Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brittany Manor during CMS and state inspections, most recent first.
Failure to administer medications according to orders and standards of practice affected two residents. One resident had an order for PRN midodrine for hypotension, but blood pressure readings showed no midodrine was given. Another resident with DM and chronic pain had ordered insulin, a Lidocaine patch, and PRN Biofreeze; however, the RN checked blood sugar without gloves or hand hygiene, gave insulin after breakfast in the hallway without privacy, and the resident reported the pain patch was not applied and pain remained severe.
Infection control and water management deficiencies were identified when an RN prepared a resident's oral meds by placing stock and prescription meds into bare hands before putting them into a med cup and administering them, despite facility policy requiring hand hygiene and no hand contact with meds or the cup. The RN said this was his usual practice, and the UM stated it was not consistent with policy or standard practice. The facility also had no documented water management team meeting, risk assessment, or review for the current year, and the spa tub was not on the flushing schedule.
Failure to Provide Dignified Incontinence Care: A cognitively intact resident with CHF, muscle wasting, and a below-knee amputation reported waiting over an hour for toileting assistance and being found incontinent in bed, soaking through her brief, pad, and sheet. Records showed frequent incontinence and frequent need for moderate to complete help with personal hygiene, and the DON reported CNA call-offs left a 4-hour overnight staffing gap.
Delayed assessment of new skin concern: A CNA found a new wound on a resident’s right gluteal fold during incontinence care and said she would notify nursing, but the skin issue was not assessed that day and no EHR assessment was documented. The RN wound nurse later confirmed the concern had not been evaluated when first identified, then assessed it and started treatment; the wound was documented as MASD and physician orders were initiated. The DON stated nursing staff should immediately assess new skin concerns and begin a treatment plan.
Failure to follow wound clinic recommendations for two residents with pressure ulcers. One resident with dementia and muscle wasting had a heel wound, but the facility continued the existing xeroform order instead of the wound clinic’s Dakin, collagen, and xeroform dressing plan. Another resident with a sacral pressure ulcer had a VAC order without the wound clinic’s Prisma/collagen under black foam recommendation. The RN wound nurse said he was unaware of the recommendations, and the DON stated the recommendations were not being received or documented in the EMR.
Inadequate Catheter and Perineal Care: A cognitively intact resident with a urinary catheter, bowel incontinence, chronic interstitial cystitis, and acute cystitis reported staff did not clean around her catheter regularly. During observed catheter care, a CNA found stool in the resident’s vagina between the labia and cleaned it from the perineal area; the resident said staff “never clean down there,” and the unit manager stated stool should never be left on a resident’s skin.
Failure to properly assess and monitor a resident’s PICC line. A resident receiving IV abx for multiple infections and chronic foot/ankle wounds had inconsistent PICC measurements, unclear baseline documentation, and incomplete nursing notes. The MAR orders did not specify the expected catheter length or what to do if measurements changed, and staff documentation showed gaps in measurement and site assessment before the line was later found not flushing and partially dislodged.
A resident with vaginal itching was ordered miconazole cream for two weeks, but the MAR and eMAR showed multiple missed doses, blank entries, and medication-not-available notes. The record did not show physician notification, resident refusal, or reassessment for ongoing symptoms, and the DON confirmed the antifungal was not given as ordered and the course was not adjusted once the medication became available.
Failure to document pneumococcal vaccine education and refusals for two residents. One resident with DM and vascular dementia had no current or historical PCV20/PCV21 documentation, and the only note said the resident was confused and waiting on the DPOA; no further evidence showed education, consent, or declination. Another resident with renal insufficiency and pulmonary conditions refused the vaccine, had no education documented, and there was no later record of re-offering or annual re-evaluation as required by policy.
