Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastwood Nursing Center during CMS and state inspections, most recent first.
Food safety deficiencies were observed in the dietary area when stainless steel bowls used to cover the plate warmer were stored in the hand sink, unlabeled spray bottles containing dishwashing liquid and sanitizer were found in the dish room, and a staff member picked up a bottle of salad dressing from the floor with gloved hands and then wrapped a sandwich without changing gloves or washing hands. A cart rinsing hose with a spray nozzle was also connected to a faucet with an atmospheric vacuum breaker, leaving the system under constant pressure.
Failure to Document Transfer Information Sent to Hospital: The facility failed to document that required transfer information was communicated to the receiving hospital for four residents sent to the ED. The EMR did not show practitioner contact information, resident representative details, advance directive information, care plan goals, discharge summary, or special instructions for ongoing care, and the DON stated the facility does not document what is given to the hospital during transfers.
An unlocked C-wing medication cart was observed unattended while the responsible CMT stepped away to the nourishment room to get juices, leaving the cart out of view behind a closed door. The DON stated medication carts should always be locked when staff walk away, and the facility policy requires all drugs and biologicals to be stored in locked compartments.
Delayed response to resident call lights was identified for multiple residents, with call light statistics showing repeated waits far beyond the expected response time. One resident reported nearly two-hour delays and said the unit lacked enough CNAs, while two other residents described unanswered lights, delayed pain medication, and poor night shift response. The ADON acknowledged the expected response time and stated she had not tracked one resident’s call light response times or reviewed the monthly call statistic report.
Advance directive status was not established, documented, or reviewed for a resident with intact cognition and a stroke history. The resident said he did not recall anyone discussing advance directives, and the EMR had no advance directive, no evidence of admission screening or education, and no care plan entry addressing his preferences. A progress note later cited by the DON was amended after the surveyor requested documentation, and the SW acknowledged the original note did not include advance directive information.
Missed Scheduled Showers: A resident with intact cognition and an ADL care plan requiring staff-assisted bathing reported not receiving showers routinely and said she received only two showers in a month despite being scheduled twice weekly. CNA records showed only two showers documented, with no refusals recorded, while an LPN and the DON confirmed the resident did not refuse care and that documentation may have been incomplete.
Missing hospice order, care plan, and hospice documentation: A resident with Alzheimer's disease and dependence for ADLs was receiving hospice services, but the EMR lacked a physician order authorizing hospice care, a facility care plan addressing hospice status and goals, and hospice nursing notes, assessments, visit records, or other hospice documentation. The DON stated an order was required and that hospice care should be reflected in the resident's care plan and EMR.
Medication Administration Errors Exceeded Allowed Rate: An LPN was observed touching a pill with bare hands, dropping a capsule to the floor without noticing, and then administering the resident’s oral meds and insulin. The LPN held the insulin site for only two seconds instead of the facility’s 6 to 10 seconds, and the omitted pill was identified as the resident’s Flomax, contributing to a 6.67% med error rate.
The facility did not have documented agreements with a water supplier for emergency drinking water and relied on an onsite well that had not been observed to function by maintenance staff, resulting in a failure to ensure subsistence needs for staff and patients during emergencies.
The facility did not provide or document required initial and annual emergency preparedness training for all staff, individuals providing services under arrangement, and volunteers. An interview with the education director confirmed the lack of annual refresher training and absence of documentation, resulting in noncompliance with federal emergency preparedness regulations.
A review of facility records and staff interviews revealed that the dry sprinkler system in the attic was not functioning properly, with the system capped and only six operational heads, resulting in non-compliance with required building construction and sprinkler system standards.
A review of facility records revealed that the dry sprinkler system in the attic had been capped off, leaving the attic without full sprinkler protection as required by NFPA 13. This was confirmed by the Maintenance Director during the survey.
The facility did not ensure that automatic sprinkler system supervisory attachments were properly installed and monitored, as the system was found capped and failed inspection, with supervisory or trouble alarms present on the fire alarm control panel indicating part of the system was shut down.
