Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Oaks Nursing Center during CMS and state inspections, most recent first.
Weights were not obtained as ordered for two residents with CHF, and both had 5-pound gains from the last documented weight with no documentation that the provider was notified or that PRN diuretics were given. A third resident with CHF, COPD, and CKD had a recorded 102.4-pound weight gain over five days, but the EMR showed no documentation that the abnormal weight was addressed or that the resident was assessed for related changes. The DON confirmed the missed weights and abnormal gains, and also stated the large weight entry was likely inaccurate after the resident was later re-weighed.
A resident with dementia, weakness, and altered mobility had a right heel pressure injury, but heel boots ordered to be worn at all times were repeatedly not in place during observations. Ordered daily wound care was not documented as completed for several days after the injury was identified, the RP was not notified until days later, and the DON later found the heel had progressed to an unstageable wound with eschar.
Controlled medication administration records did not match dispensing records for several residents. An Ativan gel dose was dispensed without documentation of administration or witnessed waste, tramadol was charted as given twice daily when only one dose was dispensed on multiple days, lorazepam refusals lacked documented waste or 2-nurse disposal, and oxycodone doses were charted as administered without waste documentation. The DON confirmed the discrepancies and stated licensed nurses were expected to follow provider orders and nursing standards.
A resident admitted for orthopedic aftercare signed a voluntary binding arbitration agreement, but later said he had no idea what it was and did not recall signing it. The NHA and AA reported the agreement was not explained well, the AA did not know residents had 30 days to revoke in writing, and the admission binder did not include a description of arbitration; the resident also signed both acceptance and declination forms.
Failure to implement EBP for a resident with a wound. A resident admitted with a stage 2 pressure ulcer had no EBP noted in the care plan, progress notes, or EMR orders despite documentation of a worsening right heel pressure injury. During wound care, the DON and a CNA assisted with the procedure but did not wear the PPE required for EBP during the high-contact activity.
A resident with diabetes, CHF, CKD, a history of inguinal hernia, and a suprapubic catheter did not receive appropriate assessment, monitoring, documentation, and care planning for multiple active conditions. Hospital instructions and recommendations for hernia management, including use of a support device and strict return precautions, were not clearly documented or followed up, and there was no ongoing hernia assessment despite repeated reports of the hernia being "out" and subsequent hospitalization for small bowel obstruction and incarcerated hernia. The resident’s CKD, hyperkalemia, and hyponatremia were treated with medications such as Lokelma and sodium chloride without documented ongoing lab monitoring or evidence of stability, and CHF management lacked a specific care plan, baseline weight reference, or documented monitoring despite fluid restriction, diuretic, and midodrine orders. Skin assessments showed dry, reddened, and excoriated areas and boggy heels, but care plans did not include a pressure ulcer risk focus, wound interventions, or a pruritis care plan. There was also confusion and conflicting documentation between Foley and suprapubic catheter care, with the resident observed having a suprapubic catheter and excoriated skin at the site while the MAR and care plans contained Foley-focused orders and lacked clear suprapubic catheter interventions.
A cognitively impaired resident with Alzheimer’s disease, dementia, anxiety, and hallucinations was subjected to verbal and physical abuse by a podiatrist during a visit in her room. Staff in a nearby room heard thumping, scuffling, and a male voice yelling and swearing, including statements such as not to "f*ck*ng" lay hands on him. A CNA reported seeing the podiatrist push the resident, causing her to fall back onto her bed, while the resident yelled at him to get out. The DOR found the resident on her bed, glasses displaced, arms flailing, yelling, crying, and physically upset. A post‑incident assessment documented redness on the resident’s forearm, a complaint of wrist pain, and her statement that people had been "beating [her] with hammers." The podiatrist had been entering resident rooms alone to provide services, and his conduct toward this resident met the facility’s own definitions of verbal and physical abuse.
The facility failed to ensure call lights were within reach for two residents with dementia and mobility assistance needs. One resident's call light was repeatedly found out of reach, despite her ability to use it when accessible. Another resident's call light was coiled on the bed, out of reach, while she sat in a chair. Both residents' care plans required staff to keep call lights accessible, which was not consistently followed.
