Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Church Of Christ Care Center during CMS and state inspections, most recent first.
Misappropriation of Resident Property: A cognitively intact resident with CKD, DM, and obesity reported $60 from the resident trust fund missing after it was placed on an overbed table. Investigation found a housekeeper entered the resident’s room on multiple occasions outside job duties and gave contradictory explanations, while the facility documented the case as inconclusive.
A resident with intact cognition and significant medical conditions repeatedly called out for help at night because they could not reach the call light and needed to be turned due to pain. An LPN and CNA delayed responding, told the resident to stop yelling and that they were not the only patient, and refused to turn the resident, stating it had not been two hours and that pain medication had already been given before saying "Goodnight" and leaving. The resident’s continued calls for help were ignored, and when the CNA later re-entered and exited the room, the CNA told the resident that if they became soiled, "that's on you." The resident later reported that the staff were mean and would not help despite their repeated calls.
A resident with significant physical limitations and a care plan requiring two-person assistance for incontinence care and bed mobility was assisted by only one CNA, who turned away during care, resulting in the resident falling from bed and sustaining a right arm fracture. The CNA was aware of the two-person assist requirement but proceeded alone due to lack of available staff, contrary to the care plan and facility policy.
PPE was not available for a resident on EBP. A CNA entered the room of a resident and roommate who were both on EBP and provided care while wearing gloves and a mask, but no gown was used because none was available. The room had an EBP sign, but no PPE was observed on the door or in the room, despite the facility policy stating gowns and gloves must be available immediately near or upon entrance to the room.
Ice machine drain lacked backflow protection near the main kitchen. During observation, the drain line was seen extending into the floor drain with no air gap between the pipe and the flood rim. The Dietary Manager confirmed the condition and said she would let Maintenance know.
Failure to develop and implement comprehensive care plans for three residents. One resident with dementia, schizophrenia, depression, and COPD had a behavior-related psychotropic care plan, but no behavior monitoring tool was in place despite staff expectations to monitor behaviors. Another resident with dementia and a fall history had an anti-roll back wheelchair intervention documented, yet the device was not on the chair during observations and the wheelchair was unlocked while the resident was bending over. A third resident with bipolar disorder and a psychiatry-documented PTSD diagnosis did not have a PTSD care plan.
Two residents did not receive necessary ADL assistance: one with severe cognitive impairment was left without the required 1:1 feeding help, resulting in food on their clothing and face, while another was not assisted with shaving according to their preference, receiving grooming only on scheduled shower days. Staff and policy reviews confirmed these lapses in providing individualized care.
Inaccurate MDS Assessment for Pressure Ulcer Status: The facility failed to complete an accurate assessment for a resident with chronic respiratory failure, moderately impaired cognition, and ADL dependence. The resident was observed in bed and reported having a pressure ulcer, but later skin observation showed a rash and no pressure ulcer. Record review showed the MDS listed an unhealed stage 2 PU and pressure-reducing devices, even though a progress note documented the stage 2 pressure injury had resolved and skin was intact; an MDS nurse stated the assessment had been marked as current despite the wound being healed.
A resident who required built-up utensils was observed eating with regular utensils even though the meal ticket was marked for adaptive equipment. The resident said the correct utensils are rarely provided and that the built-up utensils help with meals and hand pain. OT, RD, and DON all confirmed the resident still required the built-up utensils.
Failure to reposition a dependent resident with a Stage 2 buttocks pressure wound. The resident was repeatedly observed lying on the back in bed on an air mattress with heel boots on, while family voiced concern that staff were not assisting the resident out of bed after returning from the hospital. A CNA, the wound care LPN, and the DON stated dependent residents should be repositioned at least every 2 hours or more often as needed, and the resident's care plan included turning/repositioning, heel elevation, and a pressure-reducing mattress.
