Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Harmony Village Of Clinton during CMS and state inspections, most recent first.
A resident under full guardianship and legal incapacity experienced financial exploitation when a Business Office Manager facilitated unauthorized transfers of trust funds without guardian approval, resulting in unaccounted funds and psychological distress. The resident, with a history of mental health disorders, suffered increased anxiety and self-harm following the incident, and interviews confirmed violations of professional boundaries and facility policy.
Surveyors found that the facility did not consistently complete or make available required daily nurse staffing postings, with missing or incomplete forms and gaps in documentation for several months, contrary to facility policy.
Surveyors found that several residents' nebulizer and bi-pap masks were not stored in accordance with facility policy, as the equipment was left directly on nightstands without protective barriers or bags. The residents, who used the equipment regularly and required staff assistance, had their equipment exposed despite clear facility guidelines for proper storage and cleaning.
A resident's care plan was not revised to reflect the loss of their dentures, despite the resident no longer having them and previous interventions for denture care remaining in place. The care plan continued to reference denture-related tasks, and there was no updated documentation in the medical record regarding the resident's current dental status. The DON acknowledged the care plan should have been updated.
A resident was found with an oxygen cylinder left unsecured in the seat of their wheelchair, covered in dust and cobwebs, indicating prolonged improper storage. The DON acknowledged the issue and facility policy requires oxygen tanks to be secured and stored in a designated room, which was not followed in this instance.
A resident who was admitted with ill-fitting dentures had impressions taken for a reline, but the process was not completed and the dentures were not returned. The resident did not receive updates or documented interventions for pain and difficulty chewing, and the medical record lacked information about the dentures, contrary to facility policy.
A resident with multiple medical conditions had conflicting code status information in their medical record, with a DNR order displayed but a signed form requesting full resuscitation also present. The discrepancy occurred because the social worker uploaded the new form without notifying nursing staff, resulting in the code status not being updated as required by facility policy.
A resident with intact cognition and multiple medical diagnoses was found living in a room with a large, dark brown stain on the ceiling tile above the bed. The resident reported the issue upon moving in and stated it had not been addressed, despite facility policy requiring a clean and comfortable environment and ongoing audits by maintenance staff.
A resident with diabetes, depression, and hypertension, who was cognitively intact and independent, did not have OBRA Level II Evaluation recommendations for discharge to a less restrictive setting addressed or documented. The resident's request for more independent living was not followed up by social work, and the DON confirmed the lack of action on these recommendations.
A resident with multiple sclerosis, dysphagia, and impaired cognition was observed eating unassisted on two occasions, despite a documented need for 1:1 feeding assistance. The resident was seen leaning to one side with food on their gown, and both the RD and DON confirmed the requirement for 1:1 feeding support, which was not provided as per facility policy.
A resident with a history of a Stage IV pressure ulcer and impaired cognition was repeatedly observed without required positioning devices and with heels resting flat on the mattress, despite documented care plans calling for heel offloading and frequent repositioning. Staff did not consistently implement these interventions as outlined in the resident's wound care plan.
A resident with dysphagia and impaired cognition, who required nectar thickened liquids and was not to have straws, was repeatedly observed with a straw in their water cup despite clear dietary orders and documentation. Staff were either unaware or did not confirm the restriction, and the DON stated that diet orders are expected to be followed, but the deficiency persisted.
A resident with vascular dementia and severe cognitive impairment was prescribed Seroquel without any documented attempt at a Gradual Dose Reduction (GDR), as required by facility policy for psychotropic drugs. The NHA could not provide evidence of a GDR attempt during the survey.
A resident with Alzheimer's and dementia experienced a fall and exhibited wandering and incontinence behaviors, but the facility failed to update the care plan to address these issues. Despite staff observations of increased confusion and restlessness, the care plan lacked interventions for the resident's wandering and bowel/bladder behaviors. The facility's policy on care planning was not followed, resulting in a deficiency.
The facility failed to provide adequate and meaningful weekend activities for residents, as there were no activities department staff working on weekends. Residents reported being bored, and the facility relied on other staff to facilitate activities, which was insufficient compared to weekday programming.
The facility failed to maintain sanitary conditions in the kitchen, including improper storage of food and utensils, lack of cleanliness, and inadequate staff training on sanitization procedures. These deficiencies were confirmed through observations and interviews with the Dietary Manager and staff.