A deficiency was identified when the facility did not maintain or test its automatic sprinkler system as required, with inspection records showing the attic dry system was capped and only six heads were active. No documentation was available to indicate ongoing repairs or which parts of the system were functional, as confirmed by the Maintenance Director.
The facility did not implement a fire watch or post required signage when the sprinkler system was out of service, and staff including a CNA and the ADON were unaware of the outage, as revealed by inspection and interviews.
The facility did not ensure staff were informed or educated about changes in fire response procedures after a portion of the sprinkler system was found inoperable, with only six active heads in the attic. Both a CNA and the ADON were unaware of the system's status, and the deficiency was confirmed by the Maintenance Director.
A facility failed to implement interventions for a resident with bilateral hand contractures, as the resident was observed without required palm grips or splints on her left hand. Despite the care plan indicating the need for palm grips at all times, observations showed the resident without them, and staff confirmed the oversight. The resident, diagnosed with conditions like Parkinson's disease and dementia, was undergoing therapy to improve hand function.
A resident with blindness and chronic pain expressed loneliness and boredom, stating that interaction alleviated his pain. Despite this, the facility failed to provide necessary behavioral health care or make an outside referral, as confirmed by staff interviews and the Director of Nursing.
Food Safety and Sanitation Deficiencies in Dietary Operations
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. During observation, two large stainless steel bowls were found in the hand sink while the Dietary Manager stated they were normally used to cover the plate warmer and that employees had placed them there while dishing up lunch from the tray line and using plates from the plate warmer. The handwashing sink was therefore being used to store equipment rather than being kept available for employee handwashing, and the bowls were not stored in a clean, dry location protected from splash, dust, or other contamination. Additional observations showed two unlabeled spray bottles on a shelf above the dish drain curtain area in the dish machine room; the Dietary Manager identified them as dishwashing liquid and sanitizer solution. The report also documented a staff member dropping a bottle of salad dressing on the floor, picking it up with gloved hands, placing it back in the cooler, and then immediately wrapping a sandwich without changing gloves or washing hands. In another observation, a cart rinsing hose with a spray nozzle was connected to a faucet with an atmospheric vacuum breaker, leaving the hose and breaker under constant pressure.
Failure to Document Transfer Information Sent to Hospital
Penalty
Summary
The facility failed to provide documentation to the hospital to ensure a safe and effective transition of care for four residents who were transferred to the emergency department. For Resident #3, who was transferred on 2/6/26, there was no documentation in the EMR showing that the hospital received the practitioner’s contact information, resident representative information, advance directive information, comprehensive care plan goals, discharge summary, special instructions for ongoing care, or other information needed for the transfer. During interview, the DON stated that the facility does not document any information given to the hospital when a resident is transferred from the facility. Similar record review findings were identified for Resident #43, Resident #74, and Resident #101, each of whom was sent to the emergency department on the dates noted in the report. Their electronic medical records failed to show that regulatory documentation was communicated to the receiving hospital. The facility policy titled, Transfer and Discharge (including AMA), dated 2/11/25, states that for a transfer to another provider, the facility must provide the receiving provider with the practitioner’s contact information, resident representative information, advance directive information, other information necessary to meet the resident’s needs, special instructions and precautions for ongoing care, and the resident’s comprehensive care plan goals.
