Below average — CMS composite of the measures below.
The next survey window likely opens 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 Ely Manor during CMS and state inspections, most recent first.
Food service safety practices were not maintained in multiple kitchen and pantry areas. Surveyors found expired or undated ready-to-eat foods, wet-stacked clean pans, crumb debris in utensil drawers, food boxes stored on the floor, and an ice chest for hydration pass with water pooled under the ice. They also observed a leaking steam table, a leaking hot water line under the dish machine, and a dish machine that did not reach required hot water sanitizing temperatures, with multiple log entries below the minimum.
Failure to ensure the Medical Director coordinated MRR follow-up led to missed and delayed provider review of pharmacist recommendations for two residents. One resident with dementia and anxiety had Seroquel-related recommendations for labs and GDR review that were not clearly dated or timely signed, while another resident with Alzheimer's disease and major depressive disorder had an unresponded MRR for falls, hypertriglyceridemia, possible orthostatic hypotension, and later a delayed review for a B-12 lab recommendation. The DON and NHA reported the facility had been missing MRRs for several months and the Medical Director had not been involved in the process.
The facility failed to track staff illnesses and did not consistently follow IPCP measures for EBP and TBP. A resident with a catheter had the bag on the floor in a dirty room, staff provided care without required gloves and gowns, and an activity aide and an LPN entered a contact/droplet room without PPE. Several residents also had oxygen concentrators covered with dust, lint, debris, and food crumbs.
Incomplete resident-specific care planning across multiple assessed needs. The facility did not fully reflect assessed needs in care plans for residents with COPD/hospice inhaler use, self-administration of meds, bipolar disorder with routine antipsychotic use, fall risk with ordered safety interventions, and smoking-related safety concerns. Records and staff interviews showed missing or delayed care plan interventions, and one resident’s ordered fall precautions were not in place when observed.
Self-Administration of Medications Not Properly Assessed or Ordered: The facility failed to ensure that residents were clinically assessed and properly ordered to self-administer medications. One resident with COPD and chronic respiratory failure was using an inhaler at bedside before the self-administration assessment was completed, and another resident with COPD, chronic respiratory failure, and emphysema had saline nasal spray left at the bedside without an order authorizing self-administration or a resident-specific care plan. A third resident had a self-administration evaluation showing ability to self-administer, but no corresponding order was written.
Failure to protect residents from physical abuse occurred when one resident struck another resident in the face with a book and then slapped the resident across the face after yelling and attempting to move the resident's walker. The assaulted resident had Alzheimer’s disease and cognitive communication disease, while the aggressive resident had Alzheimer’s disease, major depressive disorder, and a documented history of physical and verbal aggression. Staff witnessed the altercation in the day room, and the facility administrator stated she was unsure whether the event was abuse because intent could not be determined.
Failure to report resident-to-resident physical abuse: Two residents were involved in a physical altercation in which one resident struck the other in the face with a book and slapped her. Staff reported the incident to the NHA, and one resident had a history of aggressive behavior toward other residents, but the NHA confirmed the State Agency was not notified as required by the facility abuse policy and section 1150B reporting requirements.
Incomplete Investigation of Resident-to-Resident Abuse: Staff reported an altercation between two residents in which one resident struck the other with a book and slapped her across the face. Although the DON/administrator documented that assessments, interviews, notifications, police contact, care plan review, and a mental health visit were completed or planned, the investigation file lacked supporting evidence, witness statements, verification of police notification, and key clinical record details. The written report also conflicted with the aide’s statement about how the assault occurred.
Failure to Refer Resident With Mental Illness for Level II PASARR Evaluation: A resident admitted with bipolar disorder and severe cognitive impairment triggered PASARR criteria for mental illness, including current MH dx, prior MH tx, recent antipsychotic use, and evidence of disturbed thought, conduct, emotions, or judgment. The SSD stated the resident should have been referred for a Level II PASARR screening at admission, but the referral was not made.
A resident with Alzheimer’s disease and major depressive disorder had a care plan for physical and verbal aggression, but it was not reviewed or revised after repeated resident-to-resident altercations. Staff and family described multiple aggressive episodes in which the resident yelled, grabbed another resident’s walker, hit one resident with a book, and slapped the resident across the face, while the DON and SSD confirmed no new interventions were added.
A resident with depression and smoking noncompliance was found to have kept smoking materials while unsupervised, with staff and police involved after smoke was detected in his room while oxygen was in use. Another resident with severe cognitive impairment and fall risk was observed being pushed in a wheelchair without footrests, with the resident’s legs unsupported during transport.
Failure to provide humidification for oxygen therapy: A resident with COPD, chronic respiratory failure with hypoxia, and emphysema received O2 at 2 L/min via NC but did not have a bubbler/humidifier. During observation and interview, the resident stated the oxygen caused dryness, sores, and scabs in her nose, and that a bubbler had helped at home. She reported telling nurses she wanted one, but it had not been provided; the DON observed no bubbler on the oxygen concentrator and said she was unaware of the resident’s need and request.
Wrong Methadone Dose Administered for Pain: A resident with stroke-related deficits, dementia, aphasia, depression, and hospice care received methadone at 2.5 mg instead of the ordered 5 mg dose for pain. The wrong-dose error occurred repeatedly across multiple medication passes and involved several nurses, with staff later noting the order change had not been questioned.
Failure to provide required social services, maintain guardianship records, and care plan psychotropic use: A resident with depression, paranoia, and rejection of care had overdue social service assessments and no documented social services interactions for weeks, despite reporting anxiety, paranoia, and suicidal statements. Another resident with dementia had expired guardianship paperwork, and a third resident with bipolar disorder had routine antipsychotic use noted on the MDS/CAA but no care plan focus, goals, or interventions for mood or behavior concerns.
Delayed review of pharmacist medication recommendations. The facility did not ensure timely physician response to monthly MRRs for two residents. One resident with dementia and anxiety had Seroquel-related recommendations for lipid monitoring and possible GDR, but the review was not timely or fully documented. Another resident with Alzheimer’s disease and MDD had MRRs noting falls, severe hypertriglyceridemia, possible orthostatic hypotension, and a missing B-12 level while receiving Seroquel and Glucophage, but provider response was delayed or absent. The DON and NHA stated the facility had missed multiple months of MRRs and was still catching up.
Food was served at an unpalatable texture for two residents and others in a confidential meeting. A resident with COPD, chronic respiratory failure with hypoxia, and emphysema said cooked vegetables were too soft, and another cognitively intact resident with cancer said the vegetables were runny and like mush. Three residents also reported that vegetables were consistently overcooked and mushy, with moisture draining onto other foods. During meal observation, broccoli on a test tray was found to be overly tender and mushy.
Expired guardianship paperwork was found in a resident's EMR. The resident had vascular dementia and cognitive communication deficit, and the SSD confirmed the legal document could not verify an active guardian. The SSD also could not say how often guardianship records were reviewed or whether the resident still had an active legal guardian.
Failure to Follow Antibiotic Stewardship Protocols: A resident with Alzheimer's disease and major depressive disorder had an aggressive episode, prompting staff to suspect a UTI based on history and an abnormal urine dip. The provider started Bactrim before urinalysis results were available, even though the resident had no other McGeer criteria symptoms and no risk/benefit statement was written; the antibiotic was later stopped when the resident was found not to have a UTI.
A resident with depression was found to have repeated noncompliance with the facility’s non-smoking policy, including keeping smoking paraphernalia in his room and smoking in his room despite staff expectations that his lighter and cigarettes be stored in a locked med room. Staff observed smoke and a smokey haze in his room while his O2 concentrator was running, and a deputy later confiscated a working lighter from the resident’s possession. Leave of absence records did not show staff signatures confirming return of the resident’s smoking materials after outside smoking trips.
A resident with DM, HTN, obstructive lung disease, and depression was transferred to the hospital for chest pain, SOB, abnormal labs, tachycardia, and increased respirations. The facility sent paperwork with EMS, including a face sheet, med list, bed hold policy, and transfer form, but did not provide the resident or his representative with written notification explaining the reason for the transfer or the related appeal information.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A resident with severe cognitive impairment and multiple chronic conditions did not receive showers or baths as required by their care plan and facility policy. Documentation showed only sporadic bathing over several months, with staff confirming gaps in care and a family member reporting infrequent hygiene assistance, resulting in dissatisfaction with care.