The facility failed to ensure that the Activities Director (AD) met the required professional qualifications. The AD, a Physical Therapy Assistant with no recent or previous experience in an Activities department, was not currently participating in any training or education for credentialing. The facility Administrator acknowledged the AD did not meet the required qualifications, and the facility's policy on AD qualifications was not followed.
The facility failed to ensure an Advanced Directive was in place timely for a resident with End Stage Renal Disease and Type 2 Diabetes. The resident's electronic health record lacked a code status and a signed advance directive form, which was not completed until later, contrary to the facility's policy requiring completion by day three of admission.
The facility failed to initiate a care plan for a newly identified Stage 3 pressure ulcer for a resident. Despite the resident's severe cognitive impairment and total dependence for ADLs, the care plan did not address the newly acquired pressure ulcer, as confirmed by the DON. The facility's policy mandates a relevant care plan for pressure injury management, which was not followed.
A resident with severe cognitive impairment and multiple medical conditions developed a stage three pressure ulcer due to the facility's failure to ensure timely and appropriate repositioning. Observations revealed the resident lying on their back without proper heel protection, and interviews with staff indicated inconsistencies in repositioning practices and documentation. The facility's policy on pressure injury prevention was not followed, leading to the deficiency.
The facility failed to provide and document weight loss interventions for a resident, resulting in significant weight loss. Despite being aware of the resident's severe cognitive impairment and multiple diagnoses, the facility did not resume previously ordered supplements after a hospital stay and hospice placement. The resident's weight steadily declined, and the facility did not document daily food acceptance or provide necessary supplements.
The facility failed to administer a tube feeding according to the physician's orders for a resident with severe protein-calorie malnutrition and dysphagia. The resident's tube feeding was not consistently documented as given, and residual checks were inconsistently performed, contrary to the facility's policy and physician's orders.
The facility failed to obtain physician orders for dialysis treatment and to monitor the dialysis site for a resident with End Stage Renal Disease and Type 2 Diabetes. The necessary orders were not reactivated upon the resident's readmission, and the dialysis site was not assessed or documented, contrary to the facility's policy.
The facility failed to monitor the temperatures of the medication refrigerator in Station One, with multiple days lacking temperature documentation for both AM and PM shifts across several months. The LPN acknowledged the missing documentation, and the DON confirmed the expectation for temperature logs to be completed on both shifts. The facility's policy did not address the monitoring of medication refrigerator temperatures.
Failure to Prevent Financial Exploitation and Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent financial exploitation and misappropriation of funds for a resident under full guardianship and legal incapacity. The Business Office Manager (BOM) facilitated unauthorized transfers of the resident's trust funds to a debit card without the required approval from the legal guardian. The guardian was not informed about the absence of a patient pay amount and continued to send substantial monthly funds, which were managed by the BOM. The guardian later discovered that approximately $10,000 was unaccounted for, and that funds intended for specific resident needs, such as dentures, were not used as agreed. The resident involved had a history of anxiety disorder, bipolar disorder, narcissistic personality disorder, and adjustment disorder, and required staff assistance with mobility and transfers. Despite an intact cognitive score, the resident was legally incapacitated and unable to consent to financial transactions. The resident reported increased anxiety, paranoia, lack of sleep, and suicidal ideation following the incident, and was observed with self-inflicted injuries requiring psychiatric assessment and 1:1 monitoring. The resident expressed emotional distress related to the removal of the BOM and maintained that the BOM was supportive, while expressing distrust toward facility administration. Interviews and documentation revealed that the BOM engaged in unprofessional conduct, including maintaining an inappropriate relationship with the resident and facilitating financial transactions without guardian oversight. The BOM admitted to assisting the resident with financial matters and obtaining a lawyer for the resident without involving social work or the guardian. Facility staff and the legal guardian confirmed that the BOM's actions violated professional boundaries and facility policy, resulting in substantiated findings of misappropriation of funds and psychological abuse.
