Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avista Nursing And Rehabilitation during CMS and state inspections, most recent first.
Staff failed to follow infection control practices during resident care and dining room activities. Observations showed hand hygiene was not performed between residents while serving meals, clean plates were transported against clothing, catheter drainage bags were left on the floor, a shower bed was not cleaned between uses, contact precautions were not followed for a resident with ESBL and a urinary catheter, a glucometer was used without a barrier, and PPE and hand hygiene were not used correctly during wound, PICC, and catheter care for a resident on contact precautions.
Food service deficiencies were observed in the kitchen and dining room serving area. The drain line to the ice machine was sitting directly inside the drain, an atmospheric vacuum breaker on the garbage disposal line was loose, and a hose with a chemical feeder was observed downstream of an AVB at the utility sink. During lunch service, diced tomatoes, shredded cheese, and sour cream were observed at temperatures above the required cold-holding limit, and the Dietary Manager stated cold holding should be 40 degrees or lower.
Dirty Shower Room and Damaged Shower Curtain: Surveyors found 1 of 2 shower rooms unsanitary, with an excessive amount of dirt, old dried skin, and debris on and around the shower mat, papers and dirt on the floor, a soiled glove near the toilet, dried white drippings on the inside door, and 2 large holes in the shower curtain. Staff stated the CNA who gave the shower was supposed to clean the room right after use, and the Infection Control Nurse said staff should notify her when the shower room is found dirty.
Failure to Provide Dignified Care and Timely Assistance: Multiple residents reported rude or disrespectful treatment, delayed help, and call lights left out of reach. One resident with dementia and an indwelling catheter was told to go in their brief instead of being assisted to the bathroom, while others described staff throwing clothes, ignoring requests for toileting, and taking 20 to 30 minutes or longer to answer call lights. Surveyors also observed a resident’s call light clipped to a pillow out of reach and another resident in a different resident’s bed.
Survey Results Not Readily Accessible: Residents and family members were unable to readily view the facility’s most recent survey results. Seven residents reported they did not have access and did not know how to obtain the information, and a CNA at the front desk was unsure where the binder was kept. The DON initially could not locate it and later found it behind the desk in a staff-only area, with the NHA acknowledging it was not out and accessible.
RN Staffing Not Maintained: The facility failed to ensure RN coverage for 8 consecutive hours each day. Staffing records showed multiple days with 0 RN hours and only LPN coverage, including overnight shifts with no RN listed for a census of more than 80 residents. The facility assessment stated an RN nurse manager would be called in if needed, but the daily staffing sheets did not show any added RN coverage, and the Administrator could not explain the missing RN hours.
Medication storage and labeling were deficient when a nurse found a Lasix pill on the floor in a resident’s room near a medication cup, and multiple med and treatment carts contained loose pills, expired meds, dirty containers, and opened medications without proper labels or open dates. Observations also found a treatment cart unlocked and unattended in the hallway, with drawers accessible. The DON acknowledged the dirty med cart conditions, and facility policy required meds to be stored securely and labeled properly.
Outdated vaccine education sheets and missing documentation of vaccine side effects were found for several residents. Vaccine consent forms stated that CDC/MDHHS VISs were offered or received, but there was no documentation that influenza or pneumococcal side effects were reviewed. The DON, Admissions Director, and IC Nurse all stated they were using admission packet materials that were not updated, and the packet contained outdated CDC flu and PPSV23 information sheets.
COVID-19 Vaccine Education and Documentation Deficiencies: The facility failed to document education on COVID-19 vaccine side effects and used outdated vaccine information sheets for several residents. Four residents' consents showed no side-effect education, and interviews with alert residents did not confirm receipt of vaccine information; the DON, Admissions Director, and IC Nurse each stated they were unaware the materials were outdated or that side effects were not being documented.
Failure to supervise a resident with dementia who repeatedly wandered into other residents’ rooms and slept in their beds. The resident had a BIMS score of 8/15, was identified as a wandering/elopement risk, and was observed lying in another resident’s bed; the other resident reported it happened again later, and staff said the resident commonly wandered the hall and entered other rooms. The care plan, progress notes, Kardex, and elopement book did not reflect the behavior.
Incomplete informed consent for psychotropic medications: A resident with schizophrenia, psychosis, and dementia was receiving antipsychotic and mood-stabilizing meds, but the facility’s consent process was inaccurate and incomplete. Staff acknowledged a consent listed the wrong Depakote formulation, and both SSD and the guardian stated side effects and risks/benefits were not reviewed during consent, despite the facility policy requiring that information be discussed before psychotropic therapy.
A resident with multiple chronic conditions and intact cognition had an Advance Directive form marked as if they chose to formulate directives, but no Advance Directive documentation was in the EMR and the resident said staff had not offered help setting one up. Another resident with dementia and other serious diagnoses had a code status form signed despite records showing the resident had been declared incompetent by both a physician and a psychologist, and staff stated they were told the resident had to sign on admission.
Care Plan Missing Interventions for Wandering Into Other Residents’ Rooms: A resident with dementia, moderate cognitive loss, and documented wandering was observed lying in another resident’s bed and later was reported to have entered that resident’s room again. Staff noted the resident wandered in the hallway, but the care plan did not include interventions for wandering into other residents’ rooms or sleeping in their beds, and the unit manager said she had not been notified of the incident.
The facility failed to ensure that an RN/LPN competency was completed for Nurse A. HR said completed education documents were kept in staff files, but when the yearly competency was requested, no competency evaluation for Nurse A was available. The Facility Assessment listed annual and on-hire training and competencies, and the Administrator said staff were looking into the missing competency.
Incomplete and missing nurse staffing postings were identified during record review. Several daily staffing sheets were absent, one month-only document lacked a day and year, and some forms had blank RN hours and staffing totals. The DON said the staffing documents were kept in the Scheduler’s office, and the Administrator acknowledged the missing and incomplete copies should have matched the original records.
The facility failed to keep monthly pharmacist drug regimen reviews in the medical record for three residents. One resident had dementia, pulmonary HTN, DM, and other chronic conditions; another had dementia, schizophrenia, DM, kidney disease, anemia, and HTN; and a third had Alzheimer's dementia, epilepsy, HF, psychosis, and other diagnoses. The DON said no-recommendation reviews were kept on a paper list, while only recommendation forms would be filed in the EMR. Pharmacy recommendations related to antipsychotic or antidepressant GDRs were provided to surveyors, but they were not in the residents' records and had no provider response documented.
Hospice communication and coordination records were not maintained or readily available for a resident on hospice with CHF, ASHD, COPD, DM, and CKD. The hospice binder at the nurse’s station contained only a few entries, while the calendar showed multiple visits, and the EMR had no hospice communication beyond consent and no care conference since January. The DON, SS, and an LPN all confirmed the documentation was scant, not timely, and not properly used for coordination of care.
The facility failed to ensure 4 of 5 CNAs had the required 12 hours of annual training. The HR Director could not locate proof of the training for four CNAs, later producing only partial records for two CNAs and stating there was no additional training for two others. Only one CNA had training in abuse/neglect and dementia care, and the Administrator was informed of the missing education.
A resident with a history of CVA with left hemiplegia, orthostatic hypotension, and multiple cardiac and metabolic comorbidities experienced a fall in the weight room while being assisted off a standing scale by a CNA. The incident report documented that the resident lost footing on the scale and was found alert and oriented with no injuries noted, but did not include information about footwear or any witness statements. The DON later stated she only spoke with the nurse, did not interview the CNA or the resident, and did not obtain written statements, while indicating the facility followed the existing plan of care. The resident’s fall care plan, which already addressed recurrent falls and related conditions, was not updated with the intervention to use a seated scale for weights until four days after the fall, demonstrating a failure to timely revise the fall care plan based on the incident.
