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 Briarwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple fractures and anxiety was seen by an orthopedic surgeon and returned with a pre-op Valium prescription, but the medication was not entered or administered at the facility. EMR review showed conflicting nursing documentation, no consult note initially available, and the DON and RN confirmed the order was missed. The resident later went to the hospital for surgery and did not return.
A resident with CVA-related weakness and total ADL dependence was admitted with bruising documented, but the facility did not fully assess or document skin tears until later, and wound orders were delayed. Staff accounts conflicted about whether the skin tears were present on admission, while the family reported the resident returned to the hospital with a black eye, excoriation, and large skin tears. The DON stated the admitting nurse did not complete a full skin assessment and that no task was assigned because there was no order.
A resident admitted after a CVA with dysphagia and expressive aphasia had delayed diet-order entry, incomplete care planning, and no documented fluid intake or urine output. Staff described the resident as needing feeding assistance, eating and drinking poorly, and having fluids run out of the mouth, but the EMR lacked timely diet details in the care plan and Kardex. The resident later became lethargic, hypotensive, and bradycardic and was sent to the hospital, where records showed AKI, dehydration, and altered mental status.
The facility failed to follow its own policies for advance care planning, competency determination, and verification of legal decision makers for three cognitively impaired residents. One resident with advanced dementia was repeatedly documented as rarely/never understood, non‑verbal, and unable to make decisions, yet no formal competency assessment or legal representative was established, and the resident was documented as their own decision maker while signing advance directive and psychotropic consent forms with inconsistent, unclear signatures. A second severely impaired, aphasic resident with a BIMS score of 0 had no documented competency assessment, guardianship, or DPOA, while social services recorded that the resident remained their own person and allowed a family member, who was not a documented legal representative, to refuse psych services; an advance directive form for this resident contained a clear signature resembling the LPN witness’s handwriting, which the LPN denied writing. A third severely cognitively impaired resident had only an expired temporary guardianship order in the EMR, yet the listed guardian continued to be treated as the legal decision maker without current court documentation, and social services and administration could not produce proof of active guardianship.
Surveyors found that two residents with pressure ulcers did not receive consistent implementation of ordered off‑loading and repositioning interventions. One resident with a right heel pressure injury was repeatedly observed in bed with heels directly on the mattress, while heel boots sat unused and no pillows were available to float the heels, despite EMR documentation indicating that heel‑floating tasks had been completed. Another resident with an unstageable gluteal ulcer, who was non‑ambulatory and required assistance for bed mobility, reported being turned only when changed a few times a day and was observed remaining in the same positions in bed and later in a wheelchair for extended periods without documented repositioning or incontinence care, contrary to care plan directives for Q2H turning and heel off‑loading.
The facility did not maintain the required hot water temperature at a kitchen handwashing sink and used expired chemical test strips to verify dish machine sanitizer levels. Staff were unaware of the need to monitor water temperature and test strip expiration, resulting in potential lapses in hand hygiene and dish sanitization for all residents receiving meal service.
A resident with a history of knee surgery, infection, and multiple wounds did not have care plan interventions addressing the use and monitoring of a right leg brace and a right foot PRAFO boot. Although physician orders existed for the PRAFO boot, these were not included in the care plan or Kardex, and progress notes lacked documentation of these devices, contrary to facility policy requiring such documentation.
The facility did not consistently post or retain required daily nurse staffing information, resulting in about 60 days of missing records. This failure meant that residents and visitors could not access information about which RNs, LPNs, and CNAs were present or the resident census for those days.
Two residents who required assistance with ADLs did not receive timely support with bathing, grooming, and nail care. One resident, with dementia and multiple comorbidities, was observed wearing the same clothes for several days and had not received a shower or bed bath for over a week, with no updated interventions in her care plan. Another dependent resident was observed with uncombed hair and dirty fingernails during and after a care conference, indicating a lack of proper hygiene support.
A resident with multiple complex medical conditions was readmitted after hospitalization with a PEG tube for enteral feeding and experienced significant weight loss. Despite recommendations and facility policy requiring weekly weight monitoring for the first four weeks, staff failed to consistently obtain weekly weights after an increase in tube feeding. Both the dietitian and DON acknowledged that weekly weights were missed during this period, resulting in inadequate monitoring of the resident's nutritional status.
Surveyors found that several residents receiving IV antibiotics did not have proper documentation or monitoring of their therapy. One resident's Vancomycin dose was increased without a documented clinical rationale, another missed multiple antibiotic doses during a leave of absence without physician notification, and a third did not have required PICC line measurements documented during dressing changes.
A resident with multiple cardiac conditions was prescribed both Diltiazem 60 mg four times daily and Cardizem LA 240 mg once daily, but the original Diltiazem order was not discontinued after the new Cardizem order was started. Both medications were administered concurrently, and the duplicate therapy was not addressed in the monthly medication regimen reviews. The pharmacy's recommendation to verify the necessity of both medications was not acted upon by the physician, resulting in a medication error.
The facility failed to obtain a signed consent for treatment with an antipsychotic medication for a resident and did not prevent the administration of duplicate diltiazem medications to another resident, resulting in a medication error as confirmed by the DON.
Three medication carts were found with crushed pills, loose paper, dust, and whole or partial pills in their drawers. Multiple nurses and the DON confirmed that cleaning was assigned to third shift, but any nurse could clean the carts. The facility's policy also assigned this responsibility to nurses, and the carts were not maintained in accordance with requirements for drug storage.
Surveyors found multiple unsanitary conditions in the kitchen, including dirty utensils and equipment labeled as clean, such as a can opener with a sticky substance, a mixer with dried batter, knives with dried food, and a meat slicer with oily residue. Additionally, plate covers and coffee cups were found with water inside, increasing the risk of bacterial growth. These deficiencies affected 82 residents who consumed food and beverages prepared in the facility.
Surveyors found that the facility did not ensure proper cleaning of therapy equipment, timely removal of soiled linens, or adequate decluttering and cleaning of resident rooms. Observations included unsanitary buildup on therapy machines, a dependent resident with soiled bedding, hygiene items left behind after discharge, and cluttered living spaces.
Surveyors found that the emergency backup generator annunciation panel was installed in the maintenance office, making it not readily observable by operating personnel. This configuration could result in generator alarms going unnoticed, as confirmed by the maintenance director during the survey.
An exit sign outside the staff corridor was observed to direct occupants to exit through the staff corridor in conflict with the posted emergency egress diagram. This inconsistency in exit and directional signage, confirmed by the maintenance director, could affect 25 occupants during an emergency evacuation.
Fire-rated cross corridor double doors outside the Salon failed to fully close and latch when released from magnetic hold open devices, as observed by surveyors and confirmed by the maintenance director. This deficiency could allow heat, smoke, and fire to pass between compartments, potentially affecting 50 occupants.
Surveyors found that electrical outlets supplied by the emergency generator in one area of the facility were not marked with a distinctive color as required by NFPA 99. The maintenance director confirmed that some corridor outlets on emergency power were not properly identified, which could lead to staff not using them during a power outage.
A resident with multiple health issues fell and experienced increased pain, but the LTC facility failed to conduct a comprehensive assessment as per policy. Despite high pain levels and therapy decline, the facility only managed pain with medication without further investigation. The resident was later hospitalized, revealing multiple fractures and pneumonia, highlighting a lack of thorough assessment and documentation.
A 61-year-old resident admitted post-MVA with a primary diagnosis of Traumatic Subarachnoid Hemorrhage developed an unstageable sacral pressure ulcer. The wound area significantly increased within a week, indicating ineffective interventions. The care plan lacked measures for pressure relief, offloading strategies, and repositioning schedules. The wound nurse confirmed the facility-acquired nature of the ulcer, and the physician had not assessed the wound since its discovery. Treatment documentation discrepancies and missed treatments were noted, highlighting inconsistencies in care. Facility policies on skin management and treatment orders were not adhered to, as evidenced by missing documentation and delayed assessments.