Failure to Maintain and Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings were completed and readily accessible for all residents, families, and visitors. During the survey, the Nursing Home Administrator was unable to provide complete staffing postings for the past 18 months as required. The binder provided contained forms that were incomplete, missing dates, and lacking necessary staffing information. The staffing coordinator acknowledged that the forms were incomplete, and the facility was unable to provide postings for certain months by the end of the survey. A review of the facility's own policy confirmed that nurse staffing information should be posted daily, including specific details such as facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and CNAs per shift. The policy also required that this information be maintained for at least 18 months. The survey found that these requirements were not met, as postings were missing or incomplete for several dates within the required retention period.
Improper Storage of Respiratory Equipment
Penalty
Summary
Surveyors observed that three residents' respiratory equipment, including nebulizer masks and a bi-pap mask, were not properly stored according to facility policy. Specifically, the masks were found sitting directly on nightstands without any barrier or protective bag. The residents involved had intact cognition and required staff assistance with bed mobility and transfers. Each resident reported regular use of their respiratory equipment. The facility's policy requires that nebulizer masks be stored dry in mesh bags, clear plastic bags, or other clean storage as per facility preference, and that bi-pap masks be cleaned weekly and stored properly in a bag. During an interview, the Infection Control Preventionist confirmed these requirements. The failure to follow these procedures was directly observed and confirmed through staff interview and record review.
Failure to Update Care Plan for Resident's Dental Status
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect their current dental status. The resident, who was admitted with diagnoses including Type II Diabetes, Depression, and Hypertension, reported that their dentures did not fit properly upon admission and that a dental visit for realignment had not resulted in the return of the dentures. Despite the resident no longer having dentures, the care plan continued to list interventions related to denture care, such as ensuring proper fit and secure placement. Record review showed that the care plan had not been updated since its initiation, and there was no documentation in the medical record regarding the current status of the dentures. The Director of Nursing acknowledged that the care plan was outdated and did not reflect the resident's present condition. The facility's policy requires that care plans be reviewed and revised as necessary by the interdisciplinary team, but this was not done in this case.
Oxygen Cylinder Improperly Stored in Wheelchair
Penalty
Summary
A deficiency was identified when a resident was observed with an oxygen cylinder/tank placed in the seat of their wheelchair, leaning against the back of the chair. The oxygen cylinder/tank was covered in dust and cobwebs, indicating it had been left in this position for an extended period. When asked, the resident could not specify how long the tank had been there. The Director of Nursing (DON) confirmed awareness of the oxygen cylinder/tank in the wheelchair and explained that facility policy requires oxygen tanks to be secured in a carrier and stored in the designated oxygen storage room when not in use. A review of the facility's policy on oxygen safety and storage revealed that oxygen cylinders must be properly secured in racks, carriers, or approved stands to prevent them from falling, and must be stored in an enclosed, secure area when not in use. The observed practice of leaving the oxygen cylinder/tank unsecured in the wheelchair did not comply with these requirements, resulting in a failure to provide safe and appropriate respiratory care for the resident.
Failure to Timely Follow-Up on Denture Services
Penalty
Summary
A resident who was admitted with a pair of dentures reported that the dentures did not fit properly upon admission. The resident was seen by a dentist in June of the previous year, at which time full impressions were taken for a laboratory reline of the upper and lower complete dentures, and the dentures were sent to the laboratory. Since that time, the reline has not been completed, and the resident no longer has the dentures. The resident stated that they were told a follow-up would occur but have not received any updates, and they are now experiencing jaw pain and difficulty chewing. A review of the resident's medical record did not reveal any information regarding the status of the dentures. The facility's policy requires referral for dental services within three days for lost or damaged dentures and outlines interventions to ensure residents can eat and drink while awaiting dental services, such as notifying the physician of pain, modifying diet consistency, and referring to a dietician or speech therapist. These interventions were not documented as being implemented for this resident.
