Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Corewell Health Rehab & Nursing Center-commons Far during CMS and state inspections, most recent first.
Surveyors found that the facility allowed the DON to function as a charge nurse while the census was over 60 residents. The staffing scheduler reported that, following multiple nurse and nursing assistant call-ins on a weekend, the DON and a nurse manager were placed on a medication cart and worked as charge nurses, and acknowledged this had occurred on other occasions when a charge nurse was needed. The DON confirmed working as a charge nurse when needed and was not able to provide job description documentation showing any limitations on serving in that role. This staffing practice had the potential to affect all 99 residents.
Two residents were found in a room with multiple unaddressed environmental issues, including a call light on the floor and difficult to keep within reach, an overbed tray table with peeling edges exposing non-cleanable particle board and dried dark residue, a bedside dresser soiled with a thick white substance, and a floor mat covered in dried debris and stains. One resident’s low air loss unit was turned off while the resident moaned in pain when repositioning, and the other resident’s surrounding carpet had crushed food debris and a thick red substance on the overbed table. Nursing staff acknowledged the conditions, had not placed work orders, and were unsure about the low air loss mattress, while Environmental Services staff confirmed their cleaning scope and reliance on work orders. On re-observation the next day, the soiled mat, dirty carpet, and contaminated surfaces remained unchanged, despite a facility policy requiring daily cleaning of used rooms, including floors, horizontal surfaces, visible soiling, and high-touch disinfection.
A resident with type 2 DM, a cardiac pacemaker, and dependence on staff for most ADLs was care planned to return home with HHC supports, including services from a specified home health agency starting shortly after discharge. However, the facility did not ensure that the home health referral was actually made and confirmed before discharge. The care coordinator stated they had not sent the referral and believed a former social worker had done so, and later learned from the agency that no referral had initially been received. The home health agency reported that the referral was not received until several days after discharge, at which point services were initiated, resulting in a delay between discharge and the start of home health care.
Two residents did not receive care in accordance with physician orders and nursing standards. One resident with diabetes and a pacemaker had midodrine orders with specific BP parameters, but the drug was administered multiple times outside those parameters, and leadership later acknowledged the parameters were incorrectly transcribed and not clarified with the physician. Another resident with severe cognitive impairment and multiple fractures had active orders for bilateral heel protectors, skilled care boots while in bed, and a LAL mattress, yet was observed in bed without heel protection and with the LAL unit turned off, while soft boots were stored in the room. The assigned nurse had documented these interventions as completed on the MAR/TAR despite not providing them and initially stated the resident did not use such devices, contrary to the active orders.
A resident with dementia and documented hearing impairment had physician orders for hearing aids to be applied upon awakening and removed at bedtime, with storage in the med cart, yet staff charted these tasks as completed over multiple days without using follow-up codes for missing or refused devices. On observation, the resident was in bed without hearing aids, and an RN confirmed the devices were kept on a charger at the nurses’ desk instead of in the med cart, admitted documenting application before actually doing it, and discovered that one hearing aid was missing; the DON confirmed the storage practice and could not explain how the loss went unidentified, while the care plan and MDS contained inaccurate or incomplete information about hearing aid use.
Surveyors found that the facility did not follow care-planned fall prevention interventions for two residents with severe cognitive impairment and extensive fall risk factors. One resident with Alzheimer’s disease and significant ADL dependence was repeatedly observed in a high bed without floor mats in place, despite a care plan requiring the bed in the lowest position and mats on the floor. Another resident with dementia, multiple fractures, and a documented history of a serious fall with injuries was observed in an elevated bed with a regular mattress, the call light on the floor and out of reach, and the floor mat folded against the closet instead of next to the bed, even though the care plan called for a low bed, perimeter mattress, and mats on the floor. The assigned nurse stated this resident was not considered a fall risk and was unaware of the perimeter mattress intervention, while the DON later stated staff should be aware of the resident’s fall risk and required interventions.
A resident sustained a fall and multiple injuries when a CNA attempted to provide care and reposition the resident without locking the bed wheels. The bed was in a high position and rolled backward as the CNA rolled the resident toward their body, causing the resident to fall to the floor and suffer a hematoma to the forehead, skin tears, bruising, and a closed displaced fracture of the left tibia, along with contusions and abrasions to the upper extremities. Facility documentation and staff statements confirmed that the unlocked bed wheels were the cause of the fall, despite a facility safety policy requiring bed wheels to be locked.
A resident with multiple neuropsychiatric diagnoses became less responsive, prompting a nurse to contact a PA who ordered STAT labs and later ordered D5% 0.45% NS IV fluids. The lab results showed a critically high blood glucose of 732, but the PA did not document reviewing these labs and still ordered continuous IV fluids containing dextrose, which nursing staff implemented and clarified over the next day. The resident remained on D5% 0.45% NS while serial nursing notes documented ongoing infusion, progressive lethargy, and repeated glucometer readings of "Hi," leading to insulin administration per NP orders and eventual EMS transfer to the hospital for high blood sugar and altered mental status. In interview, the PA stated they were unaware of the critical glucose level before ordering the dextrose-containing IV fluids, and the DON acknowledged the order could have been questioned by nursing staff, contrary to facility policy requiring provider review and analysis of abnormal labs.
Clean dessert cups were stored uncovered near a handwashing sink, and cooked pork loins were not properly cooled or logged according to FDA Food Code standards. The CDM confirmed the lapses in both storage and documentation practices.
A resident with hypertension did not receive a prescribed blood pressure medication for four days due to unavailability, and there was no documentation that the physician was notified or that alternative instructions were sought. The DON was unaware of the missed doses, and facility protocol for handling unavailable medications was not followed or documented.
A resident was repeatedly served pork products despite her stated preference to avoid pork, leading to frustration. The resident had communicated her dietary restriction, but the information was not consistently relayed or honored by dietary and nursing staff, resulting in inappropriate meal service.
A resident with dementia, MS, and impaired ROM reported receiving restorative ROM only about once weekly, while the record showed the restorative program had ended without clear discontinuation documentation and with active orders/tasks still in place. Another resident with severely impaired cognition was repeatedly observed leaning far forward in a wheelchair with the head pressed against a table during activities and meals, requiring staff to feed the resident in that position; therapy later documented a decline in sitting balance and abnormal posture.
Failure to Monitor Significant Weight Loss and Nutritional Decline: A resident with severe cognitive impairment, colon cancer, and pressure injuries had ongoing weight loss, poor PO intake, and clinical decline, yet the chart showed no documented re-weighs, no RD follow-up after the last assessment, and no update to the nutrition care plan despite repeated flagged weight changes and nursing notes describing decreased intake and need for IV fluids.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Surveyors found widespread unclean conditions, including debris, food spills, and soiled curtains in resident rooms and common areas. Staff personal items were improperly stored in a resident dining area, and the Environmental Services Supervisor acknowledged that cleaning and spot checks had not been adequately performed. The facility's housekeeping policy was not available when requested.
