Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sulphur Springs Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors observed that the facility did not dispose of expired food items, failed to label and date all food in the refrigerator and freezer, and did not clean the deep fryer weekly as required. The fryer was found with dirty oil and food debris, and multiple food items lacked proper labeling or were expired. Staff did not consistently document cleaning tasks, and the Dietary Manager and Administrator were not fully aware of these lapses.
A resident with chronic conditions requiring substantial assistance for ADLs fell and fractured her tibia due to inadequate supervision during a bed bath. The facility failed to provide the necessary two-person assistance, and staff were unaware of where to find information on required assistance levels, contributing to the incident.
The facility failed to properly store and label food items in accordance with professional standards, as observed in one of the kitchens. A zip lock bag of flour tortillas was not sealed, and a boiled egg lacked an expiration date. Despite recent in-services on labeling, the Dietary Manager acknowledged the oversight. The facility's policy and FDA guidelines require proper labeling to prevent foodborne illnesses.
The facility failed to maintain effective infection control practices, as evidenced by a CNA not performing proper hand hygiene during incontinent care for a resident, and a CNA and LVN not following Enhanced Barrier Precautions for another resident with a wound. These lapses occurred despite clear facility policies and signage indicating the need for such precautions.
The facility failed to provide scheduled activities for residents on multiple days, affecting their physical, mental, and psychosocial well-being. Residents, including those with heart failure, multiple sclerosis, dementia, and bipolar disorder, reported a lack of activities since December 5th, leading to feelings of boredom. The absence of the Activity Director and lack of a substitute contributed to this deficiency, as confirmed by staff observations and interviews.
A facility failed to include a resident's weight-bearing status on a fractured arm in the baseline care plan, risking increased pain and worsening of the fracture. Staff interviews revealed a lack of awareness and communication about the resident's needs, and the facility's policy on person-centered care plans was not adequately followed.
A facility failed to update a resident's care plan to include a diagnosis of staph dermatitis and the corresponding antibiotic treatment. The oversight was discovered during a record review, which showed a prescription for Bactrim DS without care plan updates. Interviews with staff revealed a lack of communication and awareness about the resident's condition, with the DON and Administrator acknowledging the risk and impediment to care quality.
The facility failed to obtain ordered lab tests for two residents, leading to deficiencies in care. A resident with COPD, heart failure, and high blood pressure did not have a lipid panel drawn as ordered due to a nurse's error and lack of follow-up. Another resident with diabetes did not receive an Hgb A1C test due to a clerical error by the lab provider and the absence of a lab tracking system.
A resident with Parkinsonism, Major Depressive Disorder, and dementia was not assisted out of bed as per his preference, despite activating his call light and communicating his desire to a transport aide. The aide claimed to have informed a CNA, but the CNA denied receiving this information. Facility staff acknowledged the expectation to meet residents' needs promptly, highlighting a failure to uphold the resident's right to self-determination.
A facility failed to provide a resident's legal representative with timely access to medical records, violating the resident's rights. The resident, with multiple health conditions, had a legal representative who requested the records. The facility's process involved several steps, including corporate approval, which delayed the release. Staff interviews revealed confusion about the timeframe for releasing records, and the facility's policy was not followed.
A resident with multiple health issues experienced a significant change in condition, including confusion and drowsiness, but the facility failed to immediately notify the physician. Attempts to contact the physician and nurse practitioner were unsuccessful, and the resident's condition worsened the following day. The telehealth physician was eventually contacted, and the resident was sent to the ER. The facility's policy for immediate physician notification was not followed, impacting continuity of care.
A facility failed to protect a resident's medical record privacy when an LVN left a computer screen unlocked, displaying the resident's MAR. The resident, who was moderately cognitively impaired and had multiple diagnoses, had her information exposed to passersby. The DON and Administrator confirmed the expectation for MARs to be closed when unattended, aligning with the facility's policy on privacy and confidentiality.
The facility failed to administer oxygen therapy as prescribed for two residents, one with COPD and another with respiratory failure. Observations showed incorrect oxygen settings, with one resident receiving less and another more than prescribed. Staff interviews revealed a lack of awareness and oversight, leading to potential risks for the residents' respiratory health.
A medication cart in the facility was left unlocked and unattended by an RN, allowing unauthorized access to medications. The RN admitted responsibility, and both the DON and Administrator emphasized the importance of keeping carts locked to prevent unauthorized access. The facility's policy mandates that all drugs be stored in locked compartments accessible only to authorized personnel.