The facility failed to implement effective antibiotic stewardship, leading to inappropriate antibiotic use for two residents. A resident with frequent UTIs received multiple antibiotics, but records were incomplete and inaccurate. Another resident was discharged with antibiotics not tracked by the facility. The Infection Control Preventionist reported issues with the tracking system and lack of follow-up on antibiotics administered over weekends.
A resident's dignity was compromised when a CNA engaged in a verbal altercation with her, making disrespectful comments and failing to maintain a professional demeanor. The incident involved the CNA asking the resident why she was 'mean muggin'' him, leading to an argument where the CNA made further inappropriate remarks.
The facility failed to implement adequate care plans for two residents, leading to deficiencies in their care. One resident, with morbid obesity and dementia, developed pressure ulcers without a care plan focus on prevention or management. Another resident, with dementia and chronic kidney disease, experienced frequent incontinence episodes without sufficient care plan interventions to address his toileting needs.
A resident with CHF and Morbid Obesity experienced significant weight gain, but the facility failed to revise her care plan to include personalized interventions, despite her expressed desire to lose weight. The care plan had not been updated since July, and the interdisciplinary care conference did not involve the resident's input or address her specific needs.
A resident with a history of dementia, chronic kidney disease, and frequent UTIs did not receive appropriate continuity of care in an LTC facility. Despite multiple antibiotic treatments and a urology consultation, there was no follow-up on planned interventions or documentation of the root cause of the UTIs. The care plan lacked focus on urinary issues, and staff did not consistently document or assist with toileting needs, leading to a deficiency in quality of care.
A facility failed to provide adequate pressure ulcer care for a resident with morbid obesity, dementia, and mixed incontinence. The resident developed two Stage II pressure wounds, but treatment orders were delayed, and required dressings were missing. The care plan lacked focus on active pressure ulcers, and staff reported difficulties in repositioning the resident. The Director of Nursing confirmed inaccuracies in skin assessments and care plans, and the facility's policy on skin assessment and treatment was not followed.
A resident with morbid obesity, dementia, and mixed incontinence was not provided timely incontinence care, resulting in moisture-associated skin damage (MASD). The resident was found in a wet chair with saturated briefs, and the CNA did not apply barrier cream due to unavailability. The resident was toileted only 2-4 times daily, with long intervals between, contrary to the facility's policy of every two hours. The Care Plan lacked MASD interventions, and the Director of Nursing acknowledged the failure to meet care expectations.
The facility failed to notify a medical provider of significant weight changes for two residents. One resident experienced a notable weight loss, while another had weight increases over several months. Despite expectations for documentation and notification, there was no evidence that the medical provider was informed of these changes.
Two residents received incontinence care without proper hand hygiene, leading to a deficiency in infection control. One resident, with cognitive impairment and incontinence, was cared for by CNAs who failed to change gloves or sanitize hands after handling soiled items. Another resident, with a yeast infection, received peri care from CNAs who did not change gloves or sanitize hands after touching contaminated surfaces. The facility's LPN confirmed the requirement for hand hygiene but noted a lack of recent audits.
An LPN in a LTC facility administered all daily medications at once to several residents, leading to a resident's hospitalization and another experiencing hypoglycemia. The LPN admitted to the error, which was done for time management, and subsequently resigned.
A resident reported feeling intimidated and threatened by an LPN, who allegedly yelled and made threatening remarks. The facility failed to report these allegations to the state survey agency in a timely manner, and the initial report was incomplete. The DON and NHA were informed but did not document or investigate the allegations promptly.
A resident with dementia was involved in an altercation, but the incident was not properly documented in her medical records. The DON acknowledged the lack of detail in the documentation, which focused on the resident's agitation related to bowel movements rather than the altercation itself. This failure to maintain accurate records is critical for effective communication and care.