Surveyors found that food items brought in from outside and stored in a community refrigerator were not labeled with resident identifiers or dates, as required by facility policy. An RN acknowledged that these items should have been properly labeled.
A resident with metastatic cancer, COPD, and chronic respiratory failure who tested positive for influenza A and was on antiviral therapy did not receive complete and accurate sepsis screening as required. Nursing staff failed to fully complete the Severe Sepsis Screening Tool, leaving sections blank or incorrectly documenting the resident's infection status, despite ongoing isolation precautions and antiviral treatment.
A resident with multiple respiratory diagnoses and a new order for PRN oxygen was not properly monitored, as staff failed to document oxygen saturation levels prior to oxygen administration and did not record PRN oxygen use on the MAR/TAR. The DON confirmed the lack of required documentation and absence of a facility policy for monitoring PRN oxygen therapy.
The facility failed to maintain kitchen sanitation and proper food safety practices. Gnats were found near the handwashing sink, and the walk-in cooler had improperly stored and dated food items. Cooked pork butt was not cooled correctly, and the dish and ice machines showed signs of neglect. The dry storage room and areas around the ice machine were unclean, with food debris and cobwebs present.
The facility failed to employ a qualified full-time social worker to meet residents' psychosocial, mental, and behavioral health needs. During a survey, it was found that the only social worker, Staff 'D', was not licensed, with their last license expiring in 2019. The Administrator was aware of this but believed a license was unnecessary. The facility, licensed for 179 beds, had not employed a licensed social worker since July 2024, leading to concerns about unmet resident needs.
The facility failed to implement adequate infection control practices during wound care for a resident with pressure ulcers, as Enhanced Barrier Precautions were not utilized. Additionally, staff did not adhere to proper PPE protocols for residents on droplet precautions related to COVID-19, as observed with an LPN and a CNA who did not wear the required face shield or goggles. These lapses indicate a failure to follow established infection control protocols.
The facility failed to ensure call lights were within reach for three residents, preventing them from summoning help. A resident with severe cognitive impairment had the call light out of reach on two occasions. Another resident in Covid-19 isolation had the call light on the floor, and a third resident, also in isolation, had the call light out of reach. Staff confirmed and corrected the placement upon notification.
The facility failed to follow protocols for changing code status preferences for three residents with severe cognitive impairments. Discrepancies were found in documentation, with verbal consents obtained without proper follow-up or legal verification. This led to conflicting records regarding residents' CPR preferences.
A resident with Type 2 Diabetes Mellitus received their morning insulin dose hours before breakfast, contrary to professional standards. The insulin was administered between 5:24 AM and 6:23 AM, while breakfast was served at 8:30 AM, creating a 2.5-hour gap. The facility's DON acknowledged that insulin should be given closer to mealtime, highlighting a deviation from recommended practice.
A resident with Alzheimer's disease was found with multiple bruises on both arms, but the facility failed to document or assess the cause. Despite observations of discoloration, there were no recent skin assessments or incident reports, and staff were unaware of the bruising. The DON suggested a nutritional deficiency but did not document it in a care plan.
A resident in an LTC facility was without prescription glasses since July, leading to headaches and difficulty in activities. Despite a social work note indicating the issue, the facility's social services were unaware of the resident's need for vision services. The resident was placed on an ancillary services list without a specific request for vision services, delaying necessary care.
A resident in an LTC facility developed pressure ulcers due to the facility's failure to implement preventative interventions and administer treatment as per physician's orders. Observations showed the resident's feet were not protected by pressure-relieving boots, and wound care was performed without proper pain assessment or hand hygiene. The resident's clinical record indicated the ulcers developed while in the facility, and necessary interventions were not in place until identified by a surveyor.
The facility failed to provide fresh water within reach for two residents, risking dehydration and electrolyte imbalances. One resident had a water cup out of reach despite orders for increased fluid intake, while another had a full cup of water inaccessible. Additionally, the facility did not adequately monitor a resident's significant weight loss, with no documented plan for addressing the issue. Staff interviews revealed a lack of awareness and monitoring of residents' hydration and nutritional needs, indicating a failure to implement facility policies effectively.
Two residents experienced unnecessary pain due to inadequate pain management in an LTC facility. One resident was left in distress during a shower, with staff failing to document or address the pain. Another resident was not assessed for pain before wound care, leading to visible distress during the procedure. The facility did not follow its pain management policies, resulting in significant deficiencies.
A facility failed to provide adequate social services for a resident on psychotropic medication, resulting in a deficiency in monitoring and implementing individualized treatment. The resident, with severe cognitive impairment and multiple diagnoses, exhibited behavioral symptoms, but the facility lacked a comprehensive care plan and did not update medication changes. The social worker did not include historical information in assessments and deferred responsibility to a psychiatric provider, leading to inadequate guidance for staff. The behavior committee meetings did not address the resident's needs, and the DON acknowledged the lack of documentation.
The facility failed to ensure that monthly drug regimen reviews by the consultant pharmacist were reviewed and acted upon by the medical provider for two residents. One resident experienced delays in monitoring and medication adjustments, while another resident's Lexapro dosage recommendation was not addressed in a timely manner, despite agreement from the facility provider.
A facility failed to justify the use of antipsychotic medication for a resident with dementia, as no targeted behaviors or psychotic symptoms were documented. Despite episodes of yelling and refusal of care, the facility did not attempt a gradual dose reduction or develop individualized non-pharmacological interventions. Staff interviews revealed a lack of clarity in monitoring and addressing behaviors, with no explanation for the absence of targeted interventions.
The facility failed to maintain accurate medical records for two residents regarding advance directives. One resident's current medical directive was missing from the EMR, while another's records contained conflicting documentation about code status and lacked a medical power of attorney. Staff interviews revealed inconsistencies in the facility's process for handling advance directives, contributing to the deficiencies.
DON Inappropriately Assigned as Charge Nurse During High Census
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) did not serve as the charge nurse when the census exceeded 60 residents, as required by regulation. During an interview, the staffing scheduler reported that on a recent weekend night shift there were usually two nursing assistants per hall and a nurse, but due to several nurse and nursing assistant call-ins, the DON and a nurse manager were assigned to a medication cart and worked as charge nurses. The staffing scheduler stated this was not typical but acknowledged there were additional times when the DON helped out as a charge nurse when needed. In a separate interview, the DON confirmed working as a charge nurse that past weekend, stated it did not happen often but would occur when needed, and indicated they were going to look further into the regulatory requirements. When requested, the facility did not provide documentation such as a DON job description that included any limitations related to serving as charge nurse. This practice had the potential to affect all 99 residents in the facility. No specific residents, medical histories, or clinical conditions were described in the report; the cited issue centers on staffing assignments and the DON’s dual role as both DON and charge nurse during periods of staffing shortages.