Two residents experienced significant changes in condition that were not comprehensively assessed or promptly communicated to providers, resulting in delayed treatment and hospitalization. One resident with CHF and COPD had substantial weight gain and repeated low SpO2 readings without required notification to the heart failure clinic or facility provider, and later had an acute desaturation episode where staff applied O2 but did not complete focused cardiac/respiratory assessments or timely notify the provider; diagnostic tests were initiated under a sepsis protocol without clear provider direction, and the provider was initially sent results without an explanation of symptoms. Another resident with severe malnutrition and advanced sacral/coccygeal pressure injuries had documented wound deterioration with foul odor, heavy exudate, and concerning culture preliminaries showing multiple organisms, yet no sepsis protocol was initiated, no additional labs or diagnostics were ordered, and no provider assessment or risk–benefit analysis for empiric antibiotics was documented; declining intake with oral thrush and a later abnormal skin assessment suggesting possible dehydration were also not followed by documented comprehensive assessment or physician notification. These actions and omissions conflicted with facility policies requiring early recognition, thorough assessment, timely practitioner notification, and accurate documentation of significant status changes.
The facility failed to maintain a complete and accurate EMR for a resident involved in an altercation with another cognitively impaired resident. After staff heard a noise and found one resident on the floor with a bloody nose and another resident nearby with a balled fist, both making threatening statements, an incident form documented that the injured resident reported being struck. However, the alleged aggressor’s EMR contained no progress notes or entries about his involvement in the incident, despite staff interviews indicating that such events should be documented, including assessments, vitals, and communication with the NHA and physician.
A CNA physically abused two residents with dementia, including shoving one resident and forcefully propelling another into a wall, resulting in a head injury and large hematoma that required emergency medical care and hospitalization. The incidents were captured on video and occurred without intervention from other staff.
Two residents, both with dementia, were involved in an incident where one struck the other. Although staff witnessed and reported the event internally, the DON delayed notifying the state agency, submitting the required report outside the mandated 2-hour window due to a misunderstanding of reporting requirements.
The facility failed to document and administer controlled substances accurately for four residents, leading to medication errors. A resident with anxiety disorder had discrepancies in diazepam administration, while another had Ativan dispensed without documentation. A third resident had Ativan dispensed without an order, and a fourth had discrepancies in Norco administration. These errors were confirmed by the DON.
The facility failed to maintain accurate medical records and ensure proper communication with residents and their families. A resident's vital signs and full physical assessment were not documented after a change in condition. Another resident's Medicare Non-Coverage notice was not properly documented. Additionally, the facility did not document guardian or DPOA consent for medication changes for three residents, nor did they provide education on the risks and benefits of these changes.
Two residents experienced deficiencies in care at the facility. A resident with multiple health issues faced a 44-minute delay in receiving assistance after activating his call light, causing frustration. Another resident, requiring assistance with eating, experienced delayed meal service and reported cold food, which staff refused to reheat. Additionally, this resident faced discomfort due to prolonged waits to return to her room after meals. The facility's policies on call light response and meal service were not followed.
The facility failed to serve meals at a palatable and safe temperature for three residents. One resident experienced delays and cold meals despite needing assistance, another reported consistently cold food and coffee, and a third resorted to external services for hot coffee. Observations confirmed suboptimal meal temperatures, and staff were reminded to maintain insulated cart doors closed during delivery.
A resident with a history of falls and dementia experienced a fall in the bathroom, resulting in significant pain and inability to move. Despite these symptoms, the facility delayed transferring the resident to the hospital for evaluation and treatment. An X-ray was ordered but not completed promptly, and there was no documentation of physician notification about the delay. The resident was eventually diagnosed with multiple fractures requiring immediate surgical intervention.
A resident with a history of falls and cognitive impairment was not transferred according to her care plan, resulting in a preventable fall. The CNA failed to use a gait belt and rolling walker, and the bed's mechanical issues contributed to the incident. The resident sustained facial injuries requiring hospital treatment.
Failure to Administer Medications and Provide Ordered Pain Care
Penalty
Summary
The facility failed to provide medication according to professional standards of practice for two residents. One resident had an active physician order for midodrine 10 mg by mouth every 8 hours as needed for hypotension when systolic blood pressure was less than 100, but the blood pressure summary and MAR showed blood pressure readings with no midodrine administered. The record also included a facility medication administration policy stating that medications are administered in accordance with written orders of the attending physician. A second resident with diabetes mellitus and chronic pain syndrome had orders for Humalog sliding scale insulin before meals after a fasting blood sugar at 7:00 AM, Lantus 15 units daily, a Lidocaine 4% patch to the upper right arm daily, and Biofreeze as needed. During observation, the resident requested the Lidocaine patch for right upper arm pain, but the RN reported no patch was available. The RN checked the resident's blood sugar without gloves or hand hygiene, administered insulin after the resident had already eaten breakfast, and gave the injections in the hallway while exposing the resident's abdomen. The resident later reported the patch was not applied and rated the pain as 8 out of 10. The MAR showed the Lidocaine patch as administered, but there was no documentation that Biofreeze was applied, and the progress notes did not reflect the resident's pain complaint or any provider communication about the patch.