Missed Weights and Unaddressed Significant Weight Gain
Penalty
Summary
The facility failed to ensure that weights were obtained in accordance with physician orders for three residents reviewed for nursing services. For one resident with CHF, the order required daily weights and PRN torsemide for a 4-5 pound weight gain in a day, but a weight was not obtained on one day, the next recorded weight showed a 5-pound gain from the prior documented weight, and there was no documentation that the provider was notified or that PRN torsemide was given. For another resident with CHF, the order required daily weights and PRN Bumex for a 3-pound gain in a day or 5-pound gain in a week, but a weight was missed on one day, the following recorded weight showed a 5-pound gain, and there was no documentation that the provider was notified or that PRN Bumex was administered. A third resident with CHF, COPD, and chronic kidney disease had a recorded weight increase of 102.4 pounds over five days, from 223.6 pounds to 326 pounds, which represented a 45.8% change in weight. The facility's weight management policy stated that patterned or significant weight loss or gain required the interdisciplinary team to assess and implement individualized interventions, but the electronic medical record contained no documentation that the weight gain was addressed or that the resident was assessed for a significant change in weight and related effects such as swelling or shortness of breath. During interview, the DON confirmed the missed weights and the 5-pound weight gains for the two residents with CHF and stated that the PRN diuretic orders would be reviewed with the provider and nurses would be educated on following orders as written. For the resident with the large weight gain, the DON stated the resident should have been re-weighed soon after the abnormal weight was recorded and acknowledged that the recorded 326-pound weight was likely inaccurate, noting that the resident later weighed 227 pounds and the earlier 326-pound entry was struck out as incorrect documentation.
Failure to Maintain Heel Offloading and Complete Ordered Pressure Ulcer Treatment
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for a resident with dementia, abnormal posture, weakness, muscle wasting and atrophy, and altered functional mobility and ADLs. The resident was admitted with a care plan that included heel boots at all times, but observations on multiple occasions showed the resident seated in a wheelchair in the common area with the heel boots not in place. After the right heel pressure injury was identified, interdisciplinary documentation described a large blister that had opened with dark discoloration and blanchable redness surrounding the area, and a foam border dressing was applied with a message left for the CCC. The resident’s responsible party was not notified until six days after the pressure ulcer was discovered. The April 2026 MAR/TAR reflected an order to cleanse the right heel, apply betadine and a heel cup, and secure with kerlix every day shift starting two days after the pressure injury was identified, but the treatment was not documented as done. The May 2026 MAR/TAR also did not document the treatment as done until 5/5/2026. When the DON assessed the wound, the right heel had progressed from a stage 2 pressure injury to an unstageable wound with eschar covering most of the wound bed, and heel boots were again not applied after the dressing procedure.
Controlled Medication Documentation and Disposal Errors
Penalty
Summary
The facility failed to ensure controlled drugs were administered in accordance with physician orders and nursing professional standards of practice for 4 residents reviewed for medication administration. The deficiency involved discrepancies between controlled drug dispensing records and the electronic medication administration record (EMAR), along with missing documentation of waste or disposal when doses were refused, withheld, or otherwise not given. For one resident with restlessness and agitation, an Ativan gel dose was dispensed but was not documented as administered on the EMAR, and there was no documentation that the medication had been wasted or that another nurse witnessed disposal. For another resident with weakness and difficulty walking, tramadol was ordered twice daily, but on multiple dates only one dose was dispensed while the EMAR documented both the morning and bedtime doses as administered. For a resident with chronic pain, lorazepam was ordered daily at 4:00 PM, but doses dispensed on two dates were documented as refused on the EMAR without documentation that the medication was wasted or that disposal was witnessed by a second nurse. For a resident with a right femur fracture, oxycodone was dispensed on three occasions and documented as administered on the EMAR, but there was no documentation that the controlled medication had been wasted. The DON confirmed the medication errors and discrepancies during interview and stated the expectation was for licensed nurses to follow physician orders and professional standards of nursing practice.
Binding Arbitration Agreement Not Properly Explained or Consented To
Penalty
Summary
The facility failed to ensure that binding arbitration was explained in a manner understood by residents and/or resident representatives and failed to obtain adequate informed consent before entering into a binding arbitration agreement for one resident. R62 was admitted from a hospital for orthopedic aftercare and was listed as his own responsible party. During interview, R62 stated he had no idea what a binding arbitration agreement was, did not recall signing it, and said his son handles those matters because they are over his head. Record review showed R62 signed a Voluntary Binding Arbitration Agreement on admission and initialed the statement indicating understanding of the binding agreement to arbitrate, including that the resident or representative fully understood the agreement. During interview, the NHA reviewed the arbitration paperwork and it was identified that R62 signed both the acceptance and the declination of the binding arbitration agreement. The AA reported she was responsible for explaining binding arbitration upon admission, but she did not know she needed to tell residents or representatives they had 30 days to change their mind in writing. The NHA and AA also stated they believed binding arbitration could be reversed at any time and did not know much about it, and the admission binder did not contain a description of binding arbitration.
