Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harold And Grace Upjohn Community Care Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective pressure ulcer prevention and wound monitoring program for multiple residents with high skin breakdown risk. One resident with severe cognitive impairment and total dependence had a sacral wound worsen to a stage 4 while staff documentation was duplicated or incomplete, and another resident with a high Braden score had a deteriorating coccyx wound with new heel, toe, and thigh skin changes that were not consistently assessed or documented. The report also notes a new facility-acquired pressure injury in another resident and inadequate monitoring for several others with existing wounds.
Failure to follow policy for resident food storage. Observation of nourishment rooms found resident-labeled leftover food and yogurt past the best by date, while the DM stated staff likely focused on regularly stocked items rather than all snack items. The facility policy required outside food to be stored safely and consumed within 72 hours or per facility food storage policy, with unconsumed items discarded for food safety concern.
Failure to Use QAPI for Repeat Deficiencies: The facility failed to identify, develop, and implement effective actions for repeat deficiencies involving resident rights, bowel/bladder incontinence/catheter care, infection control, monthly med reviews, pressure ulcers, and quality of care. The NHA stated the facility was only working on PIPs for falls and new employee orientation, and the repeat issues from the last three surveys had not been brought to QAPI as PIPs despite being identified as high-priority areas in the facility's QAPI policy.
Multiple infection control failures were observed involving residents with wounds, Foley catheters, and MDRO concerns. Staff did not consistently follow EBP or Contact Precautions, including missing gown and glove use during wound care, incontinence care, and meal delivery, and a Foley catheter bag was repeatedly left on the floor. The facility also had water management issues with disused fixtures, stagnant lines, and incomplete monitoring of the hot-water system.
Failure to track CNA annual in-service education: The facility did not ensure CNAs received at least 12 hours of required annual in-service training. The SS was unfamiliar with the hour requirement, the DON said monthly trainings were assigned online and tracked by HR, and the I-CEO could not provide tracking information. Review of CNA in-service reports did not confirm that all CNAs completed the required training, and numerous CNAs listed did not complete assigned monthly trainings.
The facility failed to consistently provide scheduled and needed ADL assistance, including bathing, grooming, and nail care, to several dependent residents. One resident with an ADL care plan and scheduled showers was observed with greasy hair and an unwashed face and had received only a fraction of the documented bathing opportunities. Another resident with dementia and physical debility was repeatedly observed with long, jagged fingernails and dark debris under the nails despite staff having access to nail care tools. A cognitively intact resident with depression and morbid obesity, care planned for bed baths and dependent for bathing, reported being cleaned only about once weekly, with records showing very few baths over two months and no additional documentation available. Another resident with CHF, major depressive disorder, and moderate cognitive impairment, scheduled for twice-weekly bathing and preferring bed baths, was offered or received bathing on only part of the scheduled opportunities and reported not being cleaned as often as desired. A CNA stated that when staffing was below scheduled levels, staff were sometimes unable to offer bathing, and a UM described the expectation for CNAs and nurses to document each bathing offer on shower sheets.
Multiple residents experienced inadequate assessment and monitoring of wounds, infections, blood glucose, and medication administration. A resident with an absent eye had thick green ocular discharge and swollen lids, yet staff only administered ordered eye drops without documenting any assessment or notifying a provider, and the issue was not placed on infection tracking. Another resident with a known basal cell carcinoma on the chin/neck had a large open wound with dried blood on clothing, but weekly skin checks were copied forward, no wound care or monitoring orders existed, and direct care staff did not cleanse or treat the wound. Two residents with DM had repeated episodes of severe hyperglycemia and hypoglycemia documented, but nurses did not notify a provider or document any follow-up despite stated thresholds for mandatory notification. Additionally, a resident with Alzheimer’s disease and hypotension received midodrine even when BP readings were outside ordered parameters, and once without any documented vital signs, indicating failure to follow physician orders and professional standards of practice.
Surveyors observed multiple hoyer lifts and sit-to-stand devices in hallways outside resident rooms that remained visibly soiled over consecutive days, with dried white and brownish/tannish material, dirt, and debris on bases, footrests, and knee pads. Some devices had gait belts draped over them and plastic bags that were initially empty of wipes, although wipes were later present while the equipment remained dirty. In an interview, the IP stated that staff had recently been re-educated, including reminders to sanitize shared resident equipment after each use.
Failure to Develop Individualized Care Plans Based on Comprehensive Assessments: The facility used generic or outdated care plans that did not reflect residents’ current wounds, incontinence, mobility limits, device use, or cognitive/behavioral needs. A resident with multiple pressure injuries and a Foley catheter, a resident with a large chin/neck wound, a resident with heel, coccyx, and toe wounds, a resident with buttock excoriation, and a resident with dementia all had care plans that omitted key assessed problems and needed interventions. Staff observations and interviews showed prolonged bed positioning, wound issues, and care needs that were not captured in the plans.
Care plan interventions for a resident at risk for skin breakdown were not updated to match a physician order for heel protectors at all times. The resident had dementia, CHF, and severe cognitive impairment, and the Kardex only listed floating heels on a pillow and skin prep to the right heel. A CNA reported relying on the Kardex for care needs and believed the heel boots were no longer needed, while observations showed the resident lying supine with both heels on the mattress and the heel protector boots left in a chair.
