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 Tri-state Village Nrsg & Rhb during CMS and state inspections, most recent first.
The facility failed to properly assess, monitor, and treat pressure ulcers for two high-risk residents who were dependent on staff for care and had multiple comorbidities and low Braden scores. For one resident, staff observed a new dark sacral wound and changes in responsiveness, but weekend wound care practices did not include measuring or staging the wound, and the NP ordered hospital transfer without personally assessing the wound that day, contrary to facility policy requiring detailed documentation and wound assessment at first observation. For another resident, surveyors observed open buttock areas during incontinence care that had not been timely reported to or assessed by the wound care nurse, despite a CNA stating she had previously notified the nurse and been told only to apply barrier cream. This resident had documented risk for skin breakdown and a care plan requiring weekly systemic skin inspection, staging, and measurement of pressure areas, yet the buttock wounds were not promptly identified, staged, or measured as required by the facility’s pressure ulcer prevention and wound management policies.
A resident with dementia, Parkinson's disease, bilateral LE edema, and gait/mobility abnormalities, identified as high fall-risk and care planned for sit-to-stand mechanical lift transfers, was left sitting on the side of the bed unattended while a CNA went to retrieve the lift. The resident, who had a documented history of multiple prior falls, began sliding and was lowered to the floor. The Restorative Nurse/Fall Coordinator later stated the resident should not be left alone on the bed edge, and the DON stated that high fall-risk residents are expected to be monitored and not left alone on the side of the bed.
A resident experienced a recurrence and worsening of a stage 3 sacral pressure ulcer due to the facility's failure to consistently assess, document, and provide wound care as ordered. Gaps in wound care orders, missed documentation of treatments, and inconsistent weekly wound assessments contributed to the decline in the resident's wound condition.
The facility did not ensure that an effective training program was developed, implemented, or maintained for all new and existing staff members, resulting in a deficiency related to staff training requirements.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
A cognitively impaired male resident with a history of wandering was able to leave the facility unsupervised through a locked dining room door without the alarm sounding. Staff were unaware of his whereabouts, and there was no evidence of consistent monitoring or thorough communication regarding his elopement risk. The resident was later found wandering in another city and brought to a hospital, highlighting failures in supervision and exit door security.
A resident with a history of stroke and cardiac issues received an Amazon package containing pills that had been opened by an LPN, who believed it was medication due to the packaging. Staff interviews confirmed that packages are supposed to be delivered unopened and that mail should not be opened by staff without resident permission, in accordance with facility policy.
Two residents were involved in an incident of inappropriate touching in the dining room, with one resident touching another's crotch area. The incident was not witnessed by staff but was reported by other residents. The facility's administrator reviewed video footage and confirmed the inappropriate behavior. Despite the facility's abuse prevention policy, the incident was substantiated, highlighting a failure in supervision and prevention measures.
A resident with acute respiratory failure and obesity hypoventilation syndrome was admitted without a baseline care plan or documented vital sign assessments. The facility failed to document oxygen administration levels or obtain necessary physician orders, leading to the resident being sent back to the hospital due to breathing difficulties. Interviews revealed a lack of proper assessment and documentation by the nursing staff.
A resident with Dementia and a high fall risk experienced multiple falls, including one with significant injuries, due to inadequate interventions and supervision. Despite being identified as a high fall risk, the facility's measures were insufficient, leading to repeated unwitnessed falls in the dining room. The resident's care plan noted the risk, but interventions failed to prevent further incidents.
A resident with a history of osteoarthritis, COPD, and osteoporosis sustained injuries due to inadequate training and supervision while using a motorized wheelchair. The resident experienced a fractured toe and a leg laceration requiring sutures. Despite claims of provided education, there was no documentation to support that the resident received proper training on safe wheelchair use. The facility's care plan was developed 26 days after the resident received the wheelchair, with no evidence of subsequent training after the incidents.
