Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with mild cognitive impairment and disorientation alleged that a CNA entered the room on a night shift, hit the resident with pillows, and threw water. Although the facility reported suspending the CNA and initiating an investigation, the investigative file lacked resident interview statements and assessments that the Administrator claimed had been completed, including documentation from the roommate who was reported by staff to have overheard the incident. Time records showed the CNA working during the period the Administrator stated the CNA was suspended, and no time correction documentation was produced to support the claim that the CNA was off the schedule. Progress notes and psychology and SW documentation showed the resident repeatedly expressed fear, reported being harmed by a woman in a white uniform, and described others yelling for the staff member to stop, yet the facility’s investigation did not contain complete, contemporaneous interviews and did not clearly demonstrate that the resident was protected from the alleged perpetrator while the investigation was ongoing.
Two residents with pressure injuries did not receive consistent Braden Scale assessments, timely wound care orders, or prompt responses to wound changes. One resident was admitted with existing hip and coccyx pressure injuries and was assessed as at risk, but only one Braden assessment was completed despite policy requiring weekly follow-ups. Wound consults documented an unstageable hip ulcer and a coccyx injury that progressed to Stage III, with specific recommendations for Medihoney and Triad treatments and a low air loss mattress; however, the MAR/TAR showed Medihoney applied daily instead of three times weekly to the hip, and there was no explanation for this discrepancy or for the delayed use of a low air loss mattress. Another resident with chronic kidney disease and heart failure had only one Braden assessment completed after admission, developed an unstageable coccyx/left buttock ulcer that progressed to Stage III, and experienced a three-day delay in starting ordered Medihoney treatment, with no documentation from front-line staff noting wound changes that were later identified by the wound clinician.
Food safety and temperature control deficiencies were observed in the kitchen. Opened dressing containers in the walk-in cooler were undated, a personal cell phone was on the food prep counter, and several spatulas had rough, damaged edges. A package of deli ham remained on the prep counter for hours and was measured at 71 degrees Fahrenheit.
Failure to Conduct Quarterly Care Conference: A resident with severe cognitive impairment, dementia with agitation, psychotic disorder with delusions, chronic kidney disease, full code status, and a court-appointed guardian did not have the required quarterly care conference completed. The record included a physician letter asking the guardian to consider changing code status to DNR due to medical decline, but there was no documentation of guardian response, follow-up, or a scheduled care conference after the last documented conference, and the guardian reported never being asked to join a care conference or receiving the letter.
A resident with chronic pain and hemiparesis had physician orders for lidocaine patches to the R shoulder and both knees, but the MAR/EMAR showed multiple missed administrations because the patches were not available. Notes documented the patches as “on order” or “not available,” and an NM acknowledged the missed doses should have been applied.
Tube Feeding and Water Flushes Not Given Per Order: A resident with a feeding tube was observed in bed with the pump at bedside, but no formula bottle or water bag was attached during observations. Record review showed the resident's Jevity 1.5 TF and ordered water flushes were not delivered in the full amounts prescribed, and the DON stated the physician's order should be followed.
Failure to obtain ordered lab tests for a resident with CHF and ESRD. A physician ordered B12, folate, and TSH testing after the resident reported bloating, gas, possible fecal incontinence, and left hand tingling, but the record showed no results for the labs. The NM stated the requisition was never completed and the labs were never done.
Failure to provide ordered built-up utensils and meal assistance. A resident with protein-calorie malnutrition, dysphagia, and bilateral UE impairment was observed trying to eat breakfast with standard silverware instead of the built-up utensils listed on the meal ticket and care plan. The breakfast tray was also left out of reach on one occasion. The NM and Dietary Director acknowledged the utensils should have been provided and that dietary was responsible for placing them on the tray.
A resident experienced a new onset of severe right foot pain and swelling after a transfer, but despite repeated complaints and inability to participate in therapy, there was no timely or thorough evaluation by a medical provider. Initial X-rays were negative, and documentation focused on chronic pain rather than the acute injury. It was only after several days and continued decline that a comprehensive assessment and further imaging revealed a comminuted avulsion fracture, confirming a delay in diagnosis and treatment.
A resident who was fully dependent for toileting and always incontinent did not receive timely incontinence care, remaining wet and soiled for approximately 11 hours despite multiple requests for assistance. Documentation for the day was incomplete, and staff confusion over assignments contributed to the lack of care, in violation of facility policy and standard care expectations.
A facility failed to obtain consent from a legally authorized representative for psychotropic medications administered to a resident with Alzheimer's and impaired cognition. Despite the resident being deemed incompetent, the facility administered Sertraline and Lorazepam without the necessary consent from the resident's DPOA-H, contrary to facility policy.
A facility failed to follow pest control procedures, resulting in a bed bug infestation affecting a resident. The issue arose when a resident's sister brought infested belongings into the facility. Despite initiating bed bug procedures, a CNA mistakenly put potentially infested clothes back on a resident after a shower, leading to bed bugs being found in the resident's hair. The resident, with a history of bipolar disorder and PTSD, experienced discomfort and required further interventions.
A resident with Alzheimer's was mistakenly taken to another resident's room by a dietary staff member, leading to an altercation where the resident was pushed out of their wheelchair. The incident highlights a failure in communication and supervision, as the staff member was unaware of room assignments and did not consult nursing staff, resulting in a violation of the facility's abuse policy.
A resident was found covered in dry feces, and the facility failed to report the neglect to the Administrator and State Agency. The DON and a nurse allegedly dismissed the need for care, citing the resident's terminal condition. Discrepancies in staff accounts and lack of documentation further highlighted the facility's failure to adhere to reporting protocols.
The facility restricted visitation hours to between 8:00 AM and 8:00 PM, affecting all 143 residents. Residents reported being unaware of their right to 24-hour visitation. The Administrator confirmed the restricted hours, and the Business Office Manager stated that announcements were made each night about the end of visiting hours. The facility lacked a formal visitor policy, and the admission packet incorrectly stated visitation hours, leading to a deficiency in ensuring residents' visitation rights.