A resident with severe dementia and a known elopement risk was observed wandering, removing his wander guard, and repeatedly trying doors and other residents’ rooms. Staff lost track of him during the evening, and he exited the building unnoticed until an off-duty RN and bystanders found him about 0.3 miles away after he had been seen walking in the road and had sustained a skin tear.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility’s obligation to follow care plans and respect resident choices.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with cognitive impairment and a history of falls sustained a serious injury when an exposed metal bracket, intended for a footboard but left uncovered at the end of the bed, impaled her buttock. Staff confirmed that nine beds had similar exposed brackets without footboards, and maintenance records showed no inspections or repairs had been performed for these hazards.
The facility did not maintain an effective QAPI program, with missed meetings and lack of required committee members, resulting in failure to identify and address deficiencies in resident care, safety, infection control, activity provision, and abuse prevention. Key data was not collected or analyzed, and no steps were taken to address known issues such as staff communication failures related to abuse.
A resident with multiple chronic conditions and mild cognitive impairment was left on the toilet and denied assistance with hygiene and clothing changes by a CNA, who responded angrily and refused to help. The incident caused the resident emotional distress and was corroborated by staff interviews and facility records.
A resident with moderate cognitive impairment and a history of falls, who was wheelchair-bound, fell from bed and was impaled by a metal bed frame, resulting in significant injuries including a deep laceration, fracture, and blood loss. The facility's investigation report to the State Agency omitted key details about the impalement and blood loss, resulting in inaccurate reporting of the incident.
A resident with a history of surgery, dysphagia, and risk for malnutrition experienced a 12% unplanned weight loss over 11 days. Despite care plan requirements and family concerns, staff did not notify the RD or physician of the significant weight loss, and there was no documentation of further evaluation or intervention.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, resulting in a deficiency related to confidentiality and record-keeping requirements.
A resident recovering from open heart surgery with a surgical wound was not provided proper Enhanced Barrier Precautions during direct care, as a CNA assisted with toileting while wearing only gloves and not a gown, despite clear signage and orders requiring full PPE. Staff interviews confirmed the expectation for PPE use, but the care plan lacked specific EBP focus and the CNA was unaware of the resident's precaution status.
The facility failed to respond to call lights promptly, affecting two residents' dignity and quality of life. One resident, with depression and diabetes, reported long wait times, especially during meals. Another resident, with a urinary tract infection and weakness, experienced distress due to delayed responses, leading to incontinence. Staff and Resident Council Minutes confirmed ongoing issues with call light response times.
The facility did not adequately address resident council concerns about lengthy call light wait times, as documented in multiple meetings. Staff interviews confirmed resident complaints, and the Nursing Home Administrator admitted that formal grievance forms were not completed for council-wide issues, leading to ongoing dissatisfaction.
A resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom, resulting in a skin tear and knee pain. The LPN on duty assessed the resident and notified the DON and on-call provider but did not contact the emergency contact due to the early hour. The responsibility was passed to the next shift, but the RN did not make the call, believing all notifications were complete. The facility's policy required immediate notification of significant health status changes.
The facility failed to protect residents from abuse, with incidents involving staff-to-resident and resident-to-resident interactions. A CNA verbally abused a resident with cognitive impairments, while two residents with mental health issues engaged in physical altercations. Lack of supervision and staffing challenges contributed to these incidents.
The facility failed to implement its abuse policy when a resident with Alzheimer's and other conditions made physical contact with another resident with intellectual disabilities and mental health disorders. The incident was not reported to management until two days later, despite policy requirements for immediate reporting, leading to potential unreported abuse incidents.
A facility failed to implement a comprehensive care plan for a resident with multiple health issues, including Alzheimer's and a history of falls. Despite the care plan specifying the use of a concave mattress and fall mat to prevent falls, observations showed these interventions were not in place. Staff interviews confirmed the care plan's requirements, but the Director of Nursing noted that fall mats were being removed and the care plan should have been updated.
A facility failed to follow physician orders to obtain a urine sample for a resident with a history of UTIs, leading to a potential delay in treatment. The resident, experiencing hallucinations, had an order for a urinalysis with culture and sensitivity, which was not completed as indicated in the MAR. Interviews confirmed the oversight, and the lab results were not found in the medical record.
Two residents with significant health conditions did not consistently receive scheduled showers or bathing assistance, as required by their care plans. Documentation was lacking for missed showers, and staff interviews revealed inconsistencies in handling and recording refusals, leading to unmet personal hygiene needs.
The facility failed to provide consistent, meaningful activities for two residents with intellectual disabilities and mood disorders, leading to potential negative impacts on their well-being. Observations and interviews revealed insufficient activity staff and inadequate supervision in the memory care unit, resulting in limited engagement and behavioral issues among residents.
A resident with mobility issues fell during a transfer due to inadequate supervision and failure to follow the care plan, which required a two-person assist. The CNA involved did not consult the care plan and attempted the transfer alone, resulting in the resident experiencing pain in her left arm. Subsequent imaging showed no acute fracture but revealed severe osteoarthrosis.
Two residents in a LTC facility experienced emotional distress and frustration due to being placed in a locked memory care unit without prior notification. Both residents, who were cognitively intact, reported dissatisfaction with the noise level and restrictions on their freedom, leading to increased anxiety and a loss of independence. Staff interviews revealed that the residents were not adequately informed about their placement, contrary to the facility's policy on resident rights.
The facility failed to develop comprehensive care plans for two residents, leading to inconsistent care. A resident with Alzheimer's disease and a pressure ulcer lacked a care plan for heel protectors, resulting in inconsistent use. Another resident with severe cognitive impairment and a urinary catheter had no care plan for catheter management, leading to discomfort. These deficiencies were identified through observations and interviews, revealing inadequate care planning and communication.
A resident's care plan was not updated after the removal of a feeding tube, which had been discontinued over a month prior. Despite the resident's condition change, the care plan still included outdated information about tube feeding. Staff interviews confirmed the tube's removal, and the MDS Coordinator acknowledged the oversight in updating the care plan.
A resident with hand contractures did not receive appropriate interventions to prevent worsening of their condition. Despite recommendations for bilateral handrolls and passive range of motion exercises, these were not included in the care plan or EHR. Observations showed the resident without handrolls, and interviews revealed staff were unaware of the need for these devices, indicating a communication lapse.
A facility failed to provide a mechanically altered diet as ordered for a resident with dysphagia, resulting in the potential for aspiration and choking. The resident, who had a history of stroke, was observed eating non-pureed meals in her room without supervision, despite orders requiring pureed foods when eating alone. Staff interviews confirmed the dietary needs and the risk of airway compromise, but the nursing staff did not ensure the dietary department was informed to provide the correct meal consistency.
The facility was found deficient in maintaining cleanliness and proper storage. The dry storage room had improper drainage from the ice machine and cooler condensers, causing water issues. In the central supply room, items were stored on raw wood shelving and the floor, which were not cleanable surfaces. Environmental Services acknowledged the need for reorganization.
A resident with a femur fracture did not receive prescribed tramadol for pain management on the first two days after admission, leading to increased pain. The LPN responsible cited workload issues for not entering medication orders, and the pharmacy confirmed no urgent request was made for delivery. The medication was administered on the third day.
Food Storage, Sanitation, and Equipment Temperature Deficiencies
Penalty
Summary
The facility failed to maintain food service safety practices in multiple areas of the kitchen and resident pantry areas. During observation, surveyors found an open container of sour cream in the walk-in cooler with a best-by date of 8/25/25, an open box of nutritional juices and Mighty Shakes in the three-door True cooler with cartons intermingled and no clear date showing when the box was pulled from the freezer, and two open containers of Vanilla Med Pass 2.0 in the Memory Care Unit pantry refrigerator with no discard date marked. A carton of milk in the A-side pantry also had a best-by date of 9/14/25. The Certified Dietary Manager stated that the nutritional juice products were thought to be good for 30 days, but the manufacturer directions indicated they were only good for 14 days from thaw, and the Med Pass product was required to be consumed within 4 days under refrigeration. Surveyors also observed food-contact and equipment sanitation concerns. Clean pots and pans were stored on an open wire rack, and two 1/2 pans were found stacked and stored wet; later, two 1/4 pans and one 1/2 pan were again observed stacked and stored wet. The clean utensil drawers contained mechanical scoops and serving spoons with crumb debris in the drawers. In the dry storage room, boxes of food items were stored on the floor near storage racks, and the CDM stated the delivery had arrived on Friday and had not been put away over the weekend. Additional observations identified equipment and plumbing problems affecting kitchen operations. The steam table had a container catching water from a leak, and the CDM stated one well had a small pinhole and had been leaking since she started a couple months earlier. The hot water line under the dish machine was leaking a steady stream onto the floor and into a nearby floor drain. The dish machine did not reach the required minimum hot water sanitizing rinse temperatures during observation, and review of the September 2025 log showed 41 logged sanitizing rinse temperatures below the minimum requirement of 180F. In the MCU pantry, an ice chest used for hydration pass contained roughly an inch of water with ice floating on top and no way to self-drain, while the CDM stated kitchen staff were responsible for filling and cleaning the coolers.
