Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Haven Of Tuscola during CMS and state inspections, most recent first.
A facility failed to maintain comfortable room temperatures for multiple residents and failed to keep one resident’s room clean and sanitary. Several residents reported hot, humid rooms without AC, including residents with COPD, CHF, asthma, and oxygen use, while staff said room temperatures were not being checked or documented and there was no policy for prioritizing AC units. In another room, staff observed a strong urine odor, urine-soaked linens, soiled clothing, and overflowing briefs, and the resident said the room was not being cleaned and the mattress stayed wet.
A dependent, cognitively intact resident with CHF, CKD III, Afib, lymphedema, chronic venous insufficiency, unsteady gait, and muscle wasting was transferred via mechanical lift to a manual wheelchair and taken to be weighed by a CNA who did not apply the wheelchair footrests. As the wheelchair was moved on and off the scale, the resident slipped down and her left foot became caught in the front wheel, causing pain and entrapment that the CNA freed but did not report to nursing or supervisors. Over the next days, the resident developed increasing left knee swelling, bruising, and pain, and the NP, unaware of any trauma, initially attributed symptoms to the resident’s chronic vascular and cellulitis history. The facility only learned of the wheelchair incident after hospital evaluation revealed a mildly displaced oblique fracture of the proximal left tibia, and the NP later stated the wheelchair trauma likely caused the fracture.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as shown by multiple days without adequate RN coverage over a three-month period. The DON confirmed the facility was not meeting this requirement, affecting all 47 residents.
Due to a supply shortage, several residents who were incontinent of bowel and/or bladder were provided with incontinence briefs that were too small, leading to discomfort and skin irritation. CNAs reported using smaller briefs that were less absorbent and harder to manage, and residents expressed dissatisfaction and concern about skin breakdown. The issue persisted for weeks and was reported to the DON and ADON, but staff were instructed to use whatever sizes were available, contrary to facility guidelines requiring proper fit.
A resident with a history of stroke and on anticoagulants experienced an unwitnessed fall, hitting their head and sustaining a subdural hematoma. The facility failed to supervise the resident effectively and did not promptly document or investigate the incident, delaying necessary medical evaluation.
A resident experienced a fall, but the facility failed to promptly notify the resident's representative and provider. The fall occurred late at night, and the provider was informed the next day. There was no documentation of notification to the Administrator, DON, or the resident's representative. The responsible nurse did not make the required notifications, and the resident's representative learned of the fall only after speaking with the resident. This was against the facility's policy for prompt notification of changes in resident condition.
The facility failed to deliver mail on Saturdays, affecting several residents who reported not receiving their mail until Monday. Staff confirmed that only cards were distributed on Saturdays, while other mail was held for review. This practice potentially affected all residents, as it did not provide reasonable access to communication methods.
The facility did not verify the eligibility of two CNAs through the healthcare workers registry before they began employment. This oversight could potentially affect all 38 residents, as all CNAs have the potential to care for any resident.
The facility failed to label and store food appropriately, as observed during a kitchen tour. Various food items in the cooler, freezer, and outdoor cooler were not labeled with dates, including chopped lettuce, shredded cheese, and cottage cheese. The dietary manager confirmed the need for labeling and acknowledged the issue of limited space leading to unlabeled items. This deficiency potentially affects all 38 residents in the facility.
The facility failed to implement COVID-19 precautions, as staff worked with symptoms and without masks, and a COVID-19 positive resident was not consistently managed under transmission-based precautions. A CNA worked while symptomatic and unmasked, and an RN delayed testing despite symptoms. A resident was seen without a mask outside their room, and staff did not consistently wear PPE.
The facility failed to provide adequate respiratory care for several residents, including the lack of implementation of physician orders, insufficient supplies, and improper maintenance of equipment. Residents experienced issues such as empty oxygen humidification bottles, dirty nebulizer and CPAP equipment, and undocumented care plans. Staff acknowledged the deficiencies, citing supply shortages and lapses in routine care.
The facility did not provide RN services for eight consecutive hours on several days and lacked a full-time DON, affecting all 38 residents. The nursing schedule showed no RNs on duty for eight hours on specific days, and the Assistant DON confirmed the absence of a DON since early January. The facility's assessment indicated the need for a DON and RNs for residents with complex conditions.
A facility failed to administer medications as ordered for several residents, leading to a deficiency in pharmaceutical services. Residents did not receive their scheduled early morning medications, including Levothyroxine, Pregabalin, and Hydrocodone, due to an agency nurse's oversight. The facility's staff confirmed the omissions, and the responsible nurse was removed from duty.
The facility failed to offer pneumococcal vaccinations to four residents over 65, as required by CDC guidelines. The residents had no documentation of receiving or being offered the vaccine, and the facility's outdated policy did not align with current recommendations. The Assistant Director of Nursing confirmed the vaccine was not included in a recent clinic, and the Regional Clinical Nurse acknowledged the issue.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. A resident was found with medications at their bedside without a physician's order or an assessment in their medical record. An LPN admitted to leaving medications for the resident to self-administer, and the ADON acknowledged the lack of necessary orders and assessments.
A resident at risk for skin abnormalities developed a wound due to the facility's failure to provide the correct size briefs. The resident was forced to wear smaller briefs, causing skin irritation and an open wound, which later became infected. Staff confirmed the frequent shortage of the correct size briefs.
A resident with hemiplegia was improperly transferred using a mechanical lift, resulting in a fall. The facility failed to secure the sling properly, leading to the incident. Additionally, the facility did not conduct a thorough investigation or document the fall details and physician notification in the resident's medical record, violating their fall prevention and notification policies.
A CNA failed to provide proper incontinence care to a resident, neglecting to thoroughly cleanse the pubic area, retract the foreskin, rinse after washing, and change gloves between contaminated and clean areas, as per facility policy.
A facility failed to monitor and document the enteral feeding process and weight checks for a resident receiving tube feedings. The resident's care plan required checks of tube placement and gastric contents, as well as daily or weekly weight monitoring, but these were not documented. The Assistant DON confirmed the lack of documentation and monitoring, indicating a failure to ensure proper nutritional and hydration status.