A resident with left hemiplegia, foot drop, orthostatic hypotension, and a history of falls was awakened in the early morning by a CNA, at an LPN’s direction, to obtain a weight. Despite care plan and therapy documentation that the resident required a left AFO and a gait belt to stand, the CNA transferred the resident barefoot and without the AFO or gait belt to a wheelchair platform scale in a small weight room with only one handrail. The resident was stood on the scale, began to black out, and fell backward to the floor, later reporting left leg and knee pain and bleeding from the left great toe. The CNA acknowledged not using the AFO or gait belt and that the resident had no socks on, while the LPN reported believing the resident had gripper socks and documented that he lost his footing on the scale. The DON stated she did not interview the CNA or the resident and obtained no witness statements, relying only on the nurse’s account, despite the facility’s fall policy requiring identification of interventions based on resident-specific risks.
Surveyors observed multiple deficiencies in the kitchen, including dirty and damaged food service equipment, improperly cleaned trays and plate warmers, and unsanitary storage conditions in the walk-in cooler and freezer. Wet and soiled items were found among clean supplies, and significant ice buildup in the freezer led to improper door closure and water accumulation, with staff acknowledging the ongoing issue.
Surveyors found that medications, including multi-dose inhalers, insulin pens, and ophthalmic drops, were stored in medication carts without required open or expiration dates, and some medications belonged to discharged residents. Nursing staff acknowledged the lack of proper dating and uncertainty about policy requirements, and loose, unidentified tablets were also found in the carts. These practices did not follow the facility's policies for medication storage and labeling.
Surveyors observed multiple infection control breaches, including a kitchen staff member with exposed hair and artificial nails, an LPN failing to use proper barrier precautions and hand hygiene during wound care for two residents, and a resident on contact precautions left with soiled linen in the room and no accessible soap for hand hygiene. These actions were not in compliance with facility policy and infection prevention standards.
Two residents did not receive timely wound care as ordered, with wound dressings remaining unchanged for multiple days despite documentation indicating daily treatments were completed. Staff interviews and record reviews revealed discrepancies between treatment records and actual care provided, resulting in missed wound care for residents with complex medical conditions.
Surveyors identified that the facility failed to implement and monitor pressure ulcer prevention measures for two residents. One resident developed a facility-acquired penile erosion due to improper urinary catheter management, with observations noting taut tubing and resident-reported pain. Another resident, dependent on staff for care, was found with a non-functional air mattress due to a bent plug, and there was no documentation or process in place for staff to check the mattress settings. These deficiencies were confirmed through observation, interviews, and record review.
A resident with multiple medical conditions, including dementia and diabetes, was observed multiple times with her trapeze device for bed mobility out of reach, despite her care plan indicating its use. Staff were unsure if the device had been repositioned during care and not returned to an accessible position, resulting in the resident being unable to access the assistive device as needed.
A resident with chronic respiratory conditions was observed to have their nebulizer mask left out on a plastic bag and later stored in a nightstand drawer, rather than in a storage bag as required by facility policy. Staff interviews confirmed the mask should have been bagged after drying, but this was not done following multiple treatments.
Surveyors observed that the facility installed a deep-fat fryer next to a new gas stove without the required baffle plate, had a shelf protruding over stove burners, failed to ensure appliances were returned to approved locations, and did not re-evaluate the kitchen fire suppression system after equipment changes, all in violation of NFPA 96 standards.
The facility did not provide documentation showing that semiannual visual inspections of fire alarm initiating devices were completed as required by NFPA 72. This was confirmed during interviews with the Maintenance Director and Regional Director.
A quarterly inspection revealed a water flow switch failure in the facility's sprinkler suppression system, and the facility did not provide documentation that this deficiency was corrected as required by NFPA standards. This was confirmed during record review and interviews with facility leadership.
Surveyors found that cross corridor smoke barrier doors near two resident rooms did not close properly when tested, failing to prevent the passage of smoke as required by NFPA 101. This deficiency was confirmed with the Maintenance Director and could affect about 25 occupants during a fire emergency.
The facility failed to maintain safe cold holding temperatures for milk, with observations showing milk temperatures exceeding the safe limit of 41°F. The Dietary Manager confirmed that the cooler was left open during meal service, contributing to the issue. Temperature logs were incomplete and did not routinely check serving temperatures, leading to multiple instances of milk being served at unsafe temperatures.
The facility did not adequately address or document responses to grievances reported during Resident Council meetings, affecting residents' quality of life. Residents expressed that their concerns were not followed up on, and a review of notes from June 2023 to May 2024 showed a lack of documentation of responses to specific issues. The facility's policy requires written responses to grievances, but the Activities Director confirmed no documentation of follow-up. Grievances included issues with food, therapy, nursing, social services, housekeeping, and maintenance.
The facility failed to honor residents' food choices and maintain food palatability and temperature, leading to dissatisfaction and hunger. A resident reported receiving disliked food items and inadequate portions, while a Resident Council meeting highlighted issues with meal timeliness, flavor, and temperature. Observations confirmed missing condiments and improperly chilled beverages.
A facility failed to assess and document a resident's incompetency before enacting a Durable Power of Attorney (DPOA), leading to medical decisions being made without legal documentation. The resident, with severe cognitive impairment, had discrepancies in advance directive documentation and informed consent for psychoactive medications. The facility's policy was not provided by the survey's conclusion.
The facility failed to provide adequate hygiene care and documentation for two residents. A female resident with severe cognitive impairment was observed with long facial hair, despite documentation indicating completed personal hygiene tasks. Staff interviews revealed a lack of specific documentation for female shaving refusals. Another resident, dependent on staff for daily living activities, was observed in bed for an extended period, contrary to their care plan. The Director of Nursing acknowledged these issues.
The facility failed to implement a comprehensive Restorative Nursing program to maintain or improve Range of Motion (ROM) for two residents, resulting in a lack of ongoing and accurate assessment and documentation of ROM and contractures. One resident with severe vascular dementia and right-sided hemiplegia had no care plan for Restorative Nursing or ROM exercises, while another resident with anoxic brain damage and impaired ROM had multiple unused splints and braces. Interviews revealed the facility was developing a Restorative Nursing Program but had not yet implemented it.
A resident suffered a fractured tibia and fibula after sliding out of their wheelchair during transport due to a faulty seat belt in a facility van. The transport staff, a recently transitioned CNA, lacked adequate training in securing residents. The facility failed to conduct a thorough investigation or report the incident, and discrepancies were found in staff accounts of the event.
A facility failed to provide proper catheter care and complete UTI treatment for two residents. One resident's catheter was unsanitary and not secured, while another experienced a delay in receiving prescribed antibiotics for a UTI, receiving only 17 of 18 doses. The facility lacked documentation of peri-care audits, indicating deficiencies in infection control practices.
A resident with a PICC line did not receive timely dressing changes as required by facility policy and healthcare provider orders, leading to concerns about care and potential infection risk. The resident's dressing was outdated, and an LPN failed to address this during an IV infusion check. The MAR inaccurately recorded a dressing change, and during an observed dressing change, the ADON compromised sterile technique. The DON confirmed the discrepancies and acknowledged the need for corrective action.
Infection Control Failures During Resident Care and Dining Room Activities
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program during multiple observed care activities and in common areas. In the dining room, staff passed resident food trays without sanitizing their hands between residents, a CNA and a housekeeper were observed with long hair not pulled back while delivering food and touching resident meals, a CNA with long pink nails touched food items while serving, and a kitchen food server carried clean plates against her clothing while transporting them from the kitchen to the tray line. Resident #2’s urinary catheter drainage bag was also observed resting on the floor under the wheelchair while the resident ate. Resident #3 had a contact precaution sign on the room door and was documented with an indwelling urinary catheter, urinary retention, and a urine culture showing ESBL E. coli. The resident was observed in the dining room sitting in close proximity to other residents despite contact precautions. The urinary catheter drainage bag was observed on the side of the bed and later dragging on the floor while the resident self-propelled in a wheelchair through the hallway and back to the activity/dining room. A staff member hugged and touched the resident without performing hand hygiene afterward, and the infection control RN stated the organism was contained in the resident’s urine and catheter drainage bag. Resident #50’s blood glucose was checked by an LPN who removed the glucometer from the medication cart, placed it directly on the resident’s overbed table, donned gloves without first performing hand hygiene, and then placed the glucometer back on top of the medication cart without a barrier. The DON confirmed that a barrier was part of the procedure and stated the observed practice was not okay. In the shower room, the blue shower mat on the shower bed was observed with dirt, dried skin, and debris on the top, sides, and underneath, with additional dirt, papers, a soiled glove, and dried drippings in the room, and staff stated the CNA who gave the shower was supposed to clean it after use. Resident #94 was on contact precautions for wound infection, sepsis, MDRO history, and had a PICC line, urinary catheter, and wound care needs. During care, Nurse M repeatedly removed and reapplied gloves and gown without hand hygiene, left the room wearing PPE, returned in the same gown, placed supplies and a wad of gloves on the bedside table without a barrier, and used bandage scissors taken from her pocket without cleaning them before use. The wound care nurse and infection control preventionist stated that hand hygiene, barrier use, and PPE practices observed were not acceptable and did not follow the facility’s infection control standards.
