Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Aria Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident with multiple sclerosis and epilepsy reported that another resident, who appeared intoxicated and had an open can of beer, struck her left arm in a day room, with a RN and CNA hearing a slap-like sound and the resident cry out, and the aggressor later admitting he had "smacked" her arm after drinking. In a separate incident, a resident with dementia and cardiac and diabetic conditions became upset over a wallet he insisted was his, and multiple staff witnesses reported that the former NHA raised his voice, got close to the resident, pointed at him, and called him a profane name while the resident was hollering and swearing, with the resident later recalling that cussing words were used toward him.
A resident with morbid obesity, multiple comorbidities, moderately impaired decision-making, and documented dependence for bed mobility had a care plan requiring a two-person assist for rolling in bed. During early-morning incontinence care, a CNA, believing the resident was an assist of one based on the Kardex, rolled the resident away from herself while the bed was elevated, causing the resident to fall to the floor. Staff found the resident face down next to the elevated bed with a large right lower-leg laceration and pain, and EMS transported the resident to the hospital, where the wound required 24 sutures and internal drains. The facility’s investigation materials lacked the CNA’s reported written witness statement, and the DON acknowledged that staff failed to follow the care-planned two-person assist for bed mobility, resulting in the fall with injury.
A cognitively intact resident with insulin‑dependent DM and other chronic conditions experienced a significant medication error when an RN administered 52 units of short‑acting Novolog instead of the ordered long‑acting insulin, resulting in wrong medication and wrong strength/quantity. Family members reported that the resident was transferred to the hospital after this large dose of fast‑acting insulin, and facility documentation, including a medication error form, nurse progress note, and physician note, confirmed the mis‑administration. The DON acknowledged that a medication error had occurred, and later observation found the resident non‑verbal and non‑responsive with hospice services in place.
A resident with multiple diagnoses and a care plan requiring calm communication was subjected to profane and inappropriate language by a CNA, as confirmed by both the resident and a housekeeper. The CNA admitted to using inappropriate language in response to the resident, and the facility's investigation substantiated the verbal misconduct, resulting in a failure to honor the resident's right to dignity and respectful treatment.
A resident with multiple diagnoses, including Parkinson's Disease and mental health conditions, was present when a CNA was overheard using profane language in their room. The incident was reported internally but not reported to the State Agency within the required two-hour timeframe, with the delay confirmed by the NHA, who could not explain the late reporting.
Surveyors identified widespread failures in cleaning and maintenance throughout the facility, including soiled ventilation grills, damaged flooring, stained ceiling tiles, loose plumbing fixtures, and unaddressed work orders. These deficiencies affected 83 residents and were not documented in the facility's maintenance system, despite policies requiring daily cleaning and prompt repairs.
Surveyors found that medications were not consistently labeled or stored according to professional standards. A resident was found with a cup of pills left on the bedside table without assessment for self-administration, and a multi-dose inhaler was discovered on a medication cart without the required date of opening. Both the RN and DON confirmed these actions were not in line with facility policy.
Surveyors identified deficiencies in the cleaning and maintenance of food service equipment, as well as failures to properly date mark ready-to-eat food items. Multiple kitchen appliances and surfaces were found soiled with dust, dirt, and food residue, and some food products lacked required open or discard dates. These issues were observed during a kitchen tour and confirmed through interviews and policy reviews.
Surveyors found that two outdoor waste receptacles were not properly maintained and the surrounding concrete pad was not cleaned, with accumulated debris and damaged receptacle components observed. Facility policy required regular trash removal and cleanliness, but no related work orders were found. These deficiencies affected 83 residents.
A resident with multiple medical conditions and moderate cognitive impairment was prescribed Olanzapine, an antipsychotic, without being informed of the medication's benefits, risks, or alternatives. The social worker and DON confirmed that no consent documentation was present, and the resident was unable to state the reason for receiving the medication, despite facility policy requiring such information be provided before starting psychotropic drugs.
The facility did not promptly address or resolve multiple resident grievances, including missing clothing, inappropriate food options, and removal of privacy amenities. Grievance forms were incomplete and lacked resident signatures, and staff interviews confirmed ongoing issues with the grievance process and laundry procedures, resulting in unresolved concerns and resident frustration.
