Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beaconshire Nursing Centre during CMS and state inspections, most recent first.
Staff did not wear gowns while providing wound and peri care to a resident on Enhanced Barrier Precautions, despite clear signage and orders. The resident had multiple complex medical conditions, including an open wound and Foley catheter. Interviews confirmed staff were aware of the requirement to use PPE during high-contact care activities, but failed to do so.
Six residents were found without functioning call lights or alternative means to summon staff in their rooms. Staff confirmed that some call lights were not working and that desk bells were intended as a temporary solution, but several residents did not have these available. At the time of inspection, the affected residents were not in their rooms and did not voice concerns, and the NHA could not provide a list of malfunctioning call lights or a policy regarding call lights.
A resident with cognitive impairment and on blood thinners was found with multiple bruises, including a large bruise under the left breast, which staff failed to promptly report or investigate as required by facility policy. Despite staff observations and a CNA notifying a nurse, the bruises were not documented or reported until later, and the DON could not explain the delay or missing documentation in prior assessments.
The facility failed to cover desserts delivered to residents and did not maintain the ice machine in a sanitary condition. Meal trays with uncovered cheesecake were delivered to residents, and the ice machine was found with rust-colored substances and black speckles. Staff were unclear about cleaning responsibilities, with the Dietary Manager and Maintenance Supervisor providing conflicting information.
The facility failed to properly dispose of refuse and maintain cleanliness in garbage areas, potentially affecting all 92 residents. Observations revealed various trash items, including used gloves and cigarette butts, on the ground and in uncovered bins. The Maintenance Supervisor cited snow as a reason for some trash accumulation, but the facility's policy requires tightly fitting lids and cleanliness to prevent pest attraction.
The facility failed to effectively implement its QAPI program, leading to deficiencies in linen management and lab draws. The NHA identified linen availability as a concern but lacked consistent monitoring and documentation. Additionally, lab draws were not completed as ordered, with no evidence of evaluation in QA meetings. The facility's QAPI program lacked systematic documentation and data tracking, contributing to these deficiencies.
The facility failed to maintain sanitary conditions in the laundry room and clean linen closet, risking infection spread. Observations revealed uncovered clean linen carts, personal items on the floor, and soiled housekeeping carts stored improperly. The Housekeeping Supervisor and Nursing Home Administrator acknowledged these issues, which violated facility policies on infection prevention and linen handling.
The facility failed to maintain a proper air gap for the kitchen's three-compartment sink, risking contamination from sewage. Observations revealed a pipe leading to a floor drain with an inadequate air gap, surrounded by a black cover. The Dietary Manager was unsure of past sewage issues, while the Registered Dietician acknowledged the need for a proper air gap. The Maintenance Director confirmed the deficiency, and no further information was provided by the administration during the exit conference.
The facility failed to secure protected health information for two residents, leading to potential unauthorized disclosure. In one case, a laptop on a medication cart was left unlocked with a resident's EHR open, displaying sensitive medication information. In another instance, a resident's EMR was left open in a hallway, visible to passersby. Both incidents were acknowledged as HIPAA violations by staff.
The facility failed to maintain a safe and homelike environment, with deficiencies in room maintenance and bathroom facilities. In one room, a heating vent cover was removed and not replaced, leading to a cold environment. The maintenance log system was not effectively used, and the Maintenance Director was unaware of the issues. In another instance, a shared bathroom had a broken paper towel dispenser and an unstable sink supported by an orange construction cone. Housekeeping staff confirmed the long-standing issues, and the DON acknowledged the need for accessible paper towels.
The facility did not meet the required minimum square footage per resident in five rooms, with each room housing two residents but providing less than the required 80 square feet per resident. Despite this, no overt concerns were noted from resident interviews and observations. The Nursing Home Administrator and DON did not provide further documentation during the exit conference.
A resident with a history of COPD and moderate cognitive impairment suffered second-degree facial burns after unsupervised smoking while on oxygen. The incident occurred due to inadequate supervision by an untrained sitter, who allowed the resident to access smoking materials. The facility's failure to implement its smoking policy and ensure proper supervision led to the resident's injury.
A resident with COPD and moderate cognitive impairment sustained facial burns after lighting a cigarette while on oxygen. The facility failed to report the incident to the abuse coordinator or authorities, and staff initially believed the resident's claim of falling. The resident was hospitalized with second-degree burns, but the facility's records did not document the burns or the transfer. Interviews revealed a lack of communication and awareness among staff regarding the incident.