Failure to Use Enhanced Barrier Precautions for Resident With Open Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for one resident with a wound. Resident 16 was admitted with diagnoses that included a stage 2 pressure ulcer, and the care plan initiated on 12/01/2025 did not reflect that the resident was on Enhanced Barrier Precautions. The resident’s interdisciplinary documentation dated 4/28/2026 noted a pressure injury to the right heel measuring 6 cm x 3.5 cm, described as a large blister that had opened with dark discoloration and blanchable redness surrounding the area, and a foam border dressing was applied. The progress notes and electronic orders did not reflect that the resident required Enhanced Barrier Precautions because of the open wound. During observation on 05/06/2026 at 9:21 AM, the DON removed the dressing from the resident’s right heel and assessed the wound, which had progressed from a stage 2 pressure injury to an unstageable wound with eschar covering most of the wound bed. The DON and a CNA assisted with the procedure, but neither donned the personal protective equipment required for Enhanced Barrier Precautions during the high-contact resident activity. In follow-up interview, the DON acknowledged the resident would require Enhanced Barrier Precautions due to the presence of a wound.
Failure to Assess, Monitor, and Care Plan for Complex Medical Conditions and Devices
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess, monitor, document, and care plan for a cognitively intact resident with multiple complex medical conditions, including diabetes, CHF, CKD, benign prostatic hyperplasia, a history of hernia with repair, and a suprapubic catheter. The resident was observed with disheveled hair and scabbing on his head, reporting that he scratched due to itching. A skin assessment documented red, dry bilateral lower extremities with scratch marks, boggy blanchable heels, and red, excoriated posterior thighs, yet the care plan only referenced a history of skin impairment and MASD to the right posterior thigh and did not include a specific pressure ulcer risk focus, wound interventions for the heel, suprapubic exit site excoriation, or MASD prevention. There was also no care plan for pruritis despite orders for topical treatments for itchy skin. Regarding the resident’s hernia and related pain, hospital emergency room notes documented a right inguinal hernia that was reduced with instructions for “strict return precautions,” but these precautions were not clarified or documented in the EMR. A nursing note relayed a hospital recommendation for an over-the-counter hernia support device and instructions to reduce the hernia if it returned, but there was no documentation that the resident ever received the hernia support or that ongoing hernia assessments and monitoring occurred. Subsequent nursing notes described episodes where the resident reported his hernia was “out,” received Norco, and was positioned with head down and feet up, but there was no ongoing assessment or monitoring documented. Later, the resident was sent to the ED with abdominal distention and brown emesis and was diagnosed with small bowel obstruction, right inguinal hernia, pneumatosis intestinalis, and AKI, with hospital records noting an incarcerated inguinal hernia and conservative management with a scrotal support belt; however, the care plan remained vague, not focused on the hernia, and contained no specific hernia-related interventions or updates after hospital return. The facility also failed to adequately monitor and care plan for the resident’s CKD, hyperkalemia, hyponatremia, and CHF. Labs showed elevated potassium and reduced eGFR consistent with CKD stage III, and the practitioner added Lokelma for hyperkalemia, but there were no subsequent potassium labs in the EMR to reflect ongoing monitoring or stability on this medication, despite continued Lokelma orders and the resident at one point declining the medication. Sodium chloride and Lokelma were ordered without documentation of ongoing sodium and potassium monitoring or evidence that the resident was stable on these medications. The resident had CHF with orders for Lasix, a fluid restriction, and midodrine (first scheduled, then PRN for MAP < 65), but there was no documented CHF monitoring protocol, no baseline reference weight clearly established, and no CHF-focused care plan or interventions, despite multiple weight fluctuations and the DON’s acknowledgment that staff likely did not know how to calculate MAP and that the order lacked typical nursing home parameters. In addition, the facility did not maintain accurate documentation or appropriate care planning for the resident’s suprapubic catheter. Staff interviews revealed confusion between a Foley catheter and a suprapubic catheter, with the EMR and MAR listing Foley catheter care orders while the resident actually had a suprapubic catheter. The resident was observed with a suprapubic catheter in place, no T-sponge, and surrounding skin that was red and excoriated, while the MAR contained both Foley catheter care orders and suprapubic catheter care orders, with the suprapubic site care order discontinued. The ADL care plan referenced Foley catheter care and a closed drainage system, but the elimination care plan described a suprapubic catheter in place for obstructive reflux uropathy and increased UTI risk, without specific suprapubic catheter interventions. Overall, the care plans contained incorrect or missing information about the resident’s current medical status and lacked pertinent interventions for the hernia, CKD, hyperkalemia, hyponatremia, CHF, suprapubic catheter, and skin conditions, and the facility did not ensure consistent assessment, monitoring, and documentation aligned with the resident’s needs and medical orders.
