Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumnwood Of Mcbain during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was admitted for respite care and experienced a significant medication error when their Carbidopa/Levodopa and Levothyroxine orders were transposed, leading to multiple overdoses of Levothyroxine. The error was not identified or corrected by nursing or medical staff, resulting in the resident's rapid decline, severe adverse effects, and eventual death.
A resident with multiple chronic conditions was admitted for respite care and experienced a significant medication error when Carbidopa/Levodopa and Levothyroxine orders were transposed during admission. The resident received excessive Levothyroxine doses and insufficient Carbidopa/Levodopa due to improper transcription and lack of a documented double-check by nursing staff. The error persisted for several days, leading to severe adverse effects and a marked decline in the resident's condition, ultimately resulting in death after discharge.
A resident with multiple chronic conditions was admitted and received an incorrect, excessive dose of Levothyroxine due to a transcription error and lack of verification by nursing staff. Despite abnormal symptoms and vital signs, staff did not question the unusual dosing frequency or check the original orders, resulting in the resident receiving five times the intended dose for several days and a significant decline in their condition.
Inadequate staffing at the facility resulted in residents being left in soiled conditions and experiencing long wait times for assistance. One resident with a leaking colostomy bag was not attended to promptly, while another waited 30 minutes for repositioning. Staff shortages, particularly during weekends and evening shifts, contributed to these deficiencies, as confirmed by staff and resident interviews.
The facility failed to store food according to professional standards, with expired and undated items found during a kitchen tour. Issues included wilted cabbage, rotten potatoes, a broken egg, moldy tomatoes, and exposed vegetarian patties. Additionally, hot dogs had an unclear use-by date. Damaged cabinetry near an ice machine was also noted, with past leakage issues confirmed. These deficiencies risked foodborne illness among 89 residents.
The facility failed to maintain functioning exhaust ventilation in resident bathrooms on the 300 Hall, affecting 19 residents. Noxious odors were noted, and an investigation revealed non-functioning exhaust systems in several rooms due to a broken belt on the motors. Maintenance checks were not conducted as required by facility policy.
The facility failed to provide dignified care to five residents, leading to feelings of frustration and low self-worth. A resident with a leaking ostomy bag was left soiled, another waited 30 minutes for repositioning assistance, and a third waited 27 minutes for bathroom help. Two residents with severe cognitive impairments faced undignified dining conditions, with one left out of reach of their meal. The DON acknowledged these issues, attributing them to staff behavior during the survey.
The facility failed to provide adequate ADL care for six residents, including assistance with personal hygiene and incontinence care. Residents were found soiled, unkempt, and without necessary grooming, with staff expressing being overwhelmed due to inadequate staffing. The facility's policy on regular checks and changes was not followed, leading to deficiencies in resident care.
The facility failed to provide appropriate respiratory care, including incorrect oxygen flow rates and lack of physician orders for some residents. Respiratory equipment was not properly maintained or stored, with nebulizers left uncleaned and undated. Some residents received oxygen therapy without documented physician orders, indicating systemic issues in respiratory care management.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.4% error rate. An LPN improperly broke an extended-release tablet for a resident with osteoarthritis, and an RN administered eye drops to a cognitively impaired resident without proper instruction. The DON confirmed the errors, which violated the facility's medication administration policy.
The facility failed to manage medication storage and labeling, resulting in expired and improperly dated medications on two medication carts. On the Maple Lane cart, a Novolin R FlexPen with an illegible date and expired Ibuprofen were found, while the Ivy Lane cart contained expired acetaminophen, nitroglycerin tablets, and undated Albuterol inhalers. The DON admitted the lack of a specific policy for medication dating and labeling, relying on a general policy and an undated document for guidance.
The facility failed to serve meals at appropriate temperatures, affecting two residents and the majority of a group meeting. Meals were delivered from the kitchen in an insulated cart, but food temperatures were below standard, with pancakes and scrambled eggs served at 98 to 106 degrees Fahrenheit. Residents reported dissatisfaction, with some resorting to ordering takeout. Despite attempts to address the issue, such as sending meals in waves, the problem persisted due to staffing challenges.
The facility failed to follow proper infection control practices during meal service and medication administration. A CNA delivered meal trays without hand hygiene or changing gloves, and contaminated ice was used. A resident with respiratory issues received medication via a nebulizer that was not properly cleaned. The medication cart was unsanitary, with personal items and uncovered food. Infection control policies were outdated, and corporate is responsible for updates.