A facility failed to ensure a nursing assistant was certified according to state laws. The assistant, who had completed a CNA training course but was not certified, provided resident care, including bathing and transfers. The DON and Administrator were aware of the situation, with the DON mistakenly believing hospitality aides could work with certified CNAs. Despite being informed not to provide care, the assistant continued working in a non-care capacity due to the holiday season, leading to a deficiency in compliance.
A resident with a right arm fracture did not have a follow-up appointment scheduled with an orthopedic specialist, as required by hospital discharge orders. The resident was cognitively intact and required the appointment to assess the healing process. Facility staff interviews revealed that the admitting nurse was responsible for scheduling the appointment, but it was not done, leading to potential quality of care issues.
A facility failed to coordinate hospice care and maintain necessary documentation for a resident receiving hospice services. The resident, with dementia and other conditions, was on hospice due to a terminal prognosis. The hospice binder lacked essential documents like the care plan and physician certification. Interviews revealed poor communication between the facility and hospice provider, with staff acknowledging the need for updated documents to ensure proper care coordination.
Two residents in an LTC facility were not treated with dignity and respect by a CNA, who spoke to them in a rude tone. One resident, with severe cognitive impairment, was told she could manage bathroom activities herself, while another resident, with no cognitive impairment, reported the CNA's disrespectful tone. Both residents' care plans lacked provisions for ensuring respectful treatment.
Failure to Properly Store, Label, and Prepare Food and Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations in the kitchen, surveyors found that expired food items were not disposed of in the refrigerator and freezer. Multiple food items, including cut-up tomatoes, pineapples, white gravy, orange juice, teas, water, salad, French fries, and diced chicken, were either missing preparation or expiration dates, or were found to be expired. The facility's policies required all food items to be labeled with preparation and expiration dates, but this was not consistently followed. Additionally, the deep fryer in the kitchen was not cleaned weekly as required by facility policy. The fryer was observed to have black cooking oil with brownish-black food crumbs floating on top, and the fryer cover had food crumbs and grease buildup. The cleaning schedule did not indicate that the fryer had been cleaned for the week in question, and staff had not initialed the cleaning log to confirm completion of cleaning tasks. The Dietary Manager acknowledged that the fryer was used daily and should be cleaned weekly, but could not confirm that this was being done consistently. Interviews with the Dietary Manager and Administrator revealed that while in-services on labeling and dating food had been conducted recently, in-services on cleaning the deep fryer had not been completed recently. The Administrator was not aware of the expired food items or the lack of fryer cleaning, and stated that she expected the Dietary Manager to report such issues. A confidential complainant described the kitchen as filthy and stated that the fryer grease was changed only once a month, despite daily use.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident that resulted in injury. A resident, who was dependent on staff for activities of daily living (ADLs) due to conditions such as chronic obstructive pulmonary disease and rheumatoid arthritis, required substantial assistance for bed mobility and bathing. Despite this, the facility did not provide the necessary two-person assistance during a bed bath, resulting in the resident falling out of bed and fracturing her right distal tibia. The incident occurred when a CNA was providing a bed bath to the resident. The CNA turned her back to the resident, who then rolled out of bed. The resident had previously expressed discomfort and resistance to the bed bath, but the CNA proceeded without the required assistance. The CNA was reportedly distracted, possibly using a phone, and did not adequately supervise the resident, leading to the fall. Interviews with staff revealed a lack of awareness and understanding of where to find information on the required level of assistance for residents. Several CNAs and nurses were unable to locate or were unaware of the electronic system (Kardex) that documented the assistance levels needed for residents' ADLs. This lack of knowledge and communication contributed to the failure to provide the necessary care and supervision, resulting in the resident's injury.
Removal Plan
- Resident #14 was assessed by charge nurse, notification to physician and X-rays obtained after the fall. Resident #14 was monitored every shift.
- The Nurse Assistance was suspended pending investigation where she was subsequently terminated due to failure to report back to work.
- The DON/Designee completed an investigation into an incident involving Resident #14.
- The DON provided in-service education to all staff on Abuse and neglect. This education was completed.
- The DON/Designee in-service education with license nurses and Nurse aide on use of PCC Kardex that determines type and amount of care residents required for all ADL's. All clinical staff are provided with training and access upon hire.
- DON/Therapy assessed all residents to determine the type and number of staff assistance required for ADL's and validated that all Kardex have been updated.
