Below 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 Suring Health And Rehab Center during CMS and state inspections, most recent first.
The facility failed to maintain its N95 respirator fit testing program as required by its respiratory protection policy and applicable OSHA, CDC, and CMS standards. Records showed the last documented fit testing occurred in early 2022, with no subsequent annual fit testing completed. A CNA hired later reported never being fit tested, and the DON confirmed that neither the DON nor other staff had been fit tested since 2022, despite a COVID-19 outbreak occurring afterward. The DON stated that staff are expected to wear N95 masks when caring for residents with COVID-19 and that anyone entering a room under airborne precautions should wear an N95, yet the facility did not ensure required fit testing for those staff.
The facility failed to keep paint and chemical supplies secured when multiple cans of paint, primer, acrylic coating, joint compound, and an aerosol enamel spray were left in an unoccupied but accessible room near resident rooms. MSDS documents for these products described inhalation, skin, eye, and chronic health hazards, and specified the need for adequate ventilation, protective equipment, and locked or restricted storage. Three residents with dementia, two with moderate cognitive impairment and one with intact cognition, were independently mobile by wheelchair or ambulation, and two lived on the same hall as the room where the supplies were stored. The maintenance director confirmed the materials had been left in the room after painting was completed and that residents could access the room, and the DON acknowledged the risk of residents entering the room and the potential for accidents from unsecured painting supplies.
Multiple residents with intact or moderately impaired cognition and significant medical conditions reported that a CNA was rough, mean, or aggressive during care, including toileting, transfers, and incontinence care, and several stated they did not want this CNA in their rooms. Family members and several CNAs, as well as an LPN unit manager, confirmed that residents complained about the CNA’s rough care and that these concerns were reported to nursing and administration. One resident directly told the administrator they felt physically and mentally abused, but there was no documented abuse investigation, no grievances, and no facility-reported incidents related to these allegations, despite a facility policy requiring immediate investigation and protection of residents when abuse is suspected or reported.
The facility failed to report multiple abuse allegations to the State Agency as required by its abuse policy. A cognitively intact resident with multiple medical conditions reported being yelled at for incontinence, forced to use a bedpan, and pinched or jabbed during care by a CNA, and stated these concerns were reported to the administrator without follow-up. Other residents with conditions such as rheumatoid arthritis, stroke, osteoarthritis, chronic kidney disease, osteomyelitis, and spastic hemiplegia, as well as a family member, reported that the same CNA was rough, aggressive, or mean with care and that they did not want this CNA in their rooms. Several CNAs and a unit manager LPN stated that residents’ concerns about rough care were reported to nursing and management, while leadership acknowledged residents refused care from the CNA but attributed this to cultural or racial issues and did not submit any abuse allegations involving this CNA to the State Agency.
The facility failed to thoroughly investigate multiple abuse allegations involving an agency CNA, despite a policy requiring immediate and comprehensive investigations of suspected abuse. A cognitively intact resident reported feeling physically and mentally abused, including being handled roughly and forced to use a bedpan, but no facility-reported incident or grievance investigation was found. Another resident’s POA contacted police with concerns about abusive practices related to therapy discontinuation and sedating medications; the facility’s investigation lacked interviews with the resident, the POA, or staff and contained only undated, general resident interviews that did not address the specific allegations. Several other residents with various medical conditions reported the same CNA was rough, aggressive, or mean with cares, did not want the CNA in their rooms, and stated concerns to staff; multiple CNAs and an LPN confirmed these reports were brought to nursing and administration, yet no corresponding investigations were documented, and leadership instead attributed refusals of care to cultural or racial issues while acknowledging investigations were not thoroughly completed.
A resident with multiple chronic conditions experienced increased pain and difficulty breathing, but staff failed to consistently assess, document, and communicate the change in condition. Orders for additional pain management and oxygen weaning were not promptly transcribed, and pain assessments and vital signs were inadequately documented. The resident's requests for relief were not effectively addressed, leading to a delayed transfer to the ER where the resident was diagnosed with sepsis, pleural effusion, and acute renal failure.
A resident suffered a head injury during a Hoyer lift transfer, but the facility delayed notifying the Hospice agency and the resident's physician. The resident experienced symptoms such as headaches and dizziness, yet the facility's communication and documentation were not timely, as confirmed by staff interviews and record reviews.
