Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Christian Park Health Care Center during CMS and state inspections, most recent first.
Unsafe wheelchair transport led to a resident’s leg slipping under the chair when a footrest/leg rest moved out of place. The resident told the CNA to slow down, but the chair kept moving, causing a loud snap, severe pain, and a hospital transfer that confirmed a distal femur fracture. Staff interviews described the footrest as broken or not latched, and the resident later remained bedbound with ongoing pain and loss of mobility.
Failure to report resident-to-resident altercation to SA: A CNA witnessed one resident enter another resident’s room during personal care and open the privacy curtain, exposing the resident. The affected resident later described being naked in bed, feeling embarrassed and afraid, and identified the other resident involved. The DON and NHA were unaware of the incident, and the event was not reported to the SA as required by facility policy.
The facility failed to carry out key infection control practices during COVID-19 and Influenza A outbreaks, which spread across multiple halls and involved resident deaths. The IP and DON did not complete outbreak summaries or real-time infection mapping, contact precautions for a resident with an MDRO were delayed, hallway doors remained open, and communal dining continued during the outbreaks. The facility also failed to properly disinfect a multi-resident glucometer and an insulin pen, maintained a medication cart with a sticky contaminated bottle, and did not properly clean and sanitize bedpans used by residents.
A cognitively intact resident with chronic hypoxic respiratory failure and morbid obesity was transferred to a hospital with unclear and poorly documented reasons in the EMR, which only noted constipation and an O2 saturation in the low 80s. The ADON acknowledged that the discharge was not properly documented and that the reason for sending the resident out was unclear. After the resident became medically stable in an out-of-state hospital, the resident, hospital CM, and Ombudsman reported that the resident wished to return and had been educated on the risks of using BiPAP instead of AVAP, but the NHA repeatedly delayed or refused readmission, citing an inability to manage AVAP and daily ABGs despite a sister facility’s experience with AVAP. A hospital-arranged transport returned the resident to the facility after a long trip, but staff, reportedly under the NHA’s direction, did not open the door or accept the resident, forcing a return trip to the hospital. These actions conflicted with the facility’s own transfer/discharge policy requiring clear physician documentation, appropriate criteria for transfer, and proper notice and process.
Failure to respond to a resident’s call light and provide needed care: A resident with cerebral palsy, anxiety, dysphagia, and severe cognitive impairment was observed crying, moaning, thrashing, and struggling with copious oral secretions while her call light remained on for over 20 minutes. Her call light was out of reach, her mouth and teeth were heavily coated with dried plaque, tartar, and secretions, and a CNA turned off the light without assessing her needs, instead checking the roommate. The CNA admitted he had not looked closely at the resident, had not provided cares since the morning, and lied when questioned.
Food service equipment was not maintained in accordance with professional standards. Surveyors observed a stand mixer covered with a plastic bag, and when uncovered, food debris was present on the bowl guard and splash zone area. Surveyors also observed that the interior stainless-steel covering on the exterior walk-in freezer door was missing, leaving the foam insulation exposed.
General Repair and Premises Maintenance Deficiencies: Surveyors observed a broken bed headboard in a resident room, with A resident stating the repair had been requested months earlier and not completed. They also observed duct tape on the hopper water hose handle used for rinsing soiled linens, and peeling sealant and missing paint on exterior soffits and window areas.
Missing and unaddressed MRRs were identified for three residents. A pharmacist repeatedly documented concerns about psychotropic and anxiolytic use, including buspirone and risperidone, but physician responses, signatures, and dates were often absent or delayed, and several MRRs were missing from the EMR. The DON stated there was a break in the MRR process during an interim DON period, and the DON and NHA acknowledged the missing records.
A resident with chronic respiratory failure and intact cognition was transferred twice to hospitals, including an out-of-state facility for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis. Review of the EMR and interviews with the ADON showed there was no written transfer notice, no documentation that bed-hold and readmission policies were provided, and no required hospital transfer paperwork, despite facility policy requiring these actions for emergency transfers. This lack of required documentation and notification caused the resident worry, fear, and frustration and contributed to a delay in readmission after a prolonged hospitalization.
A resident with mild cognitive impairment and a diagnosis of right femur fracture had conflicting advance directive documentation in the EMR: the face sheet listed Full Code by Default, while the signed advance directive document identified the resident as DNR/No Code. The ADON stated the resident should be DNR in both areas of the chart, but the status was not clear at the time of review.
