Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dimondale Nursing Care Center during CMS and state inspections, most recent first.
Three residents experienced worsening and non-healing pressure ulcers due to the facility's failure to properly assess, document, and treat wounds. For one resident, an open hand wound was not documented or communicated to the physician, and sacral and trochanter wounds were misclassified as Kennedy terminal ulcers, leading to inappropriate care. Staff relied on photographs instead of in-person wound assessments, and treatment orders were not updated despite lack of healing, resulting in significant wound progression and complications.
A review of the facility's Water Management Plan revealed missing critical elements such as team member identification, system narrative, risk area identification, and reference to industry standards. Observations included discolored water in a long-unoccupied area and inadequate flushing practices, increasing the risk for waterborne pathogens.
Surveyors identified widespread failures in cleaning and maintenance, including soiled ventilation grills, contaminated privacy curtains, damaged furniture, leaking fixtures, and accumulated dust in multiple areas. Despite facility policies and a work order system, these deficiencies were not addressed, affecting 144 residents.
Multiple residents reported incidents such as being left without care, spoken to in a rude or mean manner, or having their call light hidden by staff. These allegations were not identified or reported as abuse by facility leadership, who instead classified them as customer service concerns and failed to notify the state agency as required. Interviews with staff confirmed that these incidents were not properly investigated or documented as abuse allegations.
Multiple residents reported incidents of staff verbal abuse, neglect, and rough care, including being left without oxygen, forced to remain in soiled briefs, and having call lights hidden. Facility leadership failed to identify these as abuse allegations, did not conduct investigations, did not remove staff from resident care, and did not report the incidents to the state agency as required, instead treating them as customer service issues.
A resident with diabetes and hemiplegia reported multiple missing personal items after a hospitalization, but the facility did not document, investigate, or track these grievances as required. Despite the resident involving the Ombudsman and expressing concerns, there was no record in the grievance log, no concern forms completed, and no documentation of meetings or actions taken to resolve the issue.
The facility did not ensure that residents were protected from all forms of abuse, including physical, mental, and sexual abuse, as well as neglect and physical punishment by any individual.
Staff failed to properly label and store medications, including leaving an unlabeled medication cup with multiple pills in a medication cart and leaving a medication cup unattended in a resident's room without proper assessment or authorization for self-administration. Additionally, medication refrigerator temperature logs were found to have missing entries, with no explanation provided by the infection preventionist responsible for daily review.
A resident with multiple complex medical conditions experienced a significant change in condition, including lethargy, low oxygen saturation, and low blood pressure. Despite these changes, nursing staff administered medications without verifying vital signs or notifying the physician. The required notification to PACE of the change in condition and medication changes was also not made. The resident was eventually hospitalized and placed on life support after becoming unresponsive.
A resident with multiple complex medical conditions was administered Metoprolol and Oxycodone without prior blood pressure monitoring, despite having low blood pressure and being lethargic. The nurse did not verify blood pressure or notify the physician before administering the medications. The resident became unresponsive and required emergency transfer to the hospital. Staff interviews and record reviews confirmed that blood pressure monitoring protocols and communication of changes in condition were not followed.
A resident with known CHF experienced a 44-pound weight gain over 48 days, leading to acute re-hospitalization due to exacerbation of CHF, acute pulmonary edema, and respiratory failure. The facility failed to monitor the resident's weight consistently, notify the physician of significant weight changes, or adequately address family concerns about the resident's condition. This deficiency highlights a lack of adherence to professional standards and facility policies for managing residents with complex medical conditions.
A resident experienced severe pain after a rough transfer by a CNA, leading to a dislocated hip. The facility failed to promptly assess the resident's condition or notify the physician, resulting in inadequate pain management and delayed treatment. Staff interviews revealed a lack of training on post-operative precautions and poor communication, contributing to the deficiency.
The facility failed to provide timely and appropriate care for three residents. One resident with respiratory and heart failure had to call 911 due to the facility's delay in hospital transfer. Another resident with a history of brain injury experienced a significant change in condition, with delayed hospital transfer and inadequate diabetes management. A third resident, prescribed Oxycodone, did not receive proper constipation management, despite complaints and lack of bowel movements. These deficiencies highlight lapses in care coordination and documentation.