A resident was injured during a transfer using a Hoyer lift when staff failed to disconnect the catheter bag, causing the lift to fall. The resident showed signs of a head injury but was not offered hospital evaluation. The facility's investigation was incomplete, lacking documentation and staff education on safe transfers.
A resident with an indwelling Foley catheter was not placed on Enhanced Barrier Precautions (EBP) as required by the facility's policy. The resident's catheter drainage bag was observed on the floor and foot rest of a lift without a privacy cover, and CNAs provided high-contact care without wearing gowns. The Director of Nursing confirmed these actions were against the facility's infection control policies.
The facility failed to maintain sanitary conditions during food preparation, affecting all residents. A staff member did not perform proper hand hygiene and wore an inadequate beard net, leading to a resident finding hair in their food. Additionally, the staff did not check the water temperature of the sanitizing solution before testing its ppm, contrary to guidelines.
A LTC facility failed to follow diet orders and menus, affecting 13 residents on carbohydrate-controlled diets. During a lunch meal, full-sized desserts were served instead of diet-specific portions, and dinner rolls were omitted. A resident reported frequent menu changes and missing items. The Dietary Manager served desserts of the same size to all residents, and the Regional Dietary Manager confirmed the oversight.
A facility did not secure court-ordered protective placement for a resident with Alzheimer's and severely impaired cognition, who was under guardianship. The resident stayed over 60 days without the necessary paperwork due to court delays, as confirmed by the social worker. The responsibility for reviewing guardianship at admission was noted to be with another staff member.
A resident with moisture-associated skin damage was not consistently repositioned every 2-3 hours as required by their care plan. Interviews and documentation revealed that staff struggled to adhere to the repositioning schedule due to staffing challenges, leading to gaps in care and documentation.
A resident with a neck fracture was not consistently wearing a cervical collar as per physician's orders due to unclear documentation and communication among staff. The care plan lacked specific instructions, and staff were unable to locate the current order, leading to confusion about when the collar should be worn.
The facility failed to provide necessary nutritional care for two residents. One resident, at risk for weight loss, was not given a diet adjustment despite missing dentures, leading to inappropriate meal service. Another resident, with a gastrostomy tube, did not receive timely dietary review after a physician's request, delaying necessary interventions.
The facility failed to adhere to its infection control program, as observed when an RN did not perform proper hand hygiene during medication administration for two residents. The RN acknowledged the oversight, and the DON confirmed the lapse, which violated the facility's hand hygiene policy.
A resident was not offered the PCV20 vaccine as per CDC guidelines and the facility's policy. Despite having intact cognition and signing a consent form for other vaccines, the resident's medical record showed no offer of the PCV20 vaccine. The DON confirmed the oversight, acknowledging the resident should have been offered the vaccine.
Failure to Maintain N95 Respirator Fit Testing Program During COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program that ensured required N95 respirator fit testing for staff, as outlined in its own Respirator Protection and Fit Testing policy revised 1/1/2026. The policy required implementation and maintenance of a respiratory protection program, including medical evaluation, annual fit testing, training, and proper respirator use in accordance with OSHA, CDC, and CMS requirements. It specified that fit testing must occur prior to initial respirator use, annually thereafter, when a different respirator model or size is used, and when physical changes occur, and that staff who provide care to residents on transmission-based precautions, participate in aerosol-generating procedures, or work in outbreak/respiratory illness units must be fit tested. The Infection Preventionist or designee was designated as responsible for program implementation, monitoring, compliance, record maintenance, and annual evaluation of program effectiveness. Surveyor review of the facility’s fit testing binder showed the last documented fit testing occurred in February 2022, with additional forms from 2021, and no subsequent fit testing documented. A CNA hired in October 2025 reported not being fit tested for an N95 mask. The DON confirmed that N95 fit testing had not been done since 2022, that the DON had not been fit tested since starting at the facility, and acknowledged that staff should be fit tested annually. The DON also confirmed the facility experienced a COVID-19 outbreak that ended in February 2026 and stated that staff are expected to wear an N95 mask when caring for a resident with COVID-19 and that anyone entering the room of a resident on airborne precautions should wear an N95 mask. These interviews and record reviews demonstrated that the facility did not carry out its respiratory protection and fit testing requirements during and after a COVID-19 outbreak, affecting staff who were expected to use N95 respirators.