A resident with a below-knee amputation and cerebral palsy was discharged from a facility to a hotel for three nights without a long-term plan, resulting in unsafe living conditions. The resident required wound care and one-person assistance but was discharged without necessary support or supplies. Facility staff were unaware of the resident's situation post-discharge, failing to follow the policy for a safe and orderly discharge.
The facility failed to provide written notification to two residents and/or their representatives regarding their transfer to an acute care facility. One resident with vascular dementia and acute kidney failure was hospitalized due to low blood pressure, while another with coronary artery disease, heart failure, and COPD was transferred due to septic shock and respiratory failure. The facility's policy requires written notice, but the DON stated that notification was done verbally unless an appeal was requested.
The facility failed to provide written bed hold notifications to two residents during hospital transfers. One resident with vascular dementia and acute kidney failure was hospitalized, and a blank Bed Hold Authorization form was uploaded to their EMR. Another resident with coronary artery disease and COPD was transferred due to septic shock, but there was no evidence of receipt of the bed hold policy. The facility's policy required written notification, but lacked a procedure to ensure compliance.
The facility failed to develop and implement comprehensive care plans for two residents with ostomy care needs, leading to potential unmet care needs. One resident was observed with a leaking ostomy bag due to a lack of specific care plan directives, while another resident experienced frequent leaks from an ileostomy bag without proper staff guidance on care frequency. The facility's policy on individualized interventions was not adequately followed.
A resident with COPD, Parkinson's, and an amputation was observed eating in a wheelchair angled away from the table, causing discomfort and difficulty in eating. The wheelchair was purposely dumped as a fall intervention, despite the resident's complaints and the risk of aspiration noted by the SLP. The facility's policy on resident rights was not upheld as the resident's preferences and comfort were not addressed.
A resident with a history of diabetes and amputation developed a stage three pressure ulcer due to inadequate interventions and care. Despite being at high risk, the facility failed to update wound care orders or provide sufficient incontinence care and repositioning. Observations revealed improper wound cleaning and reuse of a dirty sock, contrary to the facility's skin management policy.
A resident with COPD and nicotine dependence was found with cigarettes and a lighter, despite the facility's non-smoking policy. The resident, who used oxygen at night, was observed smoking outside the facility. Staff interviews revealed no smoking safety assessment was conducted due to the facility's non-smoking status, and the resident frequently signed out to smoke. This failure to enforce the policy and secure smoking materials led to the deficiency.
The facility failed to administer pneumococcal vaccinations to three residents despite having signed consents from their guardians. An interview with the Infection Preventionist/RN revealed a recent change in the vaccination offering process, now conducted quarterly. However, the facility's policy required vaccinations for residents over 65, and the oversight was identified during a record review.
A facility failed to train a non-licensed employee, Activities Aide B, with the State-approved course for feeding assistance. During a breakfast observation, the aide was seen feeding a resident requiring a mechanical soft diet, despite not being certified or trained. The DON confirmed only CNAs should provide such assistance, and the facility lacked paid feeding assistants. The aide's file showed no certification or training, and the job description did not include feeding duties, increasing the risk of feeding complications.
The facility failed to employ sufficient staff with the appropriate competencies in food and nutrition services. Observations revealed improper food temperature checks and incorrect portion sizes. Resident interviews highlighted complaints about small portions and poor food quality, indicating a lack of proper training and oversight.
The facility failed to provide written bed hold notices to five residents or their representatives during hospital transfers, as required by policy. The deficiency was confirmed through interviews and record reviews, revealing that notifications were made verbally over the phone without obtaining necessary signatures.
A resident with multiple diagnoses was discharged without a recapitulation of stay or discharge plan documented in their EMR. The Social Service Director and DON confirmed the omission, mistakenly believing it was unnecessary for transfers to another skilled nursing facility, contrary to the facility's discharge planning policy.
