Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burcham Hills Retirement Center during CMS and state inspections, most recent first.
A resident with CHF and other cardiac and respiratory diagnoses was admitted on diuretics with orders for weekly weights and care plan directions to monitor weight trends. Early weights showed a decrease, prompting an NP to request a reweight, but no follow-up weight was documented until nearly two weeks later, when a 33+ lb gain was recorded without provider notification. During this period, nursing documentation showed progression from no edema to 2+ pitting edema in both lower extremities, yet the onset was repeatedly marked as unknown and the NP’s subsequent visit note did not address the significant weight gain. Staff interviews revealed that nurses were not consistently reviewing weights, some were unaware of the CHF diagnosis and associated monitoring parameters, and requested reweights from both the NP and dietitian were not completed or documented. The resident and family later voiced concern about worsening tibial edema, and the resident ultimately experienced loss of consciousness and hypoxia, leading to hospitalization, with the NP documenting concern for worsening CHF and fluid overload.
A resident with hemiplegia and moderate cognitive impairment reported going days without showers and disliking the resulting odor, despite a documented preference for twice-weekly and PRN showers. Records showed the resident received only two bed baths over several weeks and did not receive a shower until weeks after admission, with no documented refusals. On one morning, therapy staff and an LPN found the resident saturated in urine, with clothing, linens, and the mattress soaked, and had to provide incontinence care. These events occurred despite a facility policy requiring appropriate assistance with hygiene and toileting for residents unable to perform ADLs independently.
A resident with left-sided hemiplegia, hemiparesis, and moderate cognitive impairment needed to have a bowel movement but could not locate the call light, which was sometimes placed on the resident’s weak side. The resident reported feeling around the bed with the functional arm but, unable to find the call light, attempted to get out of bed independently, slid to the floor, and fell. Documentation showed the resident was found on the floor beside the bed after calling out, had a bowel movement in bed, and was entangled in bedding and a PEG tube. A post-fall evaluation confirmed the call light was not activated, despite a care plan intervention requiring that the call light be kept within reach at all times, and an LPN later confirmed the resident could use the call light appropriately when it was accessible.
A resident with complex medical needs, including diabetes and a PEG tube for enteral feeding, did not consistently receive the prescribed amount of tube feeding due to pump malfunctions, inconsistent monitoring, and poor documentation. Staff failed to accurately record the volume of nutrition administered, leading to episodes of hypoglycemia and emergency interventions. Despite orders for regular checks and documentation, significant gaps and discrepancies persisted in the records.
Due to insufficient dietary staffing, several residents experienced significant delays in receiving their meals, with some waiting over an hour past scheduled meal times. Staff shortages led to the closure of a satellite kitchen, requiring meals to be served from other floors and further delaying service. Facility policies required adequate staffing for timely meal delivery, but these standards were not met, resulting in resident discomfort and dissatisfaction.
The facility did not ensure that food was served at safe and appetizing temperatures, as hot meal items were observed to be below the required temperature when delivered to a resident. Meals were transported in a non-insulated cart, and staff did not follow policies requiring inspection of food trays for temperature and palatability, affecting all residents who consume food products.
Surveyors found that food service equipment, including an ice machine and coffee maker, was not effectively cleaned and maintained, with visible residue and mineral deposits. Additionally, unopened milk with expired use-by dates was found in a kitchenette refrigerator, and not all potentially hazardous ready-to-eat foods were properly date marked according to facility policy. These deficiencies were confirmed through staff interviews and policy reviews.
Surveyors found that two outdoor waste receptacles had broken lids or panels, and miscellaneous debris including a wooden pallet, vinyl gloves, and paper products were left on the concrete pad near the dumpsters. Facility policy requires the area to be free of debris and for lids to be closed, but these standards were not met, affecting 105 residents.
Multiple residents and CNAs reported significant delays in receiving care due to inadequate nursing staff, with some shifts staffed by only one or two CNAs for entire units. Staff were also required to assist with meal service, further limiting their ability to provide direct care. As a result, essential care activities such as toileting, repositioning, and hygiene were not completed in accordance with residents' care plans.
An LPN failed to immediately report an allegation of resident-to-resident abuse to the NHA after receiving a call from a resident’s family member about a possible assault. The LPN did not observe injuries or receive a direct complaint from the resident and did not notify facility leadership. The NHA only became aware of the incident the following day, delaying the start of the investigation.
A resident with kidney failure and diabetes was transferred to the hospital, but the required discharge MDS assessment was not completed or transmitted within the mandated timeframe. Staff interviews confirmed that the responsibility for discharge MDS submissions was assigned to a specific nurse, and the assessment was overlooked.
A resident who was found unresponsive and transferred to a hospital, where they later died, was incorrectly coded on the discharge MDS as having gone home instead of being sent to an acute care hospital. MDS coordinators confirmed the error during interviews.
A resident requiring one-person assistance for bathing did not receive regular showers or baths, as evidenced by unkempt appearance and lack of documentation in the clinical record. The DON confirmed that showers should be offered twice weekly and refusals documented, but no records supported that hygiene care was provided or refused.
Two residents did not receive care as ordered, including missed doses of a prescribed diabetes medication and incomplete wound dressing changes. Documentation was lacking for the missed medication and wound care, and there was no evidence that the physician was notified or that required follow-up actions were taken by staff, contrary to facility policy.
A resident with a history of stroke and cognitive intactness was found with a cup containing six pills left unattended in their room. Although there was a physician order allowing staff to observe from a distance during medication administration, the DON confirmed the resident was not approved for self-administration. The nurse did not ensure the medications were taken as required, resulting in a failure to safely store and administer drugs according to facility policy.
The facility did not ensure that the Infection Preventionist, an RN, had completed the required specialized training in infection prevention and control, as neither the RN nor the DON could provide documentation of course completion, and no other staff member was overseeing the program.
A resident who required assistance with dressing was sent to an outside appointment wearing only a brief and covered with a sheet, without pants, coat, or hat, despite appropriate clothing being available in the room. The nurse involved reported feeling rushed and did not contact laundry for emergency clothing. The resident reported feeling cold and humiliated by the incident.
The facility failed to monitor the respiratory status of a resident with COPD, not following orders to maintain oxygen saturation levels and inconsistently assessing lung sounds during nebulizer treatments. Another resident with respiratory failure did not receive prescribed Budesonide due to unavailability, and the physician was not notified of missed doses. Staff interviews revealed a lack of adherence to protocols for respiratory care.