Failure to Ensure Timely Medical Review of Medication Regimen Recommendations
Penalty
Summary
The facility failed to ensure the Medical Director fulfilled responsibility for implementing medication regimen review (MRR) policies and coordinating medical care between the facility and the consulting pharmacist/pharmacy for two residents. Resident #3 had diagnoses including dementia and anxiety disorder. A June 2025 MRR noted that the resident was receiving Seroquel and recommended a fasting lipid panel, with the physician response later documented as agreeing to repeat labs; however, the MD signature was dated 9/17/25. A July 2025 MRR for the same resident recommended a gradual dose reduction of Seroquel or documentation of why it was clinically contraindicated, and the response was documented as disagreeing with the note that care collaboration with Psych made GDR contraindicated, but the review was signed by the DON and had no date showing when the MD reviewed it by phone. Resident #51 had diagnoses including Alzheimer's disease and major depressive disorder. A May 2025 MRR noted new onset or worsening falls, severe hypertriglyceridemia, continued delusions, and possible orthostatic hypotension while the resident was receiving Seroquel 75 mg in the morning, 50 mg at noon, and 75 mg in the evening. The recommendation was to evaluate the current Seroquel dose, but the provider did not respond or sign the form. An August 2025 MRR noted the resident received Glucophage and did not have a serum B-12 level in the record; the physician response was documented as agreeing and ordering the lab, with MD UU signing on 9/17/25. During interview, the DON reported the facility had not been receiving MRRs in August 2025 because they were being sent to the previous DON, and that the facility was unaware that reviews had been missed for several months. The DON also stated she could not verify when Resident #3's July 2025 recommendation was reviewed and confirmed that Resident #51's May 2025 MRR had no provider verification. The NHA stated the facility discovered in August 2025 that MRRs had not been reviewed and confirmed that the Medical Director had not been involved in completing the medication reviews and had missed that the facility had not been completing MRRs for all residents for several months.
Infection Control Failures With PPE, Catheter Care, and Dirty Oxygen Equipment
Penalty
Summary
The facility failed to establish and maintain a system for surveillance of employee infections and to effectively implement infection control measures related to Enhanced Barrier Precautions, Transmission-Based Precautions, catheter care, and cleanliness of resident equipment. The Director of Nursing reported she was responsible for the Infection Preventionist role, while the Assistant DON was being trained to take over. She stated the facility had a place in the electronic medical record system to track staff illnesses, but only four staff had been entered, with the most recent entry from May 2025. She also reported a COVID-19 outbreak in July 2025 with only a few staff affected, but those cases were not entered into the tracking system, and there was no current updated list of staff illnesses with start dates and signs or symptoms to support surveillance. For one resident with a history of traumatic brain injury and neuromuscular dysfunction of the bladder, orders included Enhanced Barrier Precautions. The resident’s catheter bag was observed sitting directly on the floor of the room, surrounded by pieces of food, and the floor was sticky and soiled. On another observation, two CNAs were assisting the resident with morning care, and one CNA brushed the resident’s hair and helped put on socks without gloves or a gown. The resident’s room also had a catheter bag on the floor during the observation, and the condition of the room and equipment was documented as part of the infection control findings. For a resident with chronic kidney disease and legal blindness, orders included contact and droplet precautions. An activity aide entered the room to assist with the television without donning gloves and a gown and did not sanitize hands after leaving. Later, an LPN entered the room without PPE and assisted the resident by moving the wheelchair and handling the TV remote. The resident’s door had a sign indicating contact and droplet precautions with required PPE, and PPE was available outside the room. The care plan did not include the contact and droplet precautions, and the DON stated a care plan would be developed after respiratory panel results were received. Additional infection control observations included residents with oxygen equipment that was visibly dirty. One resident with COPD, chronic respiratory failure with hypoxia, and emphysema had an oxygen concentrator covered with dust, lint, and debris on multiple observations. Another resident with stroke had an oxygen concentrator with buildup of dust, lint, and food crumbs. A third resident with cancer and oxygen use had a concentrator with dust, lint, and debris, and no bubbler or humidifier was present. These findings were documented during the survey as part of the deficient infection prevention and control practices.
Incomplete resident-specific care planning across multiple assessed needs
Penalty
Summary
The facility failed to develop and/or implement comprehensive, resident-specific care plans for five residents reviewed for care planning. The deficiencies involved unmet needs related to medication management, psychotropic medication use, fall prevention, and smoking safety. Survey findings were based on observation, interview, and record review and showed that the residents’ care plans did not consistently reflect their assessed needs, physician orders, or documented behaviors. For one resident with COPD, chronic respiratory failure with hypoxia, and hospice services, the record showed an order allowing the resident to keep an inhaler at bedside per hospice. The resident preferred to keep the inhaler within reach, but the care plan was not implemented until 7 days after the physician’s order was written and after the recertification survey had already started. For another resident who was cognitively intact, independent with eating and dressing, and assessed as able to self-administer medications, the care plan did not include a resident-specific treatment plan for self-administration of medications even though the facility policy stated that self-administration should be reflected in the care plan with any special considerations. A third resident with stroke, dementia, and bipolar disorder had severe cognitive impairment and was receiving routine antipsychotic medication via G-tube. The psychotropic drug use CAA documented agitation, stripping clothes, and pulling at the G-tube, and stated the resident was referred for psych services and medication adjustment, but the care plan contained no focus, goal, or interventions related to bipolar disorder, mood or behavior concerns, or routine antipsychotic use. A fourth resident with dementia, anxiety, depression, tremors, and severe cognitive impairment had a fall history and a fall care plan that included nonskid tape in front of the bed and the bed against the wall, but observation showed those interventions were not in place. The DON acknowledged the missing interventions and stated they would be fixed. For the fifth resident, who had depression and chronic respiratory failure with hypoxia, the MDS did not assess depression-related feelings or suicidal thoughts because the resident refused the BIMS and short-term memory was not assessed. The care plan did not address safety issues related to smoking, hiding smoking paraphernalia, or suspected smoking in the room while unsupervised. The resident reported having had a lighter and cigarettes in the room until they were confiscated by police, and staff reported a smoky room with the smell of cigarette smoke and suspected smoking in the room. The NHA confirmed the facility had not developed a care plan to address the resident’s smoking preference, noncompliance with the smoking policy, or safety needs related to the suspected in-room smoking incident.