The facility failed to properly document and monitor the use of psychotropic medications for three residents, including missing or inconsistent diagnoses to support antipsychotic use, incomplete behavioral and side effect monitoring, unacknowledged pharmacy recommendations for dose reduction, and PRN antianxiety medication orders that exceeded regulatory time limits.
A resident with a history of repeated falls and multiple diagnoses experienced several falls over six months, some resulting in injury. Despite these incidents, the care plan was not consistently updated with new interventions, and staff discussions about the resident's needs were not reflected in the care plan documentation. This failure to revise the care plan led to the potential for further falls and unmet care needs.
The facility failed to provide adequate care for pressure ulcers, leading to the deterioration of wounds in two residents. One resident developed a Stage 2 pressure ulcer that worsened to an unstageable ulcer, resulting in hospitalization and surgery for osteomyelitis. The facility did not consistently follow the wound care plan, and incorrect treatments were administered. Another resident developed pressure sores, but the facility failed to document a wound assessment, notify the guardian, or order appropriate treatment. The care plans were not updated, and staff were unaware of the pressure injuries, leading to a lack of treatment.
The facility failed to administer medications according to physician-ordered parameters for three residents, leading to medication errors. A resident with heart disease received Metoprolol despite low blood pressure readings, another with atrial fibrillation was given Entresto without proper blood pressure checks, and a third with hypertension received Lisinopril without any blood pressure assessments. The DON confirmed these errors, which violated the facility's medication administration policy.
A resident reported being hit by a mechanical lift sling, resulting in welts, but the incident was not documented or investigated by the facility. The NHA considered it an accident and took no action against the CNA involved, despite the resident's report and photographic evidence of the injury.
A resident reported being hit by a mechanical lift sling, resulting in welts. The incident was not documented or reported by the NHA, who deemed it accidental. The CNA admitted to "goofing off" with the sling. The facility failed to prevent abuse and did not investigate or report the incident, leading to a deficiency citation.
Failure to Prevent Resident-to-Resident Physical Abuse and Administrator Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident and another resident from verbal abuse by a staff member. One resident with multiple sclerosis and epilepsy, cognitively intact per a recent MDS, reported that approximately three weeks prior she was in the day room when another resident, who appeared intoxicated and had an open can of beer, choked her and then slapped her left arm hard enough to leave red marks. On the date of the incident, a RN passing medications just outside the day room heard a slap-like sound and the resident say “ouch,” then found the alleged aggressor in a wheelchair next to the resident and observed mild redness on the resident’s left upper arm. A CNA in the day room also heard a slapping noise and the resident call out, then turned and saw the alleged aggressor sitting next to her. The facility’s investigation substantiated resident-to-resident physical abuse based on the aggressor striking the resident’s left upper arm, though the choking allegation could not be substantiated. The resident alleged that the aggressor had been intoxicated and that he grabbed the front of her neck with one hand, making her unable to breathe, and then slapped her arm. The aggressor’s medical record showed moderate cognitive impairment on the BIMS, and he later acknowledged that he “smacked” the resident’s arm, stating he had been drinking beer at a family member’s house before being dropped off at the facility and did not remember the incident, but understood from others that it was an open-hand smack. The facility’s investigation documented that he appeared intoxicated at the time, had an open can of beer in his wheelchair, and had been watching the resident talk to another male resident, which he reportedly did not like, before approaching her. Staff present in or near the day room did not prevent the physical contact, and the abuse occurred in a common area while the aggressor was in possession of alcohol and visibly intoxicated. The deficiency also includes an incident of verbal abuse toward another resident by the former Nursing Home Administrator (NHA). This resident, with chronic diastolic heart failure, diabetes, and unspecified dementia and severe cognitive impairment per a recent MDS, was in his room with a wallet that staff believed belonged to another resident. During an attempt by staff, including the former NHA, Social Services Assistant, and Scheduler, to address the wallet issue, the resident became upset, hollering, swearing, and insisting the wallet and money were his. Multiple staff witnesses reported that the former NHA raised his voice, got in the resident’s face, pointed at him, and called him a “mother f**ker” after the resident swore at him, while the resident later recalled that the man involved swore and used “cussing words” toward him. The facility’s investigation determined that the wallet was in fact the resident’s, and staff accounts consistently described the former NHA’s use of profanity and raised voice toward the resident during the interaction.