The facility failed to properly label food products, monitor refrigerated unit temperatures, and maintain sanitary conditions in the kitchen. Observations included unlabeled and expired food items, inconsistent temperature monitoring, and dirty cooking equipment. The Dietary Manager confirmed these deficiencies.
The facility failed to provide timely care and maintain resident dignity, resulting in long call light response times, unmet personal grooming needs, and limited access to the dining room. Residents reported waiting for hours for assistance and expressed frustration with the delays and lack of care.
The facility failed to ensure that residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Interviews with residents and staff revealed that mail was not being delivered on weekends, contrary to the facility's policy and residents' rights.
The facility failed to ensure resident rooms and equipment were clean and in good repair, leading to an unsanitary environment. Observations revealed debris on mechanical lifts, unlabeled basins and bedpans on the floor, and soiled items in resident rooms. The DON and CNA acknowledged the issues, and the Maintenance Director had recently resigned, leaving the interim director unavailable for an interview.
The facility failed to properly dispose of wasted medications and secure treatment carts, leading to potential drug diversion and resident access to medicated substances. Unattended treatment carts with partially open drawers and improper disposal of medications in an open garbage container were observed.
The facility failed to maintain, document, analyze, and report ongoing surveillance of infectious illnesses for employees. The Infection Preventionist reviewed employee call-in logs but did not document or analyze the data for trends or compare it with resident infections, contrary to the facility's policy.
The facility failed to update a resident's care plan to include specific interventions for personal hygiene, despite the resident's refusal to use water and preference for private care. Staff observations and interviews revealed that the resident responded well to certain strategies not documented in the care plan, leading to unmet care needs.
The facility failed to ensure proper medication administration for two residents, resulting in undocumented administrations and improper use of a lidocaine patch. Medications for one resident were not signed out on the MAR, and a nurse did not remove an old lidocaine patch before applying a new one for another resident.
The facility failed to ensure proper communication and documentation of hospice services for a resident with chronic conditions, resulting in ineffective collaboration between the facility and hospice service. The resident was unaware of the hospice schedule, and there was a lack of documentation of hospice nursing assessments in the medical record.
Missed Pre-Op Medication Order From Outside Orthopedic Provider
Penalty
Summary
The facility failed to coordinate care with an external orthopedic provider for one resident who was cognitively intact and required maximum to total assistance with ADLs. The resident had multiple diagnoses including a displaced transcondylar fracture of the right humerus, a periprosthetic fracture around the left shoulder joint, a left knee laceration, right shoulder replacement, heart disease, depression, and anxiety. The resident was seen by the orthopedic surgeon and returned with a scanned prescription for Valium 5 mg to be taken 24 hours and 12 hours before surgery, but the medication was not administered at the facility. Documentation in the resident’s EMR showed a nursing note stating the resident returned from the ortho appointment with new orders for Valium prior to surgery, but another note shortly afterward stated no new orders were given. The resident later returned to the hospital for the scheduled surgical procedure and did not come back to the facility. Review of the MAR showed the resident did not receive any Valium while at the facility. The resident also had an NPO order entered later in the stay, and HCP documentation referenced surgery on the right upper extremity, but the external orthopedic consultation note with the prescription details was not initially present in the EMR. During interviews, the DON stated the resident did not get the Valium and that the order should have been entered but was missed. The unit manager RN stated the script was for pre-op use and was not entered because the surgical date was not known, and later acknowledged the order was missed in hindsight. The facility’s policy stated outside recommendations from appointments and consults would be reviewed by the facility provider, but the report noted no consultation documentation was available in the EMR at the time of review.
Failure to Assess and Document Skin Tears on Admission
Penalty
Summary
The facility failed to correctly assess and document the wound status of a resident on admission, resulting in a lack of timely and comprehensive identification and care of altered skin integrity. The resident had a history of CVA with right-sided flaccidity, dysphagia, anarthria, depression, chronic kidney disease, and myocardial infarction, and required maximum-to-total assistance with ADLs. Admission documentation noted bruising to both antecubital areas and both hands, but the resident’s EMR did not contain skin documentation until two days later, when nursing documented extensive bruising and two skin tears to the right upper extremity with full flap loss. Wound treatment orders were not entered until that same day, and the care plan did not include specific interventions for the altered skin integrity beyond administering treatment per physician orders. Family and staff accounts conflicted about whether the skin tears were present on admission. A family member stated the resident did not have skin tears when admitted and reported that, when transferred back to the hospital, the resident had an excoriated bottom, two briefs on, a full brief with stool and urine, a black eye, and large skin tears on the right upper and lower extremities. Hospital photographs showed a saturated dressing on the right arm and bruising around the right eye. The hospital records reviewed did not show a skin tear or wound treatment during the prior hospital stay, and the facility’s own admission/readmission assessment did not document a skin tear, only bruising. Multiple staff interviews showed that the resident’s skin was not fully assessed or consistently documented at admission and that the wound was not clearly identified until later. The admitting nurse stated the resident had bruising but no skin tear and acknowledged that a thorough skin check was not completed. Other nurses and CNAs reported not seeing wound dressings or skin tears, while some later statements suggested a dressing had been present and that the skin tear was already there. The DON stated the nurse did not do a complete skin assessment and that nurses did not receive a task to address the skin tear because there was no order. The facility’s investigation documentation stated the skin tears were present on admission, but the record also showed no documentation of the wound until after admission and no hospital discharge documentation of a skin tear.
Delayed diet orders and missing intake documentation
Penalty
Summary
The facility failed to identify, comprehensively assess, and document the nutritional and hydration needs and intake for one resident who was admitted after a CVA with right-sided weakness, dysphagia, and expressive aphasia. The resident’s record showed no diet order in the EMR until 4/13/26, even though the resident was admitted on 4/11/26. The admission nursing assessment documented no natural teeth, no dentures, and adequate food intake, but the initial care planning sections for oral/dental health problems, swallowing problems, and nutritional or potential nutritional problems were not selected and implemented. The resident’s care plan did not include a diet or specific dietary interventions until 4/14/26, and the Kardex also did not include the resident’s diet or modified fluids. Task documentation showed meal percentages and bedtime snacks, but there was no documentation of oral fluid intake or urine output. The resident had a task for bladder continence and toilet use, but it did not include amount of urine output. Staff interviews described the resident as needing feeding assistance, being on a special diet with thickened liquids, spitting out food, and having fluids run out of the mouth, yet this information was not reflected in the EMR in a timely or consistent way. Nursing staff also stated they relied on report and paper slips to the kitchen, and one nurse stated the resident was not seen by OT before eating despite concern about comfort with the diet. Therapy documentation showed conflicting and delayed diet information. The hospital referral packet contained an ST evaluation recommending NDD3 with thin liquids and 1:1 supervision, while the facility’s ST evaluation later recommended pureed foods and moderately thick liquids with feeding assistance and aspiration precautions. The resident’s diet order was not entered until 4/13/26, after the resident had already been in the facility for two days. On 4/15/26, the resident became lethargic, hypotensive, and bradycardic and was transferred to the hospital. Hospital records documented altered mental status, AKI, dehydration, elevated BUN, creatinine, BUN/creatinine ratio, sodium, and WBC, and the ED note identified dehydration, sepsis, and heart failure as common causes of AKI. Family and staff interviews described the resident as increasingly confused, not eating or drinking well, and less responsive before transfer.