Food Service Plumbing and Cold Holding Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. During the initial kitchen tour, the drain line to the ice machine was observed sitting directly inside the drain, the cap to the atmospheric vacuum breaker on the water line to the garbage disposal was partially unscrewed and loose, and an attached hose with a chemical feeder downstream of an atmospheric vacuum breaker was observed at the utility sink in the kitchen. The Dietary Manager stated she was familiar with wasting [NAME] and knew that the utility sink needed one. During lunch service, cold food items were observed above the required cold-holding temperature. Diced tomatoes stored behind the steam table were temped at 51 F, then later at 52 F in the refrigerated seasoning table in the dining room serving area. Shredded cheese was temped at 47 F in the same refrigerated seasoning table, and sour cream was temped at 44 F. The Dietary Manager stated cold holding should be at 40 degrees or lower. She then removed the shredded cheese, diced tomato, and other cold items from the refrigerated seasoning unit and placed them in the freezer to cool down. Record review of an email from the Support Dietician stated the facility does not hold food for longer than 4 hours and does not record discard time because meals last approximately 1 hour and food is discarded after service.
Dirty Shower Room and Damaged Shower Curtain
Penalty
Summary
The facility failed to ensure a safe and sanitary shower room for 1 of 2 shower rooms and failed to maintain shower curtains without holes. Surveyors observed the main shower room with an excessive amount of dirt, old dried skin, and debris on and around the blue shower mat on top of the white shower bed, including underneath it, along with 2 large holes in the shower curtain, papers and dirt on the floor, dusty corners, and a dried white substance on the inside of the main door. On a later observation, the shower mat was still full of dead skin, dirt-like material, and debris, the floor remained dirty with papers and a soiled purple medical glove near the toilet, and the dried white drippings were still present on the inside door. The Housekeeping Supervisor stated the CNA was supposed to clean the shower room, including the shower mat, and the CNA stated the person who gave the shower was supposed to clean it right after use. The Infection Control Nurse stated staff should let her know when they see the shower in poor condition and dirty. Review of the facility walkthrough documentation showed no space to document observations of the shower room, and the Infection Control Education Attendance Record showed staff had been educated on cleaning the shower room.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to ensure residents were treated in a respectful and dignified manner for multiple residents, with survey observations and interviews showing call lights out of reach, delayed responses to requests for assistance, residents sleeping in other residents’ beds, and staff interactions that residents and family members described as rude or disrespectful. The report also documented uncovered urinary catheter drainage bags and a resident being told to urinate in their brief instead of receiving toileting assistance. The facility’s own resident rights and call light policies stated residents have the right to dignity and respect and that call lights must be answered promptly and positioned within reach. Resident #6 had diagnoses including heart failure, right hip replacement, depression, dementia, and anxiety, and the record showed fluctuating cognition and a care plan requiring assistance by two staff for toileting. The resident and family members reported that staff told the resident to go in their pants rather than assisting with toileting, and the resident stated this happened for both bowel movements and urination. The resident had an indwelling urinary catheter and had recently been treated for a UTI. Facility staff interviewed later acknowledged the concern had been brought up in a morning meeting and stated that telling the resident to go in their pants was not okay. Other residents described similar concerns about dignity and timely assistance. Resident #3 said staff were rude and did not change them when asked. Resident #17 reported that an aide threw clothes at them and left when assistance was needed. Resident #50 was observed unshaven with greasy hair and said some staff were not worth the effort because of how they spoke to them. Resident #2, Resident #9, Resident #30, and a confidential group of residents reported call lights taking 20 to 30 minutes, sometimes over an hour, to be answered, and Resident #69’s call light was observed clipped to the pillow out of reach. Resident #7 was found upset when another resident was lying in his bed, and the unit manager stated she had not been notified and did not know the other resident was wandering into rooms and sleeping in beds. Resident #13 and Resident #46 also reported not receiving timely help, with Resident #46 stating the call light was often out of reach and that staff sometimes acted bothered when asked for help.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent federal or state survey were kept in an area readily accessible for review by residents, family members, and resident representatives. During an interview with a confidential group of residents, seven of seven residents reported that they did not have access to the state survey results and did not know how to obtain them. A CNA at the front reception desk was asked where the survey results were kept and stated she was unsure and needed to ask the DON for assistance. When the DON was asked to locate the most recent survey results for resident and family review, she initially said she was not sure where they were and thought they might be in the NHA's office. After texting an unknown staff member, she stated the binder was at the reception desk. The DON then reviewed several binders behind the desk, an area only accessible by staff, and produced a binder with a floral pattern and difficult-to-see labeling. The DON could not explain why the binder was not accessible without asking staff. The NHA later stated she had spoken with the DON and was aware the survey results were not out and accessible, and she was unsure why they were kept behind the desk instead of on the lobby table. The admission packet stated residents have the right to examine the results of the most recent survey and any plan of correction in effect.
RN Staffing Not Maintained
Penalty
Summary
The facility failed to ensure that a Registered Nurse was on duty for eight consecutive hours a day, seven days a week. A review of the daily posted nurse staffing data sheets from June 2025 through June 2026 showed 15 days with documented 0 RN staffing hours, including 9/15/2025, 10/8/2025, 12/30/2025, 3/16/2026, 4/10/2026, 4/20/2026, 4/21/2026, 4/26/2026, 5/20/2026, 6/2/2026, 6/5/2026, 6/6/2026, 6/7/2026, 6/20/2026, and 6/21/2026. For those days, the staffing documents did not identify 8 hours of RN coverage in a 24-hour period, and the resident census ranged from 81 to 90. The staffing sheets showed LPN hours on each of the identified days, but each RN hour was listed as 0. On 5/20/2026, no RNs were listed and 2 LPNs were listed on the 7:00 PM to 7:00 AM shift for a census of 82 residents; on 3/16/2026, 3 LPNs were listed on the same shift with no RNs for a census of 82. The facility assessment dated March 2026 stated that RN coverage of 8 hours was sufficient because few duties could not be completed by an LPN, and that an RN nurse manager would be called in if needed, but the daily posted staffing sheets did not identify any RN unit manager added for those days. During review with the Administrator on 6/25/2026, the 0 RN hours were discussed, and the Administrator stated she thought the documents were copies, but they were copies of the original documents and should have matched the originals; no additional information was provided for the lack of RN hours.
Medication Storage, Labeling, and Cart Security Deficiencies
Penalty
Summary
Medication storage and labeling were not maintained in accordance with facility policy and accepted practice. During an observation in Resident #79’s room, a small white pill identified by the nurse as Lasix 20 mg was found on the floor near the bed wheel, with a clear medication cup nearby. The resident said she thought she had lost a pill but was not sure, and the nurse stated she did not know the pill was on the floor and disposed of it. The resident’s MAR showed Lasix 20 mg was ordered twice daily and documented as given that morning. Medication carts were also observed with loose pills, expired medications, and dirty storage conditions. On one medication cart, loose pills were found in drawers, Lispro insulin was open with an expired date, and a house stock bottle of RestRe liquid protein had drippings and sticky dried medication on it. On another medication cart, the same liquid protein bottle was dirty, an opened Ventolin container was expired, and multiple loose pills and crushed medication debris were found in the drawers. The DON acknowledged the dirty condition of the cart and stated nursing staff were responsible for cleaning the medication carts. Treatment carts contained multiple opened medications that were not properly labeled or dated. Observations included opened tubes and bottles of triamcinolone cream, Santyl collagenase ointment, Diclofenac gel, Silvadene cream, Calomoseptine cream, AM lactic lotion, hydrocortisone cream, triple antibiotic cream, sodium fluoride toothpaste, and wound wash, with several lacking resident names, open dates, or both. One treatment cart was also observed unlocked and unattended in the hallway with drawers accessible, and the UM locked it after the observation. Facility policy stated that drug containers with missing or improper labels are to be returned to the pharmacy, that compartments containing drugs and biologicals are to be locked when not in use, and that unlocked medication carts are not to be left unattended.