A resident exited the facility due to a lack of education for non-clinical staff on wander guards and alarmed doors. The resident, assessed as an elopement risk, left when the Admissions Director opened the door for visitors. The alarm sounded, but the director did not understand its significance. Interviews revealed inadequate orientation on elopement procedures for non-clinical staff.
Two residents experienced falls due to the facility's failure to follow care plans. One resident, with a history of falls and multiple medical conditions, suffered fractures after being transferred by a single CNA instead of the required two-person assist. Another resident, with Alzheimer's and a below-knee amputation, fell when a new CNA did not use the required EZ-Stand for transfers. The CNA involved was not adequately trained, as her personnel records showed no completed competency evaluation.
A resident with multiple medical conditions fell and sustained fractures due to improper transfer by a single CNA, contrary to the care plan requiring two-person assistance. The CNA was unaware of the requirement and had not completed a competency evaluation. The Nursing Home Administrator failed to report the incident as potential neglect to the State Agency.
A resident with multiple health issues, including a history of falls, suffered fractures after a fall during a transfer at a facility. The transfer was conducted by a single CNA, contrary to the care plan's requirement for a two-person assist. The CNA was unaware of this requirement and had not completed a competency evaluation. The incident was not immediately investigated or reported as neglect, indicating a deficiency in the facility's response.
The facility failed to ensure that five CNAs had completed the required competency evaluations necessary to care for residents. Despite working independently, the CNAs' personnel records did not demonstrate completed evaluations upon the completion of their orientation. Interviews with the Human Resource Director and Nurse Educator confirmed the absence of these evaluations, indicating a lapse in the facility's process for ensuring staff competency.
The facility failed to prevent the development and worsening of pressure ulcers for three residents, resulting in multiple facility-acquired pressure ulcers. Preventive measures were not consistently implemented, and there was a lack of communication and adherence to care plans, leading to the development of stage two and three pressure ulcers.
The facility failed to prevent recurrent falls and provide adequate supervision for two residents, resulting in head lacerations requiring emergency care. Both residents experienced falls shortly after admission, with delays in staff response and insufficient fall prevention measures. The facility's design and staffing issues contributed to the lack of timely assistance and supervision.
The facility failed to clean and maintain food service equipment, affecting 88 residents. Observations revealed soiled TurboChef oven and juice machine, a leaking vegetable preparation sink faucet, and a weak overhead spray arm spring. These issues violated the 2017 FDA Model Food Code and the facility's own maintenance policies.
The facility failed to effectively clean and maintain the physical plant, affecting 88 residents. Issues included soiled ventilation grills, damaged surfaces, and loose or missing vinyl base coving in various areas. The facility's maintenance work order system did not have specific entries related to these concerns, indicating a failure to adhere to the maintenance policy.
A resident with a PICC line had a dressing that was not changed within the required 48-hour period, leading to visible swelling and a blood-stained dressing. Staff interviews confirmed that the dressing should have been changed to assess the insertion site for signs of infection, but this was not done, increasing the likelihood of infection.
The facility failed to ensure that a resident received an assessment for meal consumption assistance and sufficient food intake, resulting in significant weight loss. Despite being noted as independent for eating, the resident was often found sleeping during meal times with untouched meals and nutritional supplements. Staff interviews and observations confirmed that the resident was not adequately monitored or assisted during meal times, leading to a 20.55% weight loss over a few months.
The facility failed to ensure sufficient nursing staff to meet resident needs, resulting in repeat falls and injuries for two residents. One resident experienced a fall three days after admission, leading to a head laceration, while another resident had two falls within a short period, both causing head lacerations. The facility's design and staffing levels were cited as contributing factors.
The facility failed to ensure that the attending physician documented and addressed the pharmacist's medication review recommendations for a resident with Alzheimer's, schizophrenia, and major depressive disorder. Recommendations to adjust medication doses and obtain a fasting lipid panel were not properly documented or acted upon, as confirmed by the DON.
The facility failed to adequately monitor a resident on risperidone for schizophrenia, despite recommendations from the pharmacist to obtain a fasting lipid panel. The last lipid panel was conducted over a year ago, as confirmed by the DON.
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN administered bisacodyl without a physician's order and failed to administer a prescribed probiotic and loperamide to a cognitively intact resident. The LPN reported the medications were not in stock, although the probiotic was documented as administered. The resident experienced loose stool/diarrhea later that day. The DON confirmed that probiotics were kept as a stock medication.
The facility failed to offer pneumococcal immunizations per CDC recommendations for two residents. Despite consent being given in November 2022, both residents did not receive the recommended dose of PCV15 or PCV20 at least one year after their last dose of PPSV23. The Infection Preventionist confirmed the oversight.
The facility failed to offer an updated COVID-19 vaccine to a resident with Parkinson's Disease, hypertension, and obstructive sleep apnea. The resident, who was cognitively intact, had not received a COVID-19 vaccine since 1/16/23, and there was no documentation of consent or declination for the updated 2023-2024 vaccine. The Infection Preventionist confirmed the oversight.
