Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Caretel Inns Of Linden during CMS and state inspections, most recent first.
A resident with dementia, diabetes, protein-calorie malnutrition, and other comorbidities experienced significant undocumented weight loss over several months while the facility failed to obtain consistent monthly and weekly weights as required by its own guidelines and prior orders. Nursing staff did not complete or document a change-of-condition (SBAR) assessment despite provider notes describing worsening debility, decreased PO intake, and a notable drop in weight. The resident’s care plans continued to state that only limited assistance with self-feeding was needed, even though observations and staff interviews showed the resident was a total assist for eating and drinking and had been downgraded to a pureed diet. Dietary documentation contained gaps, and the dietary care plan was not revised to reflect the significant weight loss or updated diet and appetite-related medications, resulting in delayed care and contributing to a 9.23% weight loss in seven weeks.
A resident with moderate cognitive impairment and multiple medical conditions sustained a painful right-hand skin tear in the dining room when another resident with dementia and documented combative behaviors pushed the wheelchair and forcefully grabbed the resident’s hand. Staff did not witness the incident and only responded after the injured resident called for help or was seen bleeding. The injured resident later reported feeling unsafe and confined herself to her room. The aggressor’s behavior care plan already noted combative behavior, wandering, and hitting at others, but contained only a general intervention for positive interaction and was not revised with specific measures to manage his combativeness or protect other residents after the altercation.
A resident with pain and hemiplegia experienced significant medication errors when scheduled Cyclobenzaprine (Flexeril) doses were missed because the drug was unavailable, and nursing staff did not notify the physician or obtain an alternative despite a standing order for around‑the‑clock pain management. Pharmacy records showed a 30‑day supply should have remained in use, with multiple days of doses unaccounted for, and the medication was not stocked in the backup box. During the same period, a Fentanyl patch dated several weeks earlier was found still applied to the resident’s chest even though the order for the patch had been discontinued, and the DON was unaware it remained in place. These events occurred despite facility and pharmacy policies requiring medications to be administered as ordered and procedures to address unavailable or delayed medications.
The facility failed to maintain an active infection prevention program, with incomplete infection surveillance, missing environmental rounds, and an incomplete water management plan for legionella and other OPPP. Infection surveillance records were absent or incomplete for multiple months, and an IP identified UTIs and ESBL E. coli concerns among residents on the same hall. The facility also had dead-end plumbing, incomplete chlorine residual logs, and an LPN was observed using gloves only instead of the required gown and gloves for a resident on enhanced barrier precautions.
Backflow Prevention Missing on Cross Connections: Surveyors observed a hose attached to a spigot without a hose bib vacuum breaker in a sub kitchen, and a chemical dispenser attached to a utility sink downstream of an AVB without a wasting tee in janitor closets serving multiple hallways. The report states that AVBs cannot be under continuous pressure for more than 12 hours and cannot be subject to continuous pressure.
Expired supplements and OTC meds, along with unlabeled meds and a loose pill, were found in medication storage areas and carts. Surveyors observed expired Jevity 1.5 in the med storage room, expired Vitamin B-12 in a med cart, and Hydroxyzine, Sertraline, and a loose baby aspirin in another cart without proper resident labeling.
Improper Dumpster Area Maintenance: Surveyors observed a McDonald's wrapper, multiple dirty gloves, dark waste on the cement around the dumpster, and one dumpster lid left open during an environmental tour. The Maintenance Director stated the dumpster area is usually cleaned every other day, but the facility had fallen behind because of the holiday weekend. The deficiency was cited under 2022 Food Code 5-501.115 for refuse areas and enclosures.
Unclean resident rooms, bathrooms, and common areas: Multiple rooms on the 100 hall and a confidential group of residents on the 100, 200, and 300 halls had foul odors, clutter, overflowing trash, rust-stained sinks and toilets, soiled toilets with feces, and uncovered toothbrushes on bare sink surfaces. Residents and family members reported rooms were not cleaned as scheduled, and housekeeping staff acknowledged the bathrooms were very soiled and that staffing was limited.
Care plans were not reviewed and revised to reflect resident-specific needs for several residents. One resident with dementia, hospice services, repeated attempts to stand or toilet, and recent falls had general fall and behavior plans but no specific toileting or medication-related interventions. Another resident with MS and recurrent UTI/MDRO history had self-catheterization and infection-control orders, but the care plan lacked catheter details, hygiene specifics, and hand hygiene measures. Two other residents had falls or pressure injuries, yet their care plans were not updated to match the events, wounds, or declining condition.
A resident receiving hospice services had DNR documented on the face sheet, code status form, and physician orders, but the care plan incorrectly listed Full Code. The Social Services Manager confirmed the discrepancy and stated the care plan had been missed and was only updated later, creating inconsistent code status documentation in the chart.
PASARR assessments were not completed yearly or posted in the EMR for two residents. One resident had no 2025 PASARR on file, and another had outdated Level I and Level II PASARR documents with no current assessment posted. The SW stated annual PASARR reviews were required by policy and admitted the forms were not uploaded, despite being her responsibility as SS Director.
Failure to Provide Ordered Wound Care and Hospice Orders: A resident with diabetes, dementia, and other chronic conditions had a nose wound and a separate raw area under the lip, but only the nose had an order and the lip area had no assessment or treatment order. Two residents receiving hospice services also lacked hospice orders in the chart; one had hospice listed in a plan of care update but not in the care plan, and another died in the facility while on hospice without a physician order for hospice eval and treat.
A resident with severe cognitive impairment, dementia, weakness, and dependence for transfers and mobility fell and was sent to the hospital with a hematoma to the forehead and head injury. The resident’s care plans were not updated to reflect the actual fall, current incontinence status, or cognitive status, and staff stated the resident does not use the call light and is monitored by anticipating needs.
Lack of consent and behavior monitoring for psychotropic medications: Two residents receiving psychotropic meds had missing consent documentation and little to no behavior monitoring in the EMR. One resident with schizophrenia, depression, anxiety, and dementia had orders for Fluoxetine and Risperdal, but no behavior monitoring order and only two behavior entries. Another resident with dementia, anxiety, CKD, and heart disease was on multiple psychotropics, including ABH Gel/Ativan, Benadryl, Haldol, Risperdal, Xanax, and Quetiapine, but had no consent for the ABH gel and no documented behavior monitoring to show need or effectiveness.
The facility failed to maintain complete infection surveillance and did not identify or review organism resistance patterns in its antibiotic stewardship process. The IP stated she could report antibiotic use, but without infection surveillance data she could not determine what organisms or infections were being treated, whether MDROs were present, whether antibiotics were appropriate, or whether infection trends existed. Some months had line listings or resident worksheets, while other months had no surveillance data or summary reporting, despite the facility’s Antibiotic Stewardship policy.
Failure to assess, educate, and document flu and pneumonia vaccinations: The facility did not consistently assess residents for flu and pneumococcal vaccines on admission, did not provide a VIS for each vaccine, and did not document vaccination information in the EMR. The IP said vaccination history was supposed to be recorded but she lacked access to the state portal, and the Admissions Coordinator said she only informed residents vaccines were offered, had no training to provide vaccine education, and was unfamiliar with the VIS. Records for several residents were missing vaccine documentation, and the facility policy was outdated and stated consent served as education.
COVID Vaccination Education and Documentation Deficiencies: The facility failed to consistently assess residents for COVID-19 vaccination, provide a VIS for each vaccination, and document vaccination status in the medical record. An IP stated vaccination history was supposed to be entered in the EMR but past records could not be accessed, and review found no COVID vaccination information for four residents. An Admissions Coordinator said residents signed consent or decline forms, but she did not provide vaccine education, was unfamiliar with VIS, and had no training to discuss vaccine risks and benefits.
Dignity and Resident Rights: Missing Property and After-Hours Access Failures. Two residents experienced problems tied to dignity and resident rights: one resident’s prescription glasses were missing for nearly a year without documented follow-up, and another resident reported a missing purple outfit with conflicting statements about replacement and no initial proof it was addressed. Residents also described repeated failures to reach staff after hours, including unanswered phones, voicemail prompts, and delays getting back inside after outside visitation, while the admin acknowledged the after-hours access and phone issues.