The facility enforced an unofficial curfew requiring residents to be inside by 8:00 PM, as indicated by signs at the entrance, restricting their freedom and visiting hours. Three cognitively intact residents expressed dissatisfaction, feeling like prisoners due to the curfew. The Nursing Home Administrator was unaware of the residents' perception and acknowledged the misleading signage, indicating plans for re-education.
The facility failed to promptly address 52 grievances reported by residents over six months, including issues with wheelchair repairs, call light response times, inappropriate clothing, falls, unauthorized room entries, and dining arrangements. The grievance handling process was inadequate, with a new program lacking proper documentation and follow-up, leaving residents with unresolved concerns and dissatisfaction.
A resident was given Cipro for seven days despite a negative urine culture, indicating no bacterial infection. The physician ordered the antibiotic based on symptoms of pain and confusion, without proper documentation or justification. The Infection Control Preventionist noted the prescription did not meet McGeer criteria and reported the issue to the Medical Director.
A resident experienced a medication error rate of 28.57% when an LPN crushed medications, including Keppra and Ferrous Sulfate, against explicit 'do not crush' orders. The medications were mixed with orange juice and administered, causing the resident discomfort. Facility resources were available to prevent such errors, but they were not utilized effectively.
A resident with a complex medical history received crushed medications, including Keppra and Ferrous Sulfate, despite clear orders not to crush them. An LPN crushed these medications and mixed them with orange juice, leading to a significant medication error. The resident showed signs of discomfort during administration, and staff interviews confirmed the error and the existence of guidelines that were not followed.
The facility failed to properly store medications in one of its medication rooms, with a vaccine refrigerator found at 60 degrees, above the recommended range. An LPN and other staff were unable to locate temperature logs, indicating a lack of proper monitoring. The DON confirmed the temperature issue and planned to dispose of affected vaccines.
The facility did not display current nurse staffing information in an accessible area for residents and visitors. Observations showed that the information was posted in a staff-only area and was outdated. HR staff responsible for posting was unaware of the requirement to display current staffing in a public area.
Failure to Identify and Treat Pressure Ulcers Resulting in Worsening Wounds
Penalty
Summary
The facility failed to correctly identify, assess, and treat pressure ulcers, resulting in worsening and non-healing wounds for three residents. For one resident, there was a lack of proper documentation and assessment for a wound on the left palm, despite clear evidence of an open wound caused by hand contractures and fingernails. The Clinical Care Coordinator was unaware of the wound's occurrence or the implementation of hand carrot orders, and there was no photographic evidence or wound assessment documented. Additionally, the physician was not notified, and no change in condition form was completed for this wound. The same resident developed a sacral wound that was initially misclassified as a Kennedy terminal ulcer (KTU) rather than a pressure injury. The wound's progression, including gradual changes in size, tissue composition, and periods of improvement and regression over 16 weeks, was inconsistent with the rapid and terminal nature of KTUs. Despite the wound's non-healing status, the treatment order remained unchanged for an extended period. The resident also developed a right trochanter wound over an implanted pain pump, which similarly persisted and worsened over several weeks, eventually exposing and dislodging the device. Both wounds were managed with treatments such as AquaCell AG, but there was a lack of timely reassessment and modification of care plans in response to the wounds' progression. Interviews with staff revealed inconsistent understanding and application of wound assessment protocols. Nurses and physicians relied heavily on photographs and electronic documentation rather than in-person assessments, and wounds were not always staged or reassessed appropriately. Weekly skin assessments failed to reflect the resident's declining skin integrity, and there was a lack of communication and documentation regarding changes in condition. The misclassification of pressure injuries as KTUs led to inadequate care planning and treatment, contributing to the worsening and non-healing of the residents' wounds.