Failure to Protect Cognitively Impaired Resident From Verbal and Physical Abuse by Podiatrist
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from verbal and physical abuse by an ancillary service provider, specifically the podiatrist. The resident had Alzheimer’s disease, dementia, anxiety disorder, osteoarthritis, muscle weakness, unsteadiness on feet, and auditory and visual hallucinations, and was documented as severely cognitively impaired with a BIMS score of 01. She required one-person assistance with ADLs, ambulated with a 4‑wheeled walker, and her daughter was the DPOA and decision maker. On observation the day after the incident, the resident was fully dressed, sitting on the side of the bed with her walker in front of her, talking to herself, not engaging with the surveyor, and appeared calm and free from visible bruises. According to staff interviews, CNA A, the DOR, and PTA D were in a nearby room when they heard thumping, scuffling, loud noises, and a male voice yelling and swearing coming from the resident’s room. CNA A reported hearing the podiatrist say, “Don’t f*ck*ng hit me,” and then, upon entering the hallway, observed the resident about three feet from her bed moving toward the podiatrist. CNA A stated he saw the podiatrist push the resident, causing her to fall back onto her bed, and heard the resident yelling at him to get out. CNA A described the podiatrist attempting to leave the area and trying to get past him, while CNA A blocked his path and instructed him not to go by other residents. PTA D corroborated hearing aggression in the male voice, yelling, swearing, and the resident being upset. The DOR reported hearing a man swearing and clearly saying, “Do not F*ck*ng lay hands on me again,” followed by CNA A stating that the resident needed help and that he had witnessed abuse. When the DOR entered the resident’s room, she found the resident on her bed with glasses askew, arms flailing, yelling, crying, and physically upset. The DON’s documentation and interview indicated that staff had reported raised voices and that the podiatrist was observed yelling at the resident, with staff reporting that the resident was attempting to ambulate past him when he pushed her back onto the bed. A post‑incident assessment noted redness on the resident’s left forearm in a broad irregular shape and a complaint of right wrist pain, though she was able to move the wrist without observable signs of pain. During assessment, the resident was tearful, resistant to touch, and repeatedly hugged a stuffed dog, and she stated that people had been “beating [her] with hammers.” The DON also reported that the podiatrist stated the resident had assaulted him and that he had previously entered resident rooms alone to provide services. These events demonstrate that the resident was subjected to verbal and physical abuse by the podiatrist, contrary to the facility’s abuse policy defining abuse as willful infliction of injury, intimidation, or conduct causing or potentially causing humiliation, fear, or mental anguish.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were consistently left within reach for two residents, both of whom were moderately cognitively impaired and required staff assistance for mobility. Resident 30, who was admitted with dementia and weakness, was observed multiple times with her call light out of reach, either hanging from the wall or under her pillow. Despite being able to use the call light when it was accessible, she frequently reported being unable to locate it. The care plan for Resident 30 directed staff to maintain personal items within her reach and encourage the use of the call light, but this was not consistently followed. Similarly, Resident 22, also admitted with dementia and weakness, was observed with her call light coiled up on her bed and out of reach while she sat in a bedside chair. She was dependent on staff for ambulation and was unaware of the call light's location. The care plan for Resident 22 included instructions to remind her to use the call light and ensure it was within reach, which was not adhered to. The Director of Nursing confirmed that both residents were capable of using their call lights and that staff should have left them within reach.
