that there were no proficiency check-offs for CNAs regarding incontinent care. In the second incident, a resident with moisture-associated skin damage, stroke, and glaucoma required Enhanced Barrier Precautions (EBP) due to a non-pressure wound. Despite signage indicating the need for EBP, a CNA and a Licensed Vocational Nurse (LVN) failed to wear gowns while providing care. Both staff members admitted they were unaware of the resident's EBP status, despite the presence of signs and available personal protective equipment (PPE). The DON stated that staff had been educated on infection control and were expected to follow EBP protocols, which include wearing gowns and gloves during high-contact care activities. The facility's policy on infection prevention and control emphasizes the importance of standard and enhanced precautions, including the use of PPE and hand hygiene. However, the observed lapses in adherence to these protocols during resident care activities highlight deficiencies in the facility's infection control practices. The Administrator reiterated the expectation for staff to follow infection control practices as indicated by signage and facility policy.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, as required by their comprehensive assessments and care plans. This deficiency was observed for three residents who were reviewed for activities. The facility did not conduct scheduled activities on December 9th, 10th, and 11th, which affected all residents, including those specifically reviewed. This lack of activities could potentially place residents at risk for not having their interests or needs met, leading to a decline in their well-being. Resident #13, a female with heart failure and multiple sclerosis, was independent in making activity choices and enjoyed group activities such as bingo and arts and crafts. However, she reported that the last activity she participated in was on December 5th, and she was unable to continue her painting project due to the absence of the Activity Director (AD). Similarly, Resident #42, who had heart failure and dementia, and Resident #48, with respiratory failure, heart failure, and bipolar disorder, also reported a lack of activities since December 5th. Both residents expressed feelings of boredom and the importance of activities to them. Observations and interviews with staff confirmed the absence of scheduled activities on the specified dates. The AD was not present, and there was no activity assistant to cover in their absence. The Director of Nursing (DON) and the Administrator acknowledged the lack of activities and its potential impact on residents' quality of life. The facility's Recreation Services policy indicated that a program calendar should be developed based on residents' needs and interests, but this was not effectively implemented during the observed period.
Failure to Address Weight-Bearing Status in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions to provide effective and person-centered care, specifically regarding the resident's weight-bearing status on a fractured right arm. The resident, a female with a fracture of the right humerus, muscle weakness, unsteadiness on feet, and lack of coordination, was admitted to the facility. The baseline care plan did not address the weight-bearing status of the resident's fractured arm, which could lead to increased pain and worsening of the fracture. Interviews with facility staff, including an RN, OTA, Treatment Nurse, DON, and the Administrator, revealed a lack of awareness and communication regarding the resident's weight-bearing status. The RN and Treatment Nurse acknowledged the importance of knowing the weight-bearing status to prevent further injury. The OTA was unable to locate the weight-bearing status, and the DON admitted to not having a process for reviewing baseline care plans. The Administrator expected therapy to address weight-bearing restrictions, but this was not reflected in the baseline care plan. The facility's policy indicated that person-centered baseline care plans should be developed and implemented for new admissions, but this was not adequately done for the resident in question.
Failure to Update Resident Care Plan for Staph Dermatitis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not reflect the resident's history of staph dermatitis, nor did it include interventions for antibiotic use or staff monitoring for possible symptoms. This oversight was identified during a review of the resident's records, which showed a prescription for Bactrim DS to treat staph dermatitis, but no corresponding updates in the care plan. Interviews with facility staff, including the Medical Director, DON, and Administrator, revealed that the staff was not adequately informed about the resident's diagnosis and treatment plan. The Medical Director expected the facility to be aware of the diagnosis and antibiotic use, while the DON acknowledged that the care plan should have been updated to include this information. The Administrator confirmed that the IDT and MDS nurse were responsible for ensuring accurate care plans, and the failure to update the care plan placed the resident at risk and impeded the quality of care provided.
Failure to Obtain Ordered Lab Tests for Residents
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for two residents, leading to deficiencies in their care. Resident #48, a cognitively intact female with chronic obstructive pulmonary disease, heart failure, and high blood pressure, did not have her lipid panel drawn as ordered on 08/14/24. The nurse did not fill out the lab requisition correctly, and the nurse managers did not follow up, resulting in the missed lab test. This oversight was only discovered after questioning by the state surveyor. Resident #12, a male with diabetes, did not have his ordered Hgb A1C test conducted. The physician had ordered the test to be done immediately and every three months thereafter. However, the facility's comprehensive care plan did not address his diabetes diagnosis, and the electronic medical record did not show that the test was obtained. A clerical error by the laboratory provider was identified as the reason for the missed test. The Director of Nursing acknowledged that a lab tracking system was not in place, which contributed to the oversight.