Deficient Water Management Plan and Inadequate Flushing Practices
Penalty
Summary
The facility failed to effectively create and maintain a comprehensive Water Management Plan, impacting 144 residents. Upon review, the Water Management Plan was found to be missing several critical components, including a clear definition of the current Water Management Team Members, a written narrative of the potable water supply system, identification of high-risk areas for legionella development, and reference to accepted industry standards such as ASHRAE 188 or CDC guidelines. Additionally, the facility did not follow recommended practices for flushing low-use water systems, as evidenced by the flushing logs and CDC guidance reviewed. During an environmental tour, a hand sink in an unoccupied area was observed to have discolored water for several seconds upon flushing, and it was revealed that this area had not been occupied for at least 12 years. Interviews with maintenance staff confirmed the prolonged disuse of this area, and records indicated that flushing procedures may not have been adequate to address stagnant water in these pipes. These deficiencies increased the likelihood of waterborne pathogen development, including Legionella, due to inadequate water management and maintenance practices.
Failure to Maintain Cleanliness and Physical Plant Standards
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 144 residents. During an environmental tour, multiple areas were observed to have significant cleanliness and maintenance issues. These included malodorous soiled utility rooms due to inadequate ventilation, heavily soiled return-air ventilation grills, damaged and soiled chairs at nursing stations, and privacy curtains in shower rooms contaminated with bodily fluids and human waste. Additional findings included etched and stained commode bases, soiled fans, leaking utility sink vacuum breakers, and loose or detached faucet handles in various rooms. The presence of accumulated dust and dirt on ventilation grills, PTAC unit filters, and fans was also noted throughout the facility. Interviews with the Director of Housekeeping and Laundry Services and the Director of Maintenance revealed that while there was an established work order system (TELS), there were no specific entries addressing the identified maintenance concerns in the past 60 days. A review of the facility's housekeeping policy indicated requirements for cleaning vents and replacing privacy curtains as needed, but these procedures were not followed as evidenced by the observed deficiencies. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or theft involving nine out of ten residents were properly identified, reported, and investigated as required. Multiple residents, most of whom were cognitively intact or only moderately impaired, submitted concern forms detailing incidents such as being left without oxygen, being left in soiled briefs for extended periods, being spoken to in a rude or mean manner by staff, and having requests for care ignored or delayed. In one case, a resident alleged being sex trafficked, and in another, a resident reported that a CNA hid her call light and shut her door, leaving her to call out for help. Despite these serious allegations, the facility consistently categorized the complaints as customer service issues rather than potential abuse, and did not report them to the state agency as required. Administrator interviews revealed a pattern of minimizing or reclassifying resident complaints. The administrator often asked residents whether they considered incidents to be abuse or customer service concerns, sometimes after explaining the definition of abuse to them. In several cases, the administrator documented that residents did not feel abused after these discussions, but there was no evidence that the allegations were reported to the state agency for further investigation. In some instances, the administrator or other staff provided education to the staff member involved, but did not document any investigation or reporting of the abuse allegations. The facility's failure to recognize and report these allegations as abuse was further highlighted by interviews with other staff, including the DON, who acknowledged that some incidents described on concern forms could constitute abuse or involuntary seclusion. However, there was no documentation that these concerns were reported to the state agency. The lack of proper identification, reporting, and investigation of abuse allegations represents a significant deficiency in the facility's responsibility to protect residents from abuse and to comply with mandatory reporting requirements.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to appropriately identify, investigate, and report multiple allegations of abuse involving nine out of ten residents. In each case, residents or their representatives submitted concern forms or made statements describing staff behavior that included verbal abuse, neglect, rough or rude care, and, in one instance, an allegation of sex trafficking. Despite these reports, the facility did not recognize these as abuse allegations, did not initiate investigations, and did not report the incidents to the state agency as required. The facility's responses were limited to providing staff education or discussing the incidents with the involved parties, without further protective measures or formal documentation of investigations. Several residents, including those with cognitive impairments and those who were cognitively intact, reported specific incidents such as being left without oxygen, being forced to sit in soiled briefs, being spoken to rudely or with an attitude by nursing staff, and having call lights hidden or being left unable to call for help. In some cases, residents' family members corroborated the allegations, describing repeated patterns of staff misconduct and lack of timely response to resident needs. The facility's administration consistently categorized these concerns as customer service issues rather than abuse, even when residents explicitly stated they felt abused or when the nature of the complaint met the regulatory definition of abuse or neglect. Interviews with facility leadership, including the Administrator, DON, and Unit Manager, revealed a lack of recognition of abuse allegations and a failure to follow required protocols for investigation and reporting. Staff involved in the alleged incidents were not removed from resident care duties during the review of the concerns, and there was no evidence of five-day investigation reports being submitted to the state agency. Documentation of interviews and follow-up actions was either absent or insufficient, and in some cases, staff could not recall the incidents or the education they purportedly received. The facility did not ensure the safety of residents or comply with regulatory requirements for abuse prevention and reporting.