The facility failed to prevent unnecessary psychotropic use for two residents. One resident with dementia and anxiety remained on risperidone for an extended period despite intact cognition, no documented behaviors, and repeated pharmacy reviews stating that anxiety was not an acceptable antipsychotic indication and that the diagnosis needed clarification or the drug should be tapered. The record also showed delayed or absent GDRs, unclear justification for the antipsychotic, and staff acknowledgment that anxiety was not an appropriate diagnosis for risperidone.
Failure to Protect a Cognitively Impaired Resident from Neglect: A resident with cerebral palsy, dysphagia, and severe cognitive impairment was found crying, moaning, thrashing, and covered with dried secretions, with severe plaque and sputum buildup in the mouth and a call light out of reach. Staff ignored the resident’s call light, did not assess her needs, and an assigned CNA admitted he turned off the light without checking on her, had not provided cares since the morning, had never done oral care, and lied during interview about what he had done.
Failure to Investigate Alleged Neglect: A resident with cerebral palsy, anxiety, difficulty swallowing, and severe cognitive impairment was observed crying, moaning, thrashing, and covered with secretions and poor oral hygiene, with the call light out of reach. A CNA admitted he had not checked on the resident closely, had not provided oral care, and lied during the interview. The DON, ADON, and NHA acknowledged the event was not completed as an abuse/neglect investigation, no Incident Report was done, and the alleged perpetrator remained on the unit with access to residents.
PASARR screening was not completed before admission for a resident with anxiety disorder, depression, bipolar disorder, and schizophrenia. The MDS showed a BIMS score of 15/15, and review of the EMR confirmed the PASARR was completed only after admission. The DON acknowledged PASARRs are supposed to be completed at admission and confirmed this one was missed.
Improper Oxygen Flow and Equipment Management: Two residents with COPD and cognitive impairment did not receive oxygen services per ordered parameters. One resident's O2 flow was lowered from the ordered 4 L/min to 3 L and then 2 L without a provider order, while staff acknowledged the change should not have been made without an NP or physician order. Another resident had oxygen tubing dated several days earlier, and the chart lacked an order for weekly tubing changes or cleaning of the oxygen concentrator.
Medication carts were left unsecured and resident inhalers were left on top of a cart during medication administration. An LPN left the 200 Hall med cart unlocked and unsupervised while entering a resident room, and on another hall two inhalers belonging to a resident were left on top of the med cart while an LPN was in a room. The DON stated carts need to be locked and not left open unsupervised, and facility policy required carts to remain locked and no medications to be kept on top of the cart.
A resident with dementia and a history of constipation experienced prolonged periods without bowel movements, despite having scheduled and PRN medications available. Staff failed to administer PRN interventions or document timely assessments, leading to worsening abdominal pain, vomiting, and eventual hospitalization for small bowel obstruction, acute kidney injury, and sepsis. Facility staff later acknowledged documentation and communication failures regarding bowel management.
A resident with dementia and cognitive impairment, identified as being at risk for constipation, experienced prolonged periods without bowel movements despite having PRN medications available. The care plan was not updated or followed, and interventions were not implemented, resulting in the resident developing a small bowel obstruction, acute kidney injury, and sepsis, requiring hospitalization.
A resident with paraplegia and a history of depression was restricted from using his electric wheelchair inside the facility after a single incident, while other residents were not similarly restricted. The resident's requests, such as excluding the DON from his care conference, were disregarded by management, leading to increased anxiety and feelings of being targeted. Staff and the ombudsman confirmed the resident felt disrespected and that his rights to dignity and self-determination were not honored.
The facility failed to provide prescribed therapeutic diets to three residents, leading to potential health risks. One resident received a dinner roll against dietary instructions, another was served non-ground turkey despite needing ground meats, and a third received a salt packet despite a no-added-salt diet due to hypertension. Staff acknowledged these errors during observations.
Unsafe wheelchair transport led to resident femur fracture
Penalty
Summary
The facility failed to ensure safe wheelchair transportation for a resident who had intact cognition and was being transported to therapy in a wheelchair with footrests. During transport, the resident told the CNA to slow down because he could feel his foot slipping off the footrest, but the wheelchair was not slowed. The resident’s foot came off the footrest and went underneath the wheelchair, and he reported hearing a loud snap and immediate severe pain. The resident was sent to the hospital, where imaging confirmed a closed fracture of the distal right femur. Facility documentation and interviews described that the wheelchair leg rest had swung out or moved away from the chair, and staff stated the resident’s leg hyperextended and twisted under the wheelchair. The DON, CNA, LPN, and rehab staff all described the incident as occurring during wheelchair transport, with staff noting that the footrest/leg rest was not secure or did not latch properly. After the injury, the resident remained in bed with persistent severe pain and limited mobility. Physician documentation noted worsening displacement of the fracture and stated the leg had not been splinted since the date of injury, likely contributing to the displaced fracture. The resident reported ongoing throbbing pain, emotional distress, and that he was no longer able to participate in therapy or get out of bed as he had been before the incident.
Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to notify the State Agency of a resident-to-resident altercation involving two residents who were both cognitively intact, with each scoring 15/15 on the BIMS. One resident entered the other resident’s room while personal care was being provided, opened the privacy curtain, and exposed the resident. The other resident later reported that a man burst into her room while she was being changed, pulled the privacy curtain open about 2 feet, and saw her naked while she was lying in bed. She stated she felt embarrassed, exposed, and afraid, and identified the other resident as the person involved. During interviews, the CNA reported witnessing the resident enter the room and open the curtain while the other resident was receiving personal care. The DON stated this was the first time she had read the charting and that no one had told her about the incident. The NHA reported being unaware of the event and stated they did not know what could be done to make staff report incidents to management. Facility policy required staff to immediately report allegations or suspicions of mistreatment, abuse, neglect, or exploitation to the Administrator and DON, and required the Administrator or DON to report incidents and accidents to the State Agency.
Infection Control Program Failures During Outbreaks and Resident Care
Penalty
Summary
The facility failed to implement a complete infection prevention and control program during COVID-19 and Influenza A outbreaks, and also failed to maintain infection control practices for resident care equipment and supplies. During the January 2026 COVID-19 outbreak, the infection control line listing showed 25 residents became infected, with the outbreak spreading from the 500 Hall to the 200, 400, and 300 Halls. Resident #93 contracted COVID-19 and died in the facility. During the February 2026 Influenza A outbreak, the line listing showed 10 residents were infected, the outbreak began on the 200 Hall and spread to the 400 and 500 Halls, and Resident #93 contracted Influenza A and died in the facility. The infection control binder had no April 2026 documentation, no line listing entry for a resident with a multidrug-resistant organism in urine, and no outbreak summaries for either the COVID-19 or Influenza A outbreaks. The report states that contact precautions for a resident with a urine culture showing an MDRO were not posted outside the room until after the resident returned from the hospital, even though the culture results were available when the resident came back. The Infection Preventionist acknowledged that the resident should have been placed on the line listing on the day the culture results were received and that the April infection control mapping was not completed in real time. The DON confirmed that no contact precaution signage had been posted until several days later, and the infection control binder for April contained no documentation, including no mapping and no line listing entries. During the outbreaks, hallway double doors were left open and communal dining and activities continued. The Infection Preventionist stated that the doors were not closed to help contain spread and that staff positive for COVID-19 were not tracked for source tracking. The facility had received CDC guidance about rapid action, limiting communal dining, and considering additional measures when spread continued, but the Infection Preventionist and DON stated they did not close the doors and did not restrict communal dining. The report also notes that the facility’s outbreak investigation policy called for line listings, mapping, control measures, and written outbreak reports, but no outbreak investigation summary was completed for either outbreak. The facility also failed to properly disinfect multiple-resident-use glucometers and resident insulin pens. An LPN used a glucometer and insulin pen in a resident’s contact precaution room, then removed a foam tray from the room and placed it directly on the medication cart. The glucometer was wrapped with a disinfectant wipe rather than having all exterior surfaces wiped clean first, and the LPN stated that insulin pens were usually not cleaned before being returned to the medication cart. The Infection Preventionist confirmed that the glucometer and insulin pen should have been wiped on all surfaces and that disposable items taken into a contact precaution room should have been discarded before exiting the room. The medication cart was also observed to be unsanitary when a concentrated liquid protein supplement bottle was returned to the cart with sticky yellow liquid dripping down the sides and top. In addition, bedpans for the five residents who used them were not being cleaned and sanitized as required. Staff described rinsing bedpans in resident bathrooms or the soiled linen room, storing them in garbage bags or closets, and sometimes using only water or foam soap. The facility policy stated that bedpans were to be rinsed and then cleaned thoroughly using a facility-approved disinfectant solution, but staff practices described in the report did not follow that process.
