Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clark Retirement Community during CMS and state inspections, most recent first.
Lack of Required RN Coverage on Weekends: The facility failed to provide the required RN coverage for 8 consecutive hours per day, 7 days per week. Review of nursing schedules showed multiple weekends without the required RN presence, including weekends with no scheduled RN coverage at all. The Scheduler reported the facility did not have enough direct care RNs for weekend coverage, and the NHA confirmed the facility was not in compliance after reviewing the schedules.
Food service sanitation and temperature control were not maintained. A scoop, utensil bins, a mixer, and a slicer were observed with food debris, the dish machine did not reach required sanitizing temperatures and the booster heater incoming water was below the indicated range, and the dish area floor had missing grout and a missing tile with standing water. In addition, an opened soy sauce container requiring refrigeration was left on the counter, and a container of pasta was found cooling in the walk-in cooler at 57F and was not listed on the cooling log.
Failure to promote dignified dining and resident respect: A resident with Alzheimer’s disease was seated with her meal covered until an LPN later assisted her, another resident with dementia and diabetes was taken away from the dining room for blood sugar testing and insulin and returned to a cold meal with no staff warming it, and a third resident with dementia and malnutrition had meals left untouched in front of her for extended periods before staff assisted. Staff were also observed using a cellphone during care, and residents reported frustration and decreased self-worth when staff were distracted.
A resident with moderate cognitive impairment and a history of falls had a stated preference for anyone entering her room to use hand sanitizer and wear a surgical mask. Her care plan reflected honoring resident preferences, and a sign on her door requested masking, but a CNA, HSK, and an LPN were observed entering and providing care without masks while the resident was present, despite her expressed concern about exposure to illness.
The facility failed to implement comprehensive care plans for two residents, leading to unmet care needs. One resident with dysphagia was left unsupervised during meals, resulting in improper eating techniques, while another resident with hearing loss was not provided with hearing aids as per their care plan. Additionally, inadequate incontinence care and pressure ulcer prevention measures were observed.
A resident with urinary retention and incontinence was not provided timely care as per their care plan, resulting in prolonged periods without incontinence checks. Staff failed to perform required checks every 2 hours, and during an observed care session, proper hygiene practices were not followed, as the CNA did not change gloves after cleaning the resident. The DON confirmed the resident should have received care every 2 hours.
The facility failed to adhere to food safety standards, with cooked beef roasts improperly cooled and bean soup not reaching the required temperature within the specified time. Additionally, dirt and debris were found in the kitchen, indicating a lack of cleanliness. Staff interviews revealed discrepancies in food handling and cooling procedures.
The facility failed to implement proper infection control precautions for residents with COVID-19 and other infections. Staff did not consistently use required PPE, such as N95 masks and eye protection, when entering rooms of COVID-19 positive residents. Additionally, Enhanced Barrier Precautions were not adequately followed for residents with infections, with staff lacking awareness and training on these measures.
The facility did not ensure all staff completed the required annual abuse prevention education, affecting 27 out of 126 employees, with no therapy or housekeeping staff listed as having completed the training. The QAA Committee's review indicated training was provided via a computer module, but documentation verifying completion for all staff was not available.
The facility failed to provide effective training on Enhanced Barrier Precautions (EBP) for all staff, as evidenced by a CNA's lack of recall of such education and the DON's admission of not initiating formal EBP training since January 2024. Despite claims of ongoing infection control training, there was no documentation verifying staff completion of EBP education.
A resident with Alzheimer's and dementia was left without entertainment or timely assistance in a recliner at the dining table. Despite expressing the need to use the restroom, staff delayed assistance, resulting in the resident sitting in soiled clothing. The situation was exacerbated by the lack of a call light and the need for PPE due to a COVID-positive roommate.
A facility failed to report an allegation of neglect involving a resident with ALS, who was allegedly left in a soiled state in a wheelchair. The DON conducted an incomplete investigation without notifying the state agency, despite facility policy requiring immediate reporting of such incidents.