The facility failed to provide a clean and homelike environment for two residents, resulting in unclean rooms and bathrooms, and a lack of clean linens. One resident's room was cluttered with bags of clothes and towels, and both residents' bathrooms had significant staining and cleanliness issues. The facility also lacked sufficient clean towels and washcloths, and was unable to provide housekeeping and linen policies when requested.
A resident with urinary retention experienced severe abdominal pain due to the facility's failure to maintain a functional bladder scanner. The scanner was inoperable, and staff were unaware of its condition, leading to complications during a trial void order. Attempts to reinsert a Foley catheter were unsuccessful, resulting in the resident being sent to the ER. The facility's policies on equipment maintenance were not followed, as no repairs or replacements were made for the broken scanner.
A resident with severe cognitive impairment and receiving hospice services developed four facility-acquired pressure ulcers due to the facility's failure to consistently implement preventive interventions. Despite having a care plan that included an air mattress and positioning aids, the resident was often observed without these measures in place. An LPN acknowledged the presence of new pressure ulcers and stated that interventions were in place, but the ulcers still developed. The facility's policy on skin management was not fully adhered to, contributing to the deficiency.
The facility failed to ensure that three CNAs completed the required 12.0 hours of annual competency training. CNA N's records lacked quantified hours and competency assessments, CNA P's records showed only 7.58 hours of training, and CNA O had no written record of completed in-service hours. The HR Director confirmed the absence of an electronic system to track training hours.
The facility failed to secure medication carts and ensure proper labeling and storage of medications. Unattended and unlocked carts were observed, with medications lacking proper labeling and topical treatments stored with oral medications. Staff acknowledged these lapses, which contravened facility policies.
The facility failed to treat residents with dignity, as call lights were not answered promptly, leading to soiled briefs and frustration. Staff were observed using personal phones during care, and grievances were not adequately addressed. Specific cases included a resident with a call light out of reach and another left in discomfort due to delayed assistance.
The facility failed to ensure a safe and sanitary environment, with an open furnace door in a resident's room and multiple sanitation issues in the kitchen, including stagnated water, sewage odors, and a water leak. The maintenance director was unaware of these issues, and no maintenance logs were available.
The facility failed to create timely, person-centered care plans for two residents within 48 hours of admission, leading to inadequate dietary management. One resident with cancer and respiratory issues struggled with chewing and required a different diet, while another with diabetes and chronic kidney disease had unmet dietary needs despite having a dialysis care plan. These care plans were delayed by four and six days, respectively, leaving staff without necessary guidance.
A resident with obstructive sleep apnea did not have a comprehensive care plan for their CPAP machine, leading to improper maintenance. The resident reported that the CPAP mask and tubing had not been changed since admission, and there was no documentation of cleaning or maintenance. The MDS Program Director acknowledged the oversight, which was contrary to facility policy requiring individualized care plans.
A resident with limited range of motion did not receive a restorative nursing program after being discharged from therapy, despite being a good candidate. The resident's medical record lacked documentation of a restorative plan, and the facility's Director of Nursing confirmed the absence of a restorative team. Efforts to train CNAs as restorative aides were ongoing but incomplete. The facility's policy required initiation of restorative programs post-therapy discharge, but this was not followed.
The facility failed to properly store, clean, and label respiratory equipment for residents, leading to potential health risks. A resident with sleep apnea reported that their CPAP mask and tubing had not been changed, and there was no documentation of cleaning. Another resident's nebulizer was improperly stored with moisture remaining, and a third resident's oxygen tubing was not labeled or dated. The facility's policies on equipment maintenance were not followed.
A facility failed to ensure complete documentation and assessment for a resident requiring dialysis. The resident, with a right-sided permacath, had inaccurate records and care plans that did not reflect the correct dialysis access site or provide proper monitoring instructions. The Hemodialysis Communication Forms lacked necessary information about the access site, and the facility's policy did not address permacath care, focusing instead on fistulas. Interviews with the DON and RN Unit Manager revealed they were unaware of these omissions.
The facility failed to ensure daily clinical staff postings were completed and available for review from January to August 2024. The DON stated that the Staffing Report, detailing the number of RNs, LPNs, and CNAs, was to be posted daily. However, reports for July 2024 were mostly missing, and several from January and February 2024 were incomplete. The Scheduler started the forms but relied on others for completion, leading to discrepancies. The receptionist was unaware of her role in this process, resulting in missing and incomplete staffing reports.
A facility failed to obtain informed consent for an antipsychotic medication prescribed to a resident with Alzheimer's dementia and other conditions. The resident's record contained an incomplete psychiatric consultation from a previous admission, lacking specific medication consent. This oversight violated the facility's policy requiring informed consent for psychotropic medications.
A resident with severe cognitive loss was sexually abused by another resident with moderate cognitive impairment. Despite a history of wandering and inappropriate behavior, there were no care plans or physician orders to address the behavior. The facility's intervention of hourly checks was ineffective, and documentation failed to reflect the resident's behavior, contributing to the incident.
A resident experienced a fall and subsequent spinal injury, but the facility failed to retain complete documentation and conduct a thorough investigation. The incident report was incomplete, lacking critical information, and the facility's investigation did not include necessary interviews or documentation to support conclusions. The Director of Nursing and Administrator acknowledged the deficiencies in the investigation and documentation process.
Two residents experienced delays in nutritional assessments and care planning, with inconsistent documentation of meal intake. One resident had difficulty chewing, and the other required dialysis, increasing nutritional risk. The facility failed to address these needs promptly, leading to deficiencies in care.
A facility failed to follow physician's orders and policy for enteral feeding for a resident with severe cognitive impairment, resulting in the resident not receiving the prescribed amount of feeding. The feeding was administered at a lower rate than ordered, and there was no documentation of the total intake. The DON acknowledged the rate was reduced due to nausea but lacked a system for documenting intake when adjustments were made.
A resident with lung cancer and metastasis experienced unrelieved pain due to the facility's failure to promptly assess and manage pain effectively. The resident's family reported ineffective pain medication and delays in processing new orders. The resident was given Tylenol, which did not alleviate the pain, and later received Morphine and Lorazepam simultaneously, which was too sedating. The care plan was delayed, and the facility did not adhere to its policy on resident rights.
Two residents in an LTC facility did not receive their prescribed medications due to unavailability. A Lidocaine Patch and Lantus insulin were not administered as ordered, resulting in a medication error rate of 6.25%. The facility's policy requires timely administration, but the medications were not in stock or delivered on time.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. Two residents did not receive their prescribed medications due to unavailability: one missed a Lidocaine patch, and the other missed a Lantus insulin injection. The nurse and DON were aware of the issues, which were attributed to stock shortages and recent admission delays.
A resident in an LTC facility did not receive their prescribed Lantus insulin due to unavailability, and there was a route error in the insulin order. Additionally, the resident's pain level was not assessed before administering Tylenol, despite an active order for Norco for severe pain. The DON acknowledged the medication unavailability due to the recent admission.
A facility failed to ensure proper documentation of hospice services for a resident with severe cognitive impairment, resulting in missing progress notes in the medical record. Despite being admitted to hospice care months earlier, the most recent note was from over two months prior. Staff interviews revealed that the hospice company was new to the facility and had not been sending updates as frequently as expected.