Unsecured Paint and Chemical Supplies Left Accessible in Resident Room
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible when paint, drywall joint compound, and spray enamel were left in an unoccupied but accessible resident room. Surveyor observations on 4/1/26 identified multiple paint products and a container of all-purpose joint compound stored in room [ROOM NUMBER], including two cans of interior latex wall paint (one previously opened), an opened and sealed can of urethane-modified acrylic paint primer, a can of acrylic coating paint, and a container of joint compound. Earlier, a Rust-Oleum hammered brown spray can was also observed, with labeling that specified it should be used outdoors in a well-ventilated area and listed flammable and potentially carcinogenic components. Material Safety Data Sheets (MSDS) for the products documented hazards such as inhalation risks, the need for adequate ventilation, potential for headache, nausea, dizziness, possible lung damage and cancer with long-term exposure to silica dust from sanding, and the need for respiratory protection and avoidance of skin and eye contact. The MSDS for the aerosol enamel indicated it was extremely flammable, could cause serious eye irritation, drowsiness or dizziness, possible cancer, and organ damage, and should be stored locked up in a well-ventilated place. These documents also specified that such materials should be kept out of the reach of children and used only with appropriate protective equipment and ventilation. Record review showed that three residents had dementia diagnoses and varying levels of cognitive impairment and mobility that made access to the unsecured room plausible. One resident had moderate cognitive impairment with a BIMS score of 8 and was independent with manual wheelchair use. Another resident had intact cognition with a BIMS score of 15 and was independent with ambulation. A third resident had moderate cognitive impairment with a BIMS score of 9, required supervision with ambulation, and was independent with wheelchair mobility. Two of these residents resided in the same hallway as room [ROOM NUMBER]. During interviews, the maintenance director confirmed that the room had been painted recently, that the paint supplies had remained in the room since the painting was completed, that resident rooms were closed but not locked during painting, and that residents could access the room and supplies. The DON acknowledged there was a risk of residents entering the room and that unsecured painting supplies in such areas posed a potential for accidents, despite initially stating there were no residents with dementia on that hall.
Failure to Investigate and Protect Residents From Alleged Rough and Abusive Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from alleged physical and mental abuse and to ensure a resident environment free from abuse, as required by its Abuse, Neglect, and Exploitation policy. The policy states that an immediate investigation is warranted when suspicion or reports of abuse occur and that the facility must respond immediately to protect alleged victims and prevent further contact with the alleged perpetrator. Despite this, the facility did not initiate any investigations or documented protective measures after repeated resident and staff reports that one CNA was rough with care and that residents did not want this CNA to provide care or enter their rooms. One cognitively intact resident with multiple medical conditions, including a left humerus fracture, diabetes with neuropathy, anxiety disorder, and cellulitis, reported being physically and mentally abused since admission. This resident stated the CNA was rough with cares, yelled at the resident for incontinence, refused to get the resident out of bed to use the bathroom, used a bedpan instead, and pinched or jabbed the resident in the hip during care. The resident reported these concerns directly to the nursing home administrator within days of admission and specifically stated feeling physically and mentally abused. The resident reported that the administrator did not take the allegations seriously, suggested the resident might be anxious or depressed, and did not follow up. The medical record contained a provider note documenting the resident’s concerns about care and desire to transfer, and an administrator note referencing a care conference and the resident appearing anxious and tearful, but no documentation of an abuse investigation or specific follow-up on the rough care allegations. Additional residents with varying levels of cognition and significant medical diagnoses also reported that the same CNA was rough with cares and that they did not want this CNA in their rooms. One resident and that resident’s family member reported the CNA was mean and rough with care and communication; another resident described the CNA working too fast and being rough with transfers, leading the resident to self-transfer to avoid being touched; another resident reported the CNA was aggressive during urinal assistance and pushed the urinal too hard, causing pain; and another resident stated the CNA was mean, rough, and caused fear. Multiple CNAs and a unit manager LPN confirmed that several residents complained the CNA was rough, that some residents would not allow the CNA in their rooms, and that these concerns were reported to nursing and administration. Despite these repeated reports, the administrator denied receiving reports that the CNA was rough, and there were no grievances, facility-reported incidents, or investigations completed related to these concerns, indicating the facility did not implement its abuse policy or ensure residents were protected from potential abuse.
