Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Courtney Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities, intact cognition, dependence for transfers, and existing lower extremity skin issues was care planned for two-assist transfers using an Invacare electronic lift and sling, with instructions to use caution to avoid striking extremities on hard surfaces. Despite this, a nurse informed a CNA that the resident could be transferred with a two-person manual assist, and the CNA and an OT transferred the resident from a beauty shop chair to a w/c without the lift. During this transfer, the resident’s leg hit the w/c foot pedal, causing large skin tears and a hematoma to the left lower leg, which required ED evaluation and ongoing wound care, as well as increased use of PRN narcotic pain medication. The DON and administrator acknowledged that the transfer should have been performed with the electronic lift as specified in the care plan.
A resident with intact cognition and multiple medical and psychiatric diagnoses repeatedly voiced concerns, through the State Ombudsman and directly, about staff being rude, turning off call lights without returning, delaying assistance, discouraging toileting by instructing use of briefs, limiting therapy focus on transfers, and prohibiting use of a personal glucometer. The Ombudsman relayed these concerns to the NHA, and the resident reported that issues persisted and had not been resolved to her satisfaction. Staff acknowledged some complaints but did not complete grievance or concern forms, and one nurse characterized the complaints as normal behavior. The Ombudsman reported the facility did not offer to complete or provide complaint forms. The NHA confirmed that no concern forms were completed for this resident, despite a written Care Program policy requiring that all oral and written concerns be documented on a Resident, Family, Employee and Visitor Assistance Form, investigated via IDT, logged for QA tracking, and followed up to ensure satisfaction. This failure to follow the grievance policy and formally document, investigate, and evaluate the resident’s concerns resulted in the cited deficiency.
Surveyors found insufficient nursing staffing and inconsistent shift coverage, with PBJ data showing low weekend staffing and facility records showing multiple shifts with limited nurse aide coverage for about 80 residents. Residents reported long waits for call light response, toileting help, and getting to bed, and said evening snacks were sometimes missed when staffing was short. The DON confirmed staff shortages, recent resignations, and repeated 16-hour shifts for nurses and nurse aides.
Food service deficiencies were observed in multiple kitchen and dining areas. Expired or improperly dated food items were found in refrigerators, a sanitizer bucket tested at zero ppm, the microwave and plates were visibly soiled, an ice machine drain line was sitting directly in the drain, and a staff member was observed using a bare hand while handling ready-to-eat food.
A resident's needs were not met timely, and call lights were canceled before assistance was provided. One resident with intact cognition reported wetting pants while waiting for bathroom help, another resident's family reported long call light waits and episodes of incontinence, and a CNA was observed canceling a call light for a resident who needed help getting up for a family visit before returning later to assist.
Incomplete Daily Nurse Staffing Postings: The facility failed to accurately post daily nurse staffing information for multiple days. A posted staffing sheet near the front entrance showed CNA hours but no RN or LPN coverage or hours, and other reviewed staffing sheets were also incomplete, with some missing RN hours or not listing RN/LPN staff at all. The DON said a new scheduler was in place, and the scheduler stated staffing sheets were supposed to be updated when call-ins occurred.
Failure to Provide and Document Nail Care: A resident with dementia, DM, depression, anxiety, and excoriation disorder was observed with long, jagged fingernails, including one nail down to the skin and another curling under. The resident said she preferred short nails and that the nails were sharp and scratched her. CNAs reported nail care was usually done during bathing or as needed, but they were unsure when it was last completed and said it depended on the resident’s mood. The record also showed skin scratching issues and a lack of documentation of refusals or attempted interventions.
A resident with dementia, cerebral ischemia, and COVID-19 had significant wt loss and a practitioner order for weekly weights, but the facility did not document the ordered weights in the medical record. The MAR showed the weekly weights as completed, yet the actual wt entries were missing for two weeks and another wt was held due to isolation precautions. The RD stated the resident had about 7% wt loss in a month, that 5% or more is significant, and that the missing weights should have been available for review and analysis.
The facility failed to manage pain effectively for two residents, leading to their verbalizations of unrelieved pain and distress. One resident with pancreatic cancer received inconsistent pain medication and inadequate assessments, while another resident with multiple health issues had no pain medication order until days after admission. The facility's pain management policy was not followed, resulting in deficiencies in care.
The facility failed to ensure timely call light responses, dignified feeding assistance, and palatable food options, leading to resident complaints. Residents experienced long wait times for call light responses, inadequate feeding assistance, and dissatisfaction with food quality and availability. Additionally, the dining room was closed on weekends due to staffing shortages, and residents faced restrictions on going outside.
The facility failed to provide a clean, comfortable, and homelike environment, with observations of damaged walls, unsanitary conditions, and unsafe storage of personal items. A resident reported unfulfilled repair promises, and a CNA acknowledged unsafe storage of an electric shaver due to a low battery.
A facility failed to follow professional standards during medication administration for two residents. One resident was left unsupervised during nebulizer treatments, and necessary assessments were not performed. Another resident was left alone with medications, which they consumed without supervision, despite not having a care plan for self-administration. The facility's policies were not adhered to, resulting in these deficiencies.
