Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Grandvue Medical Care Facility during CMS and state inspections, most recent first.
Improper Food Service Equipment Storage and Ice Machine Drain Line Conditions: A CNA used a probe thermometer to check reheated food, then returned it to storage without a protective sheath. Four plastic goblets were stored under an ice machine, with one touching the open drain line pipe. Surveyors also observed corroded, mildew-covered ice machine drain piping and an ice machine drain line inserted into a floor drain pipe. The CDM stated the goblets were not used for food service and did not know why they were stored there.
Failure to Protect Residents from Verbal and Mental Abuse: A resident with dementia and agitation repeatedly entered other residents’ rooms, yelled profanities, made threats, and raised his fist at them. Two residents with moderate cognitive impairment reported feeling nervous, uneasy, and afraid after he swore at them, pushed a wheelchair, banged on doors, and gestured aggressively. Records also showed ongoing room intrusions, yelling, and disruptive behavior, while the SW acknowledged she had not followed up with the affected residents.
Failure to report resident-to-resident abuse allegations to the SA. A resident with dementia and severe cognitive impairment repeatedly engaged in physical and verbal aggression toward other residents, including slapping, swatting, and striking them with objects, while another resident with vascular dementia also displayed verbal and physical aggression toward residents and staff. Staff interviews and witness statements confirmed the incidents, but the DON stated the events were not reported because administration did not view them as substantiated abuse or because they were not documented in Risk Management.
Failure to Investigate Resident-to-Resident Abuse: A resident entered another resident’s room, used profanity, yelled, pushed the resident’s w/c, and raised a fist, while another resident reported the same resident had also entered her room, swore at her, and called her an expletive. EMR documentation described the resident invading other residents’ rooms and insisting the rooms were his. The DON did not provide complete incident paperwork, and no risk management documentation was available for the incident despite staff stating such events should trigger an investigation.
The facility failed to notify the LTC Ombudsman of one resident’s discharge and failed to send pertinent medical documentation with two residents during ED transfers. The EMR showed one resident was omitted from the monthly transfer list, and the DON could not show that proper records were sent to the receiving hospital for either resident. The facility policy required transfer documentation and Ombudsman notification through the monthly list.
Missing Hospice Documentation: A resident with frontotemporal neurocognitive disorder and severely impaired cognition was receiving hospice services, but the EMR and hospice binder lacked hospice health aide visit notes for several months. Staff, including an LPN, the Nursing Care Coordinator, and the DON, confirmed the hospice documentation was missing, despite the facility policy and hospice services agreement requiring written records of hospice care and communications.
Improper Storage of Respiratory Equipment: Two residents had respiratory equipment left out in the open rather than stored in a bag when not in use. A resident’s nebulizer mask was repeatedly observed sitting on a nightstand open to air, with condensation still noted in the medication cup, and another resident’s nasal cannula tubing was found on the floor in a dirty area of the room. Staff stated respiratory equipment should be bagged when not in use, and that a nasal cannula on the floor should be discarded.
A resident with dementia, aphasia, urinary incontinence, and severely impaired decision-making was being assisted with a brief change by a CNA, with a second CNA called in to help due to the resident’s history of combative behavior. During the interaction, the resident became agitated, stood up, removed his brief, and made physical contact with both CNAs before eventually returning to bed and making a rude remark. One CNA then responded by calling the resident a derogatory expletive while still in the room, an exchange overheard by a social worker who entered and found one CNA present and the other leaving. Subsequent interviews with both CNAs and the social worker confirmed that the CNA directed the expletive at the resident, constituting verbal abuse under the facility’s abuse policy and resulting in psychosocial harm and mental anguish based on a reasonable person standard.
A resident with Alzheimer's disease experienced significant, unaddressed weight loss after a CNA repeatedly falsified weight documentation over several weeks. Despite concerns raised by the resident's power of attorney about the resident's declining condition, facility staff assured them there was no weight loss, relying on inaccurate records. The deficiency was confirmed through interviews, record review, and video evidence, revealing that weights were not properly obtained or documented, resulting in neglect.