The facility failed to maintain the kitchen's ventilation hood filters and dish machine in a sanitary manner, with grease buildup on the hood and inadequate sanitization temperatures in the dish machine. The dish machine's temperature log showed consistently low temperatures, and maintenance staff found forks blocking the sensor and a thick slime buildup inside.
The facility failed to maintain resident dignity and respect, as staff entered rooms without knocking and a nurse stood while feeding a resident. Additionally, a family member fed two residents without sanitizing hands between them, with no staff intervention. The residents involved had severe cognitive impairments and required assistance with eating.
A resident expressed dissatisfaction with their doctor, Dr. F, for attempting to examine them without gloves while under contact precautions. The resident, with intact cognition, explicitly stated they no longer wanted Dr. F as their physician. Despite this, Dr. F planned to see the resident again, assuming they might have calmed down. The DON confirmed that residents could change doctors at any time, and Dr. F should have informed the facility of the resident's decision.
A resident with intact cognition was moved three times within four days without proper notice or explanation, violating their rights. The facility attempted a room change at 2:00 AM without providing a reason, leading to the resident's refusal. The DON acknowledged the failure to inform the resident, and the facility's policy requiring written notice was not followed.
A facility failed to execute a DNR Advance Directive order for a resident admitted for rehabilitation. The resident, who was cognitively intact and had a history of diabetes, hypertension, and end-stage renal disease, expressed their choice of DNR status during a health care conference. Although the DNR form was completed by the resident, it was not signed by a physician until after the resident's discharge, resulting in the resident remaining a full code during their stay.
A resident with a history of diabetes, falls, and anxiety experienced a disorganized discharge process, leading to confusion and distress. The resident and their spouse received conflicting information about the discharge, with no care conference held to discuss the plan. The resignation of the social work director added to the confusion, resulting in the resident being petitioned to a hospital for psychiatric evaluation due to alleged self-harm behaviors.
A facility failed to implement a baseline care plan for a resident receiving tube feeding. The resident, admitted with stroke, major depressive disorder, and malnutrition, had a severely impaired cognition score. Despite these conditions, the baseline care plan lacked instructions for tube feeding, which was confirmed by the DON.
The facility failed to ensure accurate medication documentation and complete tube feed orders for two residents. An LPN marked medications as given before a resident refused them, contrary to protocol. Another resident's tube feed orders lacked necessary details, confirmed by the RD and RN, indicating incomplete documentation.
The facility failed to provide appropriate wound care for two residents, resulting in untreated wounds and miscommunication about treatment completion. Additionally, the facility did not follow up on a physician consult for a resident with gangrene, lacking documentation of an after-visit summary. The Director of Nursing acknowledged the failures in both wound care and coordination of care for outside appointments.
A resident admitted with pressure ulcers did not have wound care orders placed, leading to inadequate care. The resident expressed pain and concern over unchanged dressings, and was found with an abdominal wound and stage two pressure sores. The wound care nurse confirmed that orders should have been in place, but were not, due to a lapse in the admission process.
A resident with a history of falls was not promptly assessed after a fall, despite reporting leg pain and hitting their head. The facility failed to communicate the incident to the resident's spouse, who was present at the facility. The resident's symptoms of pain and nausea were not addressed until the following day, highlighting deficiencies in post-fall assessment and communication.
A LTC facility failed to maintain proper infection control protocols, including hand hygiene during meals and PPE use for residents under contact precautions. A family member assisted two residents without hand hygiene, and a doctor did not wear gloves while examining a resident with a PICC line. Additionally, a resident was incorrectly placed in a contact precaution room. The facility's policies require PPE use and proper resident placement to prevent infection transmission.
A resident requiring a mechanical Hoyer lift for transfers was manually transferred by two CNAs, leading to knee pain and a complaint from the resident's daughter. The facility's investigation revealed that the staff did not adhere to the prescribed transfer method, resulting in a deficiency report.
The facility failed to maintain a clean, comfortable, safe, and homelike environment, with observations of soiled floors, walls, trash/debris, broken chair and tile, unsecured sharps and chemicals, and visible pests. Interviews with staff revealed inconsistencies in cleaning schedules and responsibilities.
The facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications. A medication cart on the Oakridge Unit was observed unlocked and unattended, with medications accessible in all drawers, including the narcotic storage drawer. RN A confirmed the cart was left unlocked while a medication count was being performed away from the cart. The DON acknowledged that medication carts are to be locked and secured by authorized personnel.