A resident with respiratory failure, CKD, and CHF had a physician order for continuous oxygen at 4 L/min via nasal cannula, but was repeatedly observed without oxygen in use while the concentrator was on and the tubing was not being used properly. An RN believed the oxygen was PRN, while the DON stated continuous oxygen orders require repeated encouragement, close SpO2 monitoring, and physician notification if the resident is noncompliant.
A resident with dementia was physically abused by a CNA in the presence of other staff members. The incident was reported by a witness, leading to an investigation and the termination of the involved CNA. The resident was unable to recall the incident due to severely impaired cognition.
Two residents in an LTC facility experienced worsening pressure ulcers due to inadequate assessment and treatment. One resident's coccyx wound was not properly documented or treated, leading to significant deterioration, while another resident developed new Stage 2 ulcers. The facility failed to follow pressure injury prevention guidelines, resulting in a lack of individualized interventions and documentation.
The facility failed to review and report monthly pharmacist medication recommendations for four residents with various diagnoses, including Major Depression and Alzheimer's. Despite completed medication regimen reviews, records showed blank fields for actions and responses. The NHA couldn't obtain the pharmacist's reports, and the DON admitted the need for a better system to ensure irregularities and recommendations are reviewed and communicated.
The facility failed to develop comprehensive wound care plans for two residents with existing wounds. One resident had multiple wounds and cognitive impairment, while another had a spinal infection and a coccyx wound. Both care plans lacked specific wound details and treatment, focusing only on general skin integrity measures. The DON and Unit Manager acknowledged the need for more detailed care plans.
A resident expressed dissatisfaction with their living conditions and requested a cell phone to communicate with others, but the facility failed to follow OBRA II Evaluation recommendations. The resident was not informed about their trust funds, which could have been used for personal items, and there was no documented follow-up or communication regarding their request. Additionally, the resident's guardianship had expired, and there was no clear progress in appointing a new guardian. The facility lacked specific policies on social work services, guardianship, and resident rights, contributing to the oversight.
A resident with moderately impaired cognition and a diagnosis of acute respiratory failure with hypoxia did not receive scheduled showers for three weeks. The resident reported that agency staff were sometimes rude and did not change briefs timely. Documentation showed showers were not given on scheduled days, and the Unit Manager confirmed the CNA involved was agency staff.
The facility failed to follow hospital discharge instructions for a resident, including removing a Foley catheter and scheduling follow-up appointments. Additionally, the facility did not adequately assess and manage pain for another resident who experienced multiple falls and severe pain, leading to hospitalization for acute kidney injury and dehydration. Interviews with staff revealed a lack of adherence to policies regarding notification of changes and pain management.
A resident with severe cognitive impairment and a high fall risk experienced multiple falls, resulting in a right femur fracture. The facility failed to promptly establish and update a fall prevention care plan, leading to repeated falls and inadequate interventions.
A resident with a documented DNR order received CPR due to a lack of a physician's signature on the form, leading to a change in code status to full code. The family was unaware of the CPR administration, and the facility acknowledged the oversight during a transition to state-compliant forms.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to prevent misappropriation of property for one resident who reported that $60.00 obtained from the resident trust fund was missing after being placed in a pouch on the overbed table. The resident stated they did not leave the room after receiving the money, did not give it to anyone, and later reported the missing money to the NHA and local police. The resident was cognitively intact and had diagnoses including CKD, DM, and obesity, and required extensive assistance with some ADLs. The investigation identified Housekeeper A entering the resident’s room on three separate occasions outside of job duties. The NHA confirmed the resident had no visitors during the relevant period and stated that camera footage showed Housekeeper A entering the room multiple times before the scheduled shift. When interviewed, Housekeeper A gave contradictory explanations for entering the room. The facility’s investigation was documented as inconclusive, with the outcome noting it was possible the resident still had the money, gave it to a relative, or misplaced it.