- The DON/Designee provided in-service education with all license nurses and Nurse aide on use of PCC Kardex that determines type and amount of care residents required for all ADL's, and no licensed nurse or Nurse Aide will be allowed to work until this education has been provided.
- The DON/Designee reviewed all residents requiring 2 persons bed mobility and bathing to verify that care plan and C.N.A. Kardex reflected the type of care residents require.
- DON/Designee will review 24-hour nurse report daily in the morning meeting to validate that the care plan and Kardex has been reviewed/revised for any resident that has a change in bed mobility or bed bath.
- The DON/Designee will review all Incident/Accidents daily in the morning meeting to validate those residents with falls that involved bed mobility or falls during bed baths, had the appropriate number of staff needed during the transfer.
- The Regional Nurse Consultant will provide oversight into this process weekly.
- The facility will continue to provide training to all license nurse and Nurse Aides upon hire and as need on documentation procedures for the Kardex system on PCC to identify type and amount of care a resident requires.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed in one of the kitchens. During an inspection, it was noted that a zip lock bag containing flour tortillas was not sealed properly, and a boiled egg was found without an expiration date. These observations were made in Refrigerator 1 of 3, indicating a lapse in the facility's food storage practices. Interviews with the Dietary Manager revealed that she was aware of the requirement for all food items to be labeled and dated with receive, open, and expiration dates. Despite having conducted in-services on labeling and dating recently, the Dietary Manager acknowledged the oversight in sealing the flour tortillas and dating the boiled egg. The Administrator, who also oversees the dietary staff, confirmed the importance of these practices to prevent foodborne illnesses and ensure resident safety. The facility's policy on frozen and refrigerated food storage, last reviewed in July 2022, mandates proper labeling of cooked foods with preparation and expiration dates. The FDA Food Code 2022 also requires that refrigerated, ready-to-eat foods be clearly marked with dates to ensure they are consumed or discarded within safe time frames. The failure to comply with these standards could potentially place residents at risk for food contamination and foodborne illnesses.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) did not perform proper hand hygiene between glove changes while providing incontinent care to a resident with chronic obstructive pulmonary disease, bipolar disorder, thrombocytopenia, and high blood pressure. The CNA acknowledged the lapse, attributing it to forgetting her hand sanitizer in another room. The Director of Nursing (DON) and the Administrator confirmed that this failure could lead to cross-contamination or infection, and noted that there were no proficiency check-offs for CNAs regarding incontinent care. In the second incident, a resident with moisture-associated skin damage, stroke, and glaucoma required Enhanced Barrier Precautions (EBP) due to a non-pressure wound. Despite signage indicating the need for EBP, a CNA and a Licensed Vocational Nurse (LVN) failed to wear gowns while providing care. Both staff members admitted they were unaware of the resident's EBP status, despite the presence of signs and available personal protective equipment (PPE). The DON stated that staff had been educated on infection control and were expected to follow EBP protocols, which include wearing gowns and gloves during high-contact care activities. The facility's policy on infection prevention and control emphasizes the importance of standard and enhanced precautions, including the use of PPE and hand hygiene. However, the observed lapses in adherence to these protocols during resident care activities highlight deficiencies in the facility's infection control practices. The Administrator reiterated the expectation for staff to follow infection control practices as indicated by signage and facility policy.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, as required by their comprehensive assessments and care plans. This deficiency was observed for three residents who were reviewed for activities. The facility did not conduct scheduled activities on December 9th, 10th, and 11th, which affected all residents, including those specifically reviewed. This lack of activities could potentially place residents at risk for not having their interests or needs met, leading to a decline in their well-being. Resident #13, a female with heart failure and multiple sclerosis, was independent in making activity choices and enjoyed group activities such as bingo and arts and crafts. However, she reported that the last activity she participated in was on December 5th, and she was unable to continue her painting project due to the absence of the Activity Director (AD). Similarly, Resident #42, who had heart failure and dementia, and Resident #48, with respiratory failure, heart failure, and bipolar disorder, also reported a lack of activities since December 5th. Both residents expressed feelings of boredom and the importance of activities to them. Observations and interviews with staff confirmed the absence of scheduled activities on the specified dates. The AD was not present, and there was no activity assistant to cover in their absence. The Director of Nursing (DON) and the Administrator acknowledged the lack of activities and its potential impact on residents' quality of life. The facility's Recreation Services policy indicated that a program calendar should be developed based on residents' needs and interests, but this was not effectively implemented during the observed period.
