Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage House Nursing And Rehabilitation during CMS and state inspections, most recent first.
Food storage, sanitizing, and equipment cleanliness deficiencies were observed throughout the kitchen and unit kitchenette areas. Expired ready-to-eat foods were found in the walk-in cooler, uncovered baked goods were left in dry storage, undated foods were present in unit refrigerators, sanitizer levels were below required ranges for the dishwasher and wiping cloth solution, the meat slicer had residue buildup, the ice machines showed soil and calcification, the ice machine drain line was improperly positioned, and ice was found in a handwashing sink basin.
Infection Control Failures with EBP, Linen Handling, and Water Management: Staff did not follow EBP during high-contact care for two residents, including IV PICC access for a resident with MRSA history and a PICC line, and did not wear gowns as required. Staff also transported soiled linen improperly by dragging a bag on the floor and carried uncovered clean linens through the facility and into an EBP room. In addition, a hand sink tested with zero free chlorine residual, despite the facility’s water management plan and CDC guidance requiring detectable disinfectant residual in potable water.
Meal service failed to provide palatable food, include condiments consistently, and honor a resident’s food preferences. Surveyors observed trays being passed on the halls, meals arriving cold or dry, and residents reporting overcooked or undercooked items, missing condiments, and tray errors that required staff to return to the kitchen. A resident with PCM, schizophrenia, bipolar disorder, and cognitive impairment reported that he repeatedly did not receive the cheeseburgers he ordered and was instead served chicken or grilled cheese despite documented dislikes of chicken, rice, and vegetables. Residents also raised multiple food complaints in council, including poor taste, appearance, temperature, and inaccurate meal delivery.
The facility failed to provide ABN notices for 2 of 3 sampled residents, and no ABNs were found in the charts. The RN/MDS nurse said she only completed NOMNCs, while the business office could not produce the ABNs. The NHA acknowledged that ABNs were supposed to be issued so residents knew the possible amount due after Medicare Part A ended, but staff had not been doing them and therapy had previously handled the process.
A resident with repeated falls, including a fall that caused a fractured wrist and new dx of A. fib and dizziness, had a care plan requiring q2h and PRN monitoring for compliance with a soft cast and sling. However, MAR/TAR and EMR review found no documentation of the required monitoring, and the RN/unit manager stated the intervention was missed and only monitored for 3 days.
Inadequate bathing and grooming care: A resident with dementia and other medical conditions missed multiple preferred showers with no explanation documented, another resident with ESRD and diabetes said weekly wash-ups were not enough and received bed baths more often than showers, and a third resident with bipolar disorder, anemia, and DM was observed with long nails, dry skin, and unshaven facial hair while stating they still needed a shave. The records showed inconsistent bathing care, limited showering, and missing care plan documentation related to shaving.
A resident with hemiplegia, aphasia, dysphagia, and respiratory failure developed a significant RLE flexion contracture after therapy discharge. Records showed no care plan, Kardex, or progress note documentation of stiffness or contracture formation, and therapy screens initially noted no changes before later reporting increased difficulty with bed mobility and transfers. The resident was observed in bed with the R leg bent tightly against the body, and staff reported the hand and foot had been contracted for months.
A resident with intact cognition, ADL dependence, and diagnoses including acute cystitis and DM reported stomach pain and later had a positive urine culture for Proteus mirabilis. The facility notified the physician of the UA and awaited C&S, but when the final susceptibility resulted, the nurse placed the lab in the doctor’s binder instead of calling right away, and the resident was later sent to the hospital with acute cystitis listed on the discharge summary.
Delayed ileostomy assessment and ostomy care for a resident with total colectomy, ileostomy, and cerebral palsy. The admission assessment did not document key stoma and peristomal skin details, the MDS listed a colostomy, and ostomy care/appliance changes were not provided as ordered until after admission. On observation, the resident had a right abdominal appliance with stool and mildly reddened surrounding skin.
Unsecured medication carts and unlabeled open biologic pens were found during observation. Two carts at the nurses’ station were left unlocked and unattended, with a medication cup left on top of one cart after a resident refused the dose. In the med room refrigerator, two residents’ open Ozempic pens were partially used but lacked resident identifiers and open dates. The UM confirmed the pens should have been labeled and dated and that unlocked, unattended carts were not acceptable.