Unlocked Medication Cart Observed Unattended
Penalty
Summary
The facility failed to secure medications and maintain the security of one medication cart out of two reviewed for medication storage. On 6/2/2026 at 7:24 AM, surveyors observed the C-wing medication cart unlocked and unattended by a nurse. At 7:28 AM, Certified Medication Technician B, who was responsible for the cart, stated that she did not normally leave her medication cart unlocked and unattended and explained that she had gone to the nourishment room to get a couple of juices; the nourishment room was behind a closed door and the medication cart was not in her view. At 7:46 AM, the DON stated that medication carts should always be locked when staff walk away and should never be left unlocked if not directly in sight. Review of the facility's Medication Storage policy dated 6/24/24 stated that all drugs and biologicals will be stored in locked compartments.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely staff response to resident call lights for five sampled residents and two confidential residents. Review of the facility’s call light response statistics for May 2026 showed repeated delays beyond the target response time, including one resident with 10 call lights answered in 20 to 34 minutes, another with 28 call lights answered in 21 minutes to 1 hour and 33 minutes, another with 13 call lights answered in 20 minutes to 1 hour and 2 minutes, another with 11 call lights answered in 20 to 31 minutes, and another with 9 call lights answered in 21 to 35 minutes. During interview, the ADON stated she believed 10 minutes was the expected response time and acknowledged she had not tracked one resident’s call light response times or reviewed the monthly call statistic report to identify concerns. Resident interview statements described repeated delays in staff response and concerns about staffing. One resident reported frequently waiting nearly two hours for staff to answer the call light and said the unit did not have enough CNAs to meet resident needs. Two confidential residents reported that staff did not answer call lights in a timely manner, including one who said staff were at pizza while help was needed and pain medication was delayed, and another who said a light was shut off after 30 minutes and that night shift was really bad. One resident also reported having raised the concern to the DON, AD, and Social Worker two weeks earlier and had not received a response.
Advance Directive Status Not Established or Documented
Penalty
Summary
The facility failed to determine upon admission whether Resident #18 had an existing advance directive or wished to establish one, failed to provide or document information and assistance regarding advance directives, and failed to periodically review the resident’s advance directive status. Resident #18 was admitted with a diagnosis of cerebrovascular accident (stroke) and had a BIMS score of 15 out of 15, indicating intact cognition. The MDS also identified adequate hearing, clear speech, and the ability to understand and be understood. During interview, Resident #18 stated he had lived in the facility for about two years and could not recall anyone discussing advance directives with him. Review of the EMR found no advance directive on file and no evidence that the facility determined on admission whether the resident had an advance directive, whether he wanted to formulate one, or that he was offered information or assistance. The record also did not show that he declined such information or that his advance directive status was periodically reviewed. The comprehensive care plan likewise did not identify his advance directive status or preferences. The DON later identified a progress note as documentation of an advance directive discussion, but the original note dated 5/22/26 did not mention advance directives, DPOA paperwork, follow-up with family, or assistance with advance directives. The EMR audit trail showed the note was amended on 6/2/26, after the surveyor requested advance directive documentation. The SW stated the discussion had occurred in May 2026, acknowledged the note was amended, and confirmed she had been directed to add information that was not in the original documentation.
Missed Scheduled Showers
Penalty
Summary
The facility failed to ensure Resident #48 received bathing and shower services as scheduled. The resident reported during interview that she had not been receiving showers routinely and stated she had only received two showers in May 2026, despite being scheduled for showers on Tuesdays and Fridays. The resident’s MDS assessment documented intact cognition with a BIMS score of 15 out of 15, no rejection of care, and a need for partial/moderate staff assistance with bathing and showering. The care plan also directed staff to provide shower/bathe assistance with supervision and one staff member. Review of the CNA documentation for May 2026 showed only two showers were recorded for the resident, on 5/12/2026 and 5/29/2026, with no documentation of refusals. An LPN stated the resident was scheduled for showers twice weekly on Tuesdays and Fridays and described the resident as alert, oriented, reliable, and unlikely to fabricate information, adding that the resident rarely refused care and did not refuse staff assistance. The DON stated the CNA documentation may not accurately reflect all showers provided and suggested staff may have failed to document the care, while also confirming that the resident did not refuse care.