Self-Administration of Medications Not Properly Assessed or Ordered
Penalty
Summary
The facility failed to ensure that residents were assessed to determine whether self-administration of medications was clinically appropriate and failed to ensure orders were written for residents who were allowed to self-administer medications. For R43, who had diagnoses of COPD and chronic respiratory failure with hypoxia, the record showed an order allowing the resident to keep an inhaler at bedside per hospice as of 9/16/25, but the Self-Administration of Medication Assessment was not completed until 9/23/25. The care plan also showed the preference to keep the inhaler within reach was not implemented until 9/23/25. During interview on 9/24/25, R43 stated the inhaler had stayed at the bedside since it was ordered and that the resident used it every day; the resident also stated a nurse had taken it to clean it that morning and had not returned it. For R69, who was independent with ADLs and had diagnoses including COPD, chronic respiratory failure with hypoxia, and emphysema, the record showed an order for saline nasal spray as needed for dry nose, but there was no order authorizing self-administration of any medication and no resident-specific care plan for self-administration. Observation showed a bottle of saline nasal spray with the resident's name on the bedside table on multiple occasions, and R69 stated staff left it there for use because the nose became dry from oxygen use. On 9/24/25, R69 stated the nurse had taken the spray away the day before. For R31, the record showed a Self-Administration of Medication Evaluation indicating the resident was able to self-administer medications, but the order summary did not contain an order authorizing self-administration, and there was no resident-specific treatment plan for self-administering medications.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when one resident struck another resident in the face with a book and then slapped the resident across the face. Resident #49 had diagnoses including Alzheimer's disease and cognitive communication disease, and Resident #51 had diagnoses including Alzheimer's disease and major depressive disorder. The incident occurred in the day room, where staff later observed the two residents in close proximity with Resident #49's walker between them, and Resident #51 was yelling at Resident #49 before the physical contact occurred. According to staff interviews, an activity aide saw Resident #51 trying to move Resident #49's walker, screaming at Resident #49, hitting Resident #49 in the face with a book, and then slapping Resident #49 across the face with the other hand. The activity aide stated Resident #49 grabbed Resident #51's arm in an attempt to block another hit, and Resident #49 fell back in the chair when slapped. Another nurse reported hearing yelling and seeing the activity aide between the residents when he entered the day room, but he did not witness the assault because it had already been broken up. Resident #51's care plan identified a history and potential for physical and verbal aggression, including hitting, kicking, biting, slapping, yelling, screaming, and abusive language related to dementia, delusional thinking, depression, and anxiety. The facility's administrator stated she was aware of the altercation but was unsure whether it was considered abuse because the facility could not determine the residents' intent. The facility abuse policy defined physical abuse as including hitting and slapping.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime under section 1150B of the Act for two residents involved in a physical altercation. Resident #49 was struck in the face with a book by Resident #51 and was also slapped across the face during the incident. Staff interviews confirmed that the altercation occurred in the day room, that the residents were separated by staff, and that the incident was reported immediately to the Nursing Home Administrator, who was the facility’s designated abuse coordinator. Resident #51 had a history of aggressive behavior toward other residents and had been involved in multiple physical altercations at the facility. The Nursing Home Administrator acknowledged awareness of the incident and confirmed that the facility did not report it to the State Agency, despite the facility’s abuse policy requiring immediate reporting of allegations or suspicions of abuse and reporting to State or Federal agencies within the required timeframes. The record review and interviews showed that the allegation of physical abuse was not thoroughly investigated and that the required external reporting did not occur.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents and did not document a complete abuse investigation. One resident was reported to have been struck in the face with a book and then slapped across the face by the other resident during an altercation in the common day room. Staff interviews described that the residents were arguing over a walker before the physical contact occurred, and staff intervened to separate them. The resident who initiated the altercation was described by staff as having a history of aggressive behavior and multiple prior physical altercations with other residents. The investigation documentation was incomplete and inconsistent with staff statements. The administrator initially stated she was still working on the investigation and could only provide a one-page list of staff working during the incident. When the investigation report was later uploaded, it stated that assessments were completed, responsible parties, guardians, the administrator, the DON, the provider, and police were informed, staff and resident interviews were completed, care plans were reviewed and updated as needed, and a mental health provider visit was planned. However, the report did not include evidence of those actions, such as assessments, witness statements, verification that police were contacted, documentation of care plan review or updates, or verification of the planned mental health visit. The report also contained discrepancies and lacked key clinical details. The written account of the aide’s interview did not match her verbal statement that the resident struck the other resident in the face with a book; instead, the report stated the resident hit the other resident in the arm with a magazine. The investigation did not include the date and time the incident was reported to responsible parties, provider, or police, nor did it include summary information from the residents’ clinical records, such as relevant RAI, care plan, nursing, social services, lab, physician, or other discipline notes. The report concluded that no intent for abuse could be indicated because both residents had low BIMS scores and neither could recall the incident, but the investigation remained incomplete and did not fully document the event.
Failure to Refer Resident With Mental Illness for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that Resident #4 was referred for a comprehensive Level II PASARR evaluation after the resident triggered PASARR screening criteria for mental illness. Resident #4 was admitted with a diagnosis of bipolar disorder, and the MDS assessment dated 7/31/25 showed a BIMS score of 0/15, indicating severe cognitive impairment. The PASARR Level I screening form dated 7/22/25 documented that the resident had a current diagnosis of mental illness, had received treatment for mental illness, routinely received one or more prescribed antipsychotic medications in the last 14 days, and had presenting evidence of mental illness including significant disturbances in thought, conduct, emotions, or judgment. During an interview on 09/24/2025 at 12:02 PM, the Social Services Director stated that Resident #4 triggered the need for a Level II PASARR screening because of the resident’s history of mental illness. The Social Services Director also stated that a referral for a Level II PASARR screening should have been made to a community mental health agency at the time of admission, but it had not been done. The facility policy stated that persons who screen positively for mental illness are to have the Level I screen submitted to the local community mental health program for comprehensive screening, and that Level II recommendations are to be included in the plan of care.
Failure to Update Care Plan After Repeated Resident Aggression
Penalty
Summary
The facility failed to review and revise Resident #51’s comprehensive, individualized plan of care after repeated resident-to-resident aggressive incidents. Resident #51 had diagnoses including Alzheimer’s disease and major depressive disorder, and the care plan identified a history and potential for physical and verbal aggression related to dementia, delusional thinking, depression, and anxiety. The plan, initiated on 1/8/25, included interventions such as assessing needs, allowing the resident to express feelings, using communication cues to reduce anxiety, notifying nursing and social work when behaviors occurred, and observing triggers and de-escalation factors, but it was not updated after the resident’s later aggressive episodes. Record review showed that Resident #51 was involved in an aggressive incident during an evening meal in the room dining room, when a CNA reported that the resident initiated physical aggression toward another resident. Another incident report documented that the resident was heard yelling in the day room, was observed holding another resident’s walker and yelling, and was removed from the area. Staff interviews described that Resident #51 struck Resident #49 in the face with a book and then slapped Resident #49 across the face with the other hand during the altercation. Interviews with the family member, RN, activity aide, social services director, and DON confirmed that Resident #51 had a history of aggressive behavior toward other residents and had been involved in multiple altercations. These staff members also confirmed that the care plan had not been reviewed and revised after the August and September incidents, and they were unable to identify any new interventions implemented after those events. The DON stated the facility had considered moving the resident to another room, but that had not occurred, and no new interventions had been put in place to address the resident’s aggression.
Unsafe Smoking Supervision and Wheelchair Transport Without Footrests
Penalty
Summary
The facility failed to implement interventions to reduce hazards and risks for two residents reviewed for accidents. One resident with depression and a history of smoking-related noncompliance was found to have maintained possession of smoking paraphernalia while unsupervised. The record showed no care plan addressing the resident’s noncompliance with the smoking policy, hiding smoking paraphernalia, or smoking in his room. Documentation and interviews showed the resident repeatedly signed himself out to go outside to smoke, but there were no staff signatures confirming his return indoors or that his smoking materials were relinquished. Staff reported the expectation was that smoking materials would be kept in a locked medication room cupboard and regained by the nurse when the resident returned, but the materials were not present there during observation. The resident reported staff allowed him to keep his lighter and cigarettes in his room until a police officer confiscated them. Staff also described an incident in which smoke was detected in the resident’s room while his oxygen concentrator was running, and a deputy later removed a working lighter from the resident’s possession. The second resident had severe intellectual disability, a BIMS score of 3/15, and a care plan identifying fall-related injury risk. During observation, the resident was transported in a wheelchair without footrests in place while a staff member pushed the wheelchair briskly down the hall. The resident’s legs were extended above the floor and moved up and down as the wheelchair was pushed. An RN stated residents should never be pushed in a wheelchair unless footrests are in place because of the risk of the feet dropping, falling forward out of the wheelchair, or sustaining foot injuries.
Failure to Provide Humidification for Oxygen Therapy
Penalty
Summary
The facility failed to identify the need for a bubbler/humidifier to support oxygen therapy for a resident receiving oxygen at 2 L/min via nasal cannula for COPD. The resident’s diagnoses included COPD, chronic respiratory failure with hypoxia, and emphysema. Her care plan addressed potential difficulty breathing and respiratory complications related to COPD, emphysema, asthma, and oxygen use, with interventions including medications, treatments, and monitoring for adverse reactions. During observation and interview, the resident was sitting in her room wearing oxygen and stated that her nose became dry and developed sores from the oxygen she wore. She reported that she had used a bubbler/humidifier at home and that it helped with the dryness. On a later observation, she again stated that oxygen dried out her nose and caused sores and scabs, and that she had told nurses she wanted a bubbler but had not received one. The DON observed that there was no bubbler/humidifier on the oxygen concentrator and stated she was unaware of the resident’s need and request for one.
Wrong Methadone Dose Administered for Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with hemiplegia and hemiparesis following cerebral infarction, dementia, aphasia, depression, and hospice involvement. The resident’s physician order for methadone was changed from 2.5 mg by mouth every 8 hours for pain to 5 mg by mouth every 8 hours for pain, but the medication was administered at the lower 2.5 mg dose instead of the ordered 5 mg dose. The resident’s record showed that this occurred on 14 opportunities, and 5 different nurses were involved in the medication administration errors. The error was identified when the ADON reviewed the cart and noticed the resident was receiving 2.5 mg instead of the ordered 5 mg. Documentation in the record stated that the current form read methadone 5 mg, but smaller lettering indicated 2.5 mg because of half tablets, and the error was described as a wrong-dose, misread error. Interviews with nursing staff showed they were unaware of the medication error, and the DON stated the nurses who administered the medication previously did not question the order change.
