Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunny Springs Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found that staff failed to secure a medication cart and an insulin pen, allowed a resident to keep wound cleanser in his room, and left medications unattended on a resident's tray. Facility leadership confirmed that these actions did not meet expectations for medication security and administration.
A resident with multiple health conditions, who was cognitively intact but dependent on staff for daily activities, reported that meals were consistently cold and unappetizing. Similar complaints were echoed by a group of residents. During a meal observation, surveyors found some food items to be lukewarm and bland. Dietary and administrative staff were unaware of these issues, despite facility policies requiring meals to be palatable and served at appropriate temperatures.
The facility did not inform a resident or their representative about the option to enter into a binding arbitration agreement or their right to refuse, resulting in a lack of awareness of their legal rights regarding arbitration.
The facility did not ensure hospice documentation was consistently updated and maintained for three residents receiving hospice care, resulting in missing or outdated plans of care, medication lists, and IDG meeting notes. Staff interviews revealed confusion about responsibility for updating hospice binders, and recent staffing changes in medical records contributed to lapses in documentation and care coordination.
Staff failed to consistently follow infection control protocols, including proper use of PPE, glove changes, and hand hygiene, during care of residents on Enhanced Barrier Precautions and during routine care. These lapses included not changing gloves between dirty and clean tasks, not performing hand hygiene, and wearing contaminated PPE outside resident rooms, placing residents at risk for cross-contamination.
A resident with dementia and impaired decision-making was administered Remeron, an antidepressant, without a signed psychotropic consent form. Facility staff, including the charge nurse and nursing management, acknowledged that consent was not obtained prior to administration, contrary to facility policy and care plan requirements.
A resident with acute and chronic respiratory failure and moderately impaired cognition was readmitted without a physician's order for DNR status entered into the electronic medical record, despite having a care plan and Out-of-Hospital DNR form indicating DNR. Staff interviews confirmed that the required process for entering and monitoring DNR orders was not followed, resulting in the omission.
A resident with multiple medical conditions, including a recent abdominal surgery, was receiving IV antibiotics via a central line, but the care plan did not address this therapy. Although the medication was administered as ordered, the omission in the care plan meant staff may not have been aware of the need to monitor for side effects. Facility staff interviews revealed confusion over responsibility for updating care plans, and the facility's policy required comprehensive documentation of all services provided.
A resident who was fully dependent on staff for ADLs and incontinent did not receive scheduled showers or bed baths over an extended period. Despite being cognitively intact and expressing the need for hygiene care, the resident was not offered alternative bathing when the shower was unavailable, and staff failed to communicate or document missed care as required by facility policy.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care in these areas.
A resident with legal blindness and multiple health conditions was found to have three unsecured razors in his drawer, including one without a blade cover, despite requiring total assistance with personal hygiene. Facility staff and leadership acknowledged that the razors should not have been accessible, as this posed a risk of injury to the resident and others, especially with other residents known to wander. The facility's policy required daily monitoring of resident rooms to ensure safety, but the razors were not removed after care.
A resident with a feeding tube did not receive enteral nutrition as ordered by the physician, as nursing staff failed to restart the feeding pump after it was turned off for care activities, resulting in the resident missing required nutrition for a period longer than allowed. Documentation did not indicate when the feeding was to be restarted, and staff did not communicate the lapse during shift change.
A resident with COPD and shortness of breath was observed receiving oxygen therapy without a current physician's order, despite the care plan indicating a need for oxygen. Staff interviews and record review confirmed the absence of an order, and facility policy required a physician's order for oxygen administration.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, nor did it ensure appealing meal options were available. This was identified through observations and review of food service practices, showing that some residents did not receive meals tailored to their individual dietary requirements.
A resident with severe cognitive impairment was found with a bruise and skin tear on her arm, but staff did not follow required protocols for investigation, documentation, or reporting. The incident was not properly assessed, reported to management, or updated in the care plan, and no internal investigation or state notification occurred, despite facility policy requiring these actions.
A resident with severe cognitive impairment was found to have a bruise and skin tear of unknown origin, which was documented by an LPN after being reported by a family member. The required notifications to the DON, Administrator, and state agency were not completed, and no incident report or care plan updates were made. Interviews revealed that staff did not consistently follow the facility's policy for reporting and investigating such incidents, resulting in the event being overlooked and not reported as required.
The facility did not update or implement comprehensive care plans for two residents requiring contact isolation due to ESBL and MRSA infections. One resident's care plan failed to address contact isolation for ESBL, while another's care plan did not include interventions for MRSA isolation or her refusal to comply with isolation protocols, despite physician orders and staff awareness of these needs.
Staff failed to follow contact isolation protocols for two residents with ESBL and MRSA, including not wearing required PPE during care and not ensuring a resident remained in isolation. One resident with severe cognitive impairment received care from staff who did not use gowns or gloves, while another resident with MRSA was allowed to participate in group activities without proper education or care plan updates. Facility policies and physician orders for contact precautions were not consistently implemented.
The facility failed to protect residents from abuse, as evidenced by three incidents of resident-to-resident altercations. A resident with dementia was struck by another resident, another resident was grabbed under the arm, and a third resident was pushed on the head. Staff intervened in each case, but the incidents highlight a failure to ensure a safe environment.
A resident with dementia in an LTC facility did not receive medications as scheduled, including calcium, pantoprazole, and sitagliptin-metformin, leading to potential inconsistencies in treatment. Additionally, Estrace vaginal cream was not administered as ordered, and the resident received an incorrect dosage of Vitamin B-12. Staff interviews revealed lapses in following medication administration protocols.
A facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies. One resident's MDS did not reflect antibiotic use or a MRSA diagnosis, while another's discharge destination was incorrectly documented. Staff interviews confirmed the errors and emphasized the importance of accurate coding for care and billing.
The facility failed to conduct scheduled activities on two consecutive days, impacting residents' physical, mental, and psychosocial well-being. The Activity Director was absent during these times, leading to the cancellation of activities like bean bag toss and Skip Bo. The DON and Administrator acknowledged the importance of adhering to the activity schedule to prevent resident boredom and depression.
The facility failed to coordinate hospice care effectively for three residents, resulting in missing or outdated hospice documentation in their medical records. This included plans of care, medication lists, and other essential documents, which were not properly uploaded or maintained, potentially impacting the quality of end-of-life care provided.
