Below 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 Adira Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a kidney transplant and other cardiac conditions was admitted for short-term rehab with home supplies of Tacrolimus in both 1 mg and 4 mg strengths provided by family. The acute care discharge list ordered Tacrolimus ER 1 mg, 5 tabs daily, and the facility’s MAR reflected only 1 mg capsules, 5 daily, with no physician order for a 4 mg dose. Admission and personal effects documentation noted only that family supplied 1 mg Tacrolimus, without listing the number of bottles, strengths, or pill counts, and did not reference the 4 mg capsules. Nursing staff reported administering from multiple Tacrolimus bottles but did not document counts, and one nurse later found bottles in a cart drawer after the family questioned the returned medication. The infection control nurse confirmed there was no established process to receipt or reconcile home medications beyond listing the medication name and number of bottles, despite facility policies requiring documentation of delivery, receipt, and accurate reconciliation of medications on admission.
Failure to provide timely pain management after falls with fractures. Two residents with significant cognitive and medical histories were found after falls and later shown to have femur fractures requiring surgery. One resident developed escalating pain with grimacing, crying out, and an externally rotated leg, yet remained in the facility for about 31 hours with no documented pain meds or non-pharm interventions before transfer. Another resident reported hip and knee pain rated 8/10, had x-ray findings suspicious for fracture, and also had no documented pain relief before being sent out after about 12 hours.
Improper Hand Hygiene During Food Preparation: During lunch prep in the kitchen, a dietary staff member was observed removing and donning gloves without washing hands before taking food temperatures and prepping trays, including after touching her face. The DMgr stated kitchen staff should wash hands any time their hands can be contaminated and acknowledged witnessing the lack of handwashing during lunch preparation.
Improper Indwelling Catheter Drainage Bag Positioning: A cognitively intact resident with an indwelling catheter and a history of urinary infection and retention was observed multiple times with the drainage bag positioned above the bladder on a wheelchair armrest and later touching the floor in the room and therapy gym. The UM acknowledged the bag should not be placed there and confirmed it should not be on the floor; the facility policy required the drainage bag to remain lower than the bladder and off the floor.
Surveyors found expired and improperly stored meds on a medication cart, including ophthalmic solutions, nitroglycerin, atropine drops, tuberculin, and an opened Lantus pen beyond its use period. Surveyors also observed nurses sharing narcotic keys and an inconsistent controlled substance count for ABH gel during reconciliation, with the DON stating narcotic keys are not shared.
A resident with significant comorbidities developed three facility-acquired pressure ulcers, including a Stage 3 coccyx ulcer, an unstageable left heel wound, and a deep tissue injury to the left lateral malleolus. Facility staff inconsistently classified and documented these wounds, reclassifying them multiple times despite diagnostic imaging showing no vascular insufficiency. The resident was not consistently provided with off-loading devices, and daily skin inspections and timely interventions were not reliably documented, contributing to the development and progression of the wounds.
The facility did not provide staff with effective call light notifications or ensure timely responses to resident requests. Staff relied on a screen at the nurse's station, which was not visible from key areas, and walkie talkies were inconsistently used. As a result, a resident experienced repeated delays in assistance, leading to multiple falls while attempting to self-transfer to the bathroom.
The facility failed to implement and document appropriate interventions for two residents with skin breakdown and pressure ulcers, including lack of wound assessments, missing or incorrect wound treatments, and inaccurate documentation of care. Additionally, a resident with a testicular infection did not receive adequate follow-up assessment or monitoring after antibiotic treatment, with no evidence of resolution documented in the medical record.
A resident with severe cognitive impairment and multiple health conditions experienced several unwitnessed falls, some with head injuries and skin tears. Facility staff did not consistently perform or document required neurological checks after these incidents, and nursing progress notes were incomplete or missing. Policies requiring individualized interventions and care plan updates were not followed, as confirmed by the DON.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, as required, with staffing records showing multiple days with insufficient or missing RN coverage. The Administrator and DON were unable to account for these lapses during review.
The facility failed to prevent and manage pressure ulcers for several residents, leading to the development and worsening of pressure injuries. A resident with a stage three ulcer did not receive consistent care due to staffing issues, while another resident with a sore on their buttocks reported pain and inadequate repositioning. A third resident, with limited mobility, developed pressure injuries due to improper positioning and lack of staff assistance. Observations and staff interviews highlighted a lack of adherence to care plans and missed wound treatments.
The facility failed to provide dignified and professional care to residents, resulting in extended wait times for assistance, incontinence, and feelings of frustration. Residents reported discourteous staff, delayed call light responses, and inappropriate staff behavior. Specific incidents included residents being told to use their briefs due to staff unavailability, being left uncovered, and staff using cell phones during care. The facility's administrator acknowledged these concerns, indicating awareness of the deficiencies.
The facility failed to provide routine showers and hygiene care for multiple residents, leading to feelings of embarrassment and frustration. Several residents reported not receiving showers for weeks, and observations revealed poor hygienic conditions. The facility's documentation was inconsistent, and staff shortages contributed to the inadequate care.
The facility failed to properly label and store medications, with multiple medication and treatment carts containing undated and unsecured items. Observations revealed unlocked treatment carts accessible to residents and loose medication tablets in drawers. Additionally, temperature logs for medication refrigerators were incomplete or showed temperatures outside the recommended range, risking medication efficacy and safety.
The facility failed to maintain a comprehensive infection control program, with missing documentation and inadequate surveillance. Observations revealed improper disposal of soiled items and lapses in hand hygiene, increasing infection risks. Additionally, medication administration and dressing change procedures were not compliant with infection control protocols, further compromising resident safety.
The facility failed to complete advance directives for seven residents, resulting in missing or incomplete forms. Despite having physician's orders for CPR or full code by default, no signed documents indicating code status were found in the EMR. Interviews with social workers revealed that forms were supposed to be signed and uploaded, but they were unable to locate them. The facility's policy requires providing residents with information about their rights to refuse or accept treatment and to formulate advance directives, but this was not adhered to.
The facility failed to review and revise care plans for several residents, leading to unmet care needs such as missed showers, inadequate catheter care, and significant weight loss. One resident reported missing scheduled showers and inconsistent catheter care, while another experienced a notable weight loss without appropriate care plan adjustments. Additional residents faced issues with bathing due to inadequate equipment and insufficient assistance, highlighting a lack of adherence to facility policies on care plans and bathing guidelines.
A facility failed to conduct timely activity assessments for residents and did not support a resident's voting rights. The Activities Director was unaware of the requirement for quarterly assessments, leading to incomplete documentation for several residents. Additionally, a resident expressed a desire to vote, but there was no follow-up to facilitate this, contrary to the facility's policy.
The facility failed to administer medications, particularly insulin, in a timely manner, affecting multiple residents with diabetes. Staffing issues and lack of coordination led to significant delays, with medications often given hours late. Additionally, the facility did not utilize backup medication sources, resulting in residents missing doses of essential medications.
The facility failed to provide adequate catheter care and infection prevention for several residents, leading to potential and actual urinary tract infections. Residents reported irregular catheter changes and inadequate care, with observations confirming catheter bags and tubing in contact with the floor. Facility records showed gaps in documentation and compliance with physician orders, highlighting systemic issues in catheter care.
