Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accolade Healthcare Of Pontiac during CMS and state inspections, most recent first.
Failure to protect one resident from physical abuse by another resident. A resident with a history of agitation, yelling, and behavioral issues lunged at another resident in a hallway and scratched the resident’s forearm. An LPN later observed bleeding scratches, and a CNA stated the act was not accidental.
A resident who was dependent for all transfers and cognitively intact reported hearing a pop and crack in the left knee during a total body mechanical lift transfer that was performed by a CNA without the required assistance of a second staff member, contrary to facility policy. The resident’s feet touched the floor, the left knee hit the side of the bed, and the resident immediately complained of pain. Initial ED evaluation and x‑ray identified a left knee sprain with no fracture, but the resident continued to report pain and later underwent a CT scan ordered by an NP and orthopedic provider, which revealed a left knee fracture. Facility leadership, including the DON and ADON, confirmed that two staff are required for all total body mechanical lift transfers and that this requirement was not followed in this case.
A resident who was dependent for all transfers and cognitively intact reported pain above the left knee and was sent to the hospital, where imaging initially showed a sprain of the medial collateral ligament and the resident received multiple pain medications. At a later orthopedic visit, a CT scan revealed a left knee fracture. The facility’s policy required completion of an Accident/Incident Report on the shift of the event and notification of the State Agency within 24 hours for any major injury, but the DON and Administrator acknowledged that the fracture was never reported to the State Agency, resulting in a failure to follow required reporting procedures.
A resident was returned to the hospital after the facility received a criminal background report indicating the resident was a registered sexual offender, but the facility did not complete or document the required transfer/discharge process. The facility’s policy required appropriate discharge procedures and a written or telephone physician order for transfer or discharge, yet the resident was dropped off at the ED with a stated social concern and later sent back again for nursing home placement without any discharge notice or discharge orders in the medical record. The resident’s POA was informed that the transfer was due to the background check results, and the SSD confirmed the CHIRP findings, while the Administrator verified that no required discharge documentation existed in the chart.
A resident with a C2 neck fracture returned from the hospital with orders for C-Collar care, including daily skin checks and adjustments while lying flat in bed. Staff placed the resident in a recliner that did not lay flat, did not perform daily skin checks, and delayed adjusting the C-Collar, resulting in the resident experiencing pain and discomfort. Facility leadership confirmed that admission orders were not followed.
Two residents with indwelling catheters and wounds did not receive proper Enhanced Barrier Precautions (EBP) as required. EBP signage and PPE were inconsistently provided, and staff failed to use gowns and gloves during high-contact care activities. Staff interviews confirmed that EBP was not routinely practiced, and required cleaning procedures were not followed after handling potentially infectious materials.
The facility did not provide required written bed hold and transfer notices to residents and their representatives during multiple hospitalizations, as confirmed by medical record review and staff interviews. Nursing staff did not distribute the bed hold policy at the time of transfer, and there was no documentation that admissions or social services followed up with the necessary paperwork.
Two dependent residents did not receive scheduled showers as required by facility policy, with no documentation of refusals or alternative hygiene care. Staff interviews confirmed that showers were missed and not properly recorded, and one resident reported rarely receiving assistance with bathing.
A resident with COPD and Atrial Fibrillation, who was receiving oxygen therapy and an anticoagulant, did not have these treatments or their monitoring included in the comprehensive care plan. Despite physician orders and observations confirming the use of oxygen and Apixaban, the care plan was not updated to reflect these needs, as confirmed by the facility administrator.
A resident with a history of urinary tract infections and cord compression did not receive complete incontinence care, as a CNA failed to clean the groin and buttocks areas during perineal care, contrary to facility policy requiring thorough cleansing of all soiled skin areas.