Failure to Report Multiple Abuse Allegations to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report multiple allegations of abuse to the State Agency (SA) as required by its Abuse, Neglect, and Exploitation policy. The policy, revised 7/1/25, directs staff to report all alleged violations to the Administrator, SA, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other events. Despite this, allegations that one CNA was rough with care and verbally abusive were not reported to the SA as facility-reported incidents. One cognitively intact resident with a history of left humerus fracture, type 2 diabetes with neuropathy, anxiety disorder, and cellulitis reported being physically and mentally abused and yelled at for incontinence since admission. This resident stated that the CNA was rough with care, refused to get the resident out of bed to use the bathroom, forced use of a bedpan, and pinched or jabbed the resident’s hip during care, causing pain. The resident reported these concerns to the Nursing Home Administrator a few days after admission, stating feeling mentally and physically abused, but did not receive follow-up and did not believe the concerns were taken seriously. The Administrator’s progress note from a care conference documented the resident as anxious and tearful and declining therapy and medications, but did not document the specific concerns about the CNA. Additional residents with varying levels of cognition and medical conditions, including rheumatoid arthritis, history of stroke, depression, peripheral vascular disease, osteoarthritis, chronic kidney disease, osteoporosis, edema, osteomyelitis of vertebra, severe septic shock, cerebral infarction, and spastic hemiplegia, reported that the same CNA was rough, aggressive, or mean with care and that they did not want this CNA in their rooms. Some residents described rough transfers, aggressive assistance with a urinal that caused pain, and fear of the CNA. Family members and multiple CNAs reported that residents had complained about the CNA being rough and short-tempered, and that there was a list of residents who would not allow the CNA in their rooms. A unit manager LPN reported these concerns to the DON. The Nursing Home Administrator, DON, and unit manager acknowledged that several residents did not want the CNA to provide care but attributed this to cultural and racial differences and denied receiving reports that the CNA was rough with care. No allegations of abuse related to this CNA were reported to the SA, despite the facility’s policy requiring such reporting.
Failure to Investigate Multiple Abuse Allegations Against Agency CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, neglect, or rough care by one agency CNA toward several residents, despite its Abuse, Neglect, and Exploitation policy requiring immediate and comprehensive investigations. The policy directs the facility to initiate an immediate investigation when there is suspicion or reports of abuse, to identify and interview all involved persons, and to provide complete documentation. Surveyors found that for six residents, the facility either did not initiate an investigation at all or conducted incomplete investigations that lacked required interviews and documentation. One cognitively intact resident with a history of left humerus fracture, diabetes with neuropathy, anxiety disorder, and cellulitis reported feeling physically and mentally abused by a specific CNA. This resident stated the CNA was rough with cares, refused to get the resident out of bed to use the bathroom, forced use of a bedpan, and pinched or jabbed the resident’s hip during care. The resident reported these concerns directly to the NHA a few days after admission and specifically stated feeling physically and mentally abused. The NHA’s progress note from a care conference documented anxiety and tearfulness and offered telehealth therapy and medication, but did not document the specific abuse concerns or any abuse investigation. Review of facility-reported incidents (FRIs) and grievances showed no investigation related to this resident’s abuse allegation. Another resident with severely impaired cognition and an activated POA for healthcare was the subject of an abuse allegation reported by the POA to the local police, who then notified the facility. The POA alleged abusive practices, including discontinuation of therapy and administration of medication to sedate the resident. The facility submitted an FRI and initiated an investigation; however, the investigation lacked interviews with the resident, the POA, or other residents and staff. The NHA later stated that resident interviews had been completed but could not initially locate them, and confirmed that staff interviews were not done. When the interviews were produced, they were undated and contained only general questions that did not address the specific allegations of overmedication and discontinuation of therapy. Additional residents with varying levels of cognitive function and medical conditions, including rheumatoid arthritis, stroke history, osteoarthritis, chronic kidney disease, osteoporosis, osteomyelitis of vertebra, severe septic shock, cerebral infarction, and spastic hemiplegia, reported that the same CNA was rough, aggressive, or mean with cares. One resident and that resident’s family reported the CNA was rough and that the resident did not want the CNA in the room; another resident reported the CNA worked too fast and was rough with transfers, leading the resident to self-transfer to avoid being touched; another resident reported the CNA pushed a urinal too hard into the resident’s testicles; and another resident reported being fearful of the CNA and not wanting the CNA in the room. These concerns were reportedly communicated multiple times to unidentified CNAs, nurses, and administration. Staff CNAs and a unit manager LPN confirmed that several residents had reported the CNA was rough with cares and that there was a list of residents who did not allow the CNA in their rooms, and that these concerns were reported to nursing and management. Despite this, review of FRIs and grievances revealed no investigations for these residents’ allegations, and the NHA, DON, and unit manager attributed residents’ refusals of care from the CNA to cultural and racial differences, while also confirming that the facility did not thoroughly investigate the allegations of rough care and abuse.