Missing hospice order, care plan, and hospice documentation
Penalty
Summary
The facility failed to ensure appropriate coordination and documentation of hospice services for Resident #6, who was admitted with a primary diagnosis of Alzheimer's Disease and was cognitively impaired and dependent on staff for activities of daily living. Review of the electronic medical record on 6/1/26 showed the resident was receiving hospice services, but the record did not contain a physician's order authorizing hospice care. The record also did not include a facility care plan addressing the resident's hospice status, goals of care, interventions, or coordination of hospice services. The EMR further lacked hospice nursing notes, hospice assessments, hospice visit documentation, or other hospice records showing the provision, monitoring, and coordination of hospice services. During interview, the DON stated a physician's order was required for hospice services and that care plan development was expected when a resident began hospice services. The DON also stated the hospice provider developed a care plan that should be scanned into the resident's record and maintained in the EMR. The DON stated the resident was admitted to hospice on May 21, 2026. The facility policy required coordination with hospice staff, a coordinated plan of care, and obtaining hospice plan of care information, physician certification and recertification, and hospice physician and attending physician orders.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure accurate medication administration for Resident #31, resulting in 2 errors out of 30 opportunities and a medication error rate of 6.67%. During medication pass observation, an LPN was seen touching a pill lying on the medication cart with bare hands and placing it back into the medication cup. The LPN was also observed reaching around the medication cart, causing a medication capsule to fall from her hand onto the floor without noticing it had fallen. She then entered the resident’s room and administered oral medications and gave insulin by subcutaneous injection, holding the site for only two seconds. During interview, the LPN stated insulin injection sites should be held for five to ten seconds and acknowledged she had only held the site for two seconds. She also stated she normally does not touch medications with bare hands and confirmed the pill on the floor was likely the resident’s Flomax, which had been omitted during the medication pass. The DON stated medications are not to be touched with bare hands, insulin injections should be held for 6 to 10 seconds per facility policy, and medications are not to be omitted; she stated the nurse should have noticed the dropped pill and replaced the medication.
Deficient Emergency Preparedness for Subsistence Needs
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during an emergency, as required by federal regulations. Specifically, the emergency preparedness plan did not include documentation of an established relationship or emergency contract with a water supplier to provide drinking water in the event of an emergency. Although the plan referenced the intention to secure such an agreement, no evidence was provided to confirm that this had been accomplished by the time of the survey exit. Additionally, the facility's emergency plan cited the use of an onsite well as an alternative water source during emergencies. However, interviews with the Maintenance Director and his assistant revealed that neither had observed the well functioning during their respective tenures of approximately three and sixteen years. This lack of operational verification further demonstrated the facility's failure to ensure reliable access to water for subsistence needs in emergency situations.
Plan Of Correction
1. The facility failed to establish relations and obtain an agreement with a water supplier to provide the facility water in the event of an emergency. 2. Failure to ensure the facility has an agreement with a drinking water supplier could affect all residents, employees, and visitors in the event of an emergency. 3. The maintenance director has obtained an emergency drinking water agreement with Norway Springs to provide the facility with drinking water in the event of an emergency. The maintenance director has been educated on the importance of maintaining drinking water sources/agreements. 4. The Administrator is responsible for ensuring drinking water agreements are established and implemented at the facility and report to the QA committee. 5. The facility failed to maintain an accurate policy for emergency water within the emergency preparedness plan, specifically pertaining to the use of an existing onsite water well resource. 6. Failure to ensure all water emergency water sources are in place and accurate could affect all residents, employees, and visitors in the event of an emergency. 7. The onsite water well is currently not in use and has been removed from the facility emergency preparedness plan. The maintenance director has been educated on the importance of maintaining accurate emergency water resources and policies within the facility. 8. The Administrator is responsible for the implementation of accurate policies and procedures pertaining to emergency water in the event of an emergency and report to the QA committee.