A resident with COPD and moderate cognitive impairment sustained facial burns after lighting a cigarette while on oxygen. Despite the resident's admission of the incident, the facility's records only mentioned a fall and redness, failing to document the burns. Staff interviews revealed inconsistencies, and the facility's policy on accurate documentation was not followed, compromising the resident's care.
A resident with quadriplegia and muscle wasting experienced pain and mild withdrawal symptoms due to the misappropriation of their prescribed Oxycodone. The medication, delivered and signed for by an LPN, was not administered on multiple days, and its disappearance was confirmed by the DON and pharmacy staff. The facility failed to implement its policy on preventing misappropriation of resident property.
A resident with quadriplegia and no cognitive impairment was prescribed Oxycodone for pain management. On one occasion, a 30-count of Oxycodone was delivered and signed for by an LPN but was reported missing. The resident informed the DON and physician, but the incident was not reported to the state agency as required by the facility's policy. Interviews confirmed the failure to report the missing medication, which is a deficiency in regulatory compliance.
A facility failed to properly reconcile controlled substances for a resident, potentially allowing drug diversion to go undetected. A resident with cognitive impairment had seven APAP Codeine tablets in the medication cart without proper documentation of removal. LPNs and the DON confirmed that narcotics should be signed out with date, time, count, and signature, which was not done. The facility's policy requires accurate reconciliation of controlled drugs.
A resident with moderate cognitive impairment and behavior issues was inadequately supervised, leading to their elopement through a second-floor window and sustaining severe injuries. The resident, initially in a first-floor room, was moved to a second-floor lockdown unit without guardian consent. Despite a care plan indicating the need for supervision, the resident had multiple falls prior to the incident. The facility's failure to provide adequate supervision and communicate with the guardian resulted in the resident's elopement and subsequent hospitalization.
The facility did not secure windows in the second-floor dining room and a resident's bathroom, allowing them to fully open and posing a safety risk. An LPN and the Maintenance Director confirmed the issue, and the Nursing Home Administrator acknowledged that the windows were not in compliance with the facility's policy, which restricts windows from opening more than six inches to prevent resident egress.
A resident with moderate cognitive impairment exited the facility through a window and was later found outside by an LPN. The resident was transported to the hospital, but the guardian was not notified of the room change to a lockdown unit or the hospital transfer, contrary to the facility's policy.
A resident exited a second-floor window and fell, sustaining multiple injuries. The incident was observed by an LPN, and the resident was transferred to the hospital. The facility failed to report the incident to the State Agency within the required timeframe, submitting the report four days later instead of within the specified two-hour window for serious injuries.
The facility failed to maintain comfortable room temperatures, with two residents experiencing discomfort due to excessive heat. Room temperatures ranged from 82 to 86 degrees Fahrenheit, exceeding the facility's policy. One resident, with respiratory issues, reported feeling extremely hot and requested an air conditioner without receiving a response. The Maintenance Director noted issues with air conditioning units, and the Nursing Home Administrator acknowledged the expectation for resident comfort.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). On the observed date, an LPN and a CNA performed wound care and peri care for a resident with an open wound and a Foley catheter without wearing gowns, despite an EBP sign posted on the door and orders in the resident's chart indicating the need for EBP. During the procedure, a unit manager also entered the room and did not observe the staff wearing gowns. Interviews with the involved staff confirmed their awareness that gowns should have been worn during high-contact care activities for residents on EBP. The resident involved had a history of urinary tract infection, osteomyelitis, a stage IV pressure ulcer, unspecified injury at C4, and neurogenic bowel, and was cognitively intact according to the most recent assessment. Facility policy required the use of PPE, including gowns, during high-contact care activities such as wound care and device care for residents on EBP. The Director of Nursing acknowledged that staff did not follow posted signs or physician orders regarding EBP during the incident.
Failure to Provide Working Call Light System or Alternatives in Resident Rooms
Penalty
Summary
The facility failed to ensure that a functioning call light system or alternative means of summoning assistance was available in the bathrooms and bathing areas for six residents. During an inspection, it was observed that one resident's private room did not have a call light cord plugged into the outlet, nor was there a desk bell or any other device to notify staff if assistance was needed. Staff members, including a CNA and an LPN, were unable to locate a call light or bell in the room. The nurse unit manager confirmed that some call lights were not functioning and that desk bells were supposed to be provided as a temporary measure, but acknowledged that this resident did not have one. Further inspection revealed that five additional residents also lacked call lights or any alternative means to alert staff in their rooms. At the time of observation, these residents were not in their rooms and did not report concerns about the missing call lights or bells. The Nursing Home Administrator stated that the facility was in the process of repairing the call light system and that all affected residents should have had a desk bell or similar device, but was unable to provide a list of malfunctioning call lights and confirmed there was no policy in place for call lights.