Failure to Recognize and Respond to Change in Condition and Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice, specifically related to pain management, recognition of a change in condition, and timely action. The resident, who had diagnoses including heart failure, diabetes, anxiety, and lymphedema, experienced increased pain and difficulty breathing. Despite complaints and observable distress, staff did not consistently assess, document, or communicate the resident's changing condition to the appropriate medical providers in a timely manner. Orders from a nurse practitioner for additional pain management and oxygen weaning were not transcribed into the medical record until many hours after being received, and there was a lack of thorough documentation regarding the resident's assessments and interventions throughout the day. Multiple staff interviews and record reviews revealed that the resident exhibited significant pain and respiratory distress throughout the day, including crying out during care and expressing ongoing discomfort. Certified nursing assistants and nurses noted the resident's unusual pain and lethargy, but there were gaps in communication and follow-up. Pain assessments were not consistently performed or documented, and vital signs were not always recorded. The resident's requests for pain relief and reports of difficulty breathing were not adequately addressed, and there was a delay in notifying the nurse practitioner or physician about the resident's deteriorating condition. The resident ultimately requested to be sent to the emergency room, where they were diagnosed with sepsis, right pleural effusion, and acute renal failure, and subsequently admitted to the intensive care unit. The facility's failure to recognize and act upon the resident's change in condition, complete thorough assessments, and provide timely care resulted in serious harm. Staff did not follow the facility's policies on pain management and notification of changes, nor did they adhere to the nursing process as required by professional standards. The lack of timely transcription of orders, incomplete documentation, and insufficient communication among staff contributed to the deficient practice.
Removal Plan
- Complete head-to-toe assessment for all in-house residents.
- Implement eInteract Point Click Care (PCC) Evaluation for Change in Condition and use of internet tools and resources.
- Review in-house residents in Interdisciplinary Team (IDT) meetings for completion, documentation, and identification of a change in condition, assessments (including vital signs), and provider notification.
- Educate staff on the facility's policies regarding notification, pain management, identifying a change in condition, and transcription and documentation of orders.
- Implement audits and review progress notes for change of condition response.
Delayed Notification After Resident Injury
Penalty
Summary
The facility failed to ensure timely notifications following a fall with injury for a resident who was injured during a Hoyer lift transfer. The incident occurred when the lift tipped over, causing a metal bar to strike the resident in the forehead. Despite the severity of the incident, the facility did not notify the resident's Hospice agency until five days later and the resident's physician until seven days after the incident. This delay in communication is contrary to the facility's policy, which requires immediate notification of the resident's practitioner in the event of an incident or accident. The resident involved had a medical history that included hemiplegia, type 2 diabetes, and a history of transient ischemic attack and stroke. Following the incident, the resident exhibited symptoms such as headaches, vomiting, dizziness, and double vision, along with a noticeable indent and bruising on the forehead. Despite these symptoms, the facility's documentation and communication with relevant medical personnel were delayed, as confirmed by interviews with the Hospice Registered Nurse, Director of Nursing, and the resident's physician. The physician indicated an expectation for immediate notification and monitoring of the resident's condition, which was not met by the facility.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards, leading to an incident involving a resident (R1) during a transfer from bed to Broda chair using a Hoyer lift. On the day of the incident, staff did not disconnect R1's catheter bag from the bed, causing resistance that led to the Hoyer lift falling and striking R1 on the head. This incident resulted in R1 exhibiting signs of a head injury, including confusion, dizziness, and headaches, but R1 was not offered a medical evaluation at the hospital. The facility's investigation into the incident was incomplete, lacking physical assessments of R1 following the incident, statements from R1's roommate or other residents, and documentation of staff education on Hoyer lift transfers. Interviews with staff revealed that R1 had a dent on the forehead and experienced ongoing headaches and visual disturbances until R1's passing. Despite these symptoms, the facility did not document a thorough assessment or provide adequate follow-up care. Additionally, the facility did not promptly notify R1's Hospice agency or primary physician about the incident. The Director of Nursing confirmed that staff and resident interviews were not conducted, and only verbal education was provided to a limited number of staff involved in the incident. The lack of comprehensive investigation and documentation highlights a deficiency in the facility's accident and supervision policies.