Inadequate Antibiotic Stewardship and Tracking
Penalty
Summary
The facility failed to adhere to its antimicrobial stewardship policy, resulting in inappropriate antibiotic use for two residents. The policy, last revised in March 2020, mandates the use of antimicrobial stewardship strategies to improve therapy quality, minimize resistance, and optimize outcomes. However, the facility did not have an effective system for assessing, monitoring, and preventing unnecessary antibiotic usage, as evidenced by the incomplete and incorrect tracking of antibiotics administered to residents. Resident #39, who has a history of frequent urinary tract infections (UTIs) and other medical conditions, was administered multiple antibiotics over several months. The facility's records did not accurately reflect all antibiotics given, such as ceftriaxone, amoxicillin, and ciprofloxacin, among others. The infection control records were incomplete, and the Infection Control Preventionist acknowledged the inaccuracies in tracking and trending reports. There were no interventions or plans to prevent future UTIs or sepsis for this resident. Another resident, #46, was discharged from the hospital with antibiotics, but this was not tracked on the facility's antibiotic tracking sheet. The Infection Control Preventionist, who works part-time, reported that the tracking system was unreliable, with data disappearing after a few days, and that antibiotics administered over weekends were not followed up. Additionally, other residents were prescribed antibiotics without cultures or qualifying symptoms, contrary to the facility's policy to follow McGeer's Criteria for antibiotic stewardship.
Resident Dignity Compromised by CNA's Conduct
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred when the CNA entered the resident's room and engaged in a verbal altercation with the resident. The CNA asked the resident, 'Why you mean muggin' me?' which led to an argument between the two. The resident responded by telling the CNA to 'get over himself,' to which the CNA reacted by jumping in the air and stating, 'I just got over myself.' The resident then mentioned she would write up the CNA, who replied, 'Good, can't wait. I see flaming daggers come out of your eyes.' The resident later reported that the CNA insulted her intellect and injury, although she did not provide further details to avoid stirring up problems. This interaction demonstrated a lack of respect and dignity towards the resident, contributing to the deficiency noted in the report.
Failure to Implement Adequate Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement appropriate care plan interventions for two residents, leading to deficiencies in their care. Resident #6, who has diagnoses of morbid obesity, dementia, and mixed incontinence, was found to have three pressure ulcers on her left lateral foot during an observation. Despite being at risk for pressure ulcers, her care plan did not include a focus on active prevention or management of pressure ulcers or leg contractures. The care plan only included general interventions such as assessing postural alignment and encouraging the use of pressure-relieving boots, which were not sufficient to address her current condition. Resident #39, with diagnoses of dementia, cerebrovascular disease, and chronic kidney disease, experienced frequent urinary tract infections and had a history of urethral strictures. The review of his care plan revealed that he had 18 episodes of incontinence over a 30-day period, yet his care plan did not adequately address his toileting needs. The care plan indicated that he was not able to leave on the toilet and required stand-by assistance with a wheeled walker and gait belt, but it lacked specific interventions to manage his incontinence effectively.
Failure to Revise Care Plan for Resident with Weight Changes
Penalty
Summary
The facility failed to revise and implement a personalized care plan for a resident, identified as R17, who experienced significant weight changes. R17 was admitted with diagnoses including Congestive Heart Failure (CHF) and Morbid Obesity and was cognitively intact with a BIMS score of 14 out of 15. Despite R17's expressed desire to lose weight and the facility's documentation of weight increases ranging from 7.5% to 12.9%, the care plan was not updated to include interventions such as small meal portions, which R17 had requested. The care plan had not been revised since July 2023, and the interventions listed were generic and did not address R17's specific needs or the documented weight gain. During an interdisciplinary care conference, the facility's staff, including nursing, social work, and a registered dietician, documented R17's obesity and attributed her weight gain to CHF and medications without involving R17 in the discussion or considering her input. The care conference documentation lacked a plan to revise the care plan with measurable or personalized goals or interventions, despite the significant weight gain noted in the medical record. As of the survey exit, no additional information or corrective actions were provided by the facility.
