Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springtree Healthcare & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, DM, CHF, CKD, COPD, GERD, and a history of protein-calorie malnutrition was care planned for total assist with meals due to risk for weight loss and malnutrition, but staff documentation and interviews showed that CNAs frequently provided only set up, supervision, or independent-level assistance instead of feeding the resident. CNA charting over two months reflected mostly set up or independent meal assistance, with variable intake percentages, while staff reported relying on a unit "feed list" (with names in bold for residents to be fed) rather than the written care plan to determine the level of meal assistance. CNAs acknowledged they were unsure what the care plan specified about feeding and described a gradual shift from supervision to total feeding as the resident declined, demonstrating a failure to consistently follow the comprehensive person-centered care plan for meal assistance.
A resident with dementia, dysphagia, COPD, DM, protein-calorie malnutrition, CHF, CKD, and GERD experienced significant weight loss over several months while the facility failed to consistently follow RD recommendations for weekly weights and did not reliably implement care-planned total assist with meals. RD notes documented repeated significant weight changes and ordered weekly weights for monitoring, but several weekly weights were missing from the record without supporting refusal documentation, despite a policy assigning the DON and nursing staff responsibility for timely weight monitoring and recording. The care plan identified the resident as at risk for weight loss and called for encouragement to eat, supplements as ordered, total assist for meals, and weights as ordered, yet CNA documentation in one month showed the resident as mostly set-up or independent for meals, while CNAs, an LPN, the UM, and the PA described a rapid decline to dependence for eating and drinking and episodes of poor intake. This discrepancy between documented assistance levels, staff interviews, and RD-directed monitoring formed the basis of the deficiency in maintaining the resident’s nutrition and hydration status.
A resident with diabetes was admitted from the hospital with instructions for continued blood glucose monitoring and insulin administration, but facility staff did not transcribe or implement these orders upon admission. The resident did not receive blood glucose checks until several days later, after the omission was discovered. Staff interviews revealed confusion about the admission process and lack of provider review of the discharge summary, resulting in a lapse in care.
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 noncompliance with regulatory requirements.
The facility failed to ensure the secure storage of medications and blood collection tubes, leading to several deficiencies. Unlabeled and expired medications were found on medication carts, and a nurse left medication cards unsecured. Additionally, all blood collection tubes in a medication room were expired. The facility's policies require medications to be securely stored and outdated items to be removed, but these were not followed.
A resident with a history of pneumonia and other conditions was suspected of having a UTI. Despite an order for a urinalysis with culture and sensitivity, the facility staff failed to collect the urine sample, and there was no documentation explaining the omission. The facility's policy requires that all ordered tests be completed and results communicated, but this was not followed.
A resident's room was found with multiple dried, brown drips on the wall, which remained unaddressed over several days despite being observed by surveyors. The resident, who was severely cognitively impaired and had multiple diagnoses, was in a room that did not meet the facility's cleanliness standards. The issue was acknowledged by the Housekeeping Supervisor but was not resolved before the survey exit conference.
The facility failed to electronically transmit MDS assessments for two residents, leading to a deficiency. One resident with metabolic encephalopathy, muscle weakness, and diabetes had a discharge MDS assessment that was not transmitted within the required timeframe. Another resident with diabetes, muscle weakness, and chronic obstructive pulmonary disease also had a discharge MDS assessment that was not transmitted on time. These issues were identified during a survey when the Resident Assessment task flagged MDS assessments over 120 days old.
The facility staff failed to accurately complete MDS assessments for two residents. One resident was incorrectly coded as using physical restraints, while another was inaccurately coded as discharged to a hospital instead of home. These errors were identified through observations and record reviews, and confirmed by facility staff.
Two residents in an LTC facility were found to have incomplete person-centered care plans, failing to address their activity preferences and psychosocial needs. One resident, with multiple diagnoses including dementia, had no comprehensive activity care plan, while another resident's plan lacked specificity in leisure activities. The facility's policies require individualized care plans, but these were not adequately implemented.