Failure to Provide and Document Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to provide initial and annual emergency preparedness training to all new and existing staff, individuals providing services under arrangement, and volunteers, as required by federal regulations. The deficiency was identified during a record review and interview with the facility education director, who confirmed that annual emergency preparedness refresher training had not been conducted as mandated by 42 CFR 483.73(d)(1)(2). No documentation was available to demonstrate that staff had received the required refresher training on emergency preparedness policies and procedures. The absence of such documentation indicated that the facility did not maintain records of emergency preparedness training for its staff, as required by regulation. Additionally, the facility was unable to demonstrate staff knowledge of emergency procedures, as there was no evidence that training had occurred. This deficiency could potentially affect all occupants in the event of an emergency, as staff may not be adequately prepared to respond to emergency situations.
Plan Of Correction
1. The facility failed to provide annual emergency preparedness refresher training to all facility employees. 2. Failure to provide the annual emergency preparedness refresher training to facility employees could affect all residents, employees, and visitors in the event of an emergency. 3. The education director has educated all employees on the emergency preparedness plan via the Relias education platform. The education director has been educated on the importance of the annual emergency preparedness refresher training. 4. The administrator is responsible for ensuring all employees are educated during the annual emergency refresher training and report to the QA committee.
Non-Compliance with Sprinkler System Requirements in Attic Space
Penalty
Summary
The facility failed to ensure that its building construction type and number of stories complied with the requirements outlined in Table 19.1.6.1, as required unless otherwise permitted by specific exceptions. During a record review and interview, it was found that the dry sprinkler system in the attic space did not pass inspection because the system was capped and only six sprinkler heads were operational. The annual dry sprinkler inspection report confirmed this deficiency, and the Maintenance Director verified that the attic sprinkler system was not functioning properly. This failure is in violation of the requirement that all LTC facilities be fully sprinklered and maintain their systems as mandated by 73 CFR 47075.
Plan Of Correction
1. The facility did not maintain the dry sprinkler system in proper working condition throughout the building. 2. A malfunctioning dry sprinkler system poses a risk to the safety of all residents, staff, and visitors in the event of a fire emergency. 3. Corrective actions have been completed as follows: - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor and replaced 12 feet of main sprinkler piping. - The sprinkler system was flooded and tested, revealing two leaks (located above a resident room and in the boiler room); both have been repaired. - Superiorland Electronics will conduct a trip test to confirm the system is functioning properly. - The Maintenance Director has been educated on the critical importance of maintaining the dry sprinkler system in working order. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is responsible for ongoing monitoring of the dry sprinkler system to ensure it remains operational at all times and will report system status and maintenance updates to the Quality Assurance (QA) Committee.
Attic Sprinkler System Not Installed per NFPA 13
Penalty
Summary
The facility failed to provide a sprinkler system installed in accordance with NFPA 13, as required by federal regulations. During a record review, it was found that the dry sprinkler system throughout the attic space had been capped off, resulting in the attic space lacking complete sprinkler protection. This deficiency was confirmed by the Maintenance Director at the time of the review. The report does not mention any specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
1. The facility failed to maintain the dry sprinkler system in proper working condition throughout the entire building. 2. A non-functioning dry sprinkler system poses a serious risk to the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been implemented as follows: - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics was engaged to install a second air compressor and replace 12 feet of main sprinkler piping. - The system was water-tested, during which two leaks were identified (above a resident room and in the boiler room); both were repaired. - A trip test will be conducted by Superiorland Electronics to verify full functionality of the system. - The Maintenance Director has received training on the importance of routine inspection and upkeep of the dry sprinkler system. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is now responsible for ensuring the sprinkler system remains fully operational and will report on system status and any maintenance issues during regular Quality Assurance (QA) Committee meetings.