Failure to Determine Decision-Making Capacity and Verify Legal Representation for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and operationalize its policies and procedures for advance care planning, determination of decision‑making capacity, and verification of legal representation for three cognitively impaired residents. For one resident with dementia, psychosis, and anxiety, the MDS and multiple clinical notes over several months documented that the resident was rarely/never understood, alert only to self, highly cognitively impaired, and unable to make needs known. Psychiatric evaluations repeatedly described advanced dementia, profound cognitive impairment, and limited capacity for engagement, and a physician note explicitly stated the resident was cognitively impaired, unable to make decisions, and would need guardianship. Despite this, there was no documented competency assessment, no identification or activation of a legal decision maker, and no social services documentation addressing designation of a legal representative. The resident’s face sheet listed the resident as their own responsible party, and the granddaughter and daughters only as emergency contacts. During this same period, the facility obtained signatures on advance directive and psychotropic medication consent forms that were attributed to the resident, even though staff interviews confirmed the resident was not cognitively intact and did not have a DPOA or guardian. The advance directive form documented that the resident did not choose to formulate any advance directives, and psychotropic consents for Zyprexa and Remeron were signed and witnessed by staff, with illegible or inconsistent resident signatures/initials that appeared dissimilar from each other. Social services documented that the resident remained their own person and that the patient was their own decision maker, while other clinical notes described the resident as non‑verbal, unable to verbalize needs, unable to retain education, and exhibiting aggressive behaviors. Discussion with family about pursuing guardianship was not documented until approximately four months after admission, and social services acknowledged that no competency assessment was completed and that they did not address the lack of a legal decision maker because the resident was initially expected to be short‑term. For a second resident with a BIMS score of 0, severe cognitive impairment, aphasia, dysarthria, and dependence in ADLs, the MDS indicated the resident was rarely/never understood. The face sheet listed the resident’s mother as responsible party, but there was no documentation of competency assessment, guardianship, or DPOA in the EMR. Social services documented that the resident remained their own person and had no wishes to issue further advance directives, while also recording that the resident was nonverbal and that the mother refused psychiatric services on the resident’s behalf, even though she was not documented as a legal representative. When surveyors attempted to interview the resident, verbalizations were not understandable, and a CNA reported it was hard to know what the resident wanted and that they normally could not understand the resident. Despite this, an advance directive form in the EMR showed a clearly written resident signature that closely resembled the LPN witness’s signature; the LPN later denied that the signature was theirs or the resident’s and stated they did not know who signed the resident’s name. The LPN also reported the resident was admitted alone and was unsure who was making the resident’s medical decisions. For a third resident with heart disease and dementia, the MDS showed severe cognitive impairment and need for supervision to total assistance with ADLs. Two HCPs had deemed this resident incompetent to make medical decisions, and probate court documentation granted a named individual temporary guardianship for a defined period. However, no permanent or current guardianship documentation was present in the EMR after the temporary order expired, even though the face sheet continued to list this individual as the resident’s legal guardian. The Social Services Director stated that the resident had an active legal guardian and that guardianship documentation was maintained in the EMR, but when reviewed, only the expired temporary guardianship order could be produced. The director acknowledged they did not have current guardianship documentation and did not explain how they knew the individual was legally able to make decisions without proof. The facility’s own policies required ongoing assessment of decision‑making capacity, determination of when residents could no longer make their own health care decisions, and maintenance of documentation for guardianship or surrogate decision makers, but these processes were not carried out or documented for the three residents. The Administrator confirmed that social services was responsible for addressing competency and legal representation but was unable to explain why these issues were not addressed for the residents in question. The Administrator also acknowledged that the signatures on one resident’s advance directive form appeared similar and that it did not appear to be the resident’s signature, and agreed that no one else should sign for a resident unless requested and documented. The Administrator further confirmed that guardianship documentation should be scanned into the EMR and was informed that one resident’s guardianship documentation was not current, without providing further explanation. Overall, the facility did not follow its policies on advance directives, determination of advocates’ authority, and ongoing review of residents’ decision‑making capacity, resulting in the absence of timely competency determinations, lack of appropriate and legal representation for two residents, and lack of current guardianship documentation for the third resident.
Failure to Implement Pressure Ulcer Prevention and Off‑Loading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and operationalize its pressure ulcer care policies for two residents, resulting in inaccurate documentation and failure to carry out ordered interventions. For one resident with a right heel pressure ulcer present on admission, surveyors repeatedly observed the resident lying in bed on their back with both heels directly on the mattress. Heel boots ordered for off‑loading were seen unused on a table, and there were no pillows or other positioning devices in the room to float the heels. The resident reported having a pressure ulcer on the right heel and stated staff did not assist with positioning the heels off the mattress. Despite this, electronic documentation over the prior 30 days showed the task “Float heels (as tolerated) while in bed” marked as completed (“Yes”) 77 times, including multiple entries on the days when surveyors directly observed the heels not floated. Record review for this resident showed inconsistent and evolving documentation of the right heel wound, including descriptions as a stage I pressure injury, a blister, and later an unstageable pressure injury with 100% slough and serous drainage. An external wound care provider documented an open right posterior heel wound likely related to pressure and recommended Q2H turning/repositioning and heel off‑loading with boots or floating. During a wound care observation, the nurse removed a dressing from the right heel and a wound with black necrotic tissue over a bony prominence, surrounded by red/purple tissue approximately the size of a half dollar, was observed. After the dressing change, the resident was again left with heels directly on the mattress, and no pillows were present for off‑loading. When questioned, the assigned RN acknowledged that the resident’s heels had not been floated and that attempts to float the heels had not been made when no positioning device was available, despite documentation indicating otherwise. For a second resident with an unstageable pressure ulcer on the left gluteal area being treated with Santyl, the facility also failed to follow care plan interventions for turning and repositioning. This resident was non‑ambulatory, required assistance with ADLs, and had care plan interventions including encouragement to turn and reposition every two hours and assistance by two staff for bed mobility. The resident reported having a wound on the buttocks and pain in the “backside,” rating the pain as four out of ten, and stated they could not reposition themselves. The resident indicated staff turned and repositioned them only when they needed to be changed, which they described as a couple of times a day. A family member present stated the resident had not moved since their arrival several hours earlier. Subsequent observations found the resident in bed on their back and later slightly on their right side, with the resident unable to recall how long they had been in that position and reporting ongoing pain and that morning care had not yet been provided. During a wound care observation for this second resident, staff removed the dressing from the left buttocks and revealed an area of black necrotic tissue approximately the size of a nickel with bright red surrounding tissue, and a separate nearby area about the size of a dime with a white wound bed. Immediately after the dressing change, the resident was transferred by mechanical lift to a wheelchair. Hours later, the resident remained in the wheelchair, reporting feeling sore and tired, stating they had not returned to bed, had not been repositioned in the wheelchair, and that their brief had not been checked or changed since being placed in the chair. The LPN confirmed the resident had been up in the wheelchair continuously since the wound care. The facility’s own skin management policy required skin assessments, weekly wound rounds, and interventions such as turning/repositioning, heel off‑loading, and scheduled time out of bed, but the observations and interviews showed these interventions were not consistently implemented for the two residents with pressure ulcers.
Failure to Maintain Handwashing Sink Temperature and Use Valid Dish Machine Test Strips
Penalty
Summary
The facility failed to ensure proper food safety practices in two key areas within the kitchen. First, the handwashing sink used by dietary staff near the kitchen entrance did not provide hot water at the required minimum temperature of 85 degrees Fahrenheit. Observations revealed that the water remained cold even after running for an extended period, and the temperature was measured at 67 degrees Fahrenheit. Neither the dietary supervisor nor the maintenance staff were monitoring the temperature of this sink, and there was no documentation of regular checks for this critical hand hygiene point. Second, the facility did not ensure that chemical test strips used to verify dish machine sanitizer levels were within their expiration date. The dietary supervisor provided test strips that had expired several months prior and was unaware of the need to check expiration dates. There were no additional strips available at the time, and dishwashing staff were preparing to use the dish machine without a valid means to confirm proper sanitization. The dish machine log did not include information about the lot number or expiration date of the test strips, and staff had not been trained to monitor this aspect. These failures created the potential for improper hand hygiene and dish sanitization for all residents receiving meal service.