A resident's care plan was not updated to reflect changes in their code status and the implementation of comfort care measures, despite revised medical orders. The resident, with moderate cognitive impairment, was assessed as able to communicate effectively, yet their care plan still listed them as Full Code instead of DNR. The deficiency was identified during a survey, highlighting a lapse in adhering to the facility's policy of ongoing care plan updates.
A resident with multiple diagnoses, including dysphagia and hemiplegia, did not receive water flushes as ordered by their physician through their PEG tube. The pump was incorrectly set to deliver 250 mls every four hours instead of the prescribed 200 mls. LPNs confirmed the error and adjusted the pump setting after being questioned by surveyors.
A resident with respiratory conditions was observed receiving oxygen at 3 liters per minute instead of the ordered 4 liters. Despite the facility's documentation indicating compliance with the physician's order, multiple observations by a surveyor revealed the incorrect flow rate. The resident confirmed the incorrect administration, and the issue was discussed with facility leadership.
A resident's prescribed Oxycodone was unavailable for administration on multiple occasions, despite a comprehensive care plan requiring it. Additionally, a discrepancy in the count of Gabapentin tablets was found in a medication cart, indicating a failure in the facility's monitoring system. Both issues were not resolved before the survey exit conference.
Two residents in a LTC facility experienced significant medication errors due to staff failing to follow provider orders. One resident received antihypertensives despite low SBP, and did not receive Midodrine as needed. Another resident was given Insulin Glargine without a recent blood glucose check. The facility's policy on checking vital signs before medication administration was not adhered to.
A resident with multiple health issues did not receive timely radiology services as ordered by their physician. The facility delayed a chest x-ray ordered for a worsening cough and failed to complete another x-ray within the specified timeframe. The Director of Nursing confirmed these delays and omissions during a survey interview.
The facility failed to provide adequate portions of ham salad in sandwiches to four residents, as observed by a surveyor. The dietary cook used an incorrect scoop size due to the unavailability of the specified #24 scoop, resulting in insufficient servings. The issue was acknowledged by the regional director of operations and discussed with the facility's administration.
Failure to Follow Care Plan for Total Meal Assistance
Penalty
Summary
Facility staff failed to follow a comprehensive person-centered care plan for a resident who was care planned to receive total assistance with meals. The resident had multiple diagnoses including dementia, dysphagia, COPD, diabetes, protein-calorie malnutrition, congestive heart disease, chronic kidney disease, and GERD. The comprehensive care plan, initiated in late 2022 and revised in late 2025, identified the resident as being at risk for weight loss or malnutrition related to chronic disease and cognitive impairment, and included interventions such as encouragement to eat, recording meal intake, supplements as ordered, weights as ordered, and total assist for meals (revised 12/7/25). Despite this, the annual MDS assessment dated 11/19/25 documented the resident as requiring only set up or clean up assistance with meals and being able to feed self during the lookback period, and also noted a significant unplanned weight gain. Review of CNA documentation for December 2025 showed that the resident was consistently documented as needing only set up assistance (code 05) or being independent (code 06) for meals on all days except one evening meal, when the resident was documented as dependent. Across 93 meals in December, the resident’s intake was recorded mostly in the higher percentage ranges, with some meals at lower intake and two refusals. In January 2026, prior to the resident’s transfer to the hospital on 1/9/26, documentation reflected variable levels of assistance: independent for some shifts, set up or clean up assist for others, supervision for two shifts, and dependent for six shifts, with one refusal. Meal intake percentages in January ranged from 76–100% for most meals to 0–25% for several meals. Interviews with CNAs and the Unit Manager revealed that direct care staff relied on a unit “feed list” rather than the resident’s care plan to determine whether to feed the resident or provide only set up/supervision. CNA #1 and CNA #2 described the resident as initially independent or requiring supervision with meals, with staff setting up trays and checking back, and only later providing full feeding assistance as the resident’s condition declined. CNA #2 and CNA #3 both stated they did not know what the care plan said about feeding and followed the list instead. The Unit Manager confirmed the existence of a list indicating which residents should be fed (names in bold) versus set up and supervised, and believed the resident’s name was in bold at some point, but could not recall the timeframe. These interviews and documentation demonstrated that staff actions did not consistently align with the care-planned intervention of total assist for meals.