The facility failed to consistently offer nighttime snacks to residents, leading to frustration and unmet needs. Observations and interviews revealed that residents were not consistently offered snacks, with some going long periods without them. A diabetic resident expressed concern about not receiving snacks necessary for managing low blood sugar. The facility's policy did not specify responsibility for snack provision, and documentation showed inconsistencies in offering snacks. The meal schedule indicated a 14-hour gap between dinner and breakfast without consistent snack offerings.
The facility failed to maintain an effective Antibiotic Stewardship Program, leading to potential inappropriate antibiotic use among residents. Incomplete documentation and discrepancies in infection reporting were noted, with some residents receiving multiple antibiotics without proper justification. A resident was prescribed Doxycycline for a wound infection without supporting documentation, highlighting the facility's oversight issues.
A resident, who is cognitively intact, was moved from the rehab section to the LTC section without their consent, despite expressing unhappiness and not planning to stay long-term. The facility's policy allows residents to refuse such changes, but the reason for the move was marked as 'other' in the EMR. The social worker did not initially recall the resident's distress, but later documentation confirmed their dissatisfaction.
The facility failed to provide adequate notice of non-coverage and maintain documentation for two residents, leading to a lack of full disclosure related to Medicare rights and the inability to appeal discharges within the allotted time frame. One resident's form was signed on the same day services ended, while the other resident's form could not be found. The facility Administrator acknowledged the missing form and stated that forms should be provided 48 hours prior to discharge.
A resident was found in a customized chair with a chest harness that they could not remove independently, without proper assessment or monitoring. The facility lacked a current physician order for the harness and had no physical restraint policy. Staff confirmed the resident's inability to release the harness, and the MDS assessment inaccurately coded the resident as not using restraints.
The facility failed to obtain timely weights for two residents, leading to unassessed weight loss. One resident lost 17.1 pounds in 16 days, while another had issues with enteral feeding administration, with an empty bottle left unattended. Care plans were outdated, and the Corporate RD did not see the need for re-weighing despite evident weight issues.
A facility failed to ensure accurate enteral feeding orders for a resident, resulting in an incomplete order and potential for tube malfunction or weight loss. Observations revealed the resident's feeding pump was beeping due to an empty bottle, and the new bottle was not labeled. The RN noted that the night shift did not hang the full bottle, causing the feeding to run longer than intended. The order lacked documentation for hang and take-down times, deviating from physician's orders.
A facility failed to ensure effective communication and coordination for a resident requiring dialysis, resulting in duplicate influenza vaccinations. The resident, with severe cognitive impairment and multiple diagnoses, had a care plan for dialysis but lacked completed communication forms in their medical record. The facility's infection control manager confirmed the duplication and noted the absence of vaccination records in the Michigan Care Improvement Registry, highlighting a breakdown in communication with the dialysis center.
The facility failed to conduct timely medication regimen reviews for three residents, resulting in missed reviews and delayed responses to pharmacy recommendations. A resident with cerebral palsy missed a review in July, while another with moderate cognitive impairment had a delayed response to a dose reduction recommendation. A third resident with dementia had recommendations unaddressed until questioned. The facility lacked clear timeframes for responding to pharmacy recommendations.
The facility failed to ensure adequate indications and monitoring for psychotropic medications for three residents. A resident was prescribed Zolpidem without a sleep disorder diagnosis, and staff could not provide documentation for its necessity. Another resident was on Ramelteon for insomnia without a care plan or monitoring, and a third resident continued Risperdal without documented behaviors justifying its use. The facility's actions resulted in a lack of documented evidence supporting the effectiveness and necessity of these medications.
The facility failed to prevent pre-set up medications in medication carts, did not prime a new insulin pen before administration, and provided late insulin administration for a resident. An RN found pre-set up medications in unmarked cups, and an LPN administered insulin without priming the pen. A resident reported receiving insulin late, confirmed by records showing multiple late administrations, with staffing issues contributing to the delay.
A resident with cerebral palsy and other conditions did not receive routine dental services since admission to the facility. Despite being cognitively intact and having a signed dental consent form, the sections for consenting to or declining dental care were left blank. Interviews with staff confirmed the resident had not been seen by a dentist, contrary to the facility's policy on providing dental services.
The facility failed to follow its vaccination administration procedures, affecting three residents. One resident did not receive the Pneumonia vaccine despite it being ordered, another had discrepancies in vaccine documentation, and a third did not receive the Pneumonia vaccine with no documented reason. The facility's policy requires proper documentation and administration of vaccines, which was not adhered to.
The facility failed to prevent non-consensual sexual behaviors between two cognitively-impaired residents in the Dementia Unit. A female resident with bipolar disorder and dementia was found partially naked in bed with a male resident with Alzheimer's disease. The incident was not reported or investigated in a timely manner, and the facility's documentation was incomplete. The deficiency was due to inadequate supervision and failure to implement abuse prohibition policies.
A resident with severe cognitive impairment was not honored for her DNR wishes due to the facility's failure to complete necessary documentation. Despite having a designated patient advocate, the facility treated the resident as a Full Code because the Incapacity to Make Health Care Decisions Form was incomplete. This resulted in the resident receiving unwanted CPR and subsequently dying.
A resident with a medical history requiring IV antibiotics left the facility and was missing for over 24 hours. The facility failed to report the incident to local authorities or the state agency, as required by their policy. The Administrator and DON were unaware of the resident's absence until the following day, and no investigation was conducted to determine if the case was reportable.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with frequent Leaves of Absence. The first resident's Advanced Directive was not addressed, resulting in a voided DNR order and the resident receiving CPR. The second resident's care plan did not include interventions for frequent absences, and the facility did not report the resident missing when they failed to return. Facility policies on Advanced Directives and care planning were not followed.
A resident with severe cognitive impairment was subjected to CPR against their DNR wishes due to the facility's failure to process the necessary incapacity documentation in a timely manner. The resident's family, including the designated patient advocate, was not informed of the resident's declining condition and witnessed the CPR, which was contrary to the resident's documented DNR order.
Failure to Reconcile and Document Home Tacrolimus Therapy
Penalty
Summary
The deficiency involves the facility’s failure to implement a process for receipt and reconciliation of home medications for a resident admitted for short-term rehabilitation. The resident, who had a history of atrial fibrillation, kidney transplant, heart failure, cardiomyopathy, and immunodeficiency, was discharged from an acute care setting with an order for Tacrolimus ER 1 mg, 5 tablets by mouth daily. Upon admission, the resident’s son provided the facility with home supplies of Tacrolimus: two bottles of 1 mg capsules (30 capsules each) and two bottles of 4 mg capsules (30 capsules each), intending that his father receive a total daily dose of 5 mg (one 1 mg capsule and one 4 mg capsule). The son later reported confusion and concern at discharge when the MAR reflected an order for 5 capsules of 1 mg Tacrolimus daily, and the medications returned to him did not match what he had originally supplied. Record review showed that the acute care discharge list documented Tacrolimus ER 1 mg, 5 tablets daily, with a handwritten note indicating "family supply bottle." The admission checklist and audit form only documented "Tacrolimus 1 mg fam supplied" without specifying the number of bottles or any 4 mg dosage, and the nursing admission assessment and inventory of personal effects contained no mention of home medications. The MAR listed only Tacrolimus 1 mg capsules, 5 by mouth once daily for kidneys. Based on the documented 1 mg supply alone (60 capsules) and the 5 mg daily dose, the resident would have run out of medication in approximately 12 days of a 20‑day stay, and the complainant reported he did not receive any call requesting additional medication. There was no physician order documented for a 4 mg Tacrolimus dosage. Interviews with nursing staff and the infection control nurse confirmed the absence of a defined reconciliation process for home medications. One nurse recalled that at discharge the son was upset because remaining medications could not initially be located and because the facility had been administering 5 of the 1 mg capsules instead of a combination of 1 mg and 4 mg capsules; she later found two bottles in a cart drawer and counted the medications but did not document the count. Another nurse stated that the resident had several Tacrolimus bottles with two different dosages and that she administered one capsule from the 1 mg bottle and one from the higher‑dose bottle, but she was unsure what happened when medication carts were switched. The infection control nurse stated that for home medications, staff would list only the medication name and number of bottles on the inventory sheet, without documenting dosage strength or pill counts, and confirmed there was no current process or procedure to receipt or reconcile home medications. This practice conflicted with facility policies requiring documentation of delivery and receipt of medications and accurate accounting of medications, routes, and dosages upon admission.