A resident with ALS and other health issues was reportedly left in a soiled state in a wheelchair, but the facility failed to conduct a thorough investigation. The DON did not interview all relevant staff or file an incident report, and the incident was not reported to the state agency, contrary to the facility's abuse prevention policy.
A facility failed to implement a comprehensive care plan for a resident with dementia, stroke, and dysphagia. The care plan included interventions like wearing a blue boot and elevating leg rests, but observations showed these were not consistently followed. Staff interviews revealed attempts to address the resident's needs, but the care plan's directives were not consistently implemented, and refusals of care were not documented.
A resident with severe cognitive impairment and a history of falls experienced a fall resulting in a hip fracture. After hospital readmission, a new intervention involving a padded mat was implemented but not documented in the care plan. Observations confirmed the mat's presence, and staff interviews acknowledged the oversight in updating the care plan, leading to an inaccurate reflection of the resident's status.
A facility failed to implement a resident's mechanical diet order and necessary positioning interventions in a timely manner. Despite recommendations from a speech language pathologist, the resident was served meals inconsistent with her dietary needs, and no interventions were documented to address her poor positioning in a wheelchair. Observations showed the resident leaning significantly to the right side, with makeshift supports used inconsistently. Staff interviews revealed a lack of communication and follow-up regarding the resident's needs.
A resident with a history of paralysis and other conditions developed multiple pressure ulcers due to the facility's failure to implement necessary care interventions. Despite having a care plan, the resident was often left in a supine position without protective devices, leading to delayed healing and potential infection. Communication gaps among staff contributed to the deficiency.
A facility failed to implement a Gradual Dose Reduction (GDR) for an antidepressant medication for a resident with depression and anxiety. Despite a pharmacist's recommendation and the Medical Director's agreement to reduce the dose of Paroxetine from 20mg to 10mg, the reduction was not executed due to a delay in follow-up. The resident's mood was stable, and there was no contraindication to the dose reduction.
A facility failed to offer a timely pneumococcal vaccination to a resident eligible for the PCV20 vaccine. The resident, with a history of stroke, hypertension, and hyperlipidemia, had previous vaccinations but was not documented as having been offered the PCV20. The DON and IP confirmed the oversight, noting the pharmacy's role in notifying the facility of vaccine eligibility, which was not fulfilled.
Lack of Required RN Coverage on Weekends
Penalty
Summary
The facility failed to provide an RN for 8 consecutive hours per day, 7 days per week. Review of nursing schedules for 1/1-3/31/25 showed the facility did not provide RN coverage for 8 consecutive hours per day, 7 days per week during 5 of 14 weekends in that timeframe. Review of nursing schedules with a reference date of 5/1-7/27/25 showed the facility did not provide RN coverage for 8 consecutive hours per day during any of the 13 weekends included in that timeframe. During 8 of those weekends, the facility had no scheduled RN coverage at all. The RN job description stated the RN conducts initial and ongoing assessments of residents' health status and collaborates with physicians, nurse practitioners, and other healthcare providers to develop and implement care plans. The LPN job description stated the LPN works under the direction of the DON and Nursing Supervisor, makes routine rounds, administers medications, and observes and reports resident symptoms and conditions to the treating physician. In interviews, the Scheduler reported the facility had not provided at least 8 consecutive hours of RN coverage for several weekends and did not have enough direct care RNs to provide the necessary weekend coverage. The NHA stated she was unaware of the lack of RN coverage until reviewing the schedules during survey and confirmed the facility was not in compliance.