A high fall‑risk resident with vascular dementia, severe cognitive impairment, prior falls with injury, and existing vertebral fractures experienced three unwitnessed falls in their room over a short period. The resident required extensive ADL assistance and had a documented high fall‑risk care plan, yet each fall occurred in the room without staff present, resulting in elbow bruising and skin tears and a deep laceration to the hand that required sutures. The DON acknowledged awareness of the resident’s fall history and risk factors and reported that the facility did not provide continuous bedside supervision, instead relying on increased visualization and more frequent room checks, which did not prevent the repeated unwitnessed falls.
The facility failed to properly label and secure medications, with multiple instances of unlabeled and undated medications found in medication carts and refrigerators. Additionally, medication refrigerator temperature logs were incomplete, and a treatment cart was left unlocked. Staff interviews revealed non-compliance with facility policies on medication storage and monitoring.
The facility failed to ensure the accuracy of the CMS 802 form for three residents, leading to incorrect documentation of antibiotic treatment for UTIs and omission of dialysis therapy. The errors were due to manual entry mistakes and issues with updating the form, resulting in incomplete resident assessments.
A resident reported that an LPN left unrecognized pills in their room without explanation, which were later identified as Tums instead of the prescribed Simethicone. The LPN admitted to administering Tums without a healthcare provider's order and leaving medications at the bedside, assuming the resident could self-administer. The facility's DON confirmed that medications should not be given without orders, indicating a breach in protocol.
The facility failed to monitor drug regimens for four residents, leading to unnecessary medication administration. A resident received Risperidone without proper indication, while another was given Ramelteon and Aripiprazole without relevant diagnoses. A third resident was on a prophylactic antibiotic without a risk-benefit analysis, and a fourth received Olanzapine without documented consent or specific behavior identification.
A resident received levothyroxine with other medications and supplements instead of on an empty stomach as prescribed. The facility's policy requires medications to be administered safely and as prescribed, but the medication was given at 7:00 AM instead of the prescribed 5:00 AM. The error was due to an incorrect medication order entry by an LPN, which was confirmed by the RN Unit manager.
A resident with severe cognitive impairment and specific dining needs was not consistently provided with required assistive dining equipment, such as a Scoop plate and Kennedy cup, as outlined in their care plan. Observations revealed the resident often ate without these aids, and the Kennedy cup was found empty and unused. The DON was informed of these deficiencies.
The facility failed to maintain proper infection control practices, as observed with improper storage of gloves and handling of clean linen. Gloves were found exposed on a counter, and a CNA carried clean linens against their uniform, contrary to facility expectations. The DON confirmed the improper storage, and the IC Nurse was informed.
A resident with dementia and bone disorders reported ankle pain after an incident, but the facility failed to document the administration of Tylenol and the resident's complaints. Despite staff awareness, there was no record of the pain or medication in the resident's medical records, leading to a deficiency in care.
A resident was discharged from an LTC facility with another resident's medications due to a failure in following proper discharge procedures. The nurse responsible did not complete the necessary medication reconciliation or verify the medications, resulting in the resident receiving multiple incorrect medications. The facility's policy for a safe and orderly discharge was not adhered to, leading to this deficiency.
Food Storage, Sanitizing, and Equipment Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain food service best practices in multiple areas of the kitchen and unit kitchenette areas. During the initial kitchen tour, shredded lettuce with a best buy date of 5/5/26 and parmesan cheese blend with a use by date of 5/10/26 were observed in the walk-in cooler. The Dietary Manager stated the parmesan cheese blend is kept for a week, and the report cited the 2022 Food Code requirement that refrigerated ready-to-eat time/temperature control for safety food be consumed, sold, or discarded by the expiration date. Sanitizing and warewashing practices were also found deficient. Chlorine testing of the low temperature dishwasher showed zero, and the sanitizer bucket feeding the dishwasher was very low. The Dietary Manager stated he usually checks the sanitizer when he first gets to work, but had not yet done so that day. Later, the sanitizer bucket tested at 50 ppm with quaternary sanitizer test strips, while the facility instructions for the 2-compartment sink stated the sanitizer should read between 150-400 ppm with a 200 ppm target, and the facility policy required 150-200 ppm quaternary ammonium compound. Additional observations showed food and equipment storage and cleanliness issues. A tray of corn bread and blueberry muffin was left uncovered in the dry storage room. The drain line to the ice machine was observed sitting inside the drain in the main dining room. A meat slicer stored in the office adjacent to the kitchen had built-up residue near the blade. In the unit 5 and 6 kitchenette refrigerator, undated yogurt outside its original container was observed, and in the unit 1 and 2 kitchenette refrigerator, a bacon, broccoli, and cheese meal was left undated. Black splotches and calcification were also observed on the interior walls of the ice machine in the unit 1 and 2 kitchenette, and ice was observed sitting inside the basin in the hand sink in the dining area.