Failure to Provide Timely Pain Management After Falls With Fractures
Penalty
Summary
The facility failed to provide timely pain management for two residents after falls that resulted in femur fractures requiring surgical repair. For Resident #13, who had diagnoses including Alzheimer’s disease, dementia, diabetes, asthma, heart failure, and hypertension, staff found her on the floor beside her bed after an unwitnessed fall. She was returned to bed, assessed, and initially had no obvious external injuries, but later reported right foot and ankle pain. An x-ray of the foot and ankle showed a hairline, nondisplaced fracture of the 5th metatarsal. Later that night and into the next morning, she was noted to be grimacing, crying out, and reporting hip pain, with her right leg bent and externally rotated. Despite these signs of increased pain and the later finding of a right femur intertrochanteric fracture, the record showed no pain medications administered and no non-pharmacological interventions documented before transfer to the hospital. The resident remained in the facility for approximately 31 hours after the fall and about 20 hours after documentation of increased pain. Staff interviews confirmed that during repeated incontinence care, turning, and repositioning, the resident cried out in pain with light touch, yet the DON stated there was no documentation of pain medication or other interventions before transfer. The x-ray for the hip was ordered as stat, but there was an extended delay before it was completed, and the resident was not sent to the hospital until after the fracture result was received. For Resident #81, who had diagnoses including dementia, alcohol cirrhosis of the liver, alcohol-induced dementia, anxiety, major depressive disorder, and mood disorder, staff documented a fall with left hip pain and limited movement. The resident’s pain was assessed as 8/10, and x-ray results showed a suspicious fracture of the left femur neck, later confirmed as an acute nondisplaced left femoral neck fracture in the hospital. The resident reported left hip and knee pain and remained in the facility for about 12 hours before transfer. The MAR showed no pain medications administered, and the DON confirmed there was no documentation of pain medication being provided during that time. The hospital record noted the resident complained of pain that was worse with movement and underwent surgical fixation of the fracture.
Improper Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to maintain best practices in the food service area when dietary staff did not wash hands before food handling tasks. During lunch observation in the kitchen, [NAME] B was observed removing and donning gloves without washing hands before taking temperatures and prepping food, donning gloves without washing hands before taking temperatures of food on the steam table, touching her face with her finger and then opening trays at the steam table before donning gloves without washing hands, and donning gloves without washing hands before prepping food trays. The Dietary Manager C stated that kitchen staff should wash their hands any time their hands can be contaminated and acknowledged that he witnessed [NAME] B not washing her hands during lunch preparation.
Improper Indwelling Catheter Drainage Bag Positioning
Penalty
Summary
The facility failed to provide appropriate care for an indwelling catheter for one resident who was admitted with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, obstructive and reflexive uropathy, chronic kidney disease, and retention of urine. The resident had a BIMS score of 15 and was cognitively intact. During observation on 01/20/2026, the urine collection bag for the catheter was seen hanging on the left armrest of the wheelchair and positioned above the level of the bladder. On 01/21/2026, the urine collection bag was again observed below the wheelchair and touching the floor while the resident was watching TV in his room, and later the same day it was observed below the wheelchair and on the floor in the therapy gym. During interview, the Unit Manager acknowledged that the resident sometimes places the bag on the armrest, stated that it should not be up there, and confirmed that it should not be on the floor. The facility policy titled Catheter Care, Urinary stated that the drainage bag must be held or positioned lower than the bladder at all times and that the catheter tubing and drainage bag are to be kept off the floor.
Expired Medications and Unreconciled Narcotics on Medication Carts
Penalty
Summary
The facility failed to ensure safe narcotic storage, narcotic reconciliation, and the discarding of expired medications on two of three medication carts reviewed. On the Harbor medication cart, surveyors found multiple medications that were expired or improperly stored, including two bottles of Brimonidine Tartrate Ophthalmic Solution with no open or use-by date, Rocklatan Ophthalmic Solution opened on 8/25/2025 and kept beyond the labeled 6-week period, a vial of Tuberculin stored with eye drops and without an open/use-by date, Timolol Maleate Ophthalmic Solution with no open or use-by date, Nitroglycerin expired in 9/2025, Atropine Sulfate 1% sublingual oral drops expired in 11/2025 but opened on 1/1/2026, and a Lantus insulin pen opened on 12/18 with no use-by date. Nurse M stated the nitroglycerin, atropine, and Rocklatan should have been discarded, and that the tuberculin vial was not supposed to be stored in the medication cart. The Unit Manager stated the tuberculin vial should not have been in the cart and that Lantus is good for 28 days, making the opened pen expired. Surveyors also observed a narcotic key exchange between Nurse E and Nurse F, with Nurse E handing keys from her bag to Nurse F while Nurse F stated she leaves her keys at the facility in case someone needs something. Nurse F then walked past her medication cart, and later stated Nurse E must not have left because she did not give her the keys. The DON stated that narcotic keys are not shared. When Nurse E, Nurse F, and the Unit Manager began reconciling narcotics, they counted ABH gel for a resident and Nurse F quickly wrote the remaining amount as 3 after stating she had given one dose. The facility's control substance record for that resident showed an amount used of 1, administered by Nurse F, and an amount remaining of 3.
Failure to Prevent and Accurately Classify Facility-Acquired Pressure Ulcers
Penalty
Summary
A resident with multiple comorbidities, including diabetes, dementia, kidney disease, and heart disease, was admitted to the facility with no skin issues. Over the course of their stay, the resident developed three facility-acquired pressure ulcers: a Stage 3 ulcer on the coccyx, an unstageable wound on the left heel, and a deep tissue injury on the left lateral malleolus. The resident was non-ambulatory, required assistance for all activities of daily living, and was incontinent of bowel and bladder, with infrequent changes and prolonged periods between incontinence care. Facility staff, including CNAs and wound care nurses, observed and documented the wounds at various stages, but there were inconsistencies in the classification and documentation of the wounds. The wounds were initially identified as pressure injuries but were later reclassified multiple times as either moisture-associated skin damage (MASD) or diabetic/vascular ulcers, despite diagnostic imaging (doppler studies) showing no evidence of vascular insufficiency. The facility's wound care team and DON provided conflicting explanations for the reclassification, and there was a lack of clear, consistent documentation regarding the nature and progression of the wounds. Observations revealed that the resident was not consistently provided with off-loading devices, such as heel boots, and was often found with heels resting directly on the bed. Daily skin inspections and timely interventions, as outlined in the facility's own skin management policy, were not consistently documented or observed. Additionally, a new skin alteration was noted without corresponding documentation. These actions and inactions contributed to the development and worsening of the resident's pressure ulcers, as well as inconsistencies in wound assessment and care.