Failure to Maintain Clean and Safe Resident Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents when surveyors observed multiple instances of unclean and poorly maintained equipment and surfaces in their shared room. One resident was seen lying in bed with a green wedge pillow, with the call light on the floor under the overbed tray table, which lacked a clip and could not be kept within reach. The overbed tray table had lifted and peeled edging that exposed non-cleanable particle board, and the metal stand was covered with a dried dark substance. The bedside dresser surface was soiled with a thick white substance, and a blue floor mat stored against the dresser/television cabinet was covered in thick, dried, unidentifiable debris and stains. The low air loss unit attached to the bed’s footboard was set to off, and the resident was observed moaning and saying "Ow" when attempting to reposition, with eyes closed and not responding to verbal interaction. The second resident in the same room was observed in bed with carpet around the bed containing crushed food debris and a red, thick substance on the overbed tray table. Nursing staff acknowledged the low air loss mattress was off, were unsure if the current mattress was a low air loss mattress, and stated they were not aware of equipment concerns. The nurse confirmed the call light was on the floor and that no work orders had been placed for environmental or equipment issues. Environmental Services staff reported that daily cleaning included overbed tables and bedside dressers but not floor mats, which they stated were the responsibility of nursing, and that they would contact the front desk for maintenance issues such as peeling tray tables. On re-observation the following day with Environmental Services leadership, the floor mat remained stained, the carpet still had food debris, the overbed tray table remained soiled with a thick dark red substance, and the bedside dresser was still soiled with a white substance, despite the facility’s policy stating that used patient rooms are to be cleaned at least once daily, including floors, horizontal surfaces, visible soiling, and disinfection of high-touch surfaces.
Failure to Confirm Home Health Referral Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a home health care referral was made and confirmed prior to a resident’s discharge to the community. The resident had diagnoses including type 2 diabetes and a cardiac pacemaker and required staff assistance with most ADLs, with a BIMS score of 15 indicating intact cognition. The resident’s care plan documented a focus of returning home with home health care supports, with interventions directing staff to arrange required community resources such as home care, PT, OT, MD, and wound nurse. The post-discharge plan of care identified a specific home health agency and listed a planned start date for in-home services of 1/24/26. Despite this documented plan, the facility did not complete and confirm the home health referral before discharge. The care coordinator reported they had not made the referral and believed a former social worker had done so. The care coordinator also acknowledged awareness of a concern that the home health agency had not received the referral prior to discharge and later learned from the agency that no referral had been received at that time. When the home health agency was contacted by surveyors, the agency reported receiving the medical referral for services by fax on 1/27/26, with services beginning on 1/28/26, confirming a delay between the resident’s discharge and the initiation of home health services.
Failure to Follow Physician Orders and Accurately Document Medication and Pressure-Relief Interventions
Penalty
Summary
The deficiency involves failure to follow nursing professional standards of practice and physician orders for medication administration and ordered treatments for two residents. One resident with type 2 diabetes, a cardiac pacemaker, and intact cognition had physician orders for midodrine with specific blood pressure parameters. The initial order directed midodrine 10 mg by mouth three times daily for hypotension with instructions to hold the dose if systolic blood pressure (SBP) was less than 110. A subsequent order changed midodrine to 10 mg by mouth every 8 hours as needed for hypotension with instructions to hold if blood pressure was greater than 110. Review of the January MAR showed the resident received midodrine when SBP was below 110 on multiple occasions and also when SBP was above 110 on multiple occasions, meaning the medication was administered outside the stated parameters. During interviews, the nurse manager acknowledged that the parameters transcribed into the midodrine order were incorrect because midodrine is intended to be given when blood pressure is low, not held when it is low, and stated that nursing staff should have clarified the order with the physician and corrected the parameters. The DON also confirmed that the parameters in the scheduled midodrine order were incorrect and should have been clarified. These findings show that the resident’s midodrine orders were not accurately transcribed or followed as written, and that the MAR documentation reflected administration inconsistent with the physician’s parameters. For a second resident with severe cognitive impairment, multiple fractures, dementia-related diagnoses, and hospice enrollment, active physician orders included bilateral heel protectors at all times when in bed, skilled care boots while in bed and off when out of bed for heel pressure reduction, and a low air loss (LAL) mattress. MAR/TAR documentation from the beginning through most of the month showed these interventions as completed each shift, with no charting exceptions. However, observation found the resident in bed without heel protectors or soft boots in place, and the LAL mattress unit at the foot of the bed was powered off. A pair of soft boots labeled for heel protection was found stored in the room rather than on the resident. The assigned nurse initially reported the resident did not use soft boots or heel protectors, was unaware of the active LAL mattress order, and then confirmed they had documented these interventions as completed that morning despite not having actually provided them, offering no explanation. The DON stated that nurses are expected to document on the MAR/TAR after completion of ordered care, underscoring that documentation did not reflect the care actually provided.
Failure to Provide and Accurately Document Ordered Hearing Aid Use
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered hearing assistive devices and accurately document their use for a resident with known hearing impairment. The resident had physician orders for hearing aids to be applied upon awakening daily at 7:00 AM and removed at bedtime, with storage in the medication cart. MAR/TAR documentation from 4/1–4/20 showed the tasks as completed with check marks and nurse initials, without any codes indicating refusal, missing devices, or other issues. On the morning of 4/20, the resident was observed in bed without hearing aids in place, moaning and saying “Ow” while repositioning, with eyes closed and no response when spoken to. The MDS indicated severe cognitive impairment and minimal difficulty with hearing, but incorrectly documented that the resident did not use a hearing aid, and the communication care plan noted the resident was slightly hard of hearing but did not include interventions for hearing aid use. During interview, the nurse assigned to the resident stated the hearing aids should have been in a charger at the nursing desk, not in the medication cart as ordered, and confirmed the resident was not wearing hearing aids despite having documented on the MAR that the 7:00 AM application had been completed. The nurse acknowledged marking the task as done even though it had not yet been performed, stating they had the entire shift to put the hearing aids in, and later reported that only one hearing aid was available and the other was missing, without knowing when both were last seen. The DON confirmed the hearing aids were kept at the nursing desk on a charger rather than in the medication cart and could not explain how the missing hearing aid had not been identified earlier despite ongoing documentation that the devices were being applied and removed. The facility’s Hearing and Vision Services policy referenced ensuring residents receive proper treatment and assistive devices, including hearing aids, but did not address a process for ensuring placement per the plan of care.