Failure to Properly Document Transfer and Timely Readmit a Cognitively Intact Resident After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to timely and appropriately readmit a cognitively intact resident after a hospital transfer, and failure to properly document and manage the original transfer/discharge. The resident had chronic hypoxic respiratory failure, morbid obesity (over 500 pounds), used 4 L O2 during the day, and BiPAP at night and for naps. The resident’s MDS and behavioral health documentation showed a BIMS score of 14/15, indicating intact cognition. The facility’s EMR documented that the resident was sent to the ED for “no BM for 3 days,” with a change in condition note showing an O2 saturation of 84% on oxygen via nasal cannula and a recommendation to send to the ER. The ADON stated that the EMR did not clearly or properly document the reason for the transfer, that the facility’s practice was not to send residents out solely for constipation, and that alternative measures should have been used. The ADON also reported being unsure why the resident was sent out and acknowledged that the discharge was not properly documented. The NHA reported that the resident was initially transferred to the local ED for a hypoxic episode and then to an out-of-state hospital, and later stated that the resident would not be readmitted until “stable,” citing a need for an AVAP machine and daily ABGs that the facility allegedly could not manage. However, the resident’s EMR from prior months showed baseline O2 saturations in the mid‑80s, with some readings as low as 69% and 71%, and the out-of-state hospital record described chronic hypoxic respiratory failure on 2 L O2 at baseline. The hospital admission record from the out-of-state facility stated that the resident presented from the nursing facility with acute worsening dyspnea and hypoxia, with O2 saturation dropping to 55% on BiPAP at the facility, but there was no corresponding documentation in the facility’s EMR of such a drop. The NHA acknowledged being unaware that the last EMR note before transfer only referenced no bowel movement for three days and confirmed that whatever was in the EMR was all the facility had regarding the discharge. After the resident became medically stable at the out-of-state hospital, the resident, the hospital CM, and the Ombudsman all reported that the resident wished to return to the facility and had been educated extensively on the risks of using BiPAP instead of AVAP. The Ombudsman and the hospital CM stated that the NHA repeatedly delayed readmission, asserting the facility could not care for someone on AVAP, despite the Ombudsman and a DON at a sister facility confirming that the sister facility had experience with AVAP and a resident using it. The Ombudsman and CM described an incident in which the hospital discharged the resident back to the facility, arranging a nearly five-hour transport; upon arrival, facility staff, reportedly under the NHA’s direction, did not open the door or accept the resident, and the driver had to return the resident to the out-of-state hospital after another long trip. The resident reported feeling fine on the day of the original transfer, not understanding why he was sent out, and later described the return trip and refusal at the door as feeling like being treated as “garbage” in a “meat wagon.” The facility’s own transfer and discharge policy required that transfers/discharges be necessary for the resident’s welfare, properly documented by a physician, and accompanied by written notice and appeal rights, but the record review and interviews showed unclear documentation of the reason for transfer, lack of proper discharge documentation, and delayed or refused readmission despite the resident’s expressed desire and documented capacity to return. The NHA also reported that the Ombudsman had filed an appeal with the State Agency alleging an involuntary discharge and that the State Agency requested an involuntary discharge form, but the NHA had not yet provided anything back. The hospital CM stated that the resident had been medically stable for several days, no longer required daily ABGs, and that the resident understood and accepted the risks of his choices. The CM further reported repeated denials of readmission, difficulties in communicating with the facility, and that progress notes and discharge summaries had been sent to the NHA, who at times claimed not to have received them. During the survey, the NHA initially provided only 9 of 54 pages of the hospital discharge summary, attributing this to the admissions coordinator’s printer running out of paper, and there were multiple delays in providing requested documents. Collectively, these actions and omissions resulted in the resident not being timely readmitted to his home facility, despite his wishes, his cognitive capacity, and the hospital’s assessment of medical stability, and were inconsistent with the facility’s own transfer and discharge policy requirements.
Failure to Respond to Call Light and Provide Needed Care
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not respond appropriately to the resident’s call light and did not provide needed care while the resident was visibly distressed. The resident had diagnoses including cerebral palsy, anxiety, and difficulty swallowing, and was assessed as severely cognitively impaired. The resident’s care plan and CNA Kardex identified the resident as at risk for pain and directed staff to observe and report non-verbal signs of pain such as moaning, yelling out, restlessness, grimacing, and thrashing. During observation, the resident was heard crying and moaning from a distance and was found lying on her side, crying, moaning, and thrashing her head back and forth. The resident appeared sweaty, restless, tense, and was trying to swallow. There were copious secretions in her mouth, a gurgling sound from her throat, tears on her face, and her hair appeared matted and greasy. Her teeth and mouth had thick dried plaque, tartar, sputum, and crusted secretions. The resident’s call light was clipped behind her pillow and out of reach. The call light was activated and remained on for over 20 minutes before a CNA entered the room. During that time, no staff were noted on the unit, and multiple CNAs were observed in the employee breakroom across from the resident’s room. When the CNA entered, he turned off the call light, did not make eye contact or speak to the resident, and went to the roommate instead. In interview, the CNA stated he knew the resident could not use the call light, did not look closely at the resident, had not done cares on her since the morning, and did not provide oral care because he thought only nurses were to do it. He also admitted he lied when initially questioned and acknowledged he should have checked the resident’s Kardex or gotten help from the nurse to ensure she was okay.