Failure to Ensure Timely Call Light Response and Notification
Penalty
Summary
The facility failed to ensure that call light notifications were readily available to staff and that call lights were responded to in a timely manner to meet residents' needs. Observations revealed that the call light system relied on a screen located at the nurse's station, which was not visible from the hallways or dining areas where staff were often present. There were no visual or audible indicators in the hallways to alert staff when a call light was activated, and staff had to physically walk to the nurse's station to check the status of call lights. Although staff were assigned walkie talkies, these were not consistently used or audible, and some staff admitted to leaving them at the nursing station or turning the volume down. Multiple interviews and observations indicated that residents experienced significant delays in receiving assistance after activating their call lights. One resident reported waiting 20-30 minutes or more for help, and described instances where staff did not return after being asked for assistance. This resident had several documented incidents of attempting to go to the bathroom unassisted, resulting in falls, which he attributed to the lack of timely response to his call light requests. During surveyor observations, call lights were activated without any corresponding noise or alert in the hallway, and staff did not respond promptly. The facility's policy required prompt response to call lights and for staff to be aware of call light activations, but the current system and staff practices did not support this. Interviews with the administrator and DON confirmed that there were no hall lights or alarms to notify staff of call light activations, and that this was an area under consideration for improvement. The lack of effective notification and response systems directly contributed to unmet resident needs and repeated incidents of residents attempting to self-transfer, leading to falls.
Failure to Provide Appropriate Skin and Wound Care Interventions and Monitor Change in Condition
Penalty
Summary
The facility failed to provide appropriate interventions and care for residents experiencing skin breakdown and pressure ulcers, as well as for a resident with a change in condition. For one resident with a history of incontinence and previous pressure ulcers, a large, excoriated area was observed on the buttocks. Despite care plans indicating the need for daily wound assessments and treatments, there was no documentation of daily assessments or any treatment orders for the skin breakdown. The wound nurse confirmed the presence of a wound but stated the resident was not on his list to be seen, and the medical record did not reflect any wound care interventions or accurate skin assessments. Another resident with an unstageable pressure ulcer on the left lateral ankle did not receive the prescribed wound care. The dressing observed did not match the physician's order, lacking the required calcium alginate. Documentation on the treatment administration record indicated the dressing change was completed, but the nurse later admitted she had not performed the dressing change and had signed off for the wound nurse. The wound was noted to have significant drainage and was not improving, with the wound nurse and hospice nurse confirming it was facility-acquired. Additionally, a resident with a history of dementia and multiple comorbidities developed a large, red, inflamed testicle. Although antibiotics were prescribed, there was no documentation of follow-up assessments to determine if the infection had resolved. The care plan referenced impaired skin integrity and called for treatments as ordered and weekly skin assessments, but there was no evidence of ongoing monitoring or documentation regarding the resolution of the infection. The lack of assessment and monitoring was confirmed during interviews with nursing staff, who were unable to provide evidence that the resident's condition had been evaluated after the initial treatment.
Failure to Prevent Repeat Falls and Inconsistent Neurological Monitoring
Penalty
Summary
The facility failed to prevent repeat falls and provide consistent neurological monitoring for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, debility, and malnutrition. The resident experienced several unwitnessed falls, some resulting in head injuries and skin tears. Despite the facility's policy requiring individualized interventions and neurological assessments after unwitnessed falls or head injuries, documentation revealed that neurological checks were not completed or recorded following multiple incidents. Additionally, nursing progress notes and interdisciplinary team documentation were inconsistent or missing regarding the resident's falls and injuries. The facility's policies also required that changes in a resident's condition, such as falls with injury, be documented and prompt a review or revision of the care plan. However, after several falls, there was a lack of timely and thorough documentation in the resident's medical record, and interventions were not consistently updated or implemented as required. The DON confirmed that neurological monitoring should have occurred after each unwitnessed fall, but records showed this was not done, indicating a failure to follow established protocols for fall prevention and post-fall assessment.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours each day, seven days a week, as required. Review of the posted nurse staffing sheets for the period from January 1, 2025, to March 6, 2025, revealed several days where there was either no RN coverage or less than the required eight hours of RN coverage. Specifically, on multiple days in January and February 2025, the staffing sheets showed either zero RN hours, fewer than eight RN hours, or were left blank except for census and date. During a review with the Administrator and Director of Nursing, it was confirmed that there were days without the required RN coverage, and both were unable to explain the discrepancies.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for pressure ulcer prevention and management, affecting multiple residents. Resident #56 was found with a stage three pressure ulcer on their back, which was not consistently treated due to staffing issues. The resident reported that staff did not assist with turning and repositioning every two hours as required. Observations confirmed that the resident was often left lying on their back with heels against the mattress, contrary to care plan interventions. Resident #60, who was at risk for pressure ulcers, was observed with a sore on their buttocks and reported pain. The resident's care plan included interventions for turning and repositioning, but these were not consistently implemented. The resident was often found lying on their back without positioning devices, and staff were unaware of the resident's wound care needs. The facility's records indicated missed wound treatments and a lack of alternative methods to offload pressure. Resident #76, with a history of stroke and limited mobility, was observed lying on their back with feet pressed against the footboard, indicating a lack of proper positioning. The resident reported that staff did not assist with repositioning, and observations confirmed the absence of heel suspension devices. The resident developed pressure injuries on their foot and heel, which were not addressed in a timely manner. Staff interviews revealed a lack of awareness and adherence to the resident's care plan, contributing to the development of pressure ulcers.
Deficiencies in Resident Care and Staff Responsiveness
Penalty
Summary
The facility failed to provide dignified, respectful, and professional care to 12 residents, resulting in extended wait times for assistance, incontinence, and feelings of frustration and sadness among residents. Residents reported that staff were discourteous, did not respond to call lights in a timely manner, and often left them feeling like a burden. Specific incidents included a resident who had to call the facility on their phone to get help, another who was told to use their brief because staff did not have time to assist them to the bathroom, and a resident who was left uncovered and exposed in their room. Several residents reported that staff had poor attitudes, were rude, and used inappropriate language. One resident mentioned that staff told them it was easier to change their brief than to assist them to the toilet, while another resident was left with visible facial hair that staff had not offered to help remove. Additionally, residents expressed concerns about staff using their cell phones while providing care and being loud during shift changes, disrupting their sleep. The facility's failure to respond to call lights in a timely manner was a recurring issue, with residents reporting wait times of up to two hours. This lack of responsiveness led to incidents of incontinence and residents feeling neglected. The facility's administrator acknowledged the concerns and admitted that the facility had work to do, indicating awareness of the deficiencies in care and treatment provided to the residents.