A resident with adjustment disorder and spinal stenosis experienced a 17-minute delay in response to a call light request for assistance to get into a wheelchair. Despite being cognitively intact and requiring substantial assistance, the call light was not answered promptly by staff, including a CNA, laundry staff, and an LPN, who were nearby. The facility's policy mandates a response within 3-5 minutes, which was not adhered to, resulting in the deficiency.
A resident with spinal stenosis and adjustment disorder was left without assistance for 17 minutes despite activating the call light. The resident needed help to sit up and get into a wheelchair. Staff members, including a CNA and an LPN, did not respond to the call light, although it was audible at the nurses' station. The resident requires substantial assistance for daily activities, and the facility's policy is to answer call lights within 3-5 minutes.
The facility failed to follow its policy on discarding expired house stock medication in the south wing medication room. Expired Magnesium 500mg and Aspirin Low Dose 81mg were found, and staff confirmed that expired medications should be sent back to the pharmacy or discarded by nursing staff.
The facility failed to supervise smoking breaks for five residents and did not provide privacy bags for urine collection bags for two residents with catheters, compromising their dignity and violating facility policies.
The facility failed to follow its Purposeful Rounding Policy, resulting in delayed responses to a resident's call light and incontinence care needs. Despite multiple grievances and re-education efforts, the issue persisted, indicating non-compliance with the policy.
The facility failed to perform routine checks on a resident with an automatic implantable cardiac defibrillator (AICD). The resident's electronic health records lacked documentation of these checks, and the last recorded check was in July 2023, despite the requirement for checks every 91-95 days remotely and annually in the clinic.
The facility failed to label and date tube feeding bottles before administering them to two residents. Both an LPN and the ADON confirmed that the bottles should have been labeled and dated, as per the facility's policy. The residents involved had diagnoses requiring tube feeding, but the facility did not adhere to its own procedures.
A facility failed to follow its infection control policy by not isolating a resident with a bed bug infestation. Despite the resident reporting bed bugs and staff being aware, no transmission-based precautions were initiated, and staff entered the room without PPE. The facility's infection control policies were not adhered to, leading to a deficiency.
A resident with multiple diagnoses and cognitive intactness requested assistance in re-evaluating his guardianship status, but the facility failed to provide necessary support. This led to the resident feeling imprisoned, calling the police, and experiencing psychosocial harm.
The facility failed to follow dementia care and behavior management policies, immediate assessment and physician notification after a fall, and medication administration policies. A CNA continued care for an aggressive resident with dementia, a nurse delayed sending a resident with head pain to the hospital after a fall, and an LPN prepared medications in advance for multiple residents.
A facility failed to ensure a comprehensive care plan for a resident with dementia who exhibited physically aggressive behavior. The care plan lacked specific causal factors and personalized interventions, leading to an incident where a CNA was reported to be verbally and physically discourteous towards the resident. Staff interviews confirmed the resident's aggressive behavior, but the care plan was not updated to address these behaviors effectively.
Failure to Assess and Manage Pressure Ulcers for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and treat pressure ulcers for two residents with significant risk factors. One resident (R3) was dependent on staff for all care and unable to turn or reposition herself, with diagnoses including hemiplegia, hemiparesis, chronic respiratory failure, obesity, muscle wasting, peripheral vascular disease, and a history of pressure-related wounds. On the day of transfer to the hospital, the CNA observed dark areas on the resident’s buttocks, and the wound care nurse identified a new dark, blister-like sacral wound and noted that the resident was not responding to questions as usual. The NP ordered transfer to the hospital for a wound evaluation due to the new wound onset but did not personally