Failure to Implement Care-Planned Fall Prevention Interventions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for two cognitively impaired residents identified as being at risk for falls. For the first resident, who had Alzheimer’s disease, hearing loss, severely impaired cognition (BIMS score of six), and required staff assistance with most ADLs, the care plan documented a focus of being at risk for falls related to dementia, gait and mobility impairments, incontinence, osteopenia, and weakness, with a history of a fall and readmission. The care plan interventions included keeping the bed in the lowest position and placing mats on the floor with non-slip footwear at all times. On multiple observations in the same day, surveyors found this resident in bed with the bed in a high position (approximately 3.5 feet off the floor) and no floor mats in place; the mat was seen propped on its side against the wall at the foot of the bed. When shown these conditions, the nurse acknowledged the bed should be lowered and the mat placed on the floor and confirmed the resident was a fall risk. For the second resident, who had a long history in the facility, severe cognitive impairment, and multiple diagnoses including late-onset Alzheimer’s disease, dementia, prior fractures of the femur and fibula, contusion of the head, glaucoma, convulsions, manic episode, major depressive disorder, and a prior left hip fracture, the care plan documented that the resident was at risk for falls and injury related to decreased mobility, hypertension, osteoarthritis, COPD, anxiety, dementia, incontinence, high-risk medication use, and a history of falls with hematoma and multiple injuries. The care plan further specified that the resident used a sit-to-stand device for transfers, had the bed against the wall with a mat next to the bed for safety, and had interventions including a perimeter mattress, bed in low position, mats on the floor, and placement of personal items within reach. Progress notes documented a prior fall in which the bed was in a high position and unlocked, resulting in the resident falling to the floor and sustaining a hematoma to the forehead, skin tears, and pain to the left foot, with subsequent hospital transfer and diagnoses including head contusion and fibula fracture. During the current survey, this second resident was observed lying in bed with the bed elevated rather than low, a regular non-perimeter mattress in use, and the call light on the floor under the overbed tray table and out of reach. A soiled blue floor mat was folded and resting against the closet instead of being placed next to the bed as care planned. When interviewed, the nurse assigned to the resident stated they did not consider the resident a fall risk and were unaware that a perimeter mattress was an intervention for this resident. The nurse unfolded the mat and placed it next to the bed only after being questioned, and stated staff had probably forgotten to put the mat back after assisting with breakfast. The DON later stated that nursing staff should be aware of the resident’s fall risk and that interventions should be in place, consistent with the facility’s Fall Prevention Program policy, which requires individualized fall prevention interventions to be included in the care plan and communicated to staff.
Failure to Lock Bed Wheels During Repositioning Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident care area was free from accident hazards and that adequate supervision and safety practices were used during resident care, specifically by not locking the bed wheels before repositioning a resident. According to a nursing progress note, a CNA reported that while providing care, they rolled the resident toward themselves, but the bed was in a high position with the wheels unlocked and rolled backward, causing the resident to fall from the bed to the floor. The resident was found on the floor next to the bed in a curled position leaning toward the right side, with a hematoma to the forehead, a skin tear on the left deltoid, and a skin tear on the right elbow, and complained of pain to the left foot. The facility’s post-fall analysis and investigation documented that staff rolled the resident toward themselves and the bed rolled away due to unlocked wheels, which was identified as the root cause of the fall. A written statement from the CNA confirmed that while performing care and rolling the resident from the wall side toward their body, the bed slid and the resident fell onto her side, resulting in bruising to the head, arm, and leg. Hospital imaging and assessment documented a closed displaced fracture of the left tibia, a contusion of the left upper extremity, and an abrasion of the right upper extremity, with the resident made non–weight bearing on the left lower extremity. The facility’s Resident Safety and Precautions policy in effect at the time required that bed wheels be locked as part of resident safety standards, which was not followed in this incident.
Failure to Review Critical Glucose Result Before Ordering Dextrose-Containing IV Fluids
Penalty
Summary
The deficiency involves the failure of the attending provider to review and act upon critical laboratory results before ordering and continuing IV fluids containing dextrose. A resident with psychotic disorder with delusions, delirium, Alzheimer's disease, stroke, and mood disorder was noted by a CNA as "wasn't herself" on the morning of 12/8/25. Nurse B contacted the on-call PA, who ordered STAT labs including a CBC and CMP. Labs drawn that morning and reported at 12:37 PM showed a critically high blood glucose level of 732 (normal 70–99). Nurse B later documented at 3:24 PM that they reviewed the lab results with the PA while the PA was in the building, and that new orders were received for D5% 0.45% NS at 125 ml/hr for 3 liters, with an IV started but then pulled out by the resident. The PA’s progress note for 12/8/25 documented an assessment of acute kidney injury and a plan to give 2 liters of IV fluid continuous, but did not document review of the STAT labs or specify the type of IV fluid. Subsequent nursing notes show that on the afternoon of 12/8/25 the PA called back with new orders for hypodermoclysis, which was initiated. On 12/9/25, Nurse G documented placement of a new PIV and that the resident was hooked up to IV fluids as ordered, specifically D5% 0.45% NS per the PA’s prior order. Nurse H documented an order clarification for D5% 0.45% NS infusing at 125 cc/hr times 2 liters, and Nurse I documented that the resident had a peripheral IV in the right forearm with D5% 0.45% NS infusing at 125 cc, bag 2 of 2. In the early hours of 12/10/25, Nurse C documented that the resident was resting in bed with D5% 0.45% NS infusing via right arm PIV, and that the resident was hard to arouse. A blood sugar check at that time read "Hi" on the glucometer, and the on-call NP was contacted. New orders were received to give 12 units of Lispro insulin, recheck in 2 hours, and repeat 12 units if the blood sugar still read "Hi," with instructions to call back if it remained "Hi" after the second dose. Subsequent notes by Nurse C documented repeated "Hi" blood sugar readings, administration of Lispro insulin, the resident being lethargic and difficult to arouse, and that an ambulance was called for transfer to the hospital. Hospital records indicated the chief complaint was high blood sugar and altered mental status, and EMS reported the patient was receiving D5 fluid hydration on their arrival. In an interview, the PA stated they were not aware of the glucose level of 732 prior to ordering D5% 0.45% NS, acknowledged they did not document lab review, and stated they would not have ordered IV fluid with dextrose if they had known. The DON indicated that the PA’s order for D5% 0.45% NS could have been questioned by the nurse who received the critical glucose result and implemented the order. The facility’s policy requires providers to review laboratory tests during visits and analyze abnormal results with documented rationale and interventions.