A facility failed to implement a gradual dose reduction (GDR) for a resident prescribed Sertraline, despite a pharmacy recommendation and acceptance by the provider. The facility's policy requires GDR for antipsychotic medications twice a year, but no documentation showed the GDR was attempted. The Assistant Director of Nursing confirmed the oversight.
A resident with severe cognitive impairment and aggressive behavior was involved in multiple incidents of physical aggression towards other residents, including kicking and hitting. Despite the facility's Abuse Prevention Program, the resident's aggressive actions were not immediately addressed with a discharge, although the resident was eventually placed in a memory care unit by their family.
A resident with diabetes and a healing foot wound did not receive assistance with wearing prescribed compression stockings, which were crucial for managing leg swelling. The LPN assumed CNAs had applied the stockings and signed off without verifying, leading to the resident being without them for two days. The resident had reported the issue, but it was not addressed, highlighting a lapse in staff communication and procedure adherence.
A resident with wounds on the right buttock and right breast, the latter infected with MRSA, received improper wound care from an LPN who failed to follow aseptic procedures. The LPN did not change gloves or perform hand hygiene after touching contaminated surfaces and used the same gloves and gauze for different wound sites, risking cross-contamination. The facility's policy on aseptic wound care was not adhered to, leading to a deficiency.
A resident with a MRSA infection was not properly isolated due to the absence of infection control signs and staff failing to wear gowns during high-risk care activities. Despite the resident's care plan indicating enhanced barrier precautions, CNAs provided care without gowns, and the LPN did not correct this oversight. The DON confirmed the need for gowns and signage, as per facility policy.
The facility failed to ensure timely physician visits for five residents, who had not been seen by a physician since their admission. Despite having a nurse practitioner with full practice authority, the facility lacked a policy requiring physician visits for new admissions or established residents. The medical director, the only physician for all residents, does not routinely see them, leading to a deficiency in care.
A resident in a LTC facility, who was cognitively intact and dependent on staff for personal hygiene, reported being left in urine overnight despite using the call light multiple times. CNAs admitted to not providing timely care, resulting in the resident's incontinence brief and bed sheets being soaked. The DON confirmed that residents should receive care every two hours, and the failure to do so compromised the resident's dignity and quality of life.
A resident with multiple medical conditions, including Cerebral Palsy, expressed a preference to use a commode instead of a bedpan for toileting. Despite being cognitively intact and having used a commode previously, the resident was denied this preference, leading to discomfort and sore spots. The facility lacked a policy on resident preferences, although staff were expected to honor reasonable requests.
A resident with a history of skin breakdown was left in urine-soaked conditions due to staff neglect in providing timely incontinence care. Despite activating the call light multiple times, the resident's needs were not addressed until hours later, resulting in saturated briefs and bedding. The DON confirmed the importance of regular care to prevent infections and maintain dignity.
A resident with multiple medical conditions received improper incontinence care due to a CNA's failure to wash hands and change gloves during the procedure. The CNA did not apply barrier cream after care, leading to a deficiency in infection control practices.
The facility failed to provide a clean and homelike environment for residents, with issues such as unclean bathrooms, delayed housekeeping, and maintenance problems like missing closet doors and peeling paint. Residents reported dissatisfaction with the cleanliness and timeliness of services, and the maintenance log had not been updated since 2020, indicating a lack of systematic problem resolution.
A facility failed to report an allegation of mental abuse involving a resident with multiple medical conditions, including Hypertension and Chronic Kidney Disease, who was cognitively intact and required maximum assistance. The incident, involving a CNA, was documented in a grievance report, but the facility did not report it to the State Agency as required by their Abuse Prevention Program policy.
A facility failed to investigate an allegation of mental abuse by a CNA towards a resident. The CNA allegedly made inappropriate comments and left the resident without a call light. The facility did not interview staff or suspend the CNA during the investigation, violating its abuse prevention policy.
Two residents with significant medical conditions were left without functioning call lights for three weeks, relying on an ineffective bell system that could not be heard by staff. Despite being cognitively intact, the residents' ability to communicate their needs was compromised, as confirmed by facility staff and a handwritten note at the nurses' station.
The facility failed to employ a clinically qualified director of food and nutrition services, affecting all 38 residents. On two consecutive days, there was no DM or CDM onsite from 10:00 AM to 4:00 PM. The administrator confirmed that the previous CDM left in February 2024 and had not been replaced.
The facility failed to employ dietary staff with safe food handling training, potentially affecting all 38 residents. Observations revealed that no dietary or ancillary staff had completed basic safe food handling training. The administrator acknowledged the issue and mentioned ongoing changes in dietary staff and efforts to get all staff trained.
The facility failed to dispose of expired food products, monitor food and dishwasher temperatures, and maintain a sanitary kitchen environment. Staff served expired food, did not check food temperatures, and used unsanitized dishes. The kitchen was observed to be dirty, with rotten food and improper storage of chemicals.
The facility failed to serve palatable, attractive, and timely meals to residents, with multiple complaints about cold, unappetizing, and late food. Observations and interviews revealed consistent issues with food quality, including unseasoned milk-based soup and burnt fish filets.
The facility failed to prepare pureed food in a safe texture for three residents with physician orders for pureed diets. The cook served lumpy coleslaw that did not meet the required consistency, leading to one resident coughing and others expressing difficulty in eating it.
Uncomfortable Room Temperatures and Unsanitary Resident Room
Penalty
Summary
The facility failed to keep resident rooms at comfortable temperatures for seven residents. The facility policy stated ambient temperatures should be maintained between 71 and 81 degrees Fahrenheit. On observation, several resident rooms were measured at 82 degrees Fahrenheit with 86% humidity, and residents stated their rooms were hot, humid, and uncomfortable. Two residents who used oxygen and had intact cognition reported discomfort in their rooms, and one resident with COPD and chronic respiratory failure was observed wearing oxygen while the room temperature remained above the facility’s stated range. Additional residents reported ongoing lack of air conditioning in their rooms. One resident with asthma and congestive heart failure stated her room had been hot and uncomfortable and that no air conditioning had been installed yet. Another resident with COPD stated her room was hot and uncomfortable and that no air conditioning had been installed yet; this resident was also using oxygen. In another room, two residents shared a space that felt humid and sticky, had no fan or AC, and one resident using oxygen stated it would be nice to have the AC installed. Staff interviews confirmed that window AC units were being installed first for residents on constant oxygen and then for common areas, but temperatures were not being checked or documented in resident rooms, and there was no policy for which residents received AC units first. The facility also failed to provide a clean and sanitary environment for one resident. The resident’s care plan documented incontinence at night and a tendency to put soiled linens under the bed. On repeated observations, the room had an overwhelming odor of urine, bed linens had large dry urine stains covering about half the bed, soiled clothing was on the floor, and the garbage can was overflowing with soiled adult briefs. The interim DON observed the condition and confirmed the room needed to be cleaned and sanitized immediately. The resident stated that no one cleaned the room, that clean linens had to be requested, and that the mattress remained wet even after clean sheets were placed on the bed.
