Average — CMS composite of the measures below.
The next survey window likely opens around December 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 M I Nursing & Restorative Center during CMS and state inspections, most recent first.
The facility failed to provide a dignified dining experience and failed to ensure staff did not speak in a foreign language while providing care. Residents on the 4A dementia unit were observed waiting while tablemates ate, with some residents served at different times and one resident eating cereal with a finger while staff did not intervene. Surveyors also observed CNAs and other staff speaking Spanish in resident rooms, hallways, nursing stations, and dining areas on multiple units while residents with English as their primary language were present.
A facility failed to follow several residents’ care plans and orders. One resident with severe cognitive impairment did not have ordered heel booties in bed, another did not have ordered bilateral ace wraps, and another repeatedly went without ordered TED stockings. A resident with recent falls was observed in bed without floor mats in place, and a resident with a pacemaker had no comprehensive pacemaker care plan or key device details documented. Staff interviews confirmed the interventions were expected and that refusals, if any, should have been documented.
Unsecured Medications and Unlocked Carts: A resident with COPD, asthma, and moderate cognitive impairment had diclofenac gel and a Trelegy inhaler left at the bedside without any documented self-administration or self-storage assessment or care plan. Surveyors also found unlocked, unattended medication and treatment carts on two units and medications left unattended at the nurses’ station, despite facility policy requiring drugs and biologicals to be stored in locked compartments.
Advance Directives were not able to be located in one resident's chart. The resident had severe cognitive impairment, was on hospice, and had orders indicating DNR/DNI status, but the MOLST could not be found in either the paper or electronic record. Staff stated the MOLST is the order used if the resident codes, and if it is not in the chart the resident is assumed to be full code.
A resident with a hip fracture, Parkinson's disease, and severe cognitive impairment did not receive ordered PT/OT services after neurology recommended aggressive rehab to help him/her walk. The NP documented uncertainty about whether rehab had started, the resident said he/she had not worked with rehab exercises, and the DOR stated the resident had not yet been seen by PT or OT because of staffing issues.
Failure to provide nail care for a dependent resident with dementia and schizoaffective disorder. The resident was assessed as moderately cognitively impaired and dependent on staff for all ADLs, with a care plan for grooming assistance. Surveyors observed long, dirty fingernails, the resident said the nails should be cleaned and trimmed, and the CNA stated care was not provided because she assumed the resident did not want it, despite no documented refusal.
Failure to Assess, Document, and Care Plan Multiple Skin Issues: A resident with severe cognitive impairment, multiple chronic diagnoses, and hospice involvement had several bruises, skin tears, scabbed areas, and discoloration observed that were not fully captured in the skin assessment or care plan. The record lacked documentation of etiology and treatment orders for some wounds, and the hospice nurse, unit manager, and DON were unaware of the full extent of the skin issues despite staff reports that the resident had ongoing bruising and skin tears.
A facility failed to carry out ordered pressure injury prevention and treatment for three residents. One resident with frailty, severe cognitive impairment, and hospice involvement did not receive an ordered air mattress before developing a new Stage 2 pressure injury, and the wound initially lacked treatment orders and documented hospice/care plan follow-up. A second resident with a heel pressure ulcer was observed in bed without ordered Prevalon boots, and staff noted the boots should have been on. A third resident with a history of heel ulcers was repeatedly observed with the air mattress set incorrectly at the max setting and without ordered off-loading boots, despite staff confirming the resident did not refuse care.
Failure to implement ordered resting hand splint: A resident with left-sided hemiplegia and hemiparesis had a resting hand splint recommended by OT for contracture prevention, but surveyors repeatedly observed the resident’s left hand in a fist with no splint in place. The OT discharge summary documented tolerance of the splint and ongoing use for comfort and to reduce contracture risk, yet no physician order or implemented nursing intervention was found, and staff confirmed the splint had never been put into use.
A resident with CHF, Parkinson’s disease, severe cognitive impairment, and hospice services had an order for continuous O2 at 2 LPM via NC. Staff observed the resident multiple times on room air with the concentrator off and tubing set aside, including while in bed and in a wheelchair without portable O2. The resident’s oxygen tubing, humidification bottle, and concentrator filter were also found improperly maintained, with undated equipment and a dust-covered filter, despite staff acknowledging the equipment should be changed and cleaned weekly.