Failure to Document, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident's grievances regarding missing personal items were promptly documented, investigated, tracked, and resolved. The resident, who was cognitively intact and admitted for long-term care with diagnoses including diabetes and hemiplegia, reported multiple missing clothing items following a recent hospitalization. Despite making multiple complaints and involving the local Ombudsman, there was no documentation of these grievances in the facility's grievance log, nor were concern forms completed. The resident expressed a lack of trust in facility staff due to previous experiences with former administration discarding his belongings without consent. Interviews with the Ombudsman and the current Nursing Home Administrator (NHA) revealed that meetings had taken place to address the missing items, but there was conflicting information regarding the resident's wishes for reimbursement or for staff to search his room. The NHA stated that no grievance was logged because the resident did not want to file a complaint, but the Ombudsman reported that the resident only objected to staff searching his room, not to reimbursement or searching laundry. By the end of the survey, there was no documentation provided to support the facility's claims, no evidence that the laundry had been searched, and no record of the meeting with the resident and Ombudsman.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report identifies a deficiency related to the facility's inability to ensure residents were safeguarded from these forms of mistreatment. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described.
Failure to Properly Label and Store Medications and Maintain Temperature Logs
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles. One resident with multiple diagnoses, including diabetes and heart disease, was observed receiving an insulin injection and being offered nine oral medications in a cup. The resident declined to take the medications immediately, requesting to take them after breakfast. The LPN left the medication cup on the overbed table and exited the room, leaving the medications unattended. The resident confirmed that staff routinely left medications for her to take later, but there was no physician order, assessment, or care plan authorizing self-administration of medication for this resident. Additionally, a medication cart inspection revealed an unlabeled medication cup containing several pills intended for another resident with severe cognitive impairment. The LPN could not identify the medications or explain the lack of labeling. Furthermore, review of a medication refrigerator's temperature log showed missing entries for several days, and the infection preventionist could not account for the omissions, despite being responsible for daily review. These actions and omissions demonstrate failures in medication labeling, storage, and documentation practices.
Failure to Notify Physician and PACE of Change in Condition
Penalty
Summary
The facility failed to notify the physician and the Program of All-Inclusive Care for the Elderly (PACE) of a significant change in condition for a resident who was admitted for respite care following a hospital stay. The resident had multiple complex diagnoses, including encephalopathy, seizure disorder, COPD, respiratory failure, diabetes, kidney failure, anxiety, and depression. Despite being cognitively intact, the resident was dependent on staff for most activities of daily living. The care plan required staff to observe for signs and symptoms of respiratory distress and to report abnormal findings to the physician as needed. On the day of the incident, the resident exhibited significant changes in condition, including lethargy, low oxygen saturation, low blood pressure, and decreased responsiveness. Multiple CNAs and LPNs observed and reported these changes, such as the need for sternal rubs to awaken the resident, oxygen saturation levels as low as 54%, and blood pressure readings below 90/56. Despite these findings, the nurse on duty administered medications, including a beta-blocker and a narcotic, without verifying blood pressure or notifying the physician of the abnormal vital signs and change in condition. The physician was not notified until the resident became unresponsive, at which point emergency services were called, and the resident was transferred to the hospital. Additionally, the facility did not communicate the change in condition or medication changes to the PACE organization, as required by the service authorization. Interviews with staff and the DON confirmed that the facility was unaware of the requirement to notify PACE of changes in care or condition. Documentation was incomplete, with missing vital signs and lack of timely change of condition forms. The failure to notify the physician and PACE of the resident's deteriorating condition and medication changes resulted in the resident being hospitalized and placed on life support.