Failure to Review and Verify Medication Orders Results in Severe Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician properly reviewed and verified medication orders for a resident admitted with multiple complex diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. Upon admission, the resident's medication orders for Carbidopa/Levodopa and Levothyroxine were transposed, resulting in the resident receiving incorrect dosages and frequencies of both medications. The error was not identified or corrected by the admitting nurse, the physician assistant, or the physician, despite documentation indicating that the medication orders were outside the recommended dosing regimen and pending confirmation. The resident, who was ambulatory and able to care for themselves upon admission, experienced a significant decline during their stay. The medication administration record showed that the resident received multiple extra doses of Levothyroxine over several days, totaling 2800 mcg within a 96-hour period. Progress notes and interviews revealed that the resident became confused, disoriented, unable to ambulate, and exhibited signs consistent with thyroid storm, such as elevated temperature, tachycardia, and altered mental status. Family members and the medical examiner confirmed the resident's rapid deterioration and the facility's admission of the medication error. The review of the resident's records indicated that the transcription error was made by the RN/Unit Manager and confirmed by the same nurse. The physician assistant noted the need to confirm the dosing but did not discontinue or correct the erroneous orders. The medical director stated that the physician assistant should have changed the orders and that the pharmacist and nursing staff should have recognized the error, as Levothyroxine is typically administered once daily in the morning. The failure to properly review, verify, and correct the medication orders directly resulted in the resident's severe adverse effects and subsequent death.
Failure to Accurately Transcribe and Double-Check Admission Medications Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a newly admitted resident's medications were incorrectly transcribed and not properly double-checked according to facility procedures. The resident, who had a history of cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease, was admitted for respite care and was ambulatory and alert at the time of admission. The hospital discharge orders specified Carbidopa/Levodopa to be given five times daily and Levothyroxine once daily, but these frequencies were transposed during the admission process. As a result, the resident received Levothyroxine five times daily and Carbidopa/Levodopa only once daily. Multiple staff interviews and record reviews revealed that the medication orders were entered by a unit manager and were supposed to be double-checked by a second nurse, but there was no documentation or confirmation that this double-check occurred. Several nurses and the pharmacist involved in the process either assumed the orders were correct or did not verify the original admission paperwork. The error persisted for several days, with the resident receiving excessive doses of Levothyroxine, totaling 2800 mcg over a 96-hour period. The facility's process lacked a formal policy or checklist for verifying new admission medication orders, and staff relied on informal practices that failed to prevent the error. The resident's condition deteriorated during the stay, with documented confusion, fever, tachycardia, and lethargy. The error was eventually discovered after the resident exhibited significant changes in condition, including increased confusion and abnormal vital signs. The facility's medical staff and hospice personnel confirmed that the medication error led to a thyroid storm, and the resident was discharged in a significantly worsened state, ultimately passing away at home shortly after discharge. The facility's documentation and interviews confirmed that the medication transcription error was not identified or corrected in a timely manner, and the required verification steps were not properly followed.
Failure to Identify and Correct Harmful Medication Dosing Error
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in medication administration, resulting in a resident receiving harmful doses of thyroid medication. Upon admission, the resident had multiple diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. The resident was ambulatory and able to care for themselves at the time of admission. However, due to a transcription error, the frequencies for Carbidopa/Levodopa and Levothyroxine were switched, leading to the resident receiving five times the prescribed dose of Levothyroxine for several consecutive days. Nursing staff did not identify the incorrect dosing parameters or recognize the resulting side effects. Progress notes indicated that the resident became confused, febrile, tachycardic, and lethargic, with abnormal vital signs and a need for oxygen. Despite these symptoms and the fact that the medication orders exceeded the usual dosing regimen, staff assumed the orders were correct, particularly because the resident was on hospice care. Interviews with nursing staff revealed that they did not verify the medication orders against the admission paperwork or question the unusual dosing frequency, instead relying on the assumption that the orders had been entered correctly. The facility's policy required nurses to verify medication labels against the medication administration record and to resolve any discrepancies before administering medication. However, this procedure was not followed, and the resident received a total of 2800 mcg of Levothyroxine within a 96-hour period. The resident's condition deteriorated significantly during their stay, and they expired at home the day after discharge from the facility.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, resulting in significant deficiencies in care. Multiple residents were left in soiled conditions for extended periods due to insufficient staff availability. For instance, one resident with a leaking colostomy bag was not attended to promptly, leading to soiling of the bed and clothing. The resident reported that staff were unable to change the bag during the night and had to wait until after breakfast service for assistance. This situation was exacerbated by a staff shortage due to a call-in, as confirmed by a registered nurse. Another resident activated their call light for assistance with repositioning in bed, but the call went unanswered for 30 minutes. During this time, staff were observed attending to other duties, such as meal service, indicating a lack of available personnel to address immediate resident needs. Similarly, another resident waited 27 minutes for assistance to use the bathroom, during which time they expressed discomfort and urgency. The delay was attributed to staff being occupied with other residents and a lack of coverage during staff lunch breaks. The report also highlights systemic issues with staffing levels, particularly on weekends and during evening shifts. The facility's staffing data revealed instances where the number of CNAs on duty was insufficient to meet the needs of the resident population, leading to delays in care and unmet needs. Interviews with staff and residents further corroborated these findings, with reports of long wait times for assistance and inadequate response to call lights. The facility's policies on staffing and care were not effectively implemented, contributing to the observed deficiencies.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during an initial kitchen tour. Expired and undated food items were found, including wilted cabbage, rotten potatoes, a broken raw egg, moldy cherry tomatoes, and undated vegetarian burger patties exposed to the environment. Additionally, hot dogs were found with an unclear use-by date. Culinary Aide W acknowledged the need for proper labeling and sealing of food items, while Dietary Manager Y confirmed that all foods should be labeled with a use-by date and discarded accordingly. The presence of visibly spoiled food and broken eggs was also noted as requiring immediate disposal. Furthermore, the cabinetry surrounding an ice machine in the main dining room was observed to be damaged and rotted, with Maintenance Director I confirming past issues with the ice machine leaking. The damaged cabinetry was acknowledged as needing replacement. These deficiencies in food storage and equipment maintenance had the potential to result in foodborne illness among the 89 residents in the facility, as per the FDA 2022 Food Code requirements.