Failure to Monitor CHF Resident’s Weight Gain and Edema
Penalty
Summary
The deficiency involves the facility’s failure to monitor and address a resident’s significant weight gain and worsening edema in accordance with physician orders and the resident’s clinical needs. The resident was admitted with diagnoses including atrioventricular block, bradycardia, acute respiratory failure with hypoxia, congestive heart failure (CHF), and atrial flutter. On admission, non-pitting edema was documented in the palms, and the physician ordered Furosemide 20 mg twice daily and weekly weights every Wednesday evening shift. The diuretic care plan also directed staff to weigh the resident weekly and as needed, and the dietary evaluation identified impaired nutrient utilization related to altered sodium and fluid balance secondary to CHF, with instructions to continue monitoring weight trends. Weight documentation and follow-through on ordered and requested weights were inconsistent and incomplete. Early weights included 223 lbs on admission, 221 lbs the next day, and 215.6 lbs on 3/28. A nurse practitioner visit on 4/6 noted weight loss from 223 lbs to 215.6 lbs and specifically requested a repeat weight to confirm the trend and accuracy, but no reweight was documented. Scheduled weekly weights for 4/1, 4/8, and 4/15 were not recorded on the TAR, and the 4/15 weight entry was coded as “09-Other/See Nurse Note” without any corresponding nurse note explaining why the weight was not obtained. The next documented weight did not occur until 4/10, showing 249 lbs, a gain of 33.4 lbs over 13 days, and there was no documentation that this significant weight gain was reported to the provider. Edema assessments showed a progression that was not effectively recognized or acted upon. On 4/6, both the skilled nursing evaluation and the NP’s physical exam documented no edema. Subsequent skilled nursing evaluations on 4/8 and 4/9 did not identify edema, but on 4/10 the resident was documented with +1 pitting edema in both lower extremities, with the onset marked as unknown. On 4/11, 1+ pitting edema persisted bilaterally, again with onset unknown, and by 4/12 the edema had progressed to 2+ pitting bilaterally. On 4/13, 2+ pitting edema was noted in the left lower extremity and 1+ in the right, still documented as unknown if new onset. The NP’s 4/13 visit note did not mention the most recent weight or the significant weight gain. Staff interviews revealed that nurses were not consistently reviewing weights, were unaware of the resident’s CHF diagnosis or the associated monitoring expectations, and did not notify the provider of the 33.4 lb weight gain or the worsening edema. The resident and family later expressed concern about unresolved or worsening tibial edema, and the resident was ultimately sent to the emergency department for loss of consciousness and hypoxia, with the NP documenting concern for worsening CHF and fluid overload in the context of persistent and worsening lower-leg swelling despite diuretic therapy. Interviews with facility leadership and clinical staff further highlighted the gaps in monitoring and communication that led to the deficiency. The DON stated that residents with CHF were to start with daily weights on admission and that nursing was responsible for notifying the physician of a 3 lb gain in one day or 5 lb in one week, but acknowledged that this resident had only an order for weekly weights and that there was a two-week gap in documented weights followed by a large weight increase. The DON also reported receiving an email from the dietitian on 4/14 requesting a reweight, which was not completed within the expected 24 hours and was not found in the record. The NP reported that she expected the reweight requested on 4/6 to be done within a day or two and that she would have expected to be notified of the 33.4 lb weight gain and the change in edema, but she was not informed and was unaware of the weight gain at the time of her 4/13 assessment. These documented failures to obtain ordered and requested weights, to monitor and interpret weight and edema trends, and to notify the provider of significant changes in condition resulted in unrecognized worsening edema, significant weight gain, loss of consciousness, and hospitalization for this resident. The resident’s significant other reported noticing increased leg edema and the resident’s increased difficulty breathing earlier in the week before hospital transfer and believed the edema was not being addressed. Nursing staff interviews showed that day-shift and night-shift nurses divided assessment responsibilities by room number, and at least one RN reported never personally assessing the resident’s edema and not reviewing the resident’s weight. Another LPN believed the resident was admitted with 2+ pitting edema, did not know the resident had CHF because they did not see the diagnosis in the record, and was unaware of any weight changes, despite acknowledging that residents with CHF were supposed to be weighed daily and that providers should be notified of specified weight gains. These combined omissions in assessment, documentation, and provider notification form the basis of the cited deficiency.
Failure to Provide Adequate Bathing and Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically bathing and timely incontinence care, for one resident. The resident was admitted and later readmitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and had a BIMS score indicating moderate cognitive impairment, yet was able to converse and answer questions appropriately. The resident reported going days without showers, disliking the resulting body odor, and stated a preference for two showers per week with additional showers as needed. The task list reflected this preference for showers twice weekly and PRN. However, record review showed the resident received only bed baths on two dates in February and did not receive a first shower until several weeks after admission, with the next shower not occurring until early March. There were no documented shower refusals in the electronic medical record. The deficiency also includes failure to provide timely incontinence care. A progress note documented that on one morning in February the resident and bed were soiled with urine while the resident was in bed requesting to get out of bed. Therapy staff reported finding the resident “pretty saturated in urine,” with urine soaking through clothing, bed linens, and down to the mattress, and they notified nursing and assisted with incontinence care. An LPN confirmed entering the room that morning to assist therapy staff and verified that the resident was saturated in urine through clothing and bed linens. These findings occurred despite a facility policy on ADLs stating that appropriate care and services, including support and assistance with hygiene (bathing) and elimination (toileting), would be provided for residents unable to carry out ADLs independently.
Failure to Ensure Accessible Call Light Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall by ensuring a resident’s call light was within reach and that adequate supervision was provided. The resident had hemiplegia and hemiparesis affecting the left non-dominant side and was moderately cognitively impaired, scoring 9 out of 15 on the BIMS. The resident reported that staff sometimes attached the call light to his left side, where he had weakness and immobility. On the day of the fall, the resident needed to have a bowel movement but could not locate the call light despite feeling around the bed with his right arm. Unable to find the call light in time, the resident attempted to get out of bed independently to reach the bathroom, slid out of bed, and fell to the floor. Progress notes and incident documentation for the fall showed that the resident was found on the floor beside the bed after calling out for assistance, having had a bowel movement and attempting to get out of bed when he fell and hit his head. The resident was observed entangled in bedding and a PEG tube and was noted to be alert and oriented to baseline. The post-fall evaluation documented that the resident did not have the call light activated at the time of the fall. The resident’s fall care plan included an intervention to ensure the call light was within reach at all times. An LPN who was working that night reported hearing someone yelling, finding the resident on the floor, and confirming that the resident stated he had to use the bathroom and had a bowel movement in bed. The LPN also stated that the resident was able to use the call light appropriately when he had care requests.