Deficiency in Sprinkler System Supervisory Signal Monitoring
Penalty
Summary
The facility failed to ensure that automatic sprinkler system supervisory attachments were properly installed and monitored for integrity in accordance with NFPA 72 requirements. During a record review, it was found that the annual dry sprinkler inspection indicated the system had been capped and failed the inspection. Additionally, review of the fire alarm control panel (FACP) revealed that supervisory and/or trouble alarms were present, indicating that a portion of the sprinkler system had been shut down. These findings were confirmed by the Maintenance Director at the time of discovery. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
1. The facility failed to maintain the automatic sprinkler system's supervisory attachment panel in proper working condition. 2. A malfunctioning supervisory panel compromises the effectiveness of the sprinkler system, potentially placing all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions are underway as follows: - Superiorland Electronics has been contacted and has ordered a new dry pipe valve and a new control valve equipped with a tamper switch. - Once parts are installed, the system will be tested to ensure full functionality. - The Maintenance Director has been educated on the importance of maintaining a properly functioning automatic sprinkler system supervisory panel. 4. The Maintenance Director is responsible for ensuring the panel remains operational and will report system status and maintenance updates to the Quality Assurance (QA) Committee.
Failure to Maintain and Test Sprinkler System per NFPA 25
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review, it was found that the annual dry sprinkler inspection revealed the system did not pass inspection because the dry system in the attic was capped and only six sprinkler heads were active. At the time of the survey, there was no documentation available to show that corrective work was being performed or to specify which parts of the system were operational. This deficiency was confirmed by the Maintenance Director during the record review. No information was provided regarding the specific impact on residents or staff at the time of the deficiency.
Plan Of Correction
1. The facility failed to provide documentation confirming that corrective work on the dry sprinkler system was being completed to ensure proper system function. 2. Inadequate documentation and maintenance of the dry sprinkler system may compromise the safety of residents, staff, and visitors in the event of a fire emergency. 3. Corrective actions have been implemented as follows: - Excel Fire Protection replaced the 3-inch and 4-inch piping in the system. - Superiorland Electronics installed a second air compressor and replaced 12 feet of main sprinkler piping. - The system was flooded and tested; two leaks were identified (above a resident room and in the boiler room) and have been repaired. - A trip test will be conducted to confirm proper system functionality. - Both Excel and Superiorland Electronics have submitted full documentation of all repair and maintenance work to the facility. - The Maintenance Director has received training on the importance of maintaining a functional dry sprinkler system and retaining documentation of all related work. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is responsible for ensuring the sprinkler system remains operational, for maintaining complete documentation of all service and repairs, and for reporting system status to the Quality Assurance (QA) Committee.
Failure to Provide Fire Watch and Staff Notification During Sprinkler System Outage
Penalty
Summary
The facility failed to ensure that when the sprinkler system was out of service for more than 10 hours in a 24-hour period, the affected areas were either evacuated or an approved fire watch was provided, as required by relevant fire safety codes. Record review showed that the annual dry sprinkler inspection revealed the system failed due to the attic dry system being capped and only six heads active. Despite this, the facility was not conducting fire watch in the unprotected areas, and required 'out of service' signage was not posted throughout the building, contrary to the facility's fire watch policy. Additionally, staff interviews indicated a lack of awareness regarding the non-operational status of the sprinkler system. A CNA stated she was not informed about the sprinkler system being out of service and expressed that this information was important for responding to a fire. Similarly, the ADON was unaware that a portion of the sprinkler system was not working. These findings demonstrate that both procedural and communication lapses contributed to the deficiency.
Plan Of Correction
1. The facility failed to follow its fire watch policy and procedures when the dry sprinkler system was not functioning properly. Per policy, the facility must either evacuate or initiate a fire watch if the system is non-operational for 10 or more hours within a 24-hour period. 2. Failure to implement fire watch procedures as required could have endangered the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been taken as follows: - The facility promptly initiated fire watch procedures once the system malfunction was identified, including posting Out of Service signage and conducting regular monitoring rounds. - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor, replaced 12 feet of main sprinkler piping, and conducted a system water test. Two leaks (above a resident room and in the boiler room) were identified and repaired. - A trip test will be performed to confirm the full functionality of the system. - Documentation of all system repairs has been received from Excel and Superiorland. - All staff have been re-educated on the fire watch policy, including the requirement for timely implementation when the sprinkler system is out of service. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Administrator is responsible for ensuring fire watch policies and procedures are implemented without delay during any future system outage and for reporting compliance status to the Quality Assurance (QA) Committee.