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food service equipment and utensils in clean condition. During observation of the clean utensil storage area, a mechanical scoop was found stored with stuck-on food debris, and the bins containing whisks and spoons had an increased accumulation of crumb debris. The Dining Services Director stated this area should be cleaned every Tuesday. In the kitchen, the tabletop mixer had dried stuck-on food debris on the back shield and front grate of the mixing under arm, and the slicer had stuck debris that looked like tomato seeds on the top backside of the blade. The Chef stated tomatoes are used on the slicer. The dish machine was also observed not to achieve the required sanitizing temperatures. The machine required 150F for the wash cycle and 180F from the rinse manifold to ensure a contact temperature of 160F or higher, but after four full cycles the facility and surveyor thermometers both read between 153F and 156F. On revisit later the same day, the dish machine still was not achieving proper rinse temperature. Review of the incoming hot water supply to the booster heater showed the temperature gauge indicated it needed to be 130F or higher, while the incoming hot water temperature was between 118F and 124F. The facility's Dishmachine Temperature Record for July 2025 also showed multiple low temperatures below the required levels. Additional observations found physical facility and food storage issues. The floor in the dish machine area had heavy wear with missing or worn grout that allowed water to accumulate in crevices and stagnate, and one complete tile was missing under the dish machine. The floor under the dish room hand sink had a beveled lip creating an uneven surface. A half full container of less sodium soy sauce was stored on the counter near the dining room door even though the label stated to refrigerate after opening. On revisit, a full six-quart container of pasta tightly covered in saran wrap was found on a shelf in walk-in cooler #7 with condensation on the container and a temperature of 57F, and it was not listed on the cooling log despite numerous other items being actively cooled.
Failure to Promote Dignified Dining and Resident Respect
Penalty
Summary
The facility failed to promote a dignified dining experience for 3 of 4 residents reviewed for dignity. Resident #21, a female with Alzheimer’s disease, dysphagia, protein-calorie malnutrition, and weakness, was seated at a dining table with her meal covered while another resident was already eating. An LPN later opened her napkin and removed the top from her plate, then sat between Resident #21 and Resident #14 to assist both residents with dinner. Resident #21’s care plan indicated she required limited assist with eating and could at times eat on her own, and her orders included a regular diet with mechanical soft texture, nectar consistency, mechanical soft meat only, and supervision with all meals. Resident #4, a male with dementia, hypoglycemia, diabetes, dysphagia, and long-term insulin use, was seated at the dining table while a CNA prompted him to take a bite of his grilled cheese and he refused. The LPN asked if it was okay to take him to his room to check his blood sugar and provide insulin, and he went to his room with the door closed behind them. He remained waiting in his room while the nurse returned to provide insulin, then self-ambulated back to the dining room about 9 minutes later. No staff offered to warm his food when he returned, and he had not begun eating when observed again several minutes later. Resident #14, a female with dementia, protein-calorie malnutrition, anemia, and muscle weakness, was observed at meals with her food placed in front of her while she did not begin eating and appeared to need assistance. At breakfast, her meal sat untouched for at least 14 minutes while peers ate or were assisted, before the DON began assisting her. Later, a CNA assisted her while looking downward and using a cellphone on her lap. In a confidential meeting, 2 of 5 residents reported witnessing staff using personal cell phones while providing care, and 1 resident reported frustration and a feeling of decreased self-worth when waiting for care because staff were on their cellphones. The facility policy stated that staff are to protect and promote resident rights and treat each resident with respect and dignity.