Failure to Include Assistive Device Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically omitting care instructions for a right leg brace and a right foot PRAFO boot. The resident, who had a history of right knee replacement, post-surgical infection, reduced circulation in the right leg, heart disease, and arthritis, was observed with a dressing and a brace on her right lower leg. She reported previous knee surgery with subsequent infection and additional wounds on her right leg. Record review showed the resident had nine wounds on her right foot and lower leg, including wounds attributed to a medical device. The care plans in place addressed pressure ulcers but did not include interventions or instructions related to the right leg brace or the right foot PRAFO boot. Interviews with the wound nurse confirmed that while physician orders existed for the use and monitoring of the PRAFO boot, these were not reflected in the resident's care plan or Kardex. Additionally, progress notes did not mention the right knee brace or PRAFO boot. Facility policy required that recommendations for assistive devices be based on comprehensive assessment and documented in the care plan, but this was not done for the resident's leg brace or foot boot, resulting in a lack of documented guidance for staff on their application and monitoring.
Failure to Maintain and Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was properly posted and maintained as required by federal regulations. During an observation, the Administrator indicated that the nurse staffing document was posted near the facility entry, but upon review, the posted document contained an incorrect day of the week. The Administrator acknowledged the error and stated that the staff member responsible would correct it. When asked to review the prior year's posted staffing records, the Administrator provided a binder containing the documents, which were used to track the number of RNs, LPNs, and CNAs on each shift, their hours worked, the date, and the resident census. Upon further review of the binder, it was discovered that approximately 60 days of posted staffing sheets were missing for the period from October 2024 to April 2025. The Administrator confirmed that the staff member previously responsible for completing the daily posted staffing documents was no longer in that role. As a result, the facility did not have the required nurse staffing information available for multiple days, preventing residents and visitors from knowing which clinical staff were working on those days.
Plan Of Correction
Element 1: Posted Nurse Staffing document was updated with the corrected day of the week during survey. Element 2: Audit completed of Nurse Staffing binder to identify any missing postings. Element 3: Education completed with Staffing Coordinator to assure daily Nurse Staffing postings are completed accurately and available for review. The Administrator/Designee will verify daily, Monday through Friday, that Nurse Staffing is posted accurately. Weekend receptionist will verify, Saturday and Sunday, that Nurse Staffing is posted accurately and immediately notify the Administrator if not posted. Element 4: Administrator/Designee will complete random weekly audits, four weeks, of Nurse staffing posting to assure the document is posted accurately, with findings submitted to QAPI for review and recommendations. Element 5: Staffing Coordinator is responsible for maintaining compliance.
Failure to Provide Timely ADL Assistance and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADL) for two residents who required support. One resident, with a history of dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, and blindness in one eye, was observed multiple times over several days wearing the same dress and exhibiting signs of poor hygiene, such as scratching her face and emitting a strong odor. Documentation showed that she had not received a shower or bed bath for over ten days, despite her care plan indicating a need for staff oversight due to cognitive deficits and a tendency to refuse care. The care plan and progress notes did not reflect any updated or alternative interventions to address her refusals or preferences, and staff did not attempt different approaches as outlined in facility policy. Another resident, who was dependent on staff for all ADLs due to confusion, tube feeding, diabetes, dementia, stroke, and hemiplegia, was observed at a care conference and later in her room with uncombed hair and dirty fingernails. Despite being prepared for a care conference, her grooming needs were not met, as evidenced by her appearance and the presence of black debris under her nails. The facility's ADL policy required appropriate support and assistance with hygiene, including bathing, dressing, grooming, and oral care, for residents unable to perform these tasks independently. The observations and record reviews demonstrated that the facility did not consistently provide necessary ADL care, such as bathing, nail care, and hair care, for residents who were dependent or required oversight. The lack of timely and individualized interventions, as well as failure to update care plans and follow facility policy for residents who resist care, contributed to the deficiency in maintaining residents' hygiene and grooming.
Plan Of Correction
Element One: Resident #52 had her clothes changed and shower schedule was changed to 1st shift. Resident #139 had her fingernails cleaned and hair combed per her preference. Element Two: Audit completed of all Residents to ensure fingernails are clean and hair is combed per Resident preferences. Audit completed of Residents who refused showers to ensure alternative was offered and care planned. Element Three: Administrator/Designee completed education with the IDT members who conduct room rounds to ensure Residents fingernails are clean, hair is combed per resident preference and resident is not wearing the same clothing as previous day. Director of Nursing/Designee completed education with the nursing staff to ensure residents who refuse showers are offered an alternative and documented. Director of Nursing/Designee completed education with the nursing staff in regards to ensuring fingernails are clean, clothing has been changed daily and hair is combed per resident preference. Any staff not educated by May 20, 2025 will be educated on their next scheduled shift. Element Four: Nurse Manager/Designee will complete random weekly audits X4 weeks of residents to ensure Residents are dressed appropriately, fingernails are clean and hair is combed, with findings submitted to the Director of Nursing who will report findings to QAPI for review and recommendations. Element Five: The Director of Nursing is responsible for maintaining compliance.
Failure to Timely Monitor Weights for Resident on Enteral Nutrition
Penalty
Summary
A deficiency occurred when the facility failed to monitor weights in a timely manner for a resident who was readmitted after hospitalization with a significant change in nutritional status, specifically the initiation of a PEG tube for enteral feeding. The resident had a complex medical history, including intracerebral hemorrhage, gastrostomy, abdominal aortic aneurysm, dysarthria, aphasia, hemiplegia, Alzheimer's disease, and muscle wasting. Upon readmission, the resident had experienced a notable weight loss, dropping from 131.6 lbs prior to hospitalization to 118.4 lbs at readmission, and further to 114.2 lbs over the following 18 days. The resident's nutritional assessments indicated ongoing weight loss and recommended weekly weight monitoring for the first four weeks post-readmission, in accordance with facility policy and the dietitian's assessment. Despite these recommendations and the resident's continued weight loss, weekly weights were not consistently obtained after the increase in enteral feeding from four to five cartons daily. The dietitian and DON both acknowledged that the required weekly weights were missed during this critical period. Facility policy required weekly weights for residents within the first four weeks of admission or as determined by the interdisciplinary team, especially for those with significant nutritional changes. The failure to adhere to this policy resulted in a lack of timely monitoring of the resident's weight status, despite clear evidence of ongoing weight loss and changes in nutritional interventions.
Plan Of Correction
Element 1 Resident #62's weight was obtained. Physician was notified. She was assessed by Dietitian for nutritional needs and nutrition plan of care was reviewed. Weight obtained showed weight gain and that interventions were successful. Resident will continue to be followed by Dietitian. Element 2 An audit was completed for Residents who returned from the hospital to ensure weekly weights were completed x4 weeks and all Residents with significant weight loss had interventions in place. An audit was completed for Resident on enteral feeding to ensure any weight loss or changes in orders were addressed with weekly weight monitoring in place. Any concerns identified were corrected. Element 3 Director of Nurses/Designee completed re-education to Nursing staff in obtaining weekly weights x4 weeks for any new admits or any Residents who were recently admitted to the hospital and re-admitted to the facility. Director of Nursing/Designee completed education to Registered Dietitian on tracking and requesting weekly weights for new admits as well as for any Resident showing weight loss or had changes in enteral feeding. Any staff members not educated by May 20, 2025 will be educated on their next scheduled shift. Unit Managers/Designee will verify that there are no missing weekly weights for new admits x4 weeks. Registered Dietician will provide a list to nursing for Residents with weight changes or enteral feeding changes. Nurse Managers will review medical record for new admits as well as re-admits during morning meeting to ensure all weights are obtained. Nurse Managers will review medical record for Residents with weight changes or enteral feeding changes during morning meeting to ensure all weights are obtained. Element 4 Unit Manager/Designee will complete random weekly audits X4 weeks of weights to ensure no weekly weights are missed with results of findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5 Director of Nursing is responsible for maintaining compliance.