Failure to Maintain and Communicate Emergency Evacuation Plan Amid Inoperable Sprinkler System
Penalty
Summary
The facility failed to maintain a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During a record review, it was found that the annual dry sprinkler inspection revealed the attic dry system was capped, leaving only six sprinkler heads active, and the system failed inspection. At the time of the survey, both a CNA and the ADON were unaware that a portion of the sprinkler system was not operational and not functioning as designed and installed. No education or instruction was provided to staff regarding how their response to a fire should change given the inoperable sprinkler system. This finding was confirmed by the Maintenance Director during the survey. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility failed to adequately communicate to staff that the dry sprinkler system was not functioning properly throughout the building and did not clearly define emergency evacuation procedures in the event of system failure. 2. Lack of communication regarding system malfunction and absence of defined evacuation procedures could place all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions taken include: - All facility staff were immediately notified that the dry sprinkler system was not functioning and responded appropriately by initiating fire watch procedures. - The Fire Watch policy has been revised to include specific evacuation protocols. The updated policy now requires immediate evacuation of the affected fire/smoke compartment upon any detection of smoke or fire. - The Maintenance Director was educated on the importance of prompt and clear communication to all staff regarding emergency system failures. - All staff have been re-educated on the updated Fire Watch policy and the emergency evacuation procedures. 4. The Maintenance Director is responsible for timely communication of any emergency system failures to facility staff and will report compliance and communication actions to the Quality Assurance (QA) Committee.
Failure to Implement ROM Interventions for Resident with Contractures
Penalty
Summary
The facility failed to implement necessary interventions to address range of motion (ROM) for a resident with limited ROM, specifically for a resident with bilateral hand contractures. The resident, who was diagnosed with conditions including Lewy bodies, Parkinson's disease, dementia, and muscle weakness, was observed without the required palm grips or splints on her left hand, which was visibly contracted. The resident's care plan indicated that palm grips should be worn on both hands at all times, except during hygiene activities, to prevent further contracture and maintain ROM. Observations and interviews revealed that the resident was not consistently wearing the prescribed palm grips, as noted during multiple instances when the resident was seen without them. The Occupational Therapist (OT) and Registered Nurse (RN) involved in the resident's care confirmed the absence of the palm grips and acknowledged the resident's ongoing therapy services aimed at improving hand function. The Director of Nursing (DON) also confirmed that the resident should have been wearing the palm grips, indicating a lapse in adherence to the care plan designed to manage the resident's contractures effectively.
Failure to Provide Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #59, who was blind and experiencing chronic pain, anxiety, and depression. Despite having intact cognition, the resident expressed feelings of loneliness and boredom, stating that interaction with others alleviated his pain. Interviews with staff, including CNAs and a social worker, confirmed that the resident was often isolated in his room, did not participate in activities, and had not received behavioral care support in the past quarter. The social worker acknowledged that a request for an outside behavioral care consult was made but not acted upon. The facility's policies on social services and behavioral health services emphasize the importance of providing or obtaining necessary services to maintain residents' mental and psychosocial well-being. However, the facility did not adhere to these policies, as evidenced by the lack of behavioral health support and failure to make an outside referral for the resident. The Director of Nursing confirmed that the resident did not receive the needed behavioral support, which was crucial given the resident's expressed loneliness and boredom.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Marquette County Medical Care Facility | 4.8 mi | ★★★★★ | 0 | 0 |
| Mission Point Nsg & Phy Rehab Ctr Of Ishpeming | 6.1 mi | — | 0 | 0 |
| Norlite Nursing Center | 9.4 mi | ★★★★★ | 23 | 0 |
| Dj Jacobetti Home For Veterans | 9.6 mi | ★★★★★ | 7 | 0 |
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