A resident was administered Bupropion HCL ER (Wellbutrin) for depression without obtaining informed consent, as required by the facility's policy. The resident, who was cognitively intact, did not have documented consent for this psychotropic medication. Interviews with staff, including an LVN, the ADON, the DON, and the Administrator, confirmed that the consent process was not followed, and the oversight was only discovered during a state surveyor's inquiry.
A resident with multiple health conditions, including end-stage renal disease, refused ordered lab draws for four weeks, and the facility failed to notify the physician of these refusals. The LVN did not document the refusals or notify the physician, contrary to facility policy. The DON and Administrator confirmed the expectation for physician notification and documentation, which was not met.
A resident's Medication Administration Record was left visible and unattended by the ADON, compromising privacy. The resident, with a history of stroke and diabetes, required extensive assistance. The DON and Administrator emphasized the importance of confidentiality, but the facility's policy lacked specific guidance on protecting health information.
A facility failed to report an alleged neglect incident involving a resident with dementia and other conditions, who was left soiled and shaking. A CNA admitted to not attending to the resident due to the resident's behavior. Despite the facility's policy requiring immediate reporting of such incidents, the DON and Administrator did not report it, considering it merely a grievance.
A resident with dementia and other health issues was found in a neglected state by a family member, who reported the incident to the facility. The CNA involved allegedly refused care due to the resident's behavior. Despite the facility's policy requiring immediate reporting of such incidents, the Administrator and DON did not report it to the State Agency, viewing it as a grievance rather than neglect.
A facility failed to include a resident's MRSA diagnosis in their care plan, despite the resident's complex medical history. The omission was due to a lack of awareness and communication among staff, posing a risk of miscommunication and inadequate care.
An unsecured oxygen cylinder was found at the nurse's station, which was acknowledged by an LVN and the Activity Director, who admitted to forgetting to secure it. The ADON, DON, and Administrator emphasized the importance of securing oxygen cylinders to prevent accidents, as per facility policy.
A resident with end-stage renal disease did not have a physician's order for dialysis treatment, and the facility failed to monitor the resident's dialysis catheter as required. The facility's policy allowed dialysis instructions to be placed under special instructions, leading to the absence of a formal order. Staff interviews revealed a misunderstanding of the need for formal orders, placing the resident at risk for complications.
A facility failed to monitor the behavior and side effects of psychotropic medications for a resident with depression and anxiety. Despite being on Bupropion, Sertraline, and Clonazepam, there was no documentation of monitoring in the resident's records. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on psychotropic medication monitoring.
The facility failed to secure a medication cart on hall 100, leaving it unlocked and unattended, which allowed unauthorized access by staff, residents, and visitors. The ADON admitted to forgetting to lock the cart, and interviews with staff, including an LVN, DON, and the Administrator, confirmed that the cart should always be locked when unattended. The facility's policy requires medication carts to be locked when not attended by authorized personnel.
A resident with a MRSA infection in his hip wound was not placed on transmission-based precautions, despite having an antibiotic order. The facility failed to update the resident's care plan and medical records to reflect the MRSA diagnosis. Staff interviews revealed a lack of communication and understanding regarding necessary precautions, with the DON believing enhanced-barrier precautions were sufficient. The facility's policy on transmission-based precautions was not followed, posing a risk of MRSA transmission.
A facility failed to follow its smoking policy by not completing quarterly smoking assessments for a resident, as required. The resident, who was cognitively intact and required supervision for smoking, had not been assessed for over a year. Interviews with the ADON, DON, and Administrator revealed that the nursing staff was responsible for these assessments, but a system failure led to the oversight, posing a risk of burns to residents.
A resident with severe cognitive impairment did not receive proper pharmaceutical services when a card of 30 Hydrocodone-Acetaminophen tablets went missing. The medication was not secured properly by LVN C, leading to a discrepancy discovered by CMA H and RN F. The facility's procedures for handling controlled substances were not followed, posing a risk of unauthorized access to medications.
A facility failed to coordinate hospice care for a resident with dementia and Parkinson's, leading to improper transfers without a mechanical lift. Despite the care plan requiring a mechanical lift for transfers, a hospice aide was not informed of this requirement, resulting in a transfer without the lift. Facility staff did not communicate the change in transfer needs to hospice, placing the resident at risk for falls and injuries.
A CNA failed to perform hand hygiene between glove changes while providing perineal care to a resident, risking cross-contamination and infection. The resident required assistance with personal hygiene due to conditions like dementia and diabetes. Despite facility policies and expectations for hand hygiene, the CNA did not wash hands or use sanitizer between glove changes, as confirmed by interviews with facility staff.
Two residents in a facility did not have their restorative care programs included in their care plans, despite having mobility and strength issues. The care plans lacked measurable objectives and timeframes, and there were no orders for the restorative programs. Interviews revealed a lack of communication and understanding of responsibilities among staff, leading to these omissions.
The facility failed to provide appropriate restorative care to two residents with limited range of motion, as required by their Nursing Restorative Care Program plans. One resident, with severe cognitive impairment, had no documentation of a restorative program in her care plan, and there were significant gaps in the documentation of care provided. Another resident, with moderate cognitive impairment and functional limitations, also lacked documentation of a restorative program, with multiple days showing no record of care being offered. Interviews revealed a lack of oversight and understanding of responsibilities among staff, leading to the deficiency.
Failure to Secure and Properly Administer Medications
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and administration of drugs and biologicals. One nurse left a medication cart unlocked and unattended in a hallway, with an insulin pen left unsecured on top of the cart. The nurse acknowledged that she was responsible for ensuring the cart and medications were secured but failed to do so when responding to a resident's call light. Both the DON and Administrator confirmed that their expectation was for medication carts and medications to be locked and secured when not in direct view of authorized staff. Another deficiency was observed when a resident, who was legally blind and had multiple diagnoses including prostate cancer and depression, was found to have a bottle of wound cleanser in his bedside drawer. The resident reported that items were sometimes removed and returned to his room by staff. Facility leadership, including the ADON, DON, and Administrator, all stated that wound care items such as wound cleanser should not be stored in resident rooms and should be removed by nursing staff after treatments. A further incident involved a medication aide leaving a cup of medications on a resident's breakfast tray without ensuring the medications were taken. The resident, who had diagnoses including diabetes, schizoaffective disorder, and depression, was found with the full cup of medication after breakfast. The medication aide admitted to leaving the medications due to being in a hurry, and facility leadership confirmed that medications should not be left at the bedside and that staff are expected to ensure medications are administered and swallowed before leaving the room.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for at least one resident and during one observed meal. A male resident with legal blindness, high blood pressure, prostate cancer, and depression, who was cognitively intact but required assistance with most activities of daily living, reported that his food was consistently cold and unappetizing when served in his room. He had not requested reheating due to concerns about staff being short-handed. Additionally, a confidential group interview with four residents revealed similar complaints about food being cold and bland. During a lunch meal observation, surveyors and the Dietary Manager sampled a tray and found that while the fajita chicken was warm and tasted good, the refried beans and Spanish rice were lukewarm and bland. The Dietary Manager and Dietitian were unaware of any food complaints, and both, along with the DON and Administrator, stated expectations that food should be palatable and at the correct temperature. However, none were aware of the ongoing concerns. Facility policies required meals to meet nutritional standards and be served at proper temperatures, but these were not consistently followed as evidenced by resident complaints and surveyor observations.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to inform residents or their representatives of their choice to enter into a binding arbitration agreement and their right to refuse such an agreement. This omission resulted in residents or their representatives not being made aware of their legal rights regarding arbitration agreements at the time of admission or during their stay.