A resident with severe cognitive impairment and a history of falls was found sitting on the floor in another room with visible injuries, including skin tears and a bruised heel. Multiple staff assessed and treated the injuries, but did not immediately document the incident or injuries in the EMR, and required risk management documentation was not completed. Staff interviews revealed confusion about care plan instructions and reporting protocols, and facility policy confirmed that documentation should have occurred for unwitnessed falls and skin injuries.
Two residents were rehospitalized due to the facility's failure to follow physician orders. One resident received warfarin earlier than prescribed, resulting in a supratherapeutic INR, while another did not receive prescribed antibiotics for a UTI, leading to urosepsis. Communication breakdowns and procedural lapses contributed to these deficiencies.
The facility failed to ensure the QAPI committee met quarterly with required members, as the Medical Director or designee did not attend a meeting in one quarter, and no meetings were held in August or September. The DON was unaware of the absence and did not provide proof of attendance.
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for hospital transfers. This deficiency was identified for four residents, including one with dementia and Parkinson's disease and another with a traumatic brain injury. Despite having a procedure and form for issuing notifications, the facility did not complete the necessary documentation, and the reason for this lapse was not explained.
The facility failed to properly label and dispose of medications, with expired and incorrectly dated medications found in multiple medication carts and a storage room. Insulin pens lacked proper expiration dates, and a discontinued controlled substance was not destroyed promptly. The DON acknowledged the need for staff re-education on medication management processes.
A resident with severe cognitive impairment and a history of cerebrovascular accident was inaccurately documented in the MDS assessment as requiring a wander/elopement alarm. Despite staff reports indicating no attempts to leave the locked unit in over a year, the facility failed to conduct the necessary quarterly risk assessments. The oversight was acknowledged by the DON, and the facility did not provide a policy on alarm assessments upon exit.
A facility failed to update the care plan for a resident with severe cognitive impairment and pressure injuries. The care plan lacked specific instructions on repositioning frequency, despite the resident's dependence on staff for mobility and the presence of a Kennedy ulcer. Staff relied on a bedside care plan report, which also omitted necessary details, leading to potential unmet care needs.
A resident with a prosthetic heart valve on warfarin therapy experienced delays in INR testing due to the facility's contracted laboratory service's limited availability. The resident required daily INR checks, but the lab was closed on weekends and had early weekday cutoffs, leading to delayed results and a test not performed due to an expired collection device. Staff expressed concerns about the lab's service, impacting the resident's care.
The facility failed to administer the recommended pneumococcal vaccinations or document reasons for withholding them for three residents. Despite consent forms indicating their wish to receive the PCV20 vaccine, none of the residents received it, and there was no physician documentation addressing the vaccine consideration. The Infection Preventionist confirmed the lack of vaccine administration and documentation, contrary to the facility's policy.