assess the wound that day. The DON and wound care nurse stated that weekend wound care staff do not measure wounds, and the wound care nurse on duty did not measure or document the size of the new sacral wound, and another nurse on shift reported never assessing the wound, relying instead on the wound care nurse. The same resident (R3) had documented Braden scores indicating moderate to mild risk in prior months and a care plan for skin checks and reporting signs of skin breakdown, but there was no Braden score documented on the date of the new wound. The facility’s policy required that at first observation of any skin condition, the nurse describe and document it in the clinical record, notify the family and physician, and have the wound care nurse follow up with staging and measurements. Despite this, staff interviews revealed that floor and weekend wound nurses did not perform measurements, and there is no indication in the report that the new sacral wound was staged or measured before transfer. The NP explained that a wound can become infected with necrotizing fasciitis leading to sepsis and stated that the resident was sent out for a new wound onset; the report notes that this practice resulted in the resident being hospitalized for necrotizing fasciitis of the wound bed. For another resident (R4), surveyor observation during incontinence care revealed two pink open areas with scant drainage on the left and right buttocks. The CNA providing care stated it was the first time caring for this resident and did not know if the open areas were pre-existing, while another CNA indicated that the wound care nurse should know about the wounds and that barrier cream had been ordered. The NP identified the buttock wounds as new and noted excoriation to the scrotal area, ordering hydrocolloid dressings and nystatin with barrier cream. The wound care nurse reported she had not been informed of the open buttock wounds prior to this and then applied hydrocolloid dressings and topical treatments; however, another CNA stated she had informed the wound care nurse of the open buttock areas several times weeks earlier and was told only to apply barrier cream. R4 had diagnoses including hemiplegia, hemiparesis, osteoporosis, lack of coordination, Braden scores indicating moderate to high risk, and a care plan for risk of skin breakdown and a left buttock pressure area requiring weekly systemic skin inspection, staging, and measurement. The facility’s policies required head-to-toe skin assessments on admission and regular skin assessments, as well as prompt documentation and notification of new skin alterations, but staff accounts and surveyor findings show that R4’s buttock wounds were not timely communicated, assessed, staged, or measured in accordance with those policies.
Failure to Supervise High Fall-Risk Resident During Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring during a transfer for a resident with a known history of falls and multiple risk factors. The resident had diagnoses including dementia, Parkinson's disease, edema of both lower extremities, unspecified abnormalities of gait and mobility, and was identified as high risk for falls. The resident’s care plan dated 2/13/2026 indicated the need for a sit-to-stand mechanical lift for transfers due to decreased lower extremity strength and endurance, with interventions to maintain body alignment and ensure safe placement of extremities during transfers. Despite this, on 3/3/2026 a CNA sat the resident on the side of the bed and left to retrieve the mechanical lift, during which time the resident began to slide and was subsequently lowered to the floor. Interviews and record review confirmed that the resident had multiple prior falls, including an unwitnessed fall from bed on 12/21/2025 and a fall on 1/23/2026 when the resident attempted to go to the bathroom independently. On 3/10/2026, the resident reported that he was unable to maintain his balance when left sitting on the side of the bed and slid to the floor. On 3/11/2026, the CNA stated she had left the resident seated at the bedside to get the mechanical lift and returned when he yelled, then lowered him to the floor and sought assistance. On 3/12/2026, the Restorative Nurse/Fall Coordinator stated that the resident was high risk for falls and should not be left alone on the side of the bed, and the DON stated that staff are expected to monitor any high fall-risk resident and never leave them alone on the side of the bed. The facility’s Falls-Clinical Protocol identified history of falls and gait and balance disorders as risk factors for subsequent falls.