Failure to Maintain and Update Hospice Documentation and Coordination
Penalty
Summary
The facility failed to properly collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. For three residents reviewed, the facility did not maintain or update hospice binders with essential documentation such as the most recent plan of care, hospice election forms, medication lists, and physician recertifications. In one case, a resident with diagnoses including malnutrition, anxiety, and COPD had a hospice binder missing updated care plans, medication lists, and IDG meeting notes, with the last recertification and documentation being outdated. Interviews with hospice staff confirmed that documentation should be updated at least weekly after IDG meetings, but this was not consistently done. Another resident, who was legally blind and had diagnoses including prostate cancer and depression, had a hospice binder lacking an IDG comprehensive assessment and an up-to-date medication review. The most recent plan of care was outdated, and the facility's electronic medical record had not been updated with hospice documents for several months. The hospice RN acknowledged responsibility for updating the binder but noted frequent changes and admitted the binder was not current, which could result in the facility not having accurate information. A third resident with end-stage heart failure and renal disease also had a hospice binder missing updated plans of care, medication lists, and notes from nurses, aides, and social workers since the last IDG meeting. Facility staff, including the DON, Social Services, and Medical Records, were unclear about who was responsible for maintaining the hospice binders and how often updates should occur. The facility had recently experienced a gap in medical records staffing, leading to a lack of a system to ensure hospice documentation was consistently updated and available for continuity of care.
Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff caring for residents on Enhanced Barrier Precautions (EBP) and during routine care. In several instances, staff members did not adhere to required protocols for the use of personal protective equipment (PPE), glove changes, and hand hygiene. For example, a CNA was observed leaving a resident's room while still wearing the same gown and gloves used during direct care, then returning and continuing care without changing gloves. The same CNA also picked up linens from the floor, placed them in a bag, and resumed care without changing gloves. Another CNA picked up a plastic bag from the floor and placed it on a resident's bed during care. Additional observations included staff not wearing gloves or gowns throughout the entirety of care for a resident on EBP, and failing to change gloves between dirty and clean surfaces during incontinent care. Residents involved in these deficiencies had significant medical histories and care needs. One resident was dependent on staff for most activities of daily living, had moderate cognitive impairment, was always incontinent, and was on EBP due to a multidrug-resistant organism (MDRO) infection. This resident also had chronic kidney disease, diabetes, and a history of urinary tract infection with ESBL resistance. Another resident required total assistance with toileting, transfers, bathing, and bed mobility, and was observed receiving care where gloves were not changed between dirty and clean tasks, and hand hygiene was not performed between glove changes. A third resident, with chronic obstructive pulmonary disease and diabetes, was observed during a blood glucose check where the nurse failed to remove gloves or perform hand hygiene before handling the insulin pen and nurse’s cart, despite having just obtained a blood sample. Interviews with staff, including CNAs, LVNs, the DON, and the Administrator, confirmed knowledge of proper infection control procedures, such as changing gloves between dirty and clean tasks, performing hand hygiene, and not wearing PPE outside of resident rooms. However, the observed failures demonstrated a lack of consistent adherence to these protocols. Facility policies reviewed also outlined the correct procedures for perineal care, hand hygiene, and blood glucose monitoring, emphasizing the importance of glove changes and hand hygiene to prevent cross-contamination and infection.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident received informed consent prior to the administration of a psychotropic medication, specifically Remeron (Mirtazapine), which is an antidepressant. The resident, who had diagnoses including dementia, stroke, and high blood pressure, was his own responsible party but was rarely able to understand or be understood by others, and had severe daily decision-making impairment. Despite this, the resident was administered Remeron on two occasions without a signed psychotropic consent form present in his chart. The care plan indicated that staff were to educate the resident or family about the risks, benefits, and side effects of the medication, but this was not documented as having occurred. Interviews with facility staff, including the charge nurse, ADON, DON, and Administrator, confirmed that the required consent was not obtained prior to medication administration. The charge nurse admitted to forgetting to complete the consent form, and both the ADON and DON acknowledged that obtaining consent was their responsibility and should have occurred before the medication was given. The facility's policy also required that no psychotropic medication be administered without informed consent unless in an emergency, which was not the case in this situation.
Failure to Ensure DNR Order Entered in Medical Record
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician's order for Do Not Resuscitate (DNR) status was present in the medical record for one resident upon readmission. The resident, a male with acute and chronic respiratory failure and moderately impaired cognition, had a care plan and an Out-of-Hospital DNR form indicating DNR status. However, the physician's order for DNR was not entered into the electronic medical record at the time of readmission. Interviews with the ADON, DON, and Administrator confirmed that the process for entering and monitoring such orders was not followed, resulting in the omission. The facility's policy required that all documents regarding decision-makers and DNR orders be included in the resident's medical record. The ADON acknowledged that the order was missed during the admission process, and both the DON and Administrator stated that it was the responsibility of the charge nurse to input the code status and for the ADON to monitor the orders. The absence of the DNR order in the resident's chart was identified through record review and staff interviews.