Outdated vaccine education sheets and missing documentation of vaccine side effects
Penalty
Summary
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations was identified after record review and staff and resident interviews showed that the facility did not provide or document education on influenza and pneumococcal vaccine side effects for residents who were offered vaccination. For Resident #2, Resident #9, Resident #10, and Resident #94, vaccine consent forms documented that the residents had been offered or received Michigan Department of Health & Human Services/CDC Vaccine Information Sheets, but there was no documentation of education regarding side effects for influenza or pneumococcal vaccines. Resident #2 and Resident #9 were alert residents, while Resident #10 was confused and unable to be interviewed due to cognitive decline; Resident #94 was alert but could not recall receiving vaccine information during repeated interview attempts. The facility’s admission materials also contained outdated vaccine education sheets, including a CDC influenza information sheet dated 8/6/2021, a CDC PPSV23 information sheet dated 10/30/2019, and a healthcare personnel vaccination recommendations handout dated 7/22 that was not current with CDC recommendations. During interviews, the DON stated she did not complete all immunization consents because the process was electronic and she used the admission packet information, and she did not update the vaccine information because she did not know she had to. The Admissions Director stated she prepared the admission packets but did not change or update the vaccine information sheets and was unaware they were out of date. The Infection Control Nurse stated she was unaware the sheets being handed out were not current with CDC recommendations, did not go over influenza or pneumococcal side effects with residents, and was unaware that vaccine side effects were not documented on the resident vaccine consent form.
COVID-19 Vaccine Education and Documentation Deficiencies
Penalty
Summary
The facility failed to provide and document education on COVID-19 vaccine side effects and failed to provide a current COVID-19 vaccine education sheet for 4 residents reviewed for vaccine education. Review of the vaccine consent forms for Resident #2, Resident #9, Resident #10, and Resident #94 showed no documentation that education on COVID-19 side effects had been provided, even though the forms stated the residents had been offered or received the Michigan Department of Health & Human Services/CDC Vaccine Information Sheet. Resident #2 and Resident #9 were alert, Resident #10 was confused and not able to be interviewed due to cognitive decline, and Resident #94 was alert but could not recall receiving vaccine information during repeated interview attempts. Record review also showed the facility was using outdated vaccine information sheets. The current handout in use was dated 7/22 and was not current with CDC vaccine recommendations, and the admission packet contained a COVID-19 vaccine information sheet dated 10/19/23, which was also outdated. During interviews, the DON stated she did not do all immunization consents for new residents because it was electronic and she used the information in the admission packet, and she did not update the vaccine information because she did not know she had to. The Admissions Director stated she prepared the packets for nurses to review with residents or their POA/guardian but did not change or update the vaccine information sheet and was not aware it was out of date. The Infection Control Nurse stated she was unaware the vaccine information sheets given to new residents were not current with CDC recommendations and did not go over COVID-19 side effects with residents.
Failure to Supervise Resident With Dementia Who Repeatedly Entered Other Residents’ Rooms
Penalty
Summary
The facility failed to provide adequate supervision and failed to develop, enact, and evaluate interventions for a resident with dementia who repeatedly wandered into other residents’ rooms. Resident #43 was admitted with diagnoses including history of stroke, myocardial infarction, weakness of the right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The MDS showed moderate cognitive loss with a BIMS score of 8/15, and the resident needed some assistance with care. The MDS also indicated wandering occurred 4 to 6 days, and the nursing assessment marked elopement risk as yes for dementia. On 6/22/2026, Resident #43 was observed lying in another resident’s bed in the wrong room across the hall. The other resident became upset, told him to get out of his bed, and the resident reached for the other resident’s cane; the other resident then swung a reacher stick at him and yelled not to touch his cane. A nurse aide separated the residents and assisted Resident #43 back to his room. The next day, the other resident reported that Resident #43 had been in his room again the prior evening. A CNA later stated that Resident #43 wandered in the hallway, usually slept from early afternoon until about 5:30 PM, then got up and walked the hall, sometimes asking to use the phone, and she had seen him go into other residents’ rooms. The care plan, progress notes, and Kardex did not mention wandering into other residents’ rooms or lying in their beds, and the Unit Manager stated she had not been notified of the incident and did not know the resident was wandering into other residents’ rooms. The elopement book at the front desk did not include Resident #43.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure that accurate and comprehensive informed consent was obtained before starting psychotropic medications for one resident. Resident #12 was admitted with diagnoses including schizophrenia, psychosis, and dementia, and the MDS described the resident as moderately cognitively impaired and requiring supervision to maximum assistance with ADLs except eating. The resident’s June 2026 MAR showed ongoing use of Fluphenazine Decanoate IM every 14 days for psychosis and Divalproex Sodium DR 250 mg twice daily for major neurocognitive disorder with behavioral disturbance. Record review and interviews showed the consent process was incomplete and inaccurate. The facility had a consent for Fluphenazine Decanoate dated 2/18/26 and a consent for Depakote dated 10/2/25, but the Depakote consent did not specify Depakote DR, and SSD B acknowledged it was incorrect. SSD B stated they obtained the consents but did not review medication side effects with the resident or guardian and indicated nursing staff reviewed potential side effects instead. The legal guardian witness stated the facility did not go over medication side effects when obtaining consent and relied on staff information. The DON confirmed that the consent form should have the correct medication formulation and that the potential side effects and risks/benefits should be reviewed with the resident or representative before therapy begins. The facility policy required review of non-pharmacological alternatives, indications and rationale, potential risks and benefits including side effects and black box warnings, and the right to accept or decline treatment.
Advance Directive and Code Status Documentation Errors
Penalty
Summary
The facility failed to ensure one resident’s right to formulate an Advance Directive. The resident was admitted with diagnoses including diabetes mellitus, chronic respiratory failure, bipolar disorder, anxiety, chronic kidney disease, Bardet-Biedl syndrome, and urinary retention, and the MDS indicated the resident was cognitively intact and needed moderate assistance with toileting and bathing. The EMR showed the resident was full code, but an Advance Directive/Medical Treatment Decisions form in the record was checked to indicate the resident had chosen to formulate and issue Advance Directives, with no additional Advance Directive documentation such as a DPOA noted in the EMR. During interview, the SSD stated the form had been marked incorrectly and said the resident wanted to be full code, but also acknowledged that the checked option related to Advance Directives and not just code status. When asked whether the resident had been spoken to about Advance Directives, the SSD did not provide a response. The resident stated staff had not offered assistance with setting up an Advance Directive, that they would like to get something in place, and that they would need help because they were unsure about the options and what needed to be completed. The facility also failed to ensure a resident was competent to sign an Advance Directive/Code Status form. This resident had diagnoses including stroke history, MI history, right lower leg weakness, diabetes, liver disease, liver transplant history, lung disease, dementia, depression, anxiety, CKD, and gout, and the MDS showed moderate cognitive loss with a BIMS score of 8/15. The Advance Directives/Code Status document appeared unsigned, yet a staff member signed it, and the SSD stated the resident signed for CPR on admission. Records reviewed during the investigation showed the resident had been declared incompetent by both a physician and a psychologist, with documentation stating the resident was unable to understand complex medical and financial decision making and lacked insight and judgment into medical and financial decision making. The SSD stated she was told the resident had to sign when admitted and that there was no mention of competence, while also noting the resident’s girlfriend was seeking guardianship because the resident was not able to make his own decisions.