Exhaust Ventilation Failure in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the exhaust ventilation system was functioning in resident bathrooms on the 300 Hall, affecting 19 out of 89 residents. This deficiency was identified through observations of noxious odors permeating the hall on two consecutive days. An investigation revealed that the exhaust systems in several bathrooms were not creating adequate negative pressure, as evidenced by a paper towel test. The rooms affected included 302, 303/304, 305, 306, 307/308, and 309. Interviews with the Maintenance Director and Maintenance Assistant revealed that the exhaust system motors were checked monthly, but the last check was reportedly conducted earlier in the month. The Maintenance Assistant discovered a broken belt on the motors responsible for the 300 Hall's exhaust ventilation, which had not been addressed since November due to the winter season. The facility's policy on maintenance requires the Maintenance Department to ensure proper functioning of ventilation systems, but this was not adhered to, leading to the deficiency.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide dignified and respectful care to five residents, resulting in feelings of frustration, humiliation, and low self-worth. Resident #37, who was cognitively intact, experienced a leaking ostomy bag that was not changed overnight, leading to soiled bedding and clothing. Despite the resident's request for assistance, staff delayed cleaning until after breakfast, leaving the resident in an undignified state. The facility's records did not indicate any refusal of care by the resident, contradicting staff claims. Resident #51, with mild cognitive impairment, activated the call light for assistance to reposition in bed. Despite the call light being illuminated and audible at the nurse's station, staff did not respond for 30 minutes, during which the resident was unable to eat comfortably. Similarly, Resident #7, with moderate cognitive impairment, activated the call light for assistance to use the bathroom. The resident waited 27 minutes for assistance, during which time staff failed to communicate the resident's needs to others before leaving the unit. Residents #38 and #2, both with severe cognitive impairments, were subjected to undignified dining conditions. Resident #38 was seated at a table with soiled meal trays and cups, while Resident #2 was placed out of reach of their meal and left without assistance. Despite attempts to reach the meal, Resident #2 was not aided by staff, resulting in spilled food. The Director of Nursing acknowledged the issues, noting that staff were not acting as usual due to the presence of surveyors and that housing soiled items on dining tables was unacceptable.