Failure to Include IV Antibiotic Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the inclusion of IV antibiotic therapy administered via a central line. The resident, an adult female with diagnoses including partial intestinal obstruction, type 2 diabetes, and atrial fibrillation, was admitted following abdominal surgery and was receiving meropenem IV antibiotics through a central catheter. Although her care plan noted a skin impairment related to the central catheter, it did not address the ongoing IV antibiotic therapy, despite physician orders and documented administration of the medication. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The Regional MDS Coordinator, DON, and ADON each provided differing accounts of who was responsible for ensuring the care plan reflected the resident's IV antibiotic therapy. The ADON acknowledged that the omission could result in staff being unaware of the need to monitor for side effects, and the Administrator confirmed that the care plan should have included the IV medication as part of the resident's care. Review of facility policy indicated that comprehensive care plans should describe all services to be furnished to meet the resident's needs.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for activities of daily living, including bathing, did not receive scheduled showers or bed baths over a ten-day period. The resident, who was cognitively intact and required total assistance for showering, dressing, and transferring, was always incontinent of bowel and bladder. Documentation and interviews confirmed that the resident was not bathed on multiple scheduled days, and staff failed to provide either a shower or a bed bath, even when the shower room was out of order. The resident reported not being offered showers or bed baths as scheduled and expressed feeling unclean. Staff interviews revealed a lack of communication and follow-through regarding the resident's bathing schedule. The assigned CNA did not provide alternative bathing methods when the shower was unavailable, and the shower aide did not inquire about the resident's absence from scheduled showers. Nursing staff and administration were unaware that the resident had missed multiple baths, and there was no documentation of refusals or reasons for missed care. The facility's policy required residents to be offered showers at least once weekly and as requested, but this was not followed for the resident in question.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to vision and hearing services. The facility failed to ensure that the resident received necessary support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care as required.
Failure to Secure Razors Creates Accident Hazard for Visually Impaired Resident
Penalty
Summary
A deficiency was identified when a resident's environment was not kept free from accident hazards, specifically involving the improper storage of razors. During observation and interviews, it was found that a male resident with legal blindness, prostate cancer, high blood pressure, and depression had three razors in his drawer—one without a cover and two in an open package. The resident required total assistance with several activities of daily living, including personal hygiene, and staff were responsible for shaving him. Despite this, the razors were accessible in his room, contrary to facility policy and staff expectations. Interviews with the ADON, DON, and Administrator confirmed that the resident should not have had razors in his room due to the risk of injury to himself and others, especially considering his visual impairment and the presence of other residents who wander throughout the facility. The facility's policy required staff to ensure a safe environment and to monitor resident rooms daily, but the razors were not removed after care, resulting in a failure to prevent an accident hazard.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a feeding tube by not administering enteral feeding as ordered by the physician. The resident, a male with dysphagia and gastrostomy status, had a physician order for enteral feeding to be administered for at least 20 hours daily. Record review showed that the enteral feeding was removed at 11:00 AM each day, but there was no documentation of when it was restarted. On the day in question, observations confirmed that the resident's feeding pump was off from 11:10 AM through 4:20 PM, exceeding the allowed 4-hour downtime specified for care activities. Nursing staff interviews revealed that the feeding was not restarted as required, and the lapse was not communicated during shift change. The responsible nurses acknowledged that the resident was at risk for not receiving adequate nutrition due to the failure to follow the physician's orders. The facility's policy required that tube feedings be administered according to physician orders to meet nutritional requirements. The Director of Nursing and the Administrator both confirmed that the nurses were responsible for ensuring the feeding was not off for a prolonged period and that failure to do so could result in the resident not receiving necessary nutrition. The deficiency was identified through interviews, record reviews, and direct observation, all indicating that the resident's enteral feeding was not managed in accordance with the prescribed orders.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident who required oxygen therapy, as there was no physician's order in place for the administration of oxygen. The resident, an older adult with diagnoses including shortness of breath, obesity, depression, diabetes, and COPD, was observed wearing oxygen at 2 liters per minute via nasal cannula on multiple occasions. The resident's care plan indicated a need for oxygen for shortness of breath and COPD, with instructions for staff to administer oxygen as ordered by a physician. However, a review of the resident's physician orders revealed that there was no order for oxygen therapy at the time of the observations. Staff interviews confirmed that the resident had been receiving oxygen without a current physician's order, and nursing staff acknowledged the importance of having such an order to ensure proper care. The facility's policy required a physician's order specifying the oxygen flow rate, method of administration, usage, and indication for use. Despite this, the order was missing until after surveyor intervention, and staff could not explain why the order had not been entered into the electronic records. The deficiency was identified through observation, interview, and record review.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not provide appealing options as required. This deficiency was identified through observations and review of food service practices, which revealed that residents were not consistently offered meals that met their individual dietary needs and preferences.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and did not establish or follow policies and procedures to report and investigate such allegations for one resident. A resident with severe cognitive impairment, dementia, diabetes, and depression was found with bruising and a skin tear on her left arm. The incident was first reported by a family member to a nurse, who documented the injuries and provided first aid, but did not initiate a full investigation or complete all required notifications and documentation as outlined in facility policy. Subsequent record reviews showed that there were no physician orders for monitoring or treating the injuries, and no skin assessment was completed after the injuries were noted. The resident's care plan was not updated to reflect the new injuries, and there was no incident report or evidence of an internal investigation. Interviews with nursing staff revealed inconsistent understanding and application of the facility's abuse and injury reporting protocols, with some staff unaware of the incident and others unsure of the required steps for reporting and investigation. The Director of Nursing and Administrator were either unaware of the incident or did not recall it, and the required internal investigation and reporting to the state agency did not occur. The facility's own Abuse Prohibition Policy required prompt investigation and reporting of injuries of unknown origin, but this was not followed in this case, resulting in a failure to protect the resident and ensure proper oversight and response to potential abuse or neglect.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than two hours after the allegation was made. Specifically, a resident with severe cognitive impairment, as indicated by a BIMS score of 00 and diagnoses including dementia, diabetes, and depression, was found to have a bruise and a skin tear of unknown origin on her left arm. The injuries were first reported by a family member to the charge nurse, who documented the findings in the resident's progress notes. Despite the documentation of the injuries, there was no evidence that the incident was reported to the state agency as required. The facility's records did not show any incident report, physician orders for monitoring or treating the injuries, or updated care plans reflecting the new injuries. Interviews with nursing staff and facility leadership revealed that the required notifications and investigations were not completed. The charge nurse, who was new at the time, reported the injuries to the Administrator and DON but did not complete an incident report or follow all notification protocols. The Administrator and DON did not recall being notified or investigating the incident, and the event was not identified during routine reviews of the 24-hour report. The facility's policy required immediate reporting and investigation of all allegations of abuse, neglect, or injuries of unknown origin, but this process was not followed in this case. Staff interviews indicated a lack of clarity and consistency in following the reporting procedures, and the incident was ultimately overlooked by facility management. As a result, the required reporting to the state agency did not occur, and the incident was not properly investigated or documented according to facility policy.