Failure to Follow RD Weight Monitoring Recommendations and Implement Total Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutrition and hydration status for one resident by not consistently following RD recommendations for weekly weights and not providing meal assistance as outlined in the comprehensive care plan. The resident had multiple diagnoses including dementia, dysphagia, COPD, diabetes, protein-calorie malnutrition, CHF, chronic kidney disease, and GERD, and was care planned as being at risk for weight loss or malnutrition with significant weight fluctuations. The RD documented significant weight loss on multiple occasions and recommended increased nutritional supplements and weekly weights for four weeks in September, October, and December 2025. However, the clinical record lacked weekly weights for the second week of September, the third week of October, and the second week of December, and the DON was unable to provide documentation for the missing September and October weights, despite a facility policy assigning responsibility to nursing for ensuring and recording timely weights. The RD’s notes showed ongoing significant weight changes: a weight of 123 lbs on 9/5/25 with a 5% loss in 30 days and 7.5% in 90 days, followed by 116 lbs on 10/4/25 with 5% loss in 30 days, 7.5% in 90 days, and 10% in 180 days. Later, a weight of 128.5 lbs on 11/7/25 reflected a documented rebound gain, and by 12/5/25 the weight had decreased again to 121 lbs with a 5% loss in 30 days and 10% in 180 days, and then to 119 lbs on 12/26/25. The RD repeatedly recommended weekly weights for monitoring during these periods of significant loss, and the facility’s own policy required a system to weigh, monitor, and track weights, with the DON responsible for ensuring patients are weighed in an acceptable time frame. Despite this, the missing weekly weights in September and October were not supported by refusal documentation or other explanation. The facility also failed to consistently implement the care-planned intervention of total assistance with meals when the resident’s condition declined. The care plan, revised in December 2025, included interventions such as encouragement to eat, recording meal intake percentages, providing supplements as ordered, total assist for meals, and weights as ordered. However, CNA documentation for December 2025 showed the resident as requiring only set-up assistance or being independent for all meals except one evening meal, despite interviews indicating that toward the end of the resident’s stay staff had to feed the resident and that the resident became dependent for eating and drinking. Multiple CNAs and nursing staff reported that the resident transitioned from supervision/set-up to needing to be fed and that the resident was on a “feed list,” with some staff stating this dependence had been present for at least weeks to months before hospital transfer, while CNA documentation continued to reflect primarily set-up or independent status. This discrepancy between documented assistance levels and staff interviews, along with the missing weekly weights despite RD recommendations, formed the basis of the identified deficiency in maintaining the resident’s nutrition and hydration status. Interviews with the PA and nursing staff further described the resident’s decline and concerns about hydration. The PA reported that the resident experienced a decline in condition and was treated in the facility with IV fluids, labs, and antibiotics for a UTI, and later became profoundly dehydrated, prompting transfer to the hospital. The PA and nursing staff stated that the resident was on the list to be fed and that staff were feeding and offering fluids, but the PA acknowledged never being present in the room at mealtimes. CNAs and nurses described a rapid decline in the resident’s ability to eat and drink, including needing staff to hold cups, becoming total assist for meals, and sometimes refusing to open her mouth or swallow. Despite these descriptions, the December CNA documentation largely reflected only set-up or independent meal status, and the facility could not fully substantiate adherence to RD-directed weekly weight monitoring during periods of significant weight loss. The DON stated that the resident sometimes refused care, including being weighed, and produced documentation of a refusal for a December weekly weight but could not locate documentation for the missing September and October weights. The facility’s weight monitoring policy specified that weights are to be tracked, monitored, and analyzed by the IDT, and that nursing staff are responsible for recording weights in the clinical record. The lack of documented weekly weights as recommended by the RD, combined with inconsistent documentation of the resident’s need for total assistance with meals compared to staff interviews and the care plan, demonstrated that the facility did not fully implement and document the interventions necessary to maintain the resident’s nutritional and hydration status as required.
