Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Arbors Michigan City during CMS and state inspections, most recent first.
Resident lacked proper bed equipment and a headboard. The resident was observed in bed without a headboard while the new bed was in the hallway and was the wrong bed. He stated the facility had known for months that the headboard was missing and that maintenance had removed the broken headboard. The Administrator later confirmed the ordered bed had a 550-lb max weight while the resident weighed 571 lbs, and the resident had refused attempts to place the delivered bed in his room.
A resident with dementia, severe cognitive impairment, and a known history of exit-seeking and wandering was transferred from a secured memory care unit to a less restrictive unit with a wanderguard ordered but without a written safety adjustment plan, 15-minute checks, or 72-hour monitoring. Staff on the new unit, including CNAs and an activity aide, were not consistently informed that the resident was an elopement risk or wearing a wanderguard, and one CNA assigned to the resident’s room did not receive report, did not know the resident, and did not see the resident for an entire shift. Video showed the resident arriving by car and walking away from the building without a visible wanderguard, and later that day the resident was last seen at a smoke break before being discovered missing that evening, prompting a code pink and extensive searches. The DON later stated the wanderguard alarms did not sound because the resident had removed the device, and records showed the wanderguard was signed out for the evening shift despite the resident already having left. The resident was found by police more than a day later, disoriented and dirty, and transported to the ED, and surveyors found that required elopement interventions and updated care plan measures were not implemented after the transfer off the locked unit.
A resident with multiple comorbidities and existing pressure ulcers to both buttocks and the left ischial area had care plan interventions and MD orders for nightly wound care that were not documented as completed on multiple consecutive days. On readmission, nursing documentation stated there were no changes in skin integrity, but the DON later confirmed that no skin assessment was performed that day, and a new wound care regimen ordered the following day was also not signed out on the TAR for two nights. The DON acknowledged that the readmission skin assessment should have been completed the day the resident returned and that ordered treatments should have been signed out.
The facility failed to provide needed ADL assistance for dependent residents, including shaving, nail care, and hair washing. A resident with altered mental status and mild intellectual disabilities remained unshaven despite requesting it, a cognitively intact resident dependent on staff for bathing did not have her hair washed as documented or refused, and a resident with stroke and vascular dementia was repeatedly observed with facial hair and dirty fingernails. In addition, a resident on dialysis reported the facility did not always pack a lunch for dialysis days, and PT staff said he often returned hungry after dialysis.
A facility failed to follow ordered wound care and monitor skin changes for multiple residents. One resident with a skin tear had Xeroform placed on the wound instead of the ordered treatment, and staff did not document or monitor a new bruise or ensure long sleeves/geri sleeves were in use. Another resident’s post-fall bruising and swelling were not fully documented during the required follow-up period, and several residents with edema or non-pressure skin lesions had repeated observations that were not reflected on weekly skin assessments.
Incomplete clinical documentation was found for multiple residents. Food intake records were missing for two residents, including one with weight loss and another with dementia and a femur fracture. PRN morphine and lorazepam were given by QMAs without documentation of nurse authorization, oxygen use was not signed out on the MAR for a resident observed on O2, Oxycodone counts did not match between the MAR and narcotic record, and a resident who left AMA had no discharge note or documented discharge planning, medication review, or family notification.
Infection control practices were not followed for resident equipment and medication handling. A resident’s urinal was repeatedly observed hanging from the side rail with urine in it, and uncontained wash basins, toothbrushes, razors, and a urinal were found in shared bathrooms on multiple units. An RN also disinfected a glucometer with alcohol wipes instead of the facility’s required bleach solution between resident tests, and another RN placed acetaminophen tablets into her bare hand before putting them in a medicine cup.
Surveyors found multiple resident rooms, bathrooms, and medication carts in poor repair and unclean across Units 100, 200, and 300. Observations included marred walls and doors, dirty ceiling vents, cobwebs, stained toilets and floor mats, warped or peeling floor tile, missing paper towel dispenser covers, rusted and exposed toilet bolts, broken closet hardware, and a cracked outlet cover. Medication cart drawers on several units also had broken cut-out areas, and one locked cart could still be partially opened, allowing access to medication cards.
Failure to Maintain Resident Dignity During Activities: Two residents were observed in the activity room with dignity concerns. One resident with dysphagia, Parkinson's disease, and dementia was not offered an alternative snack when others were served donuts and soda, despite needing partial to moderate assistance with eating and having snacks listed in his care plan. Another resident with dementia, psychosis, and anxiety had his shirt lifted up with his abdomen exposed for an extended period while seated at the activity table, and staff did not correct it.
Failure to Report Allegation of Resident-to-Resident Abuse: A resident with dementia and severe cognitive impairment was observed falling after another resident allegedly pushed him, and staff documented the resident's complaint of hand discomfort and obtained x-rays. CNA and LPN statements indicated the push allegation was reported internally, but the DON and Administrator did not report it to the State Agency because they believed there was no injury and intent could not be proven.
Failure to obtain audiology services for a resident with hearing loss. A resident with dementia and other chronic conditions reported trouble hearing and had asked to see an Audiologist long before the survey. Her MDS noted minimal hearing difficulty and no hearing aids, but the record showed she signed consent for an Audiologist and still had not been seen, and there was no care plan for hearing issues. The SS Director confirmed the resident had never seen an Audiologist despite multiple visits to the building.
A resident with dementia, psychotic disorder, anxiety, heart disease, MDD, and HF had a history of falls and needed assistance with transfers. After an unwitnessed self-transfer fall with bruising to the face, neck, and upper chest, non-skid strips by the bed were observed missing in several spots, and the DON stated they had needed replacement.
A resident with dysphagia, Parkinson's disease, dementia, and urinary incontinence had blood-tinged urine, decreased urine output, pus, and blood in the urine. Nursing and hospice attempted to obtain a urine specimen, but collection was delayed and a straight cath was initially declined by the resident's sister. The urine later appeared thick, red, and odorous with pus, and the IP stated the antibiotic should have been started earlier.
Oxygen and Nebulizer Orders Not Followed: A resident ordered 3 L O2 via NC was observed with the concentrator set below the ordered rate and was also seen without oxygen while in a wheelchair, with no portable tank attached. Another resident receiving scheduled nebulizer treatments had no observed or documented pre- and post-treatment assessments, despite orders requiring pulse, respirations, O2 sats, and lung sounds before and after each treatment.
Failure to provide dental services and denture follow-up for two residents. One resident with altered mental status and mild ID had multiple missing teeth and no documented dental visit despite an order for dental care PRN. Another resident with dementia and other chronic conditions had multiple extractions, remaining root tips, and no dentures months later; dental notes indicated the bone level was not sufficient for dentures and implants would be needed.
A resident with severe cognitive deficits and a g-tube experienced a dislodged tube and received new antibiotic orders, but the facility failed to notify the family or representative of these significant changes, despite documentation that the family managed the resident's care.
Three residents did not receive antibiotics or wound care as ordered, including missed doses of prescribed antibiotics and incomplete or undocumented wound treatments. In each case, required documentation was lacking, and staff could not provide explanations for the omissions.
A dependent resident requiring maximal assistance with ADLs, including scheduled showers twice weekly, did not receive documented bathing over a nearly month-long period. The care plan required staff assistance for bathing, but records lacked evidence of completed showers, refusals, or rescheduling attempts when the resident was unavailable or declined care. The DON acknowledged gaps in staff documentation.
A resident with severe cognitive impairment and a right shin skin tear did not receive wound care as ordered when an LPN failed to apply skin prep during a dressing change, despite this being specified in the physician's order.
During a midnight shift, a CNA administered medications to five residents with cognitive impairments after the assigned LPN left due to a medical emergency. The CNA used the LPN's login credentials to document medication administration, despite facility policy requiring only licensed staff to perform this task. The incident was confirmed through staff statements, medication records, and video footage.
Staff on the memory care unit plated and served food using bare hands and transported uncovered food through hallways and dining areas, failing to follow sanitary protocols and facility policy. These actions affected all residents on the unit during multiple meal services.
All residents on the memory care unit experienced uncomfortably cold temperatures after the facility turned off the heat in May, as confirmed by resident and staff interviews and temperature readings as low as 68 degrees. Residents were observed bundled in extra clothing and blankets, and staff acknowledged ongoing difficulties maintaining comfortable temperatures during seasonal transitions.
Two residents with cognitive impairments and psychiatric diagnoses received PRN anti-anxiety medications without documentation that non-pharmacological interventions were attempted beforehand. Staff interviews confirmed that such interventions were expected, and facility policy required alternatives to be incorporated into care plans, but records did not reflect these actions.
A resident with cognitive impairment and physical dependency was repeatedly observed without engagement in activities or sensory stimulation, despite care plans specifying regular one-to-one and group activities. Documentation and observations confirmed missed activity opportunities and a lack of consistent implementation of the resident's activity program.
A wound nurse did not clean a resident's trauma wound with normal saline solution before applying a new dressing, as required by the physician's order. The resident had multiple medical conditions and a care plan specifying wound care procedures, but the nurse omitted the cleaning step during a scheduled dressing change.
A wound nurse applied skin prep to an open pressure ulcer on a resident's hip, contrary to physician orders and standard practice, after observing the wound was open and had dried bloody drainage. The resident had multiple medical conditions and was not cognitively intact, with care plans requiring treatments as ordered. The error was confirmed by clinical leadership, who noted the wound was now a Stage 2 ulcer.