Failure to Update Care Plans for Residents on Contact Isolation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who required contact isolation due to infections with ESBL and MRSA. For one resident with a history of urinary tract infection, diabetes, stroke, and severe cognitive impairment, a urinalysis revealed ESBL, and physician orders were in place for both antibiotics and contact isolation. However, the resident's care plan only addressed the UTI and did not include any interventions or objectives related to contact isolation for ESBL, despite visible isolation signage and orders in the medical record. For another resident with dementia, UTI, anxiety, and cognitive intactness, a urinalysis detected MRSA, and physician orders included antibiotics and contact isolation. The care plan did not address the need for contact isolation or the resident's refusal to comply with isolation protocols, as the resident was observed participating in group activities outside her room while on contact precautions. The care plan was only updated after surveyor intervention to include isolation measures. Interviews with facility staff, including the ADON, DON, Regional MDS nurse, and Administrator, revealed that care plan updates were the responsibility of the MDS nurses and management team, and that changes such as new orders should be reflected in the care plan within 24-48 hours. However, staff acknowledged that the care plans for these residents had not been updated to reflect the new isolation requirements or behavioral issues related to isolation refusal, despite being aware of the orders and discussing resident changes in daily meetings.
Failure to Adhere to Contact Isolation Protocols for Residents with ESBL and MRSA
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to contact isolation protocols for two residents with communicable infections. One resident, a severely cognitively impaired female with a history of urinary tract infection (UTI) and extended-spectrum beta-lactamase (ESBL) in her urine, was placed on contact isolation per physician order. Despite a sign posted on her door, both an LVN and a CNA entered her room and provided care, including blood sugar checks, insulin administration, and personal care, without donning the required gown and gloves. The CNA also failed to properly dispose of contaminated linen, and both staff members acknowledged their lapses, citing reasons such as forgetting the precautions or not seeing the necessary PPE supplies nearby. Another resident, who was cognitively intact and diagnosed with MRSA in her urine, was also placed on contact isolation. However, she was observed participating in group activities and socializing with other residents outside her room. Interviews revealed that she had not been adequately educated about the need to remain in her room or the nature of her infection, and her care plan did not initially address contact isolation or refusal to comply with isolation protocols. Facility leadership, including the ADON and DON, provided inconsistent information regarding the expectations for residents on contact isolation, with some staff unsure of policy details and others stating that residents should be encouraged to stay in their rooms and that refusals should be documented and care plans updated accordingly. Record reviews confirmed that both residents had physician orders for contact isolation and that facility policies required the use of gowns and gloves for staff entering rooms of residents on contact precautions. Observations and interviews demonstrated that these policies were not consistently followed, and that signage, PPE availability, and staff education were insufficient to ensure compliance. These failures were directly observed by surveyors and confirmed through staff interviews and record reviews.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, as evidenced by incidents involving resident-to-resident altercations. In the first incident, a resident with severe cognitive impairment was struck on the shoulder by another resident, also with dementia, during an altercation in the dining room. The incident was witnessed by a staff member who intervened immediately. Both residents involved had impaired cognitive functions, and the altercation arose over a misunderstanding about personal items. In the second incident, a resident with intact cognition was grabbed under the arm by another resident with severe cognitive impairment and a history of physical behavior towards others. This occurred as they passed each other in the hallway. Initially, the resident did not report any harm, but later informed the nurse that he had been grabbed. The staff was present during the incident and intervened promptly. The third incident involved a resident with dementia being pushed on the head by another resident with intact cognition and a history of potential physical behaviors. This occurred in a common area when the resident with dementia approached a family member. The staff witnessed the incident and separated the residents immediately. These incidents highlight the facility's failure to ensure a safe environment free from abuse for all residents involved.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident. The resident, a female with dementia, was not administered her medications at the scheduled times. Specifically, her calcium, pantoprazole sodium, and sitagliptin-metformin HCI were given outside the prescribed time frames, which could potentially affect the consistency of the medication's presence in her bloodstream. The Medication Administration Audit Report indicated discrepancies in the timing of medication administration, and interviews with staff revealed a lack of adherence to the scheduled times. Additionally, the resident was not administered Estrace vaginal cream as ordered. A telephone order indicated the cream was to be applied every Monday, Wednesday, and Friday, but it was not given on one of the scheduled days. The Assistant Director of Nursing (ADON) admitted to marking the task as completed without actually administering the medication, which was only discovered after a family member raised the issue. This oversight highlights a lapse in the facility's medication administration process. Furthermore, the resident was not given the correct dosage of Vitamin B-12. The order summary report specified a dosage of 2000 mcg, but only 1000 mcg was administered. The Medication Aide (MA) acknowledged the error during an interview, noting that this could lead to a vitamin deficiency. The Director of Nursing (DON) and the Administrator both emphasized the importance of following physician orders to prevent medication errors, yet the facility's policy on medication administration was not adhered to, resulting in these deficiencies.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. For one resident, the MDS did not reflect that the resident had received antibiotics during the 7-day look-back period, nor did it indicate a diagnosis of MRSA infection in the right hip. This resident, who had severe cognitive impairment and required significant assistance with daily activities, was taking antibiotics for MRSA, as confirmed by the MDS Nurse and the Director of Nursing (DON). The omission in the MDS was attributed to the MDS Nurse's lack of awareness at the time of completion. Another resident's MDS inaccurately documented the discharge destination. The MDS indicated a discharge to the hospital, whereas the resident was actually discharged to their residence. This error was acknowledged by the MDS Nurse, who admitted to relying on hearsay rather than the resident's chart for information. The Assistant Director of Nursing (ADON) and the DON both confirmed the mistake and emphasized the importance of accurate MDS coding for proper care and billing. Interviews with facility staff, including the Administrator, highlighted the expectation for accurate MDS assessments. The facility's policy on the MDS process was referenced, underscoring the need for adherence to proper coding procedures. The deficiencies in the MDS assessments were recognized as potentially impacting the care and services provided to the residents.