Failure to Respect Resident's Right to Self-Determination
Penalty
Summary
The facility failed to ensure that a resident's right to self-determination and choice was respected, as evidenced by the case of a male resident with Parkinsonism, Major Depressive Disorder, and dementia. The resident, who had a moderate cognitive impairment, expressed a preference to be assisted out of bed on a specific day. Despite activating his call light and communicating his desire to a transport aide, the resident remained in bed for several hours without assistance. The transport aide claimed to have informed a CNA of the resident's request, but the CNA denied receiving this information. Interviews with facility staff, including the Treatment nurse and the DON, revealed an expectation that residents' needs, such as getting out of bed, should be met promptly. The failure to assist the resident in a timely manner was acknowledged as potentially leading to increased depression and dissatisfaction. The facility's Resident Rights policy emphasized the importance of promoting resident self-determination, including the right to choose activities and schedules, which was not upheld in this instance.
Failure to Timely Provide Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records in a timely manner, as required by regulations. The resident, an elderly male with diagnoses including parkinsonism, dementia, hypertension, cirrhosis of the liver, and cerebrovascular disease, had a legal representative who requested access to his medical records. Despite the request being submitted, the facility did not provide the records within the required timeframe. The process for obtaining the records involved several steps, including filling out a form, obtaining approval from the regional director, and then printing the records. The facility's administrator and medical records staff acknowledged the request but cited the volume of records and the need for corporate approval as reasons for the delay. The medical records staff began processing the request only after receiving approval from the corporate office, which took several days. Interviews with facility staff, including the administrator and the Director of Nursing (DON), revealed a lack of clarity regarding the specific timeframe for releasing medical records. The facility's policy indicated that records should be available two days after receipt of payment for copies, but this was not adhered to in this case. The delay in providing the records was a violation of the resident's rights to access their medical information.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's physician and representative of a significant change in the resident's condition, which could potentially delay treatment and affect the resident's health. The resident, an elderly male with multiple diagnoses including parkinsonism, dementia, and hypertension, experienced a change in condition on November 22, 2024. The resident was noted to be confused, unable to hold his head up, and drowsy, prompting the nurse to hold his tramadol medication and attempt to contact the physician and nurse practitioner, but received no immediate response. The following day, the resident exhibited altered mental status, slurred speech, tachycardia, and hypotension. The nurse again attempted to contact the physician, leaving a message, and subsequently notified a telehealth physician who ordered lab tests and frequent vital sign monitoring. The resident's physician eventually returned the call and instructed the facility to send the resident to the emergency room for evaluation. However, the initial failure to notify the physician and document the resident's condition on the 24-hour report hindered continuity of care. Interviews with facility staff revealed that the nurse did not escalate the situation to the medical director or use the telehealth program when the physician was unreachable. The Director of Nursing and the Administrator emphasized the importance of recognizing and responding to changes in a resident's condition to ensure timely and appropriate care. The facility's policy required immediate physician notification for significant changes in a resident's status, but this protocol was not followed in this instance.
Failure to Protect Resident's Medical Record Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, a Licensed Vocational Nurse (LVN) left a computer screen unlocked on top of a medication cart, displaying the Medication Administration Record (MAR) of a resident. This occurred while the LVN entered the resident's room to check her blood sugar, leaving the MAR visible to staff and residents passing by. The LVN acknowledged the oversight, admitting it was a violation of the Health Insurance Portability and Accountability Act (HIPAA) to leave the MAR open where others could see the resident's personal information. The resident involved was a female with a history of diabetes, anxiety, depression, and high blood pressure, who was moderately cognitively impaired and required assistance with daily activities. Interviews with the Director of Nursing (DON) and the Administrator confirmed the expectation that MARs should be closed when unattended to protect resident information. The facility's policy on residents' rights emphasized the importance of maintaining privacy and confidentiality of personal and medical records.
Failure in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. Resident #14, a female with a history of COPD, muscle weakness, polyneuropathy, and hypertension, was prescribed oxygen therapy at 3 liters per minute via nasal cannula. However, observations on two separate occasions revealed that her oxygen concentrator was set at 2 liters per minute, contrary to the physician's orders. This discrepancy was not addressed by the staff, potentially compromising the resident's respiratory health. Similarly, Resident #31, who was diagnosed with acute respiratory failure, COPD, and heart failure, was prescribed oxygen at 4 liters per minute. Observations showed that her oxygen concentrator was set at 4.5 liters per minute, exceeding the prescribed amount. Despite the resident's understanding of her oxygen requirements, the staff failed to adjust the concentrator to the correct setting, which could have adverse effects on her condition. Interviews with the nursing staff, including the RN and DON, revealed a lack of awareness and oversight regarding the correct oxygen settings for these residents. The RN admitted to noticing the incorrect settings upon returning to work, while the DON and Administrator were unaware of the issue. The facility's policy on oxygen administration was not effectively implemented, as evidenced by the failure to verify and maintain the prescribed oxygen levels for the residents.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs were only accessible by authorized personnel, specifically with the 400-hall medication cart. During an observation, it was noted that the medication cart was left unlocked and unattended by RN BB while she was in a resident's room checking blood sugar levels. This oversight allowed staff and residents to pass by the unsecured cart, which was a violation of the facility's policy on medication storage. RN BB acknowledged her responsibility to lock the cart when it was not in use and recognized the situation as a HIPAA violation and a safety issue. The Director of Nursing (DON) and the Administrator both emphasized the expectation that medication carts should always be locked to prevent unauthorized access. The facility's policy on medication storage clearly states that all drugs and biologicals must be stored in locked compartments and only accessible to authorized personnel. The failure to secure the medication cart could lead to drug diversion or unauthorized access to medications, posing a risk to residents and others in the facility.