Inadequate ADL Care and Staffing Issues
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for six residents who required assistance with personal hygiene and incontinence care. Resident #35, who had severe cognitive impairment and required substantial assistance, was found soiled in urine and had not been checked on since 8:00 AM, despite being observed needing help at 11:56 AM. Similarly, Resident #36, also with severe cognitive impairment, was observed with unkempt hair, indicating a lack of assistance with personal grooming. Resident #42, who required total assistance for toileting and was frequently incontinent, was found lying in a urine-saturated soaker pad, causing skin irritation. The CNA responsible for their care had not checked on them since 3:00 AM, and the resident was left in this state until after breakfast. The CNA expressed being overwhelmed due to inadequate staffing, as they were the only CNA on duty with no additional help available. Resident #48, who required total assistance and was always incontinent, was also found in a similar state with a soiled soaker pad and bed sheets, and had not received care since the CNA's shift began at 7:00 AM. Resident #65, who required moderate assistance with personal hygiene, was observed with visible whiskers on her chin, indicating a lack of grooming. Resident #81, with severe cognitive impairment, was seen with disheveled and greasy hair, further highlighting the facility's failure to provide necessary ADL care. The facility's policy on ADL care, which includes regular checks and changes every two hours, was not adhered to, contributing to the deficiencies observed in the care of these residents.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by the lack of physician orders and improper administration of oxygen at prescribed flow rates. For instance, Resident #243 was observed with oxygen set at incorrect flow rates on multiple occasions, contrary to the physician's order of 2 LPM. Additionally, the portable oxygen tank was found empty, failing to provide the necessary supplemental oxygen. The facility's records inaccurately documented the administration of oxygen at the prescribed rate, and there were no orders allowing for adjustments in the flow rate. The facility also failed to ensure proper maintenance and storage of respiratory equipment. Several residents, including Resident #43 and Resident #88, had nebulizer equipment that was not stored with a barrier, was not dated, and was not cleaned appropriately after use. The nebulizer equipment was left assembled and exposed, increasing the risk of contamination. The Director of Nursing confirmed that nebulizers should be disassembled, rinsed, and stored in a bag, which was not adhered to in these cases. Furthermore, some residents were receiving oxygen therapy without a physician's order, such as Resident #3 and Resident #245. The facility did not have documented orders for these residents to receive supplemental oxygen, yet they were observed using oxygen concentrators. This lack of proper documentation and adherence to physician orders indicates a systemic issue in the facility's management of respiratory care, potentially compromising resident safety and care quality.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.4% error rate. This deficiency involved two residents. Resident #11, who was admitted with a primary diagnosis of osteoarthritis, had a physician's order for Tylenol 8 Hour Arthritis Pain Extended Release tablets. On a specific date, an LPN was observed breaking the extended-release tablet in half before administering it to the resident, contrary to the instructions that the tablet should be swallowed whole. The LPN justified the action by stating that the resident could not take a whole tablet. Resident #26, residing in a secured unit for cognitively impaired individuals and diagnosed with glaucoma, had a physician's order for Timolol Maleate Ophthalmic Solution. During medication administration, an RN was observed administering the eye drops in a dining room with other residents present, without instructing or assisting the resident to hold the lacrimal ducts to ensure proper absorption. The Director of Nursing confirmed that extended-release tablets should not be broken and did not provide a response regarding the proper administration of eye drops. The facility's policy on medication administration emphasizes accurate, safe, and sanitary practices, which were not adhered to in these instances.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and labeling, leading to the presence of expired and improperly dated medications on two of the three medication carts reviewed. On the Maple Lane medication cart, a Novolin R FlexPen was found with an illegible date, and it was confirmed by an LPN that it was expired and needed disposal. Additionally, a bottle of ciprofloxacin eye drops was found with conflicting dates, raising concerns about its validity. An expired bottle of Ibuprofen was also discovered, and the LPN acknowledged the need for replacement. The LPN indicated that only certain medications, such as eye drops, insulins, and inhalers, were expected to be dated when opened. On the Ivy Lane medication cart, expired liquid acetaminophen and nitroglycerin sublingual tablets were found, along with three undated inhalers of Albuterol. The RN responsible for this cart confirmed the need to reorder these medications. The Director of Nursing admitted the absence of a specific policy for dating and labeling medications, relying instead on a general medication management policy and a document listing medications with shortened expiration dates. This document was used by nurses to determine the timeframe for using opened medications, but it was undated and not formally integrated into the facility's procedures.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable and appetizing temperature, affecting two specific residents and the majority of residents in a confidential group meeting. Observations revealed that meal trays were delivered from the main kitchen in an insulated cart, but the food temperatures were below the desired levels. For instance, pancakes and scrambled eggs were served at temperatures ranging from 98 to 106 degrees Fahrenheit, which is below the standard for hot foods. An Activities Aide reported that residents often complained about receiving cold meals, and the facility attempted to mitigate this by sending meals in waves, but staffing issues hindered timely delivery. Interviews with residents highlighted ongoing dissatisfaction with meal temperatures. One resident reported consistently receiving unappetizing meals due to cool temperatures and resorted to ordering takeout. Another resident confirmed the issue, stating that food temperatures were a frequent topic of concern in group meetings. Despite improvements in meal variety, the temperature issue persisted. During a confidential group meeting, eight out of nine residents expressed that meals were consistently served at unpalatable temperatures, with hot foods often arriving cool or cold. These concerns had been previously communicated to the Dietary Manager, but the problem remained unresolved.