Improper Food Service Equipment Storage and Ice Machine Drain Line Conditions
Penalty
Summary
The facility failed to maintain best practices in the food service area, with observations showing improper handling and storage of food service equipment and utensils. On 4/20/2026 at 11:42 AM, a CNA used a probe thermometer to check the temperature of a food item being reheated in the microwave. The thermometer was taken from a drawer without a protective sheath, was wiped with an alcohol wipe before use, and then wiped again after use but was returned to the drawer without a protective sheath. On 4/20/2026 at 3:18 PM, four plastic wine goblets were observed stored in the cabinet below the Courtyard ice machine, and one goblet was touching the open drain line pipe where the ice machine drain line discharged into the floor drain. Additional observations showed ice machine drain line issues in two areas. On 4/20/2026 at 12:11 PM, the copper pipe drain line from the Lemon Tree dining room ice machine was observed discharging into a drain line in the employee kitchen downstairs, with the end of the drain line corroded for approximately 5 inches and the tip hanging above the drain coated with black mildew and mineral build up. On 4/20/2026 at 3:18 PM, the ice machine drain line in the Courtyard dining room was observed indirectly connected to the floor drain by having the drain line inserted down into the floor drain pipe. On 4/21/2026 at 10:25 AM, the Certified Dietary Manager stated the goblets were not used for food service and was not sure why they had been stored in that cabinet under the ice machine.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents’ rights to be free from verbal and mental abuse by another resident. Two residents reported that a resident with diagnoses including vascular dementia, anxiety, major depressive disorder, attention and concentration deficit, and cognitive communication deficit repeatedly entered their rooms, yelled at them, used swear words, and made threatening gestures. One resident with generalized anxiety disorder, hemiplegia, and moderate cognitive impairment stated the resident came into her room swearing, calling her names, and making her feel nervous, especially during episodes when he wandered the unit yelling at staff and residents. A second resident, who had chronic pain, major depressive disorder, a left leg amputation, and moderate cognitive impairment, stated the resident entered his room, told him to get out, pushed his wheelchair across the room, and raised his fist at him while continuing to swear. He later stated the resident banged on his closed door and looked at him meanly and raised his fist when they passed in the hallway. The resident representative acknowledged awareness that the resident had been going into other residents’ rooms and yelling at them. Facility records documented repeated disruptive and aggressive behaviors, including statements that he would kill Satan, yelling profanities at a resident while demanding to use her bathroom, entering rooms, kicking a door, screaming at residents that they needed to leave his home, pounding on walls, and trying to get behind the nurses’ station. Staff notes also described him pushing past stop signs on doors, opening closed doors to enter rooms, and raising his fist at staff and residents. The social worker stated she was aware of the incidents but had not followed up with the affected residents regarding how they felt about them.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to notify the State Agency of verbal and physical resident-to-resident altercations involving three residents. The deficiency centered on multiple incidents in which one resident with dementia and severe cognitive impairment repeatedly engaged in physical and verbal aggression toward other residents, while another resident with vascular dementia and behavioral symptoms also engaged in verbal and physical aggression toward others. The record showed that these events were reviewed by facility staff, but the incidents were not reported to the State Agency as abuse allegations. Resident #10 was admitted with diagnoses including dementia with behavioral disturbance, delirium, restlessness and agitation, and psychotic disorder. Her most recent MDS showed severely impaired cognitive skills for daily decision making, and behaviors including physical aggression, verbal aggression, and wandering occurring four to six days per week. The record documented six resident-to-resident incidents over the prior three months, including taking another resident’s cup and slapping that resident in the face, striking another resident after being redirected, swatting a resident on the head, making contact with a resident’s shoulder, throwing a ball that hit a resident in the face, and slapping a resident in the back of the head/neck. Witness statements and staff interviews confirmed these events and described the resident as unpredictable and capable of hitting others without warning. The DON stated the incidents were not reported to the State Agency because administration determined there was no outcome or that the events could not be substantiated as abuse. Resident #9 was admitted with vascular dementia, major depressive disorder, social exclusion and rejection, and attention and concentration deficit. His MDS showed moderately impaired thinking and memory, along with physical and verbal behavioral symptoms directed toward others and wandering. The record included a physical aggression report in which two residents were hitting each other, and when staff attempted to intervene, R9 admitted he hit the other resident and then struck a nurse with his cane. Additional notes documented repeated verbal aggression toward residents and an incident in which R9 verbally assaulted and physically threatened Resident #4. The DON stated she was not aware of the incidents involving R9 because they were not documented in Risk Management, and therefore she could not properly investigate or report them.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate resident-to-resident abuse involving three residents. During an interview, one resident stated that another resident had wandered into her room, swore at her, yelled at her to get out, and called her an expletive. A second resident stated that the same resident entered his room, told him to get the expletive out of his room, pushed his wheelchair across the room, and raised his fist at him while swearing, after which the resident left. The second resident stated he was now uneasy around the other resident and afraid of what he might do. Record review showed a progress note describing the resident as entering the hallway, invading other residents’ rooms, pushing past stop signs on doors, opening closed doors, and stating that nobody else had permission to live there because it was his house. When the DON was asked for accidents and incidents for the three residents, the 4/16/26 date was not included, and the DON stated the paperwork provided was complete. RN K stated that resident-to-resident incidents involving a resident entering another resident’s room and yelling should trigger a resident-to-resident risk assessment in the facility’s risk management documentation to start an investigation. When asked for risk management documentation for the incident, the DON stated there were none and said she had initiated risk management for verbal aggression at that time to begin the investigation process. The facility policy stated that when suspicion of abuse, neglect, or exploitation occurs, an investigation is immediately warranted.