Two residents with end stage renal disease and dependence on dialysis did not have current physician orders for their dialysis treatments, despite receiving dialysis regularly. Staff interviews and facility records confirmed the absence of required orders, even though the facility is responsible for coordinating and documenting dialysis care as part of each resident's plan of care.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, as required by facility policy and physician orders. On multiple occasions, a CNA and an RN emptied urine collection bags without wearing gowns, despite posted instructions and care plans specifying the need for gowns and gloves during high-contact care. The DON confirmed that staff are expected to use these precautions.
A resident experienced a severe weight loss of 10.8% in 12 days due to the facility's failure to implement an ordered nutritional supplement and notify the resident's representative. The resident, who had a recent surgery and dementia, was observed without the prescribed supplements during meals. The Registered Dietitian's recommendation was not transcribed into the medical records due to an error, and the facility's policy on providing supplements was not followed.
The facility's kitchen was found in unsanitary conditions, with a can opener covered in grease and rust, and range hood filters with grease and dust build-up. The food preparation table and sink area also had significant contamination risks. The Dietary Manager confirmed these issues, indicating a failure to maintain cleanliness as per the facility's policy.
The facility failed to trend monthly resident infections, potentially affecting all 76 residents. There was no Infection Control Surveillance and Monitoring Policy or documentation of infection patterns and interventions. The Infection Preventionist admitted to not completing the trending.
A facility failed to properly store medications, including Schedule II controlled substances, as a medication cart was found unlocked and unattended multiple times by an LPN. The cart contained controlled substances like Norco and Methylphenidate. The facility's policy requires all medications to be securely stored, with controlled substances in a separately locked drawer.
A facility failed to respect a resident's right to have a service dog present during meals and did not ensure another resident's dignity by leaving their abdomen exposed in the dining room. The facility lacked a policy for service dogs, and a resident with cognitive impairment was not properly covered by an LPN, despite acknowledging the dignity issue.
A resident with a fractured shoulder did not have a physician's order for an arm sling, despite recommendations from the occupational therapist. The resident was observed multiple times without the sling, which was necessary to prevent subluxation. The facility failed to follow the hospital's emergency room orders for continuous sling use.
A resident with chronic pain conditions, including Lumbar Degenerative Disc Disease and Fibromyalgia, reported severe pain levels and inadequate pain relief from prescribed medications. Despite repeated complaints, the facility staff failed to effectively communicate these issues to the Nurse Practitioner in a timely manner, resulting in continued unmanaged pain for the resident.
A facility failed to dispose of discontinued medications for a resident. During an observation, a medication bottle without a label was found in a medication cart, containing vials of Haldol with the resident's name. The DON confirmed the medication was a one-time order and should have been destroyed or returned. The resident's physician order indicated the medication was for intramuscular use as needed for agitation and aggression. The facility's policy requires discontinued medications to be destroyed promptly.
A resident with quadriplegia and multiple sclerosis was unable to reach their call light, which was secured to the wall behind the bed. The resident needed an incontinence brief change but could not call for assistance. Staff confirmed the call light was out of reach and attributed it to a CNA's oversight. Facility policy mandates call lights be within easy reach.
A facility failed to prevent cross-contamination during incontinence care for a resident. A CNA and an RN changed a resident's saturated brief without removing contaminated gloves or performing hand hygiene, despite the facility's hand washing policy requiring such actions after contact with body fluids and after removing gloves.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect one resident from physical abuse by another resident. The abused resident had diagnoses of delusional disorder, dementia, and paranoid schizophrenia, and the other resident had diagnoses of delusional disorder and major depression. The report documents that the resident who caused the incident had a history of behavioral issues, including becoming agitated with certain residents, refusing to leave other residents’ wheelchairs, yelling at staff, and cursing and screaming when upset. The incident occurred in the hallway when the resident who caused the incident became upset at the other resident, yelled, lunged at the resident, and scratched the resident on the left forearm. Staff separated the residents after the event. A nurse later observed visible scratches on the forearm that were bleeding, and the injured resident stated the other resident had grabbed and hurt them. A CNA who witnessed the event stated the resident lunged at the other resident and that it was not an accident.