Failure to Protect Resident From Verbal Abuse and Ignored Requests for Assistance
Penalty
Summary
The deficiency involves a failure to protect a cognitively intact resident from verbal abuse and neglect of care needs by staff on the night shift. On the night in question, the resident repeatedly called out for help beginning around 11:30 p.m. because they could not reach the call cord and needed to be turned and repositioned. Video and audio from the hallway showed the resident yelling for help while an LPN remained outside the room for several minutes before the LPN and a CNA entered. When they did enter, the LPN told the resident to stop yelling and stated the resident was not the only patient on the floor. After leaving, the resident again called out, stating they could not reach the call light. When the LPN and CNA returned to the room, the resident told them they needed to be turned due to pain. The LPN responded that it had not been two hours and, when the resident again stated they were in pain, the LPN replied that pain medication had already been given and said, "Goodnight," before exiting the room. Both staff then ignored the resident’s continued calls for help and request to be turned. Later, the CNA re-entered the room, exited, and told the resident, "Goodnight. If you get messed up (soil on self), that's on you." During an interview conducted later, the resident, who had diagnoses including malignant neoplasm of the brain and thoracic radiculopathy and a BIMS score of 12/15 indicating intact cognition, reported that the staff on that shift were mean and would not help, and that they kept yelling for help.
Failure to Provide Required Two-Person Assistance During Incontinence Care Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who required the assistance of two staff members for incontinence care and bed mobility due to physical weakness, right hemiparesis, morbid obesity, and a history of cerebrovascular accident, was provided care by only one Certified Nursing Assistant (CNA). The resident's care plan and Kardex clearly indicated the need for two-person assistance for all activities of daily living, including incontinence care and bed mobility. During morning care, the CNA assisted the resident alone, instructing the resident to grab the bed bar and turning away to retrieve cream. At this moment, the resident rolled out of bed, fell to the floor, and sustained a proximal humerus fracture of the right arm. The resident was alert, verbal, and complained of pain, and was subsequently transferred to the hospital for further evaluation and treatment. The CNA acknowledged awareness of the two-person assist requirement but stated that another staff member was not available at the time. The Director of Nursing confirmed that staff are expected to follow the care plan and minimum staffing requirements as outlined in the facility's policies. The facility's fall prevention policy required individualized interventions based on assessed risk, but this was not followed in the resident's case, directly resulting in the fall and injury.
PPE Not Available for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to have available and to don and doff PPE for one resident on Enhanced Barrier Precautions (EBP), R117, out of six residents reviewed for infection control. On 8/19/2025 at 2:00 PM, R117's door had a sign indicating the room was on EBP, but no PPE was observed on the door or in the room. At 2:08 PM, CNA J was observed entering R117's room and providing care to R117 and the roommate, both of whom were on EBP. CNA J was wearing gloves and a mask, but when asked, reported that they did not put on a gown and that there was not one available. On 8/20/2025 at 11:00 AM, the DON stated that EBP training had been completed earlier in the year and that the facility had been facing challenges since staffing changes. A review of the facility's Enhanced Barrier Precautions policy stated that gowns and gloves are to be made available immediately near or upon entrance into the resident's room.
Ice Machine Drain Lacked Backflow Protection
Penalty
Summary
The facility failed to ensure the ice machine near the main kitchen was backflow protected. During observation on 08/18/2025 at 11:45 AM, the ice machine drain line was seen extending down inside the floor drain, with no air gap between the bottom of the drain line pipe and the flood rim of the floor drain. The Dietary Manager confirmed the lack of an air gap and stated she would let Maintenance know. The report cited FDA 2022 Model Food Code, Section 5-402.11 Backflow Prevention, regarding the prohibition of a direct connection between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable objectives and time frames for three residents reviewed for care plans. For a resident with diagnoses including dementia, schizophrenia, depression, and COPD, the record showed a care plan for antipsychotic medications with an intervention for staff to monitor behaviors, including documenting behavior episodes and attempting to determine underlying causes, but the Director of Nursing stated there was no behavior monitoring tool for the resident. The resident was observed sitting on the side of the bed appearing anxious with nervous speech and finger movements, and the facility’s Comprehensive Care Plan Policy stated that each resident should have a comprehensive person-centered care plan with measurable objectives and time frames to meet identified medical, nursing, and psychosocial needs. For another resident with dementia and a fall history, the record showed a fall on 2/18/2025 and an active intervention for anti-roll backs to the wheelchair dated 3/11/2025, but anti-roll backs were not observed on the wheelchair during later observations. The resident was seen bending over and attempting to fix bed covers while the wheelchair was unlocked, and the Occupational Therapist stated the resident did not have anti-roll backs on the chair and probably needed them. For a third resident with muscle weakness and bipolar disorder, the resident was observed tearful and stated they get sad and depressed sometimes in the facility, and a psychiatry note listed PTSD as a current, chronic, unchanged diagnosis; however, the resident did not have a care plan addressing PTSD.