Improper Storage and Cooling of Food Items
Penalty
Summary
Surveyors observed that clean dessert-sized cups were stored uncovered in bins next to a handwashing sink. When questioned, the Certified Dietary Manager (CDM) acknowledged that the cups should have been covered. This storage practice did not comply with the 2022 FDA Food Code, which requires clean equipment and utensils to be stored in a clean, dry location, protected from contamination, and either covered or inverted. Additionally, two pans of whole, cooked pork loins were found on a speed rack in the food preparation area, covered with plastic wrap and dated from the previous day. The internal temperatures of the pork loins ranged from 48-51°F, and review of the facility's cooling log showed that the pork loins had not been logged to ensure proper cooling. The CDM was unsure why the cooling log was not used. This practice did not meet FDA Food Code requirements for cooling cooked food to 41°F or less within the specified timeframe.
Failure to Notify Physician and Administer Prescribed Blood Pressure Medication
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of hypertension did not receive a prescribed blood pressure medication, candesartan-hydrochlorothiazide, for four consecutive days following admission. The medication was not available on the medication cart or in the backup medication dispensing machine, and although it was ordered from the pharmacy, there was no follow-up or documentation indicating that the medication had been received or administered during this period. Progress notes and the Medication Administration Record confirmed the medication was not given on four specific days, and there was no documentation that the attending physician was notified of the unavailability of the medication. Interviews with the resident and the Director of Nursing (DON) revealed that the resident expressed concern about not receiving the medication and that the DON was unaware of the missed doses until after the fact. The DON stated that facility protocol required contacting the pharmacy and notifying the medical provider for further instructions or alternative orders when a medication was unavailable, but there was no evidence this occurred. The pharmacy technician also failed to communicate with the facility regarding the delay. Documentation from the physician and provider progress notes did not mention the medication's unavailability, and there was no indication that alternative measures were considered during the four-day lapse.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
A resident was observed during a lunch meal with a container of food pushed aside, stating she did not eat the meal because it contained pork, which she does not consume. The resident reported that the facility repeatedly served her pork products despite her clear communication that she did not eat pork. She also mentioned previous instances where she was served eggs mixed with pork products. The meal ticket for that day confirmed that pork tenderloin was served to her. Interviews with the Registered Dietician (RD) and the Director of Nursing (DON) revealed that dietary assessments are typically completed within seven days of admission, and any dietary preferences expressed prior to that should be communicated to both the RD and kitchen staff. The DON confirmed that nursing staff are expected to relay residents' food preferences to dietary staff. Despite these protocols, the resident's dietary preferences were not consistently honored, resulting in her frustration.
Failure to Provide Adequate ROM Services and Positioning
Penalty
Summary
The facility failed to provide adequate positioning and range of motion services for two residents, including one resident with dementia, multiple sclerosis, depression, and impaired range of motion in one upper extremity and both lower extremities, and another resident with severely impaired cognition and abnormal sitting posture. For the resident with multiple sclerosis, the record showed a restorative program dated 6/24/25 that included active assistive ROM, strengthening, bed mobility, balloon toss, and hand grip exercises, with a goal to maintain function. However, the resident reported wanting more ROM exercises, especially for the feet, and said restorative therapy was only about once a week. The resident also stated staff sometimes had difficulty applying positioning boots because the foot muscles were tight and uncomfortable. Review of the restorative documentation for that resident showed the last restorative progress note was dated 11/14/25. There was no documentation showing a discussion with the resident that restorative therapy was ending, no documentation of skilled oversight by nursing or therapy from 7/04/25 through 11/14/25, and the restorative program was documented as completed with an additional six weeks added, extending beyond the 12-week duration specified. The resident’s physician orders and active tasks remained in place even though the unit manager later confirmed the resident was not receiving restorative therapy services and that the orders and tasks should have been discontinued. The resident believed they were still receiving restorative services about once a week. For the second resident, staff observed repeated forward-leaning positioning in a wheelchair with the resident’s forehead or head pressed against the edge of a table in the nutrition/dayroom. The resident was seen sitting in this position while playing with building blocks and while eating lunch, requiring a CNA to place food under the corner of the table and up to the resident’s mouth because of the posture. Staff stated the resident always sat leaning forward and that they would try to get the resident to sit up, but the resident wanted their head down. Therapy staff stated the resident had been evaluated when first admitted but was not currently receiving therapy, and that they would expect staff to report a change in posture so the resident could be re-evaluated. A later PT evaluation documented a decline in sitting balance and identified abnormal posture causing extreme leaning in the wheelchair, with recommendations for seating supports.
Failure to Monitor Significant Weight Loss and Nutritional Decline
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for weight loss for one resident who had severe cognitive impairment, was dependent on staff for all aspects of care, and had diagnoses including Alzheimer’s disease, colon cancer, and pressure injuries to the right gluteal fold and coccyx. On 12/17/25, the resident was observed asleep in bed during multiple checks, and an IV pole was present beside the bed but no fluids were hung or being administered. A nurse reported the resident was clinically declining, not eating or drinking, had recently received IV fluids, and had skin breakdown. The resident’s record showed significant weight loss over several months, with weights documented as 130.6 lbs on 10/15/25, 120.7 lbs on 11/13/25, and 107.6 lbs on 12/9/25. The electronic record flagged multiple percentage losses at each interval, but there were no re-weights documented for any of these weights. The nutritional care plan, last revised on 8/18/25, included four nutritional supplements but was not updated to address the ongoing weight loss or other interventions after the declines were identified. The most recent RD assessment was completed on 10/15/25 and noted the resident was at risk for malnutrition, had weight variance over 30 days, and needed a re-weight, but there was no further RD follow-up documented after that assessment. Nursing notes documented decreased intake, poor appetite, and a change of condition with decreased food and fluid intake, functional decline, skin wound or ulcer, weight of 107.6 lbs, and IV fluids. During interview, the RD reported communication issues between nutrition and nursing, stated weights varying within five pounds were communicated for re-weights, and confirmed there had been no documented re-weights or care plan updates for the resident since October.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances of unclean and unsafe environmental conditions throughout the facility, including scattered straw wrappers, crumbs, and debris in hallways and resident rooms. Dried food matter was noted on walls, and partition curtains in several rooms were soiled and unkempt. In the dining areas, there were moderate-sized dried food spillages on carpets, and the carpet near the medication cart was heavily soiled. Additional observations included hardwood flooring with scattered debris and food crumbs, as well as soiled hallway carpeting with liquid spills and old food matter that appeared to have been run over by a wheel. Staff personal belongings were found improperly stored in a residential dining room cabinet, which was acknowledged by staff as inappropriate. During a tour with the Environmental Services Supervisor, the supervisor confirmed that the areas of dried food and soiled curtains should have been identified and cleaned. The supervisor also acknowledged that the resident rooms and hallways appeared cluttered with debris and had not been vacuumed for some time, despite claims of recent cleaning. The facility's policy for environment and housekeeping was requested but was not available at the time of exit. These findings indicate a failure to maintain a safe, clean, and comfortable environment for residents.