Failure to Monitor Blood Pressure Prior to Beta-Blocker Administration Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including encephalopathy, seizure disorder, COPD, respiratory failure, diabetes, and kidney failure, was administered Metoprolol, a beta-blocker, without prior blood pressure monitoring. The resident was admitted for respite care and was dependent on staff for most activities of daily living. On the morning of the incident, the resident was observed to be lethargic, with low blood pressure and oxygen saturation, yet the nurse proceeded to administer several medications, including Metoprolol and Oxycodone, without verifying the resident's blood pressure at the time of administration. The nurse later acknowledged that the resident's systolic blood pressure had been reported as under 90 earlier in the shift and admitted to not checking the blood pressure before giving the medication, despite knowing that Metoprolol should be held if the systolic blood pressure is less than 100. The nurse also did not notify the physician of the resident's condition or the administration of the medication under these circumstances. Other staff members reported that the resident was non-responsive, required sternal rubs to be awakened, and had poor oxygenation and color, yet these changes in condition were not communicated to the physician or the care management organization as required. The resident subsequently became unresponsive, with a heart rate of 30, respirations of 6, and oxygen saturation of 57%. Emergency services were called, and the resident was transferred to the hospital after receiving Narcan, which temporarily improved responsiveness. Interviews with staff and review of records confirmed that blood pressure monitoring protocols were not followed, abnormal vital signs were not documented or reported appropriately, and there was a lack of communication regarding changes in the resident's condition and medication administration.
Failure to Monitor and Report CHF Exacerbation Leads to Re-hospitalization
Penalty
Summary
The facility failed to adequately assess, monitor, document, and provide timely treatment for a resident with known Congestive Heart Failure (CHF), leading to significant health deterioration. The resident, a cognitively intact female with multiple diagnoses including CHF, hypertension, and chronic kidney disease, experienced a 44-pound weight gain over a period of 48 days. Despite the resident's history of CHF exacerbations and recent hospitalizations, the facility did not consistently monitor her weight or report significant weight changes to her physician as required by professional standards of practice. Observations and interviews revealed that the resident was admitted to the facility with a weight of 356 pounds, which increased to 400.4 pounds by mid-January. The facility's staff failed to notify the physician of the resident's significant weight gain, which exceeded the threshold for concern in CHF patients. Additionally, the resident's family reported concerns about her increased edema and shortness of breath to the nursing staff, but these concerns were not adequately addressed or documented. The resident was eventually sent to the hospital after family insistence, where she was diagnosed with acute exacerbation of CHF, acute pulmonary edema, and acute respiratory failure. The facility's policies and procedures for monitoring residents with CHF were not effectively implemented. Interviews with staff, including the Clinical Care Coordinator and Director of Nursing, indicated a lack of awareness and communication regarding the resident's condition and weight changes. The facility's failure to adhere to its own policies and professional standards of practice resulted in the resident's acute re-hospitalization and highlighted significant deficiencies in the care provided to residents with complex medical conditions.
Failure to Monitor and Report Changes in Resident Condition
Penalty
Summary
The facility failed to competently assess and monitor changes in condition and notify the physician of pertinent findings in a timely manner for two residents, resulting in potential and actual harm. Resident #103, a male with a history of hip surgery and other medical conditions, experienced a significant incident on 5/9/24. During a transfer by CNA D, the resident's legs were moved roughly, causing extreme pain. Despite the resident's complaints and the family's concerns, the facility did not promptly assess the resident's condition or notify the physician. The resident's pain was not adequately managed, and he went over 24 hours without pain medication. The resident's condition worsened, and he was eventually sent to the emergency room on 5/10/24, where a dislocated hip was confirmed. The facility's records showed no evidence of a STAT X-ray order on 5/10/24, and there was a delay in obtaining the X-ray results. The resident's family reported the incident as potential caregiver abuse, and the CNA involved was suspended pending investigation. The facility's investigation revealed that staff were not adequately trained on post-operative hip precautions, and the resident's pain management was insufficient. Interviews with staff and family members highlighted a lack of communication and documentation regarding the resident's increased pain and the incident. The facility's failure to assess the resident's condition promptly and notify the physician contributed to the resident's prolonged pain and subsequent hospitalization. The report indicates systemic issues in staff training, communication, and documentation, which led to the deficiency.