Failure to Address Weight-Bearing Status in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions to provide effective and person-centered care, specifically regarding the resident's weight-bearing status on a fractured right arm. The resident, a female with a fracture of the right humerus, muscle weakness, unsteadiness on feet, and lack of coordination, was admitted to the facility. The baseline care plan did not address the weight-bearing status of the resident's fractured arm, which could lead to increased pain and worsening of the fracture. Interviews with facility staff, including an RN, OTA, Treatment Nurse, DON, and the Administrator, revealed a lack of awareness and communication regarding the resident's weight-bearing status. The RN and Treatment Nurse acknowledged the importance of knowing the weight-bearing status to prevent further injury. The OTA was unable to locate the weight-bearing status, and the DON admitted to not having a process for reviewing baseline care plans. The Administrator expected therapy to address weight-bearing restrictions, but this was not reflected in the baseline care plan. The facility's policy indicated that person-centered baseline care plans should be developed and implemented for new admissions, but this was not adequately done for the resident in question.
Failure to Update Resident Care Plan for Staph Dermatitis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not reflect the resident's history of staph dermatitis, nor did it include interventions for antibiotic use or staff monitoring for possible symptoms. This oversight was identified during a review of the resident's records, which showed a prescription for Bactrim DS to treat staph dermatitis, but no corresponding updates in the care plan. Interviews with facility staff, including the Medical Director, DON, and Administrator, revealed that the staff was not adequately informed about the resident's diagnosis and treatment plan. The Medical Director expected the facility to be aware of the diagnosis and antibiotic use, while the DON acknowledged that the care plan should have been updated to include this information. The Administrator confirmed that the IDT and MDS nurse were responsible for ensuring accurate care plans, and the failure to update the care plan placed the resident at risk and impeded the quality of care provided.
Failure to Obtain Ordered Lab Tests for Residents
Penalty
Summary
The facility failed to ensure that laboratory services were obtained as ordered for two residents, leading to deficiencies in their care. Resident #48, a cognitively intact female with chronic obstructive pulmonary disease, heart failure, and high blood pressure, did not have her lipid panel drawn as ordered on 08/14/24. The nurse did not fill out the lab requisition correctly, and the nurse managers did not follow up, resulting in the missed lab test. This oversight was only discovered after questioning by the state surveyor. Resident #12, a male with diabetes, did not have his ordered Hgb A1C test conducted. The physician had ordered the test to be done immediately and every three months thereafter. However, the facility's comprehensive care plan did not address his diabetes diagnosis, and the electronic medical record did not show that the test was obtained. A clerical error by the laboratory provider was identified as the reason for the missed test. The Director of Nursing acknowledged that a lab tracking system was not in place, which contributed to the oversight.
Failure to Respect Resident's Right to Self-Determination
Penalty
Summary
The facility failed to ensure that a resident's right to self-determination and choice was respected, as evidenced by the case of a male resident with Parkinsonism, Major Depressive Disorder, and dementia. The resident, who had a moderate cognitive impairment, expressed a preference to be assisted out of bed on a specific day. Despite activating his call light and communicating his desire to a transport aide, the resident remained in bed for several hours without assistance. The transport aide claimed to have informed a CNA of the resident's request, but the CNA denied receiving this information. Interviews with facility staff, including the Treatment nurse and the DON, revealed an expectation that residents' needs, such as getting out of bed, should be met promptly. The failure to assist the resident in a timely manner was acknowledged as potentially leading to increased depression and dissatisfaction. The facility's Resident Rights policy emphasized the importance of promoting resident self-determination, including the right to choose activities and schedules, which was not upheld in this instance.