Failure to Provide Required ADL Assistance for Feeding and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident with diagnoses of cerebrovascular disease and Alzheimer's disease, and a Brief Interview for Mental Status score of 0/15 indicating impaired cognition, was observed multiple times with food on their clothing protector and face, attempting to eat with their fingers, and without staff present to provide the ordered 1:1 feeding assistance. The resident's medical record included an active physician's order for 1:1 feeding assistance, and both staff and the registered dietitian confirmed the resident required significant help with meals, especially when eating in their room. Another resident, recently admitted with hypertensive heart disease and a mood disorder, was observed to have facial stubble for several days and reported a preference to remain clean shaven but was unable to shave independently. The resident stated that staff had assisted with shaving, but not frequently. Staff interviews revealed that shaving was only provided on shower days, twice a week, and the DON confirmed that the facility protocol did not specifically assess or address resident preferences for shaving frequency in the care plan. Facility policy required that residents unable to perform ADLs receive necessary services for grooming and hygiene, but this was not consistently implemented.
Inaccurate MDS Assessment for Pressure Ulcer Status
Penalty
Summary
The facility failed to complete an accurate resident assessment for one sampled resident, R36, out of 23 residents reviewed for assessments. On 8/18/25, R36 was observed in bed and stated they had a pressure ulcer. The next day, R36’s skin was observed with a nurse and a physician, and the resident had a rash extending from the middle of the back to the back of the legs; at that time, the resident no longer had a pressure ulcer. Record review showed R36 was admitted with chronic respiratory failure and had a moderately impaired cognition and required staff assistance with activities of daily living. The annual MDS indicated R36 had one unhealed stage 2 pressure ulcer and used a pressure-reducing device for bed and chair. However, a progress note dated 5/12/25 documented that the stage 2 pressure injury to the left ischium had resolved, with skin intact and only rash and scabs remaining. On 8/20/25, the MDS Nurse stated the 7/30/25 MDS marked R36 as having a current unhealed stage 2 pressure ulcer even though it had been noted as healed on 5/12/25, and said they would need to speak with the other MDS Nurse because they did not complete the assessment for R36.
Failure to Provide Ordered Adaptive Utensils
Penalty
Summary
The facility failed to provide built-up utensils for one resident who required adaptive equipment for meals. During breakfast observation, the resident’s meal ticket was marked for built-up utensils, but the resident was eating with regular utensils. The resident stated they rarely get the right utensils and that the built-up utensils help with meals and hand pain. The resident was admitted with diagnoses of muscle weakness and bi-polar disorder, had a BIMS score of 15/15 indicating intact cognition, and required assistance with bed mobility and transfers. The OT confirmed the resident should have built-up utensils, the RD stated the resident still required them, and the DON reported the resident should have them on the tray.
