Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Suring Health And Rehab Center during CMS and state inspections, most recent first.
Missing Controlled Substance Count Signatures: The facility did not ensure accurate controlled substance administration and accountability when narcotic count books for medication carts A and B contained numerous missing staff verification signatures across multiple entries. An LPN acknowledged that two nurses are required to count narcotics and sign the record books at each shift change, and the DON reviewed and acknowledged the missing signatures.
Infection control signage and precaution status were not maintained for multiple residents. A resident with a feeding tube, a resident with a heel wound and daily dressing changes, and a resident with a colostomy were identified as being on EBP, but no EBP signs were posted outside their rooms. Another resident with multiple wounds had a contact/isolation sign on the PPE cart instead of EBP signage, and a housekeeper was observed cleaning the room without a gown. Two other residents had contact precautions signs left in their rooms even though the DON stated the precautions had been discontinued.
Unsafe transfer practices and incomplete post-fall documentation were found for three residents. A resident with CVA-related deficits was observed being transferred without proper use of a gait belt. Another resident with weakness, obesity, and COPD fell from bed when the mattress shifted during cares and sustained a humerus fracture, but the care plan was not updated after the fall. A third resident with discitis, lymphedema, BMI 60+, and osteomyelitis fell during a transfer and fractured a toe, and the care plan also was not updated with the post-fall interventions.
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.
The facility failed to maintain an effective infection prevention and control program. Residents with Influenza A, COVID-19, Foley catheters, tube feeding, and wound care needs were observed without correct isolation or EBP signage, PPE carts, or proper PPE use by CNAs and nurses. Staff reused a disposable gown, removed an N95 before exiting a room, wore an N95 over a surgical mask, and performed high-contact care without gowns. The respiratory illness line list was incomplete, one resident with an influenza-exposed roommate was not monitored for symptoms, and uncovered resident clothing was observed in the hallway.
Antibiotic stewardship was not followed for four residents. One resident received UTI antibiotics despite not meeting Loeb criteria and the physician was not updated, another resident’s UTI treatment continued even though the culture later showed normal flora, a third resident received doxycycline for a respiratory issue without meeting Loeb criteria, and a fourth resident remained on chronic prophylactic cefdinir without documented routine reassessment or a duration plan.
The facility failed to notify the provider and, in one case, the POAHC about significant resident changes. One resident with HTN had repeated low pulse readings, held BP meds, and an elevated BP without provider notification; another resident had BP meds held despite systolic readings above the hold parameter without provider notification; and a resident with Influenza A was not reported to the activated POAHC after testing positive and starting Tamiflu.
Incomplete NOMNC forms were issued to 3 residents when Medicare Part A services were ending. The forms lacked required coverage type, effective date, and QIO contact information for appeal rights. The residents had intact cognition, and the SSD acknowledged the forms were incomplete while the NHA confirmed they were not thoroughly completed.
A resident with MS, hemiplegia, and severely impaired cognition had care plan and physician-ordered interventions for a left hand splint and rolled towels in the left hand and elbow crease to manage contractures. Surveyors repeatedly observed the resident without the rolled towel or splint, while the resident and family said staff had not been providing them and a CNA said the resident often preferred to go without. The DON verified the resident’s left arm and hand were contracted.
A resident identified as a supervised smoker had cigarettes, a lighter, and an e-cigarette kept in the room instead of being secured in the med room. Surveyors observed smoking materials in the resident’s jacket pocket, hat, and on the bedside table, while the resident stated staff sometimes let the resident keep them. The DON confirmed the resident required supervision to smoke and that the smoking assessment was inaccurate because it said the resident could keep smoking supplies in the room.
Improper Handling of Tube Feeding Pump: A resident with a G-tube and ordered Osmolite 1.2 feedings had an incomplete tube feeding when a CNA turned off the pump without checking with the nurse. The LPN stated the feeding was not finished and that CNAs should not shut off a beeping tube feeding pump, and the DON said only licensed staff should manage tube feedings.