The facility experienced significant staffing shortages due to the resignation of several nurses, leading to extended work hours for remaining staff. This resulted in delayed call light responses, unmet care needs, and late medication administration. Residents reported long wait times for assistance and dissatisfaction with meal service due to insufficient staffing. Nurses were observed working beyond their shifts, and medications were administered late, impacting the quality of care provided.
A facility experienced a 33% medication error rate due to late administration and unavailable medications. Errors included a resident not receiving Fenofibrate and Diclofenac Gel, another receiving medications late, and improper insulin syringe handling. Staff working overtime and poor communication contributed to the issues.
The facility failed to ensure proper infection prevention and control practices, with inadequate surveillance and documentation of infectious illnesses. Incorrect precaution signage for a resident with MSSA was observed, and infection surveillance was limited to residents on antibiotics. PPE was not consistently used, and personal items in shared bathrooms were unlabeled. In the kitchen, hairnets were not readily accessible, posing a risk of contamination. These deficiencies highlight significant lapses in infection prevention and control practices.
The facility failed to ensure proper documentation of advance directives for two residents with severe cognitive impairment. Both residents had discrepancies between their documented code statuses and their DNR orders, as the necessary signatures from legal representatives were missing. This oversight could result in the residents receiving unwanted life-sustaining treatment.
The facility failed to maintain comprehensive and updated care plans for residents, leading to deficiencies in care. A resident ambulated unassisted without proper footwear or devices, another had a pacemaker machine unaddressed in their care plan, and a third had discrepancies in their code status documentation. Additionally, a resident suffered skin injuries from a broken chair, with no proper documentation or care plan updates.
The facility failed to provide adequate ADL care for two residents, resulting in deficiencies in personal hygiene. A resident with dementia was found with unclean nails despite needing assistance with all ADLs. Another resident, who requires substantial assistance, did not receive a scheduled shower and was incorrectly marked as having refused it. The facility's policy on handling refusals was not followed, and there was no documentation of a plan to address the missed care.
The facility failed to provide adequate supervision and follow safety care plans for residents at risk of falls, resulting in potential harm. One resident was observed walking unsteadily without supervision, while another had multiple falls with injuries. Additionally, a resident's complaint about a broken chair causing cuts was not addressed, leading to a lack of timely assessment and treatment. The facility's policies on fall management and skin care were not effectively implemented.
The facility failed to provide timely and appropriate care for residents with urostomy appliances and urinary catheters. A resident with a urostomy did not have their appliance changed as ordered, and another resident had a Foley catheter left in without a physician's order after a 24-hour urine collection. These deficiencies highlight lapses in care processes and documentation.
A resident with complex medical conditions, including diabetes and end-stage kidney disease, experienced significant weight loss due to the facility's failure to assess and address nutritional needs. The resident's care plan was incomplete, and the Registered Dietitian had not conducted a timely assessment, resulting in a lack of interventions to promote nutrition. The resident was eventually transferred to the hospital due to a change in condition.
The facility failed to communicate dialysis center orders to the practitioner for two residents, leading to missed medication orders and unfulfilled diagnostic test requests. A resident did not receive a recommended medication, and another resident's 24-hour urine collection was not completed as requested by the dialysis center. These communication lapses posed risks to the residents' dialysis care.
The facility failed to ensure proper narcotic medication reconciliation and timely administration of medications. Nurses exchanged medication cart keys without completing narcotic counts, leading to potential medication/narcotic diversion. Several residents did not receive their medications as scheduled, with discrepancies in administration records. The DON acknowledged the issues, noting that the facility's policies on medication administration and controlled substances were not followed.
The facility failed to provide adequate healthy snack options, leading to resident complaints about the lack of fresh fruits and vegetables, and the repetitive nature of meals. Observations showed limited snack availability in kitchenettes, and interviews with staff confirmed the inconsistency between the facility's snack list and actual offerings.
Failure to Follow Care-Planned Lift Transfer Resulting in Leg Lacerations
Penalty
Summary
The deficiency involves the facility’s failure to implement required transfer interventions and ensure a safe environment for a resident who was care planned for use of an electronic lift. The resident had multiple diagnoses including heart failure, history of falls, chronic kidney disease, prior stroke, hypertension, hypothyroidism, atrial fibrillation, arthritis, asthma, and left leg pain. An MDS assessment showed the resident had intact cognition (BIMS 15/15), required assistance with all care, and was dependent for transfers. The care plan documented that the resident had a functional ability deficit requiring assistance with self-care and mobility related to weakness, impaired mobility, pain, and poor endurance, and specified that transfers were to be done with a two-assist Invacare electronic lift and large sling. The care plan also identified actual skin integrity impairment, including lacerations/skin tears to both lower extremities, and directed staff to use caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces. On the date of the incident, an incident report completed by a nurse indicated that the resident was being transferred from a beauty shop chair to a wheelchair by an OT and a CNA. The nurse documented that she believed the resident was care planned as a two-assist transfer “as needed,” but the resident was actually care planned as a lift transfer at all times. During this manual two-person transfer without the electronic lift, the resident’s leg struck the wheelchair foot pedal, causing three large skin tears on the left leg with significant bleeding. Progress notes described a skin tear to the left lateral upper leg with a skin flap that initially was not approximated, approximately 8 cm in size, and a second open injury of about 10 cm distal to the first, with bleeding difficult to control. The resident was noted to be on Eliquis and aspirin, and pressure dressings were applied before the resident was sent to the emergency department for evaluation. The hospital emergency department report documented an ISTAP type 3 skin tear of the left lower leg with total flap loss, an additional skin tear of the left lower leg, a hematoma of the left lower leg, and current long-term anticoagulation use. Subsequent facility documentation showed ongoing wound treatment orders for the left leg laceration and increased use of PRN narcotic pain medication after the injury. In interviews, the DON confirmed that two staff transferred the resident from the beauty shop chair to the wheelchair and that they were supposed to use an electronic lift per the resident’s plan of care. The administrator stated that the nurse assigned to the resident had told the CNA that the resident could be transferred with a two-person assist without the Invacare lift, and the CNA then obtained help from the OT to perform the transfer, during which the resident’s leg was injured on the wheelchair foot pedal. The facility’s Fall Management policy stated that hazards and resident risk factors would be identified and interventions implemented to minimize falls and related injuries, with a plan of care developed and implemented based on this evaluation.