Infection Control Failures with EBP, Linen Handling, and Water Management
Penalty
Summary
The facility failed to follow infection control practices for enhanced barrier precautions during high-contact care for two residents, failed to appropriately transport clean and dirty linen throughout the facility, and failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. On 05/12/2026, Maintenance Director T tested free chlorine residual at a hand sink in Lakeview room and found zero in both hot and cold water. When asked what the desired range was, he stated around 0.5. The facility’s water management plan stated it includes a system to monitor control limits and effectiveness of control measures and a plan for when control limits are not met or control measures are not effective. CDC guidance dated 01/03/2025 stated to ensure disinfectant residual is detectable throughout the potable water system. On 05/11/2026, CNA W was observed dragging a large clear plastic bag containing a large amount of soiled linen on the hallway floor and then entering the dirty linen closet with the bag. When asked why the dirty linens were not separated into multiple bags, CNA W stated that they did not bag up the dirty linen. The facility’s linen policy stated that all soiled linen must be placed directly into a bag and that clean linen will remain hygienically clean. Resident #16 had an order for enhanced barrier precautions every shift for a history of MRSA and was observed with an EBP sign and PPE caddy at the room entrance. During care, CNA Y and CNA X were on either side of the bed with their uniforms touching the bedding, the resident was unclothed after a bed bath, and neither CNA wore gowns. Dirty clothing was on the floor and washcloths were tossed into the dirty pile. CNA X was also observed carrying uncovered clean linens against the uniform, entering and exiting the resident’s EBP room with clean linens, and then carrying more uncovered clean linens to another room. Resident #3 was admitted with acute respiratory failure, bacteremia, endocarditis, sepsis enterococcus, and a PICC line for IV antibiotics; the resident’s BIMS score was 15/15. During IV PICC access and medication administration, Nurse I and Nurse J wore gloves but did not wear gowns, despite the resident being on EBP for the PICC line. The ICP nurse acknowledged the improper PPE use and stated that gown and gloves were required for IV PICC medication administration under EBP.
Meal Service Failed to Meet Resident Preferences and Food Quality Expectations
Penalty
Summary
The facility failed to provide palatable food products during meal service, failed to follow one resident’s stated meal preferences, and failed to address repeated food complaints raised in resident council. During observations of breakfast and lunch service, surveyors saw trays being passed on the units, meals plated in the dining room and sent to resident rooms, and multiple instances where condiments were not included on trays. Residents and staff reported that trays often sat in hallways while aides went back to the kitchen for missing items, and several residents stated that food arrived cold, dry, overcooked, undercooked, or otherwise unappealing. One resident stated that the food was often overcooked or undercooked, another said the food was cold when received in the room, and others reported that condiments such as ketchup, mustard, and mayonnaise were not provided unless specifically requested. Resident #13 had diagnoses including toxic encephalopathy, protein calorie malnutrition, dyskinesia, schizophrenia, and bipolar disorder, and the MDS showed a BIMS score of 11/15. The resident’s record documented dislikes of chicken, rice, and all vegetables, and the care plan directed staff to honor preferences as able. Despite this, the resident reported that he ordered two cheeseburgers for lunch but was first served a chicken sandwich, then a grilled cheese sandwich, and only later had the order re-requested. The resident stated he rarely received what he ordered and that staff commonly told him the facility was out of the requested item. The corporate RD reviewed the resident’s preferences and confirmed that the tray ticket and meal choices should have reflected those preferences. At the resident council meeting, 11 residents reported multiple meal concerns, including grilled cheese that was not grilled, vegetables that were overcooked or undercooked, meats that were hard to chew, meals that did not match the meal ticket, and gravy that was thick, lumpy, and cold. Additional interviews with residents and anonymous CNAs and nurses described frequent tray errors, repeated trips back to the kitchen for missing items, and meals sitting in hallways while staff retrieved condiments or corrected orders. Facility observations also showed meal service practices that included trays being passed quickly on the halls, limited dining room participation, and food items such as dry chicken sandwiches and trays with only a single condiment packet for multiple food items.