Infection Control and Water Management Deficiencies
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because staff did not follow standard infection control practices during medication administration for one resident and the facility did not have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. R24 was admitted to the facility on 8/27/2025 with diagnoses that included congestive heart failure and received daily medications from facility staff. The facility policy for medication administration required hand hygiene prior to medication preparation and directed staff to place medications into a cup without touching the inside of the cup, and to discard medications that came into contact with bare hands. During observation on 5/13/2026, RN L was seen preparing R24's oral medications by placing stock and prescription medications into his bare hands before putting them into a medication cup. Aspirin 81 mg was poured into the nurse's bare hand, one tablet was selected, the unneeded tablets were poured back into the stock container, and the selected tablet was placed into the cup by hand; the same method was used with stock magnesium oxide 400 mg and vitamin D3 capsules. Other medications, including pyridostigmine bromide 60 mg, Lyrica 100 mg, linaclotide 72 mcg, and Lexapro 5 mg, were also directly deposited into the nurse's bare hand before being placed in the medication cup and administered to R24. RN L stated this was usually what he did, and RN UM C stated the method was not consistent with facility policy or standards of practice. For the water management component, review of the water management plan found no documentation of a water management team meeting, risk assessment, or review of policy or assessment for 2025 or 2026. The maintenance director could not locate the requested meeting minutes, agenda, or completed risk assessment forms for 2025, stated the former maintenance director had not left the documentation, and the NHA indicated the water management team meeting and risk assessment had not been completed for the current year.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
The facility failed to ensure dignified care was provided for one resident, R72, who was cognitively intact with a BIMS score of 15 out of 15. R72 was admitted with diagnoses including absence of the right leg below-knee amputation, chronic congestive heart failure, and muscle wasting and atrophy. During an interview, R72 stated that she waited for assistance to the bathroom for over an hour early in the morning until a CNA came in at 2:00 a.m., and by then she had been incontinent in bed, soaking through her brief, pad, and sheet and requiring a total bed change. R72 said the situation made her feel embarrassed and reported that the same occurrence happened at least weekly. Record review showed that from 4/29/26 through 5/11/26, R72 was incontinent 20 times out of 25 documented continence checks. The same record review showed that personal hygiene assistance was documented as moderate to complete assistance 22 times out of 26 times assistance was recorded. The DON stated that on Sunday the facility had three CNA call-offs for the evening shift, and all shifts were covered except for a four-hour period from 10:00 p.m. to 2:00 a.m. The facility's Resident Dignity & Personal Privacy procedure stated that the facility provides care in a manner that respects and enhances each resident's dignity and that staff carry out activities that assist the resident in maintaining and enhancing self-esteem and self-worth.
Delayed assessment of new skin concern
Penalty
Summary
The facility failed to promptly assess and treat a new skin concern for one resident who was admitted with diagnoses including dementia and chronic respiratory failure. During incontinence care, a CNA identified a new wound on the resident’s right gluteal fold and said she would notify nursing staff, but the resident’s electronic medical record showed no assessment of the new skin condition later that day. The RN wound nurse later reported he had not been notified of the wound when it was first identified and confirmed that nursing staff had not assessed it on the day it was found. After the unreported wound was brought to his attention, the RN wound nurse assessed the area and initiated a treatment plan. The skin check note documented a new skin issue on the right gluteal fold as moisture associated skin damage, acquired in house, and physician orders were started for cleansing the area and applying barrier cream every shift. The CNA reported she had told an RN about the skin concern when it was found, but that RN stated she had not been notified and would have contacted the medical provider and initiated a treatment plan if she had been informed. The DON stated nursing staff should immediately assess new skin concerns and initiate a treatment plan, and the facility policy required CNAs to report new skin impairment to the licensed nurse and for the licensed nurse to document the skin impairment in the EHR.