Deficient Monitoring and Documentation of IV Therapy and PICC Line Care
Penalty
Summary
A deficiency was identified regarding the administration and monitoring of parenteral/IV fluids for several residents. For one resident with osteomyelitis, there was an increase in the Vancomycin dosage from 1500 mg to 2000 mg intravenously daily, but there was no documentation in the medical record providing the clinical rationale for this change. Although a pharmacy document indicated a low trough level as the reason for the dosage increase, this information was not accessible in the resident's medical record, and no progress note was completed by the nurse to explain the adjustment. Another resident, admitted for IV antibiotics following pneumonia and a secondary joint infection, missed three antibiotic doses (one Vancomycin and two Cefepime) while on a leave of absence (LOA) with family. The medical record did not contain documentation that the resident’s physician or infection preventionist was notified about the missed doses, nor were there progress notes outlining the next steps or physician instructions following the missed medications. A third resident, who had a PICC line for IV antibiotics, did not have documented monitoring of the external catheter length during dressing changes, as required by the facility’s standard operating procedure. Additionally, there was no documentation of arm circumference measurements or assessment of the external catheter in the treatment administration record, progress notes, care plan, or admission assessment. The facility’s policy required measurement of the external catheter length at each dressing change, but this was not completed or documented for the resident.
Plan Of Correction
Element 1 Resident #8 PICC line was discontinued prior to entrance of survey team. Resident #84 medical record was updated with rationale for the increased Vancomycin. Resident #289 physician was contacted regarding missed doses due to resident being out on LOA. Element 2 An audit was completed for residents who have PICC lines to ensure measurements of the external catheter length are documented in the TAR/MAR or in a progress note. Any concerns identified were corrected. An audit was completed for residents who have had an increase in dosage of Vancomycin to ensure rationale was documented in the medical record. Any concerns identified were corrected. An audit was completed for residents who leave the facility on LOA to ensure dosage of medications were not missed. If any medications are missed due to the resident being out of the facility, documentation of physician notification in the patient's medical record. Element 3 Director of Nursing/Designee completed re-education to licensed nurses in measuring PICC line from the insertion site to the end of the PICC line on admission and weekly with dressing changes. Director of Nursing/Designee completed education to licensed nurses in the process for when pharmacy adjusts the dose of Vancomycin via phone call or fax; the staff will adjust the order and document. Director of Nursing/Designee completed education to licensed nurses in the procedure for missed doses: the nurse will contact the physician and document in the patient's medical record. Any staff members not educated by May 20, 2025, will be educated on their next scheduled shift. Unit Managers/Designee will verify that there are no missing PICC line weekly measurements during morning meetings. Nurse Managers will review medication orders during morning meetings to ensure all increases of Vancomycin dosage have documentation of physician rationale. Nurse Managers will review medical records for any missed dosage of medications while residents are out on leave to ensure physician notification is documented in the patient's medical record. Element 4 Unit Manager/Designee will complete random weekly audits for four weeks of PICC line measurements, change in Vancomycin dosage rationalization, and missed dosage documentation. The results of findings will be submitted to the DON, who will report findings to QAPI for review and recommendations. Element 5 The Director of Nursing is responsible for maintaining compliance.
Failure to Discontinue Duplicate Cardiac Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to identify and address a medication order discrepancy for a resident with multiple cardiac diagnoses, including hypertension, atherosclerotic heart disease, atrial fibrillation, and a coronary angioplasty implant. Upon admission, the resident was prescribed Diltiazem 60 mg to be taken four times daily. Later, a physician's note indicated a switch to Cardizem CD 240 mg once daily, and a new order for Cardizem LA 240 mg once daily was entered. However, the original Diltiazem 60 mg order was not discontinued, resulting in both medications being administered concurrently. The Medication Administration Record (MAR) showed that both Cardizem LA 240 mg and Diltiazem 60 mg were scheduled and administered at overlapping times. The monthly medication regimen review (MRR) conducted in February did not address the duplicate therapy, and the March MRR only raised the issue in a written recommendation to verify the necessity of both medications. This recommendation was not signed or addressed by the attending physician, and the duplicate orders remained active. Interviews with the Director of Nursing confirmed that the pharmacy's recommendations had not been acted upon and that the duplicate medication orders constituted a medication error. Facility policy required timely review and resolution of such irregularities, including immediate physician notification if resident safety was at risk, but these steps were not followed. The failure to discontinue the previous order and to act on the pharmacist's recommendations led to the ongoing administration of duplicative therapy.
Plan Of Correction
Element 1: Resident #18 order for Diltiazem 60mg was discontinued. Physician was notified of medication error during survey. Element 2: An audit of Pharmacy Medication Reviews was completed for the last 30 days to ensure reviews were completed by Physician and had documented response from the Physician in Residents' medical record. Any concerns were corrected. Element 3: Physicians were reeducated on reviewing and completing documentation of Pharmacy Medication Reviews in the Residents' medical record. Element 4: Unit Manager/Designee will complete random monthly audits of Pharmacy Medication Reviews to ensure all reviews have been documented with findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5: Director of Nursing is responsible for maintaining compliance.
Failure to Obtain Consent and Prevention of Duplicate Medication Administration
Penalty
Summary
The facility failed to obtain a signed consent for treatment with an antipsychotic medication for a resident diagnosed with dementia, depression, anxiety, and other chronic conditions. The resident was prescribed Fluoxetine for depression, but a review of the medical record did not identify a consent form for this treatment. Additionally, the resident's care plan did not mention the use of medication for depression, despite the ongoing prescription and administration of Fluoxetine. The Director of Nursing confirmed that a consent form could not be found for this medication. Another deficiency was identified when a resident with a history of hypertension, heart disease, and atrial fibrillation was administered duplicate medications containing diltiazem. The resident's physician ordered a switch from Diltiazem 60 mg four times daily to Cardizem LA 240 mg once daily, but the original order for Diltiazem 60 mg was not discontinued. As a result, the resident received both medications concurrently, as documented in the Medication Administration Record. The Director of Nursing acknowledged this as a medication error, and facility policy requires monitoring to prevent such errors.
Plan Of Correction
Element 1 Resident #52 was not on an Antipsychotic medication at the time of the survey. Consent was obtained for Antidepressant Fluoxetine. Resident #18 order for Diltiazem 60mg was discontinued, Physician was notified of medication error during survey. Element 2 An audit of Antidepressant medication orders was completed to ensure consents were present for all Antidepressant medications. Any concerns were corrected. An audit of Pharmacy Medication Reviews were completed for the last 30 days to ensure reviews were completed by Physician and had documented response from the Physician in Residents medical record. Any concerns were corrected. Element 3 Director of Nurses/Designee completed re-education to Licensed nurses on documentation of obtaining consents for Antidepressant medications and discontinuing orders per Physician order. Any licensed nurse not educated by May 20, 2025 will be educated on their next scheduled shift. Licensed Nurse will verify that there is a consent signed for any new Antidepressant Medications as part of the report during shift change. Nurse managers will review during morning meeting to ensure medication orders were discontinued per Physician changes of medications and all consent have been obtained for Antidepressant medications. Element 4 Unit Manager/Designee will complete random weekly audits X4 weeks of medication changes to ensure orders were discontinued and any resident with new Antidepressant medications has a signed consent. Results of findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5 Director of Nursing is responsible for maintaining compliance.