Food Service Equipment Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. On 4/6/2026 at 1:17 PM, surveyors observed a large stand mixer covered with a plastic bag; when the covering was removed, food debris was noted on the protective wire bowl guard and on the underneath splash zone area where the beater is attached to the unit. On 4/7/2026 at 10:04 AM, surveyors observed that the stainless-steel covering on the interior of the door to the exterior walk-in freezer was completely missing, leaving the foam insulation underneath completely exposed.
General Repair and Premises Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general repair of patient equipment and the premises. On 4/7/2026 at 8:25 AM in room [ROOM NUMBER] Bed A, surveyors observed that the headboard was broken away from the bed and sitting askew, with the left corner of the headboard on the floor. During this observation, Resident 1 stated that they had requested the repair three to four months earlier and that nothing had been done. On 4/7/2026 at 9:29 AM, surveyors observed duct tape on the handle of the hopper water hose used to rinse soiled linens, and the Maintenance Director stated the duct tape was being used to give the handle traction so it would hang in the bracket above the bowl without falling out. On 4/7/2026 at 10:04 AM, surveyors observed peeling sealant on exterior soffits on the 200 wing and just left of the emergency exit door on the 300 wing, along with missing paint below exterior window frames under four sets of windows.
Missing and Unaddressed Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were addressed by the physician in a timely manner and maintained in the clinical record for three residents reviewed. The report identified missing or unaddressed MRR documentation for Resident #45, Resident #52, and Resident #5. The consultant pharmacist’s recommendations were not consistently signed, dated, or responded to by the physician within the timeframes described in the facility policy, and several MRRs were absent from the electronic medical record. Resident #45 was admitted with diagnoses including non-Alzheimer’s dementia, anxiety disorder, and restlessness and agitation, and had a BIMS score of 15/15 with no documented behaviors. The resident was receiving an antipsychotic and an antidepressant on admission, and the pharmacist repeatedly recommended review of buspirone and risperidone use, including consideration of gradual dose reduction and clarification of the diagnosis for antipsychotic use. The report states that MRR documentation was not present or not addressed by the physician for multiple months, and several physician response sections were blank. One MRR recommendation dated 11/19/25 was not signed by the physician until 2/10/26, and later recommendations from January through March 2026 also lacked physician documentation. Resident #52 was admitted with anxiety disorder and depression and had a BIMS score of 15/15. The EMR did not contain MRR documentation for multiple months, including August and September 2025, October and November 2025, December 2025, January 2026, and March 2026. The pharmacist’s recommendation again addressed buspirone 20 mg BID and trazodone, suggesting consideration of a gradual dose reduction, but the physician response, signature, and date were absent. Resident #5, admitted with non-Alzheimer’s dementia and schizophrenia and a BIMS score of 0/15, also had missing MRRs in the EMR for August, October, November, and December 2025, as well as February and March 2026. During interviews, the DON stated there was a break in the MRR process when there was an interim DON, and the DON and NHA acknowledged the facility did not have the MRRs for Resident #5.
Failure to Provide Required Transfer Notices and Bed-Hold Information During Hospitalizations
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its transfer and discharge policy by not providing required written transfer notifications, bed-hold policy information, and hospital transfer documentation for a cognitively intact resident. The resident was originally admitted with diagnoses including respiratory failure and had a BIMS score of 14/15, indicating intact cognition. The resident’s EMR showed that he was sent to a local emergency department for no bowel movement for three days and had previously been transferred to an out-of-state hospital after the facility noted his oxygen saturation was 65% on his baseline 2 L oxygen, leading to admission for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis secondary to bilateral pneumonia, UTI, bacteremia, and cellulitis. During review, the ADON identified that the EMR reflected discharges from the facility and admissions to the hospital on two separate occasions. Despite these transfers, the EMR contained no evidence of a written notification of transfer to the resident or resident representative and no documentation that the facility’s bed-hold and readmission policies were provided, as required by the facility’s own policy. The facility’s policy specified that, for emergency transfers, notice of transfer must be provided to the resident and representative as soon as practicable, a physician’s order with date and reason for transfer must be obtained, written notice of bed-hold and readmission policies must be given at the time of transfer or within 24 hours, and a transfer form, medication list, and care plan goals must be sent to the receiving hospital, with nursing documenting the hospital transfer in the medical record. At the time of the survey exit, there was no required documentation in the resident’s EMR, including the bed-hold notice, written transfer notice, or hospital transfer paperwork, and this failure resulted in worry, fear, and frustration for the resident and delayed his readmission from a lengthy out-of-state hospitalization.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for one resident reviewed for advance directive accuracy. The resident was admitted with a diagnosis of right femur fracture and had a MDS assessment showing a BIMS score of 12/15, indicating mild cognitive impairment. Review of the resident’s EMR showed the face sheet listed the resident as "Full Code by Default," while the original signed advance directive document in the chart identified the resident as "No Code" or Do Not Resuscitate. During an interview and record review, the ADON stated the resident should be DNR in both areas of the medical chart, but said it was not clear at that time and would need to be looked into.