Failure to Monitor Weight, Document Change of Condition, and Update Care Plan for Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to monitor a resident’s weight per orders and facility guidelines, failure to complete and document a change-of-condition assessment when significant weight loss occurred, and failure to update the resident-centered care plan to reflect current needs. The resident had multiple diagnoses including protein-calorie malnutrition, diabetes, GERD, bipolar disorder, dementia, and hypertension, and was cognitively impaired with a BIMS score of 10/15, requiring assistance with care. Weight records showed gaps and significant losses: no weights documented for November 2025 and January 2026, a 5.82% loss between late October and late December 2025, and a 9.23% loss between early February and late March 2026. Despite facility guidelines requiring monthly weights and weekly weights with significant change or decline in intake, there were no current weight orders beyond an older weekly-weight order from 10/7/2024, and the DON could not account for the missing monthly weights. The facility also did not complete or document a change-of-condition assessment (SBAR or equivalent nursing assessment) in response to the resident’s significant weight loss. Provider notes in March 2026 documented worsening debility, decreased oral intake (approximately 25–50% of meals and sometimes 0%), and a documented weight drop from 143 lbs to 129.8 lbs. The PA ordered the resident to be weighed and referenced weight concerns on multiple dates, but there were no SBAR forms or nursing notes documenting a change-of-condition assessment related to the weight loss. The DON confirmed that such weight changes would be considered a significant change, that a change-of-condition assessment should have been completed, and that SBAR is the facility’s method for documenting such changes, yet none were found in the medical record. Although medical providers and dietary staff later documented weight loss and interventions, the nursing documentation of assessment and change-of-condition response was absent. In addition, the resident’s care plans were not updated to reflect current nutritional risk, weight loss, and ADL/feeding status. The bedside and nursing care plans continued to state that the resident needed only limited assistance with self-feeding using adaptive equipment, even though direct observations and staff interviews showed the resident was a total assist for eating and drinking and could not coordinate holding a cup. CNA and nurse interviews confirmed that the resident required feeding assistance and had been a total feed since therapy ended, but this was not reflected in the care plan. The dietary care plan, originally created in October 2024 and revised in January 2026, identified the resident as at risk for malnutrition and outlined monitoring for significant weight changes, but there were no further revisions to incorporate the documented significant weight loss, diet texture changes, or appetite-related medication orders. Dietary progress notes also showed gaps, with no notes between late October 2025 and late February 2026, and then none again until April 2026, despite the resident’s documented weight loss and risk for malnutrition. These combined failures resulted in delayed care contributing to a 9.23% weight loss over seven weeks. The deficiency was further illustrated by inconsistencies between practice and documentation. Observations on the survey date showed the resident in bed after breakfast with staff unable to state how much she had eaten, and later being totally fed 100% of a pureed lunch by a CNA. Staff interviews indicated that the resident had been eating better since a recent change to a pureed diet and that she could not feed herself, yet the care plan still described only limited assistance. The RD reported that she was on maternity leave during part of the period when weights and dietary notes were missing and was unaware of the December weight loss, stating that another RD should have addressed it. The DON acknowledged that the care plan did not reflect the resident’s current ADL and dietary needs, that there were no documented weekly weight orders despite RD and provider requests, and that there was no additional documentation to support appropriate monitoring and response to the resident’s significant weight loss. Overall, the facility’s inactions and documentation gaps—missing monthly and weekly weights, lack of change-of-condition assessment and nursing notes, and failure to revise the care plan to reflect total feeding assistance and significant weight loss—resulted in delayed care for a resident with known malnutrition risk and contributed to a 9.23% weight loss in seven weeks.
Failure to Protect Resident From Abuse and Inadequate Behavior Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the dining room. On the date of the incident, a female resident seated in her wheelchair in the dining room was approached by another resident who began pushing her wheelchair. The seated resident extended her right hand and asked the other resident to stop, at which point the other resident grasped the top of her right hand, causing a skin tear on the dorsal right hand. During the same timeframe, the aggressor resident was also observed on camera grabbing and shaking other residents’ wheelchairs in the dining area. Seven staff members later stated they did not witness the actual altercation and only became aware when the injured resident called for help or was observed bleeding. The injured resident had a history of generalized muscle weakness, need for assistance with personal care and ambulation, major depressive disorder, and type 2 diabetes, with a BIMS score indicating moderate cognitive impairment. She reported to the surveyor that a man in the building had “stabbed” her hand by digging his fingers between her thumb and index finger, and she stated that she did not feel safe and was staying in her room because that was where she felt safe. During a subsequent joint visit with the social worker and surveyor, she again expressed anger that the man was still “roaming the facility,” stated she felt unsafe outside her room, and said she had a plan to fight back if he came near her. Wound assessments documented a painful right-hand skin tear with sanguinous/serosanguinous drainage that persisted over multiple assessments. The resident who caused the injury had diagnoses including dementia, psychotic disorder with delusions, mood disorders, generalized anxiety disorder, and type 2 diabetes. His behavior care plan, initiated months earlier, documented that he could be combative, wander into other residents’ rooms, and hit out at other residents. The care plan goal was that he would have no evidence of behavior problems, with an intervention for caregivers to provide opportunities for positive interaction when passing by. Although the care plan showed a revision date after the altercation, it did not add any specific interventions to address his combativeness or to protect other residents from harm, and the behavior care plan was not updated following the resident-to-resident altercation. This failure to revise and individualize the behavior care plan, in the context of known behavioral risks and an actual physical altercation resulting in injury, constituted the cited deficiency in protecting residents from abuse.
Significant Medication Errors Involving Flexeril and Fentanyl Patch
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to both a scheduled muscle relaxant (Cyclobenzaprine/Flexeril) and a Fentanyl patch. During a medication pass observation, the nurse reported that the resident’s Flexeril was not available for the 1:00 PM dose and that it had also been unavailable for the 5:00 AM dose that same day. The nurse stated she had learned from the night shift that the last Flexeril dose was given the previous evening and that the pharmacy had reported it was too early to refill, with the next delivery not due until later in the month. The medication was not available in the emergency backup box, and the nurse did not notify the physician on call when the doses were missed. The resident had diagnoses including pain, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and depression, and had an opioid pain management care plan. The physician later confirmed that neither he nor his associates had been informed about the missed Flexeril doses and stated that missing a scheduled pain-relief medication without physician notification constituted a medication error. Pharmacy records showed that a 30‑day supply of Flexeril had been dispensed and should have lasted until a later date, indicating approximately nine days’ worth of doses (27 tablets) were unaccounted for. The DON acknowledged that the Flexeril was unavailable, that two doses were missed on the day of the survey, and that no provider had been notified when the medication first ran out. A second medication error was identified when a Fentanyl patch was observed on the resident’s chest, dated several weeks earlier, despite there being no current physician order for the patch. The resident requested its removal, stating it had been in place for weeks. Upon review, the DON confirmed that the Fentanyl patch order had been discontinued several weeks prior, yet the patch remained on the resident’s body and had not been removed at the time of discontinuation. The consultant pharmacist confirmed there was no active order for the Fentanyl patch and that it should have been discontinued, and also explained that Flexeril was not stocked in the backup box because the facility had not requested it and that early refills required facility authorization. Facility policies reviewed required that medications be administered as prescribed and that procedures be in place for when medications are delayed or unavailable, but these were not followed in this case, resulting in the identified medication errors.
Infection surveillance, water management, and PPE use deficiencies
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not maintaining an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, not completing routine resident and staff infection surveillance, and not ensuring appropriate PPE use. During interview, the Infection Preventionist stated she was new to the role, began collecting surveillance in April 2025, and that July 2025 was the most up-to-date information she had. She also stated that audits were being worked on but were not in writing, that hand hygiene, PPE use, and pericare education began in August 2025, and that environmental rounds had not been performed. Record review showed the facility’s infection surveillance was incomplete for much of the prior year. July 2025 had line listings, analysis, and reporting, but October through December 2024 lacked summary analysis, and January through June 2025 had no line listings, analysis, or reports. August 2025 had no surveillance data, and September 2025 had no line listing or summary report. Limited staff surveillance began in May 2025, and there was no antibiotic stewardship reporting for months without infection surveillance. The Infection Preventionist identified UTIs as an issue and noted two residents with ESBL E. coli on the same hall, both with concerns about bathrooms and rooms not being routinely cleaned or disinfected. Resident #67 was transferred to the hospital on 6/30/2025 and readmitted with UTI and sepsis, and the Infection Preventionist confirmed the facility had not been continuously monitoring infection surveillance during that resident’s stay. The facility’s water management records were also incomplete. During kitchen observation, dead-end plumbing was noted near the coffee machine. The Water Management Plan was missing a description of the building water system with both text and flow diagram, and the last Legionella meeting in the binder was dated 2/21/18. Chlorine residual and water temperature logs contained several empty lines for multiple rooms, and several chlorine residual readings were recorded as very high at 116.2, 111.2, and 77 ppm; the Maintenance Director stated the water temperatures and chlorine residuals must have been switched around. In addition, an LPN caring for a resident on enhanced barrier precautions related to an enteral tube was observed administering medication using gloves only and not wearing a gown, and the LPN stated a gown should have been worn in addition to gloves but it was an oversight.