Failure to Provide ABN Notices for Medicare Non-Covered Services
Penalty
Summary
The facility failed to provide Advanced Beneficiary Notice of Non-coverage (ABN) notices for 2 of 3 sampled residents, identified in the report as residents #7 and #87. Record review of the facility’s ABN instructions showed that when Medicare is not likely to cover a specific item or service, the resident or representative must be notified before the service is provided, and the signed ABN must be retained on file. During interview and record review, the RN/MDS assessment nurse stated that she only completed NOMNCs and that ABNs were handled by the business office. However, when the surveyor asked the business office person for the ABNs for the sampled residents, no documents were produced. In a meeting with the NHA and business office person, it was acknowledged that no ABNs were found in the residents’ charts. The NHA stated that ABNs are supposed to be issued so residents know the possible amount due after coming off Medicare Part A, but said none were present and staff had not been doing them, stating that therapy usually completed the ABNs. The business office person said the issue had fallen through the cracks and was missed. The NHA later stated that the business office would be doing ABNs going forward and that therapy had previously done them, but the NHA did not know when ABN issuance stopped. An audit of residents in the facility with no ABNs issued identified six residents, and discharged residents without ABNs were not counted.
Failure to Document Required Post-Fall Monitoring
Penalty
Summary
The facility failed to follow the comprehensive care plan for post-fall interventions for Resident #7. After a fall on 4/3/2026 that resulted in right wrist pain, an ER transfer, and a fractured wrist, the resident was diagnosed with A. fib and dizziness. The comprehensive care plan dated 4/4/2026 included interventions to monitor every 2 hours and PRN for compliance with the soft cast and sling and to ensure the resident was assisted with all needs. During record review of the April and May 2026 MAR/TAR and the electronic documentation tab, no documentation was found to support the required monitoring. RN/unit manager A stated that the intervention was missed and that the resident was only monitored post-fall for 3 days, although the monitoring should have been continuous every 2 hours and PRN. The facility records also showed prior falls on 12/20/2025 and 1/8/2026, and the care plan documentation stated that person-centered care plans should include measurable objectives and timetables to meet the resident's needs.
Inadequate bathing and grooming care
Penalty
Summary
The facility failed to provide adequate grooming and showers according to resident preferences for three residents reviewed for ADLs, resulting in resident complaints and unkempt appearances. Resident #7, who had diagnoses including adult failure to thrive, moderate protein-calorie malnutrition, dementia, a wrist fracture, anxiety, psychotic disturbance, unsteadiness on feet, and personality disorder, was assessed as needing set-up assistance from one staff member for bathing/showering and preferred showers. The record showed missed showers on multiple dates, with no documentation explaining why a shower was not given on some occasions and only one note documenting an attempted shower. On one date, antifungal powder was applied under both breasts for redness. Resident #75, who had end stage renal disease with dialysis dependence, hypertensive heart and chronic kidney disease, malignant neoplasm of the right breast, heart failure, muscle weakness, and diabetes, stated that weekly wash-ups were not enough and that she preferred showers. Her care guide called for bed showers/bed baths on Sunday and Wednesday afternoons and as needed, and the task record showed showers only on two dates while bed baths were provided on several other dates. Resident #16, who had bipolar disorder, anemia, and diabetes mellitus and required assistance with personal hygiene and oral care, was observed with long, jagged nails with brown residue, unshaven facial hair, and dry skin buildup on both feet. The resident stated they sometimes received a bed bath instead of a shower, reported shower days of Tuesday and Friday, and said they needed a shave; the care plan did not include the resident's brother visiting to shave them, although a CNA stated the brother comes in and shaves the resident.