Failure to Follow Grievance Policy and Address Resident’s Ongoing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and properly address a cognitively intact resident’s concerns that were voiced through the State Ombudsman. The resident was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, depression, anxiety disorder, paranoid personality disorder, and post‑traumatic stress disorder, and had a BIMS score of 15/15, indicating intact cognition. Functionally, the resident required varying levels of assistance with ADLs, including dependence for toileting hygiene and transfers. During an Ombudsman visit, an Elder Advocate witnessed staff responding inappropriately to the resident’s call light, including shutting off the call light, stating they were too busy, rolling their eyes, raising their voices, leaving, and not returning to assist. These concerns were relayed by the Ombudsman to the Administrator via email. In subsequent interviews, the resident reported that these issues had not been resolved and that problems with staff response to call lights and staff behavior continued. The resident described staff answering the call light and telling her they were taking care of other people, turning off the call light and not returning, instructing her to go in her brief and stating they would come back, and not returning. The resident also reported concerns about therapy not working enough on transfers to the toilet/bedside commode and being told she could not keep her own glucometer at the facility. The resident stated she preferred to communicate concerns through the Ombudsman rather than directly to the Administrator, DON, or Unit Manager, and reported that staff had not offered to help her write a concern form, had not provided her with concern or grievance forms, and had not given her any written documentation or resolutions related to the concerns she raised through the Ombudsman. Staff interviews showed that the facility did not document or process these concerns in accordance with its written Care Program grievance policy. Nursing staff acknowledged awareness of some issues, such as dressing changes, therapy participation, and behavioral concerns, but reported they had not completed grievance or concern forms, with one nurse characterizing the resident’s complaints as normal behavior and personality. The Ombudsman reported that the facility had not offered to write out a complaint form or Visitor Assistance Form and was not aware that any such forms had been completed or offered as an option. The Administrator confirmed that no concern forms had been completed for this resident’s issues, explaining that concerns were being addressed in real time and were not considered ongoing, despite the policy requiring that oral concerns be documented on a Resident, Family, Employee and Visitor Assistance Form, discussed in IDT, logged, and followed up to ensure satisfaction. As a result of not following the policy, the resident’s concerns were not formally documented, investigated, tracked, or evaluated for satisfaction as required by the facility’s Care Program. The facility’s Care Program policy specifies that any concern or grievance, whether written or oral, should be documented on the Resident, Family, Employee and Visitor Assistance Form, acknowledged, investigated, discussed in IDT, and forwarded to the Administrator for logging and tracking in the facility’s QA log, with follow‑up within seven days to ensure the concern is addressed to the complainant’s satisfaction. In this case, the resident’s concerns communicated through the Ombudsman and directly to staff were not processed through this formal mechanism. The lack of documentation and use of the required forms meant that the concerns were not entered into the facility’s tracking and trending system, not formally investigated through the IDT process, and not subject to the required follow‑up evaluation for satisfaction, as described in the policy. This failure to follow the established grievance procedure led to the cited deficiency related to honoring the resident’s right to voice grievances and ensuring prompt, documented efforts to resolve them.
Insufficient Nursing Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet resident needs and have a licensed nurse in charge on each shift. Survey review identified low weekend staffing in the facility’s PBJ Staffing Data Report for the 4th fiscal quarter of 2025, and the Administrator confirmed that weekend staffing had been low. The facility’s staffing records and daily assignment sheets also showed multiple shifts with limited nurse aide coverage for a census of about 80 to 84 residents, including days when only a small number of aides were listed for day, evening, and midnight shifts. During interviews, residents reported long waits for assistance with call lights, toileting, and getting to bed. One resident stated it took 3 hours to receive help to go to bed after asking for assistance for several hours, and another said it could take over 2 hours to receive help. Residents also reported that evening snacks were sometimes not passed because there were not enough staff, and that at times there were only 2 nurse aides for the whole building. The facility’s staffing sheets showed call-ins, partial shifts, and repeated instances where nurse aides were crossed off or identified as quit, making it difficult to determine who was working. Review of timecards and interviews with nursing leadership showed repeated 16-hour shifts for some nurses and nurse aides, with staff working mandatory overtime. The DON confirmed that several nurse aides had recently quit and acknowledged that nurses and nurse aides were sometimes working 16-hour shifts while the facility tried to hire additional staff. The facility policy stated that nursing services provide 24-hour nursing services and that the facility ensures sufficient nursing staff to meet resident needs, and the facility assessment stated staffing should be adjusted based on resident needs for each shift, including weekends.