Backflow Prevention Missing on Cross Connections
Penalty
Summary
The facility failed to ensure that appropriate backflow prevention was installed on cross connections. On 09/03/2025 at approximately 7:25 AM, surveyors observed a hose attached to a spigot without a hose bib vacuum breaker in the [NAME] sub kitchen. Later that morning, at approximately 9:15 AM, surveyors observed a chemical dispenser attached to a utility sink downstream of an atmospheric vacuum breaker (AVB) without a wasting tee in the janitor's closet in the 300, 200, and 100 hallways. The report also notes that AVBs shall not be installed where they will be under continuous pressure for more than 12 hours, and that a hose run from a faucet to a dispenser may involve a valve downstream of an AVB, which is not allowed because AVBs cannot be subject to continuous pressure.
Expired and Unlabeled Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that medications and supplements were labeled, stored, and disposed of properly. During observation of the main hall medication storage room, three expired bottles of Jevity 1.5 were found with a use-by date of 9/1/25. The DON and an LPN verified the finding, and the expired items were present in the medication storage area at the time of survey. Additional observations of medication carts showed further storage and labeling issues. In the 200 hall medication cart, one bottle of Vitamin B-12 was found expired in 08/2025 and was verified by an LPN. In the 100 hall medication cart, two medications, Hydroxyzine and Sertraline, were sitting in the top drawer without a resident name on them, along with one loose pill. RN C stated the unlabeled medications were left over from the prior night and belonged to a resident, but were no longer needed since the medications had come from the pharmacy. RN B identified the loose pill as baby aspirin and stated she was not sure how it got into the cart.
Improper Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area to reduce the presence of insects and rodents. During an environmental tour with the Maintenance Director, surveyors observed a McDonald's wrapper, multiple dirty gloves, and dark waste on the cement surrounding the dumpster, and one of the two dumpsters had its lid open. When interviewed during the tour, the Maintenance Director stated that the dumpster area is usually cleaned every other day, but that the facility had been falling behind because of the holiday weekend. The deficiency was cited under 2022 Food Code 5-501.115 for maintaining refuse areas and enclosures free of unnecessary items.
Unclean resident rooms, bathrooms, and common areas
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for residents on the 100 hall and for a confidential group of residents on the 100, 200, and 300 halls. During a tour of the building, multiple resident rooms on the 100 hall were observed with strong foul odors, cluttered surfaces, items on the floor and windowsills, overflowing wastebaskets, and bathrooms with large rust stains in sinks and toilets. Several toilets were also soiled with brown/gray stains and feces, and some resident rooms had uncovered toothbrushes stored on bare sink surfaces. Specific rooms were observed with rusty sinks and toilets, urine odor, soiled clothes on the floor, cluttered and soiled room and bathroom surfaces, and overflowing trash containers. Resident and family interviews described that rooms were not being cleaned regularly, with some residents stating their rooms were cleaned only once a week or less, despite being told they were supposed to be cleaned twice weekly. Residents reported very soiled toilets, overflowing trash, and rust-stained sinks. Housekeeping staff stated they tried to take care of the rooms as best they could and acknowledged the bathrooms were very soiled, while the housekeeping supervisor said the facility had only three housekeepers and that a third housekeeper was just starting orientation. Additional observations included soiled gloves left on a counter in a dining/day room for several hours and common area cleanliness concerns. The facility cleaning schedule showed the 100 hall was not cleaned daily, and there was no cleaning list for the 100 hall despite the documented cleanliness issues.
Care plans lacked resident-specific interventions and timely revision
Penalty
Summary
The facility failed to review and revise comprehensive care plans for four residents so that the plans reflected resident-specific interventions. For Resident #21, who had dementia, mood disturbance with anxiety, weakness, and was receiving hospice services, the record showed repeated restlessness, attempts to stand, self-transfer, and go to the bathroom, along with two recent falls. The care plan addressed behavior and fall risk in general terms, but it did not include specific interventions for the resident’s repeated attempts to stand, walk, or toilet herself, and the toileting plan was not added until after the falls had already occurred. The resident was also receiving Ativan as needed for anxiety, but this medication and its use were not addressed in the fall, behavior, or other care plans. For Resident #22, who had multiple sclerosis, neurogenic bladder, gait abnormality, urinary retention, a history of UTIs, and a BIMS score of 15/15, the record showed self-catheterization, current antibiotic treatment for a UTI, and enhanced barrier precautions for MDRO/ESBL E. coli. The care plans noted that the resident completed self-catheterization and referenced cleaning the area before catheterization, but they did not specify the catheter size, how many times the catheter could be used, exactly what area should be cleansed, or hand hygiene measures. The care plans also did not provide resident-specific interventions to help prevent further UTIs. For Resident #60, who had Alzheimer’s dementia, anxiety, hypothyroidism, chronic kidney disease, and heart disease, the record showed falls beside the bed with injuries including abrasion, redness, and a skin tear. The care plan identified fall risk related to confusion, gait and balance problems, incontinence, poor communication, medication side effects, and prior falls, but it was not reviewed or revised after the resident’s fall on 8/9/2025. For Resident #67, who had diabetes, stroke history, dementia, Parkinson’s disease, heart failure, depression, and other diagnoses, the record showed pressure injuries to the left ear, sacrum/coccyx, and left elbow, along with significant weight loss and a feeding tube after return from the hospital. The care plan addressed skin integrity risk and later listed pressure injuries to the sacrum and left elbow, but it did not include the left ear wound and was not updated to reflect the resident’s increased risk for skin breakdown related to weight loss and declining condition.
Code Status Not Consistently Documented in Care Plan
Penalty
Summary
The facility failed to ensure that Resident #21’s code status was accurately documented and accessible in the medical record care plan. The resident was admitted with diagnoses including dementia with mood disturbance with anxiety and weakness, and progress notes indicated the resident was receiving hospice services. The face sheet listed the resident’s code status as DNR, and the electronic medical record contained a Code Status Form showing Do-Not-Resuscitate was checked and signed by the resident’s responsible party, with physician signature documented later. Physician orders also identified the resident as DNR. Despite those records, the care plan for Resident #21 stated, “I am a Full Code,” with an initiation date matching the date the DNR form was signed. During interview, the Social Services Manager acknowledged that the face sheet, assessment form, and physician orders all indicated DNR, while the care plan remained incorrect and had been missed. The manager stated the care plan was updated to DNR on the day of the interview, almost one month after the code status order and over one month after the responsible party signed the DNR assessment form.
PASARR Assessments Not Completed or Posted Annually
Penalty
Summary
The facility failed to ensure PASARR assessments were completed yearly and posted in the residents’ clinical records for two residents, R7 and R10, out of three residents reviewed for coordination of PASARR and assessments. On 9/4/25, review of R7’s record showed no PASARR on file for 2025, with the last PASARR dated 7/3/2024 and no other PASARR forms found in the EMR. Review of R10’s record showed an outdated Level I PASARR dated 12/20/2021 and another outdated Level I and Level II PASARR dated 8/16/2024, with no 2025 assessment posted. The social worker was interviewed on 9/4/25 and stated that, per facility policy, the PASARR assessment must be completed within 25 days of admission and then annually. She admitted the PASARR forms were not uploaded into the EMR and that annual reviews must be done, submitted, and posted into the resident record. She also stated that ensuring the PASARR was accurately completed yearly and posted was her responsibility as the Social Services Director. R7’s record showed diagnoses including generalized muscle weakness, difficulty walking, dementia with obsessive compulsive disorders, depression, psychotic disorder with delusions, delirium, and mixed anxiety disorders, with a BIMS score of 05/15 and dependence for all ADLs except eating. R10’s record showed diagnoses including difficulty walking, dementia, bipolar disorder, depression, and anxiety disorder, with medications including Risperdal, Trazodone, and Lorazepam.