Failure to Address Psychiatric Recommendation: A resident with dementia with psychotic disturbance and severe cognitive impairment had a psychiatric eval noting anxiety, weepiness, and stealing/hiding food, with a recommendation to increase Seroquel. The record did not show the recommendation was addressed. The UM, NP, and DON stated psych recommendations should be promptly reviewed by the MD/NP, then the HCP contacted for consent if approved, but the NP did not recall being contacted and the DON said the recommendation was missed.
Failure to Schedule Cardiology Pacemaker Check: A resident with a pacemaker, afib, CHF, and severe cognitive impairment had physician orders for pacemaker checks per cardiology recommendations, but the chart and unit appointment book showed no scheduled cardiology appointment. The UM confirmed that no pacemaker check appointment had been arranged as ordered.
A facility failed to keep accurate records for two residents by documenting ordered devices as in place when surveyors observed they were not. One resident with severe cognitive impairment and total ADL dependence was observed without ordered Geri-Sleeves while the TAR showed them as applied. Another resident with dementia and severe cognitive impairment was observed without a wander guard on the right ankle while the TAR documented it there, even though staff said the device had been moved because of ankle swelling.
A resident receiving hospice services had no current hospice POC available in the chart or hospice binder, and staff could not locate the hospice schedule or service documents. The resident had severe cognitive impairment, was dependent for all ADLs, and developed skin concerns including red raised lesions and a new Stage 2 pressure injury, but the hospice nurse was not notified of the change in condition. The DON and SW both described gaps in hospice coordination and communication.
Infection control practices were not maintained on two units. On the rehab unit, an RN used a shared vitals machine on multiple residents without disinfecting it between uses, and no disinfecting wipes were available on the cart. On another unit, staff were observed carrying unbagged soiled linen through the hallway and handling a linen cart and door with gloved, potentially contaminated hands. The DON, IP, and unit managers confirmed the expected practices for disinfecting equipment and bagging dirty linen.
The facility failed to develop a care plan for a resident with PTSD and did not implement a physician's order for shin guards for another resident. The PTSD diagnosis was noted but not addressed in a care plan, while the shin guards were not applied as ordered, with no documentation of refusal. The DON confirmed the oversight.
A resident with multiple sclerosis and a stage 4 pressure ulcer did not receive the updated treatment recommended by the wound physician. The recommendation to leave the right ischium open to air was not transcribed into the medical record, leading to continued use of an outdated treatment plan. Nurse #3 followed the old order, unaware of the new instructions, and the DON confirmed the oversight.
Dignified Dining and Language Use During Care
Penalty
Summary
The facility failed to provide a dignified dining experience on the 4A certified dementia unit. The facility policy stated that individuals at the same table would be served and assisted at the same time, but during breakfast observations residents were seated in the dining room while tablemates ate and others continued to wait for their meals. On 1/28/26, 15 residents were observed in the dining area, with three tables containing residents who had not been served while watching others eat. One resident was observed eating cereal with a finger and staff did not observe or intervene. The last waiting resident was not served until 25 minutes after observations began. On 1/29/26, 12 residents were observed waiting for breakfast while staff began serving meals. At one table, two residents watched their tablemate eat before receiving their own meals, and at another table a resident was observed holding a plastic cup in his/her mouth and not eating while another resident commented, "that's weird, that's not pretty." Staff did not observe or intervene. A resident at a table of three continued waiting while the other two residents ate, and was not served until after staff noticed the delay and obtained the breakfast meal. The facility also failed to ensure staff did not speak in a foreign language while providing care on the nursing units. Surveyors observed CNAs and other staff speaking Spanish in resident rooms while providing morning care, in hallways, at the nursing station, and in dining areas on multiple units, including 4A, 4B, 3A, and the 2nd floor. In several instances, staff were speaking Spanish while residents with English as their primary language were present, including while a resident was being walked in the hallway and while care was being provided in rooms with doors ajar.