Failure to Notify Ombudsman and Send Transfer Documentation
Penalty
Summary
The facility failed to ensure the Long-Term Care Ombudsman was notified of a resident’s discharge from the facility and failed to ensure pertinent medical records were sent to the receiving provider during transfers for two residents. For Resident #3, the EMR showed a transfer to the ED on 3/12/26, and documentation provided to the LTC Ombudsman in March showed the resident was omitted from the transfer list. The EMR also showed the facility did not ensure medical documentation was communicated to the receiving hospital. For Resident #6, the EMR showed a transfer to the ED on 1/1/26, and the record did not show that medical documentation was sent to the receiving provider. During interviews on 4/21/26, the NHA confirmed Resident #3 was omitted from the March transfer list sent to the LTC Ombudsman, and the DON verified she could not show proper documentation was sent to the local hospital for Residents #3 and #6 during their transfers out of the facility. The facility policy required a transfer form with resident status, diagnoses, medications, treatments, relevant findings, precautions, and other documentation to support a safe transition of care, and required the Social Work Director or designee to provide notice of transfer to a representative of the State LTC Ombudsman via monthly list.
Missing Hospice Documentation
Penalty
Summary
The facility failed to provide hospice documentation for one resident who was receiving hospice services. The resident was admitted with active diagnoses including frontotemporal neurocognitive disorder and was unable to complete the BIMS on the MDS, with severely impaired cognition documented. The MDS also noted participation in hospice care, and physician orders included admission to the hospice agency. Review of the resident’s EMR showed a hospice care plan, but no hospice health aide visit notes were found in the EMR for January 2026 through April 2026. The hospice binder in the nursing room also contained no additional hospice documentation for that period. During interviews, an LPN stated the hospice agency sometimes communicated with facility staff but could not identify where missing documentation would be located, the Nursing Care Coordinator stated they had not received documentation from the hospice agency in quite some time, and the DON confirmed the hospice documentation was missing from the EMR. The facility policy stated hospice staff would document progress information on hospice forms and leave copies with the facility, and the services agreement required written documentation of communications and services provided.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to store respiratory equipment in a sanitary manner for two residents reviewed for respiratory care. For Resident #35, the nebulizer mask was observed intact and sitting on the nightstand, open to air and not stored in a bag on 4/20/26, 4/21/26, and 4/22/26. On 4/20/26, the resident stated he had used the nebulizer mask the day before, and the nebulizer medication cup was noted to have some condensation remaining inside. For Resident #47, the nasal cannula tubing was observed lying on the floor in the resident’s room while the resident was absent, and the floor where it lay had visible dirt and crumbs. The resident’s nebulizer mask was also observed intact and not stored in a bag on 4/20/26 and again on 4/22/26. During interview, the Infection Preventionist stated respiratory equipment should be stored in a bag when not in use and nebulizer masks are to be rinsed and dried after use. Another RN stated that respiratory equipment is to be stored in a bag when not in use and that a nasal cannula on the floor should be thrown away.