Failure to Provide Ordered Wound Care and Document Hospice Orders
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided according to orders, resident preferences, and goals for a resident with skin conditions. Resident #6, who had diabetes, dementia, chronic pain, arthritis, depression, anxiety, and moderate cognitive decline, was observed with a red, scabbed area on the tip of the nose and a red, raw area under the lip. The resident stated she had rubbed the areas and was unsure what was being done for them. The physician orders included treatment for the nose wound, but there was no order for the wound under the lip. Review of the MAR/TAR showed the nose treatment was documented as completed on some days, but when the wound was observed again, there was no evidence of ointment or a Band-Aid on the nose, and the resident said she had not had a Band-Aid that day. Nursing staff acknowledged the area under the lip did not appear to have an assessment or treatment order, and the progress notes did not mention that wound. The facility also failed to have hospice orders in place for two residents receiving hospice services. Resident #60, who had Alzheimer's dementia, anxiety, hypothyroidism, chronic kidney disease, and heart disease, had severe cognitive loss and required assistance with all care. Although a hospice plan of care update showed hospice services were being provided, the care plan did not mention hospice and there was no hospice order. Resident #65, who was admitted on hospice care with diagnoses including major depressive disorder, degenerative disease of the nervous system, hemiplegia and hemiparesis following cerebral infarction, and aphasia following cerebral infarction, expired in the facility while on hospice care. Record review showed there was no physician order for hospice to evaluate and treat the resident, and the Transitional Care Coordinator stated there should have been an order and that the absence of the order was due to miscommunication about who was entering it.
Failure to Supervise and Update Fall Care Plan
Penalty
Summary
The facility failed to provide appropriate supervision and failed to revise the care plan to prevent falls for a resident with generalized muscle weakness, difficulty walking, dementia, anxiety disorders, major depression, severe cognitive impairment, and dependence on staff for transfers, mobility, and most ADLs. The resident was also documented as always incontinent of bowel and bladder on the most recent MDS, but the care plan remained coded as occasionally incontinent and had not been updated since an earlier assessment. The resident’s cognitive impairment care plan was also not updated to reflect a BIMS score of 5/15. The resident’s fall care plan, which had been initiated for risk of falls, was last revised before the resident’s actual fall and was not updated after the fall that resulted in a hematoma to the right forehead. The incident report stated the resident was found on the floor lying next to the bed and was transported to the hospital by EMS. The report noted the resident was confused and incontinent, and that she had been seen within 2 hours before the fall and was wheeled back to her room after lunch and requested to go back to bed, with the call light within reach. Surveyor observation and staff interviews showed the resident later had bruising on the right forehead, around the right eye, and on the right side of the face, and was talking to herself and not coherent with questions. A nurse stated the resident had recently fallen and was sent to the hospital, and another nurse stated the resident does not use the call light and staff keep an eye on her and anticipate her needs. The hospital record documented a head injury with a large right frontal scalp hematoma and discharge instructions for adult head injury.
Lack of consent and behavior monitoring for psychotropic medications
Penalty
Summary
The facility failed to ensure that psychotropic medication use was supported by required consent and behavior monitoring for two residents. One resident with schizophrenia, major depressive disorder, anxiety disorder, and dementia had physician orders for Fluoxetine and Risperdal, but the record showed no physician order for behavior monitoring and only two behavior monitoring entries were documented, with no additional entries noted. During interview, the TCC stated the facility was working on a process to trigger a progress note when medication is given and acknowledged there was an issue with behavior monitoring. A second resident with Alzheimer's dementia, anxiety, hypothyroidism, chronic kidney disease, and heart disease was receiving multiple psychotropic medications, including ABH Gel/Ativan, Benadryl, Haldol, Risperdal, Xanax, and Quetiapine. The record showed no consent for the ABH gel combination that included Ativan, Benadryl, and Haldol. The MARs for June through September 2025 showed no behavior monitoring documenting the need for or effectiveness of the medications, and the Tasks section also showed no behavior monitoring for the past 30 days. The second resident’s record included behavior-related care plan interventions such as recording behavioral symptoms and side effects and monitoring target behaviors, but the documentation reviewed did not show behavior charting to support those interventions. The progress notes included one entry that the resident scratched a staff member during care, but there was no additional explanation of intent or interventions used to minimize or prevent the behavior. The Social Services Manager and DON both acknowledged the lack of consent and the lack of supporting behavior documentation for the psychotropic regimen.
Failure to Monitor Antibiotic Use and Resistance Patterns
Penalty
Summary
The facility failed to ensure a program was in place to monitor antibiotic use because resistance patterns of organisms were not identified and reviewed in the antibiotic stewardship meeting. During interview, the Infection Preventionist said she started in the role in December 2024 and completed CDC LTC training on 4/6/2025. She stated she began collecting infection surveillance in April 2025, while surveillance before that had been completed by someone else. When asked to review infection surveillance data for the prior year, she identified July 2025 surveillance with line listings, analysis, and reporting completed. There was no additional monthly infection surveillance for the year with line listings, analysis, and reporting for October 2024 through June 2025, and August 2025 and September 2025 also lacked complete surveillance data and summary reporting. Some months had individual infection worksheets for some residents, while other months had nothing. The Infection Preventionist stated that because there was no infection surveillance data including infectious organisms and infections, she could not track antibiotic resistance, and she could only report antibiotic use without additional data on what organisms or infections were being treated, whether resistant organisms such as MDROs were present, whether antibiotics were appropriate, or whether there were trends related to the infections. The facility policy titled Antibiotic Stewardship stated that the facility maintains an Antibiotic Stewardship Program to promote appropriate antibiotic use and reduce adverse events associated with antibiotic use.
Failure to Assess, Educate, and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure residents were consistently assessed for Influenza and Pneumococcal vaccinations on admission, were provided a Vaccine Information Statement for each vaccination, and had vaccination information documented in the electronic medical record. During interview, the Infection Preventionist stated that resident vaccinations were assessed on admission by the Admissions Coordinator, that she believed residents received education through a VIS for each vaccination, and that vaccination information was supposed to be placed in the medical record, but she did not have access to the Michigan vaccination portal to obtain past vaccination history. A review of the electronic medical record for Residents #27, #30, #68, and #70 found missing vaccination documentation, including no vaccination information for Flu, Pneumonia, or Covid for Residents #27, #68, and #70, and no Covid vaccination information for Resident #30. The Admissions Coordinator stated she informed residents that vaccinations were offered at the facility, including Flu, shingles, Covid, Pneumonia, and RSV, and that residents would sign a form consenting to or declining the vaccinations. She also stated she was not a nurse, did not provide education about each vaccination, was not familiar with a Vaccine Information Statement, and had not received training to talk to residents about vaccinations. Review of the facility policy titled Influenza and Vaccination, revised 12/16/2022, showed outdated information from the 2021-2022 influenza season and did not mention providing the mandatory Vaccine Information Statement; the policy also stated that consent would serve as education and that a new consent was not needed every year, which contradicted professional Standards of Practice.
COVID Vaccination Education and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that residents were consistently assessed for COVID-19, provided an educational vaccination information sheet for each vaccination, and had vaccination information documented in the medical record. During an interview, the Infection Preventionist stated that resident vaccinations were assessed on admission by the Admissions Coordinator, that she believed residents received education through a Vaccine Information Statement for each vaccination, and that vaccination information was supposed to be placed in the electronic medical record. She also stated she was unable to access the Michigan vaccination portal to gather past vaccination history. Record review showed no COVID vaccination information in the electronic medical record for Resident #27, Resident #30, Resident #68, and Resident #70. During an interview, the Admissions Coordinator stated that residents were informed vaccinations were offered at the facility and then signed a form consenting or declining, but she also stated she was not a nurse and did not provide education about the vaccinations. She further stated she was not familiar with a Vaccine Information Statement and had not received training to talk to residents about the benefits and risks of vaccinations.