Resident Preference for Masking Not Honored
Penalty
Summary
The facility failed to ensure Resident #32’s right to self-determination was honored when staff did not consistently follow her stated preference for hand sanitizer and a surgical mask before entering her room. Resident #32 was admitted with a history of falls and had a BIMS score of 11/15, indicating moderate cognitive impairment. Her care plan included honoring resident preferences, and a sign posted on her door instructed anyone entering the room to use hand sanitizer and wear a mask. During interview, Resident #32 stated she preferred these precautions because she was concerned about exposure to illness and wanted to avoid anything that could delay her recovery from a fall. Despite the posted sign and the resident’s expressed wishes, staff were observed entering and providing care without wearing masks. An unknown CNA assisted Resident #32 out of the bathroom and exited her room without a mask. Later, HSK F performed light housekeeping in the room while the resident was present without wearing a mask, and LPN H administered medications in the room without wearing a mask. Family reported that the resident had used the same precautions at home and that her daughter had placed the sign on the door a few days earlier to reflect her preference.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet care needs. Resident #106, who was admitted with dysphagia and urinary retention, had conflicting care plan interventions regarding feeding assistance. Observations revealed that Resident #106 was left unsupervised during meals, leading to improper eating techniques and potential choking hazards. Additionally, the resident's care plan for pressure ulcer prevention was inadequate, as staff did not provide timely incontinence care, leaving the resident in a wet and soiled brief for extended periods. Resident #106's care plan inconsistencies were further highlighted by interviews with staff and family members. The Director of Nursing believed the resident was independent with eating, while a CNA reported frequent coughing during meals and the need for assistance. The family member expressed concerns about the lack of regular incontinence checks, which were supposed to occur every two hours. The resident's immobility and risk for pressure ulcers were not adequately addressed, as evidenced by the lack of repositioning and incontinence care. Resident #107, diagnosed with bilateral hearing loss, was observed without hearing aids, despite care plan instructions to ensure their use. The LPN responsible for administering morning medications failed to check if the hearing aids were in place. The resident expressed a desire to wear the hearing aids but was unable to insert them independently. This oversight in care plan implementation resulted in impaired communication for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and effective incontinence care for Resident #106, who was diagnosed with urinary retention and had a care plan indicating bladder incontinence related to dementia, Parkinson's disease, and impaired mobility. The care plan required checking every 2-3 hours for incontinence and washing, rinsing, and drying the perineum. However, observations and interviews revealed that Resident #106 was left in a chair for about 6 hours without incontinence care, except when a family member notified staff of a bowel movement. The staff did not perform the required checks every 2 hours, and incontinence care was delayed until after lunch when the resident was transferred to bed. During an observation, CNA J and RN K prepared to transfer Resident #106 to bed and found the resident with a wet and soiled brief. CNA J used disposable wipes to clean the resident but did not wash the resident's penis and continued to handle various items with the same soiled gloves, including bed controls and the resident's clothing. CNA J admitted to forgetting to change gloves and rushing through the care. The Director of Nursing confirmed that Resident #106 should have received incontinence care every 2 hours, indicating a failure to adhere to the care plan and proper hygiene practices.
Food Safety and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among all 35 residents. During an initial tour of the kitchen, it was observed that four pans of cooked beef roasts were on an expediting cart in the preparation walk-in cooler, dated for the current day, with additional pans dated for the previous day. A large container of bean soup was also found cooling with ice wands. The kitchen's Cooling Log did not record the beef roasts being cooked or cooled on the current day, and the starting temperature of the bean soup was unclear. Interviews with staff revealed that the beef was cooked the previous day and had been out on the expediting rack for about an hour before being returned to the cooler. Temperature checks showed the beef was not at the correct temperature, and the bean soup was not cooled to the required temperature within the specified time frame. Additionally, during a tour of the kitchen, dirt and debris accumulation was noted behind the three-compartment sink and dish machine area. The Dining Services Director mentioned that they had begun hiring outside help for deep cleaning in certain areas of the kitchen. According to the 2017 FDA Food Code, physical facilities should be cleaned as often as necessary to maintain cleanliness. The failure to adhere to these standards and maintain proper food safety protocols was evident in the observations and interviews conducted during the survey.