Failure to Prevent and Monitor Stage 3 Sacral Pressure Ulcer
Penalty
Summary
This facility failed to provide necessary care and services to prevent the recurrence and worsening of a stage 3 sacral pressure ulcer for one resident. The resident was readmitted to the facility after hospitalization and initially had no pressure ulcers identified, but was noted to have moisture-associated skin damage (MASD). Shortly after readmission, a wound was identified on the sacrum, and wound care orders were initiated. However, there were gaps in wound care treatment orders and inconsistent documentation of wound care administration, with several dates lacking evidence that wound care was provided as ordered. Additionally, weekly wound assessments and measurements were not consistently performed or documented, and there was a period when the wound care physician did not monitor the wound. The resident's wound worsened over time, increasing in size and developing slough, indicating a decline in condition. Interviews with staff revealed that the previous wound care nurse had not been fulfilling job responsibilities, and the new wound care nurse had only recently assumed the position. The facility's documentation showed lapses in both assessment and treatment, including missing wound care documentation on multiple dates and a lack of wound management records after a certain point. These failures contributed to the recurrence and deterioration of the resident's stage 3 sacral pressure ulcer.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for all new and existing staff members. This deficiency was identified based on the lack of evidence that staff received adequate training as required by regulations. The report notes that the training program was either not in place, not properly implemented, or not maintained for both new hires and current employees. No additional details regarding specific residents, staff members, or incidents were provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Failure to Supervise Cognitively Impaired Resident and Monitor Exit Doors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a cognitively impaired resident with a history of elopement. The resident, who had a BIMS score of 5 indicating severe cognitive impairment and required supervision with ambulation, was able to exit the facility through a locked dining room door without the door alarm sounding. The resident then accessed the patio/courtyard, exited through a gate, and did not return. Multiple staff members, including the DON, Assistant Administrator, and Activity Aides, reported not hearing any door alarms during the time the resident left, and surveillance footage confirmed the resident's exit without staff intervention or alarm activation. The resident had been admitted from an assisted living facility due to safety concerns related to wandering and medication management. Despite documentation of the resident's cognitive impairment and need for supervision, there was no evidence that staff had obtained a thorough history from the resident's family or the previous facility regarding elopement risk. Staff interviews revealed a lack of awareness of the resident's whereabouts, and there was no clear documentation of consistent monitoring or supervision, especially after the scheduled smoking time when the resident was last seen. The facility's policy required staff to know the whereabouts of assigned residents and to ensure that exit doors were secured and alarmed, but these procedures were not effectively implemented. The incident resulted in the resident being missing for an extended period, during which he was found wandering in another city and subsequently brought to a hospital. The failure to secure the exit doors, ensure alarm functionality, and provide adequate supervision for a resident with known cognitive impairment and elopement risk directly led to the deficiency. The facility's lack of effective communication, assessment, and monitoring contributed to the resident's unsupervised exit and subsequent absence.
Failure to Deliver Resident Package Unopened
Penalty
Summary
Facility staff failed to follow their policy regarding resident rights by not ensuring that a resident's package was delivered unopened. The incident involved a male resident with a history of partial paralysis due to stroke, hypertensive heart disease, and a cardiac implant. The resident reported that a nurse delivered an Amazon package containing cod liver oil pills to him after it had already been opened. The nurse admitted to opening the package, stating she believed it was medication for the resident, as it was in a brown package similar to those typically used for medication deliveries. The nurse apologized to the resident, explaining her mistake. Interviews with facility staff revealed that packages are generally delivered unopened to residents, and it is not appropriate for staff to open residents' mail or packages. Staff acknowledged that medication and Amazon packages can look similar, but emphasized that all packages should be checked for proper labeling before being opened. The facility's policy clearly states that staff should never open a resident's mail unless the resident allows it, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Inappropriate Touching
Penalty
Summary
The facility failed to prevent an incident of inappropriate touching between two residents, R3 and R4, in the dining room. R3, who has a cognitive pattern score of 5 out of 15 indicating impairment, was touched in the crotch area by R4, whose cognitive pattern score is intact at 15 out of 15. R4's care plan notes a loss of social skills and symptoms of socially inappropriate behavior. The incident occurred when no staff were present in the dining room, and it was reported by other residents. A Licensed Practical Nurse (LPN) was informed of the incident by residents and reported it, although she did not witness it herself. The nurse's station does not have a view of the dining room where the incident took place. The facility's administrator was informed of the incident after arriving at the facility and took steps to report it to the police. Video footage confirmed that R4 touched R3 inappropriately, and the police report corroborated this observation. Despite the facility's abuse prevention policy, which aims to create a resident-sensitive and secure environment, the incident was substantiated, indicating a failure in supervision and prevention measures. Staff witness statements confirmed that no staff observed the incident, and it was only brought to attention by other residents.