Improper Mechanical Lift Transfer Causing Resident Knee Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hydraulic (Hoyer) lift policy requiring two staff members for total body mechanical lift transfers, resulting in an injury to a dependent resident. The facility’s policy, revised on 1/26, states that all nursing staff will be trained on proper use of hydraulic lifts and that staff must obtain assistance from a second staff member. The resident’s MDS documents that the resident is dependent for all transfers and cognitively intact. Nursing progress notes show that in the early morning hours of 11/29, the resident complained of pain above the left knee and was sent to the hospital, where an x‑ray initially showed a sprain of the medial collateral ligament of the left knee and no fracture. The ED nurse later reported that the resident stated hearing a pop when being transferred with a total body mechanical lift, and the resident received multiple pain medications, including Norco, Tylenol, fentanyl, and ketorolac, for pain management. From 11/29 through 12/3, the resident continued to complain of left knee pain and was treated with hydrocodone‑acetaminophen. On 12/3, the NP documented that the resident reported a CNA had hurt her during a prior transfer and insisted that something was wrong with her knee despite a negative x‑ray, requesting further diagnostic testing. The NP noted that an orthopedic referral would be made, and on 12/11 a CT scan of the left knee showed a fracture. On 2/9, the resident reported that a CNA had performed a total body mechanical lift transfer alone, without a second CNA, during which the CNA pushed on her, she heard a pop and a crack, her feet touched the floor, and her left knee hit the side of the bed; the CNA told her to look because she was standing, even though she had not stood in years. That same day, the CNA confirmed performing the mechanical lift transfer without assistance, and the DON and ADON both acknowledged that two staff members are required for all total body mechanical lift transfers, confirming that the transfer was not performed according to facility policy.
Failure to Timely Report Resident Fracture to State Agency
Penalty
Summary
The facility failed to report a resident’s fracture to the State Agency within the required timeframe, contrary to its Accidents and Incidents policy. The policy, revised on 1/26, requires that accidents and incidents, including injuries of unknown origin, be reported to the department supervisor with an Accident/Incident Report completed on the shift of occurrence, and that the DON or designee report any accident or incident involving a major injury to the State Agency within 24 hours. Nursing progress notes show that on 11/29 at 3:04 AM, a resident who is dependent for all transfers and cognitively intact complained of pain above the left knee and was sent to the hospital, where pain medications were administered and an X-ray resulted in a diagnosis of a left medial collateral ligament sprain before the resident returned at 6:00 AM. On 12/11, after an orthopedic visit and CT scan of the left knee, the resident was diagnosed with a left knee fracture. Despite this fracture diagnosis, the DON confirmed on 2/9 that no reportable incident was sent to the State Agency, and the Administrator confirmed that the fracture identified on 12/11 was not reported, resulting in noncompliance with required reporting procedures. The deficiency centers on the facility’s inaction in failing to recognize and report the fracture as a reportable major injury once it was identified by CT scan, despite clear policy requirements and the resident’s dependence for transfers. Surveyor interviews with the DON and Administrator confirmed that the incident was not reported to the State Agency as required.
Failure to Document Required Transfer/Discharge for a Resident Returned to Hospital
Penalty
Summary
The facility failed to follow its required transfer/discharge process and documentation requirements for one resident who was discharged without a proper discharge notice or required elements in the medical record. The facility’s Discharge/Transfer Policy, revised 1/25, requires guidelines for appropriate discharge and transfer procedures and specifies that a written or telephone order from the attending physician is needed for a resident’s transfer or discharge. The resident was admitted to the facility on an unspecified date, and later, hospital notes dated 2/23/26 show the resident was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. The facility reported that during a background check it was discovered the resident had a sexual offense and could not be admitted, and the facility attempted to find alternative placement but was unable to do so, then returned the resident to the ED for nursing home placement after receiving a CHIRP (Criminal History Information Response Process) result dated 2/23/26 indicating the resident was listed as a sexual offender. The resident’s Power of Attorney reported being told by the facility that the resident was being sent back to the hospital due to the background check results, and the Social Service Director confirmed the CHIRP findings and the decision to send the resident back to the hospital. The Administrator confirmed that no discharge documentation or discharge orders were found in the resident’s chart, indicating the required transfer/discharge process was not completed or documented.