Failure to Thoroughly Investigate Abuse Allegation and Protect Alleged Victim
Penalty
Summary
The deficiency involves the facility’s failure to conduct a timely, thorough, and well-documented investigation into an allegation of staff-to-resident abuse and to fully protect the alleged victim during the investigation. A resident with mild cognitive impairment, disorientation, and dependence on staff for all ADLs reported that a CNA entered his room on the midnight shift and hit him with pillows and threw water at him. A Facility Reported Incident indicated that the CNA identified by the resident was immediately suspended, a skin assessment was completed with no concerns noted, and increased supervision was instituted. However, the investigative record later provided to surveyors lacked key elements required by the facility’s abuse policy, including complete interviews and documentation from all potentially involved or affected residents. The investigation summary stated that all residents assigned to the implicated CNA on the relevant shift were interviewed and that no issues were identified, but the investigation file did not contain those resident statements or assessments. A CNA’s written statement reported that the alleged victim’s roommate had described hearing a CNA “beating up” on the resident and the resident yelling for help, yet there was no documented interview or statement from the roommate in the investigation materials initially provided. The Administrator’s own statement referenced directing nursing management to question competent residents on the unit about any concerns or distressed residents, and reported that a unit manager stated that several competent residents had no concerns; however, no corresponding resident interview documentation was included. When surveyors requested the complete investigation and later asked specifically for roommate and other resident statements, the Administrator was unable to produce them until the exit conference, at which time an additional resident statement from the alleged victim and the Administrator’s statement were provided. The facility also failed to clearly demonstrate that the alleged perpetrator was removed from the schedule and the building during the investigation, as required by the abuse policy. Time records showed that the CNA worked multiple shifts during the period when the investigation was purportedly ongoing. The Administrator asserted that the CNA had actually been suspended and that the timesheet had been modified only to ensure the CNA was paid, but no time correction sheets or other documentation were produced to verify this explanation. Progress notes documented that the resident was combative and stated staff were trying to hurt him, complained of right eye tenderness, and later told the psychologist that a woman in a white uniform hit him with a pillow while he and others yelled for her to stop. Social work documentation showed the resident reported not feeling safe and believing he saw the person enter his room again, and that he felt better after being told the person was not in the building. Despite these documented concerns and the resident’s detailed account, the facility’s investigation lacked contemporaneous, complete, and corroborating documentation of interviews and observations, and did not clearly show that the alleged victim was protected from the alleged perpetrator throughout the investigation. On subsequent observation and interview, the resident denied any mistreatment and made statements indicating confusion, such as believing he was in England in the middle of a war, while still stating he felt safe because he could defend himself. When surveyors interviewed the roommate, the roommate stated they could not remember or recall the incident or what they had previously said. The unit manager reported returning to the facility after being notified of the incident, performing a head-to-toe assessment on the resident, and later obtaining a description of the CNA from the resident, but could not recall the date and had no phone records to verify the timing. The Administrator stated that the investigation was completed at the time of the five-day submission to the State Agency, yet could not explain how the CNA was allowed to return to work the next day after suspension while the investigation was still ongoing. Overall, the documented actions and omissions show that the facility did not follow its abuse policy requirements for identifying and interviewing all involved persons, thoroughly documenting the investigation, and ensuring the alleged victim was protected from the alleged perpetrator during the investigative period.
Failure to Complete Braden Assessments and Timely Implement Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to complete Braden Scale assessments per policy, to accurately and timely implement wound care orders, and to promptly report and respond to abnormal wound changes for two residents with pressure injuries. One resident was admitted with a closed fracture, repeated falls, and existing skin issues including a left hip Stage II pressure injury and a coccyx suspected deep tissue injury. An admission Braden assessment scored the resident as "At Risk" with a score of 17, but this was the only Braden completed despite a facility policy requiring Braden assessments on admission, weekly for three weeks, and then quarterly. The facility’s wound nurse later confirmed that Braden assessments were expected upon admission and weekly thereafter, but the required follow-up assessments were not documented for this resident. For this same resident, wound consultation notes documented an unstageable left hip ulcer and a coccyx deep tissue pressure injury that later progressed to a Stage III ulcer. The wound clinician recommended Medihoney with foam dressing to the left hip three times weekly and Triad to the coccyx daily, later changing the coccyx treatment to Medihoney with a daily dry dressing. However, the MAR/TAR and physician orders showed Medihoney ordered and administered to both the left hip and coccyx daily, not three times weekly to the hip as recommended. There was no documentation explaining why the wound clinician’s recommendation for three-times-weekly treatment to the hip was not followed. Nursing notes also documented an open area to the coccyx and that Triad paste and a wound consult were ordered and logged for the physician, but subsequent physician notes indicated that the coccyx area was not examined on at least one visit, and multiple providers deferred to internal medicine and the wound care team without documenting direct assessment of the coccyx wound. The same resident also experienced a delay in implementation of a low air loss mattress. A nurse practitioner documented the resident’s complaint of pain to the coccyx and buttocks, noting three areas on the coccyx and buttocks with slough on the coccyx wound bed and that the resident was sore when lying on the back. The NP discussed obtaining a low air loss mattress with the nurse manager, and the physician orders showed the low air loss mattress was implemented that same day. There was no documentation explaining why this intervention had not been implemented earlier, despite the resident’s existing pressure injuries and pain. The second resident was admitted with chronic kidney disease, chronic systolic heart failure, and dependence on staff for all ADLs. An admission assessment documented a left buttock skin tear, but the only Braden assessment in the record was completed four days after admission and showed an "At Risk" score of 18, with no evidence of the required weekly Braden assessments per policy. Nursing documentation shortly after admission noted a small open area on the left buttock and that the wound care team had been consulted. A physician documented pressure sores on the left buttock and coccyx, Stage 2–3, with instructions to continue local care and offloading. Subsequent skin and wound documentation for this second resident showed progression to an unstageable pressure ulcer extending from the coccyx down the left buttock, with necrotic tissue involving approximately 50% of the proximal area. The wound clinician recommended daily Triad application to the entire area, and later documented that the ulcer had become a Stage III pressure ulcer with a recommendation to change treatment to Medihoney with a daily dry dressing. Review of the MAR/TAR and physician orders revealed that the Medihoney treatment did not begin until three days after the order date. There was no documentation explaining the delay in implementing the Medihoney treatment. Additionally, the record contained no documentation from front-line staff (nurses or aides) identifying changes or worsening of the wound that were later identified by the wound clinician during weekly consultations. Interviews with the wound nurse and wound clinician further clarified the processes and gaps related to these deficiencies. The wound nurse stated they were responsible for second skin checks on new admissions, rounding with the wound clinician, and entering new or modified orders after confirming them with the primary physician, and reported that primary physicians had not refused wound clinician recommendations. The wound nurse acknowledged the missed Braden assessments, the delayed low air loss mattress intervention, the discrepancy in the left hip Medihoney frequency, and the delay in starting Medihoney for the second resident. The wound clinician stated they had 48 hours to enter notes into the medical record and that they provided staff with written recommendations on the day of consultations, and also stated that staff had their phone number to report abnormal wound changes. The wound clinician acknowledged uncertainty about why a low air loss mattress had not been implemented earlier for one resident and confirmed that internal medicine worked with them as a team on such interventions.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety during a kitchen observation with the Certified Dietary Manager. In the walk-in cooler, there were opened, undated containers of ranch dressing, vinaigrette dressing, and thousand island dressing, and the CDM confirmed they should have been dated when opened. A personal cellular phone was also observed on the food preparation counter, and the CDM stated it should not have been there. In addition, five spatulas hanging on the utensil rack had rough edges and missing pieces around the edges, and the CDM stated he would throw them out and order new ones. A package of deli ham was observed on the food preparation counter at 9:00 AM and remained in the same spot at 11:40 AM, with an internal temperature of 71 degrees Fahrenheit.