Inadequate Hygiene Care for Residents
Penalty
Summary
The facility failed to document and provide routine showers and hygiene care for 12 residents, resulting in feelings of embarrassment and frustration among the residents. During a confidential Resident Council meeting, seven residents reported not consistently receiving their showers, with some not having had a shower in two weeks. The residents expressed frustration and felt disregarded by the facility staff. Several residents were observed in poor hygienic conditions. Resident #57, who has diagnoses including Bipolar Disorder and Major Depression, received only one shower in the last 30 days. Resident #72, with diagnoses such as Dementia and Schizoaffective Disorder, received only two showers in the same period. Resident #56, who requires a Hoyer lift for transfers, was found in a room with a foul odor and had only received one shower a week, despite needing more frequent assistance. The resident expressed reluctance to ask for more showers due to staff being busy. Other residents, such as Resident #76, who has left-sided hemiplegia, reported receiving bed baths instead of showers due to staff shortages and difficulty in transferring. This resident also had unkempt fingernails and toenails, indicating a lack of routine care. Resident #24, who is cognitively intact, reported that staff often skipped her showers, and Resident #50, with moderate cognitive impairment, confirmed receiving only four showers in the last 30 days. The facility's failure to provide adequate hygiene care was consistent across multiple residents, as evidenced by the lack of documentation and the residents' testimonies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed in multiple medication and treatment carts. Specifically, medications such as insulin pens, inhalers, and nasal sprays were found opened and used without proper dating on the packaging. Additionally, loose medication tablets were discovered in the drawers of medication carts, indicating a lack of proper organization and potential for medication errors. These observations were made across various units, including the short hall Coast unit, long hall Coast unit, and the secure dementia unit. Furthermore, the facility did not adequately secure or lock treatment carts containing prescription creams and ointments. Observations revealed that treatment carts were left unlocked in areas accessible to residents, including those who were self-ambulating. This oversight was noted in both the Bay treatment cart and the dementia unit treatment cart, where multiple prescription creams and ointments were found opened and undated, posing a risk of unauthorized access and potential misuse. The facility also failed to maintain accurate temperature logs for medication refrigerators, with missing entries and recorded temperatures outside the recommended range. This was particularly evident in the Harbor/Coast unit and Bay units, where multiple shifts had undocumented or low temperatures. The improper temperature control could compromise the efficacy and safety of stored medications, including vaccines and insulin pens. Interviews with staff revealed a lack of awareness and monitoring regarding these temperature discrepancies.
Inadequate Infection Control and Documentation in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by missing documentation and inadequate surveillance. The Infection Control (IC) Registered Nurse (RN) was unable to provide complete line listing documentation for several months, including January, February, May, and September 2024. This lack of documentation hindered the facility's ability to track and monitor infections accurately. Additionally, the IC RN admitted to not tracking potential infections that did not require antimicrobial treatment, further compromising the facility's infection control efforts. Observations revealed significant lapses in infection control practices, including improper disposal of soiled linens and waste products. On the locked dementia unit, soiled items were left in open garbage bags on the floor, and staff were observed not performing hand hygiene after handling contaminated items. These practices increased the risk of microorganism transmission among residents. Furthermore, the IC RN acknowledged awareness of these issues but failed to take corrective action, indicating a lack of effective process surveillance and staff education. Additional deficiencies were noted in medication administration and dressing change procedures. An LPN was observed not performing hand hygiene before and after medication administration, and medication cups were found without proper identification. During a dressing change, another LPN used non-sterile scissors from their pocket, risking cross-contamination. These actions demonstrate a broader issue of non-compliance with infection control protocols, contributing to the facility's failure to maintain a safe environment for residents.
Failure to Complete Advance Directives for Residents
Penalty
Summary
The facility failed to complete advance directives for seven residents, resulting in missing or incomplete advance directive forms. Each resident had a physician's order for CPR or full code by default, but no signed documents indicating code status were located in their electronic medical records (EMR). The residents involved had various medical conditions, including cerebral palsy, chronic respiratory failure, chronic kidney disease, heart failure, and type two diabetes, among others. Their cognitive statuses varied, with some being cognitively intact and others having moderate cognitive impairment. Interviews with social workers revealed that there is supposed to be a form signed by the guardian, responsible party, or resident that is uploaded to the EMR to indicate advance directives. However, the social workers were unable to locate these forms in the EMR. The facility's policy states that upon admission, residents should be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive. The policy also requires that information about whether a resident has executed an advance directive be prominently displayed in the medical record. The policy further outlines that if a resident has not established advance directives, the facility staff should offer assistance in establishing them. Despite these policies, the facility did not have the necessary signed documents in place for the residents reviewed, indicating a failure to adhere to their own procedures and potentially impacting the residents' rights to make informed decisions about their care.
Deficiencies in Care Plan Reviews and Resident Care
Penalty
Summary
The facility failed to ensure that reviews and revisions of residents' care plans were made to provide necessary interventions for care and services, affecting five residents. Resident #5 reported missing scheduled showers and inadequate catheter care, with records showing inconsistent documentation of catheter care and missed showers. The care plan indicated a preference for showers three times a week, but the resident only received seven showers in 30 days. Additionally, catheter care was not consistently documented, with several days showing no care provided. Resident #9 experienced significant weight loss, with a recorded drop from 147.2 pounds to 130.1 pounds over 16 days. Despite having a PEG tube for feeding, the care plan lacked documentation of the feeding rate, and no interventions were added following the weight loss. Resident #40 reported issues with shower equipment, leading to inadequate bathing, as the shower chair did not fit, and the tub was reportedly broken. The resident, who required assistance from two staff members, only received three showers in a 30-day period. Residents #78 and #80 also experienced deficiencies in bathing care. Resident #78 was unsure of the frequency of showers and reported being given a washcloth to wash up in the room, with records showing only three showers in a month. Resident #80 appeared unshaven and scruffy, with records indicating only three showers in a 30-day period, despite requiring assistance from two staff members. The facility's policies on comprehensive, person-centered care plans and bathing guidelines were not adhered to, resulting in unmet care needs for these residents.
Failure to Conduct Timely Activity Assessments and Support Voting Rights
Penalty
Summary
The facility failed to conduct and maintain timely activity assessments for eleven residents, as observed during a survey. The deficiency was identified when it was found that activity assessments were not completed quarterly as required by the facility's policy. For instance, Resident #4, who was admitted in May 2024, only had an initial activity assessment completed upon admission, with no subsequent assessments. This lack of regular assessments was consistent across other residents, such as Resident #5, who had no documented assessments since admission in September 2021, and Resident #26, who only had one assessment completed in June 2024. The Activities Director was unaware of the requirement for quarterly assessments, which contributed to the oversight. Additionally, the facility failed to ensure that Resident #4 was able to exercise her right to vote. During a Resident Council meeting, Resident #4 expressed a desire to vote in the upcoming Presidential election, but there was no documentation or follow-up to facilitate this. The Activities Director had noted Resident #4's interest in voting upon admission but did not take further steps to ensure her voting rights were supported. This oversight was contrary to the facility's policy, which encourages residents to exercise their voting rights and mandates assistance for those expressing a desire to vote.