Failure to Provide Required Social Services, Maintain Guardianship Records, and Care Plan Psychotropic Use
Penalty
Summary
The facility failed to provide medically related social services to support the mental and psychosocial health of 3 residents. For one resident with diagnoses including alcohol abuse, depression, and chronic respiratory failure with hypoxia, the record showed refusal of a BIMS assessment, daily rejection of care on the MDS, and a care plan addressing mood difficulties related to drug use, homelessness, and paranoid thoughts. During observation and interview, the resident reported anger, paranoia, anxiety, and stated that the room phone was tapped; he also said, "I know I'm going to die." A nursing note documented an oxygen saturation of 64% when he was not wearing supplemental oxygen, and he stated he did not need it and that he did not want to live anymore. Social services documentation for this resident was overdue. The record showed a PHQ-2/9 evaluation and a social service re-evaluation were past due, and the Social Services Director stated there had been no documented social services interactions for approximately 15 weeks. The director also confirmed the resident should have had a social services re-evaluation a few weeks earlier and that behavioral health services had not been offered in the last 12 months. The facility policy stated social services would assist with ongoing assessment, comprehensive care planning, and referrals and services as needed. For a second resident with vascular dementia and cognitive communication deficit, the facility did not maintain current guardianship paperwork. The Social Services Director confirmed the resident's letter of co-guardianship was expired and could not verify that an active guardian was in place, and could not report whether the resident still had a legal guardian. For a third resident with stroke, dementia, and bipolar disorder, the MDS identified bipolar disorder and routine antipsychotic use, and the CAA for psychotropic drug use noted Seroquel was being used to manage mood and behavior and that psych services were indicated. However, the care plan contained no focus, goal, or interventions related to bipolar disorder, mood or behavior concerns, or routine antipsychotic medication use, which the Social Services Director acknowledged.
Delayed Review of Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up with pharmacy recommendations from the consultant pharmacist’s monthly medication regimen reviews for two residents. Review of the facility policy showed that the pharmacist was to complete monthly MRRs, provide reports within 3 to 5 days, and that the attending physician was expected to review and sign the pharmacist’s recommendations within 14 days of receipt. The Director of Nursing was to follow up if there was no response within 14 days, and escalate further if needed. For one resident with dementia and anxiety disorder, the pharmacist’s June review noted the resident was receiving Seroquel and recommended a fasting lipid panel because atypical antipsychotics can be associated with abnormal lipid values. The physician response agreeing to repeat labs was not signed until 9/17/25. A July review for the same resident recommended a gradual dose reduction of Seroquel or documentation of why it was contraindicated, but the review was not dated when the DON said it was discussed by phone with the MD, and the DON confirmed she could not verify that the recommendation was reviewed timely. The DON also stated the review had not been placed in the resident’s EMR and was not available until requested. For another resident with Alzheimer’s disease and major depressive disorder, the May review identified new or worsening falls, severe hypertriglyceridemia, continued delusions, and possible orthostatic hypotension while receiving Seroquel, and recommended evaluation of the dose. The provider did not respond or sign that form. An August review for the same resident noted the resident was taking Glucophage and had no serum B-12 level in the record; that recommendation was not reviewed by a provider until 9/17/25. During interview, the DON and NHA stated the facility had discovered in August that medication regimen reviews had not been reviewed and that the facility was still working through the last 3 months of reviews for all residents.
Food Served at Unpalatable Texture
Penalty
Summary
Food was not provided at a palatable texture for two residents and for residents attending a confidential meeting. R69, who was independent with ADLs and had diagnoses including COPD, chronic respiratory failure with hypoxia, and emphysema, stated during interview that cooked vegetables were too soft. R73, who was cognitively intact with a BIMS score of 15/15 and had a cancer diagnosis, stated that the cooked vegetables were runny and like mush. In a confidential meeting, 3 of 14 residents reported they were consistently served vegetables that were overcooked and mushy, and that the moisture from the vegetables drained into other foods on their plates, making those foods unappealing as well. During a lunch meal observation, a regular tray for the Rehab/A side hall was plated with chicken fettuccine alfredo, broccoli, a roll, and dessert. The tray was the first of 18 trays loaded on the hall cart. When the meals were delivered, the test tray was observed with fettuccine at 123F and broccoli at 125F. The broccoli was tasted and observed to be overly tender to the point of being mushy.
Expired Guardianship Documentation in Resident Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for 1 of 18 residents reviewed, Resident #13. Resident #13 was admitted with diagnoses including vascular dementia and cognitive communication deficit. The record also contained a Letter of Co-Guardianship stating that the guardianship was continued without modification and that the guardian(s) were to continue filing annual reports, with the next court review listed on a future date. During interview, the Social Services Director reported that Social Work was responsible for ensuring that residents with a legal guardian had current guardianship paperwork in the EMR, but could not state how often the facility reviewed guardianship paperwork to ensure it was not expired. The Social Services Director reviewed Resident #13's Letter of Co-Guardianship and confirmed that the legal document was expired and could not be used to verify that Resident #13 had an active guardian in place. The Social Services Director was unable to report whether Resident #13 still had an active legal guardian and confirmed that the facility should have identified the expired guardianship paperwork, but missed it.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program protocols for Resident #51, who had diagnoses including Alzheimer's disease and major depressive disorder. After the resident had an aggressive episode toward another resident during an evening meal, staff notified the provider and obtained a urine dip test that was reported as abnormal. Based on the resident’s history of aggressive behavior with prior UTIs, the provider ordered a urinalysis and started Bactrim every 12 hours for three days before the urinalysis results were received. The DON confirmed that the facility normally would not start an antibiotic before receiving lab results, but believed the resident’s aggressive behavior made it prudent to begin treatment immediately. Once the urinalysis results were received, the facility discontinued the Bactrim because the resident did not have a UTI and did not have other symptoms on the McGeer criteria checklist to support antibiotic therapy. The DON also confirmed that the provider did not write a risk/benefit statement to justify starting the antibiotic before the results were available, and the resident received an unnecessary antibiotic for three days.
Failure to Enforce Non-Smoking Policy and Control Smoking Materials
Penalty
Summary
The facility failed to implement its non-smoking policy for Resident #71, who had diagnoses including depression, and there was no care plan addressing his noncompliance with the smoking policy, hiding smoking paraphernalia, or smoking in his room. The resident reported that he had been allowed to keep a lighter and cigarettes in his room until a police officer confiscated them, while staff stated the expectation was that smoking materials were to be kept in a locked medication room and regained by nursing staff after each outside smoking trip. Review of the Leave of Absence forms showed multiple self-sign-outs for outside smoking, but no staff signatures documented that the resident returned indoors and surrendered his smoking paraphernalia. Staff interviews and nursing notes showed repeated concerns that Resident #71 continued to smoke despite the facility’s policy. A CNA reported seeing him smoking just outside the front door many times, and another CNA reported smelling smoke in the hallway and finding a smokey haze in the resident’s room while his oxygen concentrator was running and his oxygen cannula was on the floor. An RN reported finding smoke in the room and that a deputy was called to address the violation and confiscated a working lighter from the resident’s room. The NHA stated residents were not supposed to smoke anywhere on the property and acknowledged the facility knew the resident had kept smoking materials in his room and had refused to surrender them at times, but no additional interventions had been put in place.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to the resident or his representative detailing the reason for transfer to the hospital for one resident reviewed for hospitalization. Resident #83 was a male with diagnoses including diabetes, high blood pressure, obstructive lung disease, and depression, and he was his own responsible party. A nurses note documented that he was sent to the hospital due to chest pain, shortness of breath, respirations of 28, abnormal lab values, and a heart rate of 122, with all parties notified. Record review showed no documentation that a written transfer/discharge notification was provided to the resident or representative when he was transferred to the hospital. During interviews, the ADON stated the resident was sent out for abnormal lab results, abnormal vital signs, and chest pain, and that paperwork sent with EMS included a face sheet, medication list, and bed hold policy, but she did not provide the resident with written notification of the transfer reason. The DON stated a transfer form is completed and sent with the hospital packet, but it is not given specifically to the resident or representative. An LPN also stated that the packet sent with the resident includes the bed hold policy, face sheet, medication list, code status information, and transfer form, and that written notification detailing the reason for transfer is not necessarily given to the resident or representative.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Showers/Baths per Resident Preference and Plan of Care
Penalty
Summary
The facility failed to provide showers or baths according to the resident's preference and plan of care for one resident reviewed for Activities of Daily Living (ADL) care. The resident, who had multiple diagnoses including obstructive lung disease, heart failure, anemia, depression, anxiety, venous insufficiency, diabetes, hypertension, and arthritis, was noted to have severe cognitive impairment with a BIMS score of 2, as well as behavioral symptoms such as inattention, disorganized thinking, and rejection of care. The care plan indicated the resident required substantial to maximal assistance with bathing due to functional deficits. Documentation revealed that in March, the resident received only a few showers or baths, with some refusals, and only one documented shower or bath in April. No showers or baths were documented in May prior to discharge. Interviews with facility staff confirmed that the available documentation was complete and that there were significant gaps in the provision of showers or baths, with only one documented in April and none in May. The DON acknowledged that residents should generally be offered showers or baths twice per week according to their preferences. The facility's policy required that residents receive necessary assistance to maintain hygiene, with showers or baths scheduled according to person-centered care. The lack of consistent bathing was corroborated by a family member, who reported that the resident rarely received showers or baths, leading to dissatisfaction with care.