Failure to Timely Report and Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting and investigation of a bruise of unknown origin for one resident, as required by policy. The resident, who had multiple diagnoses including bipolar disorder, psychotic disorder with delusions, schizophrenia, and was on a blood thinner (Eliquis), was observed with bruises on both upper arms and a large purplish red bruise under the left breast. Initial observations and interviews revealed that staff, including LPNs and CNAs, were either unaware of the bruising or had not reported it according to protocol. The resident denied any abuse or pain and declined a full skin assessment initially, but later allowed for further examination, which confirmed the presence of the bruises. Despite the facility's policy requiring immediate investigation and reporting of suspected abuse or unexplained injuries, the bruises were not promptly reported or investigated. The DON confirmed that an investigation and report to the State Agency were only initiated after the issue was brought to their attention, and could not explain the delay or the lack of documentation in prior skin assessments. The facility's policy mandates reporting all alleged violations within specified timeframes, particularly for injuries of unknown origin or those in potential areas of abuse, such as the breast, but these procedures were not followed in this instance.
Uncovered Desserts and Unsanitary Ice Machine
Penalty
Summary
The facility failed to ensure that desserts delivered to three unidentified residents were properly covered during meal service. During lunch observations, meal trays with uncovered cheesecake desserts were delivered to residents in a dining room. The Dietary Manager confirmed that all food should be covered to prevent contamination, and the Nursing Home Administrator acknowledged that the food was supposed to be covered, questioning why the meal cart was not brought closer to the dining room. Additionally, the facility did not maintain the ice machine in a clean and sanitary condition. An observation revealed a rust-colored substance on the inside hinge of the ice machine's door and numerous black speckles on the ice dispenser's hood. The outside of the machine had drip stains of an unidentified substance. The LPN present could not identify the substances or the department responsible for cleaning the ice machine. The Housekeeping Supervisor stated that housekeeping was not responsible for cleaning the ice machine, while the Dietary Manager indicated that the dietary department was responsible for the outside and the maintenance department for the inside. The Maintenance Supervisor was unaware of the need for cleaning, relying on an outside company for biannual cleanings.
Improper Disposal of Refuse and Cleanliness Issues
Penalty
Summary
The facility failed to properly dispose of refuse and maintain cleanliness in the garbage and refuse areas, which could potentially harbor pests and affect all 92 residents. During an observation at the rear of the facility, various items such as plastic cups, paper, used gloves, and cigarette butts were found on the ground. Additionally, a wooden palette, electric fan cover, and a red storage container were propped against the building, with the red storage bin uncovered and containing used gloves, soiled linen, and trash. A large broken bed frame, used gloves, plastic soda bottles, and other trash were also observed near a back door. Further observations included eight plastic storage bins, some upright and some overturned, stacked against the wall near the rear door, surrounded by trash and debris. A container covered with a yellow tarp contained frozen standing water and trash, with a plastic lid on top and a rusted shovel and trash on the ground around it. Used gloves and straws were found frozen to the ground, and a large grey bin was filled with empty plastic bottles, milk cartons, plastic cups, pieces of plaster, and other trash, without a cover. The Maintenance Supervisor acknowledged the presence of trash and debris, attributing some of it to recent snow and stating that trash should not be placed on the ground. The facility's policy on garbage disposal emphasizes the need for tightly fitting lids on refuse containers and maintaining cleanliness to prevent pest attraction, which was not adhered to in this instance.