Failure to Maintain Accurate and Updated Advance Directive Information
Penalty
Summary
The facility failed to ensure that updated and accurate advance directive information was maintained for a resident. The resident, who had diagnoses including cerebral infarction, major depressive disorder, and dysphasia, was dependent on staff for transfers and toileting. Upon review of the resident's medical record, there was a discrepancy between the code status displayed at the top of the record, which indicated DNR (do not resuscitate), and a signed Medical Treatment Decision Form in the record that indicated the resident requested full resuscitation (CPR) in the event of cardiac or respiratory arrest. Interviews with facility staff revealed that the resident had changed their mind regarding code status, but the updated form was uploaded by the social worker without notifying nursing staff, resulting in the code status not being updated in the medical record. The facility's policy requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. This failure led to conflicting information regarding the resident's advance directives.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident was observed sitting in their room beneath a large, approximately 12-inch round dark brown stain on the ceiling tile directly above the head of the bed. The resident reported that the stain was present when they moved into the room and had previously informed someone about it, but no corrective action had been taken. The resident, who has diagnoses of hemiplegia, hemiparesis following cerebral infarction, and chronic obstructive pulmonary disease, was assessed as having intact cognition. During a subsequent observation with the Maintenance Director, it was acknowledged that an audit of rooms with concerns was ongoing, and the expectation was for resident rooms to be maintained in good condition to provide a homelike environment. Facility policy requires the provision of a safe, clean, comfortable, and homelike environment, with necessary housekeeping and maintenance services.
Failure to Follow PASARR Level II Recommendations for Resident Discharge Planning
Penalty
Summary
The facility failed to follow the recommendations of an OBRA Level II Evaluation for one resident who was reviewed for PASARR compliance. The resident, who was admitted with diagnoses including Type II Diabetes, Depression, and Hypertension, was found to be cognitively intact and independent with transfers. The OBRA evaluation recommended that the facility's social work staff assist the resident in searching for a less restrictive setting, such as a senior apartment with home healthcare support, if the medical team agreed. However, there was no documentation in the resident's medical record indicating that these recommendations were addressed or followed up on. During an interview, the resident reported having asked social work about the possibility of discharge to a more independent living situation but felt their request was dismissed. The Director of Nursing acknowledged the lack of follow-up on the OBRA recommendations and stated that corporate staff would investigate further, but no additional information was provided by the end of the survey. The facility's policy requires that PASARR Level II recommendations be incorporated into the resident's assessment, care planning, and transitions of care, which was not done in this case.
Failure to Provide 1:1 Feeding Assistance for Resident with Dysphagia and Impaired Cognition
Penalty
Summary
The facility failed to provide required 1:1 feeding assistance to a resident with multiple sclerosis, dysphagia, and impaired cognition, as documented in their medical record and diet order. On two separate occasions, the resident was observed eating lunch unassisted, despite a meal ticket and diet order specifying the need for 1:1 feeding assistance. The resident was noted to be leaning to one side with food on their gown during one observation. Interviews with the registered dietitian and DON confirmed that the resident requires 1:1 feeding assistance and is followed by speech therapy, with staff expected to assist those needing help after passing trays. Facility policy states that residents unable to perform activities of daily living should receive necessary services to maintain nutrition and hygiene.
Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement pressure ulcer prevention interventions for a resident with a history of a Stage IV pressure ulcer. Multiple observations over two days showed the resident lying in bed on their back with their heels flat on the mattress and without positioning wedges or pillows in place, despite care plans and wound care notes specifying the need for heel offloading and frequent repositioning. The resident was also noted to have impaired cognition and required staff assistance for bed mobility and transfers, further emphasizing the need for staff-initiated interventions. Medical records indicated the resident was admitted with moderate protein-calorie malnutrition and a Stage IV pressure ulcer of the left buttock, and the most recent wound care note documented the need for preventative measures such as heel protectors or pillows and regular repositioning. Despite these documented interventions, observations revealed that the resident's heels were not consistently offloaded and that positioning devices were not always in use. Interviews with the unit manager confirmed the expectation for frequent repositioning and heel elevation, but these interventions were not consistently observed in practice.
Failure to Implement Dietary Restrictions for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when staff failed to implement dietary restrictions for a resident with dysphagia and muscle wasting, who was admitted with an order for nectar thickened liquids (NTL) and a specific restriction against the use of straws. Despite the diet order and documentation on the diet ticket indicating no straws, the resident was repeatedly observed with a straw in their water cup on multiple occasions. Staff interviews revealed a lack of awareness or confirmation of the dietary restriction, and the occupational therapist confirmed that the resident should not have a straw due to the risk of coughing and aspiration. The Director of Nursing acknowledged that diet orders are printed and expected to be followed, but the resident continued to have access to a straw. A facility policy regarding special dietary instructions was requested but not provided during the survey. The resident involved had impaired cognition, required staff assistance with mobility and transfers, and was at risk due to the failure to follow prescribed dietary restrictions.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) for an antipsychotic medication, Seroquel, for one resident diagnosed with vascular dementia and adjustment disorder with anxiety. The resident had a severely impaired cognition, as indicated by a BIMS score of 3/15, and required staff assistance with bed mobility and transfers. Medical records showed active physician orders for Seroquel 25 mg once daily and 50 mg at bedtime. During the survey, the Nursing Home Administrator was unable to provide documentation of any GDR attempt for this resident, despite facility policy requiring gradual dose reductions and behavioral interventions for residents on psychotropic drugs unless clinically contraindicated.