Medication administration errors occurred when staff failed to obtain timely vital signs and did not follow ordered hold parameters for blood pressure medications. For one resident with hypertension and dementia, multiple antihypertensives were given late or held without timely assessment, and metoprolol and clonidine were not consistently held when pulse was below the ordered threshold. For another resident, an LPN held lisinopril and hydrochlorothiazide for BP readings that did not meet the ordered hold criteria, and the DON confirmed the medications should have been given.
Improperly Labeled Mantoux Tuberculin Vial: Surveyors found a Mantoux Tuberculin vial stored in the med room refrigerator with a handwritten date on the outer bag, but no open date on the vial itself. Staff confirmed the vial should be dated when opened and used within 30 days, yet it was used for TB testing for a resident and an RN employee, and the actual open date was unclear because staff sometimes labeled the bag instead of the vial.
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.
Missing Controlled Substance Count Signatures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility did not ensure accurate administration of controlled substances. The facility’s Controlled Substance Administration and Accountability policy, revised 4/15/24, required controlled substances to be accounted for through clearly legible written documentation, daily visual audits, and end-of-shift inventory verification by two licensed nurses in areas without automated dispensing systems. On 6/2/26, surveyors reviewed the narcotic signature books for medication carts A and B and found numerous missing staff verification signatures in multiple controlled substance record books across many dates. For cart A, missing signatures were identified in Books 25, 26, and 27; for cart B, missing signatures were identified in Books 24 and 25. An LPN stated that nurses are required to count narcotics with another nurse at the beginning and end of each shift and sign the controlled substance record book acknowledging the narcotic count, and acknowledged the missing signatures. The DON also reviewed the missing signatures and acknowledged that two nursing staff are required to count narcotics and sign the controlled substance record books at each change of shift.
Infection Control Signage and Precaution Status Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for six sampled residents. Survey observations and record review showed that enhanced barrier precautions (EBP) signage was missing or incorrect for residents with conditions identified in the facility’s EBP policy, including a feeding tube, wounds requiring dressing changes, and an ostomy. In addition, contact precautions signs remained in place for residents whose records indicated those precautions had been discontinued, and staff did not consistently recognize whether precautions were still required. R12 had a gastrostomy tube and was identified in the care plan and staff communication list as being on EBP, but no EBP sign was posted outside the room during repeated observations. R13 had a right heel wound with daily dressing changes and was also identified as being on EBP, yet no EBP sign was posted outside the room. R2 had a colostomy and was identified as being on EBP, but no EBP sign was posted outside the room. The DON verified that R12, R13, and R2 should have had EBP signage posted. R7 had multiple wounds with dressing orders, and the staff communication list indicated R7 was on EBP, but no EBP sign was posted outside the room. Instead, a contact/isolation sign was found on the PPE cart in the room. A housekeeper was observed cleaning R7’s room without a gown, and the DON stated the contact/isolation sign should not have been there and that R7’s care plan should have included EBP and wound care interventions. R14 and R15 each had contact precautions signs on PPE carts in their rooms even though the DON stated both residents were not on precautions and that the signs should have been removed in May 2026 after the roommate’s pink eye resolved.