Failure to Use Wheelchair Footrests and Report Incident Leads to Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe wheelchair transport and timely reporting of an accident, resulting in injury to a dependent resident. The resident had diagnoses including congestive heart failure, chronic kidney disease stage III, paroxysmal atrial fibrillation, lymphedema, chronic venous insufficiency of the lower extremities, unsteady gait, muscle wasting, and difficulty walking, and was documented on the MDS as cognitively intact but totally dependent on staff for wheelchair propulsion. On the day of the incident, two CNAs used a sling-type mechanical lift to transfer the resident to a manual wheelchair, and one CNA then transported the resident to be weighed without applying the wheelchair footrests. As the CNA pushed the wheelchair onto and off the scale, the resident slipped down in the chair and her left foot became caught in the left front wheel under the wheelchair. The resident reported saying she was tangled and expressed pain, and the CNA acknowledged hearing an “ouch” and knowing she should have used the foot pedals. Following the incident, the CNA did not report the event to nursing staff or supervisors, contrary to the facility’s Accident/Incident and Unusual Occurrence Policy that requires all employees to report any accident or incident that has or could have resulted in injury. The facility remained unaware of the wheelchair incident until after a left tibia fracture was diagnosed. In the interim, progress notes documented that the resident reported left knee swelling and bruising that had been present for three days, with pain and increasing difficulty with movement. The NP, not informed of any trauma, initially assumed the symptoms were related to the resident’s history of cellulitis, lymphedema, and vascular insufficiency and treated accordingly, later stating that knowledge of the trauma would have prompted an order for an X-ray. The NP indicated it was likely that the twisting of the resident’s foot under the wheelchair caused the leg fracture, and the DON confirmed that the incident was only reported after the fracture was identified.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for eight consecutive hours each day, seven days a week, as required. Review of the nursing schedules for October through December 2025 revealed multiple days where no RN was scheduled for the required eight consecutive hours. This deficiency was confirmed by the Director of Nursing (DON), who acknowledged that the facility was not meeting the RN coverage requirement. At the time of the deficiency, the facility had 47 residents, as documented in the Midnight Census Report dated 12/27/25.
Failure to Provide Correct Size Incontinence Briefs During Supply Shortage
Penalty
Summary
The facility failed to provide the correct size incontinence briefs for three residents who were either frequently or always incontinent of bowel and/or bladder. According to Minimum Data Set (MDS) assessments, all three residents had intact cognition and required 3X size incontinence briefs due to their body size and high urine output. Due to a shipment error and ongoing supplier issues, the facility experienced a shortage of 3X briefs, resulting in staff using smaller 2X or XL briefs that were less absorbent and more difficult to manage. Certified Nurse Assistants (CNAs) reported that this shortage had persisted for weeks, and that they had informed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) multiple times. During the shortage, CNAs were instructed to use whatever sizes were available, even if they did not fit the residents properly. Residents reported discomfort, skin irritation, and concerns about skin breakdown due to the use of improperly sized briefs. Multiple residents stated that the smaller briefs rubbed their skin, were less absorbent, and required more frequent changes. Staff interviews confirmed that the issue was ongoing and that residents were unhappy with the substitute briefs. The facility's own incontinence care guidelines require that briefs fit appropriately to maintain cleanliness, comfort, and prevent skin breakdown, but these guidelines were not followed during the supply shortage.
Failure to Supervise Resident Leads to Traumatic Fall
Penalty
Summary
The facility failed to effectively supervise a resident, R1, to prevent a traumatic fall and did not thoroughly investigate the incident. R1, who had a history of cerebral infarction, mild cognitive impairment, and was on anticoagulant medication, experienced an unwitnessed fall in their room. The fall resulted in R1 striking their head on a closet door, leading to a subdural hematoma that required emergency medical evaluation and treatment at two hospitals. Despite the facility's Fall Prevention Policy, which mandates immediate assessment and documentation after a fall, the necessary procedures were not followed promptly. R1's care plan identified them as high risk for falls due to gait and balance problems, requiring assistance for transfers. On the night of the fall, R1 was found on the floor with signs of confusion, having attempted to get out of bed unassisted. The incident was not reported or documented until two days later, and R1 was not sent for immediate evaluation despite being on blood thinners and having hit their head. The facility's staff, including the LPN and CNA on duty, failed to adhere to the protocol of sending residents with unwitnessed falls or head injuries for evaluation. Interviews with staff and R1's representative revealed that R1 had been confused, believing someone was breaking into their apartment, which contributed to the fall. The facility's Regional Director of Nursing confirmed that the fall packet and necessary documentation were not completed in a timely manner, highlighting a lapse in the facility's adherence to its fall prevention and response policies.
Failure to Notify of Resident Fall
Penalty
Summary
The facility failed to promptly notify the resident's representative and provider of a fall incident involving a resident. The fall occurred at approximately 10:30 pm on January 21, 2025, but the resident's provider was not informed until January 22, 2025. Additionally, there was no documentation indicating that the facility's Administrator, Director of Nursing, or the resident's representative were notified of the fall. Interviews revealed that the nurse responsible for making these notifications did not fulfill this duty, and the resident's representative only became aware of the fall the following day when they spoke with the resident. The facility's policy requires prompt notification of changes in a resident's condition, including accidents, to appropriate individuals, which was not adhered to in this case.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, affecting five residents specifically reviewed for mail and package delivery. During a Resident Council Meeting, several residents reported that they did not receive their mail on Saturdays, with mail being left on the Activity Director's desk and distributed on Mondays. The residents involved had varying cognitive abilities, with some being cognitively intact and others moderately impaired. This issue was confirmed through interviews with staff, who acknowledged that only cards were distributed on Saturdays, while other mail was held until Monday. The Business Office Manager and the Administrator both confirmed that not all mail was distributed on Saturdays, with some mail being held for review or for the residents' Power of Attorneys. This practice was acknowledged to potentially affect all 38 residents in the facility. The facility's failure to deliver mail on Saturdays was identified as a deficiency, as it did not provide residents with reasonable access to communication methods, which is a requirement for their care and well-being.