Failure to Follow Admission Orders for C-Collar Care
Penalty
Summary
The facility failed to follow admission orders for a resident who returned from the hospital with a C2 neck fracture and an Aspen C-Collar. Upon readmission, the resident had orders for C-Collar care, including daily skin checks and the requirement to be laid flat in a bed for collar adjustments. However, staff placed the resident in a recliner instead of a bed, as the bed had been removed from the room. The recliner did not lay flat, and staff attempted to adjust the C-Collar while the resident was in the recliner, resulting in the resident experiencing pain and discomfort. No daily skin checks were performed as ordered, and the first adjustment of the C-Collar did not occur until several days after readmission. Staff interviews confirmed that the admission orders were not followed, and the facility's policy required review and implementation of all physician orders upon admission or readmission. The failure to follow these orders was acknowledged by facility leadership.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two of three residents reviewed for infection control. According to the facility's policy and CDC guidance, EBP requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or chronic wounds. Observations revealed that while an EBP sign was posted on one resident's door, it was missing from another resident's door who had an indwelling catheter. Additionally, required equipment such as gowns and gloves was not consistently available outside resident rooms, particularly for newly admitted residents over the weekend. Staff interviews and record reviews indicated that EBP was not consistently practiced. A CNA was observed emptying a resident's catheter without using the required PPE and did not clean the shared toilet after disposing of urine. The CNA admitted that staff do not routinely use EBP. Physician orders and medical records confirmed that both residents required EBP due to conditions such as urinary catheters, urinary tract infection with E-Coli, and chronic wounds. The lack of signage and equipment was attributed to the resident's recent admission and oversight by the admitting nurse.
Failure to Provide Bed Hold and Transfer Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written notifications to residents and their representatives regarding hospital transfers and bed hold policies for five residents who were hospitalized. Nursing notes documented multiple instances where residents were transferred to the emergency room or hospitalized, but there was no documentation in the medical records that a bed hold notice or written notice of transfer was provided to the residents or their representatives at the time of each transfer. The facility's own Bed Reserve Policy states that this information should be given at admission and each time a resident is transferred from the facility, but records and interviews confirmed this was not done. Interviews with facility staff, including the Social Service Director and an LPN, revealed that while the bed reserve policy is signed at admission, nursing staff do not provide the bed hold policy form when residents are transferred out. Instead, follow-up is reportedly handled by admissions or social services, but there was no evidence that this occurred for the residents in question. One resident confirmed not receiving any bed hold policy or paperwork during multiple hospitalizations. The lack of documentation and direct statements from staff and residents indicate that the facility did not meet regulatory requirements for notification during resident transfers.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two dependent residents who required assistance with activities of daily living (ADLs). According to the facility's Bath/Shower Policy, all residents are to receive a bath or shower at least weekly, with nursing assistants responsible for providing the care and charge nurses responsible for ensuring the schedule is followed. Record review showed that one resident with severe cognitive impairment and significant physical limitations missed multiple scheduled showers over a two-month period, with no documentation of refusals or alternative hygiene measures such as bed baths. Another resident, who was cognitively intact but dependent on staff for ADLs, also missed several scheduled showers, and similarly, there was no documentation of refusals or alternative care provided. Interviews with staff confirmed that showers should be provided and documented according to the schedule, and that refusals or alternative care should also be recorded. However, both the charge nurse and nursing supervisor acknowledged that the affected residents did not receive all scheduled showers and that there was no documentation of refusals or bed baths in the residents' charts. One resident reported rarely receiving scheduled showers and stated that staff often provided excuses for not assisting with bathing.