Unsafe Transfers, Bed-Related Fall, and Missing Post-Fall Care Plan Updates
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for three residents, involving unsafe transfer practices and post-fall care plan management. For one resident with metabolic encephalopathy, hemiplegia, aphasia, and a history of CVA, the care plan directed transfer with one staff using a Sara lift. During an observed transfer from wheelchair to toilet, a CNA used the Sara lift but then lifted the resident by the back of the pants rather than using a gait belt. A gait belt was observed on the resident’s nightstand, and the DON confirmed staff should use a gait belt and not lift a resident by the back of the pants. A second resident with weakness, obesity, essential tremor, and COPD fell from bed and sustained a closed fracture of the right humerus. The resident’s care plan included assistance of two staff with bed mobility and therapy recommendations for a Hoyer lift with two staff. During morning cares, staff reported the resident’s mattress shifted off the bed frame or the bed malfunctioned while the resident was being turned. The resident rolled unexpectedly toward the staff member, was lowered to the floor, and later was found to have right shoulder pain, right elbow pain, and a skin tear. The resident was sent to the ED and returned with a fracture. The record review and interviews showed the resident’s care plan did not have an intervention added after the fall related to the event. A third resident with discitis, lymphedema, BMI 60 to 60.9, osteomyelitis, and impaired mobility fell during a transfer and fractured a toe. The resident’s care plan identified fall risk and included assistance of one staff for transfers with a four-wheeled walker. During the transfer into bed, the resident’s knees buckled and the resident was lowered to the floor. The IDT review identified the root cause as the resident’s movement without awareness of activity or foot placement, and therapy provided education after the fall. Surveyor review on the date of survey found the resident’s care plan had not been updated with the new post-fall interventions, despite documentation that such interventions had been identified after the incident.
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.
Infection Control Program Failures
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. Survey observations and record review showed multiple residents on influenza, COVID-19, or enhanced barrier precautions without the required signage, PPE availability, or staff adherence to the facility’s own precautions policies. The report identified that the practice had the potential to affect all 46 residents in the facility. A resident who tested positive for Influenza A was observed without a contact/droplet sign or PPE cart outside the room, and staff entered and provided care without proper PPE. The resident was also transported and taken to common areas without a mask. Another resident with Influenza A had a precautions sign posted, but staff did not consistently wear the PPE indicated on the sign, including an N95 respirator, gown, gloves, and eye protection. A nurse reused a disposable gown and removed an N95 respirator before exiting the room. For another resident with Influenza A, CNAs entered without appropriate PPE, and for a resident with COVID-19, a CNA wore an N95 respirator over a surgical mask. The report also documented failures with enhanced barrier precautions for residents with devices or wounds. Residents with a Foley catheter, tube feeding, or wound care needs did not always have EBP signs or PPE carts outside their rooms, and staff performed high-contact care without gowns. One resident with a Foley catheter had catheter care, dressing assistance, linen handling, and transfer care performed without the required gown use, and soiled linen was placed on the floor. Another resident receiving wound care had a nurse assist without a gown and with a surgical mask pulled down while speaking to the resident. The facility’s respiratory illness line list was also incomplete, with missing symptom details, retest dates, and well dates, and one resident with a roommate diagnosed with influenza was not monitored for respiratory symptoms. Uncovered resident clothing was also observed in the hallway.
Antibiotic Stewardship Program Not Followed
Penalty
Summary
The facility did not implement its antibiotic stewardship program to ensure accurate antibiotic use for four sampled residents. The facility’s policy, revised 5/29/24, states the Infection Preventionist is to track antibiotic starts, monitor adherence to evidence-based criteria during evaluation and management of treated infections, and review clinical justification for continued antibiotic use beyond the initial ordered duration, including review of laboratory reports and cultures. R13 had diagnoses including osteomyelitis of the vertebra, lymphedema, and MRSA infection, and had intact cognition. The record showed Loeb’s criteria for a UTI on a surveillance line list with a date of infection of 10/21/25, but the form indicated R13 did not meet Loeb criteria for a UTI without an indwelling catheter and no culture or signs/symptoms of UTI were identified. Despite this, R13 received Levaquin/linezolid for a UTI, and the facility did not update the physician that R13 did not meet criteria for infection and antibiotic use. DON-B stated the provider should have been contacted to determine whether antibiotic therapy should have been continued when R13 returned from the hospital. R9, who had diagnoses including spastic quadriplegic cerebral palsy, depression, anxiety, and obstructive and reflux uropathy, also had intact cognition. The Loeb’s criteria form for UTI indicated R9 met criteria on 11/3/25, but the required culture was not attached, and the hospital culture later showed normal flora. R9 was started on Levaquin for UTI treatment while the pathogen was pending, and DON-B confirmed R9 did not meet criteria for antibiotic treatment. R11, who had Alzheimer’s disease, chronic kidney disease, and acute and chronic respiratory failure, was documented as being treated prophylactically for chest with doxycycline and as meeting Loeb’s criteria for a respiratory infection, but review showed R11 did not meet criteria for antibiotic therapy; DON-B noted chest X-rays did not show a new infiltrate and the signs and symptoms identified were not on the Loeb criteria form. R2, who had bilateral primary osteoarthritis of the knee, lymphedema, and cellulitis to both lower limbs, had an order for cefdinir 300 mg twice daily with an indication of sepsis of knee/prophylaxis, but the record did not include a duration or periodic re-evaluation plan, and the prophylactic antibiotic was not routinely assessed for continued use.