Failure to Implement Ordered Care Plans and Document Pacemaker Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered plan of care for multiple residents. For one resident with Alzheimer's disease, anxiety, depression, and severe cognitive impairment, the care plan included protective heel booties on both feet at all times when in bed, but the resident was observed in bed with both feet directly on the mattress while the heel protector booties were on top of the dresser. The record did not indicate that the resident refused the booties, and progress notes also failed to document any refusal. A nurse stated the heel protectors should have been on at all times when in bed and that the care plan should be followed, while the DON stated refusals of care should be documented in the medical record. A second resident with atrial fibrillation, heart failure, edema, and chronic venous insufficiency had physician orders and a care plan directing bilateral ace wraps to both legs each morning before getting out of bed. The resident was observed on multiple occasions washed, dressed, and seated in a wheelchair with both legs not ace wrapped. The medical record did not show that the resident refused the wraps. The resident stated assistance was needed to apply the wraps, and staff interviews confirmed the wraps were expected to be applied by overnight staff, with refusals to be documented if they occurred. Another resident with ESRD, chronic kidney disease, chronic pulmonary edema, dependence on dialysis, and edema had a care plan directing daily TED stockings at 6 A.M. for bilateral lower extremity edema, but was repeatedly observed without compression stockings. Nursing notes did not document any refusal, and staff interviewed were unsure whether the stockings were still required, while the unit manager stated the care plan should be followed if compression stockings remained part of the plan. A resident with vascular dementia, blindness in one eye, adult failure to thrive, and depression had a fall care plan dated after a recent fall that directed floor mats on both sides of the bed when the resident was in bed. The resident was observed in bed on multiple occasions with the fall mats folded next to the head of the bed rather than placed on the floor. Staff stated the resident was a fall risk and that the mats should be down on the floor as ordered when the resident was in bed. In addition, a resident with paroxysmal atrial fibrillation and a pacemaker had physician orders for pacemaker checks per cardiology recommendations, but the record lacked pacemaker-related details such as type, serial number, paced rate, and a comprehensive care plan for the pacemaker. Staff stated that such information should be included in the plan of care and available to staff.
Unsecured Medications and Unlocked Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with State and Federal requirements. The report states that medications were observed unsecured at a resident’s bedside, treatment and medication carts were left unlocked and unattended on two units, and medications were left unattended at the nurses’ station. Facility policy required all medications to be stored in locked compartments and under proper security conditions. Resident #23 was admitted in May 2022 with diagnoses including COPD and asthma. The most recent MDS, dated 1/14/26, showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The medical record did not show an assessment for self-administration or self-storage of medications, and the active care plan did not include a plan for medication self-administration or storage in the resident room. On multiple observations, the surveyor saw a tube of diclofenac topical gel and a Trelegy inhaler in the resident’s room, including at the bedside and on the over-bed table while the resident was in bed or eating. The surveyor also observed an unlocked and unattended treatment cart in the hallway on the 2B unit on two occasions, with treatment supplies and medicated ointments accessible. On the 3A unit, an unlocked medication cart and an unlocked treatment cart were observed unattended. In addition, a clear plastic container holding levetiracetam and lidocaine was left on top of the 4B nurses’ station with no staff present, and it remained there on a later observation. Staff interviews confirmed that medications should be secured when unattended, although the DON stated medications were sometimes left at the nurses’ station for pharmacy pickup.
Advance Directive/MOLST Not Located in Resident Record
Penalty
Summary
Advance Directives were not able to be located in the medical record for one resident out of a sample of 38. The resident was admitted in May 2023 with diagnoses including encounter for palliative care, congestive heart failure, Alzheimer's disease, dysphagia, and chronic kidney disease. The most recent MDS, dated 1/13/26, showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and also indicated the resident was DNR, DNI, and DNH. The resident's physician order, dated 5/23/23, documented Advance Directive status as DO NOT RESUSCITATE (DNR), DO NOT INTUBATE (DNI), and Transfer to Hospital. The care plan, dated 1/27/26, directed staff to review Advance Directives on file, if applicable. During interview and record review on 1/28/26, the Unit Manager was unable to locate the resident's MOLST in either the paper chart or the electronic medical record. Staff stated the MOLST must be in the chart because it is the order to follow if the resident coded, and multiple nurses stated that if a MOLST cannot be found in the record, the resident is assumed to be full code.