Failure to Provide Timely and Appropriate Care for Residents
Penalty
Summary
The facility failed to provide timely and appropriate care for Resident #11, who was admitted with multiple serious health conditions, including acute and chronic respiratory failure and heart failure. On one occasion, the resident experienced shortness of breath and requested to be transferred to the hospital. Despite the resident's request and the nurse checking his vital signs, the facility did not facilitate the transfer, leading the resident to call 911 himself. The resident was eventually admitted to the hospital with acute hypoxic respiratory failure and other complications. There was a lack of documentation from the provider who assessed the resident, which contributed to the delay in care. Resident #121, who had a history of traumatic brain injury and other complex medical conditions, experienced a significant change in condition that was not promptly addressed by the facility. The resident's Durable Power of Attorney (DPOA) reported that the facility failed to notify him of changes in the resident's care and delayed transferring the resident to the hospital despite repeated requests. The resident was eventually transferred with dangerously high blood sugar levels, indicating a failure to monitor and manage the resident's diabetes effectively. Additionally, there was a lack of documentation regarding the resident's significant weight gain and glucose monitoring, which contributed to the resident's deteriorating condition. Resident #15, who was cognitively intact and experiencing constant pain, was prescribed Oxycodone for pain management. However, the facility failed to manage the resident's constipation, a known side effect of opioid use. Despite the resident's complaints of constipation and the absence of bowel movements for several days, the facility did not initiate the bowel protocol or offer the prescribed as-needed constipation relief medications. This oversight resulted in the resident not receiving appropriate care for constipation, as confirmed by the Director of Nursing upon review of the medical records.
Facility Enforces Unofficial Curfew, Restricting Resident Freedom
Penalty
Summary
The facility failed to honor the residents' rights to self-determination by enforcing a curfew that required residents to be inside by 8:00 PM, as indicated by signs posted at the main entrance. This curfew was not communicated as a formal policy, yet it was enforced, restricting residents' freedom to go outside or have visitors beyond the specified hours. The signs also indicated visiting hours from 8:00 AM to 8:00 PM, further limiting residents' ability to interact with family and friends during evening hours. Three residents, all cognitively intact, expressed dissatisfaction with the curfew. One resident, who was receiving hospice care, reported feeling like a child and expressed concern about missing out on events like fireworks due to the curfew. Another resident, who enjoyed spending time outside, expressed a desire to sit on the patio in the evenings but was unable to do so because of the facility's rule. A third resident, who had been in the facility since 2018, reported feeling like a prisoner and mentioned instances where residents were locked out after 8:00 PM with no apparent way to alert staff to be let back in. The Nursing Home Administrator (NHA) was unaware of the residents' perception of a curfew and stated that the facility did not have official rules regarding visiting hours or a curfew for residents. The NHA acknowledged the misunderstanding caused by the posted signs and indicated plans to re-educate staff, residents, and families about the lack of such restrictions. However, the deficiency lies in the lack of communication and the misleading signage that led residents to believe they were subject to a curfew, thus infringing on their rights to self-determination.
Facility Fails to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly address grievances and concerns reported by residents during council meetings, resulting in unresolved issues and decreased quality of life for the residents. Over the past six months, 52 grievances were filed, including issues such as delayed wheelchair repairs, slow call light response times, inappropriate clothing provided to residents, falls due to slippery floors, unauthorized entry into residents' rooms, and inadequate dining arrangements due to staffing shortages. Additionally, residents reported receiving cold food, delayed meal services, and long wait times for specific meal orders. Interviews and record reviews revealed that the facility's grievance handling process was inadequate. The Executive Director in Training (EDIT) acknowledged receiving and logging concern forms but failed to demonstrate effective tracking or auditing of these concerns. A new program, the support and services form, was introduced to address grievances immediately, but it lacked proper documentation of follow-up actions, corrections, or root cause analysis. The program, initiated in the last month, did not resolve ongoing concerns, leaving residents with unmet needs and dissatisfaction.