Unnecessary Psychotropic Use and Delayed GDRs
Penalty
Summary
The facility failed to ensure unnecessary psychotropic medications were not administered for an extended duration and without appropriate indications for use for 2 residents reviewed for unnecessary medications/chemical restraints. One resident, who was admitted with diagnoses including non-Alzheimer's dementia and anxiety disorder and had intact cognition on MDS assessments, was maintained on risperidone and an antidepressant despite no documented behaviors on several assessments. The resident's antipsychotic was routinely administered over time, with no documented gradual dose reduction for long periods and no documented contraindication for a GDR in the medical record. For this resident, the record showed multiple medication changes and continued use of risperidone for anxiety, including an increase in dose after a nursing note described increased anxiety. Pharmacy medication review recommendations repeatedly stated that anxiety is generally not an acceptable antipsychotic use and asked for clarification of the diagnosis or taper/discontinuation if no valid diagnosis existed, but the physician response fields were blank on several recommendations. A psychiatric follow-up also documented that the resident was overdue for a GDR, that the indication for starting risperidone was unclear, and that facility staff reported no problematic behaviors. The report also noted that the facility's medication management policy required verification that psychotropic orders included an appropriate clinically supported diagnosis and that informed consent be completed before initiating or increasing psychotropic medications. During interviews, the DON acknowledged that anxiety was not an appropriate diagnosis for risperidone and stated the facility would need a different process to review the recommendations timely and contact the physician. The consultant pharmacist stated that the antipsychotic diagnosis had not been answered month after month and that communication with the physician had been a struggle.
Failure to Protect a Cognitively Impaired Resident from Neglect
Penalty
Summary
The facility failed to implement its Abuse Program Policy and Procedure and failed to immediately protect a resident from neglect. The cited policy stated that residents shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property, and that allegations of neglect must be thoroughly investigated and documented. The policy also stated that staff must report allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator immediately. Resident #8 had diagnoses including cerebral palsy, anxiety, and difficulty swallowing, and was severely cognitively impaired with a BIMS score of 99/15. The resident’s care plan indicated dependence on staff for oral hygiene, need for one-person assistance, and risk for pain related to chronic physical disability, with behaviors such as crying out, changes in breathing, vocalizations, and restlessness identified as signs of non-verbal pain. During observation, the resident was heard crying and moaning from down the unit and was found lying on her side, thrashing her head, sweating, with tears on her face, greasy and unkempt hair, and a gurgling/rattling sound from her throat. The resident’s mouth contained a copious amount of secretions, and her front upper and lower teeth had thick dry plaque, tartar, and sputum layered over them so heavily that the teeth could not be seen. Her lips, chin, and mouth also had wet and dry crusted secretions. Her call light was clipped behind her and out of reach. The surveyor observed the call light on for an extended period while no staff were on the unit, and multiple CNAs were in the employee breakroom area. When CNA J entered the room, he turned off the call light without assessing the resident and went to the roommate instead. In interview, CNA J stated he had not done cares on the resident since the morning, had not looked closely at her, had never completed oral care on her, and admitted he lied when answering the surveyor’s questions because he did not know the answers. The DON and ADON later observed the resident and stated they were concerned about her overall appearance, and the DON stated staff failed the resident by ignoring her call light and not providing proper care and services.