Failure to Conduct Quarterly Care Conference
Penalty
Summary
The facility failed to ensure quarterly health care conferences were conducted for one resident who was reviewed for care conferences. The resident was admitted with diagnoses including dementia with agitation, psychotic disorder with delusions, and chronic kidney disease, had a BIMS score of 0/15 indicating severe cognitive impairment, was full code, and had a court-appointed guardian. A letter dated 3/17/25 from the physician to the guardian stated that, based on the resident’s medical decline, the guardian should consider changing the resident’s full code status to DNR, but the clinical record contained no documentation that the guardian responded to the letter or that any follow-up was completed, including a care conference. The record showed the last quarterly health care conference was held on 3/19/25 and documented that advance directives were reviewed with the legal representative, with the conference summary stating the guardian declined care conference. However, no additional notes were found showing social service follow-up or any scheduled care conferences after that date. During interview, the Social Worker Director stated they would review the record regarding the concern, and the Guardian Case Worker stated they had never been asked to join a care conference in 2025 and had not received the 2025 letter asking the guardian to consider a code status change. The Social Worker Director later agreed that a quarterly care conference should have been scheduled for the resident.
Lidocaine Patches Not Available for Ordered Pain Management
Penalty
Summary
The facility failed to ensure lidocaine patches were available for administration to a resident with diagnoses including pain in the right leg and chronic pain. The resident’s comprehensive plan of care identified a risk for impaired comfort related to chronic pain, breakthrough pain, and hemiparesis secondary to CVA, with interventions to administer pain medication as ordered and monitor for effectiveness. Physician orders were in place for Lidocaine Max St 24 Hours 4% patch to the right shoulder twice daily for pain and lidocaine HCl external pads to both knees twice daily for knee pain on a 12-hours-on/12-hours-off schedule. A review of the MAR and EMAR progress notes showed missed administrations of the lidocaine patches on multiple dates because the patches were not available, including entries such as “on order” and “not available” for both the bilateral knees and right shoulder. The missed administrations occurred on several days in August and September 2025. When questioned, the Nurse Manager stated that the unit clerk was responsible for ensuring enough patches were available and that they should be reordered when low so the facility would not run out, and acknowledged that the patches should have been applied on the missed days.
Tube Feeding and Water Flushes Not Given Per Order
Penalty
Summary
The facility failed to ensure tube feeding and water flushes for hydration were administered according to physician's orders for one resident, R23. On 9/9/25, R23 was observed asleep in bed with a tube feeding pump on a pole at the bedside, but there was no tube feeding formula bottle or water bag for hydration attached to the pump. A second observation later that morning again showed the pump and pole present without tube feeding formula or water for hydration. The physician's order dated 6/28/25 directed Jevity 1.5 tube feeding at 75 mL per hour for 16 hours and a water flush at 85 mL per hour for 16 hours, with both starting at 8 PM and stopping at 12 PM the following day. A review of the pump values on 9/10/25 showed that for the 9/8/25 to 9/9/25 administration, R23 received 756 mL of tube feeding formula and 867 mL of water recorded on the pump. Based on the order, R23 should have received 1,200 mL of tube feeding formula and 1,360 mL of water. During an interview, the DON was informed of the observations and the pump values and stated that the physician's order should be followed and that they would look into why R23 only received 759 mL of formula and 756 mL of water. The facility policy stated that feeding tubes will be utilized according to physician orders, including the kind of feeding, caloric value, duration, mechanism of administration, and frequency of flush.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure physician-ordered laboratory tests were obtained for one resident who was reviewed for laboratory diagnostics. The resident had diagnoses including congestive heart failure and end stage renal disease. A physician evaluation documented complaints of bloating, increased plaque chills with gas, uncertainty about passing gas or stool, possible fecal incontinence, and left hand tingling since a left arm procedure. The physician ordered B12, folate, and TSH laboratory testing on 8/28/25. Review of the resident’s medical record did not reveal results for the ordered B12, folate, or TSH tests. During an interview on 9/11/25, the Nurse Manager stated the lab requisition was never completed and the lab was never done. A facility document stated that the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and that labs not drawn as ordered are reported to the attending physician for further direction.
Failure to Provide Ordered Built-Up Utensils and Meal Assistance
Penalty
Summary
The facility failed to ensure that assistive devices for eating were provided to a resident who had built-up utensils ordered with meals. R17 was observed in their room attempting to eat breakfast on multiple occasions, but standard silverware was provided instead of the built-up utensils listed on the meal ticket and in the care plan. On one occasion, the breakfast tray was also left at the foot of the bed and out of R17’s reach. R17 had diagnoses including protein-calorie malnutrition and dysphagia, and the MDS indicated bilateral upper extremity impairment and need for staff assistance with ADLs. The comprehensive care plan directed that R17 receive 1-person assist with eating and built-up utensils with all meals. A dietary nutrition review also documented that R17 required assistance with meals, was on a regular puree diet with thin liquids, and remained on enteral nutrition to meet caloric and protein needs. During the survey, the Nurse Manager reviewed the meal ticket and stated that R17 should have been provided the built-up utensils and that dietary was responsible for placing them on the tray. The Dietary Director stated the department had a checking process to ensure meal tickets were read and assistive devices were provided, but indicated staff would need to speak with the dietary aides who checked trays to ensure the meal tickets were read correctly. A facility document stated that specialized eating utensils and adaptive equipment are provided and that the interdisciplinary team will work together to provide assistive devices and appropriate assistance.