Two residents with limited ROM did not have physician-ordered anti-contracture devices in place as required. One resident with a left hand contracture was repeatedly observed without a palm protector or rolled wash cloth, despite orders and documentation indicating otherwise. Another resident with a contracted hand had no care plan or documentation of the ordered hand guard being applied or refused, and staff confirmed there was no system to record refusals or alternative interventions.
Two residents requiring oxygen therapy did not receive care in accordance with physician orders and care plans, including incorrect flow rates, lack of documentation on the MAR, and failure to document titration as ordered. Observations showed one resident adjusting her own oxygen without documentation, and another resident's oxygen flow rate was not recorded as required.
Expired Admelog and Lantus insulin pens were found on two medication carts during surveyor inspection. An LPN and an RN confirmed the insulins were past the 28-day usage period and should have been discarded. The facility was unable to provide a policy for insulin storage.
Surveyors observed an LPN discarding used lancets into a regular trash can instead of a sharps container during blood glucose testing for a resident, contrary to facility policy. Additionally, a wound nurse placed clean wound care supplies on dirty bedside tables and handled gauze with bare hands without performing hand hygiene before treating two residents with complex medical needs. The nurse consultant acknowledged the concerns.
Staff did not remain in the dining room to supervise residents with dementia and swallowing difficulties during meals, leaving them unsupervised while eating. A resident with dysphagia required supervision or assistance with eating, but staff left the area after serving food, and multiple staff interviews confirmed that supervision was expected but not provided.
The facility failed to provide adequate pressure ulcer care, resulting in the deterioration of ulcers for several residents. A resident's stage two ulcer worsened to stage four due to lack of interventions and physician notification. Another resident experienced delayed antibiotic treatment due to pharmacy communication issues. Additionally, treatments were not consistently documented, and a resident's refusal of care was not addressed with education or physician notification. A quadriplegic resident was not regularly repositioned, contributing to the deficiencies.
The facility failed to provide adequate ADL support and personal care for several residents, leading to issues such as unkempt hair, lack of mobility assistance, and poor hygiene. Residents were observed with greasy hair, dirty fingernails, and wearing the same dirty clothes for days. Care plans were not followed, and refusals of care were not documented, indicating systemic deficiencies in maintaining hygiene and personal care standards.
The facility failed to complete treatments as ordered, assess and monitor bruises, and document hospital transfers. Residents experienced lapses in medication administration and bowel management, and there was inadequate documentation of skin conditions and hospitalizations.
The facility failed to maintain clean and sanitary conditions for medication storage, with multiple medication carts and a storage room found in disarray. Loose pills were observed in the carts, and the storage room had a dirty floor and spillage on cabinets. Staff were unclear about cleaning responsibilities, contributing to the unsanitary conditions.
The facility failed to provide snacks to residents who requested them, as reported by eight residents during a Resident Council meeting. Despite the Dietary Manager's claim that snacks were prepared and delivered daily, CNAs working the second shift indicated that snacks were rarely available, particularly on weekends. The DON confirmed that snacks should be available daily for all residents who requested them.
A LTC facility failed to implement proper infection control practices, including not cleaning equipment after use, improper hand hygiene, and inadequate use of PPE. A resident's pressure ulcers were treated with ointment applied by a gloved hand instead of a sterile applicator. An LPN did not perform hand hygiene or wear an isolation gown while assessing a PEG tube site. A CNA used a soiled washcloth for a resident's gastrostomy tube and urinary catheter care. Additionally, a wound nurse did not change a soiled gown before wound treatment. These actions violated the facility's infection control policies.
The facility failed to maintain the dignity of two residents by allowing them to remain in hospital gowns during the day and posting a personal care sign above one resident's bed. One resident, with a history of pressure ulcers and dementia, was observed in a gown with a sign detailing care instructions, without a care plan addressing these issues. Another resident, with limited clothing and a history of acute kidney failure and dementia, was also observed in a gown, lacking a care plan for clothing preferences. The DON was unaware of these situations.
A resident did not receive medications at their preferred time due to an LPN's failure to administer them after the resident's smoking period. The resident, with a history of high blood pressure, heart failure, and COPD, typically received medications before or after smoking. The LPN disposed of the medications and reported them as refused, without attempting to administer them after smoking, as confirmed by the resident and DON.
A facility failed to assess a resident for self-administration of medications and lacked necessary Physician's Orders for medications found in the resident's room. The resident, who was cognitively intact, had medications including Gas-X, Systane eye drops, and Jet-Alert pills without a recent self-administration assessment or physician authorization. The ADON was unaware of these medications, and the facility's policy requiring a physician's order and assessment was not followed.
A resident reported the loss of two cell phones, but the facility failed to file a grievance form for the first missing phone and did not thoroughly investigate the issue. The resident, who was cognitively intact and had multiple diagnoses, reported the first missing phone to staff, but no grievance was filed. The ADON was aware of the first missing phone but not the second until later. A grievance form for the second phone was eventually filed with social services, but the Director of Social Services only received it on the day of the interview. A Nurse Consultant confirmed that a grievance form should have been filed for the first missing phone.
A resident, who was cognitively intact, was not invited to participate in their care planning conference. Despite having a comprehensive medical history, including kidney disease and dementia, the resident did not attend the meeting, and there was no documentation of an invitation. The Director of Social Services and the DON confirmed the oversight.
A resident at risk for falls due to cognitive impairment and other conditions experienced multiple falls because the facility failed to ensure proper use of Dycem pads in the resident's wheelchair. Observations showed the Dycem was incorrectly placed under the cushion, contrary to care plan interventions and physician's orders. Staff interviews revealed uncertainty about the correct placement of the Dycem, and the facility's Fall Prevention Program was not effectively implemented.
A facility failed to document meal consumption for a resident with a history of weight loss. The resident, who was cognitively impaired and on a mechanically altered diet, lost 8.87% of their weight over three months. The care plan required monitoring and recording of meal intake, but logs lacked documentation for several meals. The DON confirmed that staff should document meal consumption, but no policy was provided.
The facility failed to properly monitor and assess feeding tube sites for two residents. One resident had a peg tube site with drainage and was diagnosed with cellulitis, but there was no documented assessment before or after a doctor's visit. Another resident had redness and irritation around the gastrostomy tube site, which a CNA failed to report to the LPN. The facility lacked a policy for assessing peg tube sites and did not ensure CNAs reported skin changes as required.
The facility failed to provide adequate pain management for two residents due to unavailability of prescribed medications. One resident, with multiple diagnoses including fibromyalgia, experienced missed doses of MS Contin and Oxycodone-Acetaminophen. Another resident, with conditions such as depression and anemia, did not receive Tramadol over a weekend due to a missing prescription script. Staff interviews confirmed the medication shortages, and the DON acknowledged the issue.
A significant medication error occurred when an LPN mistakenly prepared four tablets of Amlodipine instead of the prescribed Furosemide for a resident. The error was identified before administration, preventing the resident from receiving five times the ordered dose of Amlodipine. The resident had a history of high blood pressure, heart failure, and COPD. The facility's policy emphasizes the Five Rights and a triple check process during medication preparation.
The facility failed to manage constipation and wound care for four residents. A resident with dementia did not receive prescribed constipation medication, while another with a toe wound lacked a care plan and consistent treatment. A third resident at risk for skin tears had improperly positioned geri sleeves, and a fourth resident's surgical wound dressing was not changed as ordered. The DON acknowledged these lapses in care.
The facility did not maintain comfortable temperature levels in the main dining room, affecting 7 residents who were observed wrapped in blankets or wearing coats. The temperature varied from 70 to 63 degrees Fahrenheit throughout the room, and residents reported feeling cold. The Director of Maintenance acknowledged the issue and indicated the temperature should be around 70-71 degrees Fahrenheit.
The facility failed to provide adequate ADL assistance for several residents, including bathing, incontinence care, nail care, and oral care. A resident with COPD did not receive the preferred bed baths, while another was left in wet clothing due to inconsistent incontinence care. Additional residents experienced neglect in personal hygiene, such as long, dirty fingernails and infrequent oral care, despite needing assistance due to medical conditions.
Resident Lacked Proper Bed Equipment and Headboard
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for a resident who was observed lying in bed without a headboard while his new bed was sitting in the hallway and was the wrong bed. The resident stated he had been without a headboard for months, that the facility knew about it, and that maintenance had come and ripped the broken headboard off the bed. He also stated he was almost 600 pounds and that the facility had ordered the wrong bed for him. The resident’s record showed diagnoses including high blood pressure, heart failure, COPD, and respiratory failure, and the Quarterly MDS dated 2/11/26 indicated he was cognitively intact for daily decision making and required supervision for bed mobility. The Maintenance Director stated the resident had refused attempts to place the delivered bed in his room and said the resident had broken three beds and had broken the headboard before because he used it to help himself get out of bed. The Administrator later confirmed the ordered bed had a maximum weight of 550 pounds while the resident weighed 571 pounds and acknowledged the concern that the bed would not accommodate the resident’s weight.