Failure to Ensure Continuity of Care for Resident with Frequent UTIs
Penalty
Summary
The facility failed to ensure continuity of care for a resident with frequent urinary tract infections (UTIs), leading to a deficiency in quality of care. The resident, who has a history of dementia, cerebrovascular disease, chronic kidney disease, benign prostatic hyperplasia, and urethral strictures, was admitted to the facility and experienced multiple UTIs. Despite being seen by urology and having a plan for cystoscopy and kidney ultrasound, there was no follow-up documentation or planned interventions to address the frequent UTIs and prevent further complications such as sepsis. The resident's medical records revealed numerous antibiotic orders for UTIs, but there was a lack of comprehensive care planning for urinary strictures or frequent UTIs. The care plan did not focus on these issues, and there was no documentation of the root cause of the frequent UTIs. Additionally, the resident experienced episodes of incontinence, and the care plan indicated a need for assistance with toileting, which was not consistently documented or followed through by the staff. Interviews with the Infection Control Preventionist and the Director of Nursing highlighted gaps in the resident's care, including the absence of urology consultation results and inadequate documentation of fluid intake. The facility's failure to implement a comprehensive care plan and follow up on urology recommendations contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and preferences.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident identified as R6. R6, who has diagnoses of morbid obesity, dementia, and mixed incontinence, was admitted to the facility and was at risk for pressure ulcers. Despite this, the facility did not follow physician orders or accurately assess and document the resident's condition. On a specific date, a skin assessment revealed two Stage II pressure wounds on R6's left ankle and foot. However, the treatment orders to cleanse and dress these wounds were not implemented until three days after the provider's assessment. Additionally, the resident was observed without the required dressings, and the staff failed to notify the nurse of the missing dressings. The care plan for R6 did not include a focus on active pressure ulcers or leg contractures, and interventions such as the use of pressure-relieving boots were not effectively implemented. Observations showed that R6 was left in the same position for extended periods, and the staff reported difficulties in repositioning due to the resident's contractures. The Director of Nursing confirmed that the skin assessments were inaccurate and that the care plan did not reflect the necessary interventions. The facility's policy on skin assessment and treatment was not adhered to, as evidenced by the lack of regular skin inspections and failure to implement pressure-relieving strategies.
Failure to Provide Timely Incontinence Care and Document MASD
Penalty
Summary
The facility failed to provide timely incontinence care and appropriate documentation and treatment for moisture-associated skin damage (MASD) for a resident with morbid obesity, dementia, and mixed incontinence. The resident, who is always incontinent of bowel and bladder, was observed in a wet Broda chair with a saturated sling and brief, emitting a strong urine smell. The resident's skin was red, macerated, and blanchable, with excoriated areas on the left upper thigh. The Certified Nursing Assistant (CNA) did not apply barrier cream after providing peri care, citing a lack of availability, and reported that the resident should be toileted every two hours, although this was not consistently done. The Treatment Administration Record (TAR) indicated orders for barrier cream application every shift, but the Care Plan lacked interventions for MASD. The resident was toileted only 2-4 times a day, with gaps of 10-12 hours between toileting. The Director of Nursing (DON) stated that residents should be toileted at least every two hours and that staff should report new skin conditions and apply barrier cream as needed. The facility's policy requires regular skin assessments and the application of skin barrier ointment with incontinence care, but these measures were not adequately implemented for the resident.
Failure to Notify Medical Provider of Significant Weight Changes
Penalty
Summary
The facility failed to ensure that significant changes in weight for two residents were reviewed by a medical provider. Resident R30 was admitted with diagnoses including dementia and weakness. Her weight decreased from 203.2 pounds to 184.1 pounds over a period of approximately one month, indicating a significant weight loss. Despite this, there was no documentation in the electronic medical record (EMR) that the weight loss was reviewed by a medical provider. The Director of Nursing confirmed that the weight loss should have been referred to a medical provider for review. Resident R17, who was admitted with diagnoses including congestive heart failure and morbid obesity, experienced weight increases ranging from 7.5% to 12.9% over several months. Although the resident expressed a desire to lose weight and had communicated with the Food Service Department and medical provider, there was no documentation that the medical provider was notified of these weight changes. Interviews with facility staff, including a Physician Assistant and a Registered Dietician, revealed an expectation for documentation and notification of significant weight changes, which was not met in this case.