Medication Carts Not Maintained in Clean and Sanitary Condition
Penalty
Summary
Surveyors observed that three out of four medication carts (located on Halls 300, 400, and 500) were not maintained in a clean and sanitary condition. The drawers of these carts contained crushed pills, loose pieces of paper, dust, and in some cases, whole or partial pills. These observations were made during walkthroughs with nursing staff, who acknowledged that the carts could have been cleaned better and stated that cleaning was typically assigned to the third shift, but any nurse could perform the task. Interviews with multiple nurses and the Director of Nursing confirmed that the responsibility for cleaning the medication carts was assigned to the third shift nursing staff, and this was consistent with the facility's Medication Storage policy. The failure to keep the medication carts clean and free of medication debris and other contaminants was directly observed and confirmed by staff, indicating non-compliance with requirements for proper storage and maintenance of drugs and biologicals.
Plan Of Correction
Element 1: Medication carts on 300, 400, and 500 halls were cleaned during survey. Element 2: Audit of medication carts was completed to ensure all medication carts are clean and sanitized, free of crushed pills, pieces of loose papers, and dust in the drawers. Any identified areas were addressed. Element 3: The Director of Nursing/Designee reeducated Licensed Nurses on cleaning of medication carts, which included making sure cart drawers are free of dust, paper particles, and crushed pill residue. Any Licensed Nurses not educated by May 20, 2025, will be educated on their next scheduled shift. Nurse managers/designee will complete random weekly audits of medication carts to ensure they are clean and sanitized. Element 4: Unit Manager/Designee will complete random weekly audits, for four weeks, of medication carts to ensure they are clean and sanitized. They will also query Nurses if they are able to verbalize the appropriate way to clean medication carts, with results reported to the Director of Nursing who will be present to QAPI for further follow-up and recommendations. Element 5: The Director of Nursing will be responsible for maintaining compliance.
Unsanitary Kitchen Equipment and Improper Food Handling
Penalty
Summary
Surveyors observed multiple instances of unsanitary conditions and improper cleaning of kitchen equipment and utensils during a kitchen tour. Specifically, a large can opener had a dark, sticky substance behind the blade, and a large counter mixer that was considered clean had dried batter-like residue on its attachment. Additionally, a carving knife and a bread knife, both labeled as clean and ready for use, were found with dried food on their blades. The meat slicer, also marked as clean, had an oily substance and dried food on its blade. These findings were confirmed by the Dietary Director during the inspection. Further observations included six plate covers stacked together with water inside, and three coffee cups ready for serving that also contained water, both of which can promote bacterial growth. The facility's Dietary Manager job description requires providing training, direction, and guidance for dietary staff, but the observed conditions indicate a failure to maintain food preparation and kitchen equipment in a sanitary and good working condition. These deficiencies affected 82 residents who consumed food and beverages prepared in the facility's kitchen and ice machine.
Plan Of Correction
Element 1: Plate covers and coffee cups that were on the rack with water were re-washed and dried properly before returning to the rack for use. Can opener, meat slicer, mixer, and knife were cleaned during survey. Element 2: Audit completed of kitchen to assure equipment cleanliness as well as plate covers and coffee cups are completely dry on the clean rack. Element 3: Education completed with Dietary staff to assure kitchen equipment cleanliness, plate covers, and coffee cups are completely dry before putting away on the clean rack. Any staff not educated by May 20, 2025, will be educated on their next scheduled shift. Dietary Manager/Designee will complete weekly kitchen audits to ensure appropriate processes are being followed. Element 4: Dietary Manager/Designee will complete random weekly audits X4 weeks of kitchen to assure kitchen cleanliness and all items dried and stored properly, with findings submitted to QAPI for review and recommendations. Element 5: Dietary Manager is responsible for maintaining compliance.
Failure to Maintain Cleanliness and Organization in Resident and Therapy Areas
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for residents, as evidenced by multiple deficiencies in cleaning and organization. In the therapy gym, equipment such as Nu Step machines and Omni Cycles were observed to have debris, sand-like buildup, hair, and deteriorating materials, despite claims that equipment is wiped down between uses and deep cleaned monthly. The cleaning schedule lacked specific tasks, and the observed buildup suggested inadequate cleaning practices. Additionally, the seat and handle covering on one machine were damaged and deteriorating, further contributing to unsanitary conditions. In resident care areas, a resident who was totally dependent on staff and cognitively impaired was found with a soiled gown and a blanket with a large brown smear near the face, and the room had visible black wheelchair marks and chipped paint. Another room contained hygiene items and a bedpan left behind by a discharged resident, and several rooms on the 100 Hall were noted to be cluttered with resident items stacked on floors and surfaces, making the environment appear unkempt. These observations indicate a failure to ensure timely removal of soiled linens, proper disposal of hygiene products after discharge, and adequate decluttering and cleaning of resident rooms.
Plan Of Correction
Element Three: Administrator/Designee completed education with the IDT members who conduct room rounds to ensure any identified cluttered rooms are addressed as well as any black marks or paint chips are identified. Housekeeping Supervisor/Designee completed education with the Housekeeping staff to ensure all rooms identified with clutter are addressed immediately and personal belongings are removed timely when residents are discharged from the facility and room is clean and ready for new resident. Administrator/Designee completed education with the Housekeeping staff and Therapy staff on cleaning of gym equipment. Administrator/Designee completed education with the Nursing staff in regards to removal of soiled clothing/gowns and linen are removed from resident beds and placed in appropriate bin to be sent to laundry and removing clutter from rooms. Any staff not educated by May 20, 2025 will be educated on their next scheduled shift. Element Four: Housekeeping Supervisor/Designee will complete random weekly audits X4 weeks of resident rooms to assure rooms are free of clutter, soiled linen has been removed and discharged residents' personal hygiene products have been removed, no black markings or chipped paint with findings submitted to Administrator who will report findings to QAPI for review and recommendations. Therapy Director/Designee will completed random weekly audits X4 weeks of therapy equipment to ensure cleanliness, with findings submitted to QAPI for review and recommendations. Element Five: The Administrator is responsible for maintaining compliance.
Emergency Generator Alarm Annunciator Not Readily Observed by Staff
Penalty
Summary
The facility failed to ensure that the emergency backup generator annunciation panel was located in a place that is readily observed by operating personnel, as required by NFPA 99 standards. During an observation, it was found that the annunciation panel was installed in the maintenance office, which is not a location that allows for easy monitoring by staff responsible for facility operations. This setup could result in generator alarms not being noticed promptly. The maintenance director confirmed these findings during the surveyor's interview at the time of observation. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. Annunciator panel was moved to an area readily observed by staff. 2. Audit completed of emergency notification systems to ensure location is easily accessible by staff. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Department on requirement that remote annunciation must be located outside of any locked rooms and easily accessible for staff to be notified of generator alarms. 4. Maintenance Director/Designee will complete random audits of emergency equipment and alarm devices are easily accessible to general staff with findings submitted to QAPI for review and recommendations. 5. Maintenance Director is responsible for maintaining compliance.
Conflicting Exit Signage and Egress Diagram
Penalty
Summary
During an observation on April 24, 2025, it was found that the exit sign outside the staff corridor directed occupants to exit through the staff corridor in the event of an emergency, which conflicted with the emergency egress diagram displayed on the wall. The exit sign was not in accordance with the requirements for exit and directional signage, which mandate continuous illumination and alignment with emergency egress routes. This discrepancy was confirmed through an interview with the maintenance director at the time of observation. The deficiency could potentially affect 25 occupants during an emergency evacuation, as the conflicting signage may delay or obstruct emergency egress down the restricted width staff corridor.