Dignity and Resident Rights: Missing Property and After-Hours Access Failures
Penalty
Summary
The facility failed to ensure residents were treated in a respectful and dignified manner for two residents, involving missing personal items and barriers to reentering the building or reaching staff after hours. During Resident Council, a family member reported that a resident’s prescription glasses had been missing for almost a year with no follow-up or resolution, and residents described difficulty getting the facility phone answered when the office was closed. One resident reported that after 5:00 PM there were too many voicemail prompts and no callback, and another described being unable to get back inside for over an hour after returning from outside visitation because repeated calls and attempts to use the prompts did not reach staff. A confidential resident also reported being unable to reenter the building after ringing the doorbell and calling the posted after-hours number for half an hour. The front door closed automatically after office hours, residents were expected to use the back door, and the administrator acknowledged there was no receptionist after 5 PM, the backdoor buzzer only went to the receptionist, and no one was available to hear it. The administrator also stated the after-hours phone issue had been ongoing since January 2025 and that the phone lines were not being answered effectively. Resident #22 was admitted with multiple sclerosis, gait abnormality/stiffness, neuromuscular bladder dysfunction, history of UTIs, glaucoma, and anxiety, and had a BIMS score of 15/15. She reported a missing purple outfit consisting of leggings and a sweatshirt and said she had been told it had already been replaced, but she did not receive it. The administrator initially stated he had replaced the clothing but had no receipt or documentation, later said he gave her $23.00 to replace the outfit, and still had no receipt, grievance form, or proof that she received it at the time of the interviews.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by the conditions observed in the rooms of two residents. Resident #1, who was admitted with multiple diagnoses including dementia and schizophrenia, was found in a room cluttered with large bags of clothes and towels, some of which were not identified as belonging to the resident. The bathroom in Resident #1's room was observed to be unclean, with orange-brown stains in the toilet bowl and yellow stains on the floor beneath the sink. Additionally, there was a lack of clean towels and washcloths available for resident use, as noted during a tour of the facility's laundry and linen storage areas. Resident #5, who had severe cognitive deficits and required assistance with all care, was found to have a bathroom with a large dark orange stain in the sink and similar stains in the toilet. The floor was also soiled with yellow stains, and an unlabeled bedpan was left on a commode chair. The facility was unable to provide a housekeeping policy for daily cleaning or a linen policy when requested. The administrator acknowledged staff turnover in the housekeeping and maintenance departments, which may have contributed to the deficiencies observed.
Failure to Maintain Bladder Scanner Leads to Resident Complications
Penalty
Summary
The facility failed to maintain essential equipment, specifically the bladder scanner, in good repair, which was necessary for assessing residents with urinary retention. This deficiency was identified during the review of a resident who had been diagnosed with urinary retention, elevated PSA, chronic kidney disease, and chronic respiratory failure. The resident was on a trial void order, which required the use of a bladder scanner to monitor urinary retention. However, the scanner was found to be inoperable, and staff were unaware of its condition until it was needed. On the day of the incident, the resident experienced severe abdominal pain, and staff were unable to measure urinary retention due to the broken bladder scanner. Despite attempts to reinsert a Foley catheter, the procedure was unsuccessful, and blood clots were observed, prompting the need to send the resident to the emergency room for catheter reinsertion. Interviews with nursing staff and the nurse practitioner revealed that the bladder scanner's malfunction was not reported or addressed in a timely manner, leading to complications in the resident's care. The Director of Nursing and the Administrator were both unaware of the bladder scanner's condition until after the incident. The Administrator admitted that no attempts were made to repair or replace the equipment, despite its critical role in resident care. The facility's policies on equipment maintenance and bladder scanner usage were reviewed, highlighting the expectation for timely repairs and the provision of backup devices, which were not followed in this case.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to implement and carry out interventions to prevent the development of pressure ulcers for a resident, resulting in the development of four facility-acquired pressure ulcers. The resident, who is severely cognitively impaired and receiving hospice services, was observed with multiple pressure ulcers, including those on both elbows and the left and right iliac crest, which were identified as facility-acquired. The care plan for the resident included interventions such as an air mattress, wedge for positioning, and offloading of heels, but these were not consistently implemented, as observed during the survey. The resident was frequently observed lying on their back without the necessary positioning aids, such as a wedge cushion, and with inconsistent use of elbow protectors. The LPN interviewed acknowledged the presence of new pressure ulcers and stated that interventions like turning the resident every two hours and using elbow guards were in place, but the pressure ulcers still developed. The LPN also mentioned the completion of an Unavoidable Skin Condition Form, which was not initially found in the electronic medical record. The facility's policy on skin management outlines the need for a comprehensive care plan addressing risk factors, preventative devices, and regular evaluation of pressure injuries, which was not fully adhered to in this case.
Deficiency in CNA Annual Competency Training
Penalty
Summary
The facility failed to maintain the required annual-based competencies and education of 12.0 hours for three Certified Nursing Assistants (CNAs) reviewed. CNA N, hired in 2013, had an in-service training record that did not specify the number of hours attended, lacked competency assessments, and had no validation of lessons by the instructor. Similarly, CNA P, hired in 2023, had education checklists without quantified in-service minutes or competency assessments. CNA O, recently hired, had no written record of in-service hours completed during orientation. The Human Resources Director acknowledged the absence of an electronic learning system to track training hours and records for each staff member. Although an electronic tracking record for CNA P was later submitted, it showed only 7.58 hours of training, falling short of the required 12.0 hours. No records were provided for CNAs N and O. The facility's policy mandates maintaining individual in-service logs and ensuring evaluations for each in-service, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medication carts and treatment carts, as well as the appropriate storage of medications. On multiple occasions, medication carts were observed unlocked and unattended, with no nurse in the vicinity. This included a treatment cart in the 300-hall entrance and dining area, and a medication cart in the 300 Hall, which was left unlocked with resident information exposed on the computer screen. Additionally, medications such as Fluticasone nasal spray and Artificial Tears were found without proper labeling, lacking resident identification and open dates. Glucose monitoring test strips were also found open and undated. Furthermore, the facility did not adhere to its policy of separating topical treatments from oral medications. Topical creams such as capsaicin, hydrocortisone, and estradiol were stored alongside oral medications and breathing treatments in the medication cart, contrary to facility policy. The staff acknowledged these lapses, with nurses indicating that the carts should be locked and medications properly labeled and stored. The facility's policies, dated November 2021, clearly state that medication carts should be locked when not attended and that oral and topical medications should be stored separately.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a respectful and dignified manner, as evidenced by multiple observations and interviews. Residents reported that call lights were not answered in a timely manner, with some waiting up to 45 minutes to an hour for assistance, particularly for toileting needs. This delay in response led to residents experiencing soiled briefs and feelings of frustration, anger, and embarrassment. Additionally, call lights were often found out of reach, preventing residents from being able to summon help when needed. Further issues were identified with staff behavior, as residents reported that staff members were frequently observed talking on personal cell phones while providing care. This behavior was noted to be disrespectful and intrusive, as residents could overhear personal conversations. The facility also failed to adequately address grievances raised by residents, with reports indicating that grievances were not consistently followed up on, leaving residents feeling unheard and disrespected. Specific cases highlighted in the report include Resident #20, who was found with a call light on the floor, out of reach, and Resident #41, who experienced extended wait times for assistance, resulting in discomfort and pain. Resident #41 also reported an incident where she fell over in bed and was left in that position without assistance. These deficiencies reflect a broader issue of inadequate staffing and resource allocation, as evidenced by the lack of sufficient housekeeping and laundry services, leading to unclean hallways and delayed laundry returns.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in both resident care areas and the kitchen, potentially affecting all 55 residents. In one instance, a door leading to a furnace and piping in a resident's room was found open and could not be closed by housekeeping staff, posing a safety risk. The maintenance director later confirmed that the door was left open after a pest control inspection and was unaware it had not been shut or locked. Additionally, the main dining room floor was observed to be sticky, and a resident's room had a strong smell of urine with stained carpet, indicating a lack of cleanliness. In the kitchen, several issues were identified, including stagnated water with a sewage smell under the three-compartment sink, a non-functional chemical treatment machine, and drain flies. Another drain emitted a strong sewage odor and was not in use, while a third drain had a water leak causing a puddle on the floor. The maintenance manager was unaware of the leak, and no maintenance logs or records were available for review. These deficiencies highlight significant lapses in maintaining a sanitary environment, which could lead to foodborne illnesses and dissatisfaction with living conditions.