Failure to Maintain ROM and Prevent Contracture Formation
Penalty
Summary
The facility failed to provide appropriate care to maintain and/or improve range of motion for one resident and did not prevent the formation of a right leg contracture. The resident was admitted with diagnoses including hemiplegia and hemiparesis, dysphagia, acute respiratory failure, aphasia, and hypertension. The record review found no care plan, Kardex, or progress note documentation indicating any decline, stiffness, or contracture formation before the issue was identified. The resident had been discharged from therapy in the winter when the affected side was described as flaccid, and therapy staff later reported that the resident’s right side had been like a “wet noodle.” Therapy staff stated the resident was placed back on therapy about one month before the survey because of the need for stretching and assistance with bed mobility and transfers, and that the right hamstring area was very tight. Therapy measurements showed the right leg contracture at -70 degrees flexion, and therapy leadership stated the resident was being worked toward 0 degrees. The therapy director also stated baseline measurements were not completed for newly admitted residents because therapy focused on function in the facility. The resident’s therapy records showed a referral screen on 1/9/2026 stating no changes per CNA, but a later screen on 4/2/2026 noted increased difficulty getting in and out of bed and increased difficulty transferring to and from the wheelchair. A therapy evaluation on 4/8/2026 requested assessment for declining mobility, reduced strength in the left upper and lower extremities, and contracture formation in the right lower extremity. During observation, the resident was seen in bed with the right leg bent at the knee and resting on the stomach/chest area. Staff interviews indicated the hand and foot had been contracted since mid-January 2026, and a PTA stated that during the January screen no concerns were reported because she did not physically assess the resident.
Delayed Notification of Positive Urine Sensitivity Result
Penalty
Summary
The facility failed to timely notify the physician of a positive urine sensitivity result for Resident #107, who had intact cognition, required assistance with activities of daily living, and had diagnoses including acute cystitis, diabetes mellitus, and unsteadiness on feet. The resident stated on 4/22/2026 that he was not feeling well and that his stomach hurt. Progress notes show the physician was notified of urinalysis results on 4/25/2026 while awaiting culture and sensitivity results, and the culture results were received on 4/26/2026 with a note that the physician was notified and sensitivity was still pending. The urine culture later finalized as positive for Proteus mirabilis with susceptibility results, but the record showed a handwritten note indicating the resident was sent to the hospital and another note stating the lab was placed in the doctor’s binder rather than the doctor being called right away. The resident was sent to the hospital on 4/27/2026 due to chest pain, and the hospital discharge summary listed acute cystitis among the discharge diagnoses. During interview, the Infection Control nurse stated the facility waited for sensitivity before treatment and acknowledged that the nurse did not call the doctor immediately when the sensitivity came back.
Delayed Ileostomy Assessment and Ostomy Care
Penalty
Summary
The facility failed to assess and monitor an ileostomy for Resident #108, who was admitted with diagnoses including total colectomy with ileostomy, left leg fracture, and cerebral palsy and required assistance with all activities of daily living with intact cognition. The record review showed physician orders for colostomy care every shift and as needed and for changing the appliance every 3 days as needed, both starting on 5/7/2026, but the treatment administration record showed the ostomy appliance was not changed until 5/8/2026 and colostomy care was not provided until the evening of 5/7/2026. During interview and record review, the wound nurse stated the admission assessment identified a right iliac crest ileostomy, but the admission assessment did not document the stoma size, color, protrusion, or the skin surrounding the ostomy site. The wound nurse also stated the admission MDS documented the resident as admitted with a colostomy. On observation, the resident had an appliance to the right abdomen with small amounts of brown stool, and the surrounding skin appeared slightly reddened with linear red areas. The unit manager stated the orders for ostomy care and changes were delayed after admission because there were no orders entered for the ileostomy until 5/7/2026.
Unsecured medication carts and unlabeled open biologic pens
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted principles when two medication carts were observed unattended and unlocked at the nursing station, with all drawers accessible. One cart had a medication cup containing applesauce and a crushed red substance on top, along with an undated applesauce container nearby. A CNA stated she did not know what was in the cup and confirmed she did not pass medications. The nurse later stated the cup contained a medication that a resident had refused and acknowledged that she had left it out after being called away. The Unit Manager later confirmed that leaving medication carts unlocked and unattended, and leaving medication accessible to staff, residents, and visitors, was not acceptable. Open biologic medications were also found improperly labeled in the main medication room refrigerator for two residents. For one resident, the Ozempic pen was open and partially used inside a box labeled with the resident’s information, but the pen itself had no resident information label and no open date. For a second resident, another open and partially used Ozempic pen was found in a box labeled with that resident’s information, but the pen also had no resident information label and no open date. Both residents had medical histories that included diabetes mellitus type 2, and one resident also had metabolic encephalopathy, cystitis, anxiety, and depression, while the other had cerebral infarct, Parkinson’s disease, drug-induced obesity, anxiety, and depression. During interview, the Unit Manager stated that the pen should have resident information on it and be dated when opened, and she verified the open biologics in both medication rooms. The facility policy stated that drugs and biologics are to be stored in locked compartments, that compartments containing drugs and biologics are locked when not in use, that unlocked medication carts are not left unattended, and that when opening a multi-dose container the date open is recorded on the container. The medication administration policy also stated that insulin pens are clearly labeled with the resident’s name or other identifying information and that medication carts are kept closed and locked when out of sight of the medication nurse.