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to provide appropriate hand hygiene during incontinence care for two residents, leading to a deficiency in infection prevention and control. Resident #6, who is moderately cognitively impaired and dependent on staff for toileting, was observed receiving incontinence care from two CNAs. During the care, one CNA did not change gloves or sanitize hands after handling urine-saturated items and before touching clean surfaces and clothing. The CNA acknowledged the lapse in hand hygiene, admitting to not changing gloves or sanitizing hands during the process. Similarly, Resident #48, who has a yeast infection and is under enhanced barrier precautions, received peri care from two CNAs. One CNA used the same soiled gloves to check for barrier cream in her pockets and then proceeded to apply a new brief and touch other objects in the room without changing gloves or sanitizing hands. The CNA admitted to the oversight in hand hygiene. The facility's LPN/Infection Control Nurse confirmed that staff are required to perform hand hygiene when moving from dirty to clean surfaces, but noted that hand hygiene audits had not been conducted recently.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that 11 out of 16 residents reviewed were provided medications as ordered, resulting in medication not being given as prescribed. On the morning of October 31, 2024, an LPN administered all daily medications at once to several residents for time management purposes. This action was discovered when a resident, who was under the care of the LPN, exhibited a change in condition and was found unresponsive with a blank stare. Upon investigation, it was revealed that the medications for the residents in the LPN's care were missing from the medication carts. The incident involved multiple residents, including one with Parkinson's disease, psychotic disorder, and dementia, who was sent to the hospital for evaluation after receiving an overdose of medications. Another resident with diabetes and schizoaffective disorder experienced hypoglycemia after receiving insulin too early, before breakfast was served. The facility's investigation found that the LPN had given all scheduled medications for the day at once, which was not in accordance with the prescribed times. Interviews with staff revealed that the LPN had previously been educated on the potential harm of administering medications all at once but continued the practice. The Director of Nursing was not informed of a similar incident that occurred earlier in the month until the more severe incident on October 31. The LPN admitted to the error and resigned following the incident, acknowledging that the action was not done with malicious intent but rather as a misguided attempt at time management.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of mental and verbal abuse in a timely manner to the state survey agency for one resident, resulting in allegations of abuse not being reported accurately and completely. The resident, who was cognitively intact, reported that a nurse yelled at her, intimidated her, and made threatening remarks. The resident felt scared and intimidated by the nurse's behavior, which included a statement that the nurse could hit her if she wanted to and that the resident could be put outside for her husband to pick up. The Director of Nursing (DON) was informed of the allegations but was not aware of the full extent of the resident's claims, including the threats made by the nurse. The DON acknowledged the situation and stated that the nurse had been educated, but there was no documentation of an investigation or follow-up with the resident. The Nursing Home Administrator (NHA) also became aware of the allegations but did not initiate an investigation until prompted by the surveyor. The NHA expressed difficulty in determining the specifics of the allegations due to the resident's varying statements. The facility's records did not contain any documentation of the resident's allegations or any investigation into the matter. The facility eventually reported the incident to the state survey agency, but the report was incomplete and did not include all the allegations made by the resident. The facility's policies required immediate reporting of abuse allegations, but this was not adhered to, resulting in a delay in addressing the resident's concerns.
Failure to Document Resident Incident
Penalty
Summary
The facility failed to maintain complete, timely, and accurate medical records for one of its residents, identified as R4. The deficiency was identified during a review of R4's medical records and interviews with facility staff. R4, a resident with dementia and severe cognitive impairments, was involved in an incident on April 4, 2024, where she became agitated and physically aggressive towards other residents. Despite the incident, there was no documentation in R4's medical records about the event, except for a vague note by a social worker that did not specify the nature of the occurrence. The Director of Nursing (DON) acknowledged the lack of detailed documentation regarding the incident. The DON stated that her interdisciplinary documentation note from April 5, 2024, was intended to address the incident, but it did not explicitly mention the resident-to-resident altercation. The note focused on R4's increased agitation related to bowel movements and constipation, which was discovered during the investigation of the incident. The DON admitted that her documentation had been lacking in detail and was working on improving it. The absence of proper documentation in R4's medical records highlights a failure in maintaining accurate and complete records, which is essential for effective communication among healthcare providers. The American Nursing Association emphasizes the importance of clear, accurate, and accessible documentation as a critical element of safe and quality nursing practice. The lack of documentation could potentially hinder the ability of healthcare providers to make informed decisions and ensure high-quality care for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baldwin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corewell Health Reed City Hospital Rehabilitation | 16.5 mi | ★★★★★ | 9 | 0 |
| The Orchards At Big Rapids | 22.1 mi | ★★★★★ | 17 | 0 |
| Mission Point Nursing & Physical Rehabilitation Of | 22.1 mi | ★★★★★ | 0 | 0 |
| Oceana County Medical Care Facility | 28.7 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Ludington | 29.1 mi | ★★★★★ | 14 | 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 August 2026) and official state health department websites.