Inadequate Implementation of Infection Control Precautions
Penalty
Summary
The facility failed to effectively implement Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) for residents diagnosed with COVID-19 and other infections, as per facility policy and CDC guidance. Observations revealed that staff, including LPNs, CNAs, and maintenance personnel, did not consistently use the required Personal Protective Equipment (PPE) such as N95 masks and eye protection when entering the rooms of COVID-19 positive residents. For instance, staff attending to a resident with COVID-19 were observed wearing only surgical masks and gloves, neglecting the use of N95 masks and eye protection, which are mandated under droplet precautions. In the case of another resident, a housekeeper entered the room of a COVID-19 positive resident wearing only a N95 mask and gloves, without a gown or eye protection. This was contrary to the facility's policy that required full PPE, including gowns and eye protection, for staff entering rooms of residents on droplet precautions. Additionally, there was a lack of clear signage indicating the need for specific PPE, leading to inconsistent adherence to precautionary measures by the staff. Furthermore, the facility did not adequately implement Enhanced Barrier Precautions for residents with infections requiring such measures. For example, a resident with a spinal infection was not properly managed under EBP, as staff failed to don gowns when accessing the resident's PICC line. Interviews with staff revealed a lack of awareness and training regarding EBP, with some staff members unsure of the requirements or unaware of which residents were on such precautions. The absence of signage and clear communication contributed to the failure in implementing these critical infection control measures.
Failure to Provide Required Abuse Prevention Education
Penalty
Summary
The facility failed to provide the required annual abuse prevention education for all staff members who provide care, services, and supports to the residents. This deficiency was identified during a review of the Vendor Course Completion Report, which revealed that 27 out of 126 employees had not completed the necessary training on Understanding Abuse and Neglect and/or Recognizing, Reporting, and Preventing Abuse. Notably, no therapy or housekeeping staff were listed on the report as having completed the training. The facility's Quality Assessment and Assurance (QAA) Committee reviewed the Facility Assessment in January 2024, which indicated that abuse and neglect training was provided through a computer module by the vendor throughout the year. However, during an interview, the Administrator and the Director of Nursing (DON) reported that the staff completed the education annually through a computer-based program, but they were unable to provide documentation verifying that all staff had received the required training.
Deficiency in Infection Control Training
Penalty
Summary
The facility failed to implement an effective training program for all staff regarding infection prevention and control, specifically Enhanced Barrier Precautions (EBP). During an interview, a Certified Nursing Assistant (CNA) reported not recalling any education on EBP, only possibly receiving a text message with unclear content. The Director of Nursing (DON) admitted that while information was posted on the electronic medical record system, it was uncertain if it was accessible to CNA staff or other departments. Furthermore, there was no documentation or signature records to confirm which staff reviewed the information. The DON, who started in January 2024, acknowledged not having initiated or provided formal education on EBP since his tenure began. Although the facility claimed to provide ongoing infection control training through various methods, including computer-based programs, there was no evidence to verify that staff completed education specifically on EBP. The facility's assessment indicated that staff training is continuous, yet the documentation reviewed did not support that all staff received the necessary training on EBP.
Failure to Promote Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to provide an environment that promoted and enhanced resident dignity for a male resident with Alzheimer's disease, dementia, and other medical conditions. The resident was observed multiple times seated in a recliner-type chair at the dining room table without any form of entertainment or engagement, such as books, magazines, or music. Despite being dependent on staff for toilet use, the resident did not have access to a call light while in the dining area, which hindered his ability to request assistance. On one occasion, the resident expressed his need to use the restroom to visitors, who then informed the staff. However, the staff did not promptly assist him, leaving him seated in soiled briefs and clothing. The Director of Nursing was informed of the situation, but assistance was delayed as the staff continued other tasks before attending to the resident. The resident was eventually taken to the shower room to use the bathroom due to his roommate's COVID-positive status, which required staff to don personal protective equipment to access the room's bathroom.