Failure to Verify CNA Eligibility Before Employment
Penalty
Summary
The facility failed to verify the eligibility for employment through the healthcare workers registry before commencing employment for two Certified Nurse's Aides (CNAs) out of five reviewed for Healthcare Worker Background checks. This oversight was identified in a sample list of 32 employees. Specifically, one CNA began employment on November 15, 2024, but their registry verification was not completed until November 19, 2024. Another CNA started on November 18, 2024, with their eligibility verified only on December 2, 2024. This lapse in procedure has the potential to affect all 38 residents residing at the facility, as confirmed by the facility's administrator, who acknowledged that all CNAs employed have the potential to care for any resident at the facility.
Failure to Label and Store Food Appropriately
Penalty
Summary
The facility failed to ensure that foods were labeled and stored appropriately, as observed during an initial tour of the kitchen. The inspection revealed that various food items in the upright cooler, upright freezer, chest freezer, and outdoor cooler were not labeled with dates, including individual plastic bags of chopped lettuce, shredded cheese, sliced cheese, cottage cheese, diced peaches, and a pitcher of orange juice. Additionally, hot dogs were found in a zip closing plastic bag dated but lacking a discard or expiration date. The upright freezer contained sealed plastic bags of frozen chicken wings, egg patties, crumbled sausage, sausage patties, and sausage links without expiration or use-by dates. Opened and unlabeled bags of breadsticks and chicken breasts were also found with ice crystallization, indicating exposure to air and contaminants. The dietary manager confirmed that all food and drinks should be labeled with opened and discard dates, acknowledging the need to discard the hot dogs and breadsticks. The manager explained that items are removed from their original packaging due to limited space, which contributed to the lack of date labels. The broccoli and cheese casserole and pork with gravy, prepared the previous day, were also not labeled with dates. This deficiency has the potential to affect all 38 residents residing in the facility, as documented in the facility's Long Term Care Application for Medicare and Medicaid.
Failure to Implement COVID-19 Precautions
Penalty
Summary
The facility failed to implement COVID-19 transmission-based precautions effectively, as evidenced by the actions and inactions of staff members. A Certified Nursing Assistant (CNA) worked with symptoms of sneezing and a runny nose, tested positive for COVID-19 during their shift, and was not wearing a mask. Another Registered Nurse (RN) worked for three days with symptoms they believed to be a sinus infection, only testing positive after a family member's positive result prompted them to do so. The facility's Assistant Director of Nursing/Infection Preventionist confirmed that the outbreak began when residents and staff tested positive, and masks were not initiated until after the outbreak was identified. Additionally, the facility failed to ensure that a COVID-19 positive resident, R14, was consistently managed under transmission-based precautions. Despite a sign indicating the need for Personal Protective Equipment (PPE) outside R14's room, staff were observed not wearing PPE, and R14 was seen without a mask when leaving the room to smoke. The Assistant Director of Nursing acknowledged that isolated residents should wear masks and staff should wear full PPE, but these procedures were not followed consistently. R14 tested positive for COVID-19 and was on isolation until a specified date, yet the precautions were not adequately enforced.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as evidenced by the lack of implementation of physician orders, insufficient supplies, and improper maintenance of equipment. For one resident, the oxygen humidification bottle was empty and had not been changed since the beginning of the month, despite the resident using oxygen continuously. The resident's care plan did not document oxygen use, and there was no active physician order for it. The Licensed Practical Nurse (LPN) acknowledged the issue, noting that the facility was out of humidification bottles and that the resident should have an order for oxygen. Another resident's room contained an oxygen concentrator and a nebulizer machine with dirty and uncovered equipment. The resident used oxygen nightly and had a nebulizer treatment earlier in the day, but the tubing and mask had not been changed as per the facility's policy. The resident's care plan did not address nebulizer or humidifier use, and the LPN admitted that the nebulizer equipment was not being cleaned or changed regularly. The Assistant Director of Nursing (ADON) confirmed that there should be physician orders for humidifier use and routine care, but was unaware of the resident's use of a humidifier. A third resident's CPAP mask was found uncovered and dirty, with the resident stating that the nursing staff did not clean it. The resident's care plan did not include CPAP use, and there were no physician orders for it. The LPN confirmed the lack of documentation and orders for CPAP use. Additionally, another resident's oxygen humidifier bottle was empty, and the resident reported dryness due to the lack of humidification. The ADON acknowledged a lapse in ordering supplies, leading to the deficiency in providing necessary respiratory care for the residents.
Failure to Provide RN Services and Employ Full-Time DON
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for eight consecutive hours each day, seven days a week, and did not employ a full-time Director of Nursing (DON). This deficiency potentially affects all 38 residents residing in the facility. The nursing work schedule for January 2025 revealed that there were no RNs on duty for eight consecutive hours on January 2, 4, 7, and 27. Additionally, the Assistant Director of Nursing confirmed that there has not been a DON on staff since January 10, 2025. The facility assessment indicated that the facility accepts residents with clinically complex conditions and that a DON and RNs are provided, which was not the case during the specified times.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered for four residents, leading to a deficiency in pharmaceutical services. The Medication Administration Policy requires medications to be prepared and administered within one hour of the designated time, with any omissions documented. However, on January 26, 2025, several residents did not receive their early morning medications as scheduled. Resident R2, diagnosed with Autoimmune Thyroiditis, did not receive her 5:00 AM dose of Levothyroxine. Similarly, Resident R33, who has multiple diagnoses including hypertension and chronic pain syndrome, did not receive her 5:00 AM medications, which included Levothyroxine, Pregabalin, Hydrocodone/APAP, and Lorazepam. The facility's staff, including V4 LPN and V5 RN, confirmed these omissions and noted that the night nurse, V24, failed to administer the medications. Additionally, Resident R28, who requires medications for rheumatoid arthritis and fibromyalgia, reported not receiving her 6:00 AM medications, including Lantus, Lyrica, and Omeprazole. The agency nurse, V24, who was new to the facility, was identified as responsible for the oversight. Resident R9 also reported not receiving the scheduled 5:00 AM dose of Hydrocodone/Acetaminophen. The facility's Assistant Director of Nursing, V2, acknowledged the issue and stated that V24 would no longer be working at the facility. These incidents highlight a significant lapse in medication administration, particularly involving agency nurses unfamiliar with the facility's procedures.