Deficiencies in QAPI Program and Linen Management
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by deficiencies in managing linen supplies and lab draws. The Nursing Home Administrator (NHA) identified linen availability as an area of concern, with a plan developed to ensure sufficient linen and staff for processing. However, the NHA was unable to provide data or documentation that the linen issue was consistently monitored or discussed in subsequent Quality Assurance (QA) committee meetings. Additionally, the NHA acknowledged that lab draws were not occurring as ordered, with seven out of 15 lab orders not completed as required in October 2024. Despite these issues, there was no evidence that the nursing concern was evaluated in the November 2024 QA meeting or subsequent meetings. The facility's QAPI program lacked systematic documentation and tracking of data, as required by its own policies. The NHA admitted that there was no report recapping QAPI activities or tracking of data, which is contrary to the facility's policy that mandates regular data collection and analysis. The facility's failure to maintain documentation and demonstrate evidence of its ongoing QAPI program, including the monitoring and evaluation of corrective actions, contributed to the identified deficiencies. During the exit conference, the NHA and Director of Nursing did not provide additional documentation or information to address these concerns.
Infection Control Deficiency in Laundry and Linen Management
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry room and clean linen closet, which could potentially lead to the spread of infection and disease transmission among residents and staff. During observations, it was noted that the clean linen closet on the first floor had a folded gown and sheet on a dusty and dirty floor, a clean linen cart without a cover, and a heavily soiled sheet on the floor. Additionally, personal items belonging to an employee were found on the floor behind the clean linen cart. On a subsequent observation, used gloves, straws, plastic wrapping, and dust were found on the floor, and the clean linen cart remained uncovered. The Housekeeping Supervisor acknowledged that the linen closets should be cleaned daily and could not explain why the linen cart cover was on the floor. Further inspection of the facility's laundry service revealed that soiled housekeeping carts were stored in the washer/dryer room, which was in use, and clean linens were transported in a cart placed next to a soiled housekeeping cart. The clean linen room had uncovered bed sheets, resident blankets, socks, and clothes. The Housekeeping Supervisor agreed that clean linens should be covered when transported and stored, and that dirty housekeeping carts should not be stored in the laundry room due to the risk of cross-contamination. The Nursing Home Administrator also agreed with these observations. The facility's policies on infection prevention and control, laundry, and handling clean linen were reviewed, highlighting the requirement to handle, store, process, and transport linens in a manner that prevents contamination and infection transmission.
Improper Air Gap in Kitchen Sink
Penalty
Summary
The facility failed to ensure the proper air gap for the three-compartment sink in the kitchen, which is necessary to protect against contamination from sewage or other sources. During an observation, a pipe under the sink was noted to lead to a floor drain with a three-inch space between them, but a black cover was observed approximately 4-5 inches from the floor over the drain, surrounding the air gap. The Dietary Manager and Registered Dietician were questioned about the air gap, with the Dietary Manager unsure of any sewage backup incidents and the Registered Dietician acknowledging the need for a proper air gap to prevent contamination. The Maintenance Director later confirmed that the sink was not properly air-gapped. During the exit conference, the Nursing Home Administrator and Director of Nursing did not provide additional documentation or information.
Failure to Secure Resident Health Information
Penalty
Summary
The facility failed to secure protected health information for two residents, resulting in potential unauthorized disclosure. On the first occasion, a laptop on a medication cart in a commonly accessible hallway was left unlocked with the electronic health record (EHR) of a resident open, displaying sensitive information about their medication. The resident had a history of schizophrenia and moderate cognitive impairment. A Licensed Practical Nurse (LPN) acknowledged the violation of HIPAA regulations when questioned about the incident. In a separate incident, another resident's electronic medical record (EMR) was left open on a computer in a hallway, visible to passersby. A social worker noticed the open EMR and alerted a nurse, who confirmed the privacy breach. The resident involved had severe cognitive impairment and multiple diagnoses, including psychosis and vascular dementia. The Director of Nursing (DON) confirmed that leaving the EMR open was a violation of HIPAA protocols.