Elopement of Dementia Resident After Transfer Off Secured Unit Without Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to implement effective, resident-specific elopement interventions and provide adequate supervision for a resident with dementia and a known history of exit-seeking and wandering. The resident had multiple diagnoses including dementia, anxiety, unspecified psychosis, traumatic brain injury, bipolar disorder, cognitive communication deficit, difficulty walking, and depression, and was assessed as having severe cognitive impairment for daily decision-making. Elopement Risk and Community Survival Skills assessments indicated the resident should be on elopement risk protocol, and care plans documented that the resident had a history of exit-seeking and wandering, resided on a secured unit due to dementia, and required supervision when out in the community. Despite this, the resident was transitioned from a secured memory care unit to a less restrictive unit without a written plan for safe adjustment, and the care plan related to exit-seeking and wandering was not updated to reflect new interventions or the room change. The resident’s transfer from the secured unit to an unsecured unit occurred with the daughter/POA present, and documentation indicated the resident tolerated the move without distress and appeared to adjust appropriately. A wanderguard was ordered and documented as placed on the resident’s left ankle, and an order was written to observe the wanderguard every shift. However, staff on the new unit were not consistently aware that the resident was an elopement risk or that a wanderguard was in place. One CNA assigned to the resident’s hallway did not receive shift report, did not know there was a new resident in the room, and did not see the resident at all during the shift, only discovering an unmade bed and a cell phone in the room later in the evening. Another CNA saw the resident around lunchtime but did not check for a wanderguard because she did not know the resident had one. The activity aide, who took the resident outside for a scheduled smoking break, was also unaware that the resident was wearing a wanderguard or was an elopement risk. On the day of the incident, video surveillance showed the resident arriving at the front of the building in a silver car late in the morning and then walking away from the building a few minutes later; the administrator noted that no wanderguard was visible on the resident’s ankle in the video. The resident was later seen by the activity aide at a 1:00 p.m. smoke break and then was not seen again by staff. That evening, staff realized the resident was missing, a code pink was called, and extensive searches of the building and surrounding area were conducted by staff and later by law enforcement. The facility’s records showed the wanderguard was signed out for the evening shift even though the resident had already left the building, and the DON later indicated the wanderguard alarms did not sound because the resident had removed the device prior to exiting. The resident was ultimately located by police more than 24 hours after leaving the facility, disoriented and covered in dirt and moss, and was transported to the hospital for evaluation. The surveyors determined there were no 15-minute safety checks, no 72-hour charting or assessments to monitor safety and adjustment after the transfer off the locked unit, and no updated care plan interventions to address the resident’s elopement risk on the unsecured unit, leading to the resident’s unsupervised elopement. The immediate jeopardy was determined to have begun when the facility was unaware that the resident had exited the facility without supervision and continued until the resident was found by local police and transported to the hospital. The administrator and regional nurse consultant acknowledged during interview that there should have been more safety checks initiated for the resident after being moved off the locked memory care unit. The facility’s policy on Code Pink-Missing Resident/Elopement specified interventions for elopement risks such as wanderguard bracelets, increased monitoring including 15-minute visual checks or 1:1 supervision, and evaluation for a secured unit if appropriate, but these measures were not implemented or documented for this resident following the transfer to the unsecured unit. The surveyors concluded that the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision to prevent the resident’s elopement.
Failure to Provide Ordered Pressure Ulcer Treatments and Timely Skin Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer treatments and to complete a timely skin assessment upon a resident’s readmission. The resident had multiple diagnoses including COPD, respiratory failure, diabetes, arthritis, heart failure, and a history of pressure ulcers, and had documented pressure ulcers to the left buttock, right buttock, and left ischial tuberosity related to immobility, incontinence, obesity, fragile skin, and prior ulcers. A care plan directed staff to provide wound treatments and nutritional supplements and to assist with offloading the lower extremities. Physician’s orders dated 12/11/25 required nightly cleansing of the left and right buttocks with soap and water, application of zinc barrier cream mixed with antifungal ointment, and coverage with bordered gauze. The December 2025 TAR showed these treatments were not signed out on three consecutive days, indicating they were not documented as completed. Upon the resident’s return to the facility on 1/1/26, a nurse’s note documented that the resident arrived via stretcher, could make needs known, and that there were no changes in skin integrity, but the DON later confirmed that a skin assessment was not performed that day. A subsequent physician’s order on 1/2/26 directed nightly wound care with Dakin’s solution, Dakin’s-soaked gauze, calcium alginate, and bordered gauze. The January 2026 TAR indicated this treatment was not signed out on two consecutive nights. During interview, the DON acknowledged that the skin assessment should have been completed on the day of readmission and that the wound treatments should have been signed out, confirming the failure to follow physician’s orders and to complete a timely skin assessment for the resident with pressure ulcers.
Failure to Provide ADL Assistance and Dialysis Meal Support
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living, including shaving, nail care, and hair washing. Resident 5, who had altered mental status and mild intellectual disabilities and required supervision or touching assistance for personal hygiene and partial to moderate assistance with bathing, was observed on multiple occasions with an accumulation of facial hair despite stating he preferred to be clean shaven and needed a shave. Although a CNA acknowledged the resident needed one and said she would get him shaved, he remained unshaven during later observations. The DON stated the resident should have been shaved per his request. Resident 11, who was cognitively intact but dependent on staff for bathing and hair washing, stated her hair was not routinely washed every week and that she wanted it washed at least three times a week. Shower sheets for multiple bed baths showed the hair-washed section left blank or marked no, and there was no documentation that she refused hair washing. Her record also noted she was resistive to showers, wound care, and daily care, but nursing notes did not document refusals related to hair washing. The DON stated staff needed to document refusals for her hair being washed. Resident 6, who had stroke, vascular dementia, and was dependent on staff for personal hygiene and bathing, was repeatedly observed with a large amount of facial hair and dirty fingernails. He stated he preferred to be shaved, and on one occasion was observed after a shower with wet hair but without shaving or nail cleaning. A CNA later acknowledged his fingernails needed cleaning and indicated male residents were usually shaved on shower days. Resident 7, who had chronic kidney disease, diabetes, required ADL assistance, and was on dialysis, stated he went to dialysis three days a week and missed lunch on those days because the facility did not always pack him a lunch, causing him to wait until supper to eat. PT staff also reported he was not regularly getting a lunch to take with him to dialysis and sometimes came to therapy hungry after returning.
Failure to follow ordered wound care and monitor bruising, edema, and skin changes
Penalty
Summary
The facility failed to provide treatment and monitoring according to orders and documented care plans for multiple residents with skin conditions, bruising, edema, and a recent fall. For one resident with diagnoses including stroke, vascular dementia, long-term anticoagulant use, and atrial fibrillation, a skin tear on the right hand was ordered to be cleansed with normal saline, treated with bacitracin, covered with gauze, and wrapped with kerlix every Monday, Wednesday, and Friday. During treatment observation, the old dressing was removed and two pieces of Xeroform were found on the wound, and the wound nurse stated that was not the ordered treatment. The same resident was also observed with a large bruise to the left elbow, and staff were not aware of the bruise or that the resident was to wear long sleeves, geri sleeves, or tubi grips for fragile skin as identified in the care plan. For another resident with dementia, psychotic disorder, anxiety, heart disease, major depressive disorder, and heart failure, an unwitnessed fall occurred while self-transferring and the resident was found with swelling and bruising to the face. Documentation showed fall follow-up on two days after the fall, but there was no documentation of fall follow-up assessments or vital signs on the third day. A weekly skin observation form noted new skin concerns, but the section for describing the new bruised areas was left blank, and bruising to the face and chest was not documented until a physician order was entered 10 days after the fall. The DON stated fall follow-up was to be completed every shift for 72 hours, and the bruises and swollen face were not documented and monitored until the later order was placed. The facility also failed to monitor edema and skin changes for other residents. One resident with dementia and edema had visibly swollen legs during multiple observations, with socks deeply indented into the ankles, while weekly skin assessments were inconsistent and one assessment did not indicate edema despite a nurse practitioner documenting 2+ and 3+ edema. Another resident with fluid overload had visibly swollen ankles during repeated observations, but weekly skin assessments did not document edema. A resident with dementia and adult failure to thrive had several small open red bloody areas on the left upper arm and a large bruise on the left forearm, yet weekly skin assessments did not document those lesions or the bruise. The policy provided to surveyors stated that non-pressure skin conditions such as bruises, abrasions, lacerations, rashes, skin tears, and surgical wounds are to be assessed weekly for healing progress and signs of complications.