Failure to Conduct Scheduled Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests and support the physical, mental, and psychosocial well-being of each resident. On two consecutive days, four out of eight scheduled activities were not conducted as per the August 2024 activity schedule. Specifically, the bean bag toss and Help Your Neighbor activities were not held on the first day, and the ball toss and Skip Bo activities were not conducted on the second day. Observations confirmed the absence of these activities in the dining room, where they were supposed to take place. Interviews revealed that the Activity Director, who had been in the role since 2017, was not present during the scheduled activities as she left the facility to pick up her grandchildren from school. The Activity Director admitted to not conducting the scheduled activities and acknowledged that residents who were bedridden received one-on-one activities. The Director of Nursing (DON) and the Administrator both stated that activities should be conducted as per the schedule to prevent residents from becoming bored or depressed. The facility's policy on the activities program did not address the need to conduct scheduled activities.
Deficiency in Hospice Care Coordination
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for three residents who were reviewed for hospice services. The facility did not obtain necessary hospice documentation, including the most recent plans of care, hospice election forms, physician certifications, and hospice medication lists for these residents. This lack of documentation and coordination could place residents at risk of receiving inadequate end-of-life care. Resident #38, a male with a diagnosis of neurocognitive disorder with Lewy bodies, cerebral infarction, seizures, and hypertension, was admitted to hospice care on 07/09/24. However, his electronic medical record did not include a hospice plan of care, hospice election form, physician certification, or hospice medication list. Despite the hospice Director of Nursing updating the hospice binder, it could not be located, and the facility had requested all documents be uploaded to the electronic medical record, which was not done. Resident #31, a male with prostate cancer and other conditions, had been on hospice services since 02/27/24. His electronic medical record lacked the most recent hospice plan of care and medication list, which should have been updated as of 08/15/24. The hospice team manager confirmed that these documents were brought to the facility but were not uploaded. Similarly, Resident #8, a male with atherosclerotic heart disease and other diagnoses, had discrepancies between his hospice orders and the medications he was receiving. The hospice nurse confirmed that updated records were delivered, but some pages were missing, and the facility's Director of Nursing acknowledged that the documents were not properly uploaded.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were informed and participated in their treatment, specifically regarding the administration of psychotropic medication. Resident #179, a cognitively intact male with diagnoses including spinal stenosis, schizophrenia, depression, and PTSD, was administered Bupropion HCL ER (Wellbutrin) for depression without obtaining informed consent. The resident's records lacked documentation of consent for this medication, which is required to inform residents or their responsible parties about the risks and benefits of the treatment. Interviews with facility staff, including an LVN, the ADON, the DON, and the Administrator, revealed that the consent process was not followed as per the facility's policy. The staff acknowledged that consent should be obtained before administering psychotropic medications, as these can alter a resident's demeanor and have potential side effects. The ADON admitted to being the admitting nurse for Resident #179 and not realizing the consent was missing until questioned by the state surveyor. The facility's policy on psychotherapeutic drug management mandates that informed consent must be obtained and documented before administering such medications, except in emergencies.
Failure to Notify Physician of Lab Draw Refusals
Penalty
Summary
The facility failed to consult with a resident's physician immediately when there was a need to alter treatment significantly. This deficiency was identified for one resident who refused ordered lab draws for four weeks. The resident, who had diagnoses including end-stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, and chronic obstructive pulmonary disease, was supposed to have weekly CBC lab draws due to low hemoglobin levels and a refusal of a blood transfusion at the hospital. Despite the resident's repeated refusals of the lab draws, the facility did not notify the physician of these refusals. The Licensed Vocational Nurse (LVN) responsible for the resident's care acknowledged that she did not document the refusals or notify the physician, stating that if it was not charted, it did not happen. The Director of Nursing (DON) and the Administrator both confirmed that the expectation was for the physician to be notified and for the refusals to be documented in the resident's medical record. The facility's policy required that changes in a resident's condition, such as the need to alter treatment significantly, be communicated to the physician in a timely manner. However, this policy was not followed, as evidenced by the lack of documentation and communication regarding the resident's refusal of lab draws. This failure placed the resident at risk of having critical lab results that the facility would not have been aware of.
Failure to Protect Resident's Medical Record Privacy
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's medical records, specifically the Medication Administration Record (MAR), which was left visible and unattended by the Assistant Director of Nursing (ADON). During an observation, the ADON left the computer screen unlocked on top of the medication cart while attending to a resident's blood sugar check. This action exposed the resident's MAR to staff, residents, and visitors passing by, compromising the resident's privacy. The ADON acknowledged the oversight, admitting it was a violation of HIPAA regulations. The resident involved was a female with a history of stroke, diabetes, and high blood pressure, who was moderately cognitively impaired and required extensive assistance with daily activities. The Director of Nursing (DON) and the Administrator both stated their expectations for maintaining privacy and confidentiality of resident information, emphasizing that staff had been educated on HIPAA violations. However, the facility's policy on privacy practices did not specifically address the protection of residents' health information.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, specifically for one resident reviewed for abuse. The incident involved a resident with dementia, diabetes mellitus, major depression, and chronic kidney disease, who was left in bed beyond soiled and shaking. A CNA reportedly stated that she did not attend to the resident because the resident hits her. The facility's policy required immediate reporting of such allegations to the state, but this was not done. The Social Worker received the grievance report from the resident's family member and notified the administrator immediately. However, the Director of Nursing (DON) and the Administrator did not consider the incident as an allegation of neglect and did not report it to the state as required by policy. The DON believed it was merely a grievance and was unsure of what should have been reported, while the Administrator also viewed it as a grievance rather than a reportable incident. This failure to report placed the resident at risk for further neglect or potential harm.
Failure to Report Allegation of Neglect in Timely Manner
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident within the required timeframe. The resident, a female with dementia, diabetes mellitus, major depression, and chronic kidney disease, was found by a family member to be in bed shaking and beyond soiled. The family member reported that a CNA stated she did not attend to the resident because the resident hits her. This incident was reported to the facility in May 2024, but the facility did not report it to the State Agency within the required 24-hour timeframe. Interviews with facility staff revealed a misunderstanding of the incident's severity. The Social Worker reported the grievance to the Administrator immediately, but the Administrator and the DON did not consider it an allegation of neglect. They viewed it as a grievance and did not report it to the appropriate authorities. The facility's policy requires immediate reporting of such allegations, but this was not followed, placing residents at risk for ongoing neglect.