Failure to Follow Bed-Mobility Care Plan Leads to Fall and Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety and to implement care-planned interventions during staff-assisted care, resulting in a resident falling from an elevated bed and sustaining a serious leg laceration. The resident was an older female with chronic heart failure, diabetes, morbid obesity, major depression, and anxiety disorder. Her MDS showed a BIM score of 11, indicating moderately impaired decision-making, and documented that she was dependent on staff for toileting, dressing, bathing, and rolling in bed. Her care plan, dated 1/2/26, specified that she had a functional ability deficit related to morbid obesity and weakness, and required a two-person assist for all aspects of bed mobility, including rolling side to side. On the morning of the fall, a CNA was providing incontinence care to the resident and rolled her away from herself while the bed was elevated to between knee and hip height. During this maneuver, the resident fell out of the bed to the floor and began screaming in pain. Another CNA and a nurse responded and observed the resident lying face down on the floor next to the elevated bed, with blood pooling under her right knee and a large open wound on her right lower leg. The resident complained of back and leg pain. Emergency services were called, and the resident was transported to the hospital, where she was treated for a significant laceration of the right lower leg requiring 24 sutures and placement of internal drains. Record review showed that the resident’s care plan required a two-person assist for bed mobility, but the CNA who provided care at the time of the fall believed the resident was an assist of one based on the Kardex and did not verify this information. The CNA reported that she had completed a written witness statement and was later educated to follow the Kardex and to roll residents toward, not away from, herself during care. However, the administrator and DON were unable to produce any written witness statements as part of the facility’s investigation, and the investigation materials provided did not include such documentation. The DON acknowledged that the facility failed to follow the care-planned interventions for two-person assist with bed mobility, which led to the resident’s fall with injury, and stated that staff were expected to follow care plans and Kardex and to roll residents toward themselves during in-bed care.
Significant Insulin Administration Error Involving Wrong Insulin Type and Dose
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for one cognitively intact resident with insulin‑dependent diabetes, anxiety, and depression. The resident’s daughter had submitted a complaint to the state alleging that insulin was not administered according to physician orders. Review of the resident’s records showed that the resident was hospitalized and not present in the facility at the time of survey. During interviews, the resident’s daughter and son both reported that the resident had been transferred to the hospital after receiving a large dose of fast‑acting insulin instead of the prescribed long‑acting insulin. The DON acknowledged that the resident had a medication error. Further review of the medical record and facility documentation confirmed that the resident was administered 52 units of Novolog (short‑acting insulin) instead of the ordered long‑acting insulin, constituting wrong medication and wrong strength/quantity. A nurse involved in the incident reported that the fast‑acting insulin was given in error in place of the long‑acting insulin and that this was reported to the DON. A nurse progress note documented that the resident returned from the emergency department with EMS, with EMS reporting that the resident’s blood glucose never dropped below 100 and the event was uneventful. A physician note documented that staff reported the resident had been transferred to the emergency department after mis‑administration of 52 units of short‑acting insulin. During a later observation, the resident was seen in bed, non‑verbal and non‑responsive to questions, with her son at the bedside and hospice services in place.
Failure to Treat Resident with Dignity and Respect Due to Staff Use of Inappropriate Language
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, who was cognitively intact and required two-person assistance with activities of daily living, was not treated with dignity and respect. The resident's care plan and Kardex specified that staff should approach and speak to the resident in a calm, quiet manner. However, the resident reported that a Certified Nursing Assistant (CNA) used obscene and inappropriate language during an interaction, including profanities and derogatory remarks. This incident was corroborated by a housekeeper who overheard the CNA loudly using profane language inside the resident's room. Further interviews confirmed that the CNA admitted to responding to the resident with inappropriate language after being called names by the resident. The facility's investigation substantiated that the staff member was verbally inappropriate in the presence of the resident. The incident demonstrated a failure to honor the resident's right to a dignified existence and respectful communication, as required by the resident's care plan and facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency for one resident. The resident, who was cognitively intact and had diagnoses including Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, was present in their room when a CNA was overheard by a housekeeper repeatedly using profane language directed at the resident. The housekeeper reported the incident to the housekeeping supervisor and the administrator. Although the incident occurred and was discovered in the early afternoon, it was not reported to the State Agency until over seven hours later, exceeding the required two-hour reporting timeframe. The Nursing Home Administrator confirmed the delay and was unable to provide an explanation for the late reporting.
Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 83 residents. During environmental tours of various facility areas, surveyors observed multiple instances of unaddressed soiling, damage, and maintenance issues. These included missing or damaged cabinet components, soiled ventilation grills, stained and warped ceiling tiles, loose or damaged commode seats and supports, leaking plumbing, and soiled or damaged flooring. Additionally, equipment such as microwaves and box fans were found to be corroded or heavily soiled, and air filters in PTAC units were observed with accumulated dust and dirt. In several resident rooms, commode base caulking was found to be etched, scored, stained, or particulate, and some hand sinks were draining slowly or not at all. Interviews with the Director of Maintenance and Housekeeping Director revealed that while a work order system (TELS) was in place, many of the observed deficiencies had not been entered into the system or addressed. For example, missing flooring tiles in a janitor closet had been unaddressed since June 2022, and no work orders were found in the TELS system for the specific maintenance concerns identified during the survey. Staff acknowledged the issues when pointed out and indicated intentions to submit work orders, but these actions had not occurred prior to the survey. A review of the facility's housekeeping policy indicated that cleaning of non-carpeted floors and other horizontal surfaces should occur daily and more frequently if visibly soiled. However, the observations made during the survey demonstrated that these procedures were not consistently followed, as evidenced by the widespread presence of dust, dirt, stains, and damaged surfaces throughout both common and resident areas. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality for residents, staff, and the public.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not consistently labeled and stored according to accepted professional standards. In one instance, a resident was found with a medication cup containing four to five pills left unattended on the bedside table for approximately 30 minutes while the resident was sleeping. The resident had not been assessed for self-administration of medications, and the Director of Nursing confirmed that residents were not permitted to self-administer medications. This indicates that staff failed to ensure medications were administered directly to the resident and not left at the bedside. Additionally, during a review of a medication cart, a multi-dose inhaler (Fluticasone Propionate Inhalation Aerosol 220 MCG) was found open and not dated as required by facility policy and professional standards. The Registered Nurse acknowledged that all medications should be dated when opened and could not explain why this was not done. The Director of Nursing also confirmed that it was expected practice to date all multi-dose medications upon opening, but could not account for the lapse in this instance.
Deficiencies in Food Service Equipment Sanitation and Date Marking
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, specifically related to the cleaning and maintenance of food service equipment and the date marking of potentially hazardous ready-to-eat food products. During an initial tour of the kitchen, several pieces of equipment, including the Avantco 2-Door Reach-In Cooler and Vulcan convection ovens, were found with non-functional interior light bulbs. Additionally, the interior and exterior surfaces of refrigerators and ovens, as well as the can opener assembly, were noted to be soiled with accumulated and encrusted dust, dirt, and food residue. Overhead light lens covers, ceiling-mounted return-air-exhaust ventilation grills, and the mechanical dish machine ventilation hood were also observed to be heavily soiled with dust and debris. Further inspection revealed that food items such as a gallon of milk and a container of cottage cheese stored in the reach-in cooler were not properly date marked to indicate when they should be consumed or discarded, despite being open and held for more than 24 hours. The manufacturer's use-by dates were visible, but there was no effective open or discard date as required by the FDA Model Food Code. These findings were confirmed through interviews with the Dietary Director, who acknowledged the issues and indicated intentions to address them. Record reviews of the facility's policies and procedures for dietary cleaning, sanitation, and food handling confirmed that the facility is required to maintain kitchen sanitation and comply with time and temperature requirements to prevent foodborne illness. However, the observed conditions did not align with these policies, as equipment and non-food contact surfaces were not kept clean, and proper food handling techniques, such as date marking, were not consistently followed.