Food Storage, Sanitizer, and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain food service best practices in multiple areas of the kitchen and dining spaces. During the initial kitchen tour with the CDM and Dietician, a bag of pepperoni with a discard date of 12/24/25 and a bag of shredded lettuce with a best by date of 1/2/26 were found in the walk-in refrigerator. A takeout pizza box dated 1/4/26 was also observed in the 400-hallway kitchenette refrigerator, and a turkey sandwich with a discard date of 1/4/26 was found in the 900-hallway kitchenette refrigerator. In the 200-hallway kitchenette, a red stain from an unknown liquid was observed on the inside wall of the refrigerator. The drain line to the ice machine in the 900-hallway kitchenette was sitting directly inside the drain. Additional observations in the main dining area showed a sanitizer bucket on the counter testing at zero with Hydrion QT-40 strips, while the CDM stated the solution should be maintained between 150-400 ppm and changed when visibly soiled or when starting a new task. The microwave in the main dining area was visibly soiled on the interior ceiling and walls, and plates stacked by the steam table had crumbs on them. During lunch observation, plates with crumbs were again seen stacked beside the steam table, and [NAME] C was observed scooping baked ziti and batting extra cheese off the utensil with a bare hand, allowing the cheese to fall back into the serving pan. The report also cites the facility's policy that food brought in must be checked, sealed, labeled, and dated, and that bare hand contact with ready-to-eat food is not permissible.
Delayed Response to Call Lights and Resident Needs
Penalty
Summary
The facility failed to ensure that residents' needs were met timely and failed to ensure that call lights were not discontinued before residents' needs were met for three residents and a confidential group of residents. A family member of one resident stated the call light wait time averaged 20 minutes and could be longer, and reported that the resident had been incontinent on a few occasions because the bathroom request was not answered in time. Another resident, who had intact cognition and required assistance with activities of daily living and had diagnoses including diabetes, stroke, and high cholesterol, complained that there was not enough help and that they had wet their pants while waiting for assistance to the bathroom. A confidential resident also reported that staff often canceled the call light before meeting the resident's needs and sometimes said it would be an hour before returning, which made the resident feel unimportant. For another resident, who had diagnoses including debility, heart failure, and anemia and required assistance with all activities of daily living, the call light was observed activated while the resident remained in bed and needed to get up and ready for a daughter's visit. A CNA entered, asked if help was needed, and then stated they would go get help while canceling the call light. The resident remained in bed with the call light on, and the CNA was later observed performing other tasks and assisting another resident before returning. The resident's call light was later answered, and the resident was eventually assisted to get up and brush teeth in the bathroom.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information was accurately completed on multiple days in December 2025 and January 2026. On 1/6/2026 at 11:40 AM, a posted staffing sheet titled "Report of Nursing Staff Directly Responsible for Patient Care" for 1/6/2026, with a census of 78 residents, was observed in the hallway near the front entryway desk and did not show any RN hours for that day. When the DON was asked about the incomplete posting at 11:45 AM, she stated there was a new scheduler and that it would be fixed. At 1:30 PM, the Staff Scheduler provided the schedule book containing the daily staff postings and assignment sheets and stated that assignment sheets were sometimes updated when staff called in for their shift and that the daily posted staffing sheets were supposed to be updated also. Review of the daily posted staffing sheets from December 2025 through 1/7/2026 identified incomplete forms for 1/5/2026, 1/6/2026, 12/29/2025, 12/17/2025, 12/16/2025, 12/13/2025, and 12/12/2025. Some forms did not indicate whether an RN worked that day or how many hours the RN worked in a 24-hour day, and some did not list RN or LPN staff or their hours. On 1/5/26 at 12:26 PM, another posted staffing sheet near the front entrance showed CNA hours for all shifts but had no documentation for RN or LPN coverage or hours.
Failure to Provide and Document Nail Care
Penalty
Summary
The facility failed to ensure nail care was provided for Resident #6, who had diagnoses including dementia, anxiety disorder, diabetes, depressive disorder, and excoriation disorder. On 1/5/26 and 1/6/26, observations showed the resident lying in bed with long fingernails, including one irregular nail down to the skin on the right fifth digit, another curling under, and several jagged and uneven nails. The resident stated she liked short nails and reported the nails were sharp and scratched her. During the same period, CNAs stated nail care was typically offered during bathing or as needed, but they were unsure when the resident last received nail care and indicated it depended on her mood whether she would allow it. The resident’s record showed she needed substantial to maximal assistance with personal hygiene and was dependent for showering/bathing. Progress notes documented skin issues related to scratching, including healing scratch marks on the lower legs and redness on the buttocks and groin, and one note stated dried skin and dry scabs were cleaned from under her fingernails. The record also showed a note on 12/10/25 stating the nails were short and well trimmed, but there was a lack of documentation of any refusal of nail care or interventions attempted from 1/6/26 back to that note. The care plan included interventions to observe fingernails on shower days and to keep fingernails short due to impaired skin integrity and scratch marks.