Delayed Evaluation and Treatment of Foot Injury
Penalty
Summary
A resident with a history of orthostatic hypotension and syncope experienced a new onset of right foot pain after being assisted with a transfer. The pain was severe, with swelling and a high pain score reported. Nursing staff notified a nurse practitioner (NP) and a STAT X-ray was ordered, which initially showed no fracture. Despite ongoing complaints of pain, swelling, and the resident's inability to participate in physical and occupational therapy, there was no documented thorough evaluation of the right foot by a medical provider in the days following the injury. Progress notes indicated that the resident continued to experience significant pain and swelling, and therapy staff repeatedly documented the resident's inability to participate in therapy due to pain. Although the resident was seen by a PM&R physician and the NP was notified, documentation did not reflect a focused assessment of the injured area or address the acute pain and functional decline. The resident's pain was sometimes attributed to chronic neuropathy, and the acute injury was not specifically evaluated. It was not until six days after the initial injury that the attending physician documented a comprehensive assessment of the right ankle, noting significant swelling, bruising, and the resident's inability to bear weight. The resident was then placed on non-weightbearing status and referred for further evaluation. Subsequent imaging, including a CT scan, revealed a moderately comminuted avulsion fracture of the calcaneus with multiple displaced bony fragments. The delay in thorough evaluation and diagnosis resulted in prolonged pain and limited participation in rehabilitation. Interviews with facility staff, including the DON and PM&R physician, confirmed gaps in documentation and assessment, with uncertainty about which NP was contacted and a lack of clear documentation regarding the evaluation of the resident's acute injury.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bowel and bladder did not receive timely incontinence care. The resident reported being left wet and soiled for approximately 11 hours, from 4:00 AM to 3:00 PM, without being changed or repositioned. The resident stated that unless they used the call light, staff on the midnight shift did not check or reposition them, and if not changed during that shift, they had to wait until after breakfast. The resident described multiple unsuccessful attempts to have their brief changed, including using the call light several times and informing various staff members, but did not receive assistance until the evening shift began. Review of the clinical record showed the resident was dependent for toileting, had no bowel or bladder program, and was care planned for incontinence care per facility policy, with instructions to keep the resident clean and dry. Documentation for the day in question was incomplete, with no records of incontinence care provided during the day shift. The resident's complaints were corroborated by their email to the DON, which detailed the lack of response to call lights and the extended period without care, resulting in urine-soaked bed linens. Interviews with staff revealed confusion regarding room assignments, with the CNA assigned to the resident unaware of the assignment until the end of the shift. The DON confirmed that the standard of care was to check for incontinence every two hours, but there was no documentation of refusals or care provided on the day in question. The facility's policy required incontinence care as needed based on resident request or regular checks, but this was not followed, leading to the resident remaining soiled for an extended period.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications from a legally authorized representative for a resident diagnosed with Alzheimer's disease, fall from bed, and cerebral infarction. The resident, who had a BIMS score indicating moderately impaired cognition, was deemed incompetent to participate in medical decision-making due to dementia and visual hallucinations. Despite having a Durable Power of Attorney for Healthcare (DPOA-H) appointed, the facility administered psychotropic medications, including Sertraline and Lorazepam, without obtaining the necessary consent from the DPOA-H. The medical record review revealed multiple instances where Sertraline was prescribed and administered to the resident without documented consent from the DPOA-H. The facility's policy required informed consent for psychotropic medications, which was not adhered to in this case. The social worker acknowledged the lack of consent documentation and indicated that it was not brought to their attention that consent needed to be obtained. The facility's policy and procedures for psychotropic medication use were reviewed, highlighting the requirement for informed consent from the resident or authorized representative. Despite this policy, the facility did not provide documentation of consent from the DPOA-H for the psychotropic medications administered to the resident, including the multiple dose increases of Sertraline and the administration of Lorazepam.
Failure to Follow Pest Control Procedures Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to follow pest control procedures for a resident, leading to a bed bug infestation. The issue began when a resident's sister visited and brought in clothing and belongings from the resident's previous apartment, which were infested with bed bugs. The bed bugs were first noted on the resident in room 414L, and subsequently, the resident's roommate was also affected. The facility initiated its bed bug policy and procedures, which included showering the residents, moving them to new rooms, and cleaning their belongings. However, the procedures were not followed correctly, as evidenced by a CNA putting the same potentially infested clothes back on a resident after a shower, leading to bed bugs being found in the resident's hair the following day. The resident involved had a medical history including bipolar disorder and post-traumatic stress disorder, and required assistance with activities of daily living. The resident was upset about having to evacuate their room due to the bed bug infestation and experienced small bites on their inner thighs. The facility's failure to adhere to its pest control procedures resulted in the resident experiencing discomfort and requiring additional interventions to address the infestation. The CNA involved was unaware of the correct procedures and was subsequently disciplined and educated on the proper protocol.