Failure to Reposition a Resident With a Pressure Wound
Penalty
Summary
The facility failed to reposition one resident, R113, in a timely manner for pressure ulcer care. R113 was admitted with diagnoses including high blood pressure, urinary tract infection, and muscle weakness, and the medical record showed the resident was dependent on staff for activities of daily living, including bed mobility. The admission nursing assessment documented a Stage 2 pressure wound on the buttocks, and the care plan dated 05/27/2025 identified the resident as at risk for skin breakdown. During observations on 08/18/2025 and 08/19/2025, R113 was repeatedly seen lying on the back in bed with the head of the bed elevated to 40 degrees, on an air mattress, wearing a hospital gown and heel boots. On 08/19/2025, the resident's family stated they were at the facility for a care conference and expressed concern that since returning from the hospital, the resident had not been talking and staff were not assisting the resident to get out of bed. Interviews with a CNA, the wound care nurse/LPN, and the DON confirmed that dependent residents were expected to be repositioned every 2 hours or more often as needed, and that R113's interventions included turning and repositioning, heel elevation, and a pressure-reducing mattress.
Failure to Apply Ordered Continuous Oxygen
Penalty
Summary
The facility failed to apply oxygen per physician order for one resident with respiratory care needs. The resident was admitted with diagnoses including respiratory failure, chronic kidney disease, and congestive heart failure, and had an order dated 03/15/2024 for continuous oxygen at 4 liters per minute via nasal cannula. The care plan also identified oxygen therapy with continuous cannula use for shortness of breath and a history of respiratory failure. During observations on 08/18/2025 and 08/19/2025, the resident was seen sitting on the side of the bed without oxygen in use, while the oxygen concentrator was on and the tubing was lying on the floor or wrapped around the concentrator. The resident was also observed leaving the facility with a family member without oxygen in use. When interviewed, an RN stated the oxygen was thought to be ordered as needed, while the DON stated that for a continuous oxygen order, nurses are expected to repeatedly encourage use, monitor SpO2 closely, and notify the physician of noncompliance and discuss possible changes to the order.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. The incident involved a Certified Nurse Aide (CNA) who was observed physically slapping a resident during care, with two other staff members present. The resident, who has a diagnosis of dementia, adjustment disorder, and anxiety, was unable to recall the incident due to severely impaired cognition. The incident was reported by a witness, another CNA, who immediately informed the nurse supervisor. The Director of Nursing confirmed that the incident was reported to the State Agency and the police, and an investigation was conducted, resulting in the termination of the involved CNA. The facility's policy on abuse, neglect, and misappropriation of resident funds or property clearly states that any form of abuse will not be tolerated and must be reported immediately. Despite the resident's inability to remember the incident, the facility's failure to prevent the abuse led to the citation.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess, identify, and provide treatment for pressure ulcers in two residents, leading to the development and worsening of their conditions. Resident R78 was admitted with multiple wounds and was identified as high risk for developing pressure ulcers. Despite this, there was a lack of documentation and treatment for R78's coccyx wound from 5/24/24 to 7/6/24, and only two weekly skin assessments were completed between 5/28/24 and 7/11/24. The wound care physician noted the worsening condition of R78's coccyx wound, which was not properly assessed or treated, leading to a significant increase in size and the presence of thick slough tissue. Additionally, R78 developed new unstageable pressure ulcers on the left foot and ankle, which were not documented or treated. The nursing staff failed to notify the nurse practitioner of changes in R78's condition, and the Director of Nursing confirmed that wound care orders were not implemented or documented in the treatment record. This lack of communication and documentation contributed to the deterioration of R78's pressure ulcers. Resident R21 also experienced a decline in skin integrity, developing a new Stage 2 pressure ulcer on the coccyx and buttocks. Despite being cognitively impaired and dependent on staff for daily living activities, R21's care plan and skin evaluations did not adequately address the risk of pressure ulcers. The facility's pressure injury prevention guidelines were not followed, as evidenced by the lack of individualized interventions and documentation of compliance with treatment orders. The facility acknowledged the issue and was aware of it during Quality Assurance meetings.