Infection Control Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during meal service and medication administration. Certified Nurse Aide (CNA) FF was observed delivering meal trays without performing hand hygiene or changing gloves between residents. Additionally, CNA FF handled a can of soda pop that had fallen into an ice chest with an ungloved, unwashed hand, and the contaminated ice was subsequently used by an Activities Aide. The facility's hand hygiene policy, effective 10/11/23, mandates hand hygiene before and after resident contact, which was not followed in these instances. Resident #88, who was admitted with acute respiratory failure and pneumonia, received medication via a nebulizer that was not properly cleaned or stored. Licensed Practical Nurse (LPN) O administered medication without assisting the resident with oral care or cleaning the nebulizer mouthpiece, which had been left on a bedside stand without a barrier. The nebulizer was not disassembled or rinsed as per the facility's procedure, which requires rinsing with sterile or distilled water and air drying. The facility's medication cart was also found to be unsanitary, with personal items and uncovered food containers placed on it. Registered Nurse (RN) A was observed drinking from a mug and placing it on the cart, alongside a cellular phone and an uncovered pudding container. The Director of Nursing confirmed that personal items should not be on medication carts and that hand hygiene is expected between resident interactions. Additionally, several infection control policies were outdated, with the Nursing Home Administrator and Infection Preventionist confirming that corporate is responsible for updating these policies annually.
Inadequate Discharge Planning for Resident with Amputation and Cerebral Palsy
Penalty
Summary
The facility failed to ensure a safe community discharge for a resident with a below-knee amputation and cerebral palsy, resulting in fear, distress, and feelings of helplessness. The resident was discharged to a hotel for three nights, paid by the facility, without a long-term discharge plan. The resident's insurance was supposed to cover his stay through October 2025, but the facility stated he no longer met the criteria for an insured stay. After the hotel stay, the resident had no place to go and ended up in a family member's travel trailer, which was not accessible for his wheelchair, leading to falls and further complications. The resident's medical record indicated he required wound care for his surgical site, but no formal wound care training or supplies were provided upon discharge. Interviews with facility staff revealed a lack of communication and planning for the resident's long-term accommodation needs. The Nursing Home Administrator and Director of Nursing were unaware of the resident's living situation after the hotel stay and did not provide adequate support or resources for his transition. The facility's policy on transfer and discharge requires sufficient preparation and orientation to ensure a safe and orderly discharge, which was not followed in this case. The resident's discharge plan indicated he needed one-person assistance for transfers, toileting, and bathing, yet he was discharged without the necessary support. The facility's actions and inactions led to the resident living in unsafe conditions without proper care or resources.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reason for their transfer to an acute care facility. This deficiency was identified for two residents. Resident #6, who was admitted with vascular dementia and acute kidney failure, was hospitalized due to low blood pressure. The facility's document titled 'Facility-Initiated Transfer for Nursing Homes' did not indicate a date of notification to the resident or guardian, nor did it have a signature. The Director of Nursing (DON) stated that the notification process involved verbal communication via telephone rather than written notice. Similarly, Resident #51, who had coronary artery disease, heart failure, and COPD, was transferred to the emergency room due to septic shock and acute hypoxic respiratory failure. The facility's transfer document noted the reason for transfer but lacked a signature from the resident or representative acknowledging receipt. The DON reported that written notice is only provided if an appeal is requested, and the reason for transfer and appeal rights are documented in the medical record. The facility's policy requires written notice of transfer or discharge, except in emergencies, where notice should be provided as soon as practicable.
Failure to Provide Written Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification of bed hold policies to two residents or their representatives during hospital transfers. Resident #6, who was initially admitted with vascular dementia and acute kidney failure, was hospitalized from November 19 to November 26, 2024. Although a blank Bed Hold Authorization form was uploaded to the resident's electronic medical record, the Business Office Manager confirmed that it was not the facility's practice to provide written notifications or obtain signatures, relying instead on verbal communication. Similarly, Resident #51, admitted with coronary artery disease, heart failure, and COPD, was transferred to the hospital on January 9, 2025, due to septic shock and acute hypoxic respiratory failure. The facility's transfer document indicated that the bed hold policy was included, but there was no evidence of the resident's or representative's receipt of this information. The facility's policy required written notification during admission and within 24 hours of hospital transfer, but it lacked a procedure to ensure this was done at the time of transfer.