Unnecessary Antibiotic Administration Due to Negative Urine Culture
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered Cipro, an antibiotic, despite having a negative urine culture for bacterial growth. The resident had undergone a urinalysis, which was reviewed by the physician, and although the results were negative for infection, the physician ordered Cipro to be administered for seven days based on the resident's symptoms of bladder and flank pain and confusion. There was no documentation explaining why the urinalysis was initially required, and the progress notes did not justify the use of antibiotics given the negative culture results. The Infection Control Preventionist, a registered nurse, followed up with the Nurse Practitioner who ordered the Cipro, indicating that the prescription did not meet the criteria for administration according to the McGeer criteria, which the facility used for antibiotic use. Despite this, the Nurse Practitioner justified the antibiotic use based on the resident's pain and urinalysis results. The Infection Control Preventionist reported to the Medical Director that the Nurse Practitioner was issuing antibiotic orders without proper indications for use.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by an observed error rate of 28.57% during a medication administration for one resident. The incident involved a Licensed Practical Nurse (LPN) who crushed several oral medications, including Keppra and Ferrous Sulfate, which were explicitly marked as 'do not crush' in the resident's orders and the facility's resource documents. The medications were then mixed with orange juice and administered to the resident, who displayed signs of discomfort during the process. The resident, identified as R121, had specific physician orders and pharmacy recommendations indicating that Keppra and Ferrous Sulfate should not be crushed. Despite these instructions, the LPN proceeded to crush these medications, citing the resident's preference for not taking medications in their original form. Interviews with other staff members confirmed that the facility had resources available to inform nurses about medications that should not be crushed, and the error was acknowledged by a nurse consultant who verified the orders and the mistake.
Significant Medication Error Due to Improper Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a medication pass task. A Licensed Practical Nurse (LPN) crushed several oral medications, including Keppra and Ferrous Sulfate, which were explicitly marked as 'do not crush' in the resident's physician orders and the facility's medication guidelines. These medications were then mixed with orange juice and administered to the resident, who displayed signs of discomfort during the administration. The resident involved was a male with a complex medical history, including traumatic brain injury, diabetes mellitus, and seizure disorder, among other conditions. The resident's Minimum Data Set (MDS) indicated a severely impaired ability to make daily decisions. Despite the pharmacist's recommendation and clear physician orders not to crush Keppra and Ferrous Sulfate, the LPN proceeded to do so, leading to a significant medication error. Interviews with facility staff confirmed the error and acknowledged the presence of resource documents that should have prevented such an occurrence.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in one of the three medication rooms reviewed, which could lead to decreased medication efficacy and adverse side effects for the residents. During an observation, an LPN reported that an RN had unlocked the south hall medication room, which contained two refrigerators. One refrigerator was designated for resident overstock medications, and the other for vaccines. Upon inspection, the vaccine refrigerator was found to have a temperature of 60 degrees, which is above the recommended range of under 40 degrees. The LPN was unable to locate the temperature log for the refrigerator, indicating a lack of proper monitoring. Further interviews revealed that the Clinical Care Coordinator and the Director of Nursing were also unaware of the location of the temperature logs, with the latter finding an incomplete log with missing entries for several days. The Director of Nursing confirmed that the vaccine refrigerator's temperature was too warm and planned to dispose of the affected vaccines. The Registered Nurse Infection Control Nurse reported that she observed the refrigerator temperatures daily from Monday to Friday and provided a log for the current month, but was unaware of the need to keep records beyond the current month, leading to the deletion of past records.
Failure to Display Current Nurse Staffing Information
Penalty
Summary
The facility failed to display current nurse staffing information in a location accessible to all 135 residents and visitors. Observations on multiple days revealed that the staffing information was posted in a staff-only area, behind doors marked with large stop signs, indicating restricted access. The posted staffing information was outdated, with the last update being from 6/10/24, despite observations occurring on subsequent days. During an interview, HR Staff Y, who had been in the position for about a month and was responsible for posting staffing information, confirmed that the postings were intended for staff review and were unaware that the information needed to be in a public area and reflect the current day's staffing.
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Illustrative
What surveyors actually found near you
We read the 133 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
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Illustrative
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Nursing homes near Dimondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holt Senior Care And Rehab Center | 4.2 mi | ★★★★★ | 11 | 0 |
| Aria Nursing And Rehabilitation | 5.5 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Capital Area | 7.1 mi | ★★★★★ | 5 | 0 |
| Medilodge Of Lansing | 8.2 mi | ★★★★★ | 12 | 0 |
| Regency At Lansing West | 8.7 mi | ★★★★★ | 4 | 0 |
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