Failure to Follow Wound Clinic Recommendations for Pressure Ulcers
Penalty
Summary
The facility failed to follow up with wound clinic recommendations for two residents with pressure ulcers. One resident was admitted with dementia and muscle wasting and had a right heel wound. The physician’s order in the facility chart directed cleansing the wound and applying xeroform, but the community wound clinic recommended cleansing with Dakin 0.125%, applying Triple Helix Collagen Dressing, and using xeroform petrolatum gauze as the secondary dressing. The electronic medical record showed no indication that these wound clinic recommendations were reviewed or started by facility staff. During an observation, the right heel dressing change was seen, and the RN wound nurse stated the current order was still xeroform and that he was not aware of the wound clinic recommendations. A second resident was admitted with a sacral pressure ulcer and muscle wasting. The community wound clinic recommended placing a pad of Prisma, or equivalent collagen, in the center of the wound bed and then black foam for the VAC dressing. The electronic medical record showed no indication that these recommendations were reviewed or initiated by facility staff, and the physician’s order only directed black foam/wound vac to the wound bed without collagen under the foam. The RN wound nurse stated he was not aware of the wound clinic recommendations and said they should have been reviewed when received and discussed by the clinical team and medical provider. The DON stated she did not believe clinical staff were receiving wound clinic recommendations from medical records staff when faxed to the facility, and also stated the recommendations should be addressed in real time and documented in the EMR.
Inadequate Catheter and Perineal Care
Penalty
Summary
Appropriate urinary catheter care was not provided for a resident who was admitted with chronic interstitial cystitis and acute cystitis and who was cognitively intact with a BIMS score of 15. The resident’s care plans identified her as incontinent of bowel and at risk for urinary tract infection, with instructions for staff to check for incontinence, cleanse the perineum front to back, and provide catheter care per policy. The resident reported that staff did not clean around her urinary catheter regularly and stated, “They never clean down there.” During an observation of catheter care, a CNA cleaned around the resident’s urinary catheter and found stool in the resident’s vagina between the labia while performing perineal care. Stool was visible on the washcloth as the CNA cleaned the area, and the CNA stated the stool should not have been there and should have been cleaned the last time the resident had a bowel movement. The resident was unsure when her last bowel movement occurred and reported that the burning sensation improved after the area was cleaned. The unit manager stated that stool should never be left on a resident’s skin. The facility policy for catheter-associated urinary tract infection prevention directed staff to clean around the catheter insertion site daily with soap and water.
Failure to properly assess and monitor PICC line
Penalty
Summary
The facility failed to ensure appropriate assessments and monitoring were implemented for a resident with a PICC line who was receiving IV antibiotics for MRSA infection, Shiga toxin-producing E. coli, Pseudomonas infection, chronic osteomyelitis with draining sinus of the left ankle and foot, and non-pressure chronic ulcers of the left ankle, heel, and midfoot. The resident’s PICC line was observed in place with a transparent dressing, and staff interviews showed differing understanding of how often the line should be measured and when dressing changes should occur. The DON stated the PICC should be measured weekly with dressing changes and that the baseline measurement should come from hospital or insertion records, but she could not determine the baseline measurement from the available insertion documentation. The resident’s MAR included orders to measure the PICC catheter length every 7 days and to change the transparent dressing every 7 days, but the orders did not specify the expected measurement or what action to take if the measurement differed from baseline. Nursing documentation showed inconsistent PICC measurements over time, including a note of 3 cm, later documentation of 12 cm, and a later measurement of 8.1 cm, with no recorded measurements between the new PICC insertion and the later documentation. One note also reflected a dressing change that was completed because the kit arrived, without documentation that the dressing was compromised or that the PICC site was measured at that time. The record further showed that on one date the resident’s medication was held due to loss of IV access, and the provider and cardiovascular team were notified, but the note did not include a PICC measurement or physical assessment of the site. A consultation form later documented that the PICC was not flushing and was partially dislodged, and that the resident required replacement of the line. The documentation also showed that after the original right upper extremity PICC was removed and a new PICC was inserted, the MAR did not reflect that the prior PICC orders had been discontinued or updated to match the new line.