Deficiency in Comprehensive Care Planning for Ostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with ostomy care needs, resulting in potential unmet care needs. Resident #37, who is cognitively intact and dependent on staff for activities of daily living, was observed with a leaking ostomy bag that was not being checked or emptied regularly as per any documented care plan directives. The resident's care plan lacked specific interventions regarding the frequency of checking and emptying the ostomy bag, as well as measures to address the frequent leakage issues. Similarly, Resident #12, who has moderate cognitive impairment and is dependent on staff for personal hygiene, reported frequent leaks from his ileostomy bag due to the facility using different supplies than he was accustomed to. The resident's care plan did not reflect the change in his ability to manage his ileostomy care, nor did it provide guidance on how often staff should check and empty the bag. The facility's policy on activities of daily living emphasized the need for individualized interventions and care plan updates, which were not adequately implemented for these residents.
Failure to Ensure Proper Positioning During Mealtimes
Penalty
Summary
The facility failed to ensure proper functional positioning during mealtimes for a resident with chronic obstructive pulmonary disease, Parkinson's disease, and an above-knee amputation. The resident was observed eating in a wheelchair that was angled away from the dining table, forcing him to balance his plate on his abdomen. This positioning was due to the wheelchair being purposely dumped as a fall intervention, which caused discomfort and difficulty in eating and swallowing. The resident expressed discomfort and difficulty reaching the table, and no assistance was provided to help him cut his food into manageable pieces. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the wheelchair's positioning was intended as a fall prevention measure, despite the resident's complaints of discomfort and difficulty in maintaining an upright posture. The Speech Language Pathologist also noted that the reclined position could increase the risk of aspiration. The facility's policy on resident rights emphasizes the importance of self-determination and freedom of choice, which was not upheld in this case as the resident's preferences and comfort were not adequately addressed.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the development of a pressure ulcer for a resident with a history of hypertension, type two diabetes mellitus, and a below-the-knee amputation. The resident was admitted with a moderate risk for pressure sores, as indicated by a Braden scale score of 14, which later increased to a high risk with a score of 12. Despite this, the resident developed a facility-acquired, unstageable pressure sore on the left Achilles, which progressed to a stage three ulcer. The care plan for the resident included addressing skin integrity issues related to decreased mobility and diabetes with neuropathy. However, the physician's progress notes during the critical period lacked any mention of the pressure sore, and the wound care orders remained unchanged despite the worsening condition. Observations revealed that the resident was left in a saturated soaker pad, indicating inadequate incontinence care, and was not repositioned frequently enough, as confirmed by a CNA's statement. Further deficiencies were noted during wound care, where a nurse attempted to reuse a dirty sock after cleaning the wound, and the cleaning method was inadequate. The facility's policy on skin management emphasized the need for appropriate preventative measures and ongoing monitoring, which were not effectively implemented in this case. Interviews with staff confirmed these lapses in care, highlighting a failure to prevent the development and progression of the pressure ulcer.
Failure to Secure Smoking Paraphernalia for Resident
Penalty
Summary
The facility failed to ensure that smoking paraphernalia was stored securely for a resident with a history of chronic obstructive pulmonary disease (COPD), nicotine dependence, and chronic respiratory failure. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15, was observed with cigarettes and a lighter in his jacket pocket, despite the facility's non-smoking policy. The resident expressed frustration about having to leave the premises to smoke and was seen smoking in the roadway in front of the facility. The resident's electronic medical record included a physician's order for oxygen use at night, highlighting the potential risk associated with smoking. Interviews with facility staff revealed that a smoking safety assessment had not been conducted for the resident due to the facility's non-smoking status. The Licensed Practical Nurse (LPN) confirmed the resident's possession of smoking materials, and the Director of Nursing (DON) reiterated the facility's policy that residents should not have smoking paraphernalia. Despite the policy, the resident had signed out of the facility multiple times to smoke, as documented in the leave of absence binder. This oversight in enforcing the non-smoking policy and securing smoking materials contributed to the deficiency.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain an effective vaccination program for three residents, as identified during a survey. The records for three residents revealed that although consents for pneumococcal vaccinations were signed by their guardians, the residents did not receive the vaccination boosters. This oversight was discovered during a record review, which showed discrepancies between the electronic medical records and the state immunization report. All three residents were noted to be over the age of 65, which places them in a high-risk category for serious complications from pneumococcal pneumonia. An interview with the Infection Preventionist/Registered Nurse (RN) D revealed that the facility had recently changed its vaccination offering process. Previously, vaccinations were offered yearly after a declination, but starting in January 2025, the facility began offering them quarterly. Despite this change, the facility's policy, dated November 2024, indicated that all residents over the age of 65 should receive the pneumococcal vaccine. The policy also required maintaining a log documenting the number of residents vaccinated, refused, or not vaccinated, and obtaining informed consent prior to vaccination. The failure to administer the vaccinations as per the signed consents and policy guidelines led to the deficiency.