Failure to Review and Implement Blood Glucose Monitoring Orders After Hospital Discharge
Penalty
Summary
Facility staff failed to ensure that a resident's total program of care was reviewed following a hospital discharge, specifically neglecting to implement blood glucose monitoring orders for a resident with a diagnosis of diabetes. The resident's hospital discharge summary included instructions to continue using insulin, a blood glucose meter, and related supplies, but these orders were not transcribed into the clinical record upon admission. The clinical record lacked any provider orders for blood glucose checks, and the resident did not receive blood glucose monitoring until several days after admission, when the omission was identified and addressed. Interviews with facility staff revealed that the admitting nurse recalled seeing information about a dexcom device but did not recall further details, and the unit manager could not confirm whether the provider had reviewed the discharge summary at the time of admission. The provider was not on site during the admission, and there was uncertainty about who approved the resident's orders. The resident confirmed that blood glucose checks were not performed until after the issue was identified. The facility's policy required verification of transfer orders with the attending physician for immediate care, but this process was not followed in this instance.
Failure to Provide Required Pharmaceutical Services
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 by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication and Storage Deficiencies
Penalty
Summary
The facility staff failed to ensure the safe and secure storage of medications and blood collection tubes, leading to several deficiencies. On the 500 Hall medication cart, three used insulin pens were found without labels indicating the resident's name or the date of opening. Similarly, the 400 Hall medication cart contained an insulin pen without a clearly identifiable resident name, an expired box of Levothyroxine tablets, and a vial of Insulin Glargine with unclear opening dates. During an observation, a registered nurse was seen using an unlabeled insulin pen, which was not stored in a labeled bag, and subsequently discarded the insulin syringe. The Director of Nursing acknowledged that insulin pens should be labeled with the resident's name, and the Unit Manager confirmed the presence of unlabeled insulin pens, which were later removed. In another instance, a registered nurse left six medication cards unsecured on top of a medication cart while administering medications to a resident. The cart was out of the nurse's line of sight for four minutes, although no staff or residents approached it during that time. Additionally, an opened box of bisacodyl suppositories with an expired date was found in the 500 Hall medication cart. The nurse involved did not respond to the surveyor's questions and walked away, leaving the cart unlocked. The facility's policy requires that all medication storage areas be locked unless under direct observation, and outdated medications should be immediately removed from inventory. Furthermore, all blood collection tubes in the medication room on Unit 2 were found to be expired. The infection preventionist acknowledged the expired tubes and reported that the facility staff do not collect laboratory samples themselves but call a laboratory service for blood collection needs. Despite the lack of a written policy regarding the maintenance of current products in medication rooms, it was noted that central supply and nursing administration were responsible for ensuring the availability of non-expired products. The expired blood collection tubes were gathered for removal from the medication room.