Inadequate Infection Control for Resident with Foley Catheter
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with an indwelling Foley catheter. The resident, who had intact cognition and was their own decision maker, was readmitted to the facility with a Foley catheter after treatment for a urinary tract infection and urosepsis. Despite the facility's policy requiring Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, the resident's medical record did not contain an order for EBP, and no sign or storage bin with gowns and gloves was observed outside the resident's room. During an observation, two Certified Nursing Assistants (CNAs) provided high-contact care to the resident without wearing gowns, as required by the facility's EBP policy. Additionally, the resident's catheter drainage bag was placed on the floor and the foot rest of a lift without a privacy cover, contrary to the facility's catheter care policy. The Director of Nursing confirmed that the resident should have been on EBP and that the catheter bag should not have been placed on the floor or foot rest, and should have been covered at all times.
Sanitation and Hygiene Deficiencies in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared in a sanitary manner, potentially affecting all 34 residents. During an observation, a staff member did not perform proper hand hygiene while plating food. The staff member was seen adjusting their beard net, touching the stove, and continuing to plate food without washing their hands. Additionally, the beard net worn by the staff member did not adequately cover all facial hair, leaving the mustache and upper cheek area exposed. This lack of proper hygiene was linked to a resident's complaint of finding hair in their food, specifically in a pea salad. Furthermore, the facility did not adhere to proper procedures for preparing sanitizing solutions. The staff member responsible for sanitizing countertops did not check the water temperature of the sanitizing solution before testing its parts per million (ppm), as required by the facility's guidelines and the instructions on the test strip package. This oversight was confirmed during an interview with the staff member, who acknowledged the failure to check or document the water temperature, despite a sign in the kitchen indicating the correct procedure.
Failure to Follow Diet Orders and Menu in LTC Facility
Penalty
Summary
The facility failed to adhere to diet orders and menus, compromising the nutritional needs of 13 residents who were on carbohydrate-controlled diets. During a lunch meal, the facility served full-sized desserts instead of the prescribed diet desserts or reduced servings for residents with specific dietary requirements. The facility's Therapeutic Diet Orders document mandates that residents receive food in the appropriate form and nutritive content as prescribed by a physician or assessed by the Interdisciplinary Team. However, the facility did not comply with these orders, as observed during the meal service. Additionally, the facility did not serve all menu items as planned, such as dinner rolls, which were omitted from the lunch service. A resident expressed concerns about frequent menu changes without prior notice and not receiving all listed meal items. The Dietary Manager was observed serving desserts of the same size to all residents, regardless of their dietary restrictions, and was unaware of the missing dinner rolls. The Regional Dietary Manager confirmed the oversight and acknowledged the failure to provide the correct serving sizes for residents on restricted diets.
Failure to Obtain Court-Ordered Protective Placement for Resident
Penalty
Summary
The facility failed to ensure court-ordered protective placement for a resident with Alzheimer's disease, who had severely impaired cognition and was under guardianship. The resident was admitted to the facility and had been residing there for over 60 days without the necessary protective placement paperwork. The social worker confirmed that the resident had a guardian but acknowledged that protective placement was not pursued due to court backlogs. The social worker also indicated that the responsibility for reviewing guardianship at the time of admission fell to another admissions staff member.
Failure to Consistently Reposition Resident with Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and promote healing of pressure injuries for a resident, identified as R5, who had moisture-associated skin damage (MASD) on the left buttock and right sacral area. R5's care plan required repositioning every 2-3 hours, but this intervention was not consistently implemented. Interviews with R5 and R5's spouse revealed that repositioning was not occurring as prescribed, and the spouse expressed concerns about staff availability to perform these tasks. The medical record review confirmed that the repositioning task was not documented as completed on several occasions. The facility's staff, including CNAs and nursing staff, acknowledged challenges in adhering to the repositioning schedule due to staffing constraints. The Director of Nursing (DON) expected CNAs to document repositioning activities, but the surveyor found gaps in documentation, indicating that repositioning was not consistently performed. The deficiency was further highlighted by the Hospice RN's observations and discussions with the facility's charge nurse, which confirmed discrepancies in the care provided to R5.