Care Plan Missing Interventions for Wandering Into Other Residents’ Rooms
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple diagnoses including history of stroke, myocardial infarction, weakness of the right lower leg, diabetes, liver disease, history of liver transplant, lung disease, dementia, depression, anxiety, chronic kidney disease, and gout. The resident’s MDS showed moderate cognitive loss with a BIMS score of 8/15 and that he needed some assistance with care. The MDS also indicated wandering behavior occurring 4 to 6 days, and a psychosocial evaluation noted a prior diagnosis of dementia and a history of striking his son with a cane and being agitated and aggressive before admission. On observation, the resident was found lying in another resident’s bed across the hall from his own room, and the other resident was upset when he found him there. The resident then reached for the other resident’s cane, and the other resident swung a reacher stick at him and yelled at him to stop touching the cane. The other resident later stated that the resident across the hall had been in his room again the prior evening. A CNA stated that the resident wandered in the hallway, and review of the care plan showed no mention of wandering into other residents’ rooms or lying in their beds. The unit manager stated she had not been notified of the incident and did not know the resident was wandering into other residents’ rooms and sleeping in their beds.
Missing Annual Competency for Nurse A
Penalty
Summary
The facility failed to ensure that nurses completed yearly competencies and training for one nurse, Nurse A, of one nurse reviewed for education and competencies. During an interview on 06/25/2026 at 9:30 AM, the Regional Human Resources/HR Director stated that completed education documents were stored in staff files in the HR office. When a yearly competency was requested for Nurse A, the HR Director later stated on 06/25/2026 at 11:29 AM that she did not have a competency evaluation for Nurse A. A review of the Facility Assessment dated March 2026 identified training and competencies as annual and on hire, in person and show me. On 06/25/2026 at 2:40 PM, the Administrator was interviewed about the absence of a competency for Nurse A and stated that staff were looking into it.
Incomplete and Missing Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that clinical staff postings were accurately completed and maintained for several days across 2025 and 2026. During review of the daily posted nurse staffing data sheets from June 2025 to June 2026, several dates were missing entirely, including 5/21/2026 and 6/16/2026, and there were two documents for 5/29/2026 with none for 5/30/2026. One staffing document was dated only January and did not include a day or year. Other forms contained missing information, including the 12/30/2025 staffing sheet, where the RN total scheduled hours for the 7:00 AM to 7:00 PM shift was blank, the RN actual hours worked was blank, and the total number of staff for RNs was listed as 0. The DON stated the staffing documents were kept in the Scheduler’s office, and the Administrator later acknowledged that some documents were missing and some contained blanks, noting she thought the documents were copies and confirming they should reflect the original documents for accuracy.
Missing Monthly Pharmacy Reviews and Recommendations in Resident Records
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews were completed, dated, and maintained in the medical record for three residents reviewed for medications. For Resident #8, who had diagnoses including dementia, pulmonary hypertension, diabetes, history of falls, back pain, stroke, auditory hallucinations, depression, peripheral vascular disease, cataracts, and hypertension, the record contained an IDT note stating the medication regimen review was completed with no recommendations, but no other monthly pharmacy reviews or recommendations were found in the medical record for the past year. The DON stated that pharmacy reviews with no recommendations were kept on a paper list in her office, and that only recommendations would be placed in the electronic medical record. For Resident #12, who had dementia, schizophrenia, diabetes, kidney disease, anemia, and hypertension, the medical record showed a note that a pharmacy review was completed, but no additional monthly pharmacy reviews or recommendations were present in the record for the past year. The DON provided a pharmacy recommendation related to Mirtazapine/Remeron and a possible GDR, but it was not in the resident's medical record and had no physician or provider response documented. For Resident #84, who had Alzheimer's dementia, diabetes, epilepsy, heart failure, urinary retention, a history of falls with left leg fracture, peripheral vascular disease, anxiety, psychosis, weakness, hypothyroidism, and hypertension, the record contained an IDT note stating the MRR was completed with no recommendations, but no other monthly pharmacy reviews were found in the medical record for the past year. The DON later provided a pharmacy recommendation related to Fluphenazine/Prolixin and a possible GDR, but it was also not in the resident's medical record and had no physician or provider acknowledgment.
Hospice communication and coordination records were not maintained or readily available
Penalty
Summary
The facility failed to ensure that communication and documentation were readily available to reflect coordination of care for a resident receiving hospice services. The resident was admitted to the facility with diagnoses including CHF, ASHD, COPD, DM, stage 2 CKD, and a history of falls, and was admitted to hospice services on 05/11/2026. The resident was cognitively intact with a BIMS score of 15/15 and reported that he remained independent in most care, with staff assisting him with showers. The resident’s care plan identified a terminal prognosis related to CHF and included interventions for a June hospice calendar and cooperation with the hospice team to meet the resident’s spiritual, emotional, intellectual, physical, and social needs. However, review of the hospice binders on the unit showed monthly visit schedules, hospice agreement, hospice care plan, and only four communications total, including three chaplain visits in May and one nurse communication dated 06/11/2026. No other coordination-of-care documentation was present in the binder despite multiple scheduled hospice visits listed on the calendar. Interviews confirmed the lack of documentation and inconsistent handling of hospice records. A CNA produced the binders from the nurse’s station, a nurse observed the scant documentation and said she was new to the unit, and the DON stated the binders were not used and that social services handled hospice care. The DON also stated she was unsure where the documentation was in the chart, and the EMR contained no care conference since January 16, 2026 and no hospice communication outside of the hospice consent. Social services later produced a stack of hospice visit and coordination notes that had not been available in the chart, and acknowledged the binder was not up to date and had not been properly utilized by hospice staff.
Missing Required Annual CNA Training
Penalty
Summary
The facility failed to ensure that 4 of 5 Certified Nursing Assistants reviewed had the required 12 hours of annual training. During an interview, the Regional HR Director stated that completed education documents were kept in staff files in the HR office and that CNA training could be downloaded from the training site on the computer. When asked to provide proof of the 12-hour CNA training for CNAs I, V, X, and Y, she was unable to locate the documentation. Later, she provided training records showing CNA X had 10.91 hours of training and CNA I had 1 hour 15 minutes of training, but stated there was no additional training for CNAs Y and V and that this was all she could locate. Only CNA X had training in Abuse Neglect and Dementia Care. The Administrator was informed of the missing required CNA education for CNAs I, V, X, and Y and stated staff were looking into it.
Failure to Timely Update Fall Care Plan After Weight-Room Fall
Penalty
Summary
The deficiency involves the facility’s failure to timely follow and update a fall care plan for one resident after a fall event, resulting in missed interventions not being incorporated into the care plan. On 4/2/2026 at 6:00 AM, a fall incident report documented that a CNA requested nursing assistance in the weight room across from the therapy office, where the resident was found alert and oriented, sitting against the wall. The CNA reported that the resident lost his footing on the weight scale as he was being assisted back to his wheelchair and stated the resident did not hit his head. The nurse’s assessment noted no bruising or injuries, and the resident reported he lost his step on his weaker side as the aide assisted him back into the wheelchair. The incident report did not mention the resident’s footwear at the time of the fall and indicated that no witness statements were obtained. The resident’s medical record showed admission from a hospital with multiple diagnoses, including heart disease, right carotid artery occlusion and stenosis, hemiplegia and hemiparesis post intracerebral hemorrhage affecting the left non-dominant side, diabetes, depression, anxiety disorder, hypothyroidism, orthostatic hypotension, anemia, moderate protein-calorie malnutrition, mitral and tricuspid valve insufficiency, and cardiomyopathy. The care plan documented that the resident required one-person assistance with ambulation using a 2-wheeled walker and left foot orthosis, and assistance with transfers, allowing increased time due to dizziness. A fall care plan dated 3/3/2026 addressed recurrent falls and related conditions, with interventions such as transferring and changing positions slowly and placing the left side of the bed against the wall. However, the intervention to use a seated scale when obtaining weights was not added until 4/6/2026, four days after the fall. In an interview, the DON stated she spoke only with the nurse, did not obtain notes or witness statements, and did not interview the CNA or the resident, while asserting that the facility followed the plan of care. The only care plan policy provided addressed baseline care plans within 48 hours of admission and did not address the timeliness of updating comprehensive care plans after incidents.