Missed antifungal doses and incomplete treatment course
Penalty
Summary
The facility failed to adhere to principles of antibiotic stewardship for one resident with a fungal infection. R24 was admitted with diagnoses including urinary tract infection, sepsis, severe obesity, and type 2 diabetes. A late entry NP note documented that R24 was seen for itching to the labia, with no redness, discharge, or burning with urination, and the NP ordered Miconazole 2% cream twice daily for two weeks for vaginal itching. The medication was not administered as ordered on multiple dates during the prescribed course. The MAR showed several missed doses, including doses marked as held or left blank, and eMAR notes indicated the medication was on order, not available, or awaiting pharmacy delivery. For some missed administrations, there was no eMAR progress note explaining why the medication was not given. Review of the available progress notes did not show that the physician was notified of the medication unavailability, and there was no documentation that R24 refused the medication or was unavailable. The record also did not show assessment for ongoing vaginal itching, discomfort, or worsening symptoms despite the missed and incomplete treatment. During interview, the DON confirmed the medication was not given as ordered and stated she did not know whether the medication was house stock or required pharmacy delivery; she also could not explain the sporadic administration and said the order should have been modified once the medication became available, which was not done.
Failure to Document Pneumococcal Vaccine Education and Refusals
Penalty
Summary
The facility failed to offer and maintain documentation of pneumococcal immunizations and related education for two residents reviewed. The facility policy titled "Immunizations: Pneumococcal Vaccinations (PPV) of Residents" stated that each resident's pneumococcal immunization status would be determined on admission or soon afterward, undocumented or unknown status would be offered the vaccine, informed consent would be obtained before vaccination, and refusals would be documented and re-evaluated annually. One resident was admitted with diabetes mellitus and vascular dementia and was severely cognitively impaired on the MDS. The EMR showed a POA for medical and financial decisions, but there was no current or historical documentation for PCV20 or PCV21, and the only pneumococcal note stated the resident was confused and waiting on the DPOA. No further documentation showed that the vaccination status was revisited with the responsible party, education was provided, or consent or declination was obtained. A second resident, who was cognitively intact and had renal insufficiency and pulmonary conditions, refused the pneumococcal vaccine and had no education documented at that time. The record contained no later documentation that the resident was offered the vaccine again or that education on the risks or benefits was provided, despite the facility policy calling for annual re-evaluation of refusals.
Failure to Assess and Notify Provider for Changes in Condition Leading to Delayed Treatment
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive nursing assessments and to identify and notify providers of significant changes in condition for two residents, resulting in delayed treatment, worsening symptoms, and hospitalization. One resident with CHF and COPD had standing orders for daily weights with specific parameters to notify the heart failure clinic for weight gains over 2 lbs in one day or 5 lbs in one week, and an order to apply O2 at 2 L/min if SpO2 fell below 90%. Over the course of a week, this resident’s weight increased by 8.1 lbs, and oxygen saturations were documented as low as 85% and 74% on room air on separate days, yet there was no documentation that the facility provider or heart failure clinic were notified as ordered. On another night, the resident’s SpO2 dropped to 84% on room air with tachycardia and elevated BP, and the nurse applied 3 L/min O2, documented the resident as DNR and on palliative care, and notified palliative care and the family, but did not complete a focused cardiac or respiratory assessment or notify the facility provider at the time of the change in condition. Subsequently, the DON initiated the facility’s sepsis protocol, which generated orders for labs and a chest x‑ray without a direct provider order, and these tests revealed a pleural effusion. The facility faxed lab and x‑ray results to the provider with a note indicating they were sent at the daughter’s request, and the provider initially responded that there were no new orders and asked if there was a special concern, indicating the provider had not been informed of the resident’s respiratory symptoms or the reason for the testing. Only later did the nurse fax additional information describing the low overnight SaO2, diaphoresis, lethargy, and the DON’s request for diagnostics, after which the provider ordered IM Lasix and monitoring of oxygen levels with instructions to notify if SpO2 dropped below 90%. Despite this, oxygen saturation was not reassessed again until the following morning, and there was no documentation of any comprehensive or focused respiratory or cardiac assessments from symptom onset through the arrival of EMS, nor any documentation of the resident’s condition, the timing, or rationale for transfer to the hospital. The second resident had diagnoses