Failure to Implement Timely Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission for two residents, resulting in inadequate guidance for staff to provide effective care. Resident #307, who was admitted with multiple serious health conditions including cancer and respiratory issues, was observed having difficulty chewing and required a different textured diet. However, the care plan addressing his nutritional needs was not created until four days after admission, leaving staff without necessary instructions to address his immediate dietary needs. Similarly, Resident #308, who had complex medical conditions including diabetes and chronic kidney disease requiring dialysis, did not have a care plan addressing his dietary needs until six days post-admission. Although a dialysis care plan was in place, it lacked any mention of dietary requirements. This delay in care planning resulted in the absence of specific instructions for staff to manage his nutritional intake effectively, as evidenced by his partially eaten meal and non-verbal dissatisfaction with his breakfast.
Failure to Implement CPAP Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's use and maintenance of a CPAP machine. The resident, who was admitted with diagnoses including diabetes, weakness, and obstructive sleep apnea, was observed using a CPAP machine that was not properly maintained. The resident reported that the CPAP mask and tubing had never been changed since their admission, and there was no documentation in the medical record regarding the cleaning of the CPAP or the replacement of its components. Additionally, the care plan for the resident did not include any information about the use and maintenance of the CPAP machine. The resident, who had moderate cognitive impairment, indicated that they had long used a CPAP machine and were aware of the need for regular maintenance, such as changing the mask every 30 days. Despite the resident's awareness and requests for the mask to be changed, the facility did not address these needs. An interview with the MDS Program Director confirmed that a care plan for the CPAP should have been in place, but it was missed. The facility's policy requires that each resident have a current and individualized care plan developed within seven days of arrival, which was not adhered to in this case.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with limited range of motion, resulting in the potential for decline in independence and physical ability. The resident, who was cognitively intact, had impairments in both lower extremities and required varying levels of assistance with daily activities. Despite being discharged from physical and occupational therapy with a home exercise program, there was no documentation of a restorative therapy plan or program in the resident's medical record. Interviews with the resident revealed that she was unaware of any restorative therapy plan following her physical therapy. The Director of Nursing confirmed the absence of a restorative team and mentioned ongoing efforts to train CNAs to become restorative aides, although the training had not been completed. The Therapy Program Manager acknowledged that the resident was a good candidate for a restorative therapy program and that such a program would not hinder her access to future therapy services. The facility's policy on restorative nursing programs indicated that such programs should be initiated when a resident is discharged from formalized rehabilitation therapy. However, the policy was not followed, as evidenced by the lack of a restorative program for the resident. The Administrator noted that the restorative therapy program had been discussed in a quality assurance meeting, but it had not yet been implemented.
Improper Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage, cleaning, and labeling of oxygen and respiratory equipment for several residents, leading to potential health risks. Resident #23, who has moderate cognitive impairment and uses a CPAP machine for obstructive sleep apnea, reported that the CPAP mask and tubing had not been changed since admission, and there was no documentation of cleaning or maintenance. The resident indicated that the CPAP machine was provided by the facility, and the Director of Nursing (DON) confirmed that there was no batch order for cleaning, which should have been documented. Resident #34, who is cognitively intact and has chronic obstructive pulmonary disease, was observed with a nebulizer that had moisture and liquid remaining in the medication chamber, indicating improper cleaning and storage. The resident's family member was unsure about the frequency of nebulizer use, and the DON acknowledged that nebulizer equipment should be cleaned and dried before storage to prevent mold growth. The facility's policy requires nebulizer equipment to be washed and air-dried completely before storage, but this was not followed. Resident #9, who has severe cognitive impairment and uses oxygen therapy, was observed with oxygen tubing that was not labeled or dated. The resident was seen using a portable oxygen tank, and the oxygen concentrator tubing was found in a bag without a date. The DON and a registered nurse both indicated that the tubing should be labeled and dated according to facility policy, which was not adhered to. The facility's policy mandates that oxygen delivery devices be changed weekly and stored in a clean bag when not in use, but these procedures were not followed for Resident #9.
Incomplete Dialysis Documentation and Assessment
Penalty
Summary
The facility failed to ensure complete and accurate documentation and assessment for a resident requiring dialysis care. Resident #308, who has multiple diagnoses including chronic kidney disease and requires renal dialysis, was admitted with a right-sided permacath for dialysis. However, the facility's records, including physician orders and care plans, did not accurately reflect the resident's dialysis access site or provide appropriate monitoring instructions. The care plan incorrectly mentioned a graft or fistula instead of the permacath IV catheter, and there was no mention of the permacath in the care plan to prevent adverse events. Additionally, the Hemodialysis Communication Forms for the resident lacked information about the dialysis access site, which is crucial for monitoring potential adverse effects or infections. The facility's policy on dialysis care did not address the specific needs of residents with a permacath, focusing instead on fistulas. Interviews with the Director of Nursing and RN Unit Manager revealed that they were unaware of the omission and planned to investigate further. The hospital discharge instructions, which included keeping the permacath clean and dry, were not incorporated into the facility's plan of care.
Deficiency in Daily Clinical Staff Postings
Penalty
Summary
The facility failed to ensure that clinical staff postings were completed and available for review for multiple days from January 2024 to August 2024. This deficiency was identified through observation, interview, and record review. The Director of Nursing (DON) stated that the Clinical Staff posting document, known as the Staffing Report, was supposed to be completed daily by the Scheduler and posted on the wall by the nurses' desk. This document was intended to show the number of RNs, LPNs, and CNAs staffed each day, along with the total hours worked per shift and the resident census. However, upon review, it was found that the daily reports for July 2024 were missing, except for one day, and several documents from January and February 2024 were also missing or incomplete, lacking staff hours and census data. The Scheduler D explained that she started the forms with information from the nurses' schedule and then sent them to the nursing supervisor. On days she was not working, she would send the documents in advance to the receptionist for completion. However, the receptionist stated she did not handle these forms and was unaware of their contents. The Scheduler D acknowledged that some forms were incomplete and could not locate the missing staffing forms from July 2024. The facility's policy on the assignment of nursing care, which was reviewed and revised in August 2024, required nursing assignments to be based on the number of staff on the units, but this was not adhered to due to the incomplete and missing staffing reports.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of an antipsychotic medication for a resident, resulting in the potential for the administration of unnecessary medication. The resident, who was readmitted to the facility with multiple diagnoses including Alzheimer's dementia, depression, and anxiety, was prescribed Risperdal, an antipsychotic medication, without documented consent. A psychiatric consultation from a previous admission was found in the resident's record, but it did not specify any medications or provide clear consent for the current treatment. The facility's policy requires that residents or their responsible parties be informed of the risks and benefits of psychotropic medications and that informed consent be documented in the medical record. However, the documentation for this resident was incomplete and did not meet the facility's policy requirements. This oversight in obtaining and documenting informed consent for psychotropic medication use highlights a deficiency in the facility's medication management process.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #59, who had severe cognitive loss and required supervision with mobility, was found in her room with Resident #309, who had moderate cognitive impairment. Resident #309 was discovered by a CNA with his hand down Resident #59's pants. The CNA immediately intervened and reported the incident to the nurse and the administrator. The investigation revealed that Resident #309 had a history of wandering and had previously been involved in a consensual relationship with another resident. Despite this history, there were no care plans or physician orders in place to address Resident #309's wandering or sexually inappropriate behavior. The facility's intervention of implementing hourly checks was ineffective in preventing Resident #309 from entering female residents' rooms. The facility's documentation, including progress notes and social services assessments, failed to accurately reflect Resident #309's behavior. The discharge planning review did not mention Resident #309's sexually inappropriate behavior, and the facility's abuse reporting policy did not address resident-to-resident abuse. This lack of documentation and planning contributed to the failure to protect Resident #59 from abuse.