Failure to Offer Pneumococcal Vaccinations to Residents
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to four residents over the age of 65, as required by CDC guidelines. The residents, identified as R1, R4, R28, and R31, were not documented as having received the pneumococcal vaccine, nor was there evidence that they were offered the vaccine prior to January 26, 2025. The facility's policy, dated November 2016, was outdated and did not align with current CDC recommendations, which may have contributed to the oversight. The Assistant Director of Nursing/Infection Preventionist confirmed that the pneumococcal vaccine was not included in the facility's recent immunization clinic and acknowledged the lack of prior offering or availability of the vaccine. The report highlights that R28 had previously received pneumococcal vaccinations in 2016, but there was no documentation of an offer for an updated vaccine. R31, R4, and R1 had no records of ever receiving a pneumococcal vaccination. R4's medical history included acute respiratory insufficiency and chronic obstructive pulmonary disease, conditions that increase the importance of receiving the vaccine. The Regional Clinical Nurse confirmed the absence of documentation and recognized the issue as a problem the facility is working to address.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as required by their policy. During an observation, a resident was found with a Wixela inhaler, a bottle of Fluticasone, and a medication cup containing several pills on their bedside table. The resident stated they self-administered one puff of the inhaler daily and would take the morning medications after breakfast. However, there were no physician orders permitting the resident to self-administer these medications, nor was there an assessment in the medical record evaluating the resident's capability to do so. The facility's Medication Administration policy requires observing residents consume medications and prohibits leaving medications unattended unless there is a physician order. Despite this, a Licensed Practical Nurse admitted to leaving the medications at the resident's bedside for self-administration, citing the resident's refusal to take them under supervision. The Assistant Director of Nursing acknowledged the need for a physician's order and an assessment for self-administration but confirmed that these had not been completed for the resident in question.
Failure to Provide Correct Size Briefs Leads to Skin Breakdown
Penalty
Summary
The facility failed to provide the correct size briefs for a resident, leading to skin breakdown. The resident, identified as R33, was at an increased risk for skin abnormalities and required weekly monitoring and safety measures to prevent dermatologic reactions. Despite this, the facility did not ensure the availability of the correct size briefs, specifically 2XL, which resulted in the resident wearing smaller XL briefs. This improper fit caused the briefs to rub against the resident's skin, leading to an open wound under the left pannus. The wound was observed to be approximately one inch wide, red, and swollen, and was later found to be infected, requiring antibiotic treatment. The facility's records indicated that the last order for 2XL briefs was placed over a month prior, leading to a shortage and the use of ill-fitting briefs. Staff interviews confirmed the frequent unavailability of the correct size briefs, contributing to the resident's skin irritation and subsequent wound development.
Failure to Ensure Safe Mechanical Lift Transfer and Proper Documentation
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a full mechanical lift, which resulted in the resident falling and hitting their head. The resident, who has a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for transfers. During the transfer, the straps of the sling were not secured properly, causing the resident to fall out of the sling. The resident was sent to the hospital but did not sustain any injuries. The incident involved two CNAs, and it was noted that the sling used was too small for the resident, who now uses an extra-large sling. The facility also failed to thoroughly investigate the fall and document the details in the resident's medical record. There was no documentation of a fall investigation or physician notification in the resident's medical record, except for a nursing note indicating the resident was sent to the emergency room. The MDS/Care Plan Coordinator confirmed the absence of a fall packet or investigation for the incident. The CNAs involved in the transfer did not position the leg straps correctly, which contributed to the fall. The facility's policies on fall prevention and notification for changes in resident condition were not followed. The fall prevention policy requires a fall huddle and documentation of the fall circumstances and new interventions, which were not completed. Additionally, the notification policy mandates that the resident's physician be informed of incidents, which was not documented. The facility's user instructions for the mechanical lift emphasize the importance of using the correct size sling and ensuring it is properly attached, which was not adhered to in this case.
Inadequate Incontinence Care Provided to Resident
Penalty
Summary
The facility failed to provide proper hygienic incontinence care to a resident, identified as R7, who was dependent on staff for toileting. The facility's policy, dated December 2017, outlines the necessary steps for incontinence care, including washing the pubic area, retracting the foreskin, rinsing, and changing gloves between contaminated and clean areas. However, during an observation on January 28, 2025, a Certified Nursing Assistant (CNA), identified as V13, did not thoroughly cleanse R7's pubic area, failed to retract the foreskin for cleaning, did not rinse the area after washing, and did not change gloves before applying a clean brief. V13 later acknowledged the oversight in the care provided to R7.
Failure to Monitor Enteral Feeding and Weight for a Resident
Penalty
Summary
The facility failed to adequately monitor and document the enteral feeding process for a resident, identified as R30, who was receiving tube feedings. The resident's care plan required that tube placement and gastric contents/residual volume be checked and documented, and that the resident maintain adequate nutrition and hydration status as evidenced by stable weights. However, the Medication Administration Record, Treatment Administration Record, and food and fluid intake and output sheets did not document tube placement checks, residual checks, or intakes and outputs. This lack of documentation indicates a failure to ensure proper monitoring of the resident's nutritional intake and hydration status. Additionally, there was a discrepancy in the monitoring of the resident's weight. The care plan dated February 13, 2024, required daily weight checks, while a physician's order dated December 16, 2024, required weekly weights. Despite these orders, the weight sheets from October 2025 through January 2025 did not document any daily or weekly weights. The Assistant Director of Nursing confirmed that inputs and outputs should always be documented for residents with tube feeding and acknowledged that the resident's weights had not been obtained or monitored as ordered.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to implement a gradual dose reduction (GDR) for a resident who was prescribed Sertraline, an antidepressant, at a dosage of 75 mg daily since November 2023. According to the facility's psychotropic medication policy, residents on antipsychotic medications should undergo a GDR at least twice a year. A pharmacy consultation report from September 2024 recommended a GDR for the resident, suggesting a reduction to 50 mg daily, which was accepted by the provider. However, there was no documentation in the resident's medical record indicating that the GDR was attempted as recommended. The Assistant Director of Nursing confirmed that the GDR should have been initiated in September 2024 but was not implemented.