Failure to Supervise an Exit-Seeking Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a resident who was identified as an elopement risk. The resident had diagnoses including severe dementia with behavioral, psychotic, mood, and anxiety disturbances, was ambulatory, wandered, was cognitively impaired, and scored 11 or higher on the elopement risk assessment. A wander guard was placed on the resident because of the elopement risk, and the care plan directed staff to apply the wander guard, redirect the resident away from exits, and provide supervision as needed. On the evening of the incident, staff observed the resident wandering throughout the lobby, halls, and near exit doors, attempting to open doors and enter other residents’ rooms. The receptionist reported that the resident removed his wander guard in front of her, and a nurse replaced it and redirected him. Multiple staff later described the resident as highly exit seeking and needing constant redirection. One nurse reported asking a CNA to watch the resident while she completed medication pass, but the resident was later not with that CNA. Staff did not realize the resident was missing until a head count was initiated after an off-duty nurse reported finding a man on the roadside with a wander guard on his ankle. The resident was found approximately 0.3 miles from the facility by an off-duty nurse and bystanders after he had exited the building unnoticed by staff. EMS documented that he had been seen walking in the road, weaving in and out of traffic, and was found lying in an embankment with a bleeding skin tear on his lower right arm. Facility staff reported that they had not been aware the resident had eloped until the head count was completed. The report also states that the root cause was determined to be staff turning the alarm off without walking outside the door and checking the perimeter.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Inspect and Maintain Bed Safety Results in Resident Injury
Penalty
Summary
The facility failed to conduct routine inspections and maintenance of resident beds, specifically neglecting to address exposed metal brackets intended for footboards on nine beds. One cognitively impaired resident with a history of falls was found after a crash was heard, lying on her side with her left buttock impaled by a metal bracket at the end of her bed. The bracket, which was designed to hold a footboard, was exposed and had entered and pressed against the resident's buttock. Multiple staff interviews confirmed that these metal brackets, some with pointed tops extending upwards, had been present on beds in use for an extended period without footboards attached. The Maintenance Director acknowledged that the beds with exposed brackets had been in use since before his tenure began, and the Nursing Home Administrator was unaware of how long the beds had been in this condition. Review of facility work orders over several months showed that none of the nine beds with exposed brackets had been reported or addressed for maintenance. Staff interviews further confirmed the presence of the hazardous brackets and the lack of footboards, directly leading to the resident's injury.
Failure to Maintain Effective QAPI Program and Address Quality Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in the inability to identify and address multiple quality deficiencies. The QAPI committee did not consistently meet as required, with missed meetings and inadequate attendance by key members such as the Infection Preventionist, Administrator, Director of Nursing, and Medical Director. The committee also failed to collect or analyze data related to critical areas, including resident change of condition, safety and maintenance of beds, infection control practices, activity provision, and abuse prevention. Sign-in sheets confirmed irregular meetings and lack of required interdisciplinary participation. As a result of these lapses, the facility did not ensure that resident treatments were completed and documented per physician orders, timely identification and assessment of changes in resident condition, proper assembly and maintenance of facility beds, implementation of infection control practices, provision of activities to meet resident needs, and maintenance of an environment free from abuse. The Nursing Home Administrator confirmed that the facility was not tracking compliance with physician notifications or care provided as ordered, and that no steps had been taken to address identified issues such as staff communication failures related to resident-to-resident abuse.
Resident Denied Dignified Care and Assistance by Staff
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with dignity and respect by refusing to assist with care needs. The resident, who had a history of depression, anxiety disorder, chronic obstructive pulmonary disease, and chronic systolic heart failure, was mildly cognitively impaired and had a care plan that emphasized the need for a trusting and non-threatening environment. On the day of the incident, the resident requested assistance from a CNA to obtain water basins for personal hygiene and to change clothes due to the warm temperature in the room. The CNA responded angrily, refused to help, and made dismissive remarks about the resident's ability to care for herself, leaving the resident on the toilet in distress. The incident was witnessed by an LPN, who found the resident crying, frustrated, and sad after the CNA left the room. The resident reported feeling unsafe and expressed concerns about not receiving necessary care. Documentation and interviews confirmed that the CNA spoke rudely, refused to assist with hygiene and clothing changes, and handled equipment in a manner that further upset the resident. The CNA denied the allegations during the investigation and was uncooperative in interviews. The facility's records and staff interviews corroborated the resident's account of being treated without dignity and respect, resulting in emotional distress.
Failure to Accurately Report Resident Impalement and Associated Injuries
Penalty
Summary
The facility failed to accurately report an incident of neglect involving an unsafe environment to the State Agency. A resident with moderate cognitive impairment, a history of falls, and limited mobility due to being wheelchair-bound, attempted to get out of bed and fell onto a metal bed frame. This resulted in a penetrating trauma, with the metal frame impaling the resident's left buttock by approximately 3-4 inches, causing significant blood loss, a comminuted fracture of the left inferior pubic ramus and ischial tuberosity, and a 4 cm laceration near the anal region. Emergency services documented the severity of the injuries, including the impalement and associated trauma. However, the facility's investigation report, authored by the Nursing Home Administrator, did not include critical details about the impalement, blood loss, or the extent of the injuries, instead only noting a fall and subsequent fracture discovered after hospital evaluation. During interviews, the administrator acknowledged that the information provided to the State Agency should have included all apparent injuries linked to the incident but was unable to explain the omission of the impalement and blood loss from the report. This resulted in inaccurate information being reported to the State Agency regarding the incident.
Failure to Notify RD and Physician of Significant Weight Loss
Penalty
Summary
The facility failed to assess and monitor the nutritional status of a resident who was at risk for malnutrition, resulting in a significant unplanned weight loss of 12% over 11 days. The resident had a history of surgical aftercare, dysphagia, and was on a mechanically altered diet, with documented difficulties in chewing and a preference for pureed foods. Despite being identified as at risk for malnutrition and having a care plan that required monitoring and notification of significant weight changes, there was no evidence that the Registered Dietitian (RD) or physician were notified of the resident's rapid weight loss. Family concerns about the resident's intake and weight loss were raised but not addressed by staff. Interviews with facility staff confirmed that the RD and physician should have been notified of the weight loss, as per facility policy, but this did not occur. The RD stated she relied on nursing management and the Certified Dietary Manager to monitor weights, but a change in staff may have led to the oversight. The Director of Nursing confirmed the lack of documentation regarding notification of the RD or physician. Review of physician notes also showed no acknowledgment or evaluation of the resident's significant weight loss during the relevant period.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a recent history of open heart surgery and a midline sternum surgical wound was not provided with proper infection control measures during personal care. The resident required Enhanced Barrier Precautions (EBP) as indicated by physician orders and signage on the resident's door, specifying the use of personal protective equipment (PPE), including gowns and gloves, during high-contact care activities such as toileting and changing bed linens. Despite these requirements, a Certified Nursing Assistant (CNA) was observed providing direct personal care to the resident while only wearing gloves and not a gown, contrary to the EBP protocol. The CNA stated a lack of awareness regarding the resident's EBP status at the time of care and admitted to not wearing a gown during the incident. Interviews with facility staff, including the wound nurse, confirmed that the facility follows CDC guidelines for EBP and that staff are trained to recognize signage and use appropriate PPE. However, the care plan for the resident did not specifically address EBP, and the CNA did not adhere to the required infection control practices during the observed care event.
Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity and respond to call lights in a timely manner, affecting two residents. Resident #104, a male with depression and type 2 diabetes mellitus, reported that his call light often took a long time to be answered, particularly during meal times. His Minimum Data Set (MDS) assessment indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Resident #105, also cognitively intact with a BIMS score of 15, reported that delayed responses to his call light sometimes resulted in him urinating in his pants, causing him distress. His diagnoses included a urinary tract infection, unsteadiness on feet, and weakness. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about long wait times for call light responses. The Resident Council Minutes from several months also documented ongoing issues with call light response times, including instances where aides turned off call lights without addressing resident needs and took excessive time to return. These findings indicate a pattern of inadequate response to resident needs, impacting their dignity and quality of life.