Failure to Include Oxygen and Anticoagulant Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for one resident, as required by its own Care Planning Policy. Despite the resident being observed with a nasal cannula in place on multiple occasions and having documented diagnoses of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, the resident's care plan did not include interventions or monitoring related to oxygen therapy or anticoagulant medication use. The resident's physician orders specified oxygen therapy to maintain O2 saturation above 90% and the use of Apixaban as a blood thinner, both of which were also reflected in the Minimum Data Set. However, a review of the current care plan revealed that it lacked any mention of the resident's oxygen use, monitoring requirements, or anticoagulant therapy and associated monitoring. The facility administrator confirmed that care plans are expected to be updated with any change in condition and acknowledged that the resident's care plan did not include these critical elements.
Incomplete Incontinence Care Provided to Resident
Penalty
Summary
Facility staff failed to provide complete incontinence care for a resident with a primary diagnosis of unspecified cord compression, who had a history of urinary tract infections and was receiving antibiotics for this condition. During observed incontinence care, a CNA cleansed, rinsed, and dried the resident's inner and outer labia but did not clean the groin or buttocks area, which was acknowledged as incomplete by the CNA when questioned. The resident reported feeling strange and had started a new antibiotic for another urinary tract infection on the same day. The facility's policy requires all soiled skin areas, especially between skin folds, to be washed and dried thoroughly during incontinence care.
Failure to Maintain Physician Orders for Dialysis Treatments
Penalty
Summary
The facility failed to maintain current physician orders for dialysis treatments for two residents who were dependent on renal dialysis and diagnosed with end stage renal disease. For one resident, the medical diagnosis sheet listed dependence on renal dialysis and end stage renal disease, but the physician's order sheet did not include any dialysis treatment orders. Staff interviews confirmed that the resident was receiving dialysis five times a week, yet the necessary orders were missing from the documentation. The regional quality assurance staff acknowledged that the dialysis order had likely been omitted from the physician's order sheet. Similarly, another resident with diagnoses of end stage renal disease, stage 4 chronic kidney disease, and dependence on renal dialysis did not have dialysis treatment orders documented from the time of readmission until a later date. This resident also confirmed receiving dialysis treatments in the facility, and a licensed practical nurse verified the absence of dialysis treatment orders. The facility's own records and agreements indicated that the LTC facility is responsible for the development and implementation of each dialysis resident's overall plan of care, including coordination of dialysis access orders, but failed to ensure that current orders were in place for these residents.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who were identified as requiring these precautions due to the presence of indwelling medical devices. According to the facility's EBP policy, staff are required to wear gowns and gloves during high-contact care activities for residents at high risk of Multidrug Resistant Organism (MDRO) acquisition, such as those with wounds or indwelling devices. Both residents had care plans and physician orders specifying the need for EBP during high-contact care, including activities involving their indwelling urinary catheters. Despite clear signage and documented orders, staff did not consistently follow EBP protocols. On separate occasions, a CNA and an RN emptied the urine collection bags of the two residents without wearing gowns, as required by policy. Both staff members acknowledged that gowns should have been worn during these activities. The Director of Nursing confirmed that all staff are expected to use gowns and gloves during high-contact care for residents on EBP.