Verbal Abuse of Cognitively Impaired Resident by CNA During Personal Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during in-room care. The resident was an elderly male with dementia, aphasia, overactive bladder, urinary incontinence, and a need for assistance with personal care, and his MDS showed severely impaired cognitive skills for daily decision-making. On the morning in question, a social worker (SW A) was entering her office when she overheard a staff member down the hall say, "You're being a complete [expletive]." SW A then entered the resident’s room and found one CNA (CNA B) bagging trash and observed another CNA (CNA/Perpetrator E) quickly leaving the room. When SW A informed CNA B of what she had overheard, CNA B indicated that CNA/Perpetrator E had made the statement toward the resident. In a later interview, CNA B reported that she had been assisting the resident with a brief change and, although the resident was known to be combative at times, he was initially in a good mood and cooperative. When CNA B could not complete fastening the brief alone, she called CNA/Perpetrator E for help and believed the loud tone and speed of CNA/Perpetrator E’s work may have upset the resident. The resident then stood up, removed his brief, and moved toward the door; CNA B attempted to redirect him by closing the curtain, during which he nudged her and laid hands on CNA/Perpetrator E. CNA B stated the resident eventually lay back down and made a rude remark under his breath, prompting CNA/Perpetrator E to say, "You're being a complete [expletive]." In a separate interview, CNA/Perpetrator E confirmed that after the resident had twisted her wrist and arm, attempted to push CNA B, and later kicked her in the back as she turned to leave, she called him an "[expletive]" while still in the room and acknowledged he probably heard her. The facility’s abuse policy defines verbal abuse as willful use of disparaging or derogatory language within a resident’s hearing, regardless of their ability to comprehend, and the incident was substantiated as mental abuse causing psychosocial harm and mental anguish based on a reasonable person standard.
Failure to Accurately Monitor and Record Resident Weights Resulting in Unaddressed Significant Weight Loss
Penalty
Summary
The facility failed to monitor and accurately record the weights of a resident with Alzheimer's disease, resulting in a significant, unaddressed weight loss. The resident was admitted at a weight of approximately 205 pounds and was noted to have severe cognitive impairment. Over a period of several weeks, staff, specifically a CNA, falsified weight documentation, recording inaccurate weights for at least eight consecutive weekly entries. This led to the facility not recognizing or intervening in the resident's substantial weight loss, which was eventually discovered to be 25.5 pounds. The resident's designated power of attorney repeatedly raised concerns about the resident's declining condition and appearance, but the facility assured them that no weight loss had occurred, based on the falsified records. Interviews and record reviews confirmed that the CNA responsible for obtaining and documenting weights did not consistently perform the task and instead entered false data. The CNA's skills checklist for measuring and recording weight was left incomplete, and the DON confirmed through video review that weights were not being properly obtained. The resident was observed to appear thin and expressed a lack of appetite. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid harm, and the investigation concluded that both abuse and neglect had occurred in this case.
Failure to Document Unwitnessed Fall and Injuries in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following an unwitnessed fall. The resident, who had a history of dementia, repeated falls, bone density disorder, and severe cognitive impairment, was found sitting on the floor in another resident's room. Multiple staff members, including CNAs and LPNs, observed and assessed the resident, noting visible injuries such as skin tears on the right forearm and bruising on the left heel. Despite these findings, there was no immediate documentation of the incident or injuries in the resident's electronic medical record (EMR) by the staff who first responded. The care plan for the resident indicated that sitting on the floor was only considered intentional and not a fall if it was witnessed. In this case, the event was unwitnessed, and staff were uncertain whether to classify it as a fall. As a result, required risk management documentation and event reporting were not completed at the time of the incident. The lack of documentation persisted even after subsequent staff discovered and treated the injuries, with some staff expressing confusion about the care plan and reporting requirements. Interviews with staff and review of facility policy confirmed that risk management documentation should have been completed for any unwitnessed fall or skin injury, including skin tears. The omission of this documentation was acknowledged by several staff members, including the DON, who stated that the expected protocol was not followed. The deficiency was identified through observation, interviews, and record review, revealing a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Medication Management Failures Lead to Rehospitalization
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to their rehospitalization. Resident #25, who had a history of gastrointestinal bleeding and was on warfarin therapy, was readmitted to the facility with specific instructions to resume warfarin on a later date. However, the facility administered the medication earlier than prescribed, resulting in a supratherapeutic INR and subsequent rehospitalization. The facility's inability to monitor INR levels effectively due to laboratory service limitations further exacerbated the situation. Resident #15 was discharged from the hospital with a prescription for amoxicillin to treat a urinary tract infection and sepsis. However, the facility failed to administer the antibiotic as it was not reflected in the Medication Administration Record. The resident's condition worsened, leading to a return to the hospital with urosepsis. The facility's on-call provider was unable to access the resident's chart or receive the hospital discharge instructions, contributing to the failure to administer the prescribed medication. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing and Medical Director were unaware of the medication errors until after the residents' conditions had deteriorated. The facility's practice of having providers enter their own orders into the electronic medical records contributed to the oversight, as the necessary orders were not entered or followed. These deficiencies highlight significant lapses in medication management and communication within the facility.