including adult failure to thrive, severe protein‑calorie malnutrition, and pressure injuries to the sacrum and coccyx, with care plans addressing dehydration risk and impaired skin integrity. A wound assessment documented an unstageable sacral pressure injury that was deteriorating, with heavy exudate, strong odor after cleansing, significant slough, tunneling and undermining, maceration, erythema, warm periwound, and saturated dressings, and a stage 4 coccygeal ulcer with moderate exudate and maceration. A provider communication requested a wound culture due to foul odor and copious drainage, and an order was obtained for culture and sensitivity. The culture, collected the next day, produced preliminary results over several days showing many gram‑negative rods, many gram‑positive rods, moderate gram‑negative cocci, and moderate WBCs, but the facility did not initiate its sepsis protocol order set, and the DON reported that the provider did not review preliminary culture results and only reviewed the final result, which was printed after the resident’s transfer to the hospital. For this resident, there was no documentation that the facility provider assessed the resident after the wound deterioration was identified, and no additional labs or diagnostics were ordered to rule out systemic infection despite documentation of foul odor, non‑healing, deterioration, and copious exudate. There was no documented risk‑versus‑benefit assessment regarding empiric antibiotics, even though preliminary culture data and prophylactic Bactrim use were present. A dietary note identified declining intake associated with oral thrush, but the record contained no documentation of interventions to promote fluid intake. A skin check later documented that baseline skin findings of warm, dry skin with normal color and turgor were “not met,” indicating a change in baseline and potential dehydration, yet there was no documentation of a comprehensive assessment or physician notification of this change. The resident was ultimately transferred to the ED at the daughter/POA’s request for further evaluation of possible wound‑related pain, with nursing documentation stating that vital signs were within normal limits and no acute changes were noted, while EMS and ED records later described hypotension, low O2 saturation, dry mucous membranes, skin tenting, toxic appearance, malodorous sacral/coccygeal ulcer, and concern for sepsis secondary to soft tissue infection. The facility’s own policies on change in status and notification of change require nurses to recognize and assess changes from baseline, obtain vital signs, review the record, observe overall condition and function, explore complaints, and promptly notify the practitioner and resident representative of significant changes or the need to significantly alter treatment, with accurate and timely documentation. The cited cases show that, despite these policies, the facility did not consistently perform comprehensive assessments, did not timely notify the attending practitioner of significant changes in condition, did not fully communicate the clinical context and symptoms when sending diagnostic results, and did not document assessments and decision‑making around changes in status and transfers. These failures led to delays in treatment, worsening of symptoms, and hospitalization for both residents.
Failure to Document Resident-on-Resident Altercation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident involved in an altercation with another resident. One resident with encephalopathy, anxiety, dementia, and a history of repeated falls was found on the floor of his room with blood coming from his nose after staff near the nurse’s station heard a banging noise. This resident’s MDS showed a BIMS score of 6, indicating severe cognitive impairment. Another resident, whose admission record listed dementia and anxiety and whose MDS showed a BIMS score of 7 (also indicating severe cognitive impairment), was observed standing nearby with his left fist balled up. Both residents were making threatening statements to each other when staff intervened. According to the Incident and Accident Investigation Form, the injured resident stated that the other resident had walked up and struck him, causing him to fall to the floor. The resident alleged to have struck him did not recall the incident when interviewed shortly after it occurred. Despite this documented incident between the two cognitively impaired residents, a review of the alleged aggressor’s EMR for the period surrounding the event did not contain any mention that he had been involved in an incident with another resident. Interviews with facility staff confirmed that the lack of documentation in the alleged aggressor’s medical record was inconsistent with expected practice. The nurse manager stated that any incident between residents, even if unwitnessed, should be documented in a progress note as basic nursing practice. An LPN stated that in such situations she would ensure resident safety, perform skin assessments, treat any wounds, contact the NHA and physician, obtain vital signs, and document the incident in a progress note. The NHA later acknowledged that there was no documentation in the alleged aggressor’s medical record regarding the incident and explained that only the injured resident had been monitored, and that an internal risk management form had been completed but was not part of the medical record.