Failure to Label and Date Resident Food Items in Community Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items brought in from outside sources and stored in the community residential refrigerator in the 2107 Dayroom were properly labeled and dated. During an inspection, several food items, including a brown paper bag from a fast food restaurant, a black three-compartment container with cornbread, a small clear container with white dressing, a Styrofoam cup with a brown liquid, a container of vanilla ice cream, and another Styrofoam cup with an unidentified frozen substance, were found in the refrigerator and freezer without any resident identifiers or dates. The facility's policy requires that all food brought in for residents be labeled with the resident's name and the date it was brought in, but this procedure was not followed. The unit manager RN confirmed that the items should have been labeled accordingly.
Failure to Complete Sepsis Screening for Resident with Active Infection
Penalty
Summary
The facility failed to conduct accurate and thorough sepsis screening for a resident who was admitted with multiple serious diagnoses, including metastatic cancer, COPD, and chronic respiratory failure. The resident tested positive for influenza A and was placed on droplet precautions, receiving antiviral therapy as ordered. According to facility policy and the Infection Control Preventionist, residents with infections treated with antibiotics or antivirals are to be monitored for sepsis using a Severe Sepsis Screening Tool throughout the duration of the illness and isolation precautions. A review of the resident's sepsis screening documentation revealed that, although the presence of infection and antiviral therapy was noted on some days, the remainder of the screening tool was left incomplete, omitting required assessments for SIRS and organ dysfunction. On subsequent days, the documentation incorrectly indicated the absence of infection and therapy, despite the resident's ongoing positive influenza status and antiviral treatment. The facility's own infection control surveillance confirmed the resident had an active infection and was under isolation precautions, but the required sepsis monitoring was not properly completed or documented.
Failure to Monitor and Document PRN Oxygen Administration
Penalty
Summary
The facility failed to appropriately monitor and document the respiratory status of a resident who experienced a change in condition. The resident, who had diagnoses including influenza A, COPD, metastatic prostate cancer with bone involvement, obstructive sleep apnea, and chronic respiratory failure, was admitted without a need for oxygen therapy. After testing positive for influenza A, a physician's order was written for PRN oxygen at 2 liters for shortness of breath. However, there was no corresponding order or documentation area on the MAR/TAR for PRN oxygen, and no consistent documentation of when oxygen was administered. Throughout the resident's stay, oxygen saturation levels were recorded only while the resident was already receiving oxygen, with no documentation of oxygen saturation prior to administration. Progress notes indicated episodes of labored breathing and low oxygen saturation while on oxygen, but failed to provide information about the resident's status before oxygen was applied. The Director of Nursing confirmed that documentation of PRN oxygen administration and pre-administration oxygen levels was lacking, and the facility did not have a policy regarding monitoring respiratory status for PRN oxygen.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure potentially hazardous food items were properly cooled, as observed during a survey. Several gnats were found flying around the handwashing sink near the kitchen entry door, and the trash can for the sink lacked a liner, attracting more gnats. The presence of insects violated the 2017 FDA Food Code, which requires premises to be free of pests. Additionally, the walk-in cooler had milk pooled on the floor, an opened cooked ham past its use-by date, an undated sliced onion, and a tub of ricotta also past its use-by date. Raw turkey was improperly stored above raw beef, which could lead to cross-contamination. The facility also failed to properly cool cooked pork butt, which was tightly covered with foil and stored in the walk-in cooler without recorded temperatures on the cooling log. The internal temperature of the pork was measured between 50-53 degrees Fahrenheit, not meeting the FDA Food Code requirements for cooling potentially hazardous food. The dish machine had a heavy buildup of limescale, and the ice machine had dust and black stains, indicating a lack of proper cleaning and maintenance. In the dry storage room, the floor was observed with cobwebs, food debris, and a leaking can of soda. The area under the ice machine had debris, a juice cup, and an ice cream cup, while the floor drain in front of the ice machine had a heavy accumulation of food debris and grease. The steam table had a bin of thickener with scattered powder, a soiled toaster, and a buildup of crumbs mixed with standing water. These observations highlight the facility's failure to maintain cleanliness and adhere to the FDA Food Code standards for food safety and sanitation.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker to meet the psychosocial, mental, and behavioral health care needs of its residents, as identified during a recertification survey. The survey, conducted from October 28 to October 30, 2024, revealed multiple concerns regarding the facility's social work practices, including mood and behavior management, psychotropic medication, psychosocial assessments, and processes for completing advance directives and coordinating decision-makers. Interviews with the Director of Nursing (DON) and Staff 'D' confirmed that Staff 'D' was the only social worker employed at the facility, which is licensed for 179 beds. Staff 'D' reported that they had been working as a social worker since January 2024 but were not currently licensed, with their last license having expired in 2019. The facility's Administrator was aware of Staff 'D's lack of licensure but believed, based on advice from other facilities and their corporate team, that a license was not necessary. The Administrator confirmed that the last licensed social worker was employed until July 5, 2024, and acknowledged the difficulty in filling the social worker role. The surveyors identified concerns with the facility's hiring of a non-licensed individual for the social worker position, which could potentially lead to unmet psychosocial needs of the residents.
Inadequate Infection Control Practices in Wound Care and Droplet Precautions
Penalty
Summary
The facility failed to ensure adequate infection control practices during wound care for a resident identified as having pressure ulcers. During observations, it was noted that Enhanced Barrier Precautions (EBP) were not in place or utilized during the wound care process. The nurse involved did not wash hands or use hand sanitizer before donning gloves and proceeded to touch multiple surfaces before handling wound care supplies. Additionally, the nurse did not change gloves after touching contaminated surfaces, which compromised the aseptic technique required for wound care. In another instance, the facility did not implement proper infection control practices for residents on droplet precautions related to COVID-19. A Licensed Practical Nurse (LPN) entered a resident's room marked for droplet isolation without donning the appropriate Personal Protective Equipment (PPE), such as a gown, gloves, or face shield. The LPN acknowledged the oversight upon being questioned and subsequently donned a gown and gloves but still failed to wear a face shield or goggles as required by the facility's policy. Similarly, a Certified Nursing Assistant (CNA) entered another resident's room on droplet precautions wearing only a gown and gloves, without the necessary face shield or goggles. The CNA admitted to the oversight when questioned. The facility's policy clearly states the need for protective eyewear and respiratory protection for droplet isolation, which was not adhered to in these instances, indicating a lapse in following established infection control protocols.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were easily accessible and within reach for three residents, resulting in their inability to summon help when needed. Resident R8 was observed on two occasions with the call light out of reach, once draped across the end of the footboard and another time tucked behind the wall and mattress. R8 had severe cognitive impairment, physical behavioral symptoms, and was always incontinent of bowel and bladder. The Director of Nursing acknowledged the issue and mentioned the need for staff re-education. Resident R7 was found with the call light on the floor, several feet from the bed, while in isolation for Covid-19. R7 had moderate cognitive impairment and was diagnosed with muscle weakness and chronic obstructive pulmonary disease. Similarly, resident R333, also in isolation for Covid-19, was observed with the call light on the floor, out of reach. R333 was dependent on oxygen. In both cases, staff confirmed the call lights were out of reach and placed them within reach upon notification.