Plan Of Correction
1. Exit sign outside the staff corridor was corrected to direct occupants as indicated on the emergency diagram displayed on the wall. 2. Audit completed of exit signs to ensure correct and match emergency diagram posted. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Director on exit signage. 4. Maintenance Director/Designee will complete random audits of exit signage to ensure occupants are directed in the appropriate direction according to emergency diagram posted with findings submitted to QAPI for review and recommendations. 5. Administrator is responsible for maintaining compliance.
Failure of Fire-Rated Corridor Doors to Close and Latch
Penalty
Summary
Surveyors observed that the fire-rated cross corridor double doors located outside the Salon did not fully close and latch when released from their magnetic hold open devices. This failure was identified during an inspection on April 24, 2025, at approximately 10:50 AM. The doors are required to resist the passage of smoke and, in this case, did not meet the necessary standards for protecting corridor openings as outlined by NFPA 19.3.6.3. The deficiency was confirmed through an interview with the maintenance director at the time of observation. The inability of these doors to close and latch properly could allow heat, smoke, and fire to pass from one compartment to another, potentially affecting up to 50 occupants. No specific residents or their medical conditions were mentioned in the report.
Plan Of Correction
1. Fire-rated cross corridor double doors outside the Salon were adjusted to close properly. 2. Audit completed of fire-rated doors to ensure proper closing. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Department on requirement that fire doors fully close and latch when released from the magnetic hold open devices. 4. Maintenance Director/Designee will complete random audits of corridor double doors to ensure doors close and latch properly with findings submitted to QAPI for review and recommendations. 5. Maintenance Director is responsible for maintaining compliance.
Failure to Distinctly Mark Emergency Power Outlets
Penalty
Summary
Surveyors observed that electrical receptacles or cover plates supplied from the life safety and critical branches in the original side of the facility were not marked with a distinctive color or marking as required by NFPA 99 standards. During the inspection, it was noted that the emergency generator provided power only to dedicated outlets, and some outlets in the corridors were on emergency power but lacked the required distinctive color marking. The maintenance director confirmed during the interview that these outlets were not properly identified, which could result in staff not recognizing or using them during a power outage. These findings were confirmed at the time of observation with the maintenance director present. No specific residents or patient medical histories were mentioned in the report, and the deficiency was based solely on facility infrastructure and staff interviews.
Plan Of Correction
Electrical receptors that are connected to the back up generator were changed to red cover plates. Audit completed of all electrical receptors connected to the back up generator to ensure those receptacles are identified with a red cover plate. Corrections made as needed. Administrator/Designee completed education to Maintenance Department on requirement that all electrical receptacles connected to the back up generator must have a distinctive red cover plate so it is easily identified by staff during an emergency situation. Maintenance Director/Designee will complete random audits of electrical receptacles to ensure emergency receptacles are identified with a red cover plate with findings submitted to QAPI for review and recommendations. Maintenance Director is responsible for maintaining compliance.
Failure to Conduct Comprehensive Assessment After Resident Fall
Penalty
Summary
The facility failed to conduct a comprehensive nursing assessment following a significant change in condition for a resident who experienced a fall. The resident, who had a history of multiple health issues including end-stage kidney disease, heart disease, and recent spinal surgery, fell on 7/2/24. Despite complaints of hip pain, the initial x-ray conducted on 7/3/24 showed no acute fractures or dislocations. However, the facility did not perform a complete pain assessment as per their policy, and the resident's pain was only managed with medication without further investigation. The resident continued to experience significant pain, which was noted by the occupational therapist on 7/4/24. The therapist informed the nursing staff of the resident's increased pain and decline in therapy participation, but this was not documented in the nursing notes. The resident's pain levels were recorded as high on multiple occasions, yet there was no comprehensive assessment or documentation of the pain's intensity, pattern, or impact as required by the facility's pain management policy. The situation escalated when the resident was eventually taken to the hospital on 7/12/24, where a CT scan revealed multiple fractures and pneumonia. The lack of thorough assessment and documentation by the facility led to a delay in the resident receiving appropriate medical attention. Interviews with staff indicated a breakdown in communication and documentation, contributing to the oversight in addressing the resident's worsening condition.
Deficiency in Pressure Ulcer Care and Prevention
Penalty
Summary
The report details a deficiency in providing appropriate pressure ulcer care and prevention for Resident #69 in the facility. Resident #69, a 61-year-old admitted post-Motor Vehicle Accident (MVA) with a primary diagnosis of Traumatic Subarachnoid Hemorrhage, developed an unstageable sacral pressure ulcer during their stay. The wound nurse noted a significant increase in the wound area within a week of discovery, indicating a lack of effective interventions to prevent worsening. Despite the resident's complaints of pain and limited mobility for repositioning, the care plan did not address poor compliance, tolerance to movement, or pressure relief interventions. The facility's failure to implement adequate interventions is evident in the lack of documented pressure relief measures, offloading strategies, or turning/repositioning schedules in the care plan. The wound nurse acknowledged the facility-acquired nature of the pressure ulcer and the absence of a wound specialist for assessment. The physician had not assessed the wound since its discovery, highlighting a gap in monitoring and treatment oversight. Additionally, discrepancies in treatment documentation and missed treatments in the Treatment Administration Record raise concerns about the consistency and effectiveness of care provided to Resident #69. The facility's policies on skin management and medication/treatment orders emphasize the importance of proactive skin assessments, timely treatment orders, and consistent documentation. However, the report indicates lapses in adherence to these policies, as evidenced by missing treatment documentation, delayed physician assessment, and incomplete skin worksheets.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food products were properly labeled with an opened and/or use by date and dispose of expired food items. During an initial tour of the kitchen, it was observed that multiple food items, including milk, juice, mustard, and pickles, were not labeled with appropriate dates. Additionally, there were instances of expired food items such as instant coffee and cocoa powder. The Dietary Manager confirmed that these items should have been labeled and dated correctly. The facility also failed to monitor and document temperatures of a refrigerated unit consistently. The temperature logs for the dairy cooler showed multiple entries with dashes instead of recorded temperatures, indicating that the temperatures were not being properly monitored. The Dietary Manager acknowledged that staff should be recording the actual temperatures rather than using dashes. Furthermore, the facility did not maintain sanitary conditions in the kitchen. Observations included dirty knives, oily muffin tins, wet and dirty metal trays, a dirty meat slicer, and a juice machine with sticky residue. Additionally, personal staff items were found in the tray prep area, and several pieces of cooking equipment were found to be wet and improperly stored. The Dietary Manager confirmed that these items should have been cleaned and stored correctly to prevent potential contamination and foodborne illness.
Deficiencies in Timely Care and Resident Dignity
Penalty
Summary
The facility failed to ensure timely care and services to maintain dignity for multiple residents, resulting in long call light response times, delays in fulfilling resident requests, lack of nail care, limited access to the dining room during meal times, lack of personal grooming, and call lights being out of reach. Residents reported waiting for extended periods, sometimes up to three hours, for staff to respond to call lights and fulfill requests. Specific instances included residents waiting for cups of ice, medications, and assistance with personal hygiene. Observations confirmed that call lights were often out of reach, and residents expressed frustration with the delays and lack of timely care. Several residents were observed with unmet personal grooming needs, such as long fingernails and unshaven beards. For example, one resident's wife and daughter had been shaving him because the facility staff did not provide this care. Another resident expressed discomfort with long fingernails and stated that staff had not offered to trim them. The facility's policies on call light use and nail care were not consistently followed, leading to residents feeling neglected and undignified. The Resident Council Meeting Minutes also highlighted ongoing issues with call light response times, late medication administration, and residents not receiving care during the night. Additionally, residents reported that their food preferences were not honored, and meals were often delivered cold when served in their rooms. The dining room was not open for breakfast, and residents who arrived late for lunch or dinner were told they had to eat in their rooms. These deficiencies indicate a systemic problem with the facility's ability to provide timely and respectful care to its residents.