Resident-to-Resident Abuse Due to Aggressive Behavior
Penalty
Summary
The facility failed to protect residents from abuse by another resident, identified as R2, who was severely cognitively impaired and exhibited aggressive behaviors. R2, who was independently mobile with a wheelchair, was involved in multiple incidents of physical aggression towards other residents. On one occasion, R2 kicked R1 on the lower leg while on the patio, causing R1 to experience pain, although no skin breakage was reported. R1, who is cognitively intact, reported frequent bruising due to blood thinners and poor circulation, and expressed feeling generally safe despite the incident. Another incident involved R2 hitting R3 on the arm after cursing at them. R3, who is also cognitively intact, reported feeling hurt and embarrassed by the slap. A witness, R5, confirmed the incident, noting R2's confusion and aggressive behavior. Additionally, R2 struck R4 in the shin during an episode of agitation with staff, despite R4's attempt to intervene and assist. R4, who is cognitively intact, recalled the incident and noted that R2 was usually friendly but was confused and upset at the time. The facility's staff, including V6 from Social Services and the Administrator, acknowledged R2's aggressive behavior, which included cursing, kicking, and hitting other residents and staff. The facility's Abuse Prevention Program outlines the residents' right to be free from abuse, defining abuse as willful actions causing physical harm, pain, or mental anguish. Despite these guidelines, the facility did not initiate R2's discharge, although R2's daughter eventually found placement in a memory care unit.
Failure to Assist Resident with Compression Stockings
Penalty
Summary
The facility failed to provide a dependent resident with the necessary assistance in dressing, specifically with the application of compression stockings, which are crucial for managing the resident's condition. The resident, who has a history of Diabetes Mellitus Type II, cerebral infarction with diabetic neuropathy, and morbid obesity, was observed without the prescribed compression hose. The resident's physician order summary indicated that the compression hose should be worn during the day and removed at bedtime to help manage swelling and prevent further complications. Despite these orders, the resident was found without the compression hose, which the resident reported had been missing for two days due to being sent to laundry. The resident's wound assessment documented a healing diabetic wound on the left foot, and the resident was noted to be at high risk for developing pressure ulcers, requiring moderate to maximum assistance with moving. During an observation, a Licensed Practical Nurse (LPN) acknowledged that the compression hose was not on the resident and admitted to signing off on the treatment sheet without verifying their application. The LPN assumed that the Certified Nursing Assistants (CNAs) had put them on, as was the usual practice, but failed to confirm this before documenting. The resident expressed awareness of the missing compression hose and had communicated this issue, indicating a lapse in communication and follow-through by the facility staff.
Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to prevent cross-contamination between wounds during wound treatment for a resident identified as R3. The resident had specific physician orders for wound care on the right buttock and right breast, with the latter being treated for an abscess with MRSA. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care without adhering to proper aseptic techniques. The LPN entered the resident's room with gloves and a gown already on, contaminating the gloves by touching the door and other surfaces before proceeding with the wound care. The LPN did not change gloves or perform hand hygiene after touching potentially contaminated surfaces and before treating the resident's wounds. The LPN used the same gloves and gauze to clean both the new wound on the resident's right posterior upper thigh and the existing wound on the right buttock, thereby risking cross-contamination. The LPN also applied treatment creams with the same soiled gloves, further compromising the aseptic procedure. The facility's policy on aseptic wound and skin treatment was not followed, as it requires handwashing, establishing clean and dirty fields, and changing gloves between different wound sites. The LPN admitted to not washing hands or changing gloves during the dressing change, attributing the oversight to nervousness due to being observed by a surveyor. This failure to adhere to proper wound care procedures led to a deficiency in the care provided to the resident.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to post infection control/contact isolation precaution signs to alert staff and visitors to wear personal protective equipment (PPE) and failed to ensure staff wore personal protective gowns during high-risk personal care activities. These failures were observed in the care of a resident (R3) who was on contact isolation precautions due to a MRSA infection in a breast wound. The resident's care plan indicated the need for enhanced barrier precautions, which were not followed by the staff. During an observation, it was noted that the infection control dresser outside R3's room was set up with gowns and gloves, but there was no sign indicating the resident was on any type of infection control isolation or enhanced barrier precautions. Two CNAs, V10 and V11, entered R3's room without wearing gowns and provided incontinence care, transferred the resident, and assisted with wound care without donning gowns, despite the resident being incontinent and having open wounds. The CNAs used hand sanitizer and gloves but did not adhere to the gown requirement. The LPN, V6, acknowledged that the CNAs should have worn gowns during the care activities and admitted to not instructing them to do so. The Director of Nursing/Infection Control Preventionist, V2, confirmed that enhanced barrier precautions, including the use of gowns, were required for residents with wounds and that appropriate signage should have been posted. The facility's policy on Enhanced Barrier Precautions outlined the need for gowns and gloves during high-contact care activities, which was not followed in this instance.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that five residents received timely physician visits, as required. The residents involved were admitted to the facility between December 2023 and July 2024, and their medical records did not document any physician visits since their admission. These residents had various medical conditions, including cognitive impairments, hypertension, hypothyroidism, cerebral palsy, diabetes, and dementia, among others. Despite the presence of a nurse practitioner with full practice authority, the facility did not have a policy requiring physician visits for new admissions or established residents. Interviews with the residents and staff revealed that the medical director, who is the only physician for all residents, does not routinely see residents and only visits the facility quarterly for meetings. The nurse practitioner handles all new admissions and follow-ups, but the facility was unaware that newly admitted residents needed to be seen by a physician. The administrator acknowledged the lack of a policy regarding physician visits and the need for the medical director to see all new residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to maintain a resident's dignity by not providing timely incontinence care for a resident who was cognitively intact and dependent on staff for dressing, toileting, and personal hygiene. The resident, who required assistance from two staff members and a mechanical lift for transfers, reported having to lay in urine all night despite using the call light multiple times. A CNA admitted to not checking on the resident every two hours, as required, and acknowledged turning off the call light without providing care. Further observations revealed that the resident's incontinence brief was fully saturated with urine, and the incontinence pad and bed sheets were wet. Multiple CNAs confirmed that they had not assisted the resident with care since the beginning of their shifts, indicating a lack of attention to the resident's needs. The resident expressed concern about developing bedsores due to prolonged exposure to urine. The Director of Nurses confirmed that residents should receive incontinence care every two hours and that call lights should remain on until care is provided. The DON acknowledged that leaving a resident in urine for hours is unacceptable and could lead to infections or pressure ulcers. The report highlights a failure to provide timely and adequate care, compromising the resident's dignity and quality of life.