Incomplete clinical documentation for nutrition, PRN meds, oxygen use, and AMA discharge
Penalty
Summary
The facility failed to maintain complete and accurate clinical records related to resident food consumption for two residents reviewed for nutrition. For one resident with diagnoses including adult failure to thrive and edema, the quarterly MDS indicated cognitive intactness and the resident required supervision or one-person physical assistance with eating. The record showed weight loss from 166 pounds to 154 pounds, yet the food consumption monitoring in the electronic record had multiple missing entries for breakfast, lunch, and dinner on several dates. The DON stated the resident's food consumption should have been documented. For another resident with Parkinson's disease, dementia with behavioral disturbance, anxiety disorder, and a right femur fracture, the record showed PRN morphine and lorazepam orders. The MAR documented multiple administrations of PRN morphine and lorazepam by QMAs, but there was no documentation that the QMAs received authorization from a licensed nurse before giving the medications. The DON stated the QMAs were to document in the nursing progress notes that they received approval from the nurse to administer PRN medications. The facility also failed to document oxygen use and medication administration accurately for other residents. One resident with epilepsy, hypertension, and aphasia following a stroke was observed using oxygen by nasal cannula at two liters on multiple occasions, but the MAR was not signed out as oxygen being in use on those dates, and there was no care plan related to oxygen use. Another resident with CHF, chronic ulcers, anxiety, depression, and fibromyalgia had Oxycodone signed out on the controlled drug record many more times than on the MAR, and staff stated the medication needed to be signed out on both records. In addition, a closed record review found that a resident who left the facility against medical advice had no discharge note and no documentation that discharge planning, medication and treatment review, or notification of the emergency contact was completed before the resident left.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented related to the storage of urinals and wash basins, the disinfection of a glucometer, and medication handling during administration. Resident 59, who had diagnoses including adult failure to thrive and edema and was cognitively intact, was observed in bed with his urinal hanging from the side rail with urine in it on multiple occasions. The resident’s record did not include a care plan related to hanging the urinal from the bedside, and the DON stated the urinal should not have been hanging from the side rail with urine in it. During an environmental tour, uncontained wash basins, toothbrushes, razors, and a urinal were observed in shared bathrooms on the 100, 200, and 300 units, including basins on counters and floors and multiple basins stacked together. Staff stated the basins were supposed to be stored in plastic bags, and the facility policy indicated bedside equipment such as wash basins and urinals may be stored in separate plastic bags in shared bathrooms or otherwise placed in plastic bags and stored in a bedside cabinet or closet. In addition, an RN cleaned a glucometer with an alcohol wipe before and after testing Resident 88’s blood sugar, although the facility policy required the meter to be cleaned and disinfected between each resident test with a bleach solution. Another RN preparing medication for Resident 10 popped acetaminophen tablets into her bare hand before placing them in a medicine cup, and staff interviews confirmed the medication should have been dispensed into the cup rather than into bare hands.
Unsafe and Poorly Maintained Resident Areas and Medication Carts
Penalty
Summary
The facility failed to keep resident rooms, bathrooms, and common care areas clean and in good repair across Units 100, 200, and 300. During an environmental tour with the Maintenance Director and Housekeeping Supervisor, surveyors observed marred and gouged walls and door frames, dirty and dusty ceiling vents, dirty walls and windows, cobwebs, stained over-bed tables and floor mats, warped and peeling floor tile, missing paper towel dispenser covers, rusted and exposed toilet bolts, stained toilets, broken closet hardware exposing a sharp screw, a cracked and missing outlet cover, and other damaged or dirty surfaces in multiple resident rooms and bathrooms. Several rooms were shared by two or more residents, and the observations included bathrooms used by multiple residents. Specific findings included marred bathroom walls and dirty vents in Unit 100 rooms, dirty room walls and over-bed tables, rusty and uncovered toilet bolts, and a broken closet door hinge exposing a sharp screw. In Unit 200, surveyors observed corrosion around a faucet, cobwebs by a window, missing paper towel holder covers, exposed toilet bolts, missing drain plugs, warped floor tile, rust stains inside toilet bowls, a stained floor mat, marred bathroom and closet doors, and a toilet seat that did not completely cover the toilet. In Unit 300, surveyors observed warped and peeling bathroom floor tile, buckled bathroom door panels, marred walls and doors, a dried brown substance on a wall, a dirty over-bed table with a missing piece, brown stains inside toilet bowls, and a cracked outlet cover with missing pieces. Medication storage observations also identified broken medication cart drawers on multiple units. On Unit 300 Team 1 and Team 2 medication carts, on the 300/400 Unit Medication Cart 2, on 200 Unit Medication Cart 2, and on 100 Unit Medication Cart 1, surveyors observed cut-out broken areas on the top lip of the second drawer. On one cart, the drawer could still be pulled out slightly even when locked, allowing access to medication cards. Staff interviewed during the observation were unsure how long the damage had been present, and the DON stated the broken drawers should have been reported. A facility policy stated that lockable medication carts, cabinets, and drawers are to be acquired and maintained for proper medication storage, preparation, and administration, and that equipment deficiencies are to be reported to the DON.
Failure to Maintain Resident Dignity During Activities
Penalty
Summary
The facility failed to maintain dignity for two residents during observations in the 300 hall activity room. One resident, who had dysphagia, Parkinson's disease, and dementia without behavioral disturbance, was seated in a broda chair at a table with other residents while donuts and coffee were served. The resident was noted to be cognitively impaired for daily decision making and required partial to moderate assistance with eating. When the activity aide stated that he could not have a donut because he was on a pureed diet, no alternative food was offered, even though the resident's care plan listed snacks among his activity preferences. The Director of Nursing later stated the resident should have been offered pudding or something else. A second resident, who had dementia with behavioral disturbance, psychosis, and anxiety disorder, was observed seated in a broda chair at the same activity table with his shirt lifted up and his abdomen exposed. The resident remained in the activity room with his shirt still lifted up for nearly an hour, and no staff in the area attempted to pull it down. The resident's quarterly MDS indicated cognitive impairment for daily decision making and partial to moderate assistance with upper body dressing, and the care plan identified an ADL self-care mobility performance deficit with interventions including partial to moderate assistance with upper body dressing. The Director of Nursing stated the resident's shirt should have been pulled down.
Failure to Report Allegation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Agency for one resident reviewed for abuse. Resident 117 had diagnoses including depression, dementia, and unspecified psychosis, and the quarterly MDS dated 9/15/25 indicated severe cognitive impairment with moderate assistance needed for ADLs and supervision or touching assistance for transfers. A nurse's note dated 11/29/25 documented that a CNA observed the resident lose balance and fall to the floor after being pushed by another resident, with the resident complaining of discomfort to the left radial hand and receiving PRN pain medication. The note also stated the nurse practitioner, responsible party, on-call nurse, and DON were informed, and x-rays were obtained of the resident's left hand, wrist, and shoulder. A fall occurrence note dated 11/29/25 recorded that when asked what happened, the resident stated, "I don't know he pushed me." CNA 1 reported seeing Resident 117 on the floor and the other resident with hands up in a position like they had just recoiled from pushing the resident, and she reported the incident immediately to LPN 1. LPN 1 stated both CNA 1 and Resident 117 indicated the unnamed resident pushed Resident 117 and he fell to the floor. The Administrator and DON both stated they did not report the incident to the State Agency because they believed there was no injury and they could not prove intent, and the Administrator had not read the nurse's notes. A list of reportable incidents showed no incidents had been reported to the State Agency since 8/29/25.
Failure to Obtain Audiology Services for Resident With Hearing Loss
Penalty
Summary
Assist a resident in gaining access to vision and hearing services was deficient because the facility did not ensure a resident with hearing loss was seen by an Audiologist. Resident 9, who had diagnoses including dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure, told the surveyor she had asked to see an Audiologist a long time ago because she was having trouble hearing. The 11/27/25 Quarterly MDS indicated she was moderately impaired for daily decision making, had minimal difficulty hearing with no hearing aides, and required partial to moderate assistance with transfers. The record showed she signed consent to be seen by an Audiologist on 1/20/23, but as of 12/4/25 she had not been seen, and there was no care plan for any hearing difficulties. The Social Service Director stated on 12/8/25 that the resident had never seen an Audiologist, despite the facility having had Audiologists in the building several times since the consent was signed.
Fall Precautions Not Maintained for Resident With History of Falls
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 9 had diagnoses including dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure. The 11/27/25 MDS indicated the resident was moderately impaired for daily decision making, had minimal hearing difficulty, and needed partial to moderate assistance with sit-to-stand and bed-to-chair transfers. The care plan, revised on 11/17/25, identified a potential for falls and the planned approach was to place anti-skid strips next to the bed. On 11/14/25, the resident had an unwitnessed fall in her room while self-transferring. The resident stated she was sleep walking and was observed with swelling and bruising to her face; a nurse's note documented bruising to the face, neck, and upper chest. The IDT fall note stated the resident said she rolled out of bed, frequently sat on the side of the bed and leaned over, and wore new crocs as clogs that slipped when she leaned too far to the side while sleeping. During interview and observation, the resident reported a recent fall while trying to transfer herself from bed into her wheelchair and had redness still present on her upper chest. The non-skid strips by the bed were observed to be missing in several spots, and the DON later indicated she thought maintenance had been told to replace them.
Delayed Treatment of UTI Symptoms
Penalty
Summary
The facility failed to ensure signs and symptoms of a urinary tract infection were treated in a timely manner for a resident with dysphagia, Parkinson's disease, and dementia without behavioral disturbance. The resident's Significant Change MDS, dated 9/16/25, indicated cognitive impairment for daily decision making, partial to moderate assistance with eating, and urinary incontinence. On 11/25/25, nursing documented blood-tinged urine in the resident's brief and hospice was contacted about obtaining a urine specimen. On 11/26/25, hospice attempted a urine dipstick collection but could not obtain a sample, and the resident's sister declined straight catheter collection and agreed to observe for further changes. The sister also expressed concern that the resident was not drinking water because he could not hold it. On 11/27/25, nursing documented decreased urine output with pus and blood present, and hospice was notified again to contact the resident's sister about proceeding with straight catheterization. On 11/28/25, hospice obtained a small amount of urine for dipstick testing; the urine was thick, red, odorous, and contained pus, and the dipstick could not be read. The nurse practitioner was notified and orders were received and faxed to the pharmacy. During interview, the Corporate Infection Preventionist stated the antibiotic should have been started on 11/28/25, but the physician's order for Nitrofurantoin oral suspension was dated 12/5/25.