Failure to Document Ordered Weekly Weights for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss was weighed as ordered by the practitioner and that the weights were documented in the medical record. Resident #25 was admitted with diagnoses including cerebral ischemia, dementia, depressive disorder, and COVID-19. The resident had severely impaired cognition, needed set-up or clean-up assistance with eating, and had documented weight loss from 172.5 lbs to 160 lbs over a one-month period. A practitioner order dated 12/8/25 directed weekly weights for 8 weeks, but the medical record did not contain documented weights for 12/15/25 and 12/22/25, even though the MAR showed those weekly weights as completed. For 12/29/25, the weight was documented as 5, with a progress note stating the weight was held because the resident was on isolation precautions. Additional progress notes showed the resident remained on COVID isolation, had intermittent symptoms earlier in the course, and was receiving fluids encouragement and dietary monitoring. During interview, the RD stated the resident had approximately 7% weight loss in a month and that 5% or more would be significant weight loss. The RD was not aware of the current weekly weights and later found a separate Vital Signs and Intake/Output Record showing weights of 161 lbs on 12/15/25 and 162 lbs on 12/22/25, with the resident’s first name only written on the page. The RD agreed those weights should have been in the medical record for analysis of the resident’s weight loss and to determine whether further interventions were needed.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to adequately assess, monitor, and manage pain for two residents, resulting in their verbalizations of unrelieved pain, frustration, and helplessness. Resident #138, who was admitted with multiple serious health conditions including pancreatic cancer and pressure ulcers, was observed moaning loudly and expressing discomfort. Despite having orders for pain medications such as Oxycodone and Morphine, the administration of these medications was inconsistent, and pain assessments were not conducted during the day when the resident was experiencing significant pain. The care plans for Resident #138 were not followed, and the interventions specified were not implemented effectively. Resident #139, admitted with acute respiratory failure, COPD, and other serious conditions, was also observed repeatedly yelling for help and moaning. The resident had no pain medication order until several days after admission, despite exhibiting signs of discomfort and having fallen twice. Pain assessments were infrequent and mostly conducted during night shifts, with little documentation of the resident's discomfort during the day. The care plan for Resident #139 lacked sufficient interventions to address the resident's pain and discomfort. The facility's policy on pain management was not adhered to, as evidenced by the lack of timely and appropriate pain assessments and interventions for both residents. The failure to manage pain effectively led to the residents experiencing unrelieved pain and distress, highlighting deficiencies in the facility's pain management practices.
Deficiencies in Resident Care and Services
Penalty
Summary
The facility failed to ensure timely and dignified responses to call lights, proper assistance with feeding, and the provision of palatable food options, which led to multiple resident complaints. Residents reported that call lights were often not answered promptly, with some waiting up to two hours for assistance, resulting in delayed care and discomfort. Additionally, call lights were not always placed within reach, particularly for residents with limited mobility or cognitive impairments, further exacerbating the issue. The facility also did not provide assistance with feeding in a dignified manner. Observations revealed that some residents were left to eat without proper supervision or assistance, leading to difficulties in consuming their meals. In one instance, a staff member was observed standing while feeding a resident, which was deemed undignified. Furthermore, residents expressed dissatisfaction with the food served, citing a lack of fresh fruits and vegetables, and meals often being served at an undesirable temperature. The dining room was also closed on weekends due to staffing shortages, forcing residents to eat in their rooms where food was often cold. Residents expressed frustration over their inability to go outside freely, as doors were frequently locked, and the dining room closure on weekends due to low staffing levels. These issues, combined with the inadequate response to call lights and poor meal quality, contributed to a decreased quality of life for the residents. The facility's policies on resident rights and call light response were not adhered to, as evidenced by the numerous complaints and observations made during the survey.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and unclean conditions in resident rooms. On several occasions, surveyors observed large gouges and holes in the walls of resident rooms, with one resident expressing that repairs had been promised but not completed since the beginning of the year. Additionally, chipped drywall was noted in multiple rooms, indicating a lack of timely maintenance and repair. Further observations revealed unsanitary conditions, such as a fan with a large amount of dusty buildup and a bathroom floor that was dirty and sticky with dried urine. An electric shaver was found plugged in and resting on the back of a toilet, with the cord appearing to be able to reach the toilet water, posing a potential safety hazard. Despite the facility's policy on keeping residents' personal property in a safe and convenient location, the shaver remained in this unsafe position over multiple days, and a CNA acknowledged that it was left there due to a low battery.