Failure to Implement Nutritional Supplement Leads to Severe Weight Loss
Penalty
Summary
The facility failed to implement an ordered nutritional supplement and did not notify a resident's representative of significant weight loss, resulting in a severe weight loss of 10.8% over 12 days for a resident. The resident, who was admitted to the facility after surgery and diagnosed with dementia, was observed without the prescribed nutritional supplements during meals. The family member present was unaware of any nutritional supplements being ordered or the resident's weight loss. The Registered Dietitian recommended nutritional supplements, which were accepted by the Nurse Practitioner, but the order was not transcribed into the resident's medical records. The Registered Nurse confirmed the absence of the order in the Electronic Medical Record, and the Registered Dietitian acknowledged the error of sending the signed recommendation to an invalid email address. The facility's policy requires that residents unable to meet nutritional needs through regular meals be provided with supplements, but this was not followed in this case.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen food service areas and equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illness affecting all 76 residents. During an initial tour of the kitchen, a commercial table-mounted can opener was found with a build-up of a grease-like substance, metal fragments, and rust. The blade of the can opener was missing silver laminate, exposing bare metal and rust. The Dietary Manager confirmed these observations and acknowledged the need for cleaning before further use. Additionally, the range hood filters above the cooking surfaces were covered in a dark and light brown grease-like substance with dust-like strands hanging over the cooking areas. The Dietary Manager admitted that the cleaning service, which cleans the filters every three months, would need to increase the frequency of cleaning. Further inspection revealed that the 15-foot-long metal food preparation table had caulking at the wall junction embedded with brown and black sticky, food-like substances. The caulking had crusted food particles, which the Dietary Manager confirmed could contaminate food preparation areas. The three-well sink area had a windowsill with a significant build-up of dust and grease, and the window frame above had rust and chipped paint. The ceiling above the clean dish racks also had chipped paint and cobwebs. The facility's policy stated that stove hoods and filters should be cleaned monthly, but the current condition indicated a failure to adhere to this schedule, as confirmed by the Dietary Manager.
Failure to Trend Monthly Resident Infections
Penalty
Summary
The facility failed to trend the monthly resident infections, which has the potential to affect all 76 residents residing in the facility. During an interview and record review, it was found that the facility did not provide an Infection Control Surveillance and Monitoring Policy, nor were there any documents showing how the facility trends monthly infections to prevent further infection. Additionally, there was no documentation for identified infection patterns or trends and interventions. On August 21, 2024, the Infection Preventionist admitted to not completing the trending for the facility's infections.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications, including Schedule II controlled substances, were stored appropriately and within the visual control of the nurse. During an observation, the medication cart in the [NAME] Wing was found unlocked and not secured to the wall, with no staff present. An opened stock bottle of Melatonin was sitting on top of the medication cart. The LPN responsible for the cart left it unattended and unlocked multiple times while attending to residents in their rooms. The Director of Nursing confirmed that the medication cart should have been locked when not in sight of the staff. The unlocked cart contained several controlled substances, including Norco and Methylphenidate, which are classified as Schedule II narcotics. The facility's policy, dated 10/2023, requires all medications to be stored safely and properly at all times, with mobile medication carts locked when not under visual control. The policy also mandates that Schedule II controlled substances be stored in a separately keyed and locked drawer within the medication cart.
Failure to Respect Resident Rights and Dignity
Penalty
Summary
The facility failed to respect a resident's right to have a visitor with a service support animal present during meal service. During an observation, a family member of a resident was asked to remove a certified service dog from the dining room despite the resident's request to keep the dog present. The facility's administrator later acknowledged that there was no policy in place for service dogs and that the dietary consulting company had recommended not having the service dog in the dining room during meals. The facility provided documentation indicating that healthcare facilities must permit the use of service animals by persons with disabilities, but this was not adhered to in this instance. Additionally, the facility failed to ensure a resident's right to dignity by not covering a resident's exposed abdomen in the dining room. The resident, who had moderate cognitive impairment and required assistance with dressing due to a stroke, was observed with a bare abdomen while seated in a wheelchair. A Licensed Practical Nurse (LPN) moved the resident's wheelchair without addressing the exposed abdomen, despite acknowledging that it was a dignity issue. This incident occurred in the presence of other residents and visitors, further compromising the resident's dignity.