Oxygen and Nebulizer Treatment Orders Not Followed
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident who was ordered oxygen at 3 liters via nasal cannula every shift. Resident 127, who had diagnoses including chronic respiratory failure with hypoxia and COPD and was cognitively intact, was observed on multiple occasions with oxygen in place but the concentrator flow rate set between 2 and 2.5 liters instead of 3 liters. The resident was also observed sitting in a wheelchair in the hallway without oxygen and without a portable oxygen tank attached to the wheelchair. The ADON stated the resident was supposed to be on 3 liters of oxygen and that nursing should have ensured oxygen was administered at all times per the physician's order. The facility also failed to document required pre- and post-nebulizer assessments for another resident receiving respiratory treatment. Resident 14, who had COPD and fluid overload and was cognitively intact, had an order for ipratropium-albuterol solution every 4 hours and a separate order requiring pulse, respirations, and O2 saturations before and after each treatment. During observation, the resident reported not yet receiving the morning nebulizer treatment, and the treatment was then initiated by QMA 1 and completed with LPN 2 removing the mask afterward. No assessments were observed before or after the nebulizer treatment, and the record lacked documentation of those assessments. The DON stated assessments should be done before and after each nebulizer treatment, and the facility policy required baseline and post-treatment pulse, respiratory rate, and lung sounds to be obtained and documented.
Failure to Provide Dental Services and Denture Follow-Up
Penalty
Summary
The facility failed to ensure that routine dental services were provided for a resident with altered mental status and mild intellectual disabilities. The resident was observed with multiple missing teeth and stated it had been a long time since he had seen a dentist. Although a physician’s order allowed dental care as needed and the facility documented multiple visits by the dentist and dental hygienist, there was no documentation that the resident actually received any dental visit after the order was obtained. The Social Service Director stated the resident had refused his last dental visit, but neither she nor the contracted dental group had a date for that visit, and the resident was placed on the list to be seen later. The facility also failed to complete follow-up for another resident who had extensive dental extractions and still had no dentures. The resident, who had dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart failure, reported that her teeth had been removed months earlier and she still had no dentures. Dental notes showed multiple extractions, remaining root tips, and later documentation that the bone level was not sufficient for dentures and that implants would be needed if she wanted dentures. Social service notes showed messages and follow-up attempts regarding dental services, but the resident was not seen by the dentist during several facility visits, and the Social Service Director stated she was unaware of some of the resident’s dental follow-up needs until later.
Failure to Notify Family of Changes in G-Tube Status and Treatment
Penalty
Summary
A deficiency occurred when the facility failed to notify a dependent resident's family or representative of significant changes related to a dislodged gastrostomy tube (g-tube) and new antibiotic orders. The resident in question had severe cognitive deficits, was dependent for bed mobility and transfers, and had a care plan indicating impaired cognition with the family managing her care. Despite this, the resident was listed as her own responsible party in the facility's records, and her family members were only listed as emergency contacts. On multiple occasions, nurse notes documented significant events, including the dislodgement of the g-tube and the initiation of antibiotic therapy for a g-tube site infection. While the nurse practitioner and physician were notified and the resident was noted as being aware, there was no documentation that the family or representative was informed of these changes. An interview with the Nurse Consultant confirmed that the resident should not have been listed as her own responsible party, as the family was managing her care.
Failure to Administer Antibiotics and Wound Care as Ordered
Penalty
Summary
The facility failed to provide necessary care and treatment as ordered for three residents with infections or wounds. For one resident with severe cognitive deficits and a g-tube, physician orders for two antibiotics were not followed, as the medications were not administered on a specified evening, and there was no documentation or explanation for the missed doses. The nurse consultant was unable to provide further information regarding the omission. Another resident, who was cognitively intact and admitted with a surgical hip wound, did not receive wound care and dressing changes as ordered. Documentation showed incomplete wound assessments, with missing details about the wound's condition and progress. The treatment administration record did not reflect that dressing changes were performed according to physician orders, and weekly wound assessments were not consistently completed as required by facility policy. The nurse consultant confirmed that orders and documentation were not followed as directed. A third resident, also cognitively intact and receiving IV antibiotics for an abdominal abscess, did not receive several scheduled doses of meropenem as ordered. The medication administration record indicated missed doses on multiple occasions, with no explanation or documentation provided for these omissions. The nurse consultant was unable to offer additional information regarding the missed antibiotic administrations.
Failure to Provide Scheduled Showers and Document ADL Care for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including diabetes, adult failure to thrive, and a chronic non-pressure skin ulcer, who was cognitively intact but required maximal assistance with activities of daily living (ADLs) and transfers, did not receive the required showers or baths as outlined in their care plan. The care plan specified that the resident needed assistance from 1-2 staff members to shower and was scheduled to receive a bath or shower twice weekly, on Tuesday and Friday evenings. Record review revealed a lack of documentation for bathing from July 1 to July 29, with no evidence of bathing or refusals on several scheduled dates, and no documented attempts to reschedule when the resident was unavailable or refused. During interview, the Director of Nursing acknowledged the need for staff education on documentation but did not provide further information.
Failure to Follow Physician's Wound Care Orders
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to complete wound care treatment as ordered for a resident with a non-pressure related skin condition. During direct observation, the LPN cleansed and dressed the resident's right shin skin tear but omitted the application of skin prep, which was specified in the physician's order. The resident involved had diagnoses including dementia and cerebral infarction, was severely cognitively impaired, and was on hospice care. The physician's order required cleansing with normal saline or wound wash, patting dry, applying skin prep, xeroform, and a dry dressing on a set schedule. The LPN acknowledged during interview that the skin prep was not applied during the wound care procedure.
Unlicensed Staff Administered Medications on Midnight Shift
Penalty
Summary
The facility failed to ensure that only licensed and qualified personnel administered medications according to each resident's written plan of care for five memory care residents during the midnight shift. Multiple residents with diagnoses including dementia, hypothyroidism, psychotic disorder, and severe intellectual disabilities received medications that were prepared, poured, and administered by an unlicensed staff member, specifically a CNA, rather than a licensed nurse as required by facility policy and physician orders. Medication administration records showed that medications such as Levothyroxine, Omeprazole, and Carbidopa-Levodopa were signed out under the name of an LPN, but were actually administered by the CNA using the LPN's login credentials. The incident occurred when the assigned LPN on the 100 unit experienced a medical emergency and left the facility, leaving the medication cart keys with a CNA. The CNA contacted the on-call scheduler and was later told that another LPN from a different unit would oversee the 100 unit. The CNA then obtained the LPN's login credentials and proceeded to administer medications to five residents, documenting the administration under the LPN's name. The LPN in question denied providing her credentials, but the CNA's statement and camera footage confirmed that the CNA prepared, poured, and administered the medications. The residents involved were not cognitively intact for daily decision-making, as indicated by their Minimum Data Set (MDS) assessments, and required medications to be administered by licensed personnel according to physician orders. The facility's policy stated that only persons legally authorized could administer medications, but this policy was not followed during the incident. The Director of Nursing confirmed that no staff, including the scheduler, notified her of the situation, and the deficiency was identified through review of records, staff statements, and video evidence.
Food Service Lacked Sanitary Practices on Memory Care Unit
Penalty
Summary
Staff on the memory care unit failed to maintain sanitary conditions during food service, as observed during multiple meal times. Certified Nursing Assistants (CNAs) and a Qualified Medication Aide (QMA) were seen plating and serving food without using proper barriers, such as tongs or gloves, and handled toast with their bare hands. Additionally, food was transported uncovered through hallways and between dining areas, contrary to facility policy and professional standards. These practices were observed during both breakfast and lunch meal services, affecting all residents on the unit. The Dietary Food Manager confirmed that staff were instructed not to touch food with bare hands and that food should be covered during transport. The facility's policy requires all food to be covered when moved from the kitchen to other areas and for items to remain covered until they reach the resident. Despite these guidelines, staff continued to handle food improperly and transport it uncovered, impacting the sanitary conditions of food service for all 27 residents on the memory care unit.