Improper Maintenance and Cleaning of Outdoor Waste Receptacles
Penalty
Summary
Surveyors observed that the facility failed to properly maintain two out of three outdoor waste receptacles and did not clean the concrete pad surface where the receptacles were located. Specifically, accumulated dirt and debris, including paper products, plastic bottles, a plastic milk crate, and a wooden pallet, were present on the concrete pad. Additionally, one of four receptacle plastic lids was missing, and one of four receptacle slider panels was broken, with a hole measuring approximately 6 inches by 6 inches. Review of facility policy indicated that trash should be removed on a specific schedule and the area surrounding the dumpster kept free of debris. However, a review of work orders for the past 180 days showed no entries related to maintenance or cleaning of the outdoor waste receptacles or the concrete pad surface. These deficiencies affected 83 residents.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, bipolar disorder, and depression, was prescribed Olanzapine, an antipsychotic medication, without being informed of the associated benefits, risks, or alternatives. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 12 out of 15. Review of the medical record showed no documentation of consent or evidence that the resident or their responsible party had been provided with information regarding the use of Olanzapine. Interviews with facility staff revealed that the social worker was responsible for ensuring that residents or their representatives received and signed consent forms for psychotropic medications. However, the social worker was unable to provide any documentation of consent for this resident, and the DON confirmed that no such consent was present in the medical record. The resident was also unable to explain why they were receiving the antipsychotic medication. Facility policy required that residents and/or their representatives be informed of the benefits, risks, and alternatives before initiating or increasing psychotropic medications, but this procedure was not followed in this case.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to act promptly on grievances reported during resident council meetings and did not provide adequate responses to grievances for six of nine residents, as evidenced by a review of resident council meeting minutes and grievance forms. Concerns and complaints, such as missing clothing, inappropriate food options, and removal of a phone that provided privacy, were repeatedly documented over several months without resolution or proper documentation indicating that the issues had been addressed. Grievance forms were found to be incomplete, lacking documentation of resolution and resident signatures to confirm satisfaction with outcomes. Residents expressed ongoing frustration during council meetings, reporting that missing clothing issues persisted for weeks or months, with some residents observing others wearing their clothes and staff failing to act when notified. Additional concerns included being served food that did not meet dietary needs or preferences, repeated offering of undesirable alternatives, and the removal of a phone that previously allowed for private conversations. Multiple residents reported receiving cold food, sour milk, and food they were allergic to, with all nine residents at the meeting sharing that their grievances remained unresolved. Interviews with facility staff revealed a lack of consistent follow-through in the grievance process. The Activity Director and other staff described the process for handling grievances but acknowledged that forms were not always completed fully or signed by residents to indicate satisfaction. The Housekeeping Director detailed ongoing issues with the laundry process, including improper labeling of clothing and incomplete personal item lists, which contributed to the unresolved complaints about missing clothing. Despite these issues being discussed in daily meetings, no changes had been made to address the underlying problems.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for the use of psychotropic medications for three out of five residents reviewed. For one resident with dementia and depression, Risperidone was prescribed without a documented allowable diagnosis to support its use, and the diagnosis of 'depression with psychotic features' was not consistently reflected in the medical record or on the active diagnoses list. The resident's care plan and behavioral documentation were incomplete, and not all possible side effects listed in the informed consent were included on the treatment administration record for staff monitoring. Additionally, a pharmacy recommendation for a gradual dose reduction (GDR) of Risperidone was not acknowledged or acted upon by the physician, and there was a lack of clear process ownership for monitoring psychotropic medications among staff. Another resident received multiple PRN (as needed) orders for Ativan, an antianxiety medication, with durations exceeding the regulatory 14-day limit for PRN antianxiety medications. These orders were not appropriately limited or reviewed within the required timeframe, indicating a failure to comply with federal regulations regarding the use of PRN psychotropic medications. A third resident was prescribed both an antipsychotic (Olanzapine) and an antidepressant (Trazodone) without corresponding physician orders for monitoring side effects. The Director of Nursing confirmed that monitoring for side effects should have been ordered and documented, but could not provide evidence that this was done. The facility's policy required monitoring for efficacy, side effects, and adverse consequences of psychoactive medications, but this was not followed for the resident in question.