Medication Administration and Supervision Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of care during the administration of nebulizer treatments for a resident. The nurse prepared the nebulizer medication and instructed the resident on how to use the machine but did not stay to observe the treatment. The resident struggled to operate the nebulizer and was left unsupervised, resulting in incomplete administration of the medication. Additionally, the nurse did not perform necessary assessments such as checking lung sounds, oxygen saturation, or heart and respiratory rates before and after the treatment, as required by the facility's policy. Another deficiency was observed in the supervision of medication administration for a different resident. The resident was left alone with a cup of medications, which they consumed without any staff present. The nurse confirmed that they had given the medications to the resident but did not stay to ensure the medications were taken properly. The resident's care plan did not include any interventions for self-administration of oral medications, which is a requirement according to the facility's policy. Both incidents highlight a lack of adherence to the facility's policies regarding medication administration and supervision. The Director of Nursing confirmed that the residents involved did not have evaluations or care plans that allowed for self-administration of medications, and the facility's policies were not followed, leading to these deficiencies.
Staffing Shortages Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide timely and adequate care for residents, resulting in long call light response times, unmet care needs, and late medication administration. The report highlights that the facility experienced a shortage of nursing staff due to the simultaneous resignation of five nurses, leading to the remaining staff being mandated to work extended hours. This situation resulted in some nurses working up to 18 hours and CNAs working double shifts to cover staffing shortages. Despite recent hiring efforts, the facility continued to struggle with maintaining adequate staffing levels, impacting the quality of care provided to residents. Several residents reported issues related to insufficient staffing. One resident was observed walking unsteadily in the hallway without supervision, as the available CNA was attending to another resident. Another resident expressed dissatisfaction with the weekend staffing, noting that it took up to an hour for call lights to be answered. A resident receiving hospice services reported experiencing significant pain and discomfort, with delays in staff response times, particularly at night. These observations and resident interviews underscore the facility's inability to meet the care needs of its residents due to staffing inadequacies. The report also details issues with medication administration, where nurses were observed working beyond their shifts to cover for absent staff. Medications were administered late, with one nurse reporting 12 residents with late medications at one point. Residents also reported dissatisfaction with meal service, as staffing shortages led to meals being served in rooms rather than the dining room, resulting in cold food. Overall, the facility's staffing challenges have led to compromised care quality, with residents experiencing delays in receiving necessary assistance and services.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 33% error rate during the survey. This was observed through 23 medication errors involving four residents out of 69 opportunities. The errors included medications not being administered on time, medications not being available, and improper medication administration practices. For instance, Resident #82 did not receive Fenofibrate and Diclofenac Gel as scheduled due to the medications not being available from the pharmacy. Additionally, the insulin syringe was improperly recapped by Nurse S, despite having a guard to cover the needle. Other residents experienced similar issues. Resident #78 received eight out of eleven medications late, and Resident #34 did not receive her nasal spray and inhaler on time, despite them being marked as administered in the system. Resident #75 received ten medications late and did not receive Miralax. The errors were attributed to staff working overtime and improper medication administration practices, such as one nurse preparing medications while another administered them, leading to confusion and delays. The Director of Nursing acknowledged the issues, noting that medications were not available and that there was a lack of communication between shifts regarding medication administration.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by inadequate surveillance and documentation of infectious illnesses among residents. The Infection Prevention and Control (IPC) Nurse was unaware of incorrect precaution signage for a resident with Methicillin Sensitive Staphylococcus Aureus (MSSA), which was mistakenly documented as Methicillin Resistant Staphylococcus Aureus (MRSA) by another nurse. This error led to inappropriate contact precautions being applied. Additionally, the facility's infection surveillance was limited to residents on antibiotics, lacking comprehensive tracking of signs and symptoms of infections, which could potentially lead to an outbreak. Observations revealed multiple instances of non-compliance with infection control protocols. Personal Protective Equipment (PPE) was not consistently used by staff when required, and hand hygiene was not performed in several instances. Personal items in shared bathrooms were unlabeled, increasing the risk of cross-contamination among residents. Furthermore, the facility's documentation of infections lacked detailed information on infectious organisms, making it difficult to track and analyze potential spread. In the kitchen, hairnets were not readily accessible, and staff had to cross clean food preparation areas without hairnets to retrieve them from a chemical storage room, posing a risk of contamination. The facility lacked a policy for hairnet use and storage, and the hand hygiene policy was not effectively implemented. These deficiencies highlight significant lapses in the facility's infection prevention and control practices, which could result in exposure to infectious organisms and an outbreak of illnesses.