Failure to Timely Provide Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records in a timely manner, as required by regulations. The resident, an elderly male with diagnoses including parkinsonism, dementia, hypertension, cirrhosis of the liver, and cerebrovascular disease, had a legal representative who requested access to his medical records. Despite the request being submitted, the facility did not provide the records within the required timeframe. The process for obtaining the records involved several steps, including filling out a form, obtaining approval from the regional director, and then printing the records. The facility's administrator and medical records staff acknowledged the request but cited the volume of records and the need for corporate approval as reasons for the delay. The medical records staff began processing the request only after receiving approval from the corporate office, which took several days. Interviews with facility staff, including the administrator and the Director of Nursing (DON), revealed a lack of clarity regarding the specific timeframe for releasing medical records. The facility's policy indicated that records should be available two days after receipt of payment for copies, but this was not adhered to in this case. The delay in providing the records was a violation of the resident's rights to access their medical information.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's physician and representative of a significant change in the resident's condition, which could potentially delay treatment and affect the resident's health. The resident, an elderly male with multiple diagnoses including parkinsonism, dementia, and hypertension, experienced a change in condition on November 22, 2024. The resident was noted to be confused, unable to hold his head up, and drowsy, prompting the nurse to hold his tramadol medication and attempt to contact the physician and nurse practitioner, but received no immediate response. The following day, the resident exhibited altered mental status, slurred speech, tachycardia, and hypotension. The nurse again attempted to contact the physician, leaving a message, and subsequently notified a telehealth physician who ordered lab tests and frequent vital sign monitoring. The resident's physician eventually returned the call and instructed the facility to send the resident to the emergency room for evaluation. However, the initial failure to notify the physician and document the resident's condition on the 24-hour report hindered continuity of care. Interviews with facility staff revealed that the nurse did not escalate the situation to the medical director or use the telehealth program when the physician was unreachable. The Director of Nursing and the Administrator emphasized the importance of recognizing and responding to changes in a resident's condition to ensure timely and appropriate care. The facility's policy required immediate physician notification for significant changes in a resident's status, but this protocol was not followed in this instance.
Failure to Protect Resident's Medical Record Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, a Licensed Vocational Nurse (LVN) left a computer screen unlocked on top of a medication cart, displaying the Medication Administration Record (MAR) of a resident. This occurred while the LVN entered the resident's room to check her blood sugar, leaving the MAR visible to staff and residents passing by. The LVN acknowledged the oversight, admitting it was a violation of the Health Insurance Portability and Accountability Act (HIPAA) to leave the MAR open where others could see the resident's personal information. The resident involved was a female with a history of diabetes, anxiety, depression, and high blood pressure, who was moderately cognitively impaired and required assistance with daily activities. Interviews with the Director of Nursing (DON) and the Administrator confirmed the expectation that MARs should be closed when unattended to protect resident information. The facility's policy on residents' rights emphasized the importance of maintaining privacy and confidentiality of personal and medical records.
Failure in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. Resident #14, a female with a history of COPD, muscle weakness, polyneuropathy, and hypertension, was prescribed oxygen therapy at 3 liters per minute via nasal cannula. However, observations on two separate occasions revealed that her oxygen concentrator was set at 2 liters per minute, contrary to the physician's orders. This discrepancy was not addressed by the staff, potentially compromising the resident's respiratory health. Similarly, Resident #31, who was diagnosed with acute respiratory failure, COPD, and heart failure, was prescribed oxygen at 4 liters per minute. Observations showed that her oxygen concentrator was set at 4.5 liters per minute, exceeding the prescribed amount. Despite the resident's understanding of her oxygen requirements, the staff failed to adjust the concentrator to the correct setting, which could have adverse effects on her condition. Interviews with the nursing staff, including the RN and DON, revealed a lack of awareness and oversight regarding the correct oxygen settings for these residents. The RN admitted to noticing the incorrect settings upon returning to work, while the DON and Administrator were unaware of the issue. The facility's policy on oxygen administration was not effectively implemented, as evidenced by the failure to verify and maintain the prescribed oxygen levels for the residents.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs were only accessible by authorized personnel, specifically with the 400-hall medication cart. During an observation, it was noted that the medication cart was left unlocked and unattended by RN BB while she was in a resident's room checking blood sugar levels. This oversight allowed staff and residents to pass by the unsecured cart, which was a violation of the facility's policy on medication storage. RN BB acknowledged her responsibility to lock the cart when it was not in use and recognized the situation as a HIPAA violation and a safety issue. The Director of Nursing (DON) and the Administrator both emphasized the expectation that medication carts should always be locked to prevent unauthorized access. The facility's policy on medication storage clearly states that all drugs and biologicals must be stored in locked compartments and only accessible to authorized personnel. The failure to secure the medication cart could lead to drug diversion or unauthorized access to medications, posing a risk to residents and others in the facility.