Failure to Develop Baseline Care Plan for Resident with Respiratory Needs
Penalty
Summary
The facility failed to develop a baseline plan of care for a resident diagnosed with acute respiratory failure, obesity hypoventilation syndrome, and shortness of breath, who required a BiPAP machine when sleeping. Upon admission, the resident's face sheet indicated these diagnoses, and the respiratory progress note detailed the resident's condition, including the use of a BiPAP machine during hospitalization. However, the Director of Nursing (V8) acknowledged that there was no baseline care plan in place, and vital sign assessments were not documented upon the resident's readmission. The Director of Nursing stated that the nurse should have assessed and documented the resident's condition, notified the physician, reviewed medications, and obtained necessary orders. Despite these expectations, the nurse did not document vital signs or assess the resident's oxygen levels upon readmission. The resident was sent back to the hospital due to breathing difficulties shortly after readmission, and there was no documentation of the oxygen levels administered via the BiPAP machine. Interviews with the nursing staff revealed a lack of documentation and assessment of the resident's vital signs and oxygen levels. The LPNs involved did not recall the specifics of the oxygen administration or the resident's vital signs, and one LPN stated that vital signs could be assessed at the end of the shift. The facility also failed to present a baseline care plan or orders for oxygen administration during the survey, indicating a significant oversight in the resident's care management.
Inadequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to develop an effective plan with interventions to prevent or reduce the risk of falling for a resident diagnosed with Dementia, wandering behaviors, and identified as a high fall risk with balance problems while standing. This deficiency affected a resident who experienced eight falls, seven of which were unwitnessed. One of these falls resulted in significant injuries, including right periorbital soft tissue swelling and a right scalp hematoma with contusion of the face and scalp. The resident, diagnosed with Dementia and requiring assistance with personal care, was noted to have wandering behaviors and balance problems. Despite being identified as a high fall risk, the facility's interventions were inadequate. The resident experienced multiple falls in the dining room, often unwitnessed, and was found on the floor on several occasions. The falls were attributed to various factors, including the resident's shuffling gait, attempts to self-toilet, and inappropriate footwear. The facility's documentation and staff interviews revealed a lack of consistent and effective interventions to address the resident's fall risk. The resident's care plan noted the risk of falling due to Dementia, weakness, and a history of falls, but the interventions implemented were insufficient to prevent further incidents. The facility's failure to provide adequate supervision and appropriate interventions resulted in repeated falls and injuries for the resident.
Inadequate Training and Supervision for Motorized Wheelchair Use
Penalty
Summary
The facility failed to provide adequate training and supervision for a resident using a motorized wheelchair, resulting in multiple accidents. The resident, who has a medical history of osteoarthritis, COPD, osteoporosis, and a history of pathological fractures, sustained a fractured toe and a laceration requiring sutures due to improper use of the wheelchair. The resident reported that her toes were broken when a door hit her foot, and she hit her leg on the bed while trying to maneuver the wheelchair. Interviews and record reviews revealed that the resident did not receive proper education on the safe use of the motorized wheelchair. The resident was observed having difficulty using the wheelchair controls and was assisted by a certified nursing aide. Despite claims from the Director of Nursing and the Director of Rehab that education was provided, there was no documentation to support that the resident received training on the safe use of the wheelchair or on preventing injuries. The facility's care plan policy requires an individualized comprehensive care plan for each resident, which includes measurable objectives and timetables to meet the resident's needs. However, the care plan for the resident was developed 26 days after receiving the motorized wheelchair, and there was no evidence of education or training provided to the resident after the incidents. The facility failed to present any documentation of education or training provided to the resident to minimize injuries when using the motorized wheelchair.
Delayed Response to Call Light Request
Penalty
Summary
The facility failed to respond promptly to a resident's call light request, resulting in a delay of 17 minutes. The resident, who has diagnoses including adjustment disorder with mixed anxiety and depression mood, and spinal stenosis, was cognitively intact with a score of 15 on a cognitive assessment. On the day of the observation, the resident activated the call light at 1:40 PM and was found by the surveyor at 1:48 PM still waiting for assistance to get into his wheelchair. The resident had been on the call light for at least 10 minutes, and it was not answered until 1:57 PM. During this time, a CNA, a laundry staff member, and an LPN were observed in the vicinity but did not respond to the call light. The resident's care plan indicated that he required substantial to maximal assistance for various activities of daily living, including sitting up, and his call light should be kept within reach at all times. The facility's call light policy, dated 5/17/24, stated that call lights should be answered promptly, within 3-5 minutes, by any staff member who hears them. Interviews with staff, including the Director of Nursing, confirmed that all disciplines are expected to respond to call lights promptly. Despite these policies and procedures, the resident's call light was not answered in a timely manner, leading to the identified deficiency.