Failure to Use AFO and Gait Belt During Early-Morning Weighing Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall and ensure that a resident’s prescribed left foot Ankle Foot Orthosis (AFO) and a gait belt were applied prior to standing the resident for a weight measurement. On the date of the incident at approximately 4:00–6:00 AM, a CNA, at the direction of an LPN, woke the resident to obtain a weight, despite the resident stating he was tired and did not want to get up. The resident reported that he needed to sit for about 10 minutes before standing due to blood pressure concerns, but he was transferred from bed to a wheelchair and then taken to a weight room across from the therapy office. The CNA later stated this was the first resident weight she had obtained since being hired and that she worked the night shift. Record review showed that the resident had multiple medical diagnoses, including hemiplegia and hemiparesis affecting the left non-dominant side after an intracerebral hemorrhage, orthostatic hypotension, diabetes, anemia, heart disease, and a history of left hip fracture. The resident’s care plan documented that he required assistance from one staff member for ambulation with a two-wheeled walker and left foot AFO, and that he received physical therapy for gait training and neuromuscular re-education. Therapy staff documented that the resident had left foot drop and required the left leg AFO and a gait belt to stand. The fall care plan identified recurrent falls and conditions such as CVA with left hemiplegia, dizziness, fatigue, and orthostatic hypotension, with interventions including transferring and changing positions slowly. During the incident, the CNA took the resident, who was barefoot and without his AFO or a gait belt, to a wheelchair platform scale in a small weight room that had only one handrail on the back of the scale. The CNA had the resident stand on the scale, and he began to fall backwards against the wall. The CNA was unable to lift him and left to get the LPN. When the nurse arrived, the resident was on the floor. The nurse’s incident report documented that the resident lost his footing on the weight scale as he was being assisted back to his wheelchair, and that no injuries were noted at that time. The resident later reported that he started to black out, fell backwards, landed on his left foot/leg, hurt his knee, and that his left big toe was bleeding. The DON stated that she did not interview the CNA or the resident and that no witness statements were obtained, and she characterized the follow-up as not a “huge investigation,” relying only on speaking with the nurse and reviewing the plan of care. Further interviews and record reviews confirmed that the resident typically used a seated chair scale located elsewhere on the unit and that, according to the resident, staff usually weighed him using that chair scale or by subtracting the wheelchair weight. The CNA acknowledged that the resident was barefoot and that she did not apply his leg splint (AFO) or use a gait belt when standing him on the scale. The LPN stated that the resident needed daily weights and that she had explained to him the severity of not getting weighed, and she believed he had yellow gripper socks on, although the CNA and resident reported he was barefoot. The facility’s fall policy stated that staff would identify interventions related to residents’ specific risks and causes to try to prevent falls and minimize complications, and defined a fall as unintentionally coming to rest on the ground, floor, or other lower level. The resident’s left knee x-ray obtained two days later documented mild osteoarthritis with clinical information of pain. The DON reported that residents were not typically awakened at that early hour solely for weights and that she believed weights could be done at any time during the day shift. However, the resident’s weight log showed a standing weight recorded shortly before 6:00 AM on the date of the incident. The DON also stated that she did not speak with the CNA or the resident about the fall and that no witness statements were collected. The lack of use of the resident’s prescribed AFO and gait belt, the decision to obtain a standing weight on a platform scale in a room with limited support surfaces, and the incomplete investigation and documentation of the event were all identified as contributing factors to the fall and the failure to ensure the area was free from accident hazards and that adequate supervision and assistive devices were used to prevent accidents.
Failure to Maintain Sanitary Food Service Equipment and Storage Areas
Penalty
Summary
The facility failed to maintain food service equipment and ensure sanitary conditions in the kitchen, as observed during a kitchen tour. Specific deficiencies included a refrigerator with a ripped door seal and food particles in the door corner, as well as streaks and smears on the exterior that were easily removed when wiped. Seven meal trays used for serving residents had jagged edges, and four plate warmers that were supposed to be clean had dried food particles. Five steam table lids had bent corners and dried food residue. The garbage can lid had a white substance, and a rack with clean, ready-to-use pans and lids was found with wet and dirty items. Additionally, a trolley in the back kitchen hallway had a resident's used meal tray and an unknown pink substance on its exterior, contrary to staff procedures for tray placement. Further issues were identified in the walk-in cooler and freezer. The cooler had a trail of water leading into the freezer, and the freezer itself had thick snow and ice buildup on the door frame, ceiling, and above the fan, which prevented the door from closing properly. There was condensation and ice on the plastic curtains and door frame, and during a delivery, boxes were observed with wet marks from ceiling drips. The freezer floor was visibly wet, with water tracking back into the cooler. The Maintenance Director acknowledged awareness of the ice and snow buildup, attributing it to dietary staff not closing the freezer door tightly. The facility's sanitization policy requires all equipment and utensils to be washed and sanitized, and for manually washed items to air dry whenever practical, which was not consistently followed.
Failure to Properly Store and Label Medications in Medication Carts
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and labeling practices across all four medication carts reviewed. Observations revealed that multi-dose medications, such as inhalers, insulin pens, ophthalmic drops, and nasal sprays, were frequently found without required open dates or expiration dates. In several instances, medications belonging to residents who had been discharged remained in the carts, and loose, unidentified tablets were discovered in various drawers. These findings were corroborated by interviews with nursing staff, who acknowledged the lack of proper dating and, in some cases, uncertainty regarding the facility's policy on medication dating. Record reviews of the facility's 'Storage of Medications' and 'Medication Administration' policies indicated that medications and biologicals are to be stored securely and dated upon opening, with certain medications requiring a shorter expiration period once opened. Despite these policies, surveyors observed opened containers of blood sugar testing strips, insulin pens, and other multi-dose medications without any indication of when they were opened or when they should be discarded. Staff interviews confirmed that these items were in use without adherence to the documented procedures for dating and discarding. The deficiency was further evidenced by the presence of medications for residents no longer residing in the facility, as well as loose tablets found in medication carts without identification or proper storage. Staff members, including RNs and LPNs, were unable to provide consistent explanations for the lack of dating or the continued presence of medications for discharged residents. These actions and inactions directly contravened the facility's own policies and accepted professional standards for medication storage and labeling.
Infection Control Failures in Kitchen, Wound Care, and Isolation Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas, as observed during the survey. In the kitchen, the Dietary Manager was seen wearing a hair net that did not fully cover her hair, with long tendrils exposed on both sides of her face, and was also found to have long artificial nails. Both of these actions were in direct violation of the facility's policy, which requires hair nets to fully cover hair and prohibits artificial nails for staff involved in food preparation. The Dietary Manager acknowledged awareness of these requirements during interviews, and the Infection Control Nurse and Director of Nursing confirmed that these practices were not in compliance with CDC recommendations and facility policy. During wound care observations, an LPN failed to use enhanced barrier precautions when assessing a resident's PEG tube site, not donning a gown or gloves before lifting the resident's shirt and breast to access the tube. In another instance, the same LPN and a CNA performed wound care on a different resident with open stage III pressure ulcers. After cleaning bowel material from the resident's buttock region, neither the LPN nor the CNA changed gloves before proceeding with wound care, and the LPN did not perform hand hygiene before donning new gloves. The LPN also reached into her uniform pocket with gloved hands to retrieve a pen, further increasing the risk of cross-contamination during the dressing change. Additionally, a resident on contact precautions for C. difficile was found in a room with a pile of soiled linen, including sheets and blankets with dried red substances, left atop a recliner. The resident reported the linen had been changed that morning, but it had not been removed from the room. The soap dispenser in the room was also found to be non-functional, as the soap bag was not properly engaged, making hand hygiene inaccessible for staff and visitors. The Infection Control Nurse confirmed both the improper storage of soiled linen and the lack of accessible soap in the resident's room.
Failure to Provide Timely and Documented Wound Care
Penalty
Summary
The facility failed to assess, monitor, and document wound care in a timely manner for two residents, resulting in missed treatments. For one resident, an occlusive dressing on the left elbow was observed to be dated several days prior, despite treatment administration records indicating that daily wound care had been completed. Interviews revealed that the nurses who signed off on the treatments were not the ones who actually performed them, and the old dressing remained in place, indicating that the required wound care was not provided as documented. The resident had diagnoses including aphasia, hypertension, and stroke, and required assistance with activities of daily living. For another resident, a wound dressing on the right foot was found to be dated two days prior, even though physician orders required daily dressing changes. The resident had a complex medical history including sepsis, diabetes, atrial fibrillation, Guillain-Barre Syndrome, Bell's Palsy, and borderline personality disorder. The discrepancy in dressing dates and documentation suggested that at least one daily wound care treatment was missed, despite staff initially believing the dressing was dated incorrectly.