Failure to Ensure CNA Certification Compliance
Penalty
Summary
The facility failed to ensure that a nursing assistant, referred to as NA EE, was certified in accordance with state laws. NA EE was hired as a full-time nursing staff trainee and completed the CNA training course, but there was no evidence of her certification. Despite this, she provided care to residents, including bathing, transfers, incontinent care, and repositioning, from her hiring date until she was informed she could no longer work as a CNA until passing her clinical test. The Director of Nursing (DON) and the Administrator were aware of the situation, with the DON mistakenly believing that hospitality aides could work alongside certified CNAs. The DON and Administrator both acknowledged the risk to resident safety due to this oversight. Interviews revealed that the DON expected uncertified staff to seek assistance from certified staff for hands-on care, but this expectation was not met. The Administrator confirmed that the Human Resources Director was responsible for monitoring CNA certifications and that NA EE was informed not to provide care. However, due to the holiday season, the Administrator allowed NA EE to continue working in a non-care capacity. The job description for a Hospitality Aide clearly stated that the role involved non-hands-on care, yet NA EE was found to have been performing tasks beyond this scope, leading to a deficiency in compliance with state certification requirements.
Failure to Schedule Orthopedic Follow-Up for Resident
Penalty
Summary
The facility failed to arrange a follow-up appointment with an orthopedic specialist for a resident who had been admitted with a fracture of the right humerus. The resident, who was cognitively intact with a BIMS score of 14, had been discharged from the hospital with orders to follow up with an orthopedic physician within 1-2 weeks. However, the facility did not ensure that this appointment was scheduled, as confirmed by the orthopedic physician's office. Interviews with facility staff, including the Treatment Nurse and the Director of Nursing (DON), revealed that the responsibility for scheduling the follow-up appointment lay with the admitting nurse. The Treatment Nurse emphasized the importance of the follow-up to assess the healing process of the fracture. The DON acknowledged that missing such appointments could lead to quality of care issues, as the nursing staff would be unaware of the healing status of the fracture. The facility's Administrator also confirmed that nursing was responsible for ensuring that hospital discharge orders, including follow-up appointments, were followed.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified for one resident who was reviewed for hospice services. The facility did not maintain the resident's hospice binder, which should have contained critical information such as the most recent plan of care, hospice election form, and physician recertification. This lack of documentation and coordination could potentially place residents at risk of receiving inadequate end-of-life care. The resident in question was an elderly female with diagnoses including dementia, depression, anxiety, and high blood pressure. She was admitted to the facility and was on hospice services due to a terminal prognosis. The comprehensive care plan indicated that the facility was to work cooperatively with the hospice team to meet the resident's needs. However, the hospice binder was missing essential documents, including the physician certification of terminal illness and the care plan, and the last interdisciplinary group meeting was not updated in a timely manner. Interviews with facility staff and hospice representatives revealed a lack of communication and coordination between the facility and the hospice provider. The hospice office manager and the facility's Director of Nursing (DON) both acknowledged the importance of having updated hospice documents at the facility to ensure proper care coordination. The facility's administrator also stated that it was the facility's responsibility to ensure all hospice documents were up to date, highlighting a failure in the process overseen by the nurse managers.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as required by resident rights regulations. This deficiency was identified through observations, interviews, and record reviews. A Certified Nursing Assistant (CNA) was reported to have spoken to the residents in a rude tone, which could potentially lead to negative emotional impacts on the residents. The incidents involved two residents, one with severe cognitive impairment and another with no cognitive impairment, both requiring substantial assistance with activities of daily living (ADLs). The first resident, who had severe cognitive impairment and multiple health conditions including dementia and COPD, was reportedly spoken to rudely by CNA B. The resident was told she was a "big girl" and could manage going to the bathroom herself, which was witnessed by her roommate. The care plan for this resident did not address her right to be treated with dignity and respect by staff. The second resident, who had no cognitive impairment but suffered from conditions such as Stage III CKD and type 2 diabetes, also reported that CNA B was rude. The resident described the CNA's tone as disrespectful, particularly when instructing her to raise the head of the bed. The care plan for this resident similarly lacked provisions for ensuring she was treated with dignity and respect. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that staff are expected to communicate respectfully with residents, although CNA B denied any wrongdoing.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 67 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sulphur Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carriage House Manor | 0.5 mi | ★★★★★ | 0 | 0 |
| Sunny Springs Nursing & Rehab | 0.5 mi | ★★★★★ | 15 | 0 |
| Rock Creek Health And Rehabilitation | 2.4 mi | ★★★★★ | 15 | 1 |
| Birchwood Nursing And Rehabilitation | 16 mi | ★★★★★ | 1 | 0 |
| Avir At Commerce | 17.8 mi | ★★★★★ | 19 | 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.