QAPI Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, which could potentially lead to quality-of-care concerns for all 93 residents. A review of the facility's QAPI sign-in sheets revealed that meetings were held on several dates, but the Medical Director or designee did not attend the meeting on 7/17/24. Additionally, there were no QAPI meetings held in August or September 2024, and the Medical Director or designee did not attend any meetings during the quarter of July, August, and September. During an interview, the Director of Nursing (DON) was unaware of the Medical Director's absence and failed to provide proof of attendance by the survey exit date.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for transfers to the hospital. This deficiency was identified for four residents who were transferred out of the facility. For Resident #87, the electronic medical record indicated a transfer to an acute care hospital due to swelling in the left lower extremity and thigh, but the Notification of Transfer and Bed Hold Authorization document did not include the reason for the transfer. Similarly, Resident #34 was sent to the hospital for possible sepsis, but the corresponding notification document lacked the reason for the transfer. Resident #25 was transferred to the hospital multiple times, yet the facility's documentation did not specify the reasons for these transfers. Resident #15 also experienced several hospital transfers, with no documented reasons provided in the notification forms. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility had a procedure for issuing written notifications of transfer, but the forms were not completed for the residents in question. The facility had a form titled Notice of Resident Transfer or Discharge, which included the necessary requirements, but it was not utilized, and the reason for discontinuing its use was not explained.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to properly label medications and dispose of expired or discontinued medications, as observed in three out of four medication carts and one out of two medication rooms. On March 18, 2025, an insulin pen with an expiration date of March 9, 2025, was found in the Valleyvue B medication cart, and a registered nurse confirmed it should not have been there. Additionally, the Lakevue B medication cart contained expired epinephrine auto-injector pens and an insulin pen without an expiration date. A registered nurse confirmed the epinephrine was expired and acknowledged the requirement for insulin pens to have expiration dates. Further observations revealed that the Lakevue A medication cart contained a haloperidol liquid without an expiration date and an insulin lispro pen with an incorrect expiration date. The cart also had two other insulin pens with incorrect dates. A registered nurse admitted the dates were incorrect. Additionally, a discontinued controlled substance, Lorazepam, was found in the Valleyvue B narcotic book, despite a physician's order to discontinue it on February 7, 2025. The nurse acknowledged that discontinued medications should be destroyed as soon as possible. In the medication storage room on Lakevue, an expired bottle of geri-tussin was found. The Director of Nursing was informed of these findings and confirmed that expired medications should be discarded and discontinued narcotics destroyed promptly. The facility's policies on medication disposal, labeling, and storage were reviewed, indicating that medications should be labeled with open and expiration dates, and expired or discontinued medications should be removed from active supply areas.