Failure to Implement and Monitor Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement preventive pressure ulcer measures and prevent new ulcers from developing for two residents. For one resident with a urinary catheter, observations revealed a left-sided penile erosion measuring 3 to 3.5 cm in length, attributed to the catheter. The catheter tubing was noted to be taut from the penis head to the left thigh, and the resident reported pain at the site. The resident also stated that the leg bag would become heavy and pull on the tubing, causing discomfort. During the observation, the LPN did not use hand sanitizer before donning gloves and had long artificial nails with jewelry attachments. The wound was confirmed to be facility-acquired, and the wound care nurse acknowledged the difficulty in measuring the wound accurately due to its location and the limitations of photographic documentation. The DON confirmed the erosion was caused by the catheter and was being treated in-house. For another resident, the facility failed to ensure the proper functioning of a prescribed air mattress intended to prevent pressure ulcers. The resident, who was dependent on staff for activities of daily living and had multiple comorbidities including diabetes, stroke, and muscle weakness, was observed in bed with an air mattress that was not plugged in and not functioning as intended. The plug was found to have a bent prong, preventing it from being plugged in. There was no documentation in the physician's orders or care records requiring staff to check the air mattress for functionality or to ensure it was set to the correct alternative pressure setting. Staff interviews confirmed that there was no established process for documenting checks of the air mattress prior to the surveyor's intervention. These deficiencies were identified through direct observation, staff and resident interviews, and record reviews. The lack of preventive measures and monitoring contributed to the development of a facility-acquired pressure injury in one resident and the risk of pressure ulcer development in another, both of whom were dependent on staff for care and at high risk for skin breakdown.
Trapeze Device Not Accessible for Bed Mobility
Penalty
Summary
A deficiency was identified when a resident's trapeze, an assistive device for bed mobility, was not accessible on multiple occasions. Observations showed that the trapeze was flipped over the stabilization bar and out of the resident's reach while she was in bed. When asked, the resident confirmed she was unable to reach the device and demonstrated her inability to access it. The care plan indicated a preference for the trapeze to assist with bed mobility, and records confirmed the resident was assessed as safe to use it. Despite the care plan and assessment, the trapeze remained inaccessible during several observations, and staff were unsure if it had been repositioned during care and not returned to an accessible position. The resident's medical history included diabetes, dementia, atrial fibrillation, and hypertension. The deficiency was based on the failure to ensure the assistive device was within reach as required to maintain or improve the resident's range of motion and mobility.
Failure to Properly Store Nebulizer Mask After Use
Penalty
Summary
A deficiency was identified when a resident who required nebulizer treatments for chronic heart and lung disease did not have their nebulizer mask stored in accordance with facility policy. The resident, who had multiple diagnoses including chronic respiratory failure, Alzheimer's Disease, and required assistance with all activities of daily living, was observed to have their dry nebulizer mask left on top of a plastic bag next to the treatment machine, rather than being placed inside a storage bag as required. This observation was made several hours after the last documented treatment, indicating the mask had sufficient time to dry and be stored properly. A subsequent observation found the nebulizer mask and attached oxygen tubing stored inside a closed nightstand drawer, with the tubing hanging out, rather than in a designated storage bag. During interviews, the resident confirmed the timing of the last treatment, and the Clinical Nurse Manager acknowledged that nebulizer masks should be stored in a bag when not in use. These findings demonstrate that staff did not follow the facility's nebulizer process policy regarding the storage of respiratory equipment.
Noncompliance with NFPA 96 Standards for Kitchen Equipment Installation
Penalty
Summary
The facility failed to ensure that cooking facilities were installed and protected in accordance with NFPA 96 standards. Observations revealed that a newly installed deep-fat fryer was placed within 16 inches of the surface flame of a new six-burner gas stove, without the required steel or tempered glass baffle plate of at least 8 inches in height between the fryer and the stove. Additionally, a shelf was found protruding over the stove top burners, which could obstruct the hood suppression system as per NFPA 96 requirements. The facility also did not provide approved methods to ensure that cooking appliances are returned to their approved design locations. Further, after the installation of the new gas stove and the addition of the deep-fat fryer, the facility did not have the kitchen Ansul fire extinguishing system re-evaluated as required by NFPA 96. These deficiencies were confirmed through interviews with the Maintenance Director and Regional Director at the time of observation. No information about specific residents or their conditions was provided in the report.
Failure to Document Semiannual Fire Alarm System Inspections
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 72. During a record review, it was found that there was no documentation available to show that the required semiannual visual inspection of the fire alarm initiating devices had been completed, as specified by NFPA 72, section 14.3. This lack of documentation was confirmed during interviews with both the Maintenance Director and the Regional Director at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Document Correction of Sprinkler System Water Flow Switch Deficiency
Penalty
Summary
The facility failed to provide documentation that a water flow switch deficiency, identified during a quarterly sprinkler inspection, had been corrected as required by NFPA 72, 17.12.2. During a review of facility records, it was found that the sprinkler suppression system inspection report indicated the water flow switch failed during testing, and there was no evidence that this issue had been addressed. This finding was confirmed through interviews with the Maintenance Director and Regional Director at the time of the record review. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Failure to Maintain Smoke Barrier Door Functionality
Penalty
Summary
Surveyors observed that the facility failed to maintain the proper operation of smoke barrier doors in accordance with NFPA 101 requirements. Specifically, during an inspection, the cross corridor doors near resident rooms #205 and #208 did not close properly when tested, which would prevent them from stopping the passage of smoke as required. These deficiencies were confirmed through interviews with the Maintenance Director at the time of observation. Approximately 25 occupants could be affected by this failure in the event of a fire emergency, as the doors did not function as intended to provide a smoke barrier.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate cold holding temperatures for potentially hazardous food, specifically milk, in the kitchen, which increased the potential for foodborne illness among the 79 residents receiving meal services. During an observation, the surveyor noted that the two-door reach-in cooler was left open during meal service, which was confirmed by the Dietary Manager (DM) as a normal practice. The temperature of the milk was found to be 55 degrees Fahrenheit, exceeding the safe temperature limit of 41 degrees Fahrenheit as per the 2017 U.S. Public Health Service Food Code. The DM acknowledged that such milk would typically be discarded. Further observations revealed that milk served to residents in the dining room and on tray carts also exceeded safe temperature limits, with readings between 47.5 and 52.3 degrees Fahrenheit. The facility's temperature logs lacked documentation for certain days and did not include start or discard times for milk, nor did they routinely check serving temperatures. The logs showed multiple instances of milk being served at unsafe temperatures, ranging from 44 to 54 degrees Fahrenheit. The facility's Food Preparation and Service Policy emphasized maintaining potentially hazardous foods below 41 degrees Fahrenheit to prevent the growth of harmful pathogens, which was not adhered to in this case.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately address and document responses to grievances reported during Resident Council meetings, affecting the quality of life for residents. During a Resident Council meeting, residents expressed that their concerns were not being followed up on or resolved, with staff only asking generalized questions about whether issues had been resolved. A review of Resident Council notes from June 2023 to May 2024 revealed that while residents voiced concerns, the notes did not specify issues with specific disciplines, nor was there documentation of responses to these concerns at subsequent meetings. The facility's policy on grievance procedures requires that all grievances, complaints, or recommendations from resident or family groups be considered and responded to in writing, including the rationale for the response. However, the Activities Director confirmed that there was no documentation of follow-up on resident concerns from Resident Council meetings. Specific grievances included issues with food palatability, therapy services, nursing care, social services, housekeeping, and maintenance, among others, with no documented resolutions or updates provided to the residents.