Resident Abuse Due to Misplacement by Staff
Penalty
Summary
The facility failed to protect a resident, R803, from physical abuse by another resident, R804. The incident occurred when R804 pushed R803 out of their wheelchair, resulting in R803 falling. R803, who has Alzheimer's Disease with hallucinations and moderately impaired cognition, was mistakenly taken to R804's room by a dietary staff member. R804, who has severely impaired cognition, became irate upon finding R803 in his room and pushed him, leading to the fall. The incident was reported by a Licensed Practical Nurse (LPN) who heard screaming and found R803 on the floor near his wheelchair. R804 admitted to pushing R803, claiming that R803 was trying to take his belongings. The facility's investigation revealed that a dietary staff member, who was trying to be helpful, had assisted R803 into R804's room without knowing it was not R803's room. This led to the altercation between the two residents. The facility's policy on abuse, which states that residents have the right to be free from abuse, was not adhered to in this case. The lack of proper supervision and communication among staff members contributed to the incident. The dietary staff member involved was not aware of the residents' room assignments and did not consult with nursing staff before assisting R803, which ultimately led to the deficiency.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect to the Administrator/Abuse Coordinator and the State Agency for a resident who was observed covered in dry feces. The incident was reported to a nurse and the Director of Nursing (DON) on the same day, but they allegedly indicated that incontinence care was not necessary as the resident was dying. The resident, who was cognitively intact, had been admitted with diagnoses including spontaneous bacterial peritonitis, cirrhosis of the liver, and malnutrition, and was discharged to home hospice care the following day. Interviews conducted during the investigation revealed discrepancies in staff accounts. The Unit Manager (UM) D, who was a family member of the resident, was not informed of the incident until after the resident's discharge. Nurse F, who was reportedly informed of the situation, denied any knowledge of the resident or the incident. The DON acknowledged hearing about the resident being left soiled but did not recall specific details or who reported it. The DON also mentioned that the resident had refused care and was combative, but no documentation supported this claim. The facility's policy requires immediate reporting of abuse or neglect allegations to the Administrator and the State Agency, but this protocol was not followed. The Administrator was unaware of the incident until informed by the DON days later. The DON later presented an undated investigation report, which included interviews with staff, but inconsistencies were noted, such as Nurse F's denial of involvement. The facility's failure to document and report the incident in a timely manner constitutes a deficiency in adhering to their abuse and neglect policies.
Facility Fails to Ensure 24-Hour Visitation Rights
Penalty
Summary
The facility failed to ensure unrestricted, 24-hour visitation rights for its residents, affecting all 143 residents. During a resident council meeting with the State Agency, several anonymous residents reported that the facility's visitor hours were restricted to between 8:00 AM and 8:00 PM, with the front door being locked at 8:00 PM. This was confirmed by the Administrator, who stated that the facility's visitor hours were indeed from 8:00 AM to 8:00 PM, and that this was announced overhead each night. The Administrator was unable to confirm whether residents were aware of their right to have visitors outside of these hours. Further investigation revealed that the facility did not have a formal visitor policy, and the admission packet provided to residents stated in large bold print that visitation was from 10:00 AM to 7:45 PM daily, with the lobby door locking at 8:00 PM. The Business Office Manager confirmed that announcements were made each night starting at 7:45 PM, informing residents and visitors of the end of visiting hours. This practice of restricting visitation hours and locking the front door at 8:00 PM was not in compliance with the residents' right to receive visitors of their choosing at any time.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain the kitchen's ventilation hood filters and dish machine in a sanitary manner, which could potentially affect all residents consuming food from the kitchen. During an observation, the cookline hood ventilation filters were found with a buildup of grease, and the Certified Dietary Manager (CDM) stated that kitchen staff were responsible for cleaning the hood vent. According to the 2017 FDA Food Code, non-food contact surfaces of equipment should be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the dish machine was not sanitizing properly. A plate simulating dishwasher tester recorded maximum temperatures of 152 and 153 degrees Fahrenheit, which were below the required 160 degrees Fahrenheit for sanitization. The dish machine's digital temperature display also showed inadequate rinse temperatures. The Temperature Log for the dish machine revealed consistently low temperatures, and the CDM was unaware of these issues. Maintenance staff later found forks blocking the sensor and a thick slime buildup inside the dish machine, further indicating a lack of proper maintenance and cleaning.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect, as evidenced by multiple observations of staff entering residents' rooms without knocking or announcing themselves. This was particularly noted in a secured unit where staff did not wait for acknowledgment before entering. Additionally, during a lunch meal, a nurse was observed standing while feeding a resident, despite available seating, which did not promote a dignified dining experience. Further dignity concerns arose when a family member was observed feeding two residents simultaneously without sanitizing their hands between assisting each resident. This occurred in the presence of nursing staff who did not intervene. The residents involved had severe cognitive impairments and required assistance with eating, as outlined in their care plans. The facility's policy on dignity, which mandates respectful treatment and acknowledgment before entering rooms, was not adhered to, leading to these deficiencies.
Failure to Honor Resident's Choice of Physician
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident who expressed dissatisfaction with their current doctor, Dr. F. The resident, who was under contact precautions, reported that Dr. F attempted to examine their PICC line and foot wound without wearing gloves, which led to a confrontation. The resident, who had intact cognition as indicated by a BIMS score of 14/15, explicitly told Dr. F that they no longer wanted them as their doctor. Despite the resident's clear communication of their desire to change doctors, Dr. F intended to see the resident again, assuming the resident might have calmed down. The Director of Nursing confirmed that residents could change doctors at any time and acknowledged that Dr. F should have informed the facility of the resident's decision to terminate their services. The facility's admission contract supports the resident's right to choose their attending physician, yet this right was not initially honored in this instance.
Failure to Provide Proper Notice for Room Change
Penalty
Summary
The facility failed to provide appropriate notice in a dignified manner regarding a room change for a resident, identified as R289, who was reviewed for room changes. R289, who had been admitted with diagnoses including an open wound of the abdominal wall, prostate cancer, and chronic kidney disease, was observed in a different room than initially assigned. Over the course of four days, R289 was moved three times without proper notification or explanation. On one occasion, staff attempted to move R289 at 2:00 AM without providing a reason, leading to the resident's refusal to move. The resident, who had intact cognition as indicated by a BIMS score of 13/15, expressed awareness of their rights and questioned the staff's actions. The Director of Nursing (DON) acknowledged that R289 should have been informed of the reason for the room change, especially during the early morning hours. An LPN involved in the attempted room change at 2:00 AM stated that they informed R289 of the reason but could not provide specific details, which led to the resident threatening to contact their attorney. The facility's policy on room changes requires that residents receive written notice, including the reason for the change, and that discussions occur with the resident or their representative. This policy was not followed, resulting in a deficiency in honoring the resident's rights.