Failure to Properly Document Advance Directives
Penalty
Summary
The facility failed to properly follow up on advance directives for two residents, resulting in discrepancies between documented code statuses and the residents' wishes. Resident #47 was admitted with severe cognitive impairment and had a Do-Not-Resuscitate (DNR) order signed by a physician, but the Power of Attorney (POA) did not sign the DNR form. The resident's care plan incorrectly indicated a full code status, which was not updated to reflect the DNR order. This lack of proper documentation and follow-up could lead to the resident receiving life-sustaining treatment against their wishes. Similarly, Resident #71, who also had severe cognitive impairment, had a DNR order documented in their medical record. However, the DNR form lacked a signature from the legal healthcare decision maker, and only verbal consent was noted with witness signatures from two nurses. The Director of Nursing (DON) was uncertain about the validity period of verbal authorization and confirmed the discrepancy in the code status documentation. The facility's policy on advance directives emphasizes the importance of obtaining and documenting the necessary signatures for DNR orders, especially for residents unable to make medical decisions. Despite this policy, the facility did not ensure that the DNR forms for both residents were properly signed by the appropriate legal representatives, leading to inconsistencies in the residents' care plans and potential violations of their rights to refuse treatment.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to ensure comprehensive and revised care plans for several residents, leading to various deficiencies. Resident #26 was observed ambulating unassisted and without proper footwear or assistive devices, despite having a history of falls and requiring assistance with activities of daily living. The care plan and Kardex for this resident did not specify the level of assistance needed for ambulation and transfers, indicating a lack of proper documentation and planning for the resident's mobility needs. Resident #53 had a pacemaker machine at their bedside, but the care plan did not mention this device or provide any instructions related to its management. The resident was unsure of their cardiologist's name and indicated that their spouse had the necessary information. This oversight in the care plan could lead to inadequate management of the resident's cardiac condition, as the care plan failed to address the presence and use of the pacemaker machine. Resident #47's care plan contained discrepancies regarding their code status. Although a DNR order was signed by a physician, the care plan still listed the resident as a full code, and there was no follow-up signature from the POA. This inconsistency could result in the resident receiving life-sustaining treatment against their wishes. Additionally, Resident #68 experienced skin integrity issues due to a broken chair, which led to cuts on their forearm. The facility failed to document the incident, assess the wound, or update the care plan to address the resident's skin impairment, highlighting a lack of proper wound management and documentation practices.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, resulting in deficiencies in personal hygiene and care. Resident #74, who has diagnoses including dementia, heart failure, and kidney disease, was observed with a large amount of brown residue under their right-hand nails. Despite requiring assistance with all ADLs, including personal hygiene, the resident's nails were not cleaned until after the issue was observed and brought to the attention of a CNA. The facility's records indicated that the resident's fingernails should be kept trimmed and clean, but this was not adhered to until after the observation. Resident #23, who has chronic kidney disease, muscle weakness, and requires substantial assistance with personal care, reported not receiving a scheduled shower. The resident, who has intact cognition, expressed frustration over being marked as having refused a shower, which they denied. The facility's policy requires staff to offer care three times and notify a nurse if a resident refuses, but there was no documentation of such a process or a plan for the refusal. The Director of Nursing confirmed that showers could be rescheduled according to resident preference, but this was not done for Resident #23.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure proper supervision and adherence to safety care plans for residents at risk of falls, leading to potential harm. One resident was observed walking unsteadily in the hallway without supervision, as the staff was occupied with other duties. This resident had a history of falls and required supervision and a wheelchair for safe ambulation. Another resident was also seen walking unsteadily without assistance, and the housekeeping staff had to intervene. This resident had multiple previous falls, some resulting in injuries, and was not wearing gripper socks as required by their care plan. Additionally, the facility did not adequately address a resident's complaint about a broken chair, which resulted in cuts on the resident's forearm. The resident had reported the issue more than a week prior, but no action was taken to replace the chair or assess the injury. When the resident's bleeding arm was finally noticed, there was no documentation of an assessment, incident report, or treatment order until the following day. The facility's skin management policy was not followed, as there was no ongoing monitoring or evaluation of the resident's wound. The facility's fall management policy, which requires identifying hazards and implementing interventions to minimize falls, was not effectively implemented. The staff was unable to provide adequate supervision due to being understaffed, and the care plans for residents at risk of falls were not consistently followed. The lack of documentation and timely response to the resident's injury from the broken chair further highlights the facility's failure to adhere to its policies and ensure resident safety.
Deficiencies in Urostomy and Catheter Care
Penalty
Summary
The facility failed to ensure timely and appropriate care for residents with urostomy appliances and urinary catheters, leading to deficiencies in care. Resident #26, who was admitted with a urostomy, did not have their ostomy appliance changed according to the physician's orders from the time of admission through several months. The treatment administration records showed missed appliance changes, and the resident was observed reinforcing their ostomy barrier with tape brought from home, indicating unmet care needs. The care plan did not reflect the resident's involvement in their own care or the use of home-brought materials, which could lead to potential complications. Resident #23, who had a Foley catheter for a 24-hour urine collection, did not have a physician's order to leave the catheter in place after the collection was completed. The resident reported that the catheter was left in due to a lost urine specimen and the desire to wait for results. The Director of Nursing confirmed that there was no order to continue the catheter, and the physician had not been notified. This oversight resulted in the catheter remaining in place without proper authorization or documentation, which could lead to further complications. The facility's failure to adhere to physician orders and ensure proper documentation and communication regarding residents' care needs resulted in deficiencies. The lack of timely urostomy appliance changes and the unauthorized continuation of a urinary catheter highlight significant lapses in the facility's care processes, potentially impacting the residents' health and well-being.