Failure to Honor Resident's Toileting Preference
Penalty
Summary
The facility failed to honor a resident's preference for personal care, specifically regarding toileting. The resident, who is cognitively intact and has multiple medical diagnoses including Hypertension, Hypothyroidism, and Cerebral Palsy, expressed a preference to use a commode instead of a bedpan. Despite this preference, the resident was made to use a bedpan at night, which caused discomfort and sore spots due to prolonged use. The resident had previously used a commode and did not understand why this preference was not being honored. The issue was brought to the attention of the facility's administrator after the resident complained about being denied the use of a commode. The MDS/Care Plan Coordinator had informed the resident that a commode could not be used due to the frequency of use. The facility lacked a policy regarding resident preferences, although staff were expected to honor reasonable preferences as a standard of care. The administrator acknowledged the oversight and indicated that the resident would be assessed for the safe use of a commode.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff assistance for toileting, resulting in the resident laying in urine for extended periods. The resident, who was cognitively intact and had a history of skin breakdown, reported that on one occasion, they activated their call light four times throughout the night, but the CNA who responded did not change their incontinence brief or pad. The resident was eventually changed by two CNAs before the end of their shift, but by then, the resident's brief, pad, and bed sheets were soaked with urine. Further observations revealed that the resident's incontinence brief was fully saturated with urine, and the pad on their recliner chair had yellow spots. The CNAs assigned to the resident's hall confirmed that they had not assisted the resident with any care since the start of their shifts, indicating a lack of regular checks and changes. The resident expressed concern about the potential for developing bedsores again due to prolonged exposure to urine. The Director of Nurses acknowledged that all residents should receive incontinence care every two hours and as needed, and that call lights should remain on if care is not immediately provided. The DON confirmed that the CNAs assigned to the resident's hall were responsible for their care during the reported incidents, and emphasized the importance of timely care to prevent infections and maintain resident dignity.
Incontinence Care Deficiency Due to Improper Infection Control
Penalty
Summary
The facility failed to prevent cross-contamination during incontinence care for a resident who was dependent on staff for dressing, toileting, and personal hygiene. The resident, who was cognitively intact, had multiple medical diagnoses including acute systolic heart failure, chronic kidney disease, and pressure ulcers. During an observation, a Certified Nurse Aide (CNA) did not wash hands prior to providing incontinence care and wore the same pair of disposable gloves throughout the procedure. The CNA did not change gloves, wash hands, or use alcohol-based hand rub during the care of the resident's perineal and buttocks areas, and failed to apply barrier cream after the care. The Director of Nurses acknowledged that staff should follow infection control guidelines, emphasizing the importance of hand washing to prevent the spread of organisms. The facility's policy on perineal cleansing highlights the need to wash from the cleanest to the dirtiest area and to change gloves and wash hands when transitioning from contaminated to clean items. The CNA admitted to not following proper procedures, which contributed to the deficiency in care provided to the resident.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four residents, as evidenced by observations, interviews, and record reviews. Residents reported issues such as aides placing clothes on the floor, unmade beds, delayed response to call lights, unchanged sheets, and visible bedpans. Housekeeping was noted to be inadequate, with trash not being picked up, floors not mopped, and bathrooms not cleaned properly. Specific incidents included a shared bathroom with paper debris, a full garbage can with soiled incontinence briefs, and a toilet riser with smeared stool, leading to a strong foul odor. Residents expressed dissatisfaction with the cleanliness and timeliness of housekeeping services. Additionally, one resident's room had maintenance issues such as a missing closet door, large areas of missing paint, and a hanging cable wire. The maintenance director acknowledged these issues, citing a lack of time to address them due to other responsibilities. The facility's maintenance report log had not been updated since 2020, indicating a lack of systematic tracking and resolution of maintenance problems. These deficiencies highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents.
Failure to Report Alleged Mental Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident mental abuse to the State Agency for one resident, identified as R5, out of a sample of six residents reviewed for abuse. R5, who has medical diagnoses including Hypertension, Chronic Kidney Disease, Cardiovascular Disease, Anemia, Hyperlipidemia, Nocturnal Muscle Spasm, and Cerebral Vascular Accident, was documented as cognitively intact and requiring maximum assistance for transfers, bed mobility, personal hygiene, and toileting. On June 6, 2024, a grievance report documented that a Certified Nurse Aide (CNA) allegedly mentally abused R5. However, the facility was unable to provide documentation that this allegation was reported to the State Agency. The Administrator confirmed that the allegation was not reported, despite the facility's Abuse Prevention Program policy requiring such reports to be made within 24 hours.
Failure to Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of mental abuse by a staff member towards a resident, identified as R5. The incident involved a Certified Nurse Aide (CNA), V10, who allegedly told R5 to wait until 10:00 PM to be put to bed and made inappropriate comments about R5's inability to control her legs and roll over. The CNA also allegedly threatened to shove R5 off the bed and left R5 without a call light. Despite the report of this incident, the facility did not conduct a comprehensive investigation, as no staff or other residents were interviewed, and the accused CNA was not suspended during the investigation. The facility's policy on abuse prevention requires that employees accused of mistreatment or abuse be immediately removed from resident contact until the investigation is complete. However, this policy was not followed, as V10 continued to work without suspension and was only asked to provide a written statement without being informed of the specific allegations. The failure to adhere to the facility's abuse prevention policy and the lack of a timely and thorough investigation constitute a deficiency in the facility's handling of the abuse allegation.