Failure to Implement DNR Order for Resident
Penalty
Summary
The facility failed to execute a Do-Not-Resuscitate (DNR) Advance Directive order for a resident who was admitted for rehabilitation from right toe gangrene. The resident had a medical history of diabetes, hypertension, end-stage renal disease, and required peritoneal dialysis. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 14/15. During a health care conference, the resident expressed their choice of DNR code status, and the DNR form was completed by the resident but was awaiting a physician's signature and order. Despite the resident's expressed wishes and the completion of the DNR form, the facility did not implement the DNR code status, and the resident remained a full code throughout their stay. The physician did not sign the DNR form until after the resident was discharged from the facility, as confirmed by the Corporate Social Services representative.
Disorganized Discharge Process Leads to Resident Confusion
Penalty
Summary
The facility failed to ensure a safe and coordinated discharge process for a resident, leading to confusion and distress for both the resident and their spouse. The resident, who had a history of type two diabetes, repeated falls, and generalized anxiety disorder, was initially informed of their discharge on a specific date. However, due to a fall that occurred on the morning of the planned discharge, the discharge was postponed without clear communication to the resident and their spouse. The resident expressed dissatisfaction with the lack of organization and communication, stating that they had not been involved in a care conference to discuss their discharge plan. The situation was further complicated by the resignation of the social work director, leaving the new social worker uncertain about the discharge process. The resident and their spouse were given conflicting information about the discharge, leading to frustration and confusion. At one point, the resident attempted to leave the facility, believing they had been discharged, only to be told by the DON that necessary arrangements, such as home care and follow-up appointments, had not been made. The facility's lack of coordination and communication resulted in the resident being petitioned to a hospital for psychiatric evaluation due to alleged self-harm behaviors, although the resident insisted they were competent and not receiving adequate collaboration from the facility staff.
Failure to Implement Baseline Care Plan for Tube Feeding
Penalty
Summary
The facility failed to implement a baseline care plan for a resident who was receiving tube feeding. The resident, identified as R287, was admitted with diagnoses including stroke, major depressive disorder, and malnutrition, and had a severely impaired cognition score of 3/15 on the Brief Interview for Mental Status exam. Despite these conditions, the baseline care plan for R287 did not include instructions for tube feeding, which is necessary to meet the resident's immediate health and safety needs. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that a care plan for tube feeding should have been in place from admission.
Medication and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were accurately documented and orders were written according to professional standards of practice for two residents. For one resident, an LPN prepared seven medications, crushed them, and mixed them with applesauce. The resident refused to take the medications, but the LPN marked them as given before the refusal occurred. The LPN admitted to marking the medications as administered before the resident had taken them, which is against the facility's protocol. The Director of Nursing confirmed that medications should only be marked as given after the resident has taken them. For another resident, who was admitted with diagnoses including stroke, major depressive disorder, and malnutrition, there was a failure to document complete tube feed orders. The resident was receiving Jevity 1.5 Cal enteral nutrition at a specified rate, but the physician orders lacked details on the type of formula and infusion rate. The Registered Dietician and a Registered Nurse confirmed that the orders should have been complete with all required elements, and that a progress note was not sufficient for tube feed orders. The facility's job description for the Unit Charge Nurse indicates responsibility for ensuring complete and accurate nursing services, which was not met in this case.
Failure to Provide Wound Care and Follow-Up on Physician Consult
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, R337 and R120, as observed during the survey. R337, who was admitted with a surgical wound to the gallbladder, reported that their wound dressings had not been changed, resulting in a wound with blood and drainage that emitted a mild odor. The wound care nurse confirmed that there were no current orders for wound care, which should have been in place following the hospital paperwork. Similarly, R120, who had a wound vac and a hand dressing, reported that their hand dressing had not been changed since 7/31/24, despite the medication administration record indicating it was completed on 8/2/24. The wound care nurse and the Director of Nursing acknowledged a miscommunication regarding the completion of the treatment. Additionally, the facility failed to follow up on a physician consult appointment for R128, who was admitted for rehabilitation from right toe gangrene and had a medical history of diabetes, hypertension, and end-stage renal disease. The Director of Nursing acknowledged that the process for coordinating care for outside appointments was not followed correctly, as there was no documentation of an after-visit summary following a doctor's appointment attended by R128's daughter. The facility's policy on coordination of care for outside appointments was requested but not provided by the end of the survey.
Failure to Initiate Wound Care Orders on Admission
Penalty
Summary
The facility failed to ensure that wound care orders were placed for a resident upon admission, leading to inadequate care for pressure ulcers. On observation, the resident was found lying in bed, expressing pain and concern that their wound dressings had not been changed. The resident showed an abdominal wound with blood, drainage, and a mild odor, indicating a lack of timely wound care. Additionally, during incontinence care, the resident's coccyx area was observed to have a reddened border and a greenish-yellow slough base, with two stage two pressure sores on the left gluteal cheek. A review of the medical records revealed that the resident was admitted with diagnoses including hyperlipidemia, type two diabetes, and a mild protein deficit, and had an intact cognition. However, there were no wound care orders placed on the day of admission. The wound care nurse confirmed that there should have been orders in place, and explained that admitting nurses are responsible for obtaining treatment orders from doctors until wound care rounds can be conducted. This oversight resulted in the resident not receiving the necessary wound care upon admission.