Failure to Obtain Order and Apply Arm Sling for Resident
Penalty
Summary
The facility failed to obtain a physician's order for an arm sling recommended by the occupational therapist for a resident with a fractured right shoulder. The resident, who had a history of a mechanical fall resulting in a comminuted transverse fracture of the right humeral neck, was observed multiple times without the prescribed arm sling. Despite the occupational therapist's recommendation for the sling to prevent subluxation, the facility did not secure the necessary order, and the resident was seen without the sling during various observations. The resident's family member and the resident themselves indicated the need for the sling, yet it was not consistently applied. The orthopedic physician assistant's nurse confirmed that the hospital's emergency room orders included wearing the sling continuously with specific movement restrictions. However, the facility did not follow through with these orders, as evidenced by the lack of a documented order and the resident's repeated appearances without the sling.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R29, who was reviewed for pain management. R29, who is cognitively intact, has a history of Lumbar Degenerative Disc Disease and Fibromyalgia, and is prescribed Acetaminophen and Ibuprofen for chronic pain. Despite these medications, R29 reported severe pain levels of 10/10 on multiple occasions and expressed that the current pain management regimen was ineffective. R29 communicated to staff that stronger medication was needed, but felt that her concerns were not adequately addressed, as she was told that stronger medications would not be provided due to concerns about addiction. The facility's Pain Management Policy emphasizes the importance of addressing resident pain through effective communication with physicians. However, the Nurse Practitioner, V11, was not informed of R29's significant pain complaints until several days after they were reported. V11 confirmed that R29 has multiple medical conditions contributing to her chronic pain and expressed reluctance to prescribe narcotic pain medication. The Director of Nurses acknowledged that R29's complaints of uncontrolled pain needed to be addressed, indicating a lapse in the facility's adherence to its pain management policy and communication protocols.
Failure to Dispose of Discontinued Medications
Penalty
Summary
The facility failed to properly dispose of discontinued medications for one resident, identified as R9, among the 22 residents reviewed for physician orders. During an observation on August 21, 2024, at 4:30 PM, it was found that the bottom drawer of the [NAME] Wing Medication Cart contained a medication bottle without a label. Inside this bottle were three new vials of Haldol, an antipsychotic medication, with a sticker bearing R9's name. The Director of Nursing, identified as V2, acknowledged that the Haldol was a one-time order and should have been destroyed or returned to the pharmacy. R9's Physician Order Sheet from July 2024 documented an order received on July 15, 2024, for Haloperidol Lactate Injection Solution 5mg/5ml, to be administered intramuscularly every 8 hours as needed for agitation and aggression, for 14 days. The facility's policy on destroying medication, dated September 2023, states that all discontinued medications or medications of discharged residents should be destroyed as soon as possible.
Call Light Out of Reach for Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident reviewed for call lights. The resident, who has diagnoses including quadriplegia, multiple sclerosis, anxiety disorder, and neuromuscular dysfunction of the bladder, was found sitting in a motorized wheelchair and unable to reach the call light, which was secured to the wall behind the bed. The resident expressed the need for an incontinence brief change but was unable to call for assistance due to the call light's placement. Staff confirmed that the call light was out of reach and explained that it had been misplaced by a CNA who made the bed earlier that morning. The facility's policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair.
Failure to Prevent Cross-Contamination During Incontinence Care
Penalty
Summary
The facility failed to prevent possible cross-contamination during incontinence care for a resident. During an observation, a CNA and an RN were changing a resident's incontinence brief, which was saturated with urine and stool. The CNA donned gloves and used disposable wipes for incontinence care but then grabbed a clean brief without removing the potentially contaminated gloves or performing hand hygiene. The resident urinated again onto the new brief, prompting the CNA to change gloves but still not perform hand hygiene. The CNA continued to provide care, cleaning another bowel movement, and again placed a clean brief under the resident without changing gloves or performing hand hygiene. The facility's hand washing policy requires hand hygiene after contact with body fluids and after removing gloves, which was not followed in this instance.
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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 Pontiac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evenglow Lodge | 0.7 mi | ★★★★★ | 0 | 0 |
| Goldwater Pontiac Nursing Home | 2.4 mi | ★★★★★ | 7 | 0 |
| Fairview Haven | 10.2 mi | ★★★★★ | 0 | 0 |
| Flanagan Rehabilitation And Health Care Center | 14.6 mi | ★★★★★ | 3 | 0 |
| Arc At Dwight | 18.9 mi | ★★★★★ | 7 | 0 |
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