Failure to Maintain Safe and Comfortable Temperatures on Memory Care Unit
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for all 27 residents on the memory care unit. Residents reported that the unit had been very cold recently, and staff confirmed that the heat was turned off earlier in May. Observations showed residents in common areas and their rooms dressed in long sleeves, sweaters, and using blankets, with ambient air temperatures ranging from 68 to 71 degrees. The dining room and several resident rooms were specifically noted to be on the lower end of this range, with some rooms as cold as 68 degrees. Staff interviews confirmed that the heating system, which is a boiler system, was routinely shut off in May, and that the facility often struggles to maintain comfortable temperatures during transitional months. Despite staff ordering warming blankets for residents due to the cold weather, these had not yet arrived at the time of the survey. Staff also used a portable heating element behind the nursing station to address the cold, primarily for staff comfort. The Maintenance Director and Administrator acknowledged the limitations of the facility's heating and cooling system and the impact on resident comfort, especially when outside temperatures dropped overnight. The deficiency was identified during a complaint investigation and was substantiated by both resident and staff interviews as well as direct temperature measurements.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were documented and attempted prior to administering PRN anti-anxiety medications for two residents. For one resident with diagnoses including major depressive disorder, anxiety, psychotic disorder, dementia, and Parkinson's disease, records showed that Ativan was administered on two occasions without any documentation of non-pharmacological interventions being attempted beforehand. The care plan indicated the use of anti-anxiety medication as needed, but there was no evidence in the medication administration record that alternatives were tried prior to medication administration. The Director of Nursing confirmed that such documentation should have been completed. For another resident with a history of stroke, dementia, psychotic disorder, and other conditions, Lorazepam was administered multiple times for behaviors such as yelling, rambling, and increased anxiety. On each occasion, there was no documentation that non-pharmacological interventions were attempted before giving the medication. Staff interviews confirmed that interventions such as offering food, changing position, or checking for incontinence were expected prior to medication administration, but these were not documented. The facility's policy required that alternatives to psychotropic medication be incorporated into the care plan, but this was not reflected in the records reviewed.
Failure to Provide Ongoing Activity Program for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement an ongoing activity program to meet the needs of a cognitively impaired and dependent resident. Multiple observations over several days showed that the resident, who has diagnoses including Parkinson's disease and vascular dementia with behavioral disturbance, was frequently in bed with her eyes open, facing the wall, and without any sensory stimulation such as television or music. The resident was also observed seated in a broda chair near the nurses' station but again without engagement in activities. Documentation revealed that the resident was to receive one-to-one visits three times weekly and enjoyed activities such as watching birds, listening to music, coloring, and sensory programming. However, there was no evidence of consistent activity participation or documentation for several days, and the resident was not observed participating in scheduled group activities, such as glamour nails. The resident's care plan and activity assessments indicated a reliance on staff for social, physical, mental, and sensory stimulation, with specific interventions outlined to encourage participation in both group and one-to-one activities. Despite these plans, records and direct observation showed a lack of implementation, with gaps in activity documentation and missed opportunities for engagement. The Activity Director acknowledged the oversight and indicated an intention to address the lack of stimulation, but at the time of the survey, the deficiency remained unaddressed.
Failure to Follow Physician's Wound Care Orders
Penalty
Summary
A wound nurse failed to follow a physician's order for wound care for a resident with a trauma-related wound on the right anterior heel. During a bandage change, the nurse removed the dirty dressing and applied a new dry dressing without first cleaning the wound with normal saline solution (NSS) as specifically ordered by the physician. The resident's medical record indicated diagnoses including after care following joint replacement, COPD, seizures, and obstructive sleep apnea, and the resident was assessed as moderately intact for daily decision making. The physician's order required the wound to be cleaned with NSS, patted dry, covered with a non-adherent pad, and wrapped with kerlix dressing on a set schedule. The care plan also directed staff to administer treatments as ordered and follow facility protocols for skin breakdown prevention and treatment. The nurse indicated she believed she had completed the procedure correctly, despite omitting the required wound cleaning step.
Inappropriate Pressure Ulcer Treatment Provided
Penalty
Summary
A deficiency was identified when a wound nurse failed to provide appropriate treatment for a resident with an existing pressure ulcer. During a treatment observation, the nurse applied skin prep directly to an open pressure ulcer on the resident's right hip, despite skin prep being intended only for intact skin and not for open wounds. The nurse had removed a bandage with dried bloody drainage and noted the wound was red and open, then proceeded to clean the wound with normal saline, pat it dry, and apply the skin prep before covering it with a foam bandage. The nurse indicated this was the first time the wound was open. The resident involved had multiple diagnoses, including stroke, dementia, protein malnutrition, psychotic disorder, osteoporosis, and high blood pressure, and was not cognitively intact for daily decision making. The care plan required treatments to be administered as ordered. Physician orders specified different treatments for the left and right hips, with the right hip to be cleaned, dried, have barrier film applied, and then covered. However, the nurse applied skin prep to the open right hip wound, contrary to the order and standard practice. Interviews confirmed the wound was now a Stage 2 pressure ulcer and that skin prep should not have been used on the open area.
Failure to Provide Physician-Ordered Anti-Contracture Devices for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) had physician-ordered anti-contracture devices in place as required. For one resident with a contracture of the left hand and wrist due to hemiplegia following a stroke, observations on multiple occasions revealed the resident's left hand was closed in a fist without a palm protector or rolled wash cloth in use, despite a physician's order for a palm protector as tolerated. The care plan indicated the resident sometimes refused the splint but would accept a rolled wash cloth, yet neither device was observed in use. Documentation on the treatment administration record indicated the palm protector was applied, but this was not consistent with direct observations. The Director of Nursing confirmed that staff should not have documented the device as applied if it was not in use. For another resident with a history of dementia, osteoarthritis, and stroke, repeated observations showed the resident's left hand was tightly closed without an anti-contracture device in place. Although there was a physician's order for a hand guard as tolerated, there was no care plan addressing the contracted hand, and no documentation on the administration records of the device being applied or refused. Staff interviews confirmed the resident often refused the device, but there was no system in place to document refusals or alternative interventions. The Director of Nursing acknowledged attempts to use alternative devices in the past, but there was no documentation of their use.
Failure to Ensure Safe and Documented Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including psychotic disorder, dementia, COPD, and hypertension, observations showed she was using oxygen at four liters via nasal cannula, despite a physician's order for three liters continuously. The resident was seen adjusting her own oxygen levels, and this change was not documented. Additionally, the Medication Administration Records (MAR) from January through May did not show that oxygen therapy was signed out, and care plans indicated the need to monitor and administer oxygen as ordered. For another resident with diagnoses such as diabetes, asthma, dementia, and depression, observations revealed she was on three liters of oxygen via nasal cannula, with a physician's order to administer oxygen at three liters as needed and to titrate up to four liters to maintain oxygen saturation above 90%. The MAR indicated PRN oxygen was signed out, but there was no documentation of the flow rate as required by the titration order. The care plan required monitoring and use of oxygen as ordered, but the lack of documentation and adherence to the prescribed flow rates contributed to the deficiency.
Expired Insulin Pens Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and timely disposal of expired medications on two of five medication carts inspected. On one cart, two Admelog SoloStar insulin pens were found with open dates and expiration dates indicating they were past the 28-day usage period; the LPN present confirmed both pens were expired and should have been discarded. On another cart, a Lantus SoloStar insulin pen was also found to be expired, with the RN present acknowledging it should have been discarded. Additionally, the facility was unable to provide a policy related to the storage of insulins during the survey. These findings demonstrate that expired medications were not removed from active medication carts as required, and there was a lack of documented policy regarding insulin storage.
Infection Control Lapses in Sharps Disposal and Wound Care Supply Handling
Penalty
Summary
The facility failed to implement proper infection control practices during blood glucose monitoring and wound care procedures. In one instance, an LPN performed a blood sugar check for a resident and discarded used lancets into a regular garbage can instead of a designated sharps container, despite facility policy requiring sharps to be disposed of in a non-porous hazardous waste container marked with the biohazard symbol. The LPN acknowledged the error during an interview. Additionally, during wound care for two residents, a wound nurse placed clean treatment supplies directly onto dirty bedside tables that were littered with crumbs and personal belongings. In one case, the nurse handled clean gauze with bare hands and did not perform hand hygiene after leaving and returning to the treatment cart. Supplies were then placed on the unclean table before being moved to a clean drape. Both residents involved had significant medical histories, including pressure ulcers and chronic conditions, and required substantial assistance with mobility and care. The nurse consultant confirmed awareness of the concerns but did not provide further information.
Failure to Supervise Memory Care Residents During Meals
Penalty
Summary
Staff failed to provide adequate supervision to residents in the memory care unit during meal times, resulting in residents being left unsupervised while eating. On two separate lunch meal observations, staff members served food to the residents and then left the dining room, leaving all residents, including one with dysphagia and dementia, without supervision. At various times, staff such as CNAs, LPNs, and QMAs entered the dining room briefly but did not remain to supervise the residents as they ate. There were periods when no staff were present in the dining room while residents were consuming food and beverages. A review of the medical record for one resident revealed diagnoses of dysphagia and dementia, with an assessment indicating the need for supervision or assistance with eating. A family member reported concerns about the lack of supervision during meals, expressing fear that a resident could choke. Interviews with staff and administration confirmed that staff were expected to remain in the dining room during meals, but this did not occur on the observed dates.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide effective pressure ulcer care and prevent the deterioration of existing ulcers for several residents. Resident F was readmitted with a stage two pressure ulcer on the coccyx, which deteriorated to a stage four ulcer requiring surgical debridements. The facility did not implement interventions for pressure relief, failed to notify the physician of the wound's deterioration, and did not ensure treatments were signed out as completed. Additionally, antibiotics for a wound infection were not started promptly, and the physician was not notified of treatment refusals. Resident E, who had a history of stroke and vascular dementia, had a stage four pressure ulcer on the coccyx that worsened. The facility delayed the initiation of an antibiotic treatment due to a lack of communication with the pharmacy regarding the availability of the medication. The treatment was not started until three days after it was ordered, and there was no documentation of the conversations with the pharmacy or the change in medication form. Resident T had multiple pressure ulcers, and the facility failed to document the completion of treatments on several occasions. Resident O, who was cognitively intact, refused wound treatments, but there was no documentation of physician notification or education provided to the resident about the importance of the treatments. Resident H, who was quadriplegic, was not regularly turned and repositioned, as indicated by the resident's statements and observations. The facility's inaction and lack of documentation contributed to the deficiencies in pressure ulcer care.