Failure to Properly Manage and Document Feeding Tube Administration
Penalty
Summary
The facility failed to properly manage and document the administration of feeding tube nutrition for a resident with multiple complex medical conditions, including type 2 diabetes, dysphagia, functional quadriplegia, and dementia. The resident had a PEG tube for enteral feeding, with physician orders specifying the type, rate, and total volume of nutrition to be administered, as well as instructions for tubing changes and documentation. Observations and record reviews revealed that the prescribed feeding regimen was not consistently followed, with documented amounts of nutrition administered frequently above or below the ordered total, and numerous instances of missing or inconsistent documentation regarding the volume infused. There were multiple occasions where the feeding pump malfunctioned or was not properly monitored, resulting in the resident not receiving the required nutrition. This led to episodes of hypoglycemia, as evidenced by low blood sugar readings and the need for emergency interventions such as oral glucose and glucagon administration. Staff interviews confirmed that there were issues with the feeding pump not functioning correctly, and that staff had not received recent education on the use of feeding tube pumps. Additionally, documentation practices were inconsistent, with repeated or decreasing totals recorded and significant gaps in the required two-hourly documentation of infused amounts. Nursing management and the DON were made aware of the issues after family concerns and direct observations of the resident not receiving the correct amount of feeding. Despite the implementation of more frequent checks, there remained missing documentation and continued inconsistencies in the administration and recording of tube feedings. The facility was unable to provide evidence that the resident consistently received the prescribed amount of nutrition, and staff were unable to explain discrepancies in the records.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal service for residents, as evidenced by interviews, observations, and record reviews. The Director of Food and Beverage (DFB) confirmed that the department was operating with 63 staff members instead of the required 75, and that efforts to recruit and orient new staff were ongoing. Due to staffing shortages, the third-floor satellite kitchenette was closed, and meals for that floor were being served from the second floor, further straining the available staff and impacting meal delivery times. Multiple residents reported and were observed experiencing significant delays in meal service. One resident stated that breakfast was an hour late and dinner was two hours late on a previous occasion. During a dining observation, several residents waited extended periods for their meal trays, with some expressing frustration and discomfort. Staff confirmed that kitchen staffing shortages led to delayed meal service, and that all meals for certain floors had to be prepared and delivered from other locations within the facility, resulting in some residents not receiving their meals until well after the scheduled times. Facility policies reviewed indicated that food and nutrition services are expected to provide adequate staffing to meet residents' dietary needs and ensure timely meal delivery. However, the observed and reported delays, as well as the closure of a satellite kitchen due to lack of staff, demonstrated that the facility was not meeting its own standards or the needs of its residents. The deficiency affected a large number of residents who rely on the facility for their daily nutrition and meal service.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide palatable food products at safe and appetizing temperatures for residents, as evidenced by observations and temperature recordings of meal trays. During lunch service, food trays were transported in a non-insulated cart, and upon arrival, the temperatures of several hot food items, including pork loin, fried item, snap peas, and egg roll, were found to be below the required 135°F as specified by the 2022 FDA Model Food Code. The beverage was served at 42.1°F, and the dessert was at room temperature. These findings were based on direct observation and temperature measurement of a resident's meal tray. Interviews with the Director of Food and Beverage confirmed the meal service times and the use of the non-insulated transport cart. Review of facility policies revealed that food and nutrition services staff are expected to ensure meals are palatable, attractive, and served at safe temperatures, with procedures in place for reporting and replacing meals that do not meet these standards. Despite these policies, the observed practices did not align with the stated guidelines, resulting in the provision of food that was not maintained at appropriate temperatures for 103 residents who consume food products.
Failure to Maintain Food Service Equipment and Properly Date Mark Perishables
Penalty
Summary
Surveyors observed that the facility failed to effectively clean and maintain food service equipment and did not properly date mark all potentially hazardous ready-to-eat food products. During a tour of the food service areas, two unopened half-gallon containers of milk with expired manufacturer's use-by dates were found in a satellite kitchenette refrigerator. Additionally, the ice dispensing spout of an ice machine was found with accumulated and encrusted mineral deposits, and a coffee machine was observed to have accumulated and encrusted food residue on its dispensing spouts, undersplash, backsplash, and drip tray assembly. The Director of Food and Beverage confirmed that the coffee machine was supposed to be cleaned daily. Record reviews of facility policies revealed that kitchenettes and equipment such as juice, cocoa, coffee makers, and ice machines were to be cleaned and sanitized regularly by staff, and that all perishable items were to be labeled with item name, employee initials, date and time of preparation, and use-by date. The policies also required that perishables be stored in a manner that maintains safety and freshness, and that date marking should follow a 'day of plus six' system. These practices were not consistently followed, as evidenced by the observations of expired milk and unclean equipment.
Improper Maintenance and Cleaning of Outdoor Waste Receptacle Area
Penalty
Summary
Surveyors observed that the facility failed to properly maintain two out of five outdoor waste receptacles, with one having a broken plastic lid and another having a broken plastic slider panel. Additionally, miscellaneous items such as a wooden pallet, vinyl gloves, and paper products were found resting on the concrete pad surface adjacent to the waste receptacles. The facility's policy requires that the dumpster area be free of debris on the ground and that lids remain closed, but these requirements were not met during the inspection. These deficiencies affected 105 residents.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple resident and staff interviews, as well as a review of staffing schedules. Several residents reported significant delays in receiving assistance, particularly with call light responses and help with activities of daily living such as toileting and mobility. One resident described waiting five to six minutes for bathroom assistance and an additional ten minutes after finishing, while another reported waiting up to an hour and a half for help after experiencing bowel incontinence. A third resident indicated that assistance was sometimes unavailable during the midnight shift, with call light response times ranging from immediate to as long as three hours, especially in the evenings. Staff interviews corroborated these accounts, with CNAs reporting that the second floor, housing approximately 34 residents, was often staffed with only one or two CNAs during certain shifts, particularly overnight. Staff noted that when nurses assisted with resident care, they were better able to meet resident needs, but agency nurses typically did not help CNAs. There were also instances where CNAs were required to assist with meal service due to dietary staff shortages, further reducing their ability to provide direct care. Staffing schedules confirmed that on multiple occasions, only one CNA was assigned to care for an entire floor during overnight shifts, and that ideal staffing levels were not consistently maintained. Additional staff interviews highlighted that inadequate staffing was a persistent issue, especially on weekends, with only two CNAs assigned to entire units. This resulted in critical care activities, such as turning and repositioning residents and performing daily hygiene routines, not being completed as required by residents' care plans. The combination of low staffing levels and additional non-nursing duties prevented staff from delivering care in accordance with established care plans, directly contributing to the deficiency.