Failure to Include MRSA Diagnosis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with MRSA infection in a wound on his right hip. Despite the resident's complex medical history, including depression, emphysema, anxiety, and heart failure, the care plan did not address the MRSA diagnosis. This omission was identified during a review of the resident's care plans, which were last revised before the MRSA diagnosis was confirmed by a lab report. Interviews with facility staff, including the ADON, MDS Nurse, DON, and Administrator, revealed that the MRSA diagnosis was not included in the care plan due to a lack of awareness and communication. The MDS Nurse, responsible for updating care plans, was unaware of the MRSA diagnosis until the day of the interview. The staff acknowledged that the absence of the MRSA diagnosis in the care plan posed a risk of miscommunication and inadequate care for the resident.
Unsecured Oxygen Cylinder at Nurse's Station
Penalty
Summary
The facility failed to ensure the proper storage of an oxygen cylinder, which was observed unsecured at the nurse's station. During an observation, a Licensed Vocational Nurse (LVN) acknowledged the unsecured cylinder and mentioned it belonged to a resident who had gone out to smoke. The LVN admitted to being unaware of the cylinder's presence at the nurse's station and confirmed that oxygen cylinders should always be secured. Further interviews revealed that the Activity Director had placed the oxygen cylinder at the nurse's station but got distracted and forgot to secure it. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both emphasized that oxygen cylinders should be stored in a designated closet and secured to prevent accidents. The Administrator reiterated that it was everyone's responsibility to ensure the cylinders were secured, as leaving them unattended could pose a danger to residents and staff. The facility's policy on oxygen administration also stated that oxygen cylinders must be secured in a cart or bracket at all times.
Failure to Ensure Proper Dialysis Orders and Monitoring
Penalty
Summary
The facility failed to provide dialysis services in accordance with professional standards of practice for a resident with end-stage renal disease. The resident, who was cognitively intact and required hemodialysis, did not have a physician's order for dialysis treatment. The facility's policy allowed for dialysis instructions to be placed under special instructions rather than as a formal order, which led to the absence of a documented physician's order for the resident's dialysis treatment. Additionally, the facility did not monitor the resident's dialysis catheter as required. The resident had a dialysis catheter in the right groin due to a clotted access in the arm, but there were no orders to monitor the catheter for complications. Although the LVN reported monitoring the catheter, there was no formal order in place to ensure consistent monitoring every shift, as required by the facility's policy. This oversight placed the resident at risk for potential complications, such as infection. Interviews with facility staff, including the LVN, DON, and Administrator, revealed a misunderstanding of the necessity for formal physician orders for dialysis treatment and catheter monitoring. The DON and Administrator acknowledged the importance of having such orders and recognized the risk of infection due to the lack of monitoring. The facility's policy on dialysis care emphasized the need for physician orders and regular monitoring of dialysis catheters, which was not adhered to in this case.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Specifically, the facility did not conduct behavior monitoring for Bupropion HCL ER (Wellbutrin) and Sertraline (Zoloft), which were prescribed for depression, nor did it monitor side effects for Clonazepam (Klonopin), prescribed for anxiety. This oversight was identified for one resident among those reviewed for unnecessary medications. The resident in question was a male with a history of spinal stenosis, schizophrenia, depression, and PTSD. He was cognitively intact, as indicated by a BIMS score of 15, and required assistance with various activities of daily living. Despite being on a regimen of psychotropic medications, there was no documentation of behavior or side effect monitoring in his medication administration records over a specified period. Interviews with facility staff, including LVNs, the ADON, the DON, and the Administrator, revealed a lack of awareness and adherence to the facility's policy on psychotropic medication monitoring. The staff acknowledged the importance of such monitoring to assess medication effectiveness and detect side effects, but it was not implemented. The facility's policy required behavior and side effect monitoring for residents on psychotropic medications, but this was not followed in the case of the resident, leading to the identified deficiency.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs were only accessible by authorized personnel, as observed with the medication cart on hall 100. During an observation, the medication cart was found unlocked and unattended, with staff, residents, and visitors walking by. The Assistant Director of Nursing (ADON) admitted responsibility for leaving the cart unlocked, stating she was in a hurry and forgot to lock it. She acknowledged that leaving the cart unlocked could allow anyone to access the medications. Interviews with various staff members, including an LVN, the Director of Nursing (DON), and the Administrator, confirmed that the medication cart should always be locked when unattended to prevent unauthorized access. The facility's policy on the storage of medications also mandates that medication carts be locked when not attended by authorized personnel. The failure to secure the medication cart could lead to unauthorized access to medications, posing a risk to residents and staff.
Failure in Infection Control for MRSA Case
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the case of a resident with a MRSA infection in his right hip wound. The resident, who had a history of depression, emphysema, anxiety, and heart failure, was not placed on transmission-based precautions (TBP) for the MRSA infection, despite having an order for antibiotics. The resident's medical records did not include an order for isolation, nor was there a care plan addressing the MRSA diagnosis. Additionally, the resident's quarterly MDS did not reflect the MRSA diagnosis or antibiotic treatment, and his roommate was moved out and back into the room without proper precautions. Interviews with staff revealed a lack of communication and understanding regarding the necessary precautions for the resident's MRSA infection. The Treatment Nurse indicated that the resident was on enhanced-barrier precautions (EBP) rather than TBP, and staff were not notified of the specific infection. The Assistant Director of Nursing (ADON) acknowledged that the facility should have implemented TBP, including signage, PPE placement, and staff notification, but these measures were not taken. The Director of Nursing (DON) believed that EBP was sufficient and did not require staff to be informed of the infection, which contradicted the facility's policy. The facility's policy on transmission-based precautions was not followed, as the resident was not placed in a private room or on contact precautions as required for MRSA infections. The Administrator confirmed that the resident should have been on TBP, and the failure to do so posed a risk of MRSA transmission within the facility. The lack of proper precautions and communication among staff members contributed to the deficiency in infection control practices.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to adhere to its established smoking policy for a resident who was reviewed for smoking. The deficiency was identified when it was observed that the facility did not complete a smoking screen assessment quarterly for the resident, as required by their policy. The resident, a male with a history of stroke and high blood pressure, was cognitively intact and required limited assistance with daily activities. His comprehensive care plan indicated that he was a smoker and required supervision for smoking, with assessments to be conducted quarterly. However, the last smoking assessment was completed over a year ago, which was not in compliance with the facility's policy. Interviews with facility staff, including the ADON, DON, and Administrator, revealed that the responsibility for completing smoking assessments lay with the nursing staff. The ADON acknowledged that the assessments were supposed to be generated in the resident's electronic medical records but were not being done, posing a risk of burns to residents. The DON admitted that the system in place for checking smoking assessments failed to trigger, leading to the oversight. The Administrator, who was new to the facility, was unaware of the specific timeframe for smoking assessments but recognized the potential risk of injury due to the lack of assessments. The facility's policy, revised in November 2023, clearly outlined the requirement for quarterly smoking assessments, which was not followed in this case.