Failure to Implement Physician's Order for Cervical Collar
Penalty
Summary
The facility failed to ensure that a cervical collar was implemented per the physician's order for a resident who was admitted following a neck fracture. The resident, who had intact cognition and was responsible for their healthcare decisions, was observed without the cervical collar on multiple occasions. The care plan did not specify when the collar should be worn or if it could be removed, and the Treatment Administration Record did not include orders for wearing the collar. A consultation report recommended wearing the collar at all times except during hygiene, but this was not reflected in the resident's current orders. Staff interviews revealed confusion regarding the order for the cervical collar. A CNA and an RN both stated that the collar should be worn at all times, but the RN could not find the order. The Director of Nursing also could not locate the current order and later indicated that a discontinuation order was mistakenly applied to the wrong resident. This lack of clear documentation and communication led to the resident not consistently wearing the cervical collar as required for their condition.
Failure to Provide Adequate Nutritional Care for Residents
Penalty
Summary
The facility failed to provide necessary treatment and services related to nutrition for two residents, R13 and R17. R13, who was at risk for weight loss and had a diagnosis of moderate protein calorie malnutrition, experienced a further decline in weight due to missing dentures, which were not reported to the dietary manager or nursing home administrator. Despite R13's inability to chew properly without dentures, the dietary staff was not informed to adjust R13's diet accordingly. This oversight led to R13 being served inappropriate meals, such as cut-up chicken, which R13 could not eat, resulting in continued weight loss and poor appetite. For R17, the facility did not contact the registered dietitian as requested by the physician to review R17's tube feeding after a new medication was started. R17, who had a gastrostomy tube and was diagnosed with throat cancer, required dietary adjustments due to low sodium and elevated potassium levels. However, the registered dietitian was not notified until eight days after the physician's request, delaying necessary dietary interventions. This lack of timely communication and action contributed to the deficiency in providing adequate nutritional care for R17.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during medication administration for two residents, R12 and R29. On September 4, 2024, a surveyor observed Registered Nurse (RN)-F preparing medication for R12 without performing hand hygiene before administering the medication. Similarly, RN-F did not perform hand hygiene before, during, or after preparing and administering medication to R29. These actions were in direct violation of the facility's Hand Hygiene policy, which mandates hand hygiene before preparing or handling medication. During interviews, RN-F acknowledged the failure to perform hand hygiene as required by the facility's policy. The Director of Nursing (DON)-B also confirmed that hand hygiene was not completed during the medication pass and stated that the expectation is for staff to perform hand hygiene before medication preparation, after preparation, and after distribution. This deficiency highlights a lapse in adherence to established infection control protocols, potentially increasing the risk of disease transmission among residents and staff.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination to a resident, identified as R10, in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and the facility's own policy. The policy, implemented in June 2023, mandates that residents be offered immunization against pneumococcal disease unless medically contraindicated or previously immunized. R10, who was admitted with diagnoses including diabetes and cerebral infarction, had a Minimum Data Set (MDS) assessment indicating intact cognition. Despite having signed a consent form for influenza and COVID-19 vaccines, which also documented previous pneumococcal vaccinations (PPSV23 in 2012 and PCV13 in 2015), there was no record of R10 being offered the PCV20 vaccine. During the survey conducted from September 3 to September 5, 2024, it was discovered that the line for the PCV15 or PCV20 vaccine date on R10's consent form was blank, and the medical record lacked any indication that the PCV20 vaccine was offered. The Director of Nursing (DON) confirmed in an interview that R10 was not offered the PCV20 vaccine, acknowledging that it should have been offered at the time R10 signed the consent form for the other vaccines. This oversight represents a failure to adhere to both CDC guidelines and the facility's vaccination policy.
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 44 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 Suring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook At Oconto Falls | 13.6 mi | ★★★★★ | 1 | 0 |
| Birch Hill Health Services | 19.6 mi | ★★★★★ | 11 | 0 |
| Evergreen Health Services | 19.8 mi | ★★★★★ | 4 | 1 |
| Shawano Health Services | 20.1 mi | ★★★★★ | 14 | 0 |
| Newcare | 23.8 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.