Failure to Obtain Ordered Urinalysis for Resident
Penalty
Summary
The facility staff failed to provide necessary laboratory services for a resident, identified as Resident #314, who was suspected of having a urinary tract infection (UTI). The resident, who was cognitively intact with a BIMS score of 14 out of 15, had a medical history that included pneumonia, generalized muscle weakness, protein-calorie malnutrition, essential hypertension, and gastro-esophageal reflux disease. On February 13, 2024, the facility's family nurse practitioner (FNP) assessed the resident after the resident's adult child reported signs of a UTI and hallucinations. Although the resident denied acute issues, a urinalysis with culture and sensitivity was ordered to be obtained between February 13 and February 16, 2024. However, the surveyor found no evidence that the urinalysis was conducted or that a urine sample was collected. The FNP confirmed that while a complete blood count (CBC) was obtained, the urine sample was not collected, and there was no documentation from the nursing staff explaining the omission. The facility's policy requires licensed nurses to ensure that all ordered laboratory tests are completed and results communicated to the provider, but this was not adhered to in this instance. The issue was discussed with the facility's administration and nursing leadership, but no further information was provided before the survey exit conference.
Failure to Maintain a Clean Environment for a Resident
Penalty
Summary
The facility staff failed to maintain a clean and sanitary environment for a resident, as observed during a survey. On three separate days, a large area of multiple dried, brown drips was noted on the wall to the left of the resident's bed. Despite multiple observations by the surveyor, the condition of the wall remained unchanged. The resident involved had a diagnosis list that included Dementia, Bipolar II Disorder, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Congestive Heart Failure. The resident was assessed with a BIMS score of 4 out of 15, indicating severe cognitive impairment. The surveyor brought the issue to the attention of the Housekeeping Supervisor, who acknowledged the condition of the wall and stated they would clean it. The facility's policy on daily room cleaning was reviewed, which included spot cleaning of necessary areas. The concern was discussed with the facility's administration and nursing leadership, but no further information was provided to the survey team before the exit conference.
Failure to Transmit MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to electronically transmit the Minimum Data Set (MDS) assessments for two residents, leading to a deficiency in the Resident Assessment task. For Resident #8, who had diagnoses including metabolic encephalopathy, muscle weakness, and diabetes, the discharge MDS assessment with an Assessment Reference Date (ARD) of 02/15/24 was not transmitted within the required timeframe. This oversight was identified during the survey process when the Resident Assessment task flagged an MDS that was over 120 days old. Upon review by the Licensed Practical Nurse (LPN) and Registered Nurse (RN), it was confirmed that the assessment had not been transmitted until the day of the survey. Similarly, for Resident #92, who had diagnoses including diabetes, muscle weakness, and chronic obstructive pulmonary disease, the discharge MDS assessment with an ARD of 12/27/23 was also not transmitted within the required period. This issue was similarly identified during the survey process when the Resident Assessment task flagged an MDS over 120 days old. The LPN and RN confirmed that the assessment had not been transmitted until the day of the survey. Both incidents were discussed in a meeting with the facility's administrative and nursing leadership, but no further information was provided to the survey team before the exit conference.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS was incorrectly coded to indicate the use of physical restraints in the form of bedrails, when in fact, the resident used assist bars that were not considered restrictive. This error was identified during a surveyor's observation and confirmed by the Director of Nursing (DON) and the Regional Nurse, who acknowledged the MDS was coded incorrectly. The MDS coordinator admitted to the mistake, noting that the MDS assessment options did not include assist bars, leading to the incorrect coding. For another resident, the facility staff inaccurately coded the discharge MDS assessment, indicating the resident was discharged to a short-term general hospital, while the resident was actually discharged home. This discrepancy was noted in the clinical record, which included a progress note from the Activities Director confirming the resident's discharge to home. The error was reviewed with the Licensed Practical Nurse (LPN) and the Regional Nurse Consultant, who later confirmed the MDS assessment had been corrected.