Deficiencies in ADL Support and Personal Care
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for several dependent residents, leading to various deficiencies in personal care. Resident Q was observed with greasy, unkempt hair and a strong urine odor, indicating a lack of timely incontinence care. Despite being cognitively impaired and requiring substantial assistance, the resident's care plan was not followed effectively, as evidenced by the resident's refusal of showers and the staff's failure to maintain hygiene standards. Resident P was observed in bed for several days without being assisted into her wheelchair, despite her care plan indicating the need for substantial assistance with transfers. This lack of mobility assistance was acknowledged by the Director of Nursing, who confirmed that the resident had not been helped out of bed all week. Similarly, Resident G was found with dirty fingernails and a dried substance on her face, highlighting a failure in personal hygiene care. The resident's care plan did not document any refusal of care, and the staff did not maintain cleanliness standards. Other residents, such as Resident C, had long fingernails digging into their palms, and Resident F had long facial hair, both indicating a lack of personal grooming. Resident H was given a bed bath without assistance, resulting in the resident's face hitting a call light, which was against the care plan's instructions to prevent injury during transfers. Resident R was observed wearing the same dirty shirt for several days, with greasy hair and dried blood under the nails, despite being cognitively intact and requesting a shower. These observations collectively demonstrate a systemic failure in providing adequate ADL support and personal care to the residents.
Deficiencies in Treatment, Medication Management, and Documentation
Penalty
Summary
The facility failed to ensure that treatments were completed as ordered and that bruises were assessed and monitored for several residents. For instance, a resident with a scabbed area below the right knee and discoloration on the right lower shin did not have the prescribed dressing applied, and there was no assessment of the discoloration. Additionally, medications were not signed out as administered on multiple occasions, indicating a lapse in medication management. Another resident experienced prolonged periods without bowel movements, yet the facility did not initiate the bowel protocol as required by their policy. This resident, who was on opioid medication, was at risk for constipation, but there was no documentation of any as-needed laxatives being administered during the periods of constipation. Similarly, other residents had bruises and skin conditions that were not assessed or documented, despite being on medications that increased the risk of such conditions. Furthermore, the facility failed to document the condition and reason for hospitalization for a resident who was transferred to the hospital multiple times. There was no record of assessments or notifications to family or physicians regarding the resident's condition prior to transfer. This lack of documentation and monitoring highlights significant deficiencies in the facility's care and record-keeping practices.
Improper Medication Storage and Sanitation Issues
Penalty
Summary
The facility failed to ensure medications were stored in clean and sanitary conditions across multiple medication carts and a storage room. Observations revealed that medication carts on the 200, 300, and 400 halls contained multiple loose pills of various sizes and colors in the bottoms of the drawers, indicating improper storage and potential contamination. Staff members, including an LPN, a QMA, and RNs, were observed with these carts and expressed uncertainty about who was responsible for cleaning them. This lack of clarity contributed to the unsanitary conditions observed. Additionally, the medication storage room on the 200 hall was found to be in a state of disrepair and uncleanliness, with a visibly dirty floor, missing tiles, exposed adhesive, trash, and dark-colored spillage on the cabinet doors. The QMA accompanying the surveyor was unaware of the cleaning responsibilities for the room, noting that housekeeping did not have access to it. The Director of Nursing and a Nurse Consultant were informed of these findings, with the DON expressing uncertainty about the cleaning responsibilities for the medication storage rooms.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were available for residents who requested them, affecting all eight residents who attended a Resident Council meeting. These residents, who were cognitively intact for daily decision-making, reported that they never received snacks when they asked for them. The Dietary Manager stated that snacks were prepared daily and delivered by 7:30 p.m., with enough for every resident, but CNAs working the second shift reported that snacks were rarely available, especially on weekends. The Director of Nursing confirmed that snacks should be available every day for all residents who requested them.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. During a random observation, a CNA used a Hoyer lift to transfer a resident without cleaning it afterward. Additionally, a wound nurse applied ointment to a resident's pressure ulcers using her gloved hand instead of a sterile applicator. The resident had multiple health issues, including morbid obesity, diabetes, and pressure ulcers. The nurse consultant acknowledged that the wound nurse should have used a different method to apply the ointment. In another instance, an LPN did not perform hand hygiene before and after glove removal while assessing a resident's PEG tube stoma site. The LPN also failed to wear an isolation gown as required by the facility's Enhanced Barrier Precautions policy. The resident had a PEG tube and was not cognitively intact, relying on the tube for nutrition. The Director of Nursing confirmed the LPN's awareness of the proper procedures but did not provide additional information. Further observations revealed a CNA using a soiled washcloth to clean a resident's gastrostomy tube site and urinary catheter, without changing gloves or water. The resident had quadriplegia and a stage 4 pressure ulcer. Additionally, a wound nurse did not change her soiled gown before starting a wound treatment after providing incontinence care to another resident. The nurse consultant expected a gown change, but the wound nurse was unaware of the soiling. These incidents highlight the facility's failure to adhere to infection control policies, as confirmed by staff interviews and policy reviews.
Failure to Maintain Resident Dignity in Attire and Personal Care
Penalty
Summary
The facility failed to maintain the dignity of two residents, identified as Residents P and F, by allowing them to remain in hospital gowns during the day while in bed, and by posting a personal care sign above Resident P's bed. Resident P was observed multiple times over several days wearing a hospital gown and having a sign above her bed that detailed specific care instructions. Her medical history included pressure ulcers, major depressive disorder, and dementia, and she required significant assistance with dressing. Despite these needs, there was no care plan addressing her attire or the presence of the sign, and the Director of Nursing acknowledged that the resident should have been dressed and the sign removed. Similarly, Resident F was observed in a hospital gown during the day on multiple occasions. This resident had a medical history of acute kidney failure, diabetes, and dementia, among other conditions, and required assistance with personal hygiene and dressing. The resident's care plan did not reflect any preference for wearing a hospital gown during the day. A CNA noted that the resident had limited clothing, which was provided by the social service department, and the Director of Nursing was unaware of the resident's attire situation, indicating a lack of a care plan for the resident's clothing preferences.
Failure to Administer Medications at Resident's Preferred Time
Penalty
Summary
The facility failed to ensure a resident's right to participate in his care by not administering medications during the resident's preferred time window. On the morning of December 11, 2024, an LPN prepared a set of medications for a resident who was outside smoking. The medications included Amlodipine Besylate, Furosemide, Losartan Potassium-HCTZ, Aspirin, Flomax, Metformin, Sertraline HCl, Trelegy Ellipta, Metoprolol Tartrate, and Potassium Chloride. The LPN attempted to deliver the medications to the resident at the smoking area, but the resident indicated he had just started smoking. Instead of waiting to administer the medications after the resident finished smoking, the LPN disposed of the medications and reported to the Nurse Practitioner that the resident had refused his morning medications. The resident's medical record indicated a history of high blood pressure, alcohol use, heart failure, COPD, and tobacco use. The Medication Administration Record for December 2024 noted the resident's refusal of morning medications on December 11, 2024, without evidence of an attempt to administer them after the smoking period. Interviews with the resident and the Director of Nursing revealed that the resident typically received medications before or after smoking, which was his preference. The Director of Nursing acknowledged the importance of the smoking time to residents and indicated that the nurse should have offered the medications before or after the designated smoking time.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications and lacked the necessary Physician's Orders for the medications observed in the resident's room. Resident 60, who was cognitively intact according to the Quarterly Minimum Data Set assessment, was observed with a package of Gas-X, Systane eye drops, and a bottle of Jet-Alert pills on a shelving unit in her room. Despite the resident's indication that she used the Systane eye drops and would use Gas-X as needed, there was no recent medication self-administration assessment completed to confirm her ability to safely self-administer these medications. The Medications Self-Administration Assessment dated several months prior indicated that the resident was unable to safely self-administer her medications. The Assistant Director of Nursing (ADON) was unaware of the medications in the resident's room and confirmed that there were no Physician's Orders for these medications. The facility's policy requires a written order from the attending physician and a completed self-administration assessment to permit a resident to administer or retain medications in their room, which was not adhered to in this case.
Failure to File and Investigate Grievances for Missing Personal Items
Penalty
Summary
The facility failed to properly file a grievance form, thoroughly investigate, and resolve grievances related to missing personal items for a resident. Resident S reported the loss of two cell phones, with the first phone reported to staff at the nurses' station. However, no grievance form was filed for the first missing phone. The resident was cognitively intact, as indicated by the Quarterly Minimum Data Set assessment, and had diagnoses including anxiety, respiratory failure, kidney disease, and depression. The Assistant Director of Nursing (ADON) on the 300 Unit was aware of the first missing phone but was not informed about the second missing phone until later. A grievance form for the second missing phone was eventually filed with social services. The Director of Social Services confirmed that she received the grievance form for the missing phone only on the day of the interview. A Nurse Consultant indicated that a grievance form should have been filed for the first missing phone, highlighting the facility's failure to adhere to its grievance policy.