Failure to Notify Physician and Representative of Significant Changes
Penalty
Summary
The facility did not ensure proper physician notification for a resident with essential hypertension, dementia, SIADH, hypo-osmolality and hyponatremia, hyperlipemia, and an abdominal aortic aneurysm. The resident’s January 2026 MAR showed multiple blood pressure medications, including lisinopril, clonidine, metoprolol, amlodipine, and hydrochlorothiazide. The record documented several instances when the resident’s pulse was below 50 and some blood pressure medications were held, as well as instances when clonidine and metoprolol were administered despite a pulse below 50. The resident also had an elevated blood pressure of 193/105, and the record did not show that the provider was notified of that reading. The record review showed that on multiple occasions the resident’s pulse was below the medication parameters, including readings of 48, 44, 46, 45, 48, 47, and 46. On some of those dates, morning doses of metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were held, while on other dates evening doses of metoprolol and clonidine were given despite the low pulse. The medical record did not indicate that the physician was notified when the pulse was below 50, when medications were held, or when medications were administered despite the low pulse. An LPN confirmed not notifying the physician when the medications were held, and the DON stated the provider should have been notified regarding held medications and the elevated blood pressure. The facility also did not ensure physician notification for another resident with hypertension, type 2 diabetes, and a right lower leg fracture. An LPN held hydrochlorothiazide and lisinopril because the resident’s blood pressure was 110/57 and later 106/53, even though the systolic pressure was greater than 100 and the orders did not include holding for those readings. The record did not show that the provider was notified when the medications were held on either day. The LPN confirmed the medications were not administered and that the provider was not notified, and the DON stated the medications should have been given because the systolic blood pressure was above the ordered hold parameter. The facility also did not notify the activated POAHC for a resident with Influenza A, cerebral infarction, and dysphagia. The resident became ill with fever, runny nose, and fatigue, was placed on isolation precautions, and later tested positive for Influenza A on a respiratory panel. Tamiflu was ordered twice daily for 5 days. During a phone interview, the POAHC stated they had not been informed of the positive Influenza A result, and a family member reported they were not updated about the resident’s illness or isolation status. The DON confirmed the POAHC was not notified when the resident tested positive for Influenza A.
Incomplete NOMNC Forms for Medicare Part A Coverage End
Penalty
Summary
The facility did not ensure that written Notice of Medicare Non-Coverage (NOMNC) forms were thoroughly completed when issued to 3 residents whose Medicare Part A services were ending. Review of the CMS-10123 NOMNC instructions showed the form must be completed with coverage type, effective date, and the Quality Improvement Organization (QIO) name and number. For R57, R58, and R59, the facility issued NOMNC forms before Medicare Part A coverage ended, but the forms were incomplete and did not include the required coverage type, effective date, or QIO contact information for appeal rights. R57 had cellulitis, a BIMS score of 15 out of 15, and an activated POAHC; R58 had overactive bladder and asthma, a BIMS score of 15 out of 15, and was responsible for healthcare decisions; and R59 had cellulitis of the right upper limb, a BIMS score of 15 out of 15, and was responsible for healthcare decisions. The Social Service Designee stated the NOMNC form is used to inform residents when Medicare services are ending and what their appeal rights are, but was not aware of the QIO name and contact information and acknowledged the forms for these 3 residents were incomplete. The NHA stated Medicare Part A NOMNC forms are completed by therapy and acknowledged the forms were not thoroughly completed.