Failure to Assess and Address Nutritional Needs
Penalty
Summary
The facility failed to assess, monitor, and implement interventions to promote nutrition and prevent weight loss for a resident, resulting in a lack of nutritional assessments to identify the resident's needs. The resident, who was admitted with multiple complex medical conditions including diabetes, end-stage kidney disease, and pressure ulcers, was observed not eating and expressing a desire for his meal tray not to be taken away. Despite these observations, the resident's nutritional care plan was blank, and no specific interventions were in place to address his nutritional needs. The resident's food intake documentation showed minimal consumption since admission, with several meals marked as refused or not available. The resident experienced a significant weight loss of 10 pounds within five days of admission. The Registered Dietitian, who was responsible for nutritional assessments, had not yet assessed the resident due to prioritizing other residents admitted earlier. Consequently, the resident's nutritional needs were not identified or addressed, and no additional dietary notes or interventions were documented. Interviews with facility staff, including the Registered Dietitian and the Unit Manager, revealed a lack of communication and timely assessment of the resident's nutritional status. The facility's policy required a comprehensive nutritional evaluation within five days of admission, which was not completed for the resident. The Registered Dietitian acknowledged not being aware of the resident's food intake or weight loss and had not reviewed the resident's care plan, which remained incomplete. The resident was eventually transferred to the hospital due to a change in condition, highlighting the severity of the oversight in nutritional care.
Communication Failures in Dialysis Care Orders
Penalty
Summary
The facility failed to ensure proper communication of dialysis center orders to the practitioner for two residents requiring dialysis care. For Resident #23, the dialysis center recommended starting Lasix 40 mg twice a day, but there was no order for this medication in the resident's medical record, nor was there documentation that the physician had been notified of this recommendation. Additionally, the resident was prescribed Vistaril for anxiety prior to dialysis, but there was no documentation indicating whether the medication was offered or administered, and the Director of Nursing (DON) acknowledged a lack of communication regarding this order. Resident #139 experienced a similar issue with communication between the dialysis center and the facility. The dialysis center requested a 24-hour urine collection to be brought to the center, but there was no physician order for this collection, and it was not completed as requested. The Unit Manager confirmed that the request was documented on the Hemodialysis Communication Form, but it was not acted upon until after the resident returned from dialysis. The resident was later transferred to the hospital due to a change in condition. These deficiencies highlight a breakdown in communication between the dialysis center and the facility, resulting in missed medication orders and unfulfilled requests for diagnostic tests. The lack of documentation and follow-through on dialysis center recommendations posed a risk to the residents' dialysis care and overall health management.
Medication Administration and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure proper narcotic medication reconciliation and timely administration of medications, as well as adherence to medication administration standards. During the survey, it was observed that narcotic medication reconciliation was not completed when the medication cart keys were exchanged between nurses. Nurse T and Nurse S were observed working together to administer medications, with one nurse preparing the medications and the other delivering them, which is against the facility's policy. Additionally, the narcotic count was not conducted when the keys were handed over, leading to a lack of accountability and potential medication/narcotic diversion. Several residents did not receive their medications as scheduled. Resident #82 did not receive Fenofibrate and Diclofenac Gel because the medications were not available from the pharmacy or the backup supply. Resident #78 received 11 medications, 8 of which were administered late. Resident #34 reported not receiving her nasal spray and inhaler, which were marked as given by another nurse, indicating a discrepancy in medication administration records. Resident #75 received 10 medications late and did not receive Miralax as scheduled. The Director of Nursing (DON) was informed of these issues, including the improper exchange of medication cart keys and the lack of narcotic reconciliation. The DON acknowledged that the nurse preparing the medication should also administer it, and that narcotic counts should be completed before the keys are handed over. The facility's policies on medication administration and controlled substances were not followed, resulting in 23 observed errors during the medication administration task.
Inadequate Snack Options Lead to Resident Complaints
Penalty
Summary
The facility failed to provide sufficient healthy snack choices for residents, leading to complaints from the Resident Council. Observations and interviews revealed that residents were dissatisfied with the lack of fresh greens, vegetables, and fruits, as well as the repetitive and processed nature of the meals. Residents expressed a desire for fresh items such as tomatoes and corn, and complained about the use of margarine instead of real butter and imitation cheese. The Certified Dietary Manager (CDM) acknowledged the complaints and mentioned that the facility offered celery, carrot snacks, and bananas, but lacked other fresh fruits like apples, oranges, or grapes. The CDM also noted that the kitchen staff was responsible for stocking the kitchenettes, which was done between 1:00 and 3:00 PM. Further observations of the kitchenettes on different halls showed a lack of variety and availability of snacks. For instance, the 400 hall kitchenette had limited items such as a half sandwich, cheese puffs, Doritos, and a honey bun, with no fresh fruit, string cheese, or yogurt. Similarly, the 900 hall kitchenette was missing sandwiches, cottage cheese, and string cheese. Interviews with CNAs revealed that string cheese was rarely seen in the kitchenettes. The facility's Available Snack List included a variety of items, but the actual availability in the kitchenettes did not match this list, contributing to resident dissatisfaction and complaints.
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 26 citations issued within 25 miles in the last 12 months — 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 Bad Axe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Huron County Medical Care Facility | 2.6 mi | ★★★★★ | 0 | 0 |
| Lakeview Extended Care And Rehabilitation | 16.6 mi | ★★★★★ | 6 | 0 |
| Medilodge Of Cass City | 16.9 mi | ★★★★★ | 12 | 0 |
| Autumnwood Of Deckerville | 22.9 mi | ★★★★★ | 8 | 0 |
| Sanilac Medical Care Facility | 27.4 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.