Failure to Revise Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised to address the ongoing care needs of a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls, diabetes, left hip pain, bipolar disorder, and dementia, experienced eight falls over a six-month period. Despite multiple incidents, including falls in the bathroom and bedroom, care plan interventions were either not updated or only minimally addressed, such as ensuring toileting after meals or applying anti-rollback bars to the wheelchair. Several falls resulted in injuries, including a 3 cm abrasion above the left eyebrow and a laceration with a knot, yet no new care plan interventions were implemented following these events. Interviews with staff revealed that the resident often attempted to self-transfer, leading to falls, and that while incidents were discussed in daily meetings, these discussions did not result in updates to the care plan. The care plan was not consistently revised to reflect the resident's changing needs or to implement new interventions after each fall. Documentation showed that recommendations, such as transferring the resident to the unit dayroom with nursing staff, were discussed but not added to the care plan or put into practice. This lack of timely and comprehensive care plan revision resulted in the potential for additional falls and unmet care needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure injuries, leading to the deterioration of wounds and subsequent hospitalization. Resident #1, a cognitively intact male with Type II Diabetes and other health issues, developed a Stage 2 pressure ulcer on his left heel during his stay. Despite initial improvement, the wound care plan was not consistently followed, and incorrect treatments were administered. The wound deteriorated to an unstageable pressure ulcer, and the resident was hospitalized with osteomyelitis, requiring surgical intervention. Resident #6, a cognitively intact female with muscle weakness and morbid obesity, was found to have a pressure sore on her left thigh and a new red spot on her right buttock. The facility failed to document a wound assessment, notify the guardian, or order appropriate treatment upon identification of the pressure injury. The resident's care plan was not updated with necessary interventions, and the staff was unaware of the pressure injuries, leading to a lack of treatment. The facility's failure to adhere to professional standards of practice for pressure ulcer care resulted in the worsening of residents' conditions. The care plans were not revised to reflect changes in the residents' skin conditions, and the necessary notifications and treatments were not completed. This lack of appropriate care and communication contributed to the deterioration of the residents' pressure injuries.
Medication Administration Errors Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician-ordered parameters for three residents, resulting in medication errors. Resident #7, a male with heart disease and hypertension, received Metoprolol despite blood pressure readings that were below the prescribed parameters on multiple occasions. Additionally, there were instances where his blood pressure was not assessed prior to medication administration, relying instead on outdated readings. Resident #8, a male with atrial fibrillation, was administered Entresto even when his blood pressure readings were below the ordered parameters, and on some occasions, his blood pressure was not assessed before medication administration. Resident #10, a female with hypertension, received Lisinopril throughout June without any blood pressure assessments to ensure compliance with the ordered parameters. The Director of Nursing confirmed that medications for these residents were administered outside of parameters or without necessary vital sign assessments. The facility's policy on medication administration, last revised in April 2019, requires that medications be administered in accordance with prescriber orders, including any necessary vital sign checks. The failure to adhere to these protocols led to the administration of medications without verifying that the residents' vital signs were within the prescribed limits, contributing to the cited deficiencies.
Failure to Prevent and Investigate Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse and did not adequately protect residents or investigate allegations, leading to the potential for continued abuse. A resident, who was cognitively intact, reported being hit on the back by a mechanical lift sling, resulting in welts. The incident was witnessed by others, and the resident had photographic evidence of the injuries. Despite the resident reporting the incident to the Nursing Home Administrator (NHA), it was not documented or addressed in the medical record. The NHA did not report the incident, considering it an accident rather than abuse, and took no disciplinary action against the involved CNA. The CNA admitted to goofing off with the mechanical lift sling, which led to the resident being hit. The NHA acknowledged discussing the incident with the resident, who expressed that the hit was painful but did not want to get anyone in trouble. The lack of documentation and failure to report or investigate the incident contributed to the deficiency.
Failure to Report and Investigate Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse and did not properly investigate or report the incident to the state agency. A resident, who was cognitively intact, reported being hit on the back by a mechanical lift sling, which left welts. The incident occurred when a CNA was "goofing off" with the sling, and the resident reported it to the Nursing Home Administrator (NHA) two weeks later. Despite the resident showing photographic evidence of the injury, the incident was not documented in the medical record. The NHA did not report the incident, believing it was an accident and not intentional abuse. The NHA also did not take any disciplinary action against the CNA involved, nor did he educate staff on the incident. The CNA admitted to "goofing off" with the sling, which led to the resident being hit. The NHA acknowledged discussing the incident with the resident, who expressed that the hit was painful but did not want to get anyone in trouble. The lack of documentation and failure to report the incident resulted in a deficiency citation for the facility.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Capital Area | 1.6 mi | ★★★★★ | 5 | 0 |
| Holt Senior Care And Rehab Center | 1.8 mi | ★★★★★ | 11 | 0 |
| Dimondale Nursing Care Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Campus Area | 5.6 mi | ★★★★★ | 11 | 0 |
| Burcham Hills Retirement Center | 6.4 mi | ★★★★★ | 4 | 0 |
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