Failure to Investigate Alleged Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident with cerebral palsy, anxiety, difficulty swallowing, and severe cognitive impairment. The resident’s care plan and CNA Kardex directed staff to observe and report signs of non-verbal pain, including changes in breathing, vocalizations, mood, eyes, face, and body, and to report abnormal findings to the physician. During observation, the resident was crying, moaning, thrashing her head, sweaty, restless, and tense, with tears in her eyes, copious secretions in her mouth, a rattle-gurgling sound from her throat, and thick dried plaque, tartar, and sputum on her teeth and around her mouth, lips, and chin. Her call light was clipped behind her pillow and out of reach. A CNA stated he had seen the call light on, knew the resident could not use it, and did not look closely at her or provide cares since the morning. He later admitted he had lied during the interview, had not checked on the resident more often, and had never completed oral care on her or provided any oral care that day. The DON and ADON observed the resident and reported concern about her overall appearance, and the DON stated the CNA’s failure to ensure goods and services were provided was not acceptable care. The facility did not complete an Incident Report or investigate the event as an allegation of abuse/neglect. The ADON stated she was unsure whether the NHA reported the matter to the State Agency and said she did not complete an Incident Report or provide abuse education to all staff. The NHA stated the incident was not reported or investigated as an allegation of abuse/neglect and said he was only told that the CNA had lied to the surveyor. The report also states the alleged perpetrator continued to have access to the resident and other vulnerable residents while the investigation was not in process.
Failure to Complete PASARR Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not obtained prior to admission for one resident. The resident had diagnoses including anxiety disorder, depression, bipolar disorder, and schizophrenia, and the MDS documented a BIMS score of 15 out of 15, reflecting intact cognition. Review of the EMR showed that the PASARR was not completed until after admission. During interviews, the DON acknowledged that PASARRs are completed when residents are admitted and confirmed that this resident’s PASARR had not been completed upon admission. The NHA also acknowledged the concern regarding the missed PASARR.
Improper Oxygen Flow and Equipment Management
Penalty
Summary
The facility failed to provide oxygen services per standards of practice for two residents with respiratory diagnoses. One resident had diagnoses including respiratory failure and COPD, a BIMS score of 0/15, and a physician order for oxygen at 4 L/min via nasal cannula for shortness of breath. The care plan also directed supplemental oxygen at 4 L as ordered. During observations, the resident was receiving oxygen from an oxygen tank set at 3 L and later at 2 L, despite the order remaining at 4 L. A registered nurse stated the order had not been changed, but the oxygen flow rate was lowered after discussion of possibly reducing it, even though there was no order from the NP yet. The DON stated the oxygen flow rate should not be changed without an order from the NP or physician, and the DON and NHA acknowledged the RN should not have changed the flow rate without such an order. A second resident with COPD and cognitive impairment had oxygen tubing dated 3/27/26, and the ADON stated oxygen tubing should have a physician's order to be changed weekly and as needed. Review of the resident's physician orders showed oxygen at 2 L/min via nasal cannula for shortness of breath, but no order to change oxygen tubing or clean the oxygen concentrator weekly.
Medication carts left unlocked and resident inhalers left unsecured
Penalty
Summary
Resident medications were not securely stored in locked compartments on the 200 Hall. During an observation, the 200 Hall medication cart, staffed by an LPN, was seen unlocked and facing outward into the hall while the LPN entered a resident room. The cart was verified as unlocked when opened in front of the Dietary Manager, who stated, “That is not good.” When asked afterward whether it was acceptable to have the medication cart unlocked and unsupervised, the LPN stated, “Absolutely not.” On the 300 Hall, two inhalers, one green and white and the other red, were left on top of the medication cart while an LPN entered a resident’s room to administer morning medications. When asked if it was acceptable to leave resident medications on top of the cart, the LPN stated, “No, absolutely not,” and identified the inhalers as belonging to a resident. The DON stated that medication carts need to be locked and not left open unsupervised. The facility policy stated that medication/treatment carts are to be kept locked until medication administration, and that no medications are to be kept on top of the cart.
Failure to Prevent and Treat Constipation Resulting in Harm
Penalty
Summary
The facility failed to implement preventative measures, promptly assess, and treat constipation for a resident with dementia, resulting in actual harm. The resident had a documented history of constipation and was prescribed both scheduled and PRN medications for bowel management. Despite this, documentation showed prolonged periods without bowel movements, including a six-day and a ten-day interval with minimal or no bowel movements. During these periods, there was no evidence that PRN medications for constipation were administered, even though they were available and ordered. Nursing and CNA documentation indicated that the resident experienced increasing abdominal pain, decreased appetite, and eventually vomiting. Nursing staff noted the absence of regular bowel movements and administered a rectal suppository only after the resident began to show significant symptoms. The resident's condition deteriorated further, with continued abdominal pain, lethargy, fever, and abnormal vital signs. The on-call physician's assistant was contacted, and an abdominal X-ray was ordered, but the resident's status continued to decline, leading to transfer to the hospital. At the hospital, the resident was diagnosed with a small bowel obstruction, acute kidney injury, and sepsis. The hospital course included non-operative management due to the resident's advanced age and comorbidities, and the plan was shifted to comfort-focused care. The facility's own staff and leadership acknowledged issues with documentation and communication regarding bowel management, and the lack of timely intervention and follow-through on bowel protocols contributed to the resident's decline and subsequent hospitalization.