Failure to Adequately Supervise High Fall‑Risk Resident Resulting in Repeated Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for a high fall‑risk resident, resulting in three unwitnessed falls in the resident’s room. The resident was admitted with wedge compression fractures of T7–T8, a fracture of the first thoracic vertebra, vascular dementia, anxiety, and a history of falls with injury prior to admission, including falls at an assisted living facility. A Brief Interview for Mental Status on 3/26/2026 showed severely impaired cognition, and the resident required extensive assistance with ADLs. A fall assessment dated 3/30/2026 identified the resident as high risk for falls, and the fall‑risk care plan cited vascular dementia, history of falls with injuries, history of CVA, new surroundings, and self‑transferring in a deconditioned state as contributing factors. Despite these identified risks, the resident experienced three unwitnessed falls in their room over a 10‑day period. On 3/20/2026 at 2:45 PM, staff were called to the resident’s room and found the resident on the floor by the bathroom; the resident was newly admitted, confused, unable to describe what happened, and sustained a bruise and skin tears to the elbows. On 3/26/2026 at 3:45 PM, the resident was again found on the floor near the dresser with a back brace and cervical collar in place and a deep, jagged laceration to the right palm, with minimal bleeding and no reported pain; the incident was unwitnessed, and the root cause was documented as confusion and self‑transferring. An After Visit Summary from that date documented placement of two sutures in the resident’s hand and provided fall prevention information. On 3/30/2026 at 8:45 AM, a nurse heard a loud crash from the hallway and found the resident on the floor next to the bathroom door, again in the room, with head toward the door and feet toward the bed, wearing nonskid socks, a cervical collar, and brace. The resident stated they fell but could not provide further details, and no injuries were noted at that time. All three falls were unwitnessed and occurred in the resident’s room. During interview, the DON acknowledged awareness of the resident’s fall risk, including prior falls at assisted living and admission with back fractures from falls, and stated that the facility did not provide continuous bedside supervision, instead relying on increased visualization and more frequent room checks. The pattern of unwitnessed falls in the room for a resident with severe cognitive impairment, high fall risk, and known history of falls reflects the facility’s failure to provide appropriate supervision to prevent accidents as required.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications across multiple medication carts and treatment areas. Observations revealed that medications were not labeled with open dates, including Dorzolamide eye drops, Fiasp insulin pens, Ventolin inhalers, Timolol ophthalmic solutions, Flonase nasal spray, and Latanoprost eye drops. Additionally, loose tablets were found in medication cart drawers, and a treatment cart containing prescription medications was left unlocked and unattended. The facility also failed to maintain accurate and complete medication refrigerator temperature logs. The logs showed numerous instances where temperatures were not recorded, and some entries indicated temperatures outside the recommended range. This issue was compounded by the improper handling of controlled substances, as evidenced by crossed-out entries on the control substance record for Lorazepam, which is not the correct procedure for documenting narcotic waste. Interviews with nursing staff revealed a lack of adherence to the facility's policies on medication storage and temperature monitoring. Staff were unable to provide accurate information on when certain medications were opened, and there was a general lack of accountability for ensuring medication carts and refrigerators were properly secured and monitored. These deficiencies indicate a systemic issue with medication management within the facility.