Failure in Pharmaceutical Services and Medication Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of Hydrocodone-Acetaminophen tablets. The resident, who had severe cognitive impairment and required pain management for chronic pain, was supposed to receive 115 tablets of Hydrocodone-Acetaminophen. However, a discrepancy was noted when a card of 30 tablets was missing, despite the medication administration record indicating no missed doses. The issue arose when LVN C signed for the delivery of the medication without noting the date or time and placed the medications on the counter in the medication room instead of securing them in the controlled box on the medication cart. This oversight allowed for the possibility of unauthorized access to the medications. CMA H and RN F later discovered the discrepancy during a routine count, but the medication cart had not been counted the previous night, and the missing card of tablets could not be accounted for. Interviews with staff revealed that the medications were not properly counted upon receipt, and there was a lack of adherence to the facility's procedures for handling controlled substances. The Director of Nursing acknowledged the failure in the process and the risk it posed, while the Administrator confirmed that an investigation was conducted, but the missing tablets were never found. The facility's policy on abuse prevention and prohibition emphasizes the importance of protecting residents from misappropriation of property, which was not upheld in this instance.
Failure to Coordinate Hospice Care and Use Mechanical Lift
Penalty
Summary
The facility failed to coordinate hospice care planning for Resident #9, who was receiving hospice services. This lack of coordination was evident in the failure to communicate with hospice representatives, including the hospice medical director and the resident's attending physician, regarding the care plan for Resident #9. The deficiency was identified during a review of the resident's records and interviews with facility and hospice staff. Resident #9, a female with diagnoses including unspecified dementia and Parkinson's disease, was dependent on staff for all activities of daily living (ADLs) and required the use of a mechanical lift for transfers, as per her care plan and physician's orders. However, on a specific date, Hospice Aide A transferred Resident #9 from her wheelchair to her bed without using the mechanical lift, contrary to the care plan. Hospice Aide A was not informed by the facility staff about the requirement for a mechanical lift, and her hospice aide care plan only mentioned assistance with transfers. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) C, revealed a lack of communication with the hospice regarding the change in Resident #9's transfer needs. The DON acknowledged that the charge nurse should have informed the hospice about the need for a mechanical lift, but LVN C admitted she did not notify the hospice of such changes. This communication breakdown placed Resident #9 at risk for falls and injuries due to improper transfer methods.
Inadequate Hand Hygiene During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during perineal care for a resident. The CNA did not perform hand hygiene between glove changes while providing care, which is a critical step in preventing cross-contamination and the spread of infection. This lapse was observed during a care procedure for a resident who was dependent on staff for personal hygiene due to conditions such as dementia, high blood pressure, chronic obstructive pulmonary disease, and diabetes mellitus. The resident's care plan indicated a need for assistance with activities of daily living, including toileting. During the observation, the CNA changed gloves multiple times without washing hands or using hand sanitizer, despite acknowledging the importance of this practice in preventing the transmission of germs and bacteria. Interviews with the CNA, the Director of Nursing (DON), the Administrator, and the Assistant Director of Nursing (ADON) confirmed the expectation for CNAs to perform hand hygiene between glove changes. The facility's policy on perineal care also outlined the requirement for handwashing or the use of hand sanitizer between glove changes. The failure to adhere to these protocols placed the resident at risk for contamination and infection.
Failure to Include Restorative Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. This deficiency was identified during a review of the care plans and interviews with staff and residents. The care plans for both residents did not include their restorative care programs, which were necessary to address their mobility and strength issues. Resident #1, an elderly female with severe cognitive impairment, required maximum assistance with daily activities and was involved in a restorative care program aimed at improving her ability to ambulate and transfer safely. However, her care plan did not reflect this program, and there were no orders for it in her records. During an interview, the resident mentioned inconsistencies in receiving therapy, indicating a lack of proper implementation of her restorative care. Resident #2, who had moderate cognitive impairment and functional limitations in her extremities, also had a restorative care program to enhance her strength and range of motion. Similar to Resident #1, her care plan did not include this program, and there were no corresponding orders. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed a lack of communication and understanding of responsibilities, leading to the omission of the restorative care programs in the residents' care plans.
Failure to Provide Restorative Care for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate restorative care to two residents with limited range of motion, as required by their Nursing Restorative Care Program plans. Resident #1, an elderly female with severe cognitive impairment, was admitted with diagnoses including muscle weakness and reduced mobility. Her care plan, initiated in January 2024, did not address a restorative program, and there were no orders or documentation for such a program in her records. Despite having a plan to increase her ability to ambulate and transfer, there were significant gaps in the documentation of restorative care provided, with several days showing no record of care being offered or completed. Resident #2, who had moderate cognitive impairment and functional limitations in both upper extremities and one lower extremity, also did not have a restorative program documented in her care plan. Her records similarly lacked orders or documentation for a restorative program. Although her plan included exercises to maintain strength and range of motion, there were multiple days without documentation of care being provided. Interviews revealed that the CNA responsible for restorative care did not consistently offer or document the care, citing reasons such as being occupied with other tasks or residents not having documentation areas in their electronic health records. Interviews with staff, including the Director of Nursing (DON) and the MDS Coordinator, highlighted a lack of oversight and understanding of responsibilities regarding the restorative program. The DON admitted to not routinely reviewing the restorative program logs and assumed the MDS Coordinator was responsible for adding restorative care to the residents' electronic health records. The MDS Coordinator, new to the position, was unaware of the residents receiving restorative care and uncertain about his role in ensuring it was included in care plans. The facility's policy indicated that the DON or their designee should manage the program, but this was not effectively implemented, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 68 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near 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 | 0.2 mi | ★★★★★ | 0 | 0 |
| Sulphur Springs Health And Rehabilitation | 0.5 mi | ★★★★★ | 16 | 0 |
| Rock Creek Health And Rehabilitation | 1.9 mi | ★★★★★ | 15 | 1 |
| Birchwood Nursing And Rehabilitation | 16.4 mi | ★★★★★ | 1 | 0 |
| Avir At Commerce | 18.3 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.