Failure to Review and Report Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review and reported medication recommendations for four residents. The residents involved had various diagnoses, including Major Depression, Hypertension, Diabetes, Generalized Anxiety Disorder, Schizoaffective Disorder, Alzheimer's Disease, and Dementia. Despite the completion of multiple medication regimen reviews, the records for these residents showed blank fields for actions and responses to the pharmacist's recommendations, indicating a lack of follow-up on identified irregularities. Interviews with facility staff revealed that the Nursing Home Administrator was unable to obtain the pharmacist's reports, and the Director of Nursing acknowledged the need for a better system to ensure that irregularities and recommendations are reviewed by the physician and communicated to the pharmacist. The facility's procedure for drug regimen reviews requires that irregularities be documented and sent to the attending physician, medical director, and director of nursing, with urgent issues reported immediately. However, the attending physician's documentation of review and action taken was missing, highlighting a breakdown in the communication and documentation process.
Failure to Implement Comprehensive Wound Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive wound care plan for two residents, R78 and R91, as observed during a survey. R78 was admitted with multiple wounds on the sacrum/coccyx, left hip, left foot, and left thigh, alongside diagnoses of muscle weakness, need for assistance with personal care, and unspecified encephalopathy. Despite these conditions, R78's care plan only addressed general skin integrity risks and interventions, such as using cushions, encouraging nutrition, and repositioning, without specific mention of the existing wounds or tailored treatment plans. Similarly, R91, who was admitted with a diagnosis of osteomyelitis of the vertebra and a wound on the coccyx, had a care plan that failed to address the specific wound. The care plan included general interventions for skin integrity, such as using a pressure-reducing mattress and monitoring skin changes, but lacked details on the wound's location and treatment. Interviews with the DON and Unit Manager revealed an expectation for more detailed care plans that include specific wound locations and treatment plans, which were not met in these cases.
Failure to Address Resident's Preferences and Guardianship
Penalty
Summary
The facility failed to adhere to the OBRA II Evaluation recommendations for a resident, identified as R22, who expressed dissatisfaction with their living conditions and a desire for a cell phone to communicate with individuals outside the facility. Despite being cognitively intact, R22 was not informed about their resident trust funds, which could have been used to purchase personal items like a cell phone. The facility's social worker and staff were aware of the resident's request and the need for a state ID to obtain a cell phone, but there was no documented follow-up or communication with the resident, their guardian, or phone service providers. Additionally, the guardianship for R22 had expired, and there was no clear progress or communication regarding the appointment of a new guardian. The facility also lacked specific policies on social work services, guardianship, and resident rights, which contributed to the oversight in addressing R22's needs and preferences. The Director of Nursing acknowledged the importance of following OBRA assessment recommendations and the necessity of having a guardian in place but admitted to insufficient knowledge about the resident trust concerns. The absence of communication and action regarding R22's requests and the lack of policy guidance highlight the facility's failure to honor the resident's preferences, choices, values, and beliefs, as required by federal regulations.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide showers for a resident, identified as R19, who was unable to perform activities of daily living independently. R19 reported that it had been three weeks since they last received a shower, despite being scheduled for showers on Tuesday PM and Friday AM shifts. On one occasion, a Certified Nursing Assistant (CNA) informed R19 that they could not receive their scheduled shower because they returned to their room too late. The facility's documentation in the Electronic Medical Record (EMR) for R19's showers showed entries marked as 'N/A' for the scheduled shower dates, indicating that the showers were not given. R19, who has a diagnosis of acute respiratory failure with hypoxia and moderately impaired cognition, expressed dissatisfaction with the care provided by agency staff, noting that they were sometimes rude and did not change briefs in a timely manner. The Unit Manager was unable to explain why the shower was not given and confirmed that the CNA involved was agency staff. The facility's policy on Activities of Daily Living (ADLs) emphasizes the need for personalized care plans based on comprehensive assessments to ensure residents' needs and preferences are met, which was not adhered to in this case.