Medication Administration Delays and Backup Source Failures
Penalty
Summary
The facility failed to ensure the timely administration of medications, particularly insulin, to meet the needs of residents with diabetes and other conditions. Multiple residents experienced delays in receiving their insulin, which was often administered hours after the prescribed times. This was observed in several residents, including one who reported receiving morning insulin late and another who experienced significant weight loss potentially due to inconsistent insulin administration. The facility's medication administration policy requires medications to be given within one hour of the prescribed time, but this was not adhered to, leading to multiple instances of late administration documented in the Medication Administration Records (MAR). The report highlights the challenges faced by the facility in managing medication administration due to staffing issues. A Registered Nurse/Infection Preventionist was called in unexpectedly to cover shifts, leading to unfamiliarity with residents and further delays in medication administration. The nurse reported being overworked and not receiving timely communication about shift changes, contributing to the late administration of medications. The facility's Director of Nursing and other managerial staff did not assist with floor duties, exacerbating the staffing shortages and impacting the timely delivery of care. Additionally, the facility failed to retrieve medications from the backup source, resulting in residents not receiving their prescribed medications. One resident did not receive their antidepressant and anti-anxiety medications on multiple occasions due to alleged unavailability, despite these medications being present in the backup supply. This lack of coordination and failure to utilize available resources further contributed to the deficiencies in medication administration and resident care.
Inadequate Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to provide adequate care and services to prevent urinary tract infections for several residents, as evidenced by the lack of consistent catheter care and documentation. Resident #5 reported that her suprapubic catheter was not changed as scheduled, and there were multiple instances where catheter care was not documented. The resident expressed concerns about the risk of infections due to irregular catheter maintenance. The facility's records corroborated these claims, showing gaps in catheter care documentation and missing notes on catheter changes. Resident #40 also experienced issues with catheter care, reporting that her suprapubic catheter was not changed as ordered, leading to a hospital visit for an infection. Observations and record reviews revealed signs of infection at the catheter site, and the resident had to request hospital care. The facility's records showed no documentation of catheter changes despite physician orders, and the resident returned from the hospital with a prescription for antibiotics due to a urinary tract infection. Other residents, including #83, #11, and #81, were observed with urinary catheter bags and tubing in direct contact with the floor, which poses a risk for contamination and infection. Resident #11 reported frequent UTIs and inadequate catheter care due to staffing issues. Observations confirmed that catheter bags were not properly secured, and family members of Resident #81 noted that the catheter bag was consistently found on the floor during visits. These findings indicate a systemic issue with catheter care and infection prevention in the facility.
Inconsistent Nighttime Snack Provision
Penalty
Summary
The facility failed to consistently offer and provide nighttime snacks to residents, resulting in feelings of frustration and unmet needs. Observations, interviews, and record reviews revealed that seven residents were not consistently offered snacks at bedtime, leading to extended periods of time between dinner and breakfast. During a Resident Council meeting, eleven out of twelve residents reported that nighttime snacks were not consistently offered, and staff often claimed that no snacks were available. The Dietary Manager acknowledged awareness of these concerns, which were also documented in resident council and food council notes over the past six months. The facility's policy on snacks did not specify who was responsible for offering and preparing them. A review of nighttime snack documentation showed inconsistencies in offering snacks to residents, with some residents receiving snacks only a few times over a 30-day period. A resident with diabetes expressed concern about not receiving nighttime snacks, which are crucial for managing low blood sugar. Despite a physician's order for diabetic nighttime snacks, records showed that this resident went several consecutive days without receiving a snack. The facility's meal service schedule indicated a 14-hour gap between dinner and breakfast, during which residents were not consistently offered nourishing snacks.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and maintain an effective Antibiotic Stewardship Program, resulting in the potential for inappropriate antibiotic utilization and antibiotic resistance among all 84 residents. The facility's Infection Control documentation from December 2023 to October 2024 was incomplete, lacking line listing and Antibiotic Stewardship documentation for several months. The Infection Control Registered Nurse (IC RN) admitted to tracking antibiotic use on a monthly line list but failed to ensure that all residents met the McGeer criteria for antibiotic use. Discrepancies were noted between the number of residents receiving antibiotics and those included in the monthly infection summary, with some residents excluded due to a lack of confirmed infections. The report highlights specific cases where residents received multiple antibiotics without proper documentation or justification. One resident was treated with three different antibiotics for a urinary tract infection, while another received two antibiotics for a UTI, with one discontinued due to an allergy without a specified date. Other residents were treated with antibiotics for conditions such as C-diff, wound infections, and elevated white blood cell counts, but the facility failed to document whether these treatments met the McGeer criteria. The IC RN was unable to provide a clear explanation for these discrepancies and admitted to being unaware of some antibiotic orders until after they were initiated. Resident #58's case exemplifies the facility's failure to ensure appropriate antibiotic use. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease and acute kidney failure, was prescribed Doxycycline for a wound infection without any progress notes or laboratory results to justify the treatment. The Infection Preventionist was unaware of the antibiotic administration and confirmed that the resident did not meet the McGeer criteria for antibiotic usage. The lack of documentation and oversight in this case reflects the broader issues within the facility's antibiotic stewardship practices.
Resident's Right to Refuse Room Change Not Respected
Penalty
Summary
The facility failed to respect a resident's right to refuse a room change, which is a violation of their self-determination and choice. The resident, who is cognitively intact with a BIMS score of 15, expressed feelings of sadness and hopelessness after being moved from the rehabilitation section to the long-term care section without their consent. The resident, who has been at the facility for about six months, was visibly upset and stated that they did not agree to the room change and were unhappy about it. The resident emphasized that they did not plan on staying long-term and were no longer receiving therapy. The facility's policy on room changes, revised in May 2017, states that residents have the right to refuse a room change if it involves moving from a skilled nursing unit to a non-skilled unit, or vice versa, or if the move is solely for staff convenience. Despite this policy, the resident was moved without their agreement, and the reason for the room change was marked as 'other' in the electronic medical record. The social worker interviewed did not recall the resident being upset about the room change, but later documentation confirmed the resident's dissatisfaction with their current placement.
Failure to Provide Adequate Notice of Non-Coverage
Penalty
Summary
The facility failed to provide adequate notice of non-coverage and maintain documentation for two residents, resulting in a lack of full disclosure related to Medicare rights and the inability to appeal the discharge within the time frame allotted by Medicare. For Resident #76, the Notice of Medicare Non-Coverage Form indicated that services would end on 7/21/24, and the form was signed by the resident on the same date. However, for Resident #187, the facility could not provide the Notice of Medicare Non-Coverage Form upon request, despite the resident's discharge date being 7/1/24. Interviews with the Social Worker and Social Services Director revealed that the form for Resident #187 could not be found. The facility Administrator acknowledged awareness of the missing notification form and stated that such forms should be provided at least 48 hours prior to discharge and maintained as part of the medical record.
Inadequate Monitoring and Documentation of Physical Restraint Use
Penalty
Summary
The facility failed to ensure that Resident #75 was free from the use of physical restraints without proper assessment and monitoring. During an initial tour, Resident #75 was observed in a customized chair with a chest harness that had four non-self-release buckles, which the resident could not remove independently. The resident's medical record indicated a physician's order for a postural chest harness, which was discontinued months prior, and there was no new order or consistent monitoring upon the resident's readmission. The care plan and progress notes contained contradictory information regarding the resident's ability to release the harness, and the MDS assessment inaccurately coded the resident as not using physical restraints. Interviews with staff, including the Therapy Director and MDS Coordinator, confirmed that Resident #75 could not release the harness independently, and there was no current physician order for its use. The facility also lacked a physical restraint policy, as reported by the administrator. This lack of assessment, monitoring, and policy adherence resulted in the inappropriate use of a physical restraint on Resident #75, violating the requirement that residents be free from restraints unless medically necessary and properly documented.