Failure to Immediately Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of resident-to-resident abuse to the Nursing Home Administrator as required. On the day of the incident, a cognitively intact resident was reportedly assaulted by another resident, as relayed by the first resident’s family member to an LPN. The LPN, who was assigned to both residents, observed one resident yelling and the other resident shutting the door, but did not witness any visible injuries or hear a direct allegation of abuse at that time. Despite receiving a phone call from the resident’s friend alleging an assault, the LPN did not notify the Nursing Home Administrator or Director of Nursing, believing that nothing significant had occurred since the resident appeared unharmed and did not verbalize abuse. A few hours later, police arrived at the facility after being contacted by the resident’s family, at which point the resident reported being struck in the head by the other resident. The Nursing Home Administrator was not made aware of the abuse allegation until the following day, when the Director of Nursing attended a care conference with the resident and their family. This delay in reporting resulted in the investigation not being initiated until the day after the alleged incident.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessment in a timely manner for one resident. The clinical record review showed that a resident admitted with kidney failure and diabetes was transferred to the hospital on 3/15/24, but no discharge MDS assessment had been completed or transmitted as required. During interviews, it was revealed that the MDS nurse responsible for discharge MDS assessments and submissions was not present, and another MDS coordinator acknowledged that the discharge MDS should have been completed and transmitted within 14 days of discharge but was overlooked.
Inaccurate Discharge MDS Assessment Coding
Penalty
Summary
The facility failed to ensure the accuracy of a discharge Minimum Data Set (MDS) assessment for one resident. The clinical record showed that the resident was admitted to the facility and later found unresponsive, resulting in a transfer to the hospital where the resident subsequently died. However, review of the discharge MDS revealed that question A2105 was incorrectly coded to indicate the resident went home, rather than being transferred to an acute care hospital. During interviews, MDS coordinators confirmed that the resident was not discharged home and that the MDS should have been coded to reflect a hospital transfer.
Failure to Provide and Document Required Bathing Assistance
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including depression, seizure disorder, and fracture, and requiring one-person assistance for bathing, did not receive adequate support with activities of daily living (ADLs), specifically bathing. Observation revealed the resident's hair was greasy and unkempt, and the resident reported having received only one shower since admission, despite requiring assistance. The resident expressed dissatisfaction with her hygiene and stated that staff were aware her showers had not been completed. Review of the resident's clinical and task records showed no documentation of showers or baths provided since admission, with only 'not applicable' responses recorded. The DON confirmed that showers should be offered twice weekly and that refusals should be documented, with a bed bath provided if a shower is refused. However, no documentation was found to support that showers or alternative hygiene care were provided, and no additional records were produced to verify care delivery. Facility policy requires appropriate support and assistance with hygiene for residents unable to perform ADLs independently.
Failure to Administer Medication and Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that wound treatments and medication administration were provided as ordered for two residents. One resident with Type 2 Diabetes Mellitus, diabetic neuropathy, major depressive disorder, and anxiety disorder did not receive her prescribed weekly diabetes medication, Mounjaro, on three out of six scheduled occasions. Documentation showed that the medication was unavailable on those dates, and there was no evidence that the facility physician was notified of the missed doses. Progress notes indicated that the nurse did not document contacting the pharmacy or physician, and the DON confirmed that staff are expected to reach out to both and document these actions when a medication is unavailable. Another resident with dementia, peritoneal abscess, cutaneous abscess of the abdominal wall, major depressive disorder, and bipolar disorder had a wound requiring dressing changes every eight hours. The treatment administration record showed that several scheduled dressing changes were not documented as completed, and there was no documentation explaining the missed treatments. The resident reported that dressing changes were sometimes missed, and the DON confirmed that there was no documentation of the rationale for the missed wound care. Both deficiencies were identified through observation, interview, and record review, revealing a lack of adherence to physician orders and facility policy regarding medication and wound care administration. The failures included missed doses and treatments, lack of documentation for missed care, and insufficient communication with the physician and pharmacy as required by facility policy.
Medications Left Unattended in Resident Room Without Proper Supervision
Penalty
Summary
A deficiency was identified when a resident, who had a history of hemiplegia and hemiparesis following a stroke and was cognitively intact, was observed with a medication cup containing six pills left unattended on a stand in their room. The observation occurred in the morning, and the pills were confirmed by the RN to be the resident's morning medications. The RN explained that the resident had a physician order stating that nursing staff should not stand over him while he took his medications, but could observe from a visual distance to ensure all medication was taken. Despite this order, the Director of Nursing confirmed that the resident did not have approval to self-administer medications, and facility policy required nurses to observe residents taking their medications unless self-administration was specifically authorized by a physician. The failure to ensure the medications were administered as required and not left unattended in the resident's room constituted a breach in safe medication storage and administration practices.
Infection Preventionist Lacked Required Training Documentation
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed the required specialized training in infection prevention and control. The Infection Preventionist, a registered nurse, was unable to provide a certificate of completion for the necessary training and reported that she had only recently begun retaking the course, which was not yet finished. Additionally, the Director of Nursing confirmed that the facility could not locate any certificate of completion for the Infection Preventionist, and no other employee was overseeing the infection prevention and control program during this period.
Resident Sent to Appointment Without Proper Clothing, Dignity Not Maintained
Penalty
Summary
A resident with a history of traumatic subdural hemorrhage and muscle weakness, who was cognitively intact and required substantial to maximal assistance with lower body dressing, was sent to an outside medical appointment without proper clothing. The resident was transported wearing only a brief and covered with a sheet, without pants, a coat, or a hat, despite cold weather conditions. The resident and his family member reported that clean pants, a coat, and a hat were visibly available in the resident's room at the time, and the family member confirmed that multiple pairs of pants were present at the facility. The nurse responsible for sending the resident to the appointment stated she was unable to find clean or dry pants and felt rushed due to the transportation provider's arrival, leading her to wrap the resident in a blanket or sheet. The nurse did not see the available clothing items in the resident's room and did not reach out to the laundry department, which maintains emergency clothing for such situations. The resident expressed feeling cold and humiliated by the experience. Facility policy requires residents to be treated with dignity and respect, including proper attire and privacy during care.