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident diagnosed with amyotrophic lateral sclerosis (ALS), heart disease, muscle wasting, and obstructive uropathy. The resident was frequently incontinent and required assistance for mobility. An incident occurred where the resident was allegedly left in a wheelchair with a soiled brief and wet chair, which was reported by a Certified Nursing Assistant (CNA) who worked the third shift. The CNA claimed that the resident had been left in this state for an extended period, leading to concerns of neglect. The Director of Nursing (DON) conducted an investigation but did not complete an incident report or notify the state agency as required. The investigation involved interviews with the resident and staff, but not all relevant staff members were interviewed. The resident, who was alert and oriented, did not express any concerns during the interview, and no physical signs of neglect were observed. However, the investigation was deemed inconclusive, and the allegation was not reported to the state agency. The facility's policy on abuse prevention and reporting requires immediate reporting of any known or alleged incidents of abuse or neglect to the appropriate authorities. Despite this policy, the incident involving the resident was not reported within the required timeframe, and the investigation was not thorough, as not all staff members were interviewed. This failure to report and adequately investigate the allegation of neglect resulted in a deficiency being cited during the survey.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse/neglect involving a resident diagnosed with amyotrophic lateral sclerosis (ALS), heart disease, muscle wasting and atrophy, repeated falls, and obstructive uropathy. The resident was reported to have been left in a wheelchair with a soiled brief and wetness in the chair, which was not adequately addressed by the staff. The investigation conducted by the Director of Nursing (DON) was incomplete, as not all relevant staff and residents were interviewed, and no incident report was filed. The incident was initially reported by a Certified Nursing Assistant (CNA) who found the resident in a compromised state and expressed concerns about neglect. The CNA reported the situation to the nurse on duty and sent an email to the DON, but the email was not reviewed until days later. The DON admitted to not having interviewed all staff members involved in the shifts during which the incident occurred, nor did he interview other residents or staff who might have had relevant information. The facility's policy on abuse prevention and reporting requires thorough and immediate investigation of all allegations, including completing an incident report and notifying the appropriate authorities. However, in this case, the policy was not followed, as evidenced by the lack of a completed incident report and the failure to report the incident to the state agency. This oversight allowed for the potential mistreatment and/or abuse of the resident to go unaddressed.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident #28, who has diagnoses including dementia, stroke, and dysphagia. The care plan, revised on 8/21/24, included interventions such as encouraging the resident to wear a blue boot on the right foot and keeping leg rests elevated when in a wheelchair. However, observations on multiple occasions revealed that these interventions were not consistently implemented. For instance, the resident was observed without the blue boot, with legs not elevated, and leaning to the right side in her wheelchair, contrary to the care plan's directives. Interviews with staff, including a CNA and the DON, indicated that there were attempts to address the resident's needs, such as using pillows for comfort and support. However, the care plan's interventions were not consistently followed, and there was a lack of documentation for refusals of care. The facility's policy on comprehensive, person-centered care plans requires measurable objectives and timeframes, and the coordination of services to maintain the resident's well-being, which was not adequately adhered to in this case.
Failure to Update Care Plan After Resident's Condition Change
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for a resident after a significant change in condition, specifically following a fall that resulted in a hip fracture. The resident, who has severe cognitive impairment and a history of falls, was found on the floor and subsequently admitted to the hospital for surgery to repair the fracture. Upon readmission, a new intervention involving a padded mat on the floor was implemented to prevent further injury, but this intervention was not documented in the resident's care plan. Observations over several days confirmed the presence of the padded mat as a new safety measure, yet the care plan remained unchanged, lacking any mention of this intervention. Interviews with the unit manager and an LPN revealed awareness of the new intervention but also confirmed the oversight in updating the care plan. This failure to revise the care plan resulted in an inaccurate reflection of the resident's current status and care needs.