Inaccurate CMS 802 Form for Resident Care Categories
Penalty
Summary
The facility failed to ensure the accuracy of the CMS 802 form, which is used to list all current residents and note pertinent care categories, for three residents. Resident #48 was inaccurately listed as being administered an antibiotic for a current UTI, despite the Medication Administration Record (MAR) indicating that the antibiotic treatment had ended in February. Similarly, Resident #93 was also incorrectly noted as receiving antibiotic treatment for a UTI, although the treatment had concluded on March 1, 2025. The Infection Preventionist confirmed that Resident #93 was not currently being treated for a UTI, and the MDS Coordinator acknowledged the oversight in updating the CMS 802 form, attributing it to manual completion errors. Resident #49's CMS 802 form failed to identify the resident's dialysis therapy, despite the resident being on a hemodialysis schedule. During an interview, the Licensed Practical Nurse confirmed the resident's dialysis schedule and the presence of a hemodialysis catheter. The MDS assessment nurse admitted to missing the dialysis category on the CMS 802 form, citing issues with the update process and manual entry errors. The oversight was attributed to the failure to transfer the information from the electronic medical record to the CMS 802 form, resulting in an incomplete and inaccurate resident assessment overview.
Medication Administration Deficiency Due to LPN's Actions
Penalty
Summary
The facility failed to ensure the competency of licensed nursing staff in medication administration, resulting in a deficiency involving a resident. A resident, who was cognitively intact and required supervision for certain activities, reported a negative experience with a new LPN during the night shift. The resident stated that the LPN left two unrecognized pills in their room without explanation. Upon inquiry at the nurses' station, the resident discovered the pills were Tums, not the prescribed Simethicone, and the LPN reacted rudely when confronted. The Unit Manager confirmed the resident's concerns and revealed that the LPN administered Tums instead of Simethicone because they could not locate the prescribed medication. The LPN admitted to leaving the medications at the resident's bedside, assuming the resident was capable of self-administration, despite not knowing the facility's policy on medication self-administration. The LPN also acknowledged administering Tums without a healthcare provider's order and failing to document the administration. The Director of Nursing stated that the facility does not administer medications without orders, highlighting a breach in protocol. The LPN's actions, including administering medication without an order, leaving medications at the bedside, and failing to document the administration, contributed to the deficiency. The report indicates a lack of adherence to professional standards and facility policies regarding medication administration.
Inadequate Monitoring of Drug Regimens and Documentation
Penalty
Summary
The facility failed to effectively monitor the drug regimens of four residents, leading to the administration of unnecessary medications. Resident #60 was prescribed Risperidone for Major Depressive Disorder, which is not an appropriate indication for this medication. Although the resident had a diagnosis of psychosis, it was not integrated into the resident's diagnoses list, leading to inappropriate medication use. Resident #256 was prescribed Ramelteon and Aripiprazole without any mental health or sleep disorder diagnoses, and the signed consent forms did not specify the conditions being treated. It was later discovered that these medications were prescribed for hospital-acquired delirium, but the diagnoses were not updated in the clinical record. Resident #76 was administered a prophylactic antibiotic, Cephalexin, for recurrent urinary tract infections without a documented risk versus benefit analysis by the physician. The facility's antibiotic stewardship policy requires documentation of specific criteria supporting the use of antibiotics, which was not adhered to in this case. The lack of a risk versus benefit analysis for the prophylactic use of antibiotics was acknowledged by the Infection Control Preventionist, who confirmed that such documentation should have been obtained. Resident #85 was prescribed Olanzapine for unspecified dementia with psychotic disturbance, but the consent form did not identify specific behaviors being treated. The Social Worker and Registered Nurse involved in obtaining consent acknowledged that the diagnosis was incorrect and that the consent form lacked necessary details. Additionally, there was no documentation of phone consent from the resident's guardian, as required by the facility's procedures. This oversight in documentation and consent processes contributed to the inappropriate administration of antipsychotic medication.
Improper Administration of Levothyroxine
Penalty
Summary
The facility failed to ensure the proper administration of medication for a resident, resulting in the resident receiving levothyroxine, a thyroid hormone replacement, with other medications and supplements. According to the facility's 'Medication Administration' policy, medications should be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed time unless specified otherwise. Levothyroxine is recommended to be given on an empty stomach, preferably one hour before breakfast. However, the resident received levothyroxine at 7:00 AM with other medications and supplements, contrary to the prescribed administration time of 5:00 AM on an empty stomach. The issue was identified during an observation and interview with a Registered Nurse (RN) who administered the medication. The RN provided the resident with cranberry juice after a blood sugar check and then administered the medications, including levothyroxine, with a Med pass supplement and other medications. The Licensed Practical Nurse (LPN) manager confirmed that the medication order was incorrectly entered for 7:00 AM instead of 5:00 AM. The RN Unit manager also confirmed that levothyroxine should be administered at 5:00 AM on an empty stomach. This discrepancy in medication administration timing led to the deficiency noted by the surveyors.