Failure to Promptly Assess and Communicate After Resident Fall
Penalty
Summary
The facility failed to promptly assess a resident, identified as R29, after a fall, which occurred on the morning of 8/5/24. R29, who has a history of repeated falls and was supposed to receive assistance when using the restroom, was found unassisted in the bathroom. After the fall, R29 reported hitting their head and experiencing leg pain. However, the initial assessment by the nursing staff did not document any pain, and the resident was not thoroughly evaluated for potential injuries, such as a head injury, despite the fall. The nurse practitioner ordered a bolus for hypotension and neurochecks, but there was no immediate follow-up on the resident's complaints of pain and nausea. The following day, R29 reported feeling sick, experiencing vomiting, and continued leg pain, which they had communicated to the facility staff. However, the Unit Manager stated that R29 had not complained of any symptoms the previous day. It was only after further inquiry by the surveyor that the Unit Manager agreed to contact the doctor for further evaluation, including ordering x-rays and medication for nausea. Additionally, R29's spouse was not informed of the fall by the facility, despite being present at the facility all day. This lack of communication and delayed response to the resident's symptoms highlights the deficiency in the facility's protocol for post-fall assessment and communication with family members.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices, particularly in hand hygiene during meals and the use of personal protective equipment (PPE) for residents under transmission-based precautions. During a dining observation, a family member was seen assisting two residents, R42 and R73, with their meals without using hand sanitizer or washing hands between assisting the residents. Despite the presence of nursing staff, no intervention was made to address the family member's actions. Both residents had severe cognitive impairments and required assistance with eating, as noted in their care plans. In another incident, R288, who was under contact precautions, reported that their doctor, Dr. F, touched their PICC line and foot wound dressing without wearing gloves. Despite being informed by R288 to wear gloves, Dr. F did not comply and expressed reluctance. The facility's infection control nurse and the director of nursing confirmed that all staff, including physicians, must wear PPE when entering a contact precaution room. R288 had intact cognition and refused further examination by Dr. F due to the lack of PPE use. Additionally, R289 was mistakenly placed in a contact precaution room, which was not appropriate given their medical condition. The resident was moved to a room with a contact precaution sign, but the midnight manager claimed there was no sign on the door at the time of the move. The director of nursing acknowledged the error and stated that R289 should not have been placed in that room. The facility's policy on infection control and transmission-based precautions emphasizes the importance of proper resident placement and the use of PPE to prevent the transmission of infectious agents.
Improper Transfer Method Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R901, according to the plan of care and facility policy. The resident, who required a mechanical Hoyer lift with two-person assistance for transfers, was instead transferred manually by two CNAs. During this transfer, the resident complained of knee pain, which was not immediately addressed by the staff. The incident was reported by the resident's daughter, who was present at the time and insisted on hospital evaluation for her mother. The investigation into the incident revealed discrepancies in the staff's account of the transfer. The CNAs involved in the transfer reported that the resident was assisted to stand and pivot without any signs of pain during the process. However, shortly after the transfer, the resident began to complain of knee pain, which led to further evaluation. The resident's daughter, although not witnessing the transfer, believed her mother's account of the incident, which included allegations of being dropped to the floor, although this was not corroborated by staff interviews. The facility's documentation and interviews with staff and the resident's daughter indicated a lack of adherence to the prescribed transfer method using a mechanical lift. The resident's care plan clearly stated the need for a mechanical lift, yet the staff opted for a manual transfer, which was against the facility's policy. This deviation from the care plan and policy led to the resident experiencing pain and the subsequent complaint filed with the State Agency.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment, as evidenced by soiled floors, walls, trash/debris throughout the facility, broken chair and tile, unsecured sharps and chemicals, and visible harborage of pests. Multiple observations were made during the survey, including debris in hallways, soiled linens and used gloves on the floor, and unsecured chemicals in shower rooms. Additionally, there were instances of mold-like substances in grout, dead bugs in shower rooms, and food debris in dining areas. At various times during the survey, specific areas such as the Anna's House unit, Oakridge unit, and Hickory unit were found to have significant cleanliness issues. For example, the shower rooms had used briefs, gloves, towels, and washcloths scattered on the floor and handrails. Unsecured chemicals and personal care items were also found in these areas. The dining rooms had food debris, spider webs, and pests, and the flooring throughout the facility was littered with trash and debris. Interviews with staff, including the Director of Housekeeping and Laundry, revealed inconsistencies in cleaning schedules and responsibilities. Housekeeping staff were reported to clean certain areas before leaving for the day, but there were gaps in coverage, especially after dinner and on weekends. The Director of Housekeeping confirmed the observations and acknowledged the need for changes in cleaning routines and responsibilities. However, there was no clear policy or documentation provided by the facility to address the maintenance of a clean, comfortable, safe, and homelike environment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications. On 5/28/24 at 3:23 PM, a medication cart located on the Oakridge Unit, in front of room [ROOM NUMBER], was observed unlocked and unattended by authorized staff. The medications were accessible in all drawers, including the narcotic storage drawer. Registered Nurse (RN) A returned to the cart on the Oakridge Unit indicating a medication count was being performed with another nurse, away from the assigned medication cart. RN A confirmed the cart was left unlocked, unattended, and medications, including scheduled narcotics were accessible to unauthorized personnel. On 5/28/24 at 3:38 PM, the Director of Nursing (DON) was interviewed and acknowledged medication carts are to be locked and secured by authorized personnel. Review of the facilities policy titled 'Medication and Treatment Cart Storage' dated 5/4/22 documented that all drugs and biologicals will be stored in locked compartments (i.e., medication carts) and narcotics and controlled substances are to be stored under double-lock and key.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Southfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Village Of Beverly Hills | 1.4 mi | — | 15 | 1 |
| Lahser Hills Care Centre | 1.6 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Southfield | 1.7 mi | ★★★★★ | 25 | 1 |
| Greenfield Rehab And Nursing Center | 1.8 mi | ★★★★★ | 4 | 0 |
| The Lakeland Center | 3 mi | ★★★★★ | 27 | 0 |
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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.