Failure to Ensure CNA Certification Compliance
Penalty
Summary
The facility failed to ensure that a nursing assistant, referred to as NA EE, was certified in accordance with state laws. NA EE was hired as a full-time nursing staff trainee and completed the CNA training course, but there was no evidence of her certification. Despite this, she provided care to residents, including bathing, transfers, incontinent care, and repositioning, from her hiring date until she was informed she could no longer work as a CNA until passing her clinical test. The Director of Nursing (DON) and the Administrator were aware of the situation, with the DON mistakenly believing that hospitality aides could work alongside certified CNAs. The DON and Administrator both acknowledged the risk to resident safety due to this oversight. Interviews revealed that the DON expected uncertified staff to seek assistance from certified staff for hands-on care, but this expectation was not met. The Administrator confirmed that the Human Resources Director was responsible for monitoring CNA certifications and that NA EE was informed not to provide care. However, due to the holiday season, the Administrator allowed NA EE to continue working in a non-care capacity. The job description for a Hospitality Aide clearly stated that the role involved non-hands-on care, yet NA EE was found to have been performing tasks beyond this scope, leading to a deficiency in compliance with state certification requirements.
Failure to Schedule Orthopedic Follow-Up for Resident
Penalty
Summary
The facility failed to arrange a follow-up appointment with an orthopedic specialist for a resident who had been admitted with a fracture of the right humerus. The resident, who was cognitively intact with a BIMS score of 14, had been discharged from the hospital with orders to follow up with an orthopedic physician within 1-2 weeks. However, the facility did not ensure that this appointment was scheduled, as confirmed by the orthopedic physician's office. Interviews with facility staff, including the Treatment Nurse and the Director of Nursing (DON), revealed that the responsibility for scheduling the follow-up appointment lay with the admitting nurse. The Treatment Nurse emphasized the importance of the follow-up to assess the healing process of the fracture. The DON acknowledged that missing such appointments could lead to quality of care issues, as the nursing staff would be unaware of the healing status of the fracture. The facility's Administrator also confirmed that nursing was responsible for ensuring that hospital discharge orders, including follow-up appointments, were followed.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified for one resident who was reviewed for hospice services. The facility did not maintain the resident's hospice binder, which should have contained critical information such as the most recent plan of care, hospice election form, and physician recertification. This lack of documentation and coordination could potentially place residents at risk of receiving inadequate end-of-life care. The resident in question was an elderly female with diagnoses including dementia, depression, anxiety, and high blood pressure. She was admitted to the facility and was on hospice services due to a terminal prognosis. The comprehensive care plan indicated that the facility was to work cooperatively with the hospice team to meet the resident's needs. However, the hospice binder was missing essential documents, including the physician certification of terminal illness and the care plan, and the last interdisciplinary group meeting was not updated in a timely manner. Interviews with facility staff and hospice representatives revealed a lack of communication and coordination between the facility and the hospice provider. The hospice office manager and the facility's Director of Nursing (DON) both acknowledged the importance of having updated hospice documents at the facility to ensure proper care coordination. The facility's administrator also stated that it was the facility's responsibility to ensure all hospice documents were up to date, highlighting a failure in the process overseen by the nurse managers.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as required by resident rights regulations. This deficiency was identified through observations, interviews, and record reviews. A Certified Nursing Assistant (CNA) was reported to have spoken to the residents in a rude tone, which could potentially lead to negative emotional impacts on the residents. The incidents involved two residents, one with severe cognitive impairment and another with no cognitive impairment, both requiring substantial assistance with activities of daily living (ADLs). The first resident, who had severe cognitive impairment and multiple health conditions including dementia and COPD, was reportedly spoken to rudely by CNA B. The resident was told she was a "big girl" and could manage going to the bathroom herself, which was witnessed by her roommate. The care plan for this resident did not address her right to be treated with dignity and respect by staff. The second resident, who had no cognitive impairment but suffered from conditions such as Stage III CKD and type 2 diabetes, also reported that CNA B was rude. The resident described the CNA's tone as disrespectful, particularly when instructing her to raise the head of the bed. The care plan for this resident similarly lacked provisions for ensuring she was treated with dignity and respect. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that staff are expected to communicate respectfully with residents, although CNA B denied any wrongdoing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sulphur Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carriage House Manor | 0.5 mi | — | 0 | 0 |
| Sunny Springs Nursing & Rehab | 0.5 mi | — | 15 | 0 |
| Rock Creek Health And Rehabilitation | 2.4 mi | — | 4 | 1 |
| Birchwood Nursing And Rehabilitation | 16 mi | — | 0 | 0 |
| Avir At Commerce | 17.8 mi | — | 18 | 0 |
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