Failure to Protect Residents from Physical Abuse by Staff
Penalty
Summary
A staff member, specifically a Certified Nurse Aide (CNA), physically abused two residents with dementia. One resident, a female who was independent with mobility and self-feeding, reported that staff had previously shoved her, which made her angry. On the incident date, video and audio footage showed the CNA shoving a male resident in the hallway, causing him to stumble. The CNA then entered a room where the female resident was present. Shortly after, the female resident was seen being propelled across the hallway, hitting the back of her head on the wall, resulting in a loud thud. The female resident sustained an open, bleeding cut to the back of her head that required sutures and developed a large hematoma on her buttock, necessitating emergency medical attention and hospital admission for monitoring. The CNA's actions were not accompanied by any verbal instruction or calls for help, and no other staff were present in the immediate area during the incident. The facility's failure to protect these residents from physical abuse by a staff member resulted in significant injury and the need for hospitalization.
Failure to Timely Report Abuse Incident as Required by Policy
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of a reasonable suspicion of a crime, specifically regarding an incident of abuse between two residents. One resident with dementia and Parkinson's disease struck another resident, who also had dementia and encephalopathy, in the activity room. This event was witnessed by staff and reported to the DON on the same day. However, the required 2-hour notification to the state agency was not submitted until the following morning, exceeding the mandated reporting timeframe. The DON stated in an interview that she believed the facility had 24 hours to report abuse incidents to the state unless the incident caused serious injury, which led to the delay in reporting. Facility policy, however, required that all abuse allegations be reported to the state agency within 2 hours. The deficiency was identified during a complaint investigation and was based on the facility's failure to follow its own abuse reporting policy and federal requirements.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to accurately document the administration of controlled substances and ensure narcotic medications were administered according to physician orders for four residents. Resident #23, a male with generalized anxiety disorder, had discrepancies in the administration of diazepam, with a dose documented as administered but not dispensed according to the Controlled Substance Proof of Use form. Similarly, Resident #74, diagnosed with anxiety disorder, had doses of Ativan dispensed but not documented as administered on multiple occasions. Resident #84, also with anxiety disorder, had Ativan dispensed without corresponding documentation of administration, and there was no order for Ativan on one of the dates it was dispensed. Resident #10, with diabetic neuropathy, had a discrepancy between the dispensed and documented administration of Norco. These discrepancies were confirmed by the Director of Nursing during an interview, highlighting medication errors in the facility's handling of controlled substances.
Deficiencies in Medical Record Documentation and Communication
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation and communication. For Resident #88, the medical record lacked documentation of vital signs and a full physical assessment after a change in condition was noted. The Licensed Practical Nurse (LPN) on duty did not document the vital signs or the decision not to send the resident to the hospital, as per the family's wishes. Additionally, there was no documentation indicating that the resident's daughter was informed of the change in condition and the new order for a chest x-ray. For Resident #69, the facility did not provide adequate documentation regarding the Notification of Medicare Non-Coverage. The notice was signed by the resident's wife, but there was no progress note or administrative note indicating that the resident himself was informed or had signed the notice. This lack of documentation raises concerns about whether the resident was properly informed of the changes in coverage. Residents #2, #73, and #76 experienced deficiencies related to the documentation of medication changes. The facility failed to document the involvement and consent of guardians or Durable Power of Attorneys (DPOAs) in the Gradual Dose Reduction (GDR) of psychotropic medications. There was no evidence that the guardians or DPOAs were educated on the risks and benefits of the medication changes, nor was there documentation of their consent. This lack of documentation indicates a failure to ensure that all necessary parties were informed and involved in the decision-making process regarding medication management.
Deficiencies in Resident Care and Meal Service
Penalty
Summary
The facility failed to provide dignified care and services for two residents, R10 and R34, as observed during a survey. Resident R10, a male with a tracheostomy, diabetes, kidney disease, and heart disease, was moderately cognitively impaired and required assistance with transfers using a mechanical lift. On the morning of 03/26/25, R10 activated his call light to request assistance to get out of bed and into his wheelchair. Despite his call light being turned off by staff multiple times without his needs being met, R10 experienced a delay of 44 minutes before receiving assistance, causing him visible frustration. Resident R34, who was mildly cognitively impaired and required substantial assistance with eating, experienced delays in meal service. During lunch on 3/25/25, R34 was the last to receive her meal, which was not set up for her to eat independently. She reported that her food was often cold and that staff refused to reheat it. Additionally, R34 experienced discomfort due to an extended wait to return to her room after meals, which exacerbated a sore on her bottom. The facility's policies on call light response and meal service were not adhered to, as evidenced by the delayed response to R10's call light and the delayed meal service for R34. The Nursing Home Administrator and North Unit Manager were informed of these deficiencies, but no additional information or comments were provided by the staff regarding the incidents.