Failure to Provide Timely Assistance to Resident
Penalty
Summary
The facility failed to provide timely assistance to a resident, identified as R7, who required help with activities of daily living. R7, who has diagnoses including adjustment disorder with mixed anxiety and depression mood, and spinal stenosis, was observed with a call light on for 17 minutes without receiving assistance. During this time, R7 was attempting to sit up and get into a wheelchair but was unable to do so independently. Despite the call light being activated, staff members, including a CNA and a laundry staff member, were observed walking near R7's room without responding to the call light. Additionally, an LPN was present at the nurses' station where the call light beep was audible but did not respond. R7's cognitive assessment indicates that he is cognitively intact, with a score of 15, and requires substantial to maximal assistance for various activities, including sitting up. Interviews with staff, including a CNA and the Director of Nursing, confirmed that R7 needs assistance with all activities of daily living and that call lights should be answered within 3-5 minutes. The failure to respond promptly to R7's call light, as outlined in his care plan, resulted in a delay in providing necessary assistance.
Failure to Discard Expired Medications
Penalty
Summary
The facility failed to follow its policy on discarding expired house stock medication in the south wing medication room. During an observation, a can of Magnesium 500mg and Aspirin Low Dose 81mg were found with expiration dates of 3/2024. An LPN confirmed that expired medication should be sent back to the pharmacy. The Assistant Director of Nursing stated that expired house stock medications are to be discarded by nursing staff, who are responsible for removing expired medications. The facility's policy mandates that all expired medications be removed from the active supply and destroyed in the facility.
Failure to Supervise Smoking Breaks and Provide Privacy Bags for Catheters
Penalty
Summary
The facility failed to follow their smoking policy by not providing supervision for smokers during the 5:00 PM and 7:00 PM smoking breaks. This failure affected five residents who reported missing their smoke breaks due to the activity aide leaving early. The Assistant Administrator and other staff members were unaware of the missed smoke breaks, and it was noted that the activity aide should have notified the administrator to assign another staff member for supervision. The facility's smoking policy requires that residents who pose a hazard with smoking materials must be supervised by a staff member from any department, but this was not adhered to in this instance. Additionally, the facility failed to provide privacy bags for urine collection bags for two residents with catheters. Observations revealed that the urine collection bags were left uncovered and visible from the hallway, compromising the residents' dignity. Both the Licensed Practical Nurse and the Assistant Director of Nursing confirmed that urine collection bags should be covered to maintain dignity. The care plans for these residents indicated the need for privacy bags, but this was not implemented. The facility's policies on resident rights and dignity were not followed, leading to these deficiencies. The smoking policy and the quality of life policy both emphasize the importance of supervision and maintaining dignity, but the facility did not comply with these standards, resulting in the reported issues.
Failure to Follow Purposeful Rounding Policy
Penalty
Summary
The facility failed to follow its Purposeful Rounding Policy by not rounding on residents regularly to meet their needs. This deficiency was highlighted by the experience of a resident who reported that it took three hours for a CNA to respond to his call light. Interviews with the Assistant Administrator and Assistant Director of Nursing revealed that they were unaware of any concerns regarding delayed call light responses or incontinence care. Both stated that staff should answer call lights within two minutes and round every two hours. However, the resident's grievance and complaint forms documented multiple instances of delayed ADL care and call light responses, indicating a pattern of non-compliance with the rounding policy. The resident, who is alert and able to use his call light, had previously expressed concerns about delayed incontinence care. Multiple grievance forms from different dates documented similar issues, including overnight CNAs not changing the resident and not performing patient care. These forms also showed that staff had been re-educated on the importance of prompt call light responses and ADL care, but the recurring nature of the complaints suggests that the facility's corrective actions were not effective in resolving the issue. The failure to adhere to the rounding policy and promptly respond to call lights directly impacted the resident's care and well-being.