Failure to Provide Ordered Splinting and Positioning Support
Penalty
Summary
The facility did not ensure adaptive equipment was provided to maintain a resident’s current level of function and prevent contracture. The resident had diagnoses including multiple sclerosis, hemiplegia, chronic pain, osteoarthritis, schizoaffective disorder, bipolar disorder, and anxiety, and had severely impaired cognition with a BIMS score of 4 out of 15. The resident’s care plan included interventions for a left hand splint to be worn at all times or as tolerated, with monitoring for skin breakdown, and the Kardex and physician orders directed staff to place a rolled washcloth in the left hand and a rolled towel in the elbow crease every shift for left hand and elbow contractures. Surveyors reviewed the resident’s record and found the treatment record documented the rolled towel intervention as completed most shifts, but there were blanks or other documentation on some shifts. During multiple observations, the resident was seen in a wheelchair in the room, community room, and during activities without a rolled towel in the left hand or elbow crease. Surveyors also did not observe a brace or splint on the resident’s left upper extremity during these observations, despite the care plan directing that the left hand splint be worn at all times or as tolerated. The resident and family member stated staff did not provide the rolled towel for the left hand and elbow crease and reported they had not seen the splint in months. A CNA stated staff attempted to place the rolled towel but the resident preferred to go without, and the CNA did not think it helped. The DON verified the resident’s left arm and hand were contracted, stated staff used the rolled towel to prevent yeast growth and skin breakdown, and confirmed the resident did not currently have a restorative therapy program.
Smoking Materials Not Secured for Supervised Smoker
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible for one resident, R20, because staff did not keep R20’s cigarettes, lighter, and e-cigarette in a secure location even though the resident was identified as a supervised smoker. R20 had diagnoses including COPD, mild cognitive impairment of unknown etiology, osteomyelitis of the vertebra, anxiety, multiple left rib fractures, and chronic hepatitis. The resident’s MDS assessment showed a BIMS score of 13 out of 15, and the facesheet stated that all smoking materials must be kept locked up in the medication room. The smoking evaluation dated 1/3/26 indicated R20 did not need the facility to store cigarettes and a lighter, but did require supervision to smoke. The care plan, however, identified that R20 requires supervision while smoking and included interventions to keep cigarettes with staff. The medical record also contained an order stating R20 was a supervised smoker and that no smoking materials were to be on the person if supervised. The evaluation did not assess e-cigarette use, even though the facility’s smoking policy stated residents who wish to use e-cigarettes should be assessed for their ability to safely manage the device. Survey observations and interviews showed R20 had smoking materials in the room despite being a supervised smoker. Surveyors observed an e-cigarette on the bedside table, cigarettes and a lighter in a jacket pocket and later in a winter hat on the resident’s table. R20 stated staff sometimes threatened to take the cigarettes and lighter away but did not because the resident followed the rules. CNA-D stated supervised smokers should have smoking supplies stored in the medication room and that R20 should not have had smoking supplies in the room. The DON confirmed R20 required supervision to smoke, that all smoking supplies should be stored in the medication room, and that the smoking assessment was in error because it indicated R20 could keep smoking supplies in the room.
Improper Handling of Tube Feeding Pump
Penalty
Summary
The facility did not provide the necessary tube feeding services for one sampled resident, R7, who had a diagnosis of gastrostomy status and required tube feeding after a hospital stay. R7’s care plan, revised 1/8/26, identified an alteration in nutrition and directed Osmolite 1.2, 474 ml via G-tube three times daily, with observation of tolerance to tube feeding. The facility’s policy on care and treatment of tube feedings stated that the resident’s plan of care would address feeding tube use, including strategies to prevent complications. On 1/27/26 at 9:38 AM, the surveyor observed CNA-D leave R7’s room and tell LPN-F that R7’s tube feeding was done and that CNA-D had turned the pump off. LPN-F told CNA-D that the pump should not have been turned off and stated the feeding was not complete because the pump only allowed 400 ml to infuse at once, while R7’s ordered feeding was 474 ml total and 74 ml still needed to be added. LPN-F also stated CNAs should not turn off a tube feeding pump that is beeping because the tube could be clogged or something else could be wrong. CNA-D later verified that CNA staff should not turn off a tube feeding pump and should instead notify the nurse if the pump is beeping. The DON stated that only licensed staff should manage tube feedings for residents.