Failure to Provide Ordered PT/OT Services
Penalty
Summary
The facility failed to ensure staff implemented physician orders for Resident #87 by not providing physical therapy and occupational therapy services as ordered. Resident #87 was admitted with diagnoses including a periprosthetic fracture around the internal prosthetic right hip joint, Parkinson's disease, and conversion disorder with seizures, and the MDS showed severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15. A neurology consult dated 1/15/26 stated that the resident needed aggressive rehab to help him/her walk, including PT, OT, and ST. Record review showed the NP documented on 1/21/26 that the resident needed PT/OT and that she was unsure whether the resident had been receiving those services, and on 1/27/26 she documented that the PT/OT order had been placed the prior week but the resident was still saying he/she had not worked with PT/OT. During observation on 1/27/26, the resident was in bed and a CNA was preparing to assist the resident out of bed with a hoyer lift. During interview, the resident stated he/she had not been working with rehab doing exercises. The Unit Manager said a request had been completed for rehab to see the resident after the neurology appointment, and the DOR stated the resident was supposed to be screened but had not yet been seen by PT or OT due to staffing issues.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide nail care for one resident who was unable to perform activities of daily living. Resident #7 was admitted in February 2024 with diagnoses including dementia, schizoaffective disorder, and adult failure to thrive. The Minimum Data Set assessment dated [DATE] showed the resident was moderately cognitively impaired with a Brief Interview for Mental Status score of 12 out of 15 and dependent on staff for all activities of daily living. The care plan identified a self-care deficit and noted the resident preferred a dressing/grooming routine in the early morning and was dependent on 1-2 staff for grooming needs. Record review did not show that Resident #7 refused care. The progress notes and CNA documentation dated 1/27/26 did not indicate refusal of nail care. On 1/27/26 and again on 1/28/26, the surveyor observed the resident eating in the dining room and noted the fingernails were long and dirty. During interview, the resident stated a desire to have the nails cleaned and trimmed. The CNA responsible for care said she did not clean or trim the nails because she did not think the resident wanted it done, but also stated the resident did not specifically refuse. A nurse stated that if a resident refuses nail care, the CNA should document it and notify nursing, and the DON stated that refusals should be documented in the medical record.
Failure to Assess, Document, and Care Plan Multiple Skin Integrity Issues
Penalty
Summary
The facility failed to ensure Resident #74 received appropriate assessment, monitoring, treatment, and care planning for multiple skin integrity issues in accordance with the resident’s assessed needs and hospice status. Resident #74 was admitted with diagnoses including CHF, anemia, dorsalgia, protein-calorie malnutrition, Parkinson’s disease with dyskinesia, and adult failure to thrive. The most recent MDS showed a BIMS score of 3, indicating severe cognitive impairment, and the resident was dependent on staff for all ADLs. The facility’s skin program required daily CNA skin inspections, weekly licensed nurse skin inspections, and documentation of skin concerns in the electronic record. On observation, Resident #74 had multiple skin findings that were not reflected in the skin assessment, including dark purple and pink bruises to the top right hand, right wrist, and lower right arm; dried blood and scabbed areas between the middle and index finger of the left hand; a round raised dark black scabbed area with surrounding pink and red discoloration on the outer left knee; and an oval area of light brown and pink discoloration with a small swollen pinhole opening on the right shin. The skin assessments dated 1/20/26 and 1/27/26 documented bruising to the rear right thigh, a rash on the lower back, and skin tears to the front left knee, left dorsum left hand, and left dorsum 3rd digit, but did not identify the additional bruising, scabbed areas, discoloration, or open area observed by the surveyor. The medical record did not show documentation of care plan interventions addressing the newly identified skin issues or documentation of the etiology of the injuries. Active physician orders included weekly skin assessment and Geri-Sleeves to both arms, but there was no order for treatment of the left knee skin tear, front left knee skin tear, or left middle finger skin tear. During interviews, the CNA said new skin issues were reported to nursing and that the bruising and skin tears had been present for some time; however, the hospice nurse, unit manager, and DON stated they were unaware of the resident’s skin integrity issues. The NP stated she had been notified of bruising and skin tears and gave verbal treatment orders, but did not keep track of the orders or the number of wounds, and nursing staff did not document the orders or update the plan of care accordingly.