Plan Of Correction
Resident #104 and #105 continue to reside in the facility. Care plans have been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated staff on the Resident Rights Policy and the Call Light Policy. Staff members who have not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will complete an audit of 10 random call lights during and around mealtimes to ensure residents' needs are met in a timely manner. An audit will be completed once a week for four weeks, then once every month for three months, to ensure call lights are being answered in a timely manner. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Failure to Address Resident Council Concerns on Call Light Wait Times
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding lengthy call light wait times. Interviews with staff, including a Certified Nurse Aide (CNA) and an Activities Assistant (AA), confirmed that residents had complained about the delays in response to call lights. The Resident Council Minutes from multiple meetings over several months documented ongoing issues with call light response times, including reports of aides turning off call lights without addressing resident issues and taking an extended time to return. The Nursing Home Administrator (NHA) acknowledged that while the activity director shared the resident council meeting minutes with the management team, a formal concern or grievance form was not completed for issues raised by the resident council as a whole. Instead, only resident-specific concerns were documented. This lack of formal documentation and tracking of resident council concerns contributed to the ongoing dissatisfaction with call light response times and the potential for resident frustration.
Plan Of Correction
No residents were identified in this citation. Residents residing in the facility have the potential to be affected by the deficient practice. The Administrator re-educated the Activities Director of the Guest/Resident Council policy and the proper use of grievance/concern forms to be used for concern resolution. The Administrator will audit resident council minutes to ensure guest/resident concerns are resolved in a timely manner and concern forms are completed appropriately. The Administrator will complete the audit monthly for four months to ensure substantial compliance. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Administrator is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to inform a resident's emergency contact of a fall in a timely manner, resulting in a delay in notification. The resident, who was cognitively intact and had undergone joint replacement surgery, fell while attempting to use the bathroom. The fall resulted in a skin tear on the right elbow and pain in the right knee. The incident was documented by an LPN, who assessed the resident and notified the Director of Nursing and the on-call provider but did not contact the emergency contact due to the early morning hour. The LPN passed the responsibility of notifying the emergency contact to the next shift, but the RN on the following shift did not make the call, believing all necessary notifications had been made. The resident expressed a preference for family notification in such events, and the facility's policy required immediate notification of significant changes in health status. The Nursing Home Administrator confirmed that emergency contacts should be notified immediately, regardless of the time of day.
Plan Of Correction
Resident #101 continues to reside in the facility. The resident's care plan has been reviewed and deemed appropriate. Residents residing in the facility have the potential to be affected by the deficient practice. The Director of Nursing/designee has re-educated the licensed nurses of the Notification of change policy. Any licensed nurse who has not received education by March 24, 2025, will be removed from the schedule until education has been received. The Director of Nursing/designee will audit fall documentation to ensure that all appropriate parties have been notified in a timely manner. The Director of Nursing/designee will conduct the audit once a week for four weeks, then once every month for three months, to ensure appropriate parties are being notified timely. Results of the audits will be reported to the facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Director of Nursing is responsible for attaining and maintaining compliance. Compliance Date: March 24, 2025
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by multiple incidents involving both staff-to-resident and resident-to-resident interactions. One incident involved a Certified Nursing Assistant (CNA) who was reported to have verbally abused a resident with cognitive impairments and Parkinson's disease by swearing at her and forcibly pushing her in a wheelchair against her will. The resident, who had severe cognitive impairment and was prone to hallucinations, was unable to recall the incident, but witnesses confirmed the abusive behavior. The CNA admitted to swearing but claimed it was an unintentional reaction to being scratched by the resident. Another incident involved two residents, both with significant cognitive and mental health issues, engaging in physical altercations. One resident with Alzheimer's disease and impulsiveness struck another resident with intellectual disabilities and schizoaffective disorder. The incident was not immediately reported to management, and the care plan for the aggressive resident was not updated to prevent future occurrences. A subsequent altercation occurred between the same residents, with one resident striking the other in the face, highlighting ongoing supervision and intervention issues. Additionally, a resident with severe intellectual disabilities and mood disorders was involved in an altercation where she was hit by another resident. The facility's investigation revealed that the activities aide was unable to intervene in time to prevent the physical contact. Observations noted a lack of supervision in common areas, contributing to the potential for resident-to-resident incidents. The facility's staffing challenges and lack of consistent supervision in the memory care unit were identified as contributing factors to these incidents.
Failure to Report Abuse Incident in a Timely Manner
Penalty
Summary
The facility failed to ensure that staff fully implemented the abuse policy for reporting an incident of abuse involving two residents. Resident #101, who has Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and a history of stroke, made physical contact with Resident #102, who has intellectual disabilities, bipolar disorder, anxiety, schizoaffective disorder, and experiences restlessness and agitation. The incident occurred on October 19, 2024, but was not reported to management or the Administrator until October 21, 2024, when the MDS Coordinator discovered a progress note detailing the altercation. The facility's policy requires that any allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source be reported immediately to the Administrator and DON. However, the incident was not reported in a timely manner, as the agency nurse who documented the progress note did not notify management. This delay in reporting resulted in the potential for incidents of abuse going undetected, unreported, or without thorough investigation, as the facility's abuse prevention policy was not fully implemented by the staff involved.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Falls
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, resulting in a lack of service to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The resident, a female with Alzheimer's disease, chronic fatigue, diabetes, impulsiveness, chronic pain, psychosis, COPD, and stroke, was identified as being at risk for fall-related injuries due to confusion, gait/balance problems, a history of falls, incontinence, medication use, and mobility issues. Despite these risks, the care plan interventions, such as placing a fall mat next to the bed and using a concave mattress, were not implemented as observed during multiple instances. Observations revealed that the resident was frequently found lying close to the edge of the bed without the prescribed concave mattress or fall mat in place. Interviews with staff, including CNAs and the Unit Manager, confirmed that the care plan specified these interventions, but they were not being followed. The Director of Nursing acknowledged that the resident should have had a concave mattress and that the facility was in the process of removing fall mats, indicating that the care plan should have been updated accordingly.
Failure to Follow Physician Orders for Urine Sample Collection
Penalty
Summary
The facility failed to ensure that nursing staff followed physician orders to obtain a urine sample for a resident, leading to a potential delay in treatment. The resident, a female with a history of Alzheimer's disease, diabetes, and urinary tract infections, was found lying on the bathroom floor experiencing hallucinations. A physician's order was issued to obtain a urinalysis with culture and sensitivity to investigate the cause of the hallucinations, with a specific instruction not to mark the order as completed in the Medication Administration Record (MAR) until the test was performed. Upon review, it was discovered that the order was not marked as completed in the MAR, indicating that the urinalysis was not performed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the order was not executed, and the lab results were not found in the resident's medical record. This oversight resulted in a failure to adhere to the care plan, which required obtaining labs and reporting abnormal results to the physician, potentially delaying the identification and treatment of the resident's condition.
Failure to Provide Consistent Bathing Assistance
Penalty
Summary
The facility failed to consistently provide showers or bathing assistance to two residents, resulting in unmet personal hygiene needs. Resident #100, who has multiple health conditions including heart failure, diabetes, and COPD, was noted to have missed several scheduled showers over a 30-day period without documentation of refusal or explanation. The care plan for Resident #100 indicated a need for substantial or maximal assistance with bathing, yet records showed instances where showers were marked as not applicable without further clarification. Similarly, Resident #101, diagnosed with Alzheimer's disease, diabetes, and other chronic conditions, also experienced lapses in receiving scheduled showers. The care plan for Resident #101 required substantial assistance and documentation of any refusals, but records showed missed showers without proper documentation of refusal or leave of absence. Interviews with CNAs and the Unit Manager revealed inconsistencies in documenting refusals and a lack of follow-up when residents declined showers, contributing to the deficiency in care.
Inadequate Resident Activities and Supervision
Penalty
Summary
The facility failed to provide consistent, meaningful, person-centered activities for two residents, resulting in potential negative impacts on their psychosocial well-being. Resident #102, who has intellectual disabilities, bipolar disorder, anxiety, and schizoaffective disorder, was not observed participating in activities or receiving one-to-one activities as outlined in her care plan. Despite interventions being in place, such as offering distractional activities and one-to-one support, the resident had limited engagement in activities over several months, with only a few days of one-to-one activities recorded. Observations revealed that the resident often requested to go for walks but was not accommodated promptly, leading to behavioral issues. Resident #104, diagnosed with anxiety, severe intellectual disabilities, and mood disorder, also did not receive adequate one-to-one activities as recommended in her care plan. The resident was observed to be agitated and vocal when left unsupervised in the day room, and her care plan interventions, such as providing a tray table to create personal space, were not consistently implemented. The resident's limited participation in activities was noted, with only a few days of one-to-one activities recorded over several months. Interviews with staff revealed that the facility had insufficient activity staff, leading to inadequate supervision and engagement of residents in the memory care unit. The Social Services Director and other staff members acknowledged the challenges in providing consistent activities due to staffing shortages and the high number of residents. The lack of consistent staff presence and engagement in the memory care unit contributed to resident-to-resident incidents and behavioral issues, highlighting the deficiency in meeting the residents' needs for meaningful activities.