Failure to Follow Protocols for Code Status Changes
Penalty
Summary
The facility failed to adhere to appropriate protocols for changing residents' treatment preferences regarding code status, affecting three residents. Resident R32, who was admitted with Alzheimer's Disease and had a severely impaired cognition score, had conflicting documentation regarding their code status. The resident's legal guardian had signed a form indicating a preference for CPR, but a care conference note later indicated a change to DNR without evidence of the resident's involvement in the decision-making process. Resident R63, also with a diagnosis of dementia and severely impaired cognition, had discrepancies in their code status documentation. The legal guardian had signed a form indicating CPR, but the electronic medical record showed No CPR. There was no evidence that the resident was included in discussions about changing their code status, and verbal consent was obtained without a follow-up signature from the legal guardian. Resident R52, with severe cognitive impairment and functional quadriplegia, had conflicting documentation regarding their code status. The facility's records showed a lack of proper documentation for a Durable Medical Power of Attorney, and verbal consent for a DNR order was obtained from a daughter without verification of legal authority or the resident's prior wishes. The facility's process for handling advance directives was inconsistent, with verbal consents being used without proper follow-up, leading to discrepancies in residents' code status documentation.
Insulin Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure insulin administration was performed according to professional nursing standards of practice for a resident with Type 2 Diabetes Mellitus. The resident expressed concerns about receiving their breakfast tray late, around 9 AM, while their morning insulin dose was administered hours earlier, between 5:24 AM and 6:23 AM, over several days. The scheduled time for the morning insulin dose was 6 AM, but the breakfast trays were delivered at 8:30 AM, creating a gap of 2.5 hours between insulin administration and meal delivery. The resident's physician orders specified the use of Humalog KwikPen Subcutaneous Solution per sliding scale four times per day, which according to the manufacturer's guidelines, should be injected within 15 minutes before or right after a meal. The Director of Nursing confirmed that short-acting insulin should be given closer to mealtime, indicating a deviation from the recommended practice. This discrepancy between insulin administration and meal delivery times led to the deficiency identified by the surveyors.
Failure to Identify and Document Bruising in Resident
Penalty
Summary
The facility failed to identify, assess, and determine the root cause of bilateral arm bruising for a resident reviewed for skin conditions. The resident, who has Alzheimer's disease, was observed with multiple areas of discoloration on both arms, resembling bruises. Despite these observations, there was no documentation of recent skin impairments in the resident's clinical record, progress notes, or care plans. Additionally, the resident was not on any medications that would increase the risk of bruising, and no incident reports were available for the discoloration observed. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed a lack of awareness and explanation for the bruising. The DON stated that any skin impairments should be documented in weekly skin assessments or progress notes, but this was not done for the resident in question. A progress note was written after the discoloration was observed, but it lacked further assessment. The DON later suggested a possible nutritional deficiency as the cause, but this was not documented in a care plan or diagnosed by a medical provider. An incident report from four months prior noted a skin tear but did not mention any bruising.
Failure to Coordinate Timely Vision Services for Resident
Penalty
Summary
The facility failed to timely coordinate vision services for a resident who had been without prescription glasses since July. The resident, who was admitted with diagnoses including bipolar disorder, depression, and anxiety, reported to have lost their glasses prior to admission and only had reading glasses available. This situation led to the resident experiencing headaches, eye pain, and difficulties in reading television content and participating in activities like bingo. Despite the resident's intact cognition, as indicated by a perfect score on the Minimum Data Set assessment, the facility's social services were not aware of the resident's need for prescription glasses or the associated symptoms. A social work progress note from July indicated the resident's lack of prescription glasses, but no specific action for vision services was taken until the resident was placed on an ancillary services list without a specific request for vision services. Vision service providers were scheduled to visit the facility in November, but the resident's needs were not addressed in a timely manner.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to implement preventative pressure ulcer interventions and administer treatment according to physician's orders for a resident identified as R70. Observations revealed that R70 was lying in bed on a low air loss mattress with their feet tucked under a blanket, adding pressure to the tips of the feet and toes. There were no pressure-relieving boots in use or available in the room, despite orders to suspend heels while in bed. Wound care supplies were found on the bedside table, and it was unclear if the treatment had been completed as documented by Nurse G. During wound care observation, it was noted that neither Nurse N nor Nurse L assessed the resident for pain or offered pre-medication before starting the wound care. The resident exhibited signs of pain during the procedure, and it was only after the resident expressed discomfort that pain medication was offered. Additionally, the wound care was performed without proper hand hygiene, as Nurse L used the same gloves to touch multiple surfaces and then proceeded to clean the wound. The resident's clinical record indicated that the pressure ulcers developed while in the facility, with a Stage II ulcer on the coccyx and a deep tissue injury on the left great toe. The care plan included interventions such as turning and repositioning every two hours and using skilled care boots, which had been discontinued without re-implementation. Interviews with the Director of Nursing and Wound Nurse E confirmed awareness of the issues, but the necessary interventions were not observed in place until identified by the surveyor.
Deficiencies in Hydration and Nutrition Management
Penalty
Summary
The facility failed to provide fresh water at the bedside, within reach, and offer it throughout the shift for two residents, resulting in the potential for continued dehydration and electrolyte imbalances. Observations revealed that one resident had a water cup dated from the previous day, placed out of reach, and containing room temperature water. Despite multiple physician orders to encourage oral fluid intake due to dehydration and other medical conditions, the resident's care plans did not address the need for increased hydration. Another resident was observed with a full cup of water out of reach, despite care plans indicating a risk for dehydration and the need for fresh water within reach. The facility also failed to ensure accurate assessment and adequate monitoring of weight loss for another resident. This resident expressed dissatisfaction with the facility's food and reported significant weight loss. The clinical record showed a substantial weight loss over a year, but there was no documented plan for monitoring this weight loss. The resident's nutritional assessments indicated a risk for malnutrition, yet the facility's documentation did not reflect ongoing monitoring or intervention for the resident's weight loss. Interviews with staff, including the Director of Nursing and a Registered Dietician, revealed a lack of awareness and monitoring of the residents' hydration and nutritional needs. The facility's policies on water distribution and nutrition monitoring were not effectively implemented, leading to deficiencies in resident care. The observations and interviews highlighted a failure to adhere to established protocols, resulting in potential harm to the residents due to inadequate hydration and nutrition management.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, R32 and R70, leading to unnecessary pain. R32 was observed in significant distress while seated in a shower chair, yelling and crying due to pain. Despite the resident's clear expression of discomfort, the staff did not document the incident or implement new interventions to prevent future pain. The assigned nurse, LPN 'A', dismissed the resident's cries as a behavior rather than addressing the pain, and no additional measures were taken to alleviate the discomfort during showers. R70 experienced inadequate pain management during wound care. The resident was not assessed for pain or offered pre-medication before the procedure, resulting in visible and audible signs of distress. Despite the resident's cries of pain, the nurses continued the wound care without addressing the pain adequately. The facility's records showed a lack of documentation for pain management, and the care plan was not updated to include interventions for the resident's pressure ulcers until after the surveyor's observation. The facility's policies on pain assessment and management were not followed, as evidenced by the lack of timely interventions and documentation for both residents. The Director of Nursing acknowledged the issues but did not provide additional follow-up by the end of the survey. The failure to assess and manage pain effectively for R32 and R70 highlights significant deficiencies in the facility's care practices.