Untrained Staff Providing Feeding Assistance
Penalty
Summary
The facility failed to ensure that a non-licensed employee, Activities Aide B, received the State-approved training course for feeding assistance to residents. During a breakfast observation, Activities Aide B was seen feeding a resident who required assistance with a level 3 advanced mechanical soft diet. When questioned, Activities Aide B stated that she was providing assistance because other staff were unavailable. The Director of Nursing confirmed that only Certified Nurse Aides are allowed to provide feeding assistance, and the Nursing Home Administrator verified that the facility does not employ any paid feeding assistants. A review of Activities Aide B's employee file revealed that she was not certified and had not completed the required State-approved training course for feeding assistance. This training includes essential skills such as feeding techniques, communication, safety procedures, and recognizing changes in residents' behavior. Additionally, the facility's job description for the Activity Aide position did not include feeding assistance as part of the essential functions and responsibilities. This oversight resulted in an increased risk of feeding complications for the residents requiring assistance during mealtimes.
Deficiency in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. During an interview, Dietary Cook (Staff) H admitted she had not completed the Certified Dietary Manager's (CDM) course work and relied on a CDM from another facility to help with tracking residents' weights. Observations revealed that Staff I was unable to bring tacos up to the required temperature of 135 degrees Fahrenheit and used improper methods to check the temperature. Additionally, Staff I incorrectly measured serving sizes, using a 4-ounce scoop for ham and potato casserole instead of the required 6-ounce serving size. The Nursing Home Administrator confirmed the absence of a full-time CDM at the facility. Further observations showed that Dietary Aide (Staff) J also failed to serve the correct portion sizes, using a 2-ounce scoop for collard greens instead of the required 4-ounce serving size. Resident interviews revealed complaints about small portion sizes and poor food quality, with one resident representative describing the food as often over or undercooked and portions varying significantly. These deficiencies indicate a lack of proper training and oversight in the facility's food and nutrition services, leading to inadequate meal preparation and serving practices.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure written information was provided to five residents or their representatives regarding bed hold policies during hospital transfers. Specifically, the facility did not obtain signatures from the residents or their representatives on the Bed Hold Authorization forms for residents who were transferred to the hospital. This deficiency was identified through a review of progress notes, clinical census reports, and Bed Hold Authorization forms for five residents. In each case, the forms indicated that the resident or their representative was informed via telephone, but no written notice or signatures were obtained as required by the facility's policy. During an interview, the Accounts Receivable Manager confirmed that written notices were not issued and acknowledged that the bed hold policies were communicated verbally over the phone. The Nursing Home Administrator also acknowledged a system failure regarding the bed hold notifications. The facility's policy, revised on 2/14/22, mandates that residents or their responsible parties must sign the bed hold agreement, and these signed agreements should be part of the resident's business file. The failure to provide written notices and obtain signatures represents a clear deviation from this policy.
Failure to Complete Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to ensure a recapitulation of stay was completed for a resident at the time of a planned discharge. The resident, who had diagnoses including bipolar disorder, major depressive disorder, suicidal ideations, and post-polio syndrome, was discharged from the facility without a discharge plan or recapitulation of stay documented in their electronic medical record (EMR). The Social Service Director and the Director of Nursing confirmed that no post-discharge summary was completed because the resident was transferred to another skilled nursing facility, under the mistaken belief that a recapitulation of stay was not needed for such transfers. The facility's policy on discharge planning, revised on 9/7/23, mandates that all planned discharges must include a completed post-discharge plan and summary by the interdisciplinary team. This includes a recapitulation of the resident's stay, a final summary of the resident's status at discharge, medication reconciliation, and a post-discharge plan developed with the resident's participation. The failure to follow this policy resulted in the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mcbain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wexford Senior Care Center | 10.2 mi | ★★★★★ | 0 | 0 |
| King Nursing & Rehabilitation Community | 23.9 mi | ★★★★★ | 1 | 0 |
| Corewell Health Reed City Hospital Rehabilitation | 26.6 mi | ★★★★★ | 9 | 0 |
| North Woods Nursing Center | 27.5 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Clare | 34.1 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.