Deficiencies in Room Maintenance and Bathroom Facilities
Penalty
Summary
The facility failed to maintain a safe and homelike environment for residents in specific rooms, resulting in several deficiencies. In one room, the heating vent cover was removed and left propped against the vent, accumulating thick dust and dirt. Residents reported that the cover was removed during maintenance work on the heating system, but it was never replaced, leading to a cold room environment. Additionally, the plastic covering on the windows was removed by maintenance and not replaced, further contributing to the cold temperature. A small heating unit was present but was not effectively heating the room. The Maintenance Director was unaware of the ongoing issues, as residents had not reported them directly, and the maintenance log system was not effectively utilized. In another instance, the shared bathroom of certain rooms had a broken paper towel dispenser and an orange construction cone supporting the bathroom sink. The paper towel dispenser was non-functional, making it difficult for residents to access paper towels. The orange cone was used to stabilize the sink, which was at risk of dislodging. Housekeeping staff confirmed the long-standing issues with the bathroom facilities, and the Director of Nursing acknowledged that residents should have access to paper towels. The Maintenance Director admitted that the bathroom sink should have been fixed, indicating a lapse in maintenance oversight.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in five rooms, specifically rooms 111, 115, 119, 219, and 231. Each of these rooms housed two residents but did not meet the regulatory requirement of at least 80 square feet per resident. Rooms 111, 115, 119, and 219 were each 157 square feet, providing only 78.5 square feet per resident, while room 231 was 159 square feet, providing 79.5 square feet per resident. Despite these deficiencies, resident interviews and observations did not reveal any overt concerns related to the room size. During the exit conference, the Nursing Home Administrator and Director of Nursing did not provide additional documentation or information when asked.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident on oxygen with a known history of unsupervised smoking and noncompliance with the smoking policy. This lack of supervision led to a fire incident where the resident sustained second-degree facial burns and required hospitalization in a burn unit. The incident occurred when an untrained facility staff member, acting as a sitter, failed to properly supervise the resident during a smoke break, allowing the resident to obtain a lighter and cigarette. Subsequently, the resident attempted to smoke in the bathroom while inhaling oxygen through a nasal cannula, resulting in the fire. The resident, who had a history of chronic obstructive pulmonary disease (COPD), schizophrenia, and moderate cognitive impairment, was admitted to the facility with a care plan that included specific interventions to prevent smoking-related incidents. Despite these measures, the resident was able to access smoking materials unsupervised, highlighting a failure in the facility's implementation of its smoking policy. Interviews with staff revealed that the sitter was not trained or authorized to supervise smoking, and the specific reasons for the sitter's presence were not communicated effectively. The facility's policy required that only trained staff, such as nurses, activities staff, and security personnel, supervise residents during smoking breaks. However, the sitter, who was not trained, took the resident out to smoke unsupervised, contrary to the facility's policy. This oversight, along with the failure to secure smoking materials, directly contributed to the incident, demonstrating a significant lapse in the facility's safety protocols and supervision practices.
Removal Plan
- The Director of Nursing/designee began an in-service with licensed nursing staff on independent smoker and dependent smokers, including resident choice of time smoking.
- All residents who smoke will be in-serviced by the Director of Nursing/designee on the smoking policy during a special resident council meeting to include the nonadherence to the policy that may result in revoking privileges and/or initiating a discharge plan care.
- Smoking signs were implemented asking families and visitors to not give residents smoking materials for the safety of our residents and turn in all smoking materials to be used only during scheduled smoking times.
- Staff was in-service on the updated smoking policy; to report any residents with smoking material immediately, staff includes security and sitters, and the updated policy includes reporting immediately to the charge nurse and management if any resident have any smoking materials and residents will be searched immediately.
- Unscheduled smoking times will not be permit without approval from administration. Residents that smoke will be offered a nicotine patch or offered to be taking out to smoke with a nurse or Cena.
Failure to Report Resident's Facial Burns from Smoking Incident
Penalty
Summary
The facility failed to report an incident of potential neglect involving a resident, identified as R401, who sustained facial burns after lighting a cigarette while on oxygen. The incident occurred on 11/10/2025, but the facility did not report it to the abuse coordinator or proper authorities. R401 was admitted to the hospital with second-degree burns to the face, lips, and nose, and required transfer to a burn center. Despite the severity of the injuries, the facility's records did not document the facial burns or the acute care transfer. R401, who has a history of COPD, schizophrenia, and moderate cognitive impairment, was observed with significant facial injuries during an interview at the hospital. The resident admitted to lighting a cigarette in the bathroom while on oxygen, which resulted in the burns. The facility staff, including LPNs and the sitter, initially believed R401's claim of falling in the bathroom, and no immediate action was taken to address the burns or report the incident as required by the facility's policy. Interviews with facility staff revealed a lack of awareness and communication regarding the incident. The Nursing Home Administrator and Director of Nursing were not informed of the true cause of R401's injuries until after the resident was hospitalized. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, resulting in a failure to protect the resident's health and safety.