Failure to Implement Ordered Pressure Injury Prevention and Wound Care
Penalty
Summary
The facility failed to provide necessary pressure injury prevention and treatment services for three residents who were at risk for skin breakdown or already had pressure injuries. The report states that the facility did not implement ordered pressure-relieving interventions consistently, did not follow wound treatment orders for a newly identified pressure injury, and did not maintain ordered equipment settings for residents with skin breakdown risk. For one resident with a history of pressure ulcers, severe cognitive impairment, frailty, malnutrition, Parkinson’s disease, and hospice involvement, a nurse practitioner documented a recommendation for an air mattress on 1/11/26, but the mattress was not in place when surveyors observed the resident in bed on 1/27/26 and 1/28/26. The resident later developed a new Stage 2 pressure injury to the left gluteus/left buttocks, but the record initially lacked orders for assessment, monitoring, or treatment of that wound. The medical record also did not show hospice notification or care plan interventions addressing the new pressure injury when it was identified. For another resident with severe cognitive impairment, dependence on staff for ADLs, and a pressure ulcer on the left heel, the physician ordered Prevalon boots on both feet while in bed. Surveyors observed the resident in bed without the boots on multiple occasions, with the heels directly on the mattress, and one boot was seen in the room. Nursing and CNA staff stated the boots should have been on as ordered, and the wound provider note described progression of the heel wound to a deep tissue pressure injury with strict offloading recommended. For a third resident with severe cognitive impairment, a history of heel pressure ulcers, and an order for an air mattress set to 160 pounds plus Prevalon boots while in bed, surveyors repeatedly observed the air mattress set at the maximum 400-pound setting and the resident’s heels resting directly on the mattress. The off-loading boots were observed on the floor next to the bureau rather than on the resident. Staff interviews confirmed the resident did not refuse care, that the mattress setting was incorrect, and that the ordered boots were not being applied.
Failure to Implement Ordered Resting Hand Splint
Penalty
Summary
The facility failed to ensure nursing implemented a resting hand splint as ordered and recommended for contracture prevention for a resident with left-sided hemiplegia and hemiparesis following a cerebral infarction. The resident’s most recent MDS showed a BIMS score of 13 out of 15 and functional limitations in ROM to one upper extremity. During multiple survey observations, the resident’s left hand was resting in a fist and no splint or orthotic device was in place or observed in the room, and the resident stated the fingers could not be straightened. Review of the OT discharge summary showed the resident had tolerated a left upper extremity resting hand splint for several hours and that continued use was planned to decrease the risk of further contractures and reduce swelling. However, review of active and discontinued physician orders did not show that the splinting order had been implemented, and the active ROM care plan listed a left hand splint as an intervention that was still being trialed with OT. Staff interviews confirmed that therapy recommendations were communicated to nursing, that nothing was being implemented for the resident at the time of survey, and that the resting hand splint order had never been implemented even though it should have been.
Failure to Maintain Ordered Continuous Oxygen Therapy and Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for one resident. The resident had diagnoses including congestive heart failure, anemia, Parkinson’s disease with dyskinesia, protein-calorie malnutrition, and adult failure to thrive, and the most recent MDS indicated severe cognitive impairment with a BIMS score of 3 out of 15, dependence on staff for all ADLs, and hospice services. The resident had physician’s orders for continuous oxygen at 2 LPM via nasal cannula to maintain saturations above 90%, with oxygen saturation checks ordered weekly. During observations, the resident was seen receiving oxygen via nasal cannula, but the oxygen humidification bottle was undated, the oxygen tubing was dated 1/5/25, and the oxygen concentrator filter had a thick coating of dust. These conditions were observed multiple times, and the Unit Manager stated the tubing should be changed weekly, the humidification bottle had no date and must be changed weekly, and the filter needed to be cleaned and replaced because of dust buildup. The facility policy required oxygen concentrator filters to be rinsed and dried weekly and nebulizers, aerosols, and humidifiers to be changed every 7 days or as needed for soiling. The medical record did not show a physician’s order or care plan for the care of the oxygen tubing, humidification bottle, or oxygen concentrator, and the TAR/MAR documented oxygen and humidification as administered daily as ordered. In addition, the resident was observed at times without oxygen therapy in place: the oxygen concentrator was off, the tubing was on the table next to the bed, and the resident was on room air while in bed and while in a wheelchair without a portable oxygen tank attached. Staff, including the Unit Manager, a CNA, a nurse, and the DON, acknowledged that the resident had an order for continuous oxygen and should not be without it, and the DON stated staff should not leave the resident in the room or hall without oxygen.