Failure to Revise and Implement Care Plan for Constipation Management
Penalty
Summary
The facility failed to implement, review, and revise the care plan and interventions for a resident at risk for constipation, resulting in a delay in treatment and subsequent medical complications. The resident, who had dementia and was cognitively impaired, was identified as being at risk for constipation due to decreased mobility, medication side effects, and opioid use. The care plan included interventions such as monitoring for signs and symptoms of constipation, administering medications as ordered, and reporting abnormal findings to the physician. However, documentation revealed that the resident went extended periods without bowel movements, specifically six days without a bowel movement and another ten-day period with only one medium bowel movement. Despite having PRN medications available for constipation relief, including stool softeners, laxatives, suppositories, and enemas, there was no documentation that any of these were administered during the periods of constipation. Progress notes indicated that the resident later experienced a large episode of dark brown emesis and was subsequently sent to the hospital for evaluation of fever and hypotension. Hospital records confirmed the development of a small bowel obstruction, acute kidney injury, and sepsis. Interviews and record reviews confirmed that the care plan was not followed or updated to reflect the resident's changing condition. The Director of Nursing acknowledged that the care plan should have been person-centered and interventions implemented to meet the resident's goals. Reference materials cited in the report emphasized the importance of revising care plans based on the resident's current status and needs, which was not done in this case.
Failure to Honor Resident Dignity and Rights
Penalty
Summary
A resident with paraplegia and a history of major depressive disorder was admitted to the facility and was cognitively intact, as evidenced by a BIMS score of 15/15. The resident had previously been involved in an incident where he accidentally bumped into another resident with his electric wheelchair, resulting in no injury but some pain. Following this incident, the facility restricted his use of the electric wheelchair within the building, allowing him to use it only when leaving the facility. The resident expressed that other residents were not similarly restricted after incidents, and he felt targeted and unfairly treated. Staff interviews confirmed that the resident had not been given a second chance to use his electric wheelchair inside the facility, and no education or interventions were provided to address the incident or prevent recurrence. The resident repeatedly voiced feelings of anxiety, frustration, and fear of retaliation or discharge due to the way management handled his situation. He reported that his requests, such as not having the DON present at his care conference, were disregarded by the former NHA, who insisted on the DON's attendance despite the resident's objections. Multiple staff members and the facility ombudsman corroborated that the resident felt disrespected, bullied, and that his rights were not honored. The resident also experienced additional distress when required to use a large orange flag on his wheelchair against his wishes and when his television access was disrupted without timely resolution from management. Documentation and interviews revealed that the facility failed to maintain the resident's dignity and respect his rights to self-determination and participation in care planning. Staff did not document or communicate the resident's grievances or emotional distress to management or the social worker, and interventions to establish a trusting relationship and maintain a non-threatening environment were not effectively implemented. The facility's own policies on resident dignity and rights were not followed, as the resident's preferences and autonomy were repeatedly overridden by management decisions.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents received food as prescribed by a physician and in accordance with their preferences, affecting three residents. For one resident, a lunch tray included a dinner roll despite instructions indicating no bread unless it was a sandwich. The resident did not consume the roll, which was returned untouched. The Certified Dietary Manager acknowledged that bread should not have been on the tray with manicotti, as per the resident's request. Another resident was observed attempting to cut a turkey slice with a fork, although their therapeutic diet required ground meats. The resident indicated a preference for ground turkey, and a Certified Nurse Aide recognized the error and sought to correct it by obtaining ground turkey from the dietary department. Additionally, a third resident received a breakfast tray with a salt packet, contrary to their prescribed diet of no added salt due to hypertension. A Registered Nurse confirmed the presence of salt was inappropriate for the resident's condition.
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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 Escanaba
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Park Village | 0.2 mi | ★★★★★ | 2 | 0 |
| Bishop Noa Home For Senior Citizens | 0.4 mi | ★★★★★ | 11 | 0 |
| Pinecrest Medical Care Facility | 21.6 mi | ★★★★★ | 0 | 0 |
| Roubal Care And Rehabilitation Center | 34.2 mi | ★★★★★ | 1 | 0 |
| Serenity Spring Senior Living At Scandia Village | 38.4 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.