Failure to Document Resident's Facial Burns
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who sustained facial burns after lighting a cigarette while on oxygen. The incident occurred when the resident, who had a history of chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, lit his face on fire in the bathroom. Despite the resident's admission of the incident, the facility's documentation did not accurately reflect the occurrence of facial burns, as the records only mentioned a fall and redness to the face. Interviews with staff members revealed inconsistencies in the documentation and awareness of the incident. Licensed Practical Nurse (LPN) D and Sitter E, who were present during the incident, reported seeing redness but did not document burns. The resident's request to be transferred to the hospital due to pain was eventually honored, but the facility's records did not include a completed acute care transfer sheet, which would have documented the reason for the transfer. The Director of Nursing (DON) and other staff members acknowledged the resident's hospitalization for facial burns, yet the medical records lacked this critical information. The facility's policy on documentation requires accurate and complete records of residents' experiences and care. However, the failure to document the facial burns and the circumstances leading to the resident's hospitalization indicates a significant lapse in adhering to these standards. The absence of accurate documentation not only violates the facility's policy but also compromises the quality of care and safety of the resident.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to prevent the misappropriation of medication for a resident, resulting in the resident experiencing pain and potential withdrawal symptoms. The resident, who was admitted with quadriplegia and muscle wasting, had a scheduled pain medication regimen that included Oxycodone 30 mg to be administered every six hours. However, the Medication Administration Record for July 2024 showed that the medication was not given on multiple days. A delivery of 30 Oxycodone pills was made on July 18, 2024, and signed for by an LPN, but the medication was reported missing shortly after. Interviews with the resident, the Director of Nursing, the Pharmacy Manager, and the Pharmacy Driver confirmed the delivery and subsequent disappearance of the medication. The resident reported increased pain and mild withdrawal symptoms due to the missing medication. The facility's policy on abuse, neglect, and exploitation, which includes preventing misappropriation of resident property, was not effectively implemented, leading to this deficiency.
Failure to Report Misappropriation of Medication
Penalty
Summary
The facility failed to report allegations of misappropriation of medication for a resident diagnosed with quadriplegia and muscle wasting. The resident, who had no cognitive impairment and was on a scheduled pain medication regimen, was prescribed Oxycodone 30 mg to be taken every six hours. On July 18, a 30-count of Oxycodone was delivered and signed for by an LPN, but the medication was reported missing shortly after. The resident informed the Director of Nursing (DON) and the physician about the missing medication, but the incident was not reported to the state agency as required. Interviews with the DON, Unit Manager, and Nursing Home Administrator (NHA) confirmed that the missing narcotics were not reported to the state agency. The facility's policy mandates that any allegations of abuse, neglect, or misappropriation should be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. Despite this policy, the facility did not report the missing medication, which constitutes a failure to comply with regulatory requirements for reporting suspected abuse or misappropriation.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to properly reconcile controlled substances for a resident, identified as R102, which could potentially allow drug diversion to go undetected. During an observation and interview, it was found that R102 had seven tablets of APAP Codeine 300-30mg in the medication cart, but there was no proof of use record with dates, times, or signatures for medication removal. Licensed Practical Nurse (LPN) B admitted to counting the medication when removing it but not signing it out. This oversight was confirmed by interviews with LPN A and the Director of Nursing (DON), who both stated that narcotics should be signed out with date, time, count, and signature when removed from the medication cart. R102 was admitted to the facility with diagnoses including dementia and a fracture of the skull and facial bones. The Minimum Data Set (MDS) assessment indicated that R102 had significant cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 1 out of 15. Physician orders for R102 included Acetaminophen-Codeine Tablet 300-30mg to be administered as needed for pain. The facility's Pharmacy Services policy, revised on the date of the observation, mandates accurate reconciliation of controlled drugs, which was not adhered to in this instance.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a moderately cognitively impaired resident with behavior issues, resulting in the resident exiting a second-floor window and sustaining serious injuries. The resident, who had diagnoses including schizophrenia and a left calcaneus fracture, was initially admitted to a first-floor standard room. The care plan indicated the resident was at risk for injury due to behaviors and impaired cognition, requiring supervision and cueing to maintain safety. Despite these interventions, the resident had multiple falls prior to the incident, indicating a pattern of inadequate supervision. On the night of the incident, the resident was moved to a second-floor lockdown unit without the guardian's permission or notification. The resident was placed in bed at 10:30 PM, but by 10:45 PM, the window was found open, and the resident was missing. The resident was discovered outside on the ground, having fallen from the window, and was subsequently transported to the hospital with severe injuries, including a collapsed lung and multiple fractures. The facility's policy on abuse, neglect, and exploitation emphasizes the need for trained and qualified staff to meet residents' needs and prevent neglect. However, the failure to provide adequate supervision and the unauthorized room transfer contributed to the resident's elopement and subsequent injuries. The guardian was not informed of the room change or the incident until contacted by the hospital, highlighting a communication breakdown within the facility.