Failure to Update Care Plan for Resident with Wandering and Incontinence Issues
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R901, to reflect their wandering behavior, falls, and bowel and bladder issues. The resident, who was admitted with Alzheimer's Disease, Dementia, Muscle Weakness, Difficulty Walking, and Hearing Loss, experienced a fall on 06/21/24, resulting in a head injury and hospitalization. Despite documented incidents of increased confusion, restlessness, and wandering, the care plan did not include interventions for these behaviors. The resident's wandering was not captured in the Minimum Data Set (MDS) assessments, and the care plan lacked updates to address the resident's changing needs. Interviews with staff and other residents revealed that R901 frequently wandered into other residents' rooms, sometimes taking items or sitting on their beds. The resident was also reported to have bowel incontinence incidents in inappropriate locations, such as other residents' beds. Staff noted that R901 was often confused, unsteady, and required frequent redirection. Despite these observations, the care plan did not include specific interventions to manage the resident's wandering and bowel/bladder behaviors. The facility's policy on care planning, which requires the development and implementation of a comprehensive care plan based on the resident assessment instrument, was not followed. The care plan for R901 did not reflect the resident's current condition and behaviors, and there was no care plan addressing the identified concerns of wandering and inappropriate bowel and bladder use. The Director of Nursing acknowledged the worsening dementia and roaming behaviors but had not considered one-to-one supervision or other interventions to address these issues.
Inadequate Weekend Activities for Residents
Penalty
Summary
The facility failed to provide adequate and meaningful weekend activities for its residents, as evidenced by interviews and record reviews. Eight anonymous group participants reported that the facility no longer had activities department staff working on weekends, resulting in a lack of organized or meaningful activities. The facility's activities calendar for March and April 2024 indicated only independent leisure activities on Saturdays and limited activities on Sundays. The Activities Director confirmed that the facility no longer employed activities aides and that other staff, such as CNAs and nurses, were expected to assist residents with activities on weekends. However, this arrangement was insufficient compared to the weekday activities programming. The facility Administrator verified that the activities aides positions were eliminated and that there were no dedicated activities department staff scheduled on weekends. The Administrator stated that other facility staff were instructed to facilitate activities on weekends, but the residents reported being bored and having nothing to do. The facility's policy on activities, dated January 1, 2024, stated that the facility would provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. The lack of dedicated activities staff on weekends led to the deficiency in providing meaningful activities for the residents.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour. A personal cell phone was found on the food preparation counter, which was confirmed by the Dietary Manager (DM) as inappropriate. Additionally, a scoop was improperly stored inside a flour bin with its handle resting in the flour. A box of orange juice concentrate was used to prop open the dry storage room door, and the top surface of the Southbend steamer had a buildup of grease and crumbs. A wet wiping cloth was found lying on the food preparation counter instead of being stored in a sanitizer bucket, and there were no prepared sanitizer buckets in the kitchen. The inside surface of the microwave had dried food splatter, and the shelf at the front of the steam table was warped with large cracks and exposed, porous particle board, making it difficult to clean. The DM acknowledged the need for a new shelf. Dietary staff members were also observed using the dish machine without knowing how to check for adequate sanitization or chemical sanitizer levels, and the sanitization log was blank for two meals. These observations indicate multiple violations of the 2017 FDA Food Code, including improper storage of food and utensils, lack of cleanliness, and inadequate staff training on sanitization procedures. The deficiencies were confirmed through interviews with the DM and dietary staff, who acknowledged the issues and their non-compliance with the FDA Food Code standards.