Failure to Timely Obtain Weights and Administer Enteral Feeding
Penalty
Summary
The facility failed to obtain timely weights for two residents, resulting in unassessed weight loss. Resident #9 experienced a significant weight loss of 17.1 pounds, equating to an 11.62% decrease over 16 days. Despite having a care plan for malnutrition related to dysphagia, the latest intervention was dated a month prior, and there was no indication of timely re-assessment or intervention following the weight loss. Resident #9 expressed confusion about the weight loss during an interview, indicating a lack of communication and monitoring by the facility. Resident #80 was observed to be thin and had issues with the administration of enteral feeding. The feeding pump was found beeping with an empty bottle, indicating a lapse in feeding schedule adherence. The bottle, which should have been replaced at 4 AM, was left empty until 8:12 AM. The resident's care plan had been revised for significant weight loss following hospitalization, but interventions had not been updated since June 2024. The Corporate Registered Dietitian acknowledged the need for re-weights when requested but did not see the necessity for re-weighing these residents, despite evident weight issues.
Inaccurate Enteral Feeding Orders Lead to Deficiency
Penalty
Summary
The facility failed to ensure the accuracy of enteral feeding orders for a resident, resulting in an incomplete order with the potential for enteral tube malfunction or weight loss. During an observation, it was noted that the resident appeared thin and was receiving a Peractive tube feeding solution at 60cc/hr. A subsequent observation revealed that the resident's peg tube pump was beeping, indicating an issue. The feeding bottle was empty, and a new bottle was set on the overbed table but was not labeled. The RN stated that the night shift leaves the full bottle at the bedside without hanging it, leading to the feeding running longer than intended. A review of the resident's Medication Administration Record showed an order for enteral feeding at bedtime due to dysphagia, with specific instructions for the feeding rate and water flush. However, the order was incorrect in the electronic medical record, lacking documentation for both the hang time and take-down time. The Corporate Clinical Specialist, acting as the DON, confirmed that the order was incorrect and had been written without a take-down time, which was a deviation from the physician's orders. The facility's 'Enteral Nutrition' policy emphasizes providing adequate nutritional support as ordered, but this was not adhered to in this instance.
Failure in Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to implement an effective communication and coordination procedure for a resident requiring dialysis care, leading to a deficiency. The resident, who was severely cognitively impaired and required maximum assistance for daily activities, was admitted with multiple diagnoses including end-stage renal disease with dialysis dependence. The resident's care plan indicated scheduled dialysis sessions twice a week, but there were no completed dialysis communication forms in the resident's electronic medical record. A binder at the nurses' desk contained only blank forms, and it was revealed that completed forms were removed by administration. The deficiency was further highlighted when the resident received duplicate influenza vaccinations due to a lack of communication between the facility and the dialysis center. The resident was administered the vaccine at the facility and again during a dialysis session. The facility's infection control unit manager confirmed the duplication and noted that the vaccination was not entered into the Michigan Care Improvement Registry by either the facility or the dialysis center. The facility's policy on influenza vaccination did not address coordination with the dialysis center, contributing to the communication breakdown.
Failure to Conduct Timely Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed timely monthly medication regimen reviews (MRR) for three residents, resulting in missed reviews and delayed responses to recommendations. Resident #19, who is cognitively intact but has a guardian, did not have an MRR completed in July 2024. Resident #42, with moderate cognitive impairment, also missed an MRR in July 2024, and a recommendation for a gradual dose reduction (GDR) made in March 2024 was not signed off until over two months later. Resident #67, who has dementia and other conditions, had MRRs performed in February and April 2024 with recommendations for dose reductions that were not addressed by the physician until the facility was questioned. The facility's policy requires that MRR findings be communicated within 24 hours and acted upon by the prescriber, but there were no specified timeframes for responses to pharmacy recommendations. The administrator confirmed that the physician did not address the MRRs for Resident #67 from February and April 2024, and the facility was unable to provide a policy indicating appropriate timeframes for the MRR process. This lack of timely response and adherence to policy led to the deficiency noted in the report.
Inadequate Indications and Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents had adequate indications for the usage of psychotropic medications, proper care plan implementation, and appropriate monitoring. Resident #75 was observed without a sleep disorder diagnosis, yet was prescribed Zolpidem for sleep issues. The social worker and psychiatric nurse practitioner could not provide documentation supporting the need for this medication, as it was continued from a previous hospital stay without a documented indication for its use. Resident #80 was prescribed Ramelteon for insomnia, but there was no care plan, monitoring, or sleep tracking related to his hypnotic usage. The medication was initially started during a hospital admission and continued upon readmission to the facility. The social worker acknowledged that a care plan and monitoring should have been in place for the resident's hypnotic usage. Resident #82 was on Risperdal, an antipsychotic medication, without documented behaviors justifying its use. The medication was continued from a previous prescription upon admission, and the psychiatric nurse practitioner was uncertain about the indication for its use. The social worker later provided documentation from the FDA regarding Risperdal's use for irritability associated with autistic disorder, but this was not appropriately categorized in the resident's medical record until questioned by the surveyors.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to prevent pre-set up medications from being found in two of five medication carts. During an observation, a registered nurse discovered pre-set up medications, including metoprolol tablets, in an unmarked plastic cup in a medication cart. Additionally, a licensed practical nurse was observed handling medication without performing hand hygiene and found two medication cups with crushed and whole tablets in a cart drawer, lacking proper identification or resident names. The facility also failed to prime a new insulin pen before administration. An LPN on the secure dementia unit was observed administering insulin to a resident without priming the new insulin pen, which is necessary to ensure the pen is working correctly and to avoid incorrect dosing. Furthermore, the facility did not provide timely insulin administration per a physician's order for a resident. The resident reported receiving morning insulin late, which was confirmed by a review of the medication administration record showing multiple instances of late insulin administration. The RN responsible for the late administration cited staffing issues and last-minute schedule changes as contributing factors to the delay.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide dental services to a resident, identified as R19, who had not received routine dental care since their admission. R19, a cognitively intact individual with a BIMS score of 13, expressed a desire to see a dentist, noting they had not seen one since arriving at the facility. Despite having a guardian due to the inability to make their own medical decisions, R19 had a dental consent form in their electronic medical record, signed and dated, but the sections to consent to or decline dental care services were left blank. Interviews with facility staff revealed that R19 had not been seen by a dentist during their stay. The social worker, SW S, confirmed that R19 was only recently placed on a list to be seen by the dentist, indicating a lapse in routine dental care provision. The facility's policy on dental services, which includes providing routine and emergency dental services through various means, was not adhered to in this case, resulting in the deficiency.
Failure in Vaccination Administration Procedures
Penalty
Summary
The facility failed to implement and operationalize its policies and procedures for vaccination administration, affecting three residents. Resident #1 expressed a desire to receive both the Influenza and Pneumonia vaccines. While the Influenza vaccine was administered, the Pneumonia vaccine was not, despite being ordered. The failure was attributed to the floor nursing staff not administering the vaccine as ordered. Resident #56's documentation showed discrepancies between the vaccine ordered and the vaccine education provided. Although Prevnar 20 was ordered and administered, the documentation incorrectly noted Prevnar 13, and there was no documentation of follow-up monitoring after administration. The facility also failed to document the Vaccine Information Statement (VIS) version provided. Resident #75 wanted the Pneumonia vaccine, but it was never administered, despite being available and ordered. There was no documentation explaining why the vaccine was not given. The facility's policy requires that all residents be offered pneumococcal vaccines and that documentation should include the date of vaccination, lot number, expiration date, person administering, and site of vaccination. However, these procedures were not followed, leading to the deficiency.