Failure to Monitor Respiratory Status and Administer Medications
Penalty
Summary
The facility failed to adequately assess and monitor the respiratory status of a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The resident was dependent on supplemental oxygen, with orders to maintain blood oxygen saturation levels between 88% and 92%. However, there were multiple instances where the resident's oxygen saturation levels were recorded below the prescribed range, and there was no documented follow-up or adjustment to the oxygen therapy. Additionally, the resident's lung sounds were not consistently assessed before and after administering nebulizer treatments, as required by the physician's orders. Another resident with acute and chronic respiratory failure and asthma did not receive their prescribed Budesonide Inhalation Suspension as ordered. The medication was not administered on several occasions due to unavailability, and there was no documentation that the physician was notified of the missed doses. The facility's Director of Nursing indicated that the expectation was for the pharmacy to be contacted and for the physician to be informed if medications were not administered. Interviews with facility staff revealed a lack of awareness and adherence to the protocols for monitoring and administering respiratory treatments. A Licensed Practical Nurse admitted to not remaining with the resident during nebulizer treatments, despite knowing the resident sometimes removed their nebulizer mask. The Director of Nursing confirmed that lung sounds should have been assessed with each nebulizer treatment and that the physician should have been notified of any issues with medication availability.
Failure to Educate Non-Clinical Staff on Elopement Procedures
Penalty
Summary
The facility failed to educate non-clinical staff about the use of wander guards, alarmed exit doors, and staff responsibilities during an elopement, which resulted in a resident exiting the facility. The resident, who was assessed as an elopement risk and had a wander device placed on her wrist, managed to leave the building when the Admissions Director opened the door for visitors. The alarm was triggered, but the Admissions Director did not understand its significance and did not take action to bring the resident back inside. The resident, who had a history of wandering and attempts to exit the building, was outside for approximately one minute before being escorted back inside by staff. The resident was alert, dressed appropriately, and had a BIMS score of 8, indicating she was able to be interviewed. Despite the alarm sounding, the Admissions Director, who was not familiar with long-term care, did not recognize the need to respond to the alarm. Interviews with various staff members revealed a lack of education and documentation regarding the facility's elopement procedures and the use of wander guards. The Director of Maintenance and Grounds and the Infection Control/Staff Development RN both indicated that non-clinical staff were not adequately oriented on these procedures. The facility's policies on resident wandering and elopement were not effectively communicated to new employees, contributing to the incident.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to prevent accidents by not adhering to the care plans for two residents, resulting in actual harm for one resident and potential harm for another. Resident #3, who had a history of falls and multiple medical conditions, including COPD, diabetes, and epilepsy, suffered a fall that resulted in fractures of the right tibia and fibula. The fall occurred during a transfer from the toilet to a wheelchair, where the resident was assisted by only one CNA, contrary to the care plan that required a two-person assist. The CNA involved was not aware of the care plan requirements and had not been educated on the necessity of reading the Kardex prior to providing care. Resident #2, who had diagnoses including Alzheimer's disease, dementia, and a below-knee amputation, experienced a fall in the bathroom when a CNA attempted to assist him without using the required mechanical lift, the EZ-Stand. The resident was unable to stand, and another CNA had to assist in lowering him to the floor. The CNA assisting the resident was new and unaware of the requirement to use the EZ-Stand, as she did not read the Kardex and relied on verbal information from other CNAs. The personnel records revealed that the CNA involved in both incidents had not completed a competency evaluation upon completion of her orientation. The lack of adherence to the care plans and the failure to ensure that staff were adequately trained and informed about resident care requirements led to these incidents, highlighting deficiencies in the facility's supervision and training processes.
Failure to Report Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to report allegations of abuse or neglect concerning a resident who sustained injuries due to improper care. The resident, who was admitted with multiple medical conditions including COPD, diabetes, and a history of falls, experienced a fall at the facility that resulted in fractures to her right leg. The resident was supposed to be transferred with the assistance of two staff members, as per her care plan, but was instead assisted by only one Certified Nurse Aide (CNA), leading to the fall and subsequent injuries. The incident occurred when the resident was being transferred from the toilet to her wheelchair. The CNA involved in the transfer was not aware of the requirement for two-person assistance and admitted to not reading the Kardex, which outlines the care plan for residents. The CNA had only been employed at the facility for a month and had not completed a competency evaluation after her orientation. This lack of adherence to the care plan and insufficient training contributed to the resident's fall and injuries. The Nursing Home Administrator was aware of the incident but did not ensure that it was reported as a potential case of neglect to the appropriate State Agency. The administrator acknowledged that the failure to follow the care plan could be considered neglect but did not take immediate action to report it. This oversight in reporting and investigating the incident promptly represents a deficiency in the facility's handling of potential abuse or neglect cases.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to investigate, implement preventive measures, and take corrective action for an allegation of neglect involving a resident. The resident, who was admitted with multiple diagnoses including COPD, diabetes, and a history of falls, experienced a fall at the facility that resulted in fractures to her right leg. The resident was being transferred from the toilet to her wheelchair by a single CNA, despite her care plan requiring a two-person assist for transfers. This failure to follow the care plan led to the resident's fall and subsequent injuries. The incident occurred when the resident's right leg gave out during the transfer, causing her to fall to the floor. The CNA involved in the transfer was not aware of the resident's need for a two-person assist and admitted to not reading the Kardex, relying instead on verbal information from other CNAs. The CNA had been employed at the facility for a month and had not completed a competency evaluation upon finishing her orientation. The Nursing Home Administrator was aware of the incident but was on vacation at the time. Upon returning, the Administrator acknowledged that the failure to follow the care plan could be considered neglect. However, the incident was not immediately investigated or reported to the appropriate state agency, as required. The lack of immediate investigation and reporting highlights a deficiency in the facility's response to the incident.