Deficiency in Serving Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to ensure that food and beverages were served at a palatable and safe temperature for three residents. Resident 34, who requires substantial assistance with eating, experienced delays in receiving her meal and reported that her food was often not hot enough. Despite requesting reheating, staff reportedly did not comply. Observations confirmed that Resident 34's meal service was delayed, and she was left without beverages initially. Resident 59, who has diagnoses of protein-calorie malnutrition and muscle wasting atrophy, reported that the food and coffee were consistently cold, both in the dining room and when served in her room. Despite acknowledging the staff's busyness, Resident 59 noted that the temperature of her meals was not satisfactory. The North Unit Manager was informed of these issues but did not provide additional comments or solutions. Resident 41, who suffers from paraplegia and moderate to severe protein-calorie malnutrition, expressed dissatisfaction with the temperature of the meals and coffee, resorting to external delivery services for hot coffee. During an observation, the meal tray intended for Resident 41 was found to have food and coffee at suboptimal temperatures. The Dietary Manager confirmed that the temperature loss occurred during the delivery process, and staff were reminded to keep insulated cart doors closed to maintain temperatures. After the surveyor's intervention, Resident 41 received a fresh meal tray, which was reported to be satisfactory.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to promptly identify and act upon a change in condition for a resident, resulting in unnecessary pain and a delay in evaluation and surgical intervention for a femur fracture. The resident, a male with a history of difficulty walking, muscle wasting, and dementia, experienced a fall in the bathroom. Despite reporting significant pain and being unable to move, the resident was not transferred to the hospital until two days later. The incident report and subsequent documentation revealed that the resident was confused and unable to bear weight on his right leg following the fall. Although an X-ray was ordered, it was not completed in a timely manner, and there was no documentation of physician notification regarding the delay. The resident's pain was noted to be manageable at rest but aggravated by movement, yet comprehensive assessments of the pain and physical condition were lacking. Interviews with the resident and family members indicated a desire for earlier hospital evaluation, and the family expressed concern over the delay in treatment. The Director of Nursing confirmed that additional monitoring and assessments were not completed, and there was no rationale provided for the delay in obtaining the X-ray or notifying the physician. The resident was eventually transferred to the hospital, where multiple fractures were identified, necessitating immediate surgical intervention.
Failure to Follow Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was transferred according to care planned interventions and standards of practice, resulting in a preventable fall. The resident, an elderly female with a history of difficulty walking and muscle wasting, was moderately cognitively impaired and at high risk for falls. Despite these conditions, the resident was not transferred using a gait belt and rolling walker as specified in her care plan. During a transfer from the bathroom to her bed, the resident leaned to the right, and the CNA assisting her lost control, causing the resident to fall and sustain facial bruising and lacerations. The incident was further complicated by the mechanical issues with the resident's bed, which did not lock when in the lowest position, contributing to the fall. The CNA involved lacked the necessary understanding of the bed's mechanics and failed to ensure it was locked before attempting the transfer. The Director of Nursing confirmed that the CNA did not use a gait belt, which was a standard practice, and this oversight led to the resident's fall and subsequent injury. The facility's failure to adhere to the care plan and ensure proper equipment use directly resulted in the resident's accident.
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 214 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 Midland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stratford Pines Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 20 | 0 |
| Medilodge Of Midland | 5.2 mi | ★★★★★ | 3 | 0 |
| Carriage House Nursing And Rehabilitation | 11.5 mi | ★★★★★ | 12 | 0 |
| Huron Woods Nursing Center | 11.9 mi | ★★★★★ | 16 | 0 |
| Caretel Inns Of Tri-cities | 12.5 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.