Inadequate Supervision and Reporting of Non-Consensual Sexual Behavior
Penalty
Summary
The facility failed to implement and operationalize abuse prohibition policies and procedures, resulting in inadequate supervision to prevent non-consensual sexual behaviors between two cognitively-impaired residents in the locked Dementia Unit. The incident involved two residents who were found partially naked in bed with genitals exposed. The facility did not report or investigate the incident in a timely manner, as the Administrator and DON were informed two days after the event occurred. Resident #705, a female with bipolar disorder, major depressive disorder, disorganized schizophrenia, and dementia, was moderately cognitively impaired and had a legal guardian. She was found in bed with Resident #706, a male with Alzheimer's disease and dementia, who was severely cognitively impaired. Both residents were deemed incompetent and unable to make informed decisions. The facility's documentation revealed that Resident #705 had previously exhibited behaviors of offering intercourse with other residents, and Resident #706 had a history of attempting to bring female residents into his room. Interviews with staff indicated that the residents were found by CNAs during a night shift, and the incident was not immediately reported to the DON or Administrator. The facility's investigation was initiated two days later, and there was a lack of comprehensive documentation, including a police report, staff schedule, and camera footage timeline. The facility's investigation concluded that the allegation could not be substantiated, but the lack of timely reporting and supervision contributed to the deficiency.
Failure to Honor Resident's DNR Wishes Due to Incomplete Documentation
Penalty
Summary
The facility failed to honor the resident's wishes and identify the designated patient advocate, despite legal documentation provided by the family upon admission. This resulted in a resident receiving CPR for over an hour and subsequently dying, contrary to the resident's Do Not Resuscitate (DNR) wishes. The resident had a BIMS score of zero, indicating severe cognitive impairment, and had appointed her husband as the primary patient advocate and her daughter as the successor. However, the facility did not recognize these designations due to incomplete documentation. The facility's failure to complete the necessary Incapacity to Make Health Care Decisions Form, which required signatures from two physicians, led to the resident being treated as a Full Code. Despite the presence of a signed DNR order by the designated patient advocate, the facility deemed it invalid because the form lacked dates and the incapacity form was not completed in a timely manner. This oversight resulted in the resident's DNR wishes not being honored, as the facility continued to treat her as a Full Code. The facility's policies did not clearly outline the process for determining a resident's incapacity and the authority of a patient advocate. The Director of Nursing acknowledged the error in not filling out the forms correctly, and the Director of Social Services confirmed the delay in obtaining the necessary physician signatures. The facility's failure to adhere to its own policies and procedures regarding patient advocacy and decision-making authority contributed to the deficiency, ultimately leading to the resident's undesired resuscitation and death.
Failure to Report and Investigate Missing Resident
Penalty
Summary
The facility failed to adhere to its policy for immediately reporting, investigating, and informing local authorities about a missing resident, resulting in a deficiency. Resident #802, who had a medical history including osteomyelitis requiring IV antibiotic therapy, diabetes, and other conditions, left the facility and did not return for over 24 hours. The resident's absence was not reported to the Administrator or the Director of Nursing (DON) until the morning after the resident was discovered missing. Despite the resident's failure to return, the facility did not notify local authorities or the state agency as required by their policy. The Administrator and DON were unaware of the resident's absence until the morning stand-up meeting, and no staff member had notified them of the situation. The facility attempted to contact the resident through phone calls and by visiting the last known address, but these efforts were unsuccessful. The Administrator and DON personally searched for the resident but did not report the incident to the police or state agency, as they did not consider it an elopement due to the resident's alert and oriented status and ability to leave on Leave of Absence (LOA) status. The facility's policies, including the Signing Residents Out Policy and the Elopement Policy, were not followed. The resident did not sign out upon leaving, and no investigation was conducted to determine if the case was reportable. The facility's policy required a search and notification of authorities if a resident could not be located, but these steps were not taken. The lack of adherence to these policies resulted in a deficiency, as the facility did not ensure the resident's safety or report the incident as required.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to significant deficiencies. For one resident, the facility did not appropriately address the resident's Advanced Directive. The resident was admitted with severe cognitive impairment, as indicated by a BIMS score of zero. Despite this, the facility did not complete the necessary DO-NOT-RESUSCITATE (DNR) form correctly, and the incapacity determination was not signed timely by two physicians. Consequently, the resident's code status remained Full Code, and the DNR order was voided. The resident received CPR and was pronounced dead before the family could sign the DNR order form. For another resident, the facility failed to address the resident's frequent Leaves of Absence (LOA) in the care plan. This resident had a history of mental illness and was receiving treatment for various conditions, including osteomyelitis and HIV. The resident often left the facility during the day and returned at night, but on one occasion, did not return after midnight. The facility did not report the resident as missing to local authorities or the state agency, as they considered the resident to be on LOA. The care plan did not include interventions or actions to monitor and maintain the resident's safety during these absences. The facility's policies on Advanced Directives and care planning were not adhered to, as evidenced by the lack of a care plan for the Advanced Directive and the absence of a care plan addressing the frequent LOA for the second resident. The facility did not provide the Care Planning Policy during the survey exit, further indicating a lack of compliance with established procedures.
Failure to Honor DNR Order Leads to Unwanted CPR
Penalty
Summary
The facility failed to honor the Do Not Resuscitate (DNR) wishes of a resident, resulting in the resident receiving full code status and undergoing Cardiopulmonary Resuscitation (CPR) against the expressed wishes of the resident's designated patient advocate. The resident, who had severe cognitive impairment with a BIMS score of zero, was found unconscious by a nurse, and CPR was initiated by the staff until emergency medical personnel arrived. The resident's family, including the designated patient advocate, was not notified of the resident's declining condition and witnessed the CPR being performed, which was contrary to the resident's documented DNR order. The deficiency arose from the facility's failure to properly process and validate the resident's DNR status. Although the resident's husband was designated as the patient advocate and had signed the DNR order, the facility did not complete the necessary incapacity form in a timely manner, which required signatures from two physicians. This delay resulted in the resident being treated as a full code, as the facility did not recognize the DNR order due to the missing physician signatures. The facility's Director of Nursing acknowledged the oversight and the delay in obtaining the required documentation. Interviews with staff revealed that there was confusion and a lack of communication regarding the resident's code status. The staff relied on the electronic medical record, which incorrectly indicated a full code status, leading to the initiation of CPR. The facility's policies on determining a resident's healthcare decision-making authority and the process for activating a patient advocate's authority were not effectively implemented, contributing to the failure to honor the resident's advance directives.
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Illustrative
What surveyors actually found near you
We read the 198 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saginaw Senior Care And Rehabilitation Center, Llc | 0.7 mi | ★★★★★ | 8 | 0 |
| Hoyt Nursing & Rehab Centre | 1.5 mi | ★★★★★ | 1 | 0 |
| Covenant Skilled Nursing And Rehabilitation At Wel | 2.6 mi | ★★★★★ | 15 | 0 |
| Great Lakes Rehabilitation Center | 3.1 mi | ★★★★★ | 24 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 3.5 mi | ★★★★★ | 26 | 0 |
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