Failure to Complete CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) had completed the required initial competency evaluations necessary to care for residents. The personnel records for CNAs D, E, F, G, and H did not demonstrate completed competency evaluations upon the completion of their orientation. CNA D was hired on June 17, 2024, CNA E on August 24, 2023, CNA F was a contracted CNA starting on December 28, 2023, CNA G was hired on May 30, 2024, and CNA H on May 16, 2024. Despite these CNAs working independently, their competency evaluations were not documented as completed. During interviews, the Human Resource Director and Nurse Educator confirmed the absence of the completed competency evaluation forms for these CNAs. The Human Resource Director was unable to locate the forms, and the Nurse Educator explained that competency evaluations were supposed to be completed by Nurse Managers after orientation, allowing staff to work independently. However, the Nurse Educator could not explain why the evaluations were not completed, indicating a lapse in the facility's process for ensuring staff competency.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for three residents, resulting in multiple facility-acquired pressure ulcers. Resident #13 developed pressure ulcers on both heels due to prolonged pressure from resting on the bed. Despite being at risk for pressure ulcer development, no preventive measures such as offloading devices were initially used. After the ulcers were discovered, interventions like foam boots and a foam wedge were implemented, but the ulcers had already progressed to stage two and three. The resident's resistance to using offloading devices was noted, but there were no documented refusals of care in the medical record. Resident #24 developed a pressure ulcer on the lateral side of the left foot due to a medical device (external fixator) pressing into the skin. The resident's care plan and Kardex did not include instructions to elevate the left lower extremity as per orthopedic instructions. Multiple CNAs confirmed that they did not see a foam cushion used to elevate the resident's leg. The wound nurse and other staff were unaware of how the pressure injury developed, indicating a lack of communication and adherence to preventive measures. Resident #45 developed a deep tissue injury on the left heel and a stage two pressure ulcer on the coccyx. The resident's care plan included an order to keep the left lower extremity elevated, but observations revealed that the heel was resting directly on the mattress. The wound nurse attributed the development of the pressure ulcers to the use of flat pillows and irregular staffing, as the resident's regular CNA was on vacation. The lack of consistent care and proper offloading techniques contributed to the resident's pressure ulcers.
Failure to Prevent Recurrent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement timely interventions, provide appropriate supervision, and ensure that staff assisted with transfers to prevent recurrent falls for two residents. Resident #70, a male with a history of Parkinson's Disease, polyosteoarthritis, and multiple fractures, experienced a fall three days after admission. He was found on the floor with a head laceration after calling his wife for help. The staff was alerted by the wife, and there was a delay in attending to the resident. The resident required emergency care and staples for the head injury. The fall incident report lacked details on when the resident was last observed or if any interventions were in place at the time of the fall. The facility's design and staffing issues were noted as contributing factors to the delay in assistance and supervision. Resident #547, a female with a history of hypotension, falls, and a subdural hematoma, experienced two falls within a short period after admission. The first fall resulted in a head laceration requiring staples, and the second fall occurred three days later, causing another head laceration. Both falls were unwitnessed, and the incident reports did not provide information on when the resident was last observed or if the call light was used. The care plan did not include new interventions after the first fall, and there was a lack of follow-up documentation. The facility's layout and staffing issues were again noted as contributing factors to the lack of supervision and timely assistance. Interviews with staff revealed that the facility had identified a need for improvement in root cause analysis and gathering additional information at the time of falls. The Director of Nursing and Registered Nurse responsible for fall investigations acknowledged the deficiencies in the fall reports and the lack of new interventions in the care plans. The facility's design and staffing challenges were highlighted as ongoing issues affecting the supervision and safety of residents, particularly those at high risk for falls.
Failure to Maintain Clean and Functional Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 88 residents. During an initial tour of the food service area, the TurboChef oven was found with accumulated and encrusted food residue. The Director of Food and Beverage acknowledged the issue and indicated that staff would clean and sanitize the oven. Additionally, the vegetable preparation sink faucet was leaking, and the overhead spray arm spring near the mechanical dish machine was weak, allowing the valve assembly to invade the flood plane level of the sink basin. These conditions were in violation of the 2017 FDA Model Food Code sections 4-601.11 and 5-205.15, which require food-contact surfaces to be clean and plumbing systems to be maintained in good repair, respectively. Further inspection of the Center for Health & Rehabilitation (CHR) 2 Kitchenette revealed that the interior surface of the juice machine was also soiled with accumulated and encrusted food residue. The Director of Food and Beverage again indicated that staff would clean and sanitize the machine. Record reviews of the facility's policies and procedures showed that maintenance service was supposed to be provided to all areas of the building, grounds, and equipment, and that kitchenettes were to be cleaned regularly by Nursing and Hospitality Services staff. However, these policies were not effectively implemented, leading to the observed deficiencies.
Failure to Maintain Clean and Safe Physical Plant
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 88 residents. During an environmental tour of the facility's laundry service, the chemical room's entrance door was found with a damaged laminate surface, and the exhaust ventilation grill was soiled with accumulated dust and dirt. In a common area tour, multiple issues were noted, including soiled ventilation grills in the shower room, a loose commode base seat and stained ceiling in the public restroom, and a soiled utility room refrigerator with accumulated ice. Additionally, the mop closet had a non-functional light bulb and a soiled ventilation grill, while the therapy restroom also had a soiled ventilation grill. On the third floor, the mop closet had a cracked sink basin and damaged plaster wall, and the public restroom had a soiled ventilation grill. Further observations in sampled resident rooms revealed soiled ventilation grills, damaged drywall surfaces, and loose or missing vinyl base coving in several restrooms. The facility's maintenance work order system, WorxHub, did not have specific entries related to these maintenance concerns. A review of the facility's maintenance policy indicated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. However, the observed deficiencies indicate a failure to adhere to this policy, leading to an increased likelihood of cross-contamination, bacterial harborage, and decreased air quality.
Failure to Change PICC Line Dressing Timely
Penalty
Summary
The facility failed to provide services that met acceptable standards of clinical practice for PICC line dressings for Resident #543. The resident, a [AGE] year old male with a recent right great toe amputation and current IV antibiotic treatment, had a PICC line with a dressing dated 5/20/24. Observations on 5/21/24 and 5/23/24 revealed that the dressing, which included gauze under a transparent covering, had not been changed within the required 48-hour period. The resident's right arm was visibly swollen compared to the left arm, and there was a blood stain on the dressing. Despite these signs, there were no nursing progress notes mentioning the swelling from 5/20/24 to 5/23/24, and the physician was not aware of the issue until it was reported on 5/23/24. Interviews with staff, including the LPN, Unit Manager, and DON, confirmed that the dressing should have been changed within 48 hours to assess the insertion site for signs of infection. The LPN reported being unable to see the insertion site due to the gauze covering, and the DON stated that staff are expected to report abnormal findings to the physician and document them in the medical record. The failure to change the dressing and assess the site as required increased the likelihood of infection for the resident.