Failure to Provide Assistive Dining Equipment
Penalty
Summary
The facility failed to provide necessary assistive dining equipment to a resident, resulting in a deficiency in care. The resident, who was admitted with diagnoses including amnesia, anorexia, and seizures, required assistance with activities of daily living and had severely impaired cognition. The care plan for the resident specified the use of a Scoop plate and a Kennedy cup to aid in dining, but these were not consistently provided. Observations over several days showed that the resident was often given meals without the required Scoop plate and Kennedy cup, or the equipment was not used correctly. On multiple occasions, the resident was observed eating without the necessary assistive devices, and when the Kennedy cup was provided, it was found empty and upside down. A CNA explained that the resident did not like to use the Kennedy cup, but this was not addressed in the care plan. The Director of Nursing was informed of the oversight, indicating a lapse in following the care plan interventions designed to maintain the resident's nutritional and hydration status.
Infection Control Deficiency: Improper Storage and Handling of Linen and Gloves
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by the improper storage and handling of clean linen and gloves. During an observation, a box of clear gloves was found on a counter with gray gloves piled on top, some of which were touching the counter surface. A resident confirmed that staff used these gloves. Additionally, a CNA was observed carrying a pile of clean linens against their uniform, which was uncovered, contrary to facility expectations. The Director of Nursing confirmed that gloves should not be stored exposed, and the Infection Control Nurse was informed of these observations.
Failure to Document Pain Management and Assessment
Penalty
Summary
The facility failed to document the administration of pain medication and complaints of ankle pain for a resident, resulting in a lack of documented assessments and treatment. The resident, who had a history of dementia and bone disorders, reported ankle pain after getting her foot caught in the bed. Despite the resident's complaints and the administration of Tylenol by a nurse, there was no documentation of the pain or the medication given in the resident's medical records. The incident involved multiple staff members who were aware of the resident's complaints and the administration of Tylenol, yet failed to document these events. The Director of Nursing conducted an investigation and found that the resident had complained of pain and received Tylenol, but these actions were not recorded in the progress notes or medication administration record. This lack of documentation led to a deficiency in providing appropriate treatment and care according to the resident's needs and preferences.
Resident Discharged with Incorrect Medications
Penalty
Summary
The facility failed to maintain professional standards and ensure a comprehensive and safe discharge for a resident, resulting in the resident being discharged with another resident's medications. The incident involved a resident who was discharged with multiple medications that were not prescribed to her. The resident, who was only prescribed 2-3 medications, received a large number of medications upon discharge, which she found unusual. It was later discovered by her home health care nurse that the medications belonged to another resident. The Director of Nursing (DON) reported that the nurse responsible for the discharge, Nurse L, did not complete the necessary medication reconciliation or review the medications given to the resident. Nurse L admitted to being busy and not verifying the medications due to room changes on the day of discharge. The medications that were incorrectly sent home included several blister packs of various drugs not prescribed to the resident. The facility's investigation revealed that the medications were indeed in the facility at the time of discharge, but Nurse L failed to locate them and instead provided medications from the cart. The facility's policy required a safe and orderly discharge process, including providing written and oral instructions and completing a medication reconciliation form. However, these procedures were not followed, leading to the resident receiving incorrect medications. The incident was further complicated by miscommunication and a lack of proper documentation, as Nurse L did not complete the medication reconciliation form or provide the correct discharge instructions.
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What surveyors actually found near you
We read the 186 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bay Shores Senior Care And Rehab Center | 1.6 mi | ★★★★★ | 13 | 0 |
| Caretel Inns Of Tri-cities | 3.8 mi | ★★★★★ | 3 | 0 |
| Hampton Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 0 | 0 |
| Huron Woods Nursing Center | 6.7 mi | ★★★★★ | 15 | 0 |
| Bay County Medical Care Facility | 7.8 mi | ★★★★★ | 14 | 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 August 2026) and official state health department websites.