Deficiencies in Food Service and Resident Satisfaction
Penalty
Summary
The facility failed to ensure that residents' food choices were honored, food was palatable, and an adequate amount of food was offered. During a noon meal observation, residents were served chili and salad without the Texas toast that was listed on the menu. The Dietary Manager acknowledged that the toast was overlooked and mentioned that staffing issues have delayed the implementation of a system to take residents' meal preferences. Resident #47, who is alert and able to make healthcare decisions, reported receiving food items he disliked, such as oatmeal, and not being informed about alternative menu options. The resident also expressed dissatisfaction with the portion sizes and the temperature of the food. During a Resident Council meeting, attendees expressed concerns about the timeliness, flavor, and temperature of meals, as well as inconsistent portion sizes and accompaniments. An observation of a lunch meal revealed missing condiments and accompaniments, and the beverages were not served at a cold temperature. The Dietary Manager confirmed the issues with food temperature during subsequent observations. These deficiencies resulted in residents feeling anger, frustration, and hunger.
Failure to Ensure Proper Incompetency Assessment Before Enacting DPOA
Penalty
Summary
The facility failed to ensure proper assessment and documentation of incompetency before enacting a Durable Power of Attorney (DPOA) for a resident, leading to medical decisions being made without legal documentation of incompetency. Resident #28, who was admitted with diagnoses including dementia with behavioral disturbance, was found to have a DPOA enacted before a formal determination of incompetency by two physicians. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment, requiring supervision for Activities of Daily Living (ADL). The review of the resident's records revealed discrepancies in the documentation of advance directives and the signing of informed consent for psychoactive medications. The Advance Directives/Medical Treatment Decisions form was improperly completed, lacking the resident's signature and only signed by a facility LPN. Additionally, the Informed Consent for Psychoactive Medications form for Seroquel was signed by a family member before the resident was deemed incompetent. Interviews with the Social Services Director and the Administrator confirmed these findings, and the facility's policy/procedure was not provided by the conclusion of the survey.
Deficiencies in Hygiene Care and Documentation
Penalty
Summary
The facility failed to provide adequate hygiene care for two residents, resulting in deficiencies in personal grooming and documentation. Resident #28, a female with severe cognitive impairment and multiple health issues, was observed with long, visible facial hair on two separate occasions. Despite the documentation indicating that personal hygiene tasks were completed, the facial hair was not removed. Interviews with staff revealed that there was no specific area in the electronic medical record (EMR) to document the refusal of shaving for female residents, unlike for male residents. The Director of Nursing acknowledged the lack of documentation for refusals and the understanding of the issue. Resident #23, who is dependent on staff for all activities of daily living due to conditions such as stroke and dementia, was observed resting in bed for an extended period. Despite the care plan indicating the need for repositioning and activity out of bed, the resident remained in bed until the surveyor's inquiry prompted action. The Director of Nursing was informed of the situation, and the resident was later observed sitting comfortably in a reclining wheelchair. These observations highlight the facility's failure to ensure proper documentation and execution of care plans for residents requiring assistance with daily living activities.
Failure to Implement Restorative Nursing Program for ROM
Penalty
Summary
The facility failed to implement a comprehensive Restorative Nursing program to maintain or improve Range of Motion (ROM) for two residents, resulting in a lack of ongoing and accurate assessment and documentation of ROM and contractures. Resident #36, who has severe vascular dementia and right-sided hemiplegia, was observed with a bent right arm and fist, indicating contractures. Despite being at high risk for contracture development, there was no care plan in place for Restorative Nursing or ROM exercises, and no splints or braces were observed in the resident's room. Resident #44, with a history of anoxic brain damage and impaired ROM in both upper and lower extremities, was found to have multiple splints and braces piled on top of their closet, which were rarely used. The resident reported that staff no longer assisted with ROM exercises, and there was no current order for Restorative Nursing or ROM. The resident's care plan included discontinued interventions for passive ROM and brace use, and there was no documentation of current ROM assessments or therapy evaluations. Interviews with facility staff, including the Director of Nursing (DON), revealed that the facility was in the process of developing a Restorative Nursing Program but had not yet implemented it. The DON confirmed the presence of contractures in both residents but could not provide explanations for the lack of Restorative Nursing services or specific ROM exercises. The facility did not provide a policy or procedure for Restorative Nursing by the conclusion of the survey.
Inadequate Staff Training and Equipment Monitoring Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate staff training, equipment monitoring, and accident prevention, leading to a serious incident involving a resident. The resident, who was cognitively intact but required maximum assistance for daily activities, suffered a fractured tibia and fibula after sliding out of their wheelchair during transport in a facility van. The incident occurred because the seat belt securing the resident was not properly engaged, allowing the resident to fall and sustain injuries. The investigation revealed several deficiencies in the facility's procedures. The transport staff member, who had recently transitioned from a CNA role, did not receive adequate training or demonstrate competency in securing residents in the van. The seat belt in the van was faulty, as it clicked but did not securely latch, and this issue was not identified or addressed prior to the incident. Additionally, the facility did not conduct a thorough investigation or report the incident to the State Agency, and there was a lack of documentation regarding the training and competency of the transport staff. Interviews with the resident and staff highlighted discrepancies in the facility's account of the incident. The resident reported that their legs were caught under the chair during the fall, and they experienced significant pain and swelling upon returning to the facility. The facility's Administrator and DON were unable to provide consistent information about the incident, and there was no documentation of a comprehensive investigation or corrective actions taken to prevent future occurrences.
Deficiencies in Catheter Care and UTI Treatment
Penalty
Summary
The facility failed to ensure proper assessment, maintenance, and care of an indwelling urinary catheter for one resident and did not complete the treatment of a urinary tract infection (UTI) for another resident. For the resident with the indwelling urinary catheter, the catheter was observed to be maintained in an unsanitary manner, with the tubing soiled with a brown substance resembling bowel movement and not secured inside the securement device. The securement device itself was soiled and appeared old, indicating a lack of adherence to professional standards of practice for catheter care. Another resident experienced a delay and incomplete antibiotic therapy for a UTI. The resident was readmitted to the facility after a hospital discharge with a prescription for Cefpodoxime Proxetil to treat the UTI. However, the medication was not available upon the resident's return, and the first dose was not administered until two days later. The resident ultimately received only 17 out of the prescribed 18 doses. The facility's infection control audits revealed numerous and recurrent UTIs for this resident, yet there was no documentation of peri-care audits to ensure staff were performing perineal care correctly. The facility's Director of Nursing and Infection Control Nurse acknowledged the lack of documentation for peri-care audits and the delay in starting the prescribed antibiotic. The failure to secure the catheter properly and the delay in antibiotic administration highlight deficiencies in the facility's infection control practices and adherence to care protocols, potentially contributing to ongoing health issues for the residents involved.
Improper PICC Line Care and Documentation Issues
Penalty
Summary
The facility failed to provide appropriate care for a resident with a Peripherally Inserted Central Catheter (PICC line), as evidenced by the lack of timely dressing changes and improper sterile technique during a dressing change. The resident, who was cognitively intact and required assistance with activities of daily living, had a PICC line dressing dated 5/24/24, despite facility policy and healthcare provider orders requiring weekly changes. The resident expressed concerns about the lack of care, indicating they had informed the nursing staff about the overdue dressing change, which was not addressed. During an observation, a Licensed Practical Nurse (LPN) failed to address the outdated PICC line dressing while attending to a beeping IV infusion. The Medication Administration Record (MAR) inaccurately documented a dressing change on 6/2/24, which was contradicted by the actual dressing date. Furthermore, during a dressing change observed by the Assistant Director of Nursing (ADON), sterile technique was compromised when the ADON turned their back on the sterile field, allowing for potential contamination. The Director of Nursing (DON) confirmed the discrepancy in the dressing change records and acknowledged the need for corrective action.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 314 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hoyt Nursing & Rehab Centre | 5.5 mi | ★★★★★ | 16 | 0 |
| Adira Nursing And Rehabilitation | 6 mi | ★★★★★ | 12 | 0 |
| Saginaw Senior Care And Rehabilitation Center, Llc | 6.7 mi | ★★★★★ | 8 | 0 |
| Wellspring Lutheran Services | 8.1 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 8.3 mi | ★★★★★ | 27 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.