Failure to Implement Timely Dietary and Positioning Interventions
Penalty
Summary
The facility failed to ensure that a resident's mechanical diet order, recommended by the speech language pathologist (SLP), was implemented in a timely manner and followed during meals. Resident #28, who has diagnoses including dementia, stroke, and dysphagia, was at risk for altered nutrition and hydration status. Despite a discharge summary from the SLP on 6/12/24 recommending a mechanical soft diet with thin liquids, the order was not entered into the resident's medical record until much later. Observations revealed that the resident was served meals that did not comply with the recommended diet, such as whole peas and strips of bacon, which were not consistent with the mechanical soft diet. Additionally, the facility did not implement necessary interventions to address the resident's positioning during meals, which was crucial due to her propensity to lean to the right side in her wheelchair. The occupational therapy evaluation noted significant upper body weakness and poor positioning, yet no interventions were documented in the care plan to assist with positioning while the resident was in her wheelchair. Observations showed the resident leaning significantly to the right side, with makeshift supports like a decorative throw pillow being used inconsistently. Interviews with staff revealed a lack of communication and follow-up regarding the resident's dietary and positioning needs. The Unit Manager was unsure why the SLP's recommendations were not promptly entered into the medical record, and the Physical Therapist reported not receiving a request to assess the resident's positioning. This lack of coordination and timely action resulted in the resident not receiving the appropriate care and interventions necessary to manage her conditions effectively.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care and services to prevent and treat pressure ulcers for a resident, leading to delayed healing and potential for infection. The resident, who had a history of paralysis following a stroke, diabetes, muscle weakness, and altered mental status, was observed to have multiple pressure ulcers, including a stage 2 ulcer on the left buttock and an unstageable ulcer on the right foot. Despite having a care plan in place that included interventions such as offloading by turning side to side in bed and using heel booties, these measures were not consistently implemented. Observations revealed that the resident was often left in a supine position without the necessary positioning devices, such as a foot tent or bolster, to prevent pressure on vulnerable areas. The resident's care plan was not adequately followed, as evidenced by the lack of repositioning and the absence of protective devices during multiple observations. Interviews with staff indicated that there were communication gaps and inconsistencies in implementing the care plan, with some staff unaware of the specific needs and interventions required for the resident. The resident's condition was further compromised by the facility's failure to address the resident's complaints of leg pain and the need for additional interventions to prevent further skin breakdown. Despite discussions in meetings and shift huddles, the necessary changes to the care plan were not effectively communicated or implemented, resulting in the deterioration of the resident's pressure ulcers. The lack of a formal interdisciplinary team and reliance on informal communication methods contributed to the deficiency in care.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to implement a required Gradual Dose Reduction (GDR) for an antidepressant medication, specifically Paroxetine, for a resident diagnosed with depression and anxiety. The resident was admitted with a prescription of 20mg of Paroxetine daily. A pharmacist recommended reducing the dose to 10mg, which was agreed upon by the Medical Director (MD) but was not executed. The MD noted that the resident's mood was stable and there was no contraindication to attempting a dose reduction. Despite the agreement to reduce the dose, the reduction was not carried out due to an unusually long lapse between the pharmacy's recommendation and the MD's planned follow-up visit. The Unit Manager confirmed that the resident had been seen by both the MD and a Nurse Practitioner after the recommendation, yet the dose remained unchanged. This oversight resulted in the potential for the resident to receive an unnecessary dose of medication.
Failure to Offer Timely Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident eligible for a recommended vaccine was offered the pneumococcal vaccination in a timely manner. The policy in place required that residents be assessed for vaccine eligibility upon admission and offered the vaccine within thirty days unless contraindicated or already completed. However, for one resident, this process was not followed, resulting in a delay in offering the PCV20 vaccine. The resident in question was an elderly female with a history of cerebral infarction, hypertension, and hyperlipidemia. Her immunization record showed previous vaccinations with Prevnar 13 and Pneumovax 23, but there was no documentation of the PCV20 vaccine being offered or refused. The Director of Nursing and Infection Preventionist confirmed the oversight, noting that the pharmacy was responsible for notifying the facility of vaccine eligibility, which did not occur in this case.
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What surveyors actually found near you
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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 Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beacon Hill At Eastgate | 1 mi | — | 2 | 0 |
| Mary Free Bed Sub-acute Rehabilitation | 1.8 mi | ★★★★★ | 2 | 0 |
| Corewell Health Grand Rapids Hospitals Rehabilitat | 2.3 mi | ★★★★★ | 10 | 0 |
| Optalis Health & Rehabilitation At Leonard | 2.5 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Grand Rapids | 2.6 mi | ★★★★★ | 2 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.