Failure to Perform Routine Cardiac Defibrillator Checks
Penalty
Summary
The facility failed to perform routine checks on a resident with an automatic implantable cardiac defibrillator (AICD). During a record review, it was found that the resident's electronic health records did not contain any documentation of cardiac defibrillator checks. The Assistant Director of Nursing (V4) confirmed that they were still waiting for the vendor to provide the defibrillator check documentation. An interview with the Cardiac Defibrillator Specialist (V21) revealed that the last check on the resident's cardiac defibrillator was conducted in July 2023, and it should be checked every 91-95 days remotely and annually in the clinic. The resident was last checked in the clinic in February 2023. Further review of the resident's general orders and progress notes indicated that there were orders for pacemaker checks on multiple dates, and the presence of the AICD was noted in the nursing and nurse practitioner progress notes. The facility's policy on the care of residents with implanted cardiac devices stated that pacemaker checks should be performed as ordered. However, the facility did not adhere to this policy, leading to a lapse in the routine checks for the resident's cardiac defibrillator.
Failure to Label and Date Tube Feeding Bottles
Penalty
Summary
The facility failed to label and date tube feeding bottles before administering them to residents, as observed in two cases. On multiple occasions, Resident 24 and Resident 169 were found with ongoing tube feedings that were neither labeled nor dated. Licensed Practical Nurse (LPN) V20 confirmed during interviews that the tube feeding bottles should have been labeled and dated before administration. The Assistant Director of Nursing (ADON) V4 also stated that it is the facility's policy to label and date all tube feeding bottles before use. Resident 24 had a diagnosis of gastrostomy status and severe protein-calorie malnutrition, with a tube feeding order starting from February 13, 2024. Similarly, Resident 169 had a diagnosis of encounter for attention to gastrostomy and dysphagia following a cerebral infarction, with a tube feeding order starting from April 12, 2024. The facility's policy on gastric tube feeding, revised in May 2017, mandates that all bags, bottles, syringes, and tubing must be timed and dated to determine the discard date. This policy was not followed in the observed cases, leading to the deficiency noted in the report.
Failure to Follow Infection Control Policy for Bed Bug Infestation
Penalty
Summary
The facility failed to follow its infection control policy by not initiating isolation protocols for a resident with a bed bug infestation. On 04/23/2024, the resident was observed in bed without any transmission-based precautions, sharing the room with another resident. Despite the resident reporting bed bugs on 04/21/2024, no isolation or contact precautions were initiated, and staff were observed entering the room without PPE. The Assistant Director of Nursing/Infection Preventionist was unaware of the infestation until informed by the surveyor on 04/23/2024. The Licensed Practical Nurse and Housekeeping Manager were aware of the bed bug issue since 04/21/2024, but no immediate action was taken to isolate the resident or inform the infection control team. The pest control company was scheduled to treat the room on 04/23/2024, but the resident remained in the infested room without proper precautions. The facility's policy on bed bug management, which includes isolating the resident and using contact precautions, was not followed. Interviews with various staff members, including the Administrator and Housekeeping Manager, confirmed that the facility's infection control policies were not adhered to. The resident's medical history includes multiple conditions such as polyneuropathy, hemiplegia, and major depressive disorder. Despite the presence of bed bugs being reported and observed by multiple staff members, the necessary steps to prevent the spread of infestation were not taken, leading to a deficiency in infection control practices.