Incomplete Documentation and Investigation of Resident Fall
Penalty
Summary
The facility failed to retain documentation regarding an injury after a fall investigation for a resident, resulting in missed opportunities to prevent potential abuse or neglect. The incident involved a resident who was found on the floor by a CNA, attempting to leave the facility. The initial incident report was incomplete, with unchecked boxes and missing pertinent information, such as pain level and mental status. The resident was later diagnosed with an acute traumatic injury of the spine, which was not documented in the facility's investigation. The Director of Nursing (DON) acknowledged the incompleteness of the incident report and attributed it to an agency nurse who was responsible for filling it out. The DON, who was new to the position at the time, did not recall many details of the incident. The facility's investigation lacked interviews, staff involvement lists, and written statements, and there was no documentation to support the conclusion that neglect was not substantiated. The facility's policy required retention of internal investigation reports for four years and nursing incident reports for three years, but the documentation for this incident was not retained. The facility's Falls Management Guideline emphasized the importance of reviewing and updating the resident's plan of care following a fall, but this was not done in this case. The Administrator confirmed the investigation was incomplete and should have been retained, especially since it was reported to the State Agency.
Delayed Nutritional Assessments and Monitoring
Penalty
Summary
The facility failed to ensure timely interventions to promote nutrition for two residents, resulting in a lack of timely assessments and monitoring of their nutritional needs. Resident #307 was admitted with multiple serious diagnoses, including cancer and respiratory failure. Despite the family's concerns about the resident's difficulty chewing and the need for a different textured diet, the facility did not accurately document the resident's food intake or address the chewing problem until four days after admission. The initial dietary assessment and care plan were delayed, and the resident's nutritional needs were not promptly addressed. Resident #308, who was admitted with conditions such as diabetes and chronic kidney disease requiring dialysis, also experienced delays in nutritional assessment and care planning. The resident's dietary preferences were not assessed until five days after admission, and there was inconsistency in documenting meal intake. The resident was not eating well, and the facility did not consistently monitor his nutritional needs, despite the increased risk due to dialysis. The dietary profile and care plan were completed six days after admission, indicating a significant delay in addressing the resident's nutritional requirements. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, including participating in care planning. However, the delayed assessments and inconsistent documentation of meal intake for both residents indicate a failure to adhere to this policy. The lack of timely intervention and monitoring of nutritional needs for these residents highlights deficiencies in the facility's processes for ensuring adequate nutrition and care planning.
Failure to Follow Enteral Feeding Orders and Document Intake
Penalty
Summary
The facility failed to adhere to physician's orders and facility policy regarding enteral feeding for a resident with severe cognitive impairment and multiple medical conditions, including dysphagia and cerebral infarction. The resident was observed receiving enteral feeding at a rate of 50ml/hr, contrary to the physician's order of 60ml/hr for 16 hours. This discrepancy resulted in the resident not receiving the total ordered amount of 960ml of enteral feeding. Additionally, there was a lack of documentation regarding the total amount of enteral feeding infused, as the facility's Medication Administration Record (MAR) only indicated the start and stop times of the feeding. The Director of Nursing (DON) acknowledged that the feeding rate had been reduced due to the resident experiencing nausea, but there was no system in place for staff to document the total intake when the rate was adjusted. The facility's policy on enteral tube care and maintenance requires the pump to be cleared at the end of each shift after documenting the total amount infused, which was not followed. The DON assumed that the resident was receiving the total ordered amount based on staff signing off on the order, despite the lower infusion rate and lack of documentation.
Inadequate Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of lung cancer with metastasis to the liver and bone, pulmonary edema, respiratory failure, pneumonia, and glaucoma. Upon admission, the resident was not promptly assessed or provided with effective pain relief, resulting in the resident experiencing significant pain and discomfort. The resident's family reported that the pain medication provided was not effective, and there was a delay in processing new medication orders from the physician. The resident was initially given Tylenol, which did not adequately manage the pain, as indicated by the resident's pain rating of 10 on a 0-10 scale. Further complications arose when the resident was administered Morphine and Lorazepam simultaneously, which the family and resident found too sedating. The facility's care plan for the resident was not initiated until two days after admission, despite the resident's high risk for pain due to their medical condition. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, and allowing them to participate in care planning, which was not adhered to in this case.
Medication Unavailability Leads to Errors
Penalty
Summary
The facility failed to ensure that medications were available and administered timely as ordered for two residents, resulting in medication errors. During a medication administration observation, it was noted that a Lidocaine 4% Patch for one resident and Lantus insulin for another resident were unavailable. The Lidocaine Patch was not in stock, and no backup supply was available, leading to a delay in administration. The insulin was unavailable because the resident had just been admitted, and the medication had not yet been delivered by the pharmacy. The Director of Nursing confirmed that the Lidocaine Patch was reordered three days prior but was not delivered as expected. The insulin was not available in the backup medication supply, and the pharmacy had not restocked it. The facility's policy requires medications to be administered as prescribed, but the unavailability of these medications led to a medication error rate of 6.25% during the observation period. The failure to provide these medications as ordered resulted in potential adverse reactions for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate during a medication administration observation. This deficiency was identified when two medications were omitted for two residents. The first resident, who was cognitively intact with a BIMS score of 15/15, did not receive their prescribed Lidocaine 4% patch due to its unavailability in the facility. The nurse attempted to locate the patch in the stock/storage medication rooms but found none available and informed the Director of Nursing (DON) about the situation. The patch was reordered three days prior but was not delivered as expected. The second resident, admitted with multiple diagnoses including diabetes mellitus, did not receive their scheduled Lantus insulin injection because it was unavailable. The nurse discovered the absence of the insulin while preparing the resident's medication and was unable to find it in the backup kiosk. The DON explained that the insulin was unavailable due to the resident's recent admission and the pharmacy's delay in restocking. Both incidents contributed to the facility's medication administration error rate exceeding the acceptable threshold.
Medication Errors and Pain Management Deficiency
Penalty
Summary
The facility failed to prevent significant medication errors for a resident, resulting in the potential for serious adverse effects. The resident, who was recently admitted with multiple diagnoses including diabetes mellitus and vertebrogenic low back pain, did not receive their prescribed Lantus insulin injection due to its unavailability. Nurse K, responsible for administering the medication, was unable to locate the insulin in the backup medication supply and did not administer it as scheduled. Additionally, there was an error in the medication order for Insulin Glargine, which incorrectly stated to administer it by mouth, indicating a route error. Furthermore, during the morning medication pass, Nurse K did not assess the resident's pain level before administering a single tablet of Tylenol, despite the resident expressing a pain level of 6 out of 10 and a preference for stronger pain relief. The resident had an active order for Norco for moderate to severe pain, which was not considered. The Director of Nursing acknowledged the unavailability of the Lantus insulin due to the recent admission, and the facility's policy was reviewed, highlighting the need for proper medication administration and availability.
Failure to Document Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in the absence of progress notes in the medical record. The resident, who is severely cognitively impaired and receiving hospice services, was admitted to the facility with diagnoses including dysphagia, cerebral infarction, traumatic brain injury, and pressure ulcers. A record review revealed that the most recent hospice note in the electronic medical record was from over two months prior, despite the resident being admitted to hospice care several months earlier. Interviews with facility staff, including the medical records personnel and the Director of Nursing, confirmed the lack of recent hospice documentation. The medical records staff acknowledged that the hospice company involved was new to the facility and had not been sending notes as frequently as other companies, which typically provide updates within a week. The Director of Nursing stated that the goal is to receive progress notes weekly, aligning with the facility's policy that emphasizes regular communication and documentation from hospice agencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Linden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fenton Healthcare | 3.6 mi | ★★★★★ | 5 | 0 |
| Argentine Care Center | 3.6 mi | ★★★★★ | 6 | 0 |
| Wellbridge Of Fenton | 4.5 mi | ★★★★★ | 9 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 7.6 mi | ★★★★★ | 23 | 0 |
| Wellbridge Of Grand Blanc | 8.4 mi | ★★★★★ | 14 | 0 |
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