Inadequate Supervision and Care Plan Implementation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and implement care plan interventions for a resident, resulting in a fall. The resident, who had a history of unsteadiness on feet, weakness, and low back pain, required substantial assistance with mobility due to her condition. The care plan specified that the resident needed a two-person assist for transfers, but this was not followed during the incident. On the day of the incident, a CNA attempted to transfer the resident from her wheelchair to her bed without the required assistance. The CNA mistakenly believed the resident was a one-person assist and did not consult the care plan. During the transfer, the resident became weak and fell into the bed, resulting in pain in her left upper arm. An x-ray suggested a possible fracture, but a subsequent CT scan revealed no acute fracture, though it did show severe osteoarthrosis and potential chronic issues. Interviews with staff revealed that the CNA did not use a gait belt properly and was not aware of the resident's care plan requirements. The CNA was responding to a call light and did not perform a formal assessment of the resident's needs. The incident was not initially considered a fall by the LPN who assisted afterward, and no immediate pain was reported by the resident until the following day.
Failure to Provide Homelike Environment and Autonomy
Penalty
Summary
The facility failed to provide a homelike environment that promoted autonomy for two residents, resulting in emotional distress and frustration. Resident #334, who was cognitively intact and had a history of major depressive disorder and generalized anxiety disorder, was placed in a locked memory care unit without prior notification. This placement led to increased anxiety and dissatisfaction due to the noise level and restrictions on her freedom to move around the facility. Despite being promised that the unit would be converted to a regular hall, this change had not occurred, leaving Resident #334 feeling trapped and unable to participate in activities of interest. Similarly, Resident #333, who was also cognitively intact and had a history of major depressive disorder and anxiety disorder, expressed dissatisfaction with being placed in the locked memory care unit. She felt a loss of control over her life and was unable to move freely around the facility or access the courtyard without assistance. This situation led to feelings of being overly supervised and a loss of independence, contributing to her anxiety and depression. Both residents were not informed prior to their admission that they would be placed in a locked unit, which they found distressing and contrary to their preferences for independence. Interviews with staff, including CNAs, the Admissions Director, and the Nursing Home Administrator, revealed that the residents were not adequately informed about their placement in the locked memory care unit. The facility's policy on resident rights emphasizes the importance of informing residents about their rights and the rules governing their stay, which was not adhered to in this case. The lack of communication and failure to provide a suitable environment for these residents led to significant emotional distress and a feeling of confinement, highlighting a deficiency in the facility's care and communication practices.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident #34, diagnosed with Alzheimer's disease, was observed without heel protectors on multiple occasions despite having a pressure ulcer on her left heel. The care plan for Resident #34 did not include any focus, goals, or interventions related to her heel wound or the use of heel protectors. Interviews with staff, including a CNA, Unit Manager, and Hospice Nurse, revealed a lack of clarity and communication regarding the care plan for Resident #34, resulting in inconsistent application of necessary pressure-relieving devices. Resident #332, who was admitted with severe cognitive impairment and a history of urinary issues, also had an incomplete care plan. Although a urinary catheter was ordered for Resident #332, the care plan did not include any management strategies for the catheter, such as hygiene, positioning, or monitoring. An incident was reported where Resident #332 experienced discomfort due to lying on the catheter tubing, which was not addressed in the care plan. The lack of a comprehensive care plan for Resident #332's catheter care led to potential complications and discomfort for the resident. The deficiencies in care planning for both residents were identified through observations, interviews, and record reviews. The facility's failure to update and implement care plans in response to the residents' changing needs and conditions resulted in inadequate care and potential harm. The Director of Nursing acknowledged the expectation for care plans to be developed for new pressure ulcers and other significant changes in residents' conditions, highlighting the oversight in these cases.
Failure to Update Care Plan After Feeding Tube Removal
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after a significant change in condition, specifically the removal of a feeding tube. The resident, who had a history of stroke with left-sided weakness and dysphagia, was initially assessed as cognitively intact and had a care plan that included tube feeding. However, the feeding tube was accidentally dislodged and subsequently discontinued over a month prior to the survey, yet the care plan was not updated to reflect this change. Interviews with staff, including an LPN and the Unit Manager, confirmed that the feeding tube had been removed and was not replaced. Despite this, the care plan still contained outdated information regarding tube feeding. The MDS Coordinator acknowledged that the care plan should have been revised to remove the tube feeding information, as care plans are meant to be updated with any changes in a resident's condition to ensure accurate and effective care.
Failure to Implement Interventions for Hand Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent the worsening of contractures in a resident with right and left hand contractures. The resident was admitted with these conditions, but the current care plan did not include any focus or interventions for managing the contractures. Additionally, there were no active physician orders in place for the resident's hand contractures. An occupational therapy discharge summary recommended the use of bilateral handrolls and passive range of motion exercises, but these recommendations were not reflected in the resident's electronic health record (EHR). Observations over several days revealed that the resident was not wearing handrolls or any other devices to prevent a decline in range of motion. Interviews with the rehabilitation director, registered nurse, certified nursing assistants, and licensed practical nurse unit manager indicated a lack of awareness and communication regarding the resident's need for handrolls. The rehabilitation director stated that the order for handrolls was communicated to the nursing team, but it was not entered into the EHR. Consequently, the nursing staff and CNAs were unaware of the requirement for the resident to wear handrolls, leading to the deficiency in care.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
The facility failed to provide a mechanically altered diet as ordered for a resident with a history of stroke, muscle weakness, and dysphagia, which resulted in the potential for aspiration and choking. The resident was observed eating in her room without supervision, contrary to her dietary orders that required pureed foods if she chose to eat alone. On two separate occasions, the resident was served non-pureed meals, including a taco salad and chocolate cake for lunch, and scrambled eggs and toast for breakfast, without any staff present to supervise her. Interviews with facility staff, including a unit manager, speech therapist, and registered dietitian, confirmed the resident's dietary needs and the requirement for pureed foods when eating in her room. The staff acknowledged the resident's significant risk of airway compromise due to her condition. The dietary orders were documented in the resident's care plan and Kardex, but the nursing staff failed to ensure the dietary department was informed of the resident's location to provide the correct meal consistency.
Deficiencies in Cleanliness and Storage Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper storage in two areas: the dry storage room and the central supply storage room. During a tour, it was observed that the floor drain in the dry storage room was improperly used for draining the ice machine and walk-in cooler condensers. This misuse resulted in black lines between the floor tiles and visible water seeping from the gaps when walked on. In the central supply storage room, some shelving was made from raw wood, which was not smooth or easily cleanable. Clean and sanitary items, including catheter care equipment, ice bags, hair brushes, bottles of saline, reusable urinals, and personal protective equipment, were stored on the floor and on the raw wood surface. Environmental Services H acknowledged the need to reorganize the central supply to accommodate these items properly.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide adequate pain management for a resident who was admitted with a fracture of the right femur. The resident was prescribed tramadol, a pain medication, to be taken as needed every six hours. However, the resident did not receive the medication on the first two days following admission, resulting in increased pain. The resident's family reported the issue to the Unit Manager LPN, who assured them that the medication would be administered, but the resident still did not receive it until the third day. Interviews with staff revealed that the nurse responsible for the resident on the night of admission was unable to complete all tasks due to a heavy workload, leading to the omission of entering medication orders or contacting the pharmacy. The Unit Manager LPN acknowledged being informed of the missed medications but could not explain the delay in administration. The pharmacy confirmed that no urgent request was made to deliver the medication on the day of admission, and it was only sent on the third day.
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 196 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Allegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allegan County Medical Care Facility | 1.3 mi | ★★★★★ | 8 | 0 |
| Alamo Nursing Home Inc | 11.7 mi | ★★★★★ | 11 | 0 |
| Life Care Center Of Plainwell | 12.3 mi | ★★★★★ | 20 | 0 |
| The Laurels Of Sandy Creek | 16.4 mi | ★★★★★ | 6 | 1 |
| Medilodge Of Westwood | 17.7 mi | ★★★★★ | 2 | 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.