Failure to Assist Resident in Re-evaluating Guardianship Status
Penalty
Summary
The facility failed to honor a resident's request to obtain assistance in re-evaluating his guardianship status, which affected his ability to leave the facility and maintain his highest practical well-being. The resident, a cognitively intact male with multiple diagnoses including hemiplegia, CHF, seizures, HTN, and CAD, expressed his desire to have his guardianship status re-evaluated. Despite his repeated requests to the Social Service Director, no assistance was provided to him until after a surveyor's interview. This lack of action resulted in the resident feeling imprisoned and calling the police due to his inability to leave the facility and having his phone taken away by his guardian. The resident was initially assigned a temporary guardian while in a medically induced coma, which later became permanent. The resident expressed dissatisfaction with his guardian and requested assistance from the facility to dispute the guardianship. However, the Social Service Director only provided contact information for legal aid and the ombudsman after the surveyor's interview, and there was no prior documentation of assistance. The facility's failure to respond to the resident's grievances and provide necessary social services led to psychosocial harm for the resident.
Failure to Follow Dementia Care, Fall Protocol, and Medication Administration Policies
Penalty
Summary
The facility failed to follow its policy and procedures for dementia care and behavior management. A certified nursing assistant (CNA) continued to provide care to a resident with dementia who became physically aggressive, instead of discontinuing care and reapproaching later. The resident, who has a history of physical aggression and pseudobulbar affect, was reported to have been pushed and struck by the CNA, although the CNA denied these actions. The facility's dementia care policy emphasizes the need to identify triggers and use behavior management techniques, which were not followed in this instance, leading to the escalation of the resident's aggressive behavior. The facility also failed to follow its policy for immediate assessment and physician notification after a resident experienced head pain following an unwitnessed fall. The resident, who has multiple diagnoses including rheumatoid arthritis and cerebral infarction, fell while attempting to get out of bed and hit her head. The CNA on duty reported the fall to the nurse, but the nurse did not immediately send the resident to the hospital for evaluation, as required by the facility's fall protocol. The nurse on duty at the time of the fall did not complete the necessary fall report and left the responsibility to another nurse who arrived later. Additionally, the facility did not adhere to its Medication Administration Policy. An LPN was observed preparing medications in advance for several residents at the same time, a practice that is against professional nursing standards and the facility's policy. The LPN admitted to this practice, stating it was done to ensure timely medication administration, despite knowing it was incorrect. The facility's policy requires medications to be administered as prescribed and not set up in advance, which was not followed in this case.
Failure to Implement Comprehensive Care Plan for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to follow their policy and procedures for dementia/behavior care planning by not ensuring a care plan for a resident who exhibits physically aggressive behavior towards staff included comprehensive personalized interventions for behaviors. This deficiency was identified for a resident with a history of Dementia without Behavioral Disturbance, Chronic Diastolic Heart Failure, Stage 3 Chronic Kidney Disease, COPD, and Syncope/Collapse. The resident's care plan did not include specific causal factors or potential triggers for her physically aggressive behavior and lacked personalized interventions to address these behaviors. The resident's progress notes and interviews with staff indicated that she often exhibited physically aggressive behavior, such as hitting, biting, and swinging at caregivers, especially during care activities. Despite these documented behaviors, the care plan only included general interventions and did not provide specific strategies tailored to the resident's needs. Staff interviews revealed that the resident's aggressive behavior was known, but the care plan was not updated to reflect personalized interventions to manage these behaviors effectively. An incident on 11/05/2023 highlighted the deficiency when a family member of another resident reported witnessing a CNA being verbally discourteous and physically aggressive towards the resident. The police were notified, and although no injuries were observed, the incident underscored the need for a more comprehensive and personalized care plan. The facility's Director of Nursing acknowledged that the care plan could include more personalized interventions, and the facility's Dementia Care Policy emphasized the importance of individualized care plans to manage dementia-related behaviors effectively.
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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 Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thryve Of South Holland | 0.8 mi | ★★★★★ | 15 | 0 |
| Munster Med-inn | 2.5 mi | — | 44 | 2 |
| Countryside Nursing & Rehab Ctr | 2.9 mi | ★★★★★ | 2 | 0 |
| Elevate Care South Holland | 3.2 mi | ★★★★★ | 12 | 0 |
| Rehabilitation Center At Hartsfield Village | 3.4 mi | ★★★★★ | 11 | 0 |
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