Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avista Nursing And Rehabilitation during CMS and state inspections, most recent first.
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.
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.
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What surveyors actually found near you
We read the 227 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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 | ★★★★★ | 1 | 0 |
| Adira Nursing And Rehabilitation | 6 mi | ★★★★★ | 13 | 0 |
| Saginaw Senior Care And Rehabilitation Center, Llc | 6.7 mi | ★★★★★ | 8 | 0 |
| Wellspring Lutheran Services | 8.1 mi | ★★★★★ | 17 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 8.3 mi | ★★★★★ | 26 | 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.