Non-Functional Call Lights for Two Residents
Penalty
Summary
The facility failed to provide functioning call lights for two residents, identified as R1 and R2, in their shared room. Both residents have significant medical conditions, including acute kidney injury, chronic depression, and diabetes for R1, and osteoarthritis, urinary incontinence, and chronic pain for R2. Despite being cognitively intact, both residents reported that their call lights had been non-functional for three weeks. Instead, they were given a single bell to ring for assistance, which was ineffective as it could not be heard outside their room or at the nurses' station. This issue was confirmed by staff, including a Licensed Practical Nurse and a Certified Nurse Aide, who acknowledged the call lights had been out for weeks. The Maintenance Director confirmed that the call lights for R1 and R2 had been non-functional for three weeks and that an electrician was scheduled to fix them. A handwritten note at the nurses' station indicated that the call light for R1 and R2's room was not working outside their room or on the call light board, only sounding from the board. The Administrator also confirmed the non-functionality of the call lights, acknowledging the delay in repair. This deficiency highlights the facility's failure to ensure a working call system in the residents' bathroom and bathing area, compromising the residents' ability to effectively communicate their needs to the staff.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a clinically qualified director of food and nutrition services, which has the potential to affect all 38 residents residing in the facility. On two consecutive days, there was no Dietary Manager (DM) or Certified Dietary Manager (CDM) onsite from 10:00 AM to 4:00 PM. The facility's administrator confirmed that the previous CDM left in February 2024 and had not been replaced by the time of the survey. This deficiency was identified through observation, interview, and record review.
Lack of Safe Food Handling Training in Dietary Staff
Penalty
Summary
The facility failed to employ dietary staff who had completed safe food handling training, potentially affecting all 38 residents. Observations from 4/25/24 to 4/30/24 revealed that no dietary or ancillary staff assisting in the dietary department had completed basic safe food handling training. On 4/25/24, a housekeeper assisted in the kitchen during lunch service without a Food Handler's Certificate. Additionally, from 11:00 AM to 1:30 PM on the same day, three cooks, a dietary aide, and the housekeeper confirmed they did not have their Food Handler's Certificates. On 4/26/24, the administrator acknowledged that none of the dietary department employees had the required certification and mentioned that the facility was undergoing major changes in dietary staff and working on getting all staff trained.
Expired Food and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure expired food products were disposed of and not served to residents. On multiple occasions, cooks were observed using expired tartar sauce and other food items, which were confirmed to be past their expiration dates. Despite recognizing the expiration, the cooks proceeded to serve these items to residents. Additionally, the facility did not monitor food temperatures properly, with cooks relying on visual cues rather than using thermometers to ensure food safety. This included both cooked and raw food items, which were not checked for appropriate temperatures before serving to residents. The facility also failed to maintain proper sanitation and hygiene standards in the kitchen. The dishwasher's sanitizer levels and temperatures were not adequately monitored, and the sanitizer container was found empty on several occasions. Staff admitted to not knowing how to operate or check the dishwasher properly, leading to potentially unsanitized dishes being used for resident meals. The kitchen environment was observed to be unsanitary, with rotten food items, unclean surfaces, and improper storage of food and chemicals. The walk-in cooler contained rotten bananas, tomatoes, and celery, which were leaking onto other food items, and the cooler itself had a musty odor and debris on the floor. Furthermore, the facility did not have a Certified Dietary Manager or a proper cleaning schedule in place. Staff admitted that the kitchen had not been managed or cleaned properly for an extended period. Food items in the reach-in cooler and freezer were not labeled with open or expiration dates, and chemicals were stored next to food storage areas. The kitchen walls, utensils, and storage areas were observed to be dirty, with food debris and splatters of unknown substances. The lack of proper management and cleaning schedules contributed to the overall unsanitary conditions in the kitchen.
Facility Fails to Provide Palatable and Timely Meals
Penalty
Summary
The facility failed to serve foods that were palatable, attractive, and at a safe and appetizing temperature to five residents. Observations and interviews revealed that residents consistently received meals that were cold, unappetizing, and often late. For instance, one resident was observed struggling to cut through a burnt and cold breaded fish filet, while another resident, who is the Resident Council President, reported multiple complaints about the quality of food, including cold meat, room temperature drinks, and meals that were typically an hour late. The soup served was described as unseasoned milk with a few pieces of carrot and hard uncooked navy beans, which residents found inedible and unappetizing. Further interviews with other residents echoed similar complaints about the food quality, with descriptions of cold meals, unseasoned and improperly cooked food, and consistent delays in meal service. A Certified Nurse Aide confirmed that the soup served on a particular evening looked like white milk with carrots and beans, and was an hour late. The facility administrator acknowledged that the kitchen staff were all new employees and admitted that meals should be palatable and served at the proper temperature, recognizing the residents' dissatisfaction with the food quality and service timing.
Failure to Provide Properly Pureed Food
Penalty
Summary
The facility failed to prepare pureed food in a safe texture for three residents who had physician orders for pureed diets. On 4/26/24, the cook prepared coleslaw that was lumpy and not in a pureed texture, which was then served to three residents (R6, R7, R8). The cook acknowledged that coleslaw does not puree well and that the prepared coleslaw did not meet the required consistency of pureed food, which should be like pudding. R8 was observed eating the lumpy coleslaw and began coughing while swallowing it. R7, who was also served the lumpy coleslaw, expressed difficulty in eating it. R6, despite recognizing that the food might not be appropriate, consumed the coleslaw because it was given to them by the staff. The facility's policy on therapeutic and mechanically altered diets states that such diets should be ordered by the physician and planned by the dietician to manage health conditions and facilitate oral intake, which was not adhered to in this instance.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 233 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tuscola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Arcola | 7.5 mi | ★★★★★ | 20 | 0 |
| Arthur Home, The | 11.5 mi | — | 0 | 0 |
| Hilltop Skilled Nsg & Rehab | 15.3 mi | ★★★★★ | 4 | 0 |
| Newman Rehab & Health Care Ctr | 16.2 mi | ★★★★★ | 9 | 0 |
| The Haven Of Bement. | 18.3 mi | ★★★★★ | 20 | 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 July 2026) and official state health department websites.