Failure to Follow Discharge Instructions and Manage Pain
Penalty
Summary
The facility failed to follow hospital discharge instructions and orders for a resident who was admitted with a displaced intertrochanteric fracture of the left femur, retention of urine, and dementia. The hospital discharge instructions included removing a Foley catheter on a specific date and scheduling follow-up appointments with various specialists. However, the facility did not make these appointments, and the unit secretary was unable to provide documentation or copies of the appointments. Interviews with staff, including the unit manager and the Director of Nursing (DON), revealed that there was an expectation for nurses to follow up on orders and instructions, but this was not done in this case. In another instance, the facility failed to assess and address a change in condition and control pain for a resident with Alzheimer's and essential hypertension. The resident experienced multiple falls and complained of severe pain, which was not adequately managed. Despite being prescribed Tramadol for pain management, the resident continued to report severe pain and a decrease in food intake. The facility's records indicated that the resident's condition deteriorated, leading to hospitalization for acute kidney injury, dehydration, and hypotension. The hospital records also revealed that the resident had healing rib fractures, which were not previously identified or addressed by the facility. Interviews with the DON and other staff members highlighted a lack of adherence to the facility's policies regarding notification of changes and pain management. The DON stated that the process for handling falls and pain complaints involved assessing the resident, notifying the physician, and conducting further evaluations, but these steps were not followed. The Unit Manager acknowledged that the pain was not addressed appropriately and emphasized the importance of following up on issues noted in progress reports. The facility's failure to manage the resident's pain and follow hospital discharge instructions contributed to the resident's decline and subsequent hospitalization.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement measures to prevent multiple falls for a resident with severe cognitive impairment, resulting in a right femur fracture that required surgical repair. The resident, who had a high fall risk score upon admission, experienced their first fall one week after admission. Despite this, a fall prevention care plan was not established until four days later. Subsequent falls occurred on multiple occasions, but new fall prevention interventions were not consistently added to the care plan in response to these incidents. The resident's care plan history indicated that after the initial fall, the only intervention added was monitoring for signs and symptoms of pain and other issues. After subsequent falls, minimal or no new interventions were added, even though the resident continued to fall. The resident's condition worsened, requiring additional assistance with transfers and pain management following the fracture. The facility's Director of Nursing acknowledged that the fall prevention care plan was not established promptly and that new interventions were not consistently added after each fall. The facility's policy on fall prevention was not followed, as it required immediate initiation of prevention protocols for high-risk residents and revision of the care plan after each fall. The policy also outlined specific interventions that should be considered for high-risk residents, such as assistive devices, increased frequency of rounds, and therapy services referral. However, these interventions were not consistently implemented for the resident, leading to repeated falls and a significant injury.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor the advance directive/code status wishes for a resident (R707) who had a documented Do Not Resuscitate (DNR) order. Despite having a DNR status documented and signed by the family member and facility staff, the form lacked a physician's signature. This led to confusion and a change in the resident's code status to full code during a transition to state-compliant forms. Consequently, when R707 was found unresponsive, CPR was administered, contrary to the resident's and family's wishes. The family was not aware that CPR had been performed and expressed concern over the incident. The Director of Nursing (DON) and the facility Administrator acknowledged the situation, explaining that the code status was changed due to the lack of a physician's signature on the DNR form. The Vice President of Clinical Operations (VPCO) confirmed that the form had been unsigned by the physician since the resident's transfer to hospice services, which prompted the change to full code status. The facility's policy on residents' rights regarding treatment and advance directives was reviewed, revealing that the facility is supposed to support and facilitate a resident's right to request, refuse, and/or discontinue treatment, which was not adhered to in this case.
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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 Clinton Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakepointe Senior Care And Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Fraser Villa | 4.2 mi | ★★★★★ | 7 | 0 |
| Martha T Berry Mcf | 4.3 mi | ★★★★★ | 7 | 0 |
| Harmony Village Of Clinton | 4.4 mi | ★★★★★ | 1 | 0 |
| Shorepointe Nursing Center | 5 mi | ★★★★★ | 1 | 0 |
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