Failure to Address Psychiatric Recommendation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident in the sample by not timely approving or denying a psychiatric recommendation. The resident was admitted in February 2024 with diagnoses including dementia with psychotic disturbance, and the most recent MDS showed a BIMS score of 3, indicating severe cognitive impairment. A follow-up psychiatric evaluation documented anxiety, weepiness, and stealing and hiding food, and recommended increasing Seroquel to 50 mg PO TID. The medical record did not show that the psychiatric recommendation had been addressed. During interviews, the Unit Manager stated psychiatric recommendations should be followed up on immediately, with the Physician or NP contacted first for approval or denial and the HCP contacted for consent if approved, and that these interactions should be documented in the EHR. The NP said she did not recall being contacted about the recommendation and expected immediate notification so she could evaluate and approve or deny it, followed by HCP notification if approved. The DON stated the recommendation was missed because the ADON who manages these recommendations had been away.
Failure to Schedule Cardiology Pacemaker Check
Penalty
Summary
The facility failed to ensure that a recommended cardiology follow-up was scheduled for Resident #14, who was admitted with diagnoses including paroxysmal atrial fibrillation and the presence of a cardiac pacemaker. The resident’s most recent MDS assessment showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. Physician orders dated 11/12/25 directed staff to change the reason for Jardiance to CHF, not afib, and to schedule pacemaker checks per cardiology recommendations with the resident’s cardiologist. A provider visit note dated 11/13/25 documented that the resident had a pacemaker and that pacemaker checks would be arranged as recommended. However, review of progress notes since admission did not show that staff scheduled a cardiology appointment for a pacemaker check, and review of the unit’s appointment book did not show any upcoming or previous appointments for the resident. During interview, the Unit Manager stated that no appointment had been scheduled for the pacemaker check as indicated in the physician’s orders.
Inaccurate Documentation of Ordered Geri-Sleeves and Wander Guard Placement
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by documenting care that was not observed to be in place. For one resident with congestive heart failure, anemia, dorsalgia, protein-calorie malnutrition, Parkinson’s disease with dyskinesia, and adult failure to thrive, the most recent MDS showed severe cognitive impairment and total dependence for ADLs. The resident had active physician orders for Geri-Sleeves to both arms during the day and removal each evening, but surveyor observations on multiple occasions found the resident sleeping without the Geri-Sleeves in place while the January 2026 TAR documented them as in place. For the second resident, who had dementia and anxiety disorder and a BIMS score indicating severe cognitive impairment, active physician orders directed that a wander guard be on the right ankle and checked each shift, with weekly function checks. Surveyor observations found the resident without a wander guard on the right ankle on multiple occasions, including while sitting in a recliner and on the side of the bed. The record also included a progress note stating the resident had attempted elopement, was returned to the room, and the wander guard was placed on the right ankle after family encouragement. The documentation in the January 2026 TAR stated the wander guard was in place on the right ankle throughout the month except for one shift, despite observations and staff statements that it had been moved from the ankle to the walker because of swelling and was not always on the ankle. Interviews with nursing staff, the unit manager, and the DON confirmed that staff should not sign off that the Geri-Sleeves or wander guard were in place when they were not, and that the wander guard location should have been accurately documented.