Failure to Ensure Activities Director Met Professional Qualifications
Penalty
Summary
The facility failed to ensure that the Activities Director (AD) met the required professional qualifications. The AD, who had been in the position for approximately one month, was a Physical Therapy Assistant (PTA) with no recent or previous experience in an Activities department. The AD reported plans to pursue Therapeutic Recreation-related credentialing but was not currently participating in any training or education. The facility Administrator acknowledged that the AD did not meet the required qualifications and stated that the facility had provided resources for the AD to pursue credentialing and arranged for mentoring from an AD at a sister facility, but these processes were not completed before the AD assumed the role and responsibilities in the facility. The facility's policy on Activities Director Qualifications, dated 01/01/24, requires that the AD be licensed or registered by the State and meet one or more specific criteria, such as being eligible for certification as a therapeutic recreation specialist, having relevant experience, being a qualified occupational therapist or assistant, or having completed a State-approved training course. The qualifications of the AD were not verified prior to hire, leading to the deficiency identified during the survey.
Failure to Timely Complete Advance Directive
Penalty
Summary
The facility failed to ensure an Advanced Directive (AD) was in place timely for one resident (R73) of four reviewed for Advance Directives. The electronic health record (EHR) revealed that R73 did not have a code status in the banner or a signed advance directive form. R73 was originally admitted to the facility and later readmitted with pertinent diagnoses including End Stage Renal Disease and Type 2 Diabetes. A Minimum Data Set (MDS) assessment indicated that R73 had no cognitive impairment and required dialysis. An advance directive was requested for R73, but it was not completed until a later date, contrary to the facility's policy that an AD should be completed by day three of admission. In an interview, the Social Worker (SW) confirmed that the AD for R73 was completed late and should have been done prior to the day it was actually completed. The facility's policy on Resident's Rights Regarding Treatment and Advance Directives states that the facility will determine if a resident has executed an advance directive upon admission and, if not, will determine whether the resident would like to formulate one. The failure to complete the AD in a timely manner resulted in the potential for R73's preferences for medical care to not be followed by the facility or other healthcare providers.
Failure to Initiate Care Plan for Newly Identified Pressure Ulcer
Penalty
Summary
The facility failed to initiate a care plan for a newly identified facility-acquired pressure ulcer for one resident. On multiple observations, the resident was seen lying in bed on their backside, grimacing in pain. The resident's medical record indicated severe cognitive impairment and total dependence for Activities of Daily Living. Despite a wound doctor's report identifying a Stage 3 pressure ulcer on the resident's sacral area, the care plan did not address this newly acquired pressure ulcer. The Director of Nursing confirmed that the care plan should reflect the resident's current status, which it did not in this case. The facility's policy on Skin and Pressure Injury Risk Assessment and Prevention mandates that the interdisciplinary team develop a relevant care plan with measurable goals for pressure injury management, which was not done for this resident. The existing care plan only addressed the risk of impaired skin integrity related to incontinence and did not include interventions for the newly identified pressure ulcer.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure timely and appropriate repositioning for a resident, resulting in the development of a stage three pressure ulcer. The resident, who had severe cognitive impairment and multiple medical conditions including atrial fibrillation, myocardial infarction, and morbid obesity, was observed multiple times lying on their back with heels on the bed surface without proper heel protection. Despite having a foam pressure-reducing mattress, the resident's care plan did not include specific interventions for pressure wound care or prevention, and there was no documentation of repositioning or refusal to reposition in the electronic medical record (EMR). Nursing staff, including a nurse and two certified nursing assistants (CNAs), were interviewed and revealed inconsistencies in their knowledge and practices regarding repositioning schedules and documentation. The nurse was unaware of where refusals to reposition were documented, and the CNAs had different understandings of the repositioning schedule and documentation process. The Director of Nursing (DON) also indicated that the repositioning schedule mentioned by one of the CNAs was not a facility practice and did not see the need for a specific care plan for the resident, as the resident could stand. The facility's policy on skin and pressure injury risk assessment and prevention was not followed, as evidenced by the lack of documented interventions in the care plan and the absence of evidence-based treatment for the resident's pressure injury. The resident's sacral wound, identified as a stage three pressure ulcer, was not properly addressed, and there were multiple incidents where the resident's heels were not floated as required. This failure to provide appropriate pressure ulcer care and prevent new ulcers from developing led to the deficiency noted in the report.