Failure to Provide Adequate Social Services for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to provide adequate medically related social services for a resident receiving psychotropic medication, leading to a deficiency in monitoring, identifying, and implementing individualized treatment and behavioral interventions. The resident, who was admitted with severe cognitive impairment and multiple diagnoses including psychotic disorder and dementia, exhibited physical and verbal behavioral symptoms. Despite these behaviors, the facility did not have a comprehensive care plan addressing the resident's specific behaviors or the use of antidepressant medication. The care plan was outdated and did not reflect changes in the resident's antipsychotic medication. The facility's social worker, Staff 'D', did not include historical information from the resident or family regarding mood, behaviors, and psychotropic medication in the initial assessment. Instead, they referred residents to a contracted psychiatric provider. There was a lack of follow-up from social work to address requests for evaluation, and the behavior committee documentation did not address the resident's use of antipsychotic and antidepressant medication or specific behaviors identified by nursing staff. The social worker deferred responsibility for identifying specific behaviors and interventions to the psychiatric provider, resulting in a lack of clear guidance for direct care staff. Interviews with Staff 'D' and the Director of Nursing (DON) revealed a lack of interdisciplinary communication and documentation regarding the resident's care. The behavior committee meetings did not adequately address the resident's needs, and there was no documentation of non-pharmacological interventions or specific targeted behaviors. The DON acknowledged the lack of documentation and concern but was unable to provide further explanation. This deficiency highlights a failure in the facility's processes for managing residents with complex behavioral and medication needs.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medical provider for recommendations to act upon for two residents. For one resident, the pharmacist identified irregularities in the drug regimen on three separate occasions, recommending monitoring of serum magnesium levels, a dose reduction of Protonix, and a TSH level check. However, these recommendations were not reviewed or acted upon by the medical provider in a timely manner, resulting in delayed monitoring and adjustments to the resident's medication regimen. The resident's magnesium level was checked over two months after the recommendation, the Protonix dose was reduced two months later, and the TSH level was checked three months later, which revealed an abnormally high level requiring a dosage change. For another resident, the pharmacist recommended a gradual dose reduction of Lexapro, noting the resident's hospice status but emphasizing compliance with CMS regulations. The facility provider agreed with the recommendation but noted that the patient's medications were managed by hospice. However, there was no communication from the hospice provider regarding the pharmacist's recommendation, and the Lexapro dosage remained unchanged for over two months. The Director of Nursing later indicated that hospice would evaluate the Lexapro, suggesting that the recommendation had not been addressed in a timely manner.
Failure to Justify Antipsychotic Use and Implement Interventions
Penalty
Summary
The facility failed to provide justification for the use of antipsychotic medications in a resident with dementia, identified as R37, and did not develop or implement individualized non-pharmacological interventions. R37 was observed multiple times sleeping in a wheelchair, and their clinical record showed a prescription for Rexulti, an antipsychotic medication, for dementia, agitation, and delusion. Despite a documented attempt at a gradual dose reduction (GDR) being clinically contraindicated, there was no evidence of psychotic symptoms or targeted behaviors identified in the resident's care plan or behavior management committee meeting minutes. The facility's behavior management committee failed to document targeted behaviors or symptoms for R37, and no GDR of Rexulti was attempted as previously discussed. Progress notes indicated episodes of yelling, abusive language, and refusal of care, but there was no documented evidence of psychotic symptoms. Evaluations by the consulting psychiatry provider noted that non-pharmacological interventions had not sufficiently relieved target symptoms, yet no specific target symptoms were identified, and the GDR was deemed contraindicated. Interviews with facility staff, including Social Services Staff and the Director of Nursing, revealed a lack of clarity and responsibility in monitoring behaviors and developing interventions for residents prescribed antipsychotic medications. The interdisciplinary team approach was mentioned, but there was no explanation for the absence of individualized interventions or targeted behaviors for R37. The facility's behavior committee program was supposed to address these issues, but the Director of Nursing could not explain why this was not done for R37.
Deficiency in Maintaining Accurate Medical Records for Advance Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R28 and R52, regarding their advance directives. For R28, the facility did not have current documentation in the electronic medical record (EMR) of a medical directive regarding decisions for code status since their admission. The only available documentation was from a previous admission, and the facility's process for documenting such directives was inconsistent, as noted by Social Services staff who indicated that medical directive forms were kept in binders and not formally loaded into the EMR. For R52, the facility's records were also incomplete and conflicting. The resident's profile identified two daughters as durable power of attorney, but the available documentation was only for financial decisions and did not include medical directives. The EMR contained a physician order for no CPR, but there was no corresponding medical directive form in the EMR. Additionally, there were discrepancies in the documentation by different medical staff regarding the resident's code status, with conflicting entries by a Physician Assistant and a Physician. The facility lacked documentation of a medical power of attorney and had not declared the resident incompetent as required to activate such a power. Interviews with facility staff, including the Director of Nursing and Social Services, revealed a lack of clarity and consistency in the process for handling advance directives. The Director of Nursing acknowledged the discrepancies and the need for immediate attention. Social Services staff admitted to the absence of a medical power of attorney in the records and could not explain why verbal consent was accepted without proper verification. The facility's practice of keeping medical directive forms in binders rather than integrating them into the EMR contributed to the deficiencies in maintaining accurate and complete medical records.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,205 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Farmington Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Manor Of Farmington Hills | 0.8 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Livonia | 1 mi | ★★★★★ | 10 | 0 |
| Medilodge Of Farmington | 2.2 mi | ★★★★★ | 23 | 0 |
| The Orchards At Redford | 3.1 mi | ★★★★★ | 20 | 0 |
| Majestic Care Of Livonia | 3.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Corewell Health Rehab & Nursing Center-commons Far.
100% money-back within 48 hours.
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.