Deficiencies in Person-Centered Care Plans for Residents
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their activity preferences and psychosocial needs. For one resident, the facility did not create a comprehensive activity care plan despite the resident's diagnoses, which included Major Depressive Disorder, Bipolar Disorder, and Dementia, among others. The resident's cognitive skills were moderately impaired, as indicated by a BIMS score of 9 out of 15. The surveyor could not locate documentation of an activity-focused care plan, and the only intervention noted was 'Activities of resident choice,' which was insufficient to meet the resident's needs. Another resident's care plan also lacked specificity in addressing activity preferences and interests. This resident was assessed as having moderate cognitive impairment with a BIMS score of 11 out of 15 and was able to communicate effectively. The care plan included a focus area on leisure activities but did not specify the resident's preferences, such as listening to music, being around animals, and socializing. The Activity Director acknowledged the care plan was incomplete, and it was later revised to include more specific interventions. The facility's policies on care planning emphasize the need for individualized, person-centered care plans developed by a licensed nurse in coordination with the interdisciplinary team. These plans should support the highest practicable physical, mental, and psychosocial well-being of the residents. However, the survey findings revealed that the facility did not adhere to these policies, resulting in incomplete and inadequate care plans for the residents involved.
Failure to Update Care Plan for Resident's Code Status and Comfort Care
Penalty
Summary
The facility staff failed to review and revise the comprehensive person-centered care plan for one resident, identified as Resident #37, following a change in the resident's code status and the implementation of comfort care measures. The resident's most recent Minimum Data Set (MDS) assessment indicated moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of nine out of 15. Despite being assessed as able to make themselves understood and usually able to understand others, the care plan did not reflect the resident's updated medical provider orders, which included comfort care measures and a Do Not Resuscitate (DNR) status. The deficiency was identified during a survey when the care plan was found to still list the resident as having an advanced directive of Full Code, without addressing the comfort care measures. The medical provider orders had been revised to include comfort care and DNR status, but these changes were not reflected in the care plan until the surveyor's inquiry prompted an update. The facility's policy requires care plans to be updated on an ongoing basis as changes occur, but this was not adhered to in the case of Resident #37.
Failure to Follow Physician's Orders for Water Flushes
Penalty
Summary
The facility staff failed to provide care and services as ordered by the primary care physician for one resident in the survey sample. Specifically, the staff did not ensure that water flushes were delivered according to the physician's order through the resident's PEG tube. The resident, who has diagnoses including dysphagia following a cerebrovascular accident, hemiplegia, hemiparesis, unspecified protein-calorie malnutrition, and unspecified heart failure, was observed with a tube feeding pump set to deliver 250 milliliters of water every four hours, contrary to the physician's order of 200 milliliters every four hours. Upon review, the Medication Administration Record indicated that the order was signed off as administered correctly each day, despite the discrepancy in the pump setting. When questioned, the LPNs confirmed the error and adjusted the pump to the correct setting. The issue was discussed with the facility's administration and clinical leadership, but no further information was provided to the survey team before the exit conference.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility staff failed to administer oxygen according to the attending medical provider's orders for a resident. The resident, who had diagnoses including heart failure, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid severe obesity, was observed multiple times receiving oxygen at 3 liters per minute via nasal cannula, despite the physician's order specifying 4 liters per minute. The resident, who had intact cognition, confirmed to the surveyor that she was on 3 liters of oxygen. The facility's documentation, including the medication administration record and the comprehensive care plan, indicated that oxygen was to be administered as ordered. However, observations by the surveyor on different occasions showed that the oxygen was not being administered at the correct flow rate. The facility's policies on physician's orders and respiratory care emphasized the importance of following the provider's order, including the correct flow rate for continuous oxygen therapy. This discrepancy was discussed with facility leadership during meetings with the survey team.