Hospice Coordination and Care Plan Missing
Penalty
Summary
The facility failed to coordinate hospice care and services for one resident receiving hospice services. The resident was admitted with diagnoses including CHF, anemia, dorsalgia, protein-calorie malnutrition, Parkinson’s disease with dyskinesia, and adult failure to thrive, and the most recent MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The MDS also indicated the resident was dependent on staff for all ADLs and was receiving hospice services. Review of the record showed a physician order for hospice evaluation and admission and a hospice care plan stating the resident had a terminal prognosis and had been admitted to hospice with a named hospice provider, with instructions to consult with physician and social services and to work cooperatively with the hospice team. The medical record did not contain a current hospice plan of care available to facility staff, and staff could not locate a hospice binder for the resident. A hospice nurse stated she was unaware of any skin integrity issues and expected to be notified of changes in condition, including skin concerns and treatment updates. Facility staff identified that the resident had skin issues, including multiple red raised lesions on the lower back and a new Stage 2 pressure injury, and that an air mattress should have been in place, but the recommendation was not communicated to the hospice team or followed up on. The DON stated she had no involvement with coordination of care or care plans with hospice, and the SW stated the resident may have been missed and that hospice residents must have a care plan and service contract available to staff on the units.
Infection Control Failures With Shared Vitals Equipment and Soiled Linen Handling
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. On the 3A Rehab Unit, Nurse #2 obtained blood pressures on four residents in three different rooms without disinfecting the shared blood pressure machine between residents. The shared vitals machine did not have disinfecting wipes in the basket, and staff interviews confirmed that the machine and blood pressure cuff should be disinfected after each resident use. On the 2B Unit, staff failed to follow infection control practices related to soiled linen disposal. A staff member was observed leaving a resident room carrying dirty, unbagged linen in her hand and walking across the hall to another room to dispose of it while potentially contaminating the hallway door handle. On another observation, a staff member assisting with resident care opened the resident room door twice with gloved hands, then moved the dirty linen cart in the hallway with those same potentially contaminated gloves while disposing of dirty linen. Interviews with the Unit Manager, DON, and Infection Preventionist confirmed that dirty linens should be bagged before transport and that staff should not touch hallway items with gloved, potentially contaminated hands.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement appropriate care plans for two residents, leading to deficiencies in their care. For one resident with a diagnosis of post-traumatic stress disorder (PTSD), the facility did not create a care plan to address this condition. Despite the resident's history of PTSD being noted in their trauma-informed care assessment and Minimum Data Set (MDS) assessment, staff did not identify potential triggers or develop interventions to manage the condition. The MDS Coordinator confirmed that a care plan should have been created but was not. For another resident, the facility did not implement a physician's order for the use of shin guards. The resident, who is dependent on staff for lower body dressing, had a physician's order to apply shin guards during the day and remove them in the evening. However, observations on multiple occasions showed the resident without shin guards, and there was no documentation indicating the resident refused the application of the shin guards. The Director of Nursing acknowledged that the shin guards should have been applied as ordered.
Failure to Implement Updated Pressure Ulcer Treatment
Penalty
Summary
The facility failed to implement the updated treatment orders for a pressure ulcer as recommended by the wound physician for a resident with multiple sclerosis, stage 4 pressure ulcer, and paraplegia. The resident was admitted with a pressure ulcer and required assistance with all activities of daily living. The wound physician recommended leaving the pressure area on the right ischium open to air, but this recommendation was not transcribed into the resident's active physician's order. Instead, the treatment administration record indicated that the previous treatment order, which involved cleansing the area, applying calcium alginate, and covering it with bordered foam, was still being followed. During an interview, Nurse #3 confirmed that she completed the treatment as per the outdated order and was unaware of the new recommendation to leave the area open to air. The Director of Nursing and Assistant Director of Nursing acknowledged that the new treatment recommendation was missed and not correctly transcribed into the electronic medical record. This oversight resulted in the resident not receiving the correct treatment as per the wound physician's updated recommendation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lawrence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkeley Retirement Home,the | 0.5 mi | — | 0 | 0 |
| Royal Wood Mill Center | 1 mi | ★★★★★ | 4 | 0 |
| Nevins Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 13 | 0 |
| Cedar View Rehabilitation And Healthcare Center | 1.5 mi | ★★★★★ | 5 | 0 |
| Prescott House | 2.4 mi | ★★★★★ | 22 | 0 |
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