Failure to Ensure Adequate Food and Fluid Intake
Penalty
Summary
The facility failed to ensure that Resident #24 received an assessment for meal consumption assistance and sufficient food intake, resulting in significant weight loss. Resident #24, who was admitted with multiple diagnoses including cognitive communication deficit and muscle weakness, was observed multiple times with untouched meals and nutritional supplements. Despite being noted as independent for eating in the care plan, Resident #24 was often found sleeping during meal times and did not stay alert long enough to consume food. The resident's weight dropped from 207.8 lbs on 2/22/2024 to 165.1 lbs on 5/21/2024, indicating a 20.55% weight loss. Observations revealed that the resident's meals and nutritional supplements were often left unattended and untouched, and the resident was not adequately monitored or assisted during meal times. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), confirmed that Resident #24 was not consuming meals due to decreased alertness and cognition. The Registered Dietician (RD) also noted difficulty in monitoring the resident's intake due to these issues. Despite initial assessments and recommendations for nutritional supplements, the resident's condition deteriorated, and subsequent assessments were not effectively carried out. The facility's failure to provide adequate assistance and monitoring for meal consumption led to the resident's significant weight loss and potential health risks.
Insufficient Nursing Staff Leads to Repeat Falls and Injuries
Penalty
Summary
The facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision, resulting in repeat falls including injury for two residents. Resident #70, a male with Parkinson's Disease and other conditions, experienced a fall three days after admission, resulting in a head laceration that required several staples. The resident's family reported difficulty in reaching the facility by phone, leading to a delay in assistance. The fall was unwitnessed, and the investigation lacked details on when the resident was last observed or if interventions were in place. The facility's design and staffing levels were cited as contributing factors to the incident. Resident #547, a female with a history of falls and other medical conditions, experienced two falls within a short period after admission. The first fall resulted in a head laceration requiring staples, and the second fall occurred three days later, causing another head laceration. Both falls were either unwitnessed or witnessed but not prevented, and the investigation reports lacked details on the last observation, call light usage, and specific interventions. The facility's layout and staffing levels were again noted as contributing factors. Interviews with staff, including LPNs and the Director of Nursing, revealed gaps in the fall investigation process and documentation. The facility's assessment indicated a high number of residents requiring assistance with daily activities, but the staffing levels were insufficient to meet these needs. The facility's design also made it difficult for staff to monitor residents effectively, particularly those at high risk for falls. The lack of timely and thorough investigations and appropriate interventions contributed to the repeated falls and injuries experienced by the residents.
Failure to Document and Address Pharmacist's Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for one resident. Resident #30, who was admitted with diagnoses including Alzheimer's Disease, schizophrenia, and major depressive disorder, had several recommendations from the pharmacist that were not addressed or documented properly. These recommendations included decreasing the dose of pantoprazole and obtaining a fasting lipid panel due to the potential of antipsychotic medications to cause hyperlipidemia. The recommendations from 8/27/23 and 3/18/24 were not addressed, and the physician's response to the recommendation on 12/31/23 was not documented in the medical record. Additionally, the order for laboratory tests recommended on 5/16/24 was written on 5/24/24, indicating a delay in action. The Director of Nursing (DON) confirmed that the recommendations from 8/27/23 and 3/18/24 were not addressed and that the physician's follow-up to the recommendation on 12/31/23 was not documented in the medical record. The DON also reported that the order for laboratory tests recommended on 5/16/24 was written on 5/24/24. This lack of documentation and follow-up on the pharmacist's recommendations indicates a failure in the facility's process to ensure proper medication management and review for Resident #30.
Failure to Monitor Antipsychotic Medication
Penalty
Summary
The facility failed to ensure adequate monitoring with the use of an antipsychotic medication for one resident. The resident was admitted with diagnoses including Alzheimer's Disease, schizophrenia, and major depressive disorder. The resident was prescribed risperidone for schizophrenia, with a physician's order to check lipid panel every 6 months. Despite recommendations from the pharmacist on two occasions to obtain a fasting lipid panel, the last lipid panel was conducted over a year ago. The Director of Nursing confirmed that the most recent lipid panel was completed in February 2023.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in an 8% error rate. This was observed when an LPN administered bisacodyl to a resident without a corresponding physician's order and failed to administer a prescribed probiotic and loperamide. The resident, who was cognitively intact, had a physician's order for a probiotic daily and loperamide for loose stools. The LPN reported that the medications were not in stock, although they documented the probiotic as administered. The resident experienced loose stool/diarrhea later that day. The Director of Nursing confirmed that probiotics were kept as a stock medication in the facility.
Failure to Administer Pneumococcal Immunizations
Penalty
Summary
The facility failed to offer pneumococcal immunizations per CDC recommendations for two residents. Resident #24, who has diagnoses including diabetes and chronic kidney disease stage 3, was admitted and readmitted to the facility. The resident's medical record showed they received Pneumovax 23 in 2015 and refused Prevnar 13. Despite consent being given for a pneumococcal immunization in November 2022, the resident did not receive the recommended dose of PCV15 or PCV20 at least one year after their last dose of PPSV23, as per CDC guidelines. Similarly, Resident #69, who has diagnoses including Parkinson's Disease, hypertension, and obstructive sleep apnea, was admitted to the facility. The resident's medical record indicated they received Pneumovax 23 in 2011 and 2015. Although consent for a pneumococcal immunization was given in November 2022, the resident did not receive the recommended dose of PCV15 or PCV20 at least one year after their last dose of PPSV23, as per CDC guidelines. The Infection Preventionist confirmed that both residents were due for and had consented to the pneumococcal immunization but did not receive it.
Failure to Offer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer an updated COVID-19 vaccine to one resident (R69) of five reviewed. Resident #69 was admitted with diagnoses including Parkinson's Disease, hypertension, and obstructive sleep apnea. The resident was cognitively intact, scoring 14 out of 15 on the BIMS. The medical record showed that the last COVID-19 vaccine was received on 1/16/23, and there was no documentation indicating that the resident was offered the updated 2023-2024 COVID-19 vaccine. During an interview, the Infection Preventionist confirmed that the resident was due for another COVID-19 vaccine and admitted that there was no record of consent or declination from the resident.
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 153 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 East Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Campus Area | 1 mi | ★★★★★ | 11 | 0 |
| Medilodge Of East Lansing | 1.1 mi | ★★★★★ | 28 | 0 |
| Medilodge Of Okemos | 2 mi | ★★★★★ | 13 | 0 |
| The Willows At Okemos | 2.4 mi | ★★★★★ | 7 | 0 |
| The Willows At East Lansing | 3.5 mi | ★★★★★ | 11 | 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.