Medication Availability and Monitoring Deficiencies
Penalty
Summary
The facility staff failed to ensure that a resident's provider-ordered narcotic pain medication, Oxycodone, was available for administration. The resident, who had a history of malignant neoplasm of the bronchus of the lung, chronic obstructive pulmonary disease, muscle weakness, and cirrhosis of the liver, had a comprehensive care plan that included administering medications as ordered. Despite a provider order for Oxycodone dated January 11, 2024, the medication was documented as unavailable on multiple occasions, including April 20, April 29, and May 5, 2024. Interviews with the resident and staff revealed that the medication was not always available, and the facility's stat box did not contain the medication. The facility policy required notifying the provider and discussing alternative orders if necessary, but no further information was provided to the survey team before the exit conference. Additionally, the facility staff failed to correctly implement the scheduled/control monitoring system for a medication cart, resulting in a discrepancy in the count of Gabapentin 600 mg tablets for another resident. The resident had diagnoses including cerebral infarction, Alzheimer's disease, type 2 diabetes mellitus, and bilateral foot calcaneal spurs, with a provider order for Gabapentin 600 mg every 12 hours. A reconciliation of the medication cart revealed a discrepancy of one tablet, with the actual count not matching the documented count. The facility's policy required documentation of administration in the MAR or TAR and the controlled substance sign-out record, but the discrepancy was not resolved before the exit conference.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility staff failed to ensure that residents were free from significant medication errors, as evidenced by the cases of two residents. For one resident, the staff did not adhere to medical provider orders for the administration of Diltiazem, Metoprolol Tartrate, and Midodrine. Despite the provider's orders to hold Diltiazem and Metoprolol Tartrate if the systolic blood pressure (SBP) was less than 110, these medications were administered on two occasions when the resident's SBP was below the threshold. Additionally, Midodrine, which was ordered to be administered if the SBP was less than 105, was not given on the same days when the resident's SBP was below the specified level. The registered nurse involved acknowledged the medication error upon review. In another case, the facility staff failed to follow the physician's order for administering Insulin Glargine to a resident with Type 2 Diabetes Mellitus. The order specified that the insulin should be held if the blood glucose level was below 140. However, the insulin was administered without documenting a blood glucose level immediately prior to administration, with the last recorded level being taken hours earlier. The facility's policy required checking vital signs or other tests before medication administration, which was not followed in these instances.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility staff failed to provide timely radiology services for a resident, identified as Resident #44, who had multiple medical conditions including heart failure, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid severe obesity. The resident had physician's orders for chest x-rays due to a worsening cough and a history of pneumonia. The first order, dated 1/19/24, required a chest x-ray by 1/22/24, but the x-ray was not completed until 1/23/24. Additionally, there was no record of the x-ray ordered on 2/13/24 being completed within the specified timeframe. During an interview on 5/23/24, the Director of Nursing (DON) confirmed that the x-ray ordered on 1/19/24 was delayed and that the x-ray ordered on 2/13/24 was missed entirely, with a subsequent x-ray only being completed on 2/20/24. The facility's policy on physician's orders was reviewed, which emphasized the importance of timely treatment orders and follow-up appointments. However, no further information was provided to the survey team before their exit.
Inadequate Ham Salad Portions Served to Residents
Penalty
Summary
The facility staff failed to provide a nourishing, well-balanced diet to four residents by serving an inadequate amount of ham salad in their sandwiches. On the evening of May 21, 2024, a resident showed the surveyor her ham salad sandwich, which contained only a minimal amount of ham salad, approximately the size of a teaspoon. Another resident in the same room had a similar issue with her sandwich. The administrator was informed and offered additional sandwiches to the residents. The regional director of operations for dietary services acknowledged the problem and noted that the serving size was not followed as per the diet guide. Further investigation revealed that the dietary cook used the wrong scoop size due to the unavailability of the correct #24 scoop. Instead, a #16 scoop was used, which resulted in insufficient ham salad being served. The cook admitted to not consulting the regional director for guidance when the correct scoop was unavailable. The corporate recipe specified using a #24 scoop, but the facility did not have one available, leading to the deficiency. This issue was discussed in meetings with the facility's administration and clinical services team.
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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.
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Nursing homes near Roanoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Star City Rehabilitation And Nursing | 0.7 mi | ★★★★★ | 0 | 0 |
| Berkshire Health & Rehabilitation Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Our Lady Of The Valley | 3.1 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 4.2 mi | ★★★★★ | 0 | 0 |
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