Failure to Provide and Document Weight Loss Interventions
Penalty
Summary
The facility failed to provide and document weight loss interventions for a resident (R5), resulting in significant weight loss. R5 was observed to be very thin and emaciated, with visible bones beneath the skin surface. The resident's medical record revealed a history of severe cognitive impairment and multiple diagnoses, including Protein-Calorie Malnutrition and Dysphagia. Despite being aware of R5's significant weight loss of 17.97% over a six-month period, the facility did not resume the previously ordered supplements after R5 returned from a hospital stay and was placed on hospice care. The Registered Dietician (RD) confirmed that R5 often refused supplements, but there was no documentation of these refusals in the medical record. Additionally, the facility's electronic medical record (EMR) showed a steady decline in R5's weight over several months, with no documented interventions to address the weight loss after the resident's return from the hospital. The Director of Nursing (DON) stated that all residents should be assessed and receive appropriate interventions regardless of their hospice status. However, the facility failed to document daily food acceptance and did not provide supplements as previously ordered. The nutritional summary indicated that R5's caloric needs were not being met, and the resident's appetite fluctuated significantly. Despite consuming 75% or more of most meals before the hospital stay, R5's weight continued to decline, highlighting the facility's failure to implement and document effective weight loss interventions for the resident.
Failure to Administer Tube Feeding According to Physician's Orders
Penalty
Summary
The facility failed to administer a tube feeding in accordance with the physician's orders for a resident with severe protein-calorie malnutrition and dysphagia. Observations revealed that the resident's tube feeding pump was present but not running. The resident had a physician's order for Jevity 1.5 to be administered once daily at 5 p.m. until the dose was complete. However, the Medication Administration Record (MAR) showed multiple instances where the tube feeding was not documented as given, and residual checks were inconsistently documented. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the tube feeding should be documented after administration and that residual checks should be performed before feedings and medication administration, although the physician indicated that routine residual checks were not necessary unless there was a concern with the PEG tube or feeding. The facility's policy on the care and treatment of feeding tubes stated that feeding tubes should be utilized according to physician's orders and that tube placement should be verified before beginning a feeding and before administering medications. Despite this policy, the facility did not consistently document the administration of the tube feeding or perform residual checks as required. The Nurse Practitioner (NP) also noted that chronic tube feeding residents do not require consistent residual checks unless there is an identified concern. This lack of adherence to the physician's orders and facility policy resulted in the potential for weight loss and dehydration for the resident.
Failure to Obtain Physician Orders and Monitor Dialysis Site
Penalty
Summary
The facility failed to obtain physician orders for dialysis treatment and to monitor the dialysis site for a resident who required such services. The resident, who had diagnoses of End Stage Renal Disease and Type 2 Diabetes, was readmitted to the facility without reactivating the necessary orders for dialysis. Licensed Practical Nurses (LPNs) confirmed that there were no active orders for the resident to receive dialysis or to monitor the dialysis site. The Director of Nursing (DON) also acknowledged that the orders were not reactivated upon the resident's readmission. Observations and record reviews revealed that the dialysis site was not assessed or documented, and the resident was observed with a port in the right upper chest. The deficiency was identified through interviews, record reviews, and observations. The resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment, and required dialysis on specific days of the week. Despite this, the facility did not have the necessary physician orders in place, and the dialysis site was not monitored as required. The facility's Dialysis Special Needs Care policy, which mandates providing care and treatment consistent with professional standards and physician orders, was not followed in this case.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor the temperatures of the medication refrigerator in Station One, which stored drugs and biologicals. During an observation on 4/25/24, it was found that the temperature log for April 2024 had no documentation for the AM shift and was missing entries for the PM shift on 4/23, 4/24, and 4/25. Similar issues were noted for March, February, and January 2024, with multiple days lacking temperature documentation for both AM and PM shifts. When questioned, the LPN acknowledged the missing documentation and expressed embarrassment. The Director of Nursing was informed of these findings and confirmed that the expectation was for temperature logs to be completed on both shifts. The facility's policy on the storage and stability of medications did not address the monitoring of medication refrigerator temperatures.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Clinton Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Sterling Heig | 2.1 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Sterling Heights | 2.7 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Shoreline | 2.8 mi | ★★★★★ | 8 | 0 |
| Fraser Villa | 2.9 mi | ★★★★★ | 7 | 0 |
| Lakeside Manor Nursing And Rehabilitation Center | 3.2 mi | — | 12 | 0 |
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