Resident Not Invited to Care Plan Conference
Penalty
Summary
The facility failed to ensure that a resident was invited to attend and participate in their care planning conference. Resident U, who was cognitively intact for daily decision-making as indicated by the Quarterly Minimum Data Set (MDS) assessment, reported not attending a care plan meeting. The resident's medical history included kidney disease, asthma, respiratory failure, depression, and dementia. A Care Plan Progress Note documented a meeting between the Director of Social Services and the resident's son regarding the resident's quarterly assessment, but there was no evidence that the resident was invited to or attended the care conference. Interviews with the Director of Social Services and the Director of Nursing confirmed that the resident was not invited to the care plan conference, which was an oversight.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for Resident J, who was at risk for falls due to cognitive impairment and other medical conditions such as hypertension, dementia, and depression. Observations revealed that the resident's wheelchair had a Dycem pad placed incorrectly underneath the cushion, rather than on top, which was intended to prevent the resident from sliding off the wheelchair. This improper placement of the Dycem pad was identified as the root cause of two previous falls, one of which resulted in a major injury. Despite a physician's order and care plan interventions specifying the use of Dycem in the wheelchair, staff were unsure of its correct placement, leading to inadequate fall prevention measures. Interviews with staff, including CNAs and an LPN, indicated a lack of clarity and education regarding the proper use of Dycem pads. The Director of Nursing acknowledged that staff did not consistently check the presence and correct placement of the Dycem pad, contributing to the resident's falls. The facility's Fall Prevention Program policy required safety interventions for residents at risk, but these were not effectively implemented or maintained, as evidenced by the repeated incidents involving Resident J.
Failure to Document Meal Consumption for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for a resident with a history of weight loss. Resident 3, who had diagnoses including dementia, hypertension, anxiety, bipolar disorder, and schizophrenia, was cognitively impaired and required partial to moderate assistance for eating. The resident was on a mechanically altered therapeutic diet. The care plan for the resident, which was revised on 12/22/21, included interventions to monitor and record meal intake and report any significant weight loss to the physician. Despite these interventions, the resident experienced an 8.87% weight loss over three months, dropping from 191.6 lbs to 174.6 lbs. The Task Nutrition-Amount Eaten Logs lacked documentation for several meals over the last 30 days, including breakfast and lunch on 12/3/24 and multiple dinners in November and December. During an interview, the Director of Nursing confirmed that staff should document the amount eaten for every meal, but no facility policy was provided for meal consumption logs.
Failure to Monitor and Report Feeding Tube Site Conditions
Penalty
Summary
The facility failed to ensure proper monitoring, assessment, and cleaning of feeding tube sites for two residents, Residents C and H. For Resident C, during an observation, it was noted that the peg tube stoma site had a bandage that was sticking to the skin, requiring saline to remove it. The stoma site was clean but had a moderate amount of drainage. The resident's care plan required monitoring and documentation of infection at the tube site, but there was no documented assessment of the peg tube stoma site before or after a doctor's visit for a possible infection. The resident was diagnosed with cellulitis at the gastrostomy tube site and was prescribed antibiotics, but the facility lacked a policy regarding assessing the peg tube site. For Resident H, during a bed bath, a CNA observed redness and irritation around the gastrostomy tube site but failed to report it to the LPN before leaving the building. The resident's care plan required CNAs to report any changes in skin status, and the facility's bed bath policy also required reporting of any reddened areas or skin discoloration. The Director of Nursing was informed of the findings but had no further information to provide.
Deficiency in Pain Medication Availability for Residents
Penalty
Summary
The facility failed to ensure the availability of pain medications for two residents, leading to deficiencies in pain management. Resident K reported issues with the facility running out of her scheduled pain medications. Her medical record indicated she had multiple diagnoses, including fibromyalgia and major depressive disorder, and was prescribed MS Contin and Oxycodone-Acetaminophen for pain management. However, the Medication Administration Record (MAR) showed instances where these medications were not administered due to unavailability, as confirmed by the Director of Nursing. Similarly, Resident 101 experienced a lack of pain medication over a weekend, resulting in unmanaged pain. Her diagnoses included depression, anxiety, and anemia, and she was prescribed Tramadol for pain. The MAR indicated that Tramadol was not administered on two consecutive days. Interviews with staff revealed that the medication was ordered but not available due to a missing prescription script, which required the physician's intervention. The Director of Nursing acknowledged the issue but had no further information to provide.
Significant Medication Error Due to Incorrect Drug Dispensing
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a significant medication error for one resident. During a medication administration observation, an LPN prepared a dose of Furosemide 40 mg for a resident but mistakenly dispensed four tablets of Amlodipine 10 mg instead. The LPN realized the error before administering the medication, noting that she had prepared five times the resident's ordered dose of Amlodipine. The LPN then disposed of the entire cup of pills. The resident involved had a medical history that included high blood pressure, alcohol use, heart failure, COPD, and tobacco use. The resident's physician orders included Furosemide 40 mg, one tablet daily, and Amlodipine Besylate 10 mg, one tablet daily. The Director of Nursing was aware of the medication error and was following up with the LPN. The facility's medication administration policy emphasizes the importance of the Five Rights and recommends a triple check process during medication preparation.
Deficiencies in Constipation and Wound Care Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for four residents, leading to deficiencies in managing constipation and wound care. Resident 20, who had multiple diagnoses including dementia and chronic pain, was at risk for constipation due to decreased mobility and opioid use. Despite having physician's orders for Milk of Magnesia and Docusate Sodium to manage constipation, the Medication Administration Record indicated that the Milk of Magnesia was not administered from June 17 to June 22, 2024. The Director of Nursing was unable to provide additional information regarding this lapse in care. Resident C, who was cognitively intact and had a new wound on his left great toe, did not have a care plan for his arterial ulcer. Although a treatment order for Bacitracin was obtained and later changed to Skin Prep, the Treatment Administration Record showed that the Skin Prep was not consistently applied as ordered. The Director of Nursing acknowledged that treatments were to be completed as ordered, but there were gaps in the administration of the prescribed care. Resident 45, who was at risk for skin tears and bruising, was observed multiple times with improperly positioned geri sleeves, and on one occasion, without any sleeves. The care plan indicated that geri sleeves should be provided to protect her fragile skin, but the records showed inconsistent documentation of their use. Additionally, Resident 329, who had a surgical wound on her head, reported that her dressing was not changed as ordered after returning from the hospital. Despite the Treatment Administration Record indicating daily dressing changes, observations confirmed the absence of a dressing. The Assistant Director of Nursing noted that the wound had closed, and the order should have been reconciled, while the Director of Nursing acknowledged the discrepancy in the treatment records.
Failure to Maintain Comfortable Temperature in Dining Room
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in the main dining room, affecting 7 out of 14 residents during a random observation. On the specified date, the ambient air temperature in the dining room was observed to be cool, with several residents wrapped in blankets or wearing coats while waiting for their meal. The thermostat on the wall showed a temperature of 68 degrees Fahrenheit. The Director of Maintenance was asked to check the temperature, which registered 70 degrees Fahrenheit at the entrance, 68 degrees Fahrenheit five feet into the dining room, 65 degrees Fahrenheit an additional five feet in, and 63 degrees Fahrenheit at the back of the dining room. During interviews, seven residents expressed feeling cold, and the Director of Maintenance acknowledged the need to adjust the temperature, indicating it should be around 70-71 degrees Fahrenheit.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents, leading to deficiencies in care. Resident B, who required maximum assistance for bathing due to conditions such as COPD and an above-knee amputation, did not receive the preferred bed baths twice a week as documented. The bath sheets indicated that the resident only received a bath on three occasions in June, contrary to the care plan that specified a bed bath every Tuesday and Friday evening. Resident E, who was incontinent and required substantial assistance for toilet hygiene, was not changed promptly after incontinence episodes. Observations revealed that the resident was left in wet clothing for extended periods, and documentation of incontinence care was inconsistent and incomplete. The Director of Nursing acknowledged that the resident should have been checked or changed every two hours, but the task section for urinary incontinence was not completed by the staff. Residents C, D, and F also experienced deficiencies in personal hygiene care. Resident C had long, dirty fingernails despite needing assistance for personal hygiene due to hemiplegia. Resident D, who was totally dependent on staff for personal hygiene, did not receive oral care consistently, with documentation showing infrequent entries. Resident F was observed wearing a hospital gown with dirty fingernails and food debris, despite having a care plan that included preferences for choosing clothing and personal hygiene. The Director of Nursing confirmed that these residents should have received appropriate care as per their care plans.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 267 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 Michigan City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Michigan City | 1.8 mi | ★★★★★ | 9 | 0 |
| Brickyard Healthcare - Terrace Care Center | 10.4 mi | ★★★★★ | 2 | 0 |
| Brickyard Healthcare - Laporte Care Center | 10.5 mi | ★★★★★ | 20 | 0 |
| Addison Pointe Health & Rehabilitation Center | 10.8 mi | ★★★★★ | 15 | 0 |
| Chesterton Manor | 11.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.