Failure to Secure Windows Poses Safety Risk
Penalty
Summary
The facility failed to ensure the safety of residents by not securing windows in the second-floor dining room and a resident's bathroom from fully opening. During an observation with an LPN, it was noted that the bathroom window in a resident's room could be fully opened as the top pane did not lock, posing a safety risk. The LPN acknowledged that the window should lock and not open completely to prevent residents from exiting through it. Similarly, an observation with the Maintenance Director revealed that several windows in the second-floor dining room could also be fully opened, which the Maintenance Director confirmed could allow residents to exit the building. The Nursing Home Administrator stated that the facility's policy restricts windows from opening more than six inches to prevent resident egress and injury, acknowledging that the windows in question were not properly secured. The facility's Preventive Maintenance Program, revised in January 2024, is intended to ensure a safe environment, but the failure to secure these windows indicates a lapse in its implementation.
Failure to Notify Guardian of Room Change and Hospital Transfer
Penalty
Summary
The facility failed to timely notify the guardian of a resident, identified as R402, of an acute change in condition and did not obtain consent for a room change to a lockdown unit. The incident occurred when R402 exited the facility through a second-floor bedroom window and was later found outside by LPN C. The resident was then transported to the hospital. The clinical record indicated that R402 had moderate cognitive impairment and required substantial assistance for mobility. Despite having a guardian with the correct contact information, the guardian was not informed of the room change or the hospital transfer. The facility's policy on Notification of Changes requires informing the resident's representative of significant changes, including accidents and room changes. However, the guardian reported not receiving any notification from the facility about the room change or the hospital transfer. Instead, the guardian was informed by the hospital the following day. The facility's documentation and interviews revealed a lack of communication with the guardian, which is a violation of their policy.
Failure to Timely Report Elopement Incident
Penalty
Summary
The facility failed to immediately report an elopement incident resulting in injury to the State Agency. The incident involved a resident who exited a second-floor window and fell to the ground, sustaining multiple abrasions on the mid back, both legs, right hand, and right thigh. The resident was subsequently transferred to the hospital for further evaluation and treatment. The incident was observed by an LPN, who noted the injuries. The Facility Reported Incident (FRI) was submitted to the State Agency four days after the incident occurred, which was not in compliance with the facility's policy. According to the facility's policy on Abuse, Neglect, and Exploitation, such incidents should be reported immediately, but not later than two hours after the event if it involves serious bodily injury. The Nursing Home Administrator acknowledged that the FRI should have been submitted the day after the incident, indicating a failure to adhere to the specified reporting timeframes.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, resulting in discomfort and a decrease in their quality of life. Observations revealed that room temperatures ranged from 82 to 86 degrees Fahrenheit, exceeding the facility's policy of maintaining temperatures between 71 and 81 degrees Fahrenheit. Resident R303, who has medical conditions including Chronic Obstructive Pulmonary Disease and respiratory failure, reported feeling extremely hot and uncomfortable, stating that it felt like she was going to pass out. She had requested an air conditioner but had not received a response. Resident R302, who has quadriplegia and other medical conditions, also reported discomfort due to the heat in his room and other areas of the facility. The Maintenance Director acknowledged that the facility was in the process of replacing motors in air conditioning units, but the new units were not providing adequate cooling. Portable air conditioning units were being used as a temporary solution, but there were not enough available for all residents. The Nursing Home Administrator stated that resident comfort should be reported to operations and maintenance, and it is expected that residents do not feel uncomfortable. The facility's policy emphasizes maintaining safe and comfortable temperature levels, but the current situation indicates a failure to adhere to this policy, impacting the residents' comfort and well-being.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,246 citations issued within 25 miles in the last 12 months — including the 6 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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How nearby facilities compare on the same public inspection record.
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| West Oaks Senior Care & Rehab Center | 1.3 mi | ★★★★★ | 1 | 0 |
| The Villa At Great Lakes Crossing | 1.7 mi | ★★★★★ | 8 | 0 |
| Regency Heights-detroit | 1.7 mi | ★★★★★ | 0 | 0 |
| The Orchards At Redford | 2.5 mi | ★★★★★ | 20 | 0 |
| Oakland Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
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