Inaccurate MDS Assessment for Resident with Alarm
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment documentation for a resident, identified as Resident #23, who was admitted with diagnoses including cerebrovascular accident, hemiplegia, and dementia. The MDS assessment indicated the use of a wander/elopement alarm daily, despite multiple staff interviews revealing that the resident had not attempted to leave the locked unit in over a year. The last risk assessment for the alarm was completed on 8/9/24, and the resident had not been assessed quarterly as required. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, confirmed that the resident's condition had changed, and the use of the alarm was no longer necessary. The facility's policy on elopement and wandering residents emphasized the need for systematic monitoring and assessment, which was not adhered to in this case. The Director of Nursing acknowledged the oversight in not conducting the required quarterly assessments, and the facility failed to provide a policy regarding the assessment or use of alarms upon exit.
Failure to Update Care Plan for Resident with Pressure Injuries
Penalty
Summary
The facility failed to update the person-centered care plan for a resident with severe cognitive impairment and dependence on staff for all transfers and bed mobility. The resident, who was admitted with diagnoses including Parkinson's Disease and dementia, was observed with pressure injuries that were not adequately addressed in the care plan. The care plan lacked specific instructions on repositioning frequency, despite the resident's inability to reposition independently and the presence of a Kennedy ulcer noted in a provider's assessment. During observations and interviews, it was revealed that the care staff relied on a bedside care plan report, which also did not include necessary details on repositioning frequency or weight offloading for the resident's wounds. The Nursing Care Coordinator confirmed that the care plan was not updated to reflect the resident's current condition and needs, including the presence of the Kennedy ulcer and the requirement for repositioning every two hours. This oversight resulted in the potential for unmet care needs for the resident.
Failure to Provide Timely Laboratory Services for Anticoagulation Monitoring
Penalty
Summary
The facility failed to provide timely and adequate laboratory services for a resident with a prosthetic heart valve who was prescribed warfarin, an anticoagulant requiring regular monitoring through INR tests. The resident was transferred to the hospital multiple times due to supratherapeutic INR levels, indicating excessive blood thinning. Upon returning from a hospital stay, the discharge instructions specified daily INR checks, but the facility was unable to comply due to limited laboratory service availability on weekends and evenings. This resulted in delayed INR testing and reporting, with one instance where a specimen was submitted in an expired collection device, leading to a test not being performed. Interviews with facility staff, including the Clinical Care Coordinator and the Assistant Director of Nursing, revealed ongoing challenges with the contracted laboratory service provider. The laboratory was not open on weekends, and specimens had to be ready for pick-up by 4:00 PM on weekdays, with testing conducted out of state, causing further delays in receiving results. Despite management being aware of these issues, the facility continued to experience significant delays in obtaining critical laboratory results, impacting the care and safety of the resident.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to administer the recommended pneumococcal vaccinations or document the clinical reasons for withholding them for three residents. Resident #36, who was cognitively intact upon admission, had signed a consent form to receive the PCV20 vaccine as per CDC guidelines. However, the resident did not receive the PCV20 vaccine, and there was no documentation from the physician addressing this request. Resident #36 was later transferred to the emergency department with pneumonia. Similarly, Resident #75 and Resident #15, both of whom had consented to receive the PCV20 vaccine, did not receive it, and there was no physician documentation in their EMRs regarding the consideration of the vaccine. The Infection Preventionist confirmed that the residents did not receive the PCV20 vaccine as per their consent forms and that there was no documentation of the vaccine being considered for administration. The facility's policy requires offering pneumococcal vaccinations in accordance with CDC guidelines and documenting the provision of education and the administration or refusal of the vaccine. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and administration of the PCV20 vaccine for the residents in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boulder Park Terrace | 10.9 mi | ★★★★★ | 9 | 0 |
| The Villa At The Bay | 14.5 mi | ★★★★★ | 3 | 0 |
| Meadow Brook Medical Care Facility | 18.4 mi | ★★★★★ | 7 | 0 |
| Bay Bluffs-emmet County Medical Care Facility | 18.8 mi | ★★★★★ | 17 | 0 |
| Medilodge Of Gaylord | 24.6 mi | ★★★★★ | 13 | 0 |
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