Medication Administration and Blood Pressure Parameter Errors
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration for two residents. One resident had diagnoses including essential hypertension, syndrome of inappropriate secretion of antidiuretic hormone, hypo-osmolality and hyponatremia, hyperlipidemia, abdominal aortic aneurysm-not ruptured, and dementia, with a BIMS score of 8 indicating moderately impaired cognition. The resident’s care plan addressed altered cardiovascular status and potential altered fluid maintenance, and a physician note stated hydrochlorothiazide 25 mg daily had been added because of high blood pressure and resistant hypertension. For this resident, survey review showed multiple instances in which vital signs were not completed timely before medications were administered or held. On several dates, metoprolol, amlodipine, lisinopril, hydrochlorothiazide, and clonidine were administered or held without timely vital sign documentation. The resident’s physician and standing orders required metoprolol and clonidine to be held when pulse was less than 50, but those orders were not followed on multiple occasions when the resident’s pulse was documented below that threshold. The record also showed delayed administration of several blood pressure medications outside the facility’s medication pass times, and the DON stated nurses should obtain vital signs just prior to medication administration and contact the provider when parameters were outside the order. The second resident had diagnoses including hypertension, type 2 diabetes, and a right lower leg fracture, and had intact cognition with a BIMS score of 15. The care plan directed staff to give antihypertensives as ordered. On one morning, an LPN observed the resident’s blood pressure as 110/57 and held hydrochlorothiazide and lisinopril, even though the resident’s lisinopril order only directed holding for systolic BP less than 100. The MAR reflected that hydrochlorothiazide and lisinopril were held for that blood pressure, and the LPN confirmed the medications were not given because the BP was considered outside parameters. The DON verified the resident did not have an order to hold BP medication for 110/57 or 106/53 and stated the medications should have been administered because the systolic BP was greater than 100.
Improperly Labeled Mantoux Tuberculin Vial
Penalty
Summary
The facility did not ensure a stock Mantoux Tuberculin vial was labeled and used in accordance with manufacturer recommendations and accepted professional principles. Surveyors observed the medication room refrigerator containing a Mantoux Tuberculin vial stored inside a brown prescription bottle and clear plastic bag, with a handwritten date on the bag label that appeared to be either 4/25 or 4/28. The vial itself did not have a handwritten open date, although staff confirmed that the open date should be on the vial and that the solution should be used within 30 days after opening. The vial had a manufacturer expiration date of 4/2028, but staff identified the handwritten date as the date the vial was opened and stated the vial was past the date it should be used, after which it was discarded. Record review showed the same vial was used for TB testing for a newly admitted resident and for a registered nurse employee who needed a TB test. The resident’s MAR documented a two-step Mantoux test, but the lot number was only partially recorded. RN-I stated the open date on the bag label read 4/25 and that the vial was expired, while RN-R stated the date may have been 4/28 and acknowledged staff sometimes labeled the bag rather than the vial, making the actual open date unknown. The DON stated Mantoux Tuberculin vials should have a handwritten date on the vial label when opened, and the NHA confirmed the discarded vial was the only vial in the medication room.
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
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Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near 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 | ★★★★★ | 12 | 0 |
| Birch Hill Health Services | 19.6 mi | ★★★★★ | 13 | 0 |
| Evergreen Health Services | 19.8 mi | ★★★★★ | 0 | 0 |
| Shawano Health Services | 20.1 mi | ★★★★★ | 14 | 0 |
| Newcare | 23.8 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.