Failure to Ensure Mail Delivery on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, which resulted in residents not being able to exercise their right to receive mail and access communication. During an interview with a group of residents, it was revealed that they did not receive mail on Saturdays because the mail lady had weekends off. The Activity Director and Activities Aide both confirmed that they did not recall mail being delivered on weekends, and the Front Desk Receptionist was unsure if mail was actually being delivered on Saturdays. The Administrator was also unaware if the residents were receiving mail on Saturdays. A review of the facility's policy titled 'Mail and Electronic Communication' indicated that residents should receive mail within twenty-four hours of delivery, including Saturdays. Additionally, the 'Rights of Residents in Michigan Nursing Facilities' document stated that residents have the right to send and receive mail. The facility's failure to ensure mail delivery on Saturdays was a clear violation of these policies and residents' rights.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure that resident rooms and equipment were clean and in good repair, leading to an unsanitary environment. Observations revealed that the Sit-to-Stand mechanical lifts in the 100 and 200-unit hallways had whitish/yellowish debris on the pads and base, where residents' legs and feet would rest. Additionally, resident rooms and shared bathrooms were found to be unclean and in disrepair. For instance, a bathroom shared by rooms 101 and 103 had unlabeled basins and a bedpan on the floor, while room 101-1 had a soiled brief, wipes, and washcloths on the floor. The CNA and DON acknowledged the debris but indicated it should not have been left from the night shift. Other rooms, such as 208, had chipped floor tiles and scrapes on the walls, and the bathroom shared by rooms 204 and 206 was very soiled with plumbing pipe pieces in the basins. The facility's Infection Prevention and Control program was reviewed, and it was noted that the Maintenance Director had recently resigned, leaving the interim Maintenance Director unavailable for an interview. The report highlights that the facility did not adhere to the residents' rights to live in a clean and safe environment, as outlined by the Michigan Long Term Care Ombudsman Program. The lack of proper labeling and storage of personal items, as well as the general uncleanliness and disrepair of the facility, contributed to the unsanitary conditions observed by the surveyors.
Failure to Properly Dispose of Medications and Secure Treatment Carts
Penalty
Summary
The facility failed to properly dispose of wasted medications and secure treatment carts containing prescription treatment medications and medical supplies. On multiple occasions, treatment carts were observed unattended with drawers partially open, allowing access to medications and supplies. Specifically, on the 200 Hall Unit, a treatment cart was found with a drawer that was not fully closed, leaving it accessible despite being locked. Similarly, on the 400 Hall Unit, a treatment cart was observed with a partially open drawer containing wound treatment supplies. Nurses acknowledged that the carts should have been locked and secured properly. Additionally, during medication administration, a nurse was observed discarding medications, including Metformin and a Tums tablet, into a garbage container attached to the medication cart. The garbage container did not have a lid, making the discarded medications accessible to residents. The nurse left the medication cart unattended in the hallway while retrieving backup medications, during which time a resident in a wheelchair was observed near the cart. The Director of Nursing confirmed that medications should not be disposed of in the garbage and that the facility's policy requires medication carts to be kept closed and locked when out of sight of the administering nurse or aide.
Failure to Maintain and Report Employee Infection Surveillance
Penalty
Summary
The facility failed to ensure ongoing surveillance of infectious illnesses for employees was maintained, documented, analyzed, and reported. During a review of the Infection Prevention and Control Program, the Infection Preventionist (IP) acknowledged that while he reviewed employee call-in logs for illnesses during morning Interdisciplinary Team Meetings, he did not document or analyze this data for trends or compare it with resident infections. The IP only collected ongoing data for employee COVID-19 infections and did not report employee illness information at the Infection Control Committee meetings, despite the facility's policy requiring such surveillance and reporting. A review of the facility's monthly infection surveillance line listings and summary reports from August 2023 to March 2024 revealed no surveillance data for employee illnesses, although resident infection data was documented. The facility's policy on Infection Prevention and Control Program emphasized the importance of tracking both employee and resident infections and using this data to oversee infections and spot trends. However, the IP admitted to not monitoring, analyzing, or reporting infection surveillance for employees, which is a deviation from the facility's established policies and procedures.
Failure to Update Care Plan for Resident with Hygiene Issues
Penalty
Summary
The facility failed to review and revise care plans with resident changes to ensure necessary interventions for care and services were provided for Resident #45. During a tour, it was observed that Resident #45 had poor personal hygiene, with soiled clothes and bed linens, and an unwashed appearance. Interviews with staff revealed that the resident often refused help with personal care and preferred to perform hygiene tasks privately in his room. Despite these observations, the care plan did not reflect specific interventions that staff described, such as setting up supplies for the resident to use in his room or encouraging visits to the facility salon, which the resident seemed to respond positively to. The care plan for Resident #45 contained generic and sometimes contradictory interventions. It repeatedly noted the resident's aversion to water but did not include alternative interventions like waterless bathing and hair washing products. The care plan also failed to address the impact of the resident's hygiene habits on his roommate. Staff interviews indicated that the resident had a history of living alone without running water and had neighbors who complained about his hygiene. Despite this background, the care plan lacked specific, personalized strategies to manage his hygiene needs effectively. The facility's policy on comprehensive, person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the care plan for Resident #45 did not align with this policy, as it did not build on the resident's strengths or reflect recognized standards of practice. The interdisciplinary team did not update the care plan to include effective interventions, resulting in unmet care needs for the resident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered per the physician's order for two residents, resulting in multiple medication administrations not being documented in the Electronic Health Record (EHR) and improper administration of a lidocaine patch. Resident #53 had several instances where medications, including daptomycin, donepezil, mirtazapine, atorvastatin, amlodipine, calcitonin, losartan, and senna, were not signed out on the Medication Administration Record (MAR). There was no documentation of refusal or a reason for not administering these medications. The Director of Nursing (DON) acknowledged the omissions but did not provide an explanation for why they occurred. Resident #237 had an order for a Lidocaine Pain Relief 4% patch to be applied to the back every morning and removed at bedtime. During a medication administration observation, it was found that the nurse did not remove the old patch before applying a new one. The nurse admitted that the old patch should have been removed. These deficiencies indicate a failure to follow proper medication administration protocols, potentially leading to adverse reactions and skin irritation for the residents involved.
Failure to Ensure Proper Communication and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in ineffective collaboration between the facility and hospice service. The resident, who had diagnoses including chronic obstructive pulmonary disease, depression, anxiety, and dependence on supplemental oxygen, was under hospice care but was unaware of the hospice schedule and did not have a calendar to refer to. The hospice binder contained outdated information, and there was a lack of documentation of hospice nursing assessments in the resident's medical record. During an interview, the Director of Nursing (DON) acknowledged the absence of an up-to-date calendar and the lack of documentation in the medical record. The DON confirmed that hospice notes, assessments, and all related documentation should be included in the resident's medical record. The deficiency resulted in the potential for unmet care needs due to the lack of proper communication and documentation of hospice services.
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 280 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Flint
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kith Haven | 5.4 mi | ★★★★★ | 15 | 0 |
| Regency At Grand Blanc | 7.1 mi | ★★★★★ | 3 | 0 |
| Villa At Beecher Place | 7.4 mi | ★★★★★ | 13 | 1 |
| Willowbrook Manor | 7.4 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Grand Blanc | 8 mi | ★★★★★ | 22 | 0 |
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 July 2026) and official state health department websites.