A facility failed to keep complete and accurate records for multiple residents, with repeated problems in wound documentation, duplicated skin checks, missing assessments, and absent provider notes. Several residents had documented pressure injuries, open wounds, or skin changes that were not properly evaluated or reflected in the chart, including a resident with sacral and gluteal wounds, a resident with a large open chin/neck lesion, and a resident with sacral, heel, and toe wounds. The record also lacked an NP assessment for a resident sent out for urgent evaluation.
A resident with legal blindness and a right leg amputation, who was cognitively intact, was not provided with a functional room layout or adequate environmental accommodations for low vision. Furniture placement left only a narrow space to access a chest of drawers and stereo, and the resident had only one electrical outlet with two sockets, limiting his ability to use and charge his laptop, phone, talking book machine, and braille writer. He reported repeated, unaddressed requests for a power strip and an LED bulb to improve lighting, and difficulty seeing a white overhead light cord against a white wall despite a small piece of glow-in-the-dark tape. The resident also reported that a highly visible privacy curtain he preferred was replaced with a dull curtain without his input. A facility form documented his earlier complaints about room accessibility and limited space, and staff interviews confirmed his concerns, yet his care plan contained only an intervention for eye care consultation and no individualized environmental or low-vision modifications, contrary to the facility’s own accommodation policy.
Failure to assess safe self-administration of medication: A cognitively intact resident with depression and schizoid personality disorder was approved to self-administer acetaminophen, but was observed in bed with a bedside cup containing pudding mixed with unknown medication. The resident's most recent self-administration assessment was outdated, and the record showed the resident had not been reassessed as required by facility policy and the NHA's stated annual review expectation.
Delayed Response to Call Light Led to Loss of Resident Dignity: A resident with DM, mild cognitive impairment, and mobility limitations reported that staff took too long to respond when he used his call light, causing him to have bowel movements in his pants and feel embarrassed. The resident said he tried to call before needing help, and a CNA reported recent staffing levels made it challenging to meet resident needs.
Failure to honor a resident’s preference for shower timing. A resident with an ADL deficit and weakness/debility was scheduled for showers on specific days, but staff did not provide the shower at her preferred day-shift time. The resident reported declining a late-night shower because she was tired, and shower documentation showed repeated requests to move showers to day shift, with staff and the UM aware of the preference.
Failure to Document and Resolve Resident Grievances: Two residents voiced concerns that were not processed through the facility’s grievance system. One resident with legal blindness and other significant diagnoses complained about room layout, lighting, and limited access to outlets, while another resident reported missing pajama tops. Staff and leadership confirmed grievance forms were not completed, concerns were handled informally or not followed up, and the facility’s grievance process was bypassed instead of being documented and resolved.
A resident with dementia and mobility limitations had repeated unwitnessed falls despite a care plan with fall interventions, and the record showed the plan was not updated after the falls. Staff documentation noted the resident was found on the floor, on his knees between the bed and heater, and later beside the bed after rolling out, with no immediate safety intervention documented. The facility also failed to ensure safe Hoyer transfers for one resident, whose lower leg and feet were caught on the Hoyer base during transfer, and failed to ensure safe wheelchair transport for another resident with severe cognitive and visual impairment, who was moved with feet unsupported and footrests folded up.
A resident with a Foley catheter and sacral wound had no catheter-specific care plan, no observed securement device, and tubing was pulled tight across the leg; the catheter was also noted during wound care without full barrier PPE. Another resident who was fully dependent for toileting reported delayed response to call light use and was found sitting in a wet brief, with staff later confirming incontinence care had not been provided for more than 5 hours and a new open area was seen in the buttock crease.
Failure to Ensure Physician Supervision of Wound Care: A resident with multiple pressure injuries and toe discoloration had incomplete wound documentation, inconsistent skin checks, and no ongoing provider assessment or progress notes after an initial MD visit noted heel pressure injuries, toe gangrene, and concern for gangrene. Staff interviews and record review showed the coccyx wound, heels, and toes were not consistently evaluated, and a wound communication log noted purulent drainage and new wounds without corresponding provider documentation.
Delayed Physician Response to Pharmacy Medication Review Recommendations: Pharmacy MRRs identified irregularities for 3 residents, but physician follow-up was not documented or could not be verified. One resident with insomnia remained on zolpidem 10 mg despite a pharmacist recommendation to reduce the dose, another resident with dementia had an empty provider response for psychotropic and benzodiazepine therapy, and a third resident had prolonged clotrimazole use without documented stop-date review. The facility’s MRR policy required written communication of irregularities and documentation in the medical record.
The facility failed to ensure the MD carried out MRR responsibilities for 3 residents reviewed for medications. The Interim CEO confirmed there was no documentation showing the MD completed monthly pharmacy recommendation reviews or signed the pharmacy reports, and the MD did not return the surveyor’s call before exit. The facility’s MRR policy requires monthly pharmacist review of each resident’s drug regimen and chart, with staff acting on recommendations.
A facility failed to make the most recent survey results available for resident and guest review. A survey results binder in a common area contained outdated survey findings, and the MCM said she did not know the binder existed or that it needed to be available for review. The NHA stated he had not updated the binder, though the most recent survey results and POC were available online.
Failure to Post Daily Staffing Information: The facility did not ensure staffing hours were posted daily, as the posting at the main entrance remained dated and unchanged over multiple days. The Scheduler said she was responsible for the posting but had been absent and did not know who would post it when she was away. The NHA said the DON would be responsible when the Scheduler was absent, while the DON said any manager could post it, but staffing hours were not posted when management was not in the building on weekends or holidays.
A resident with severe cognitive impairment experienced a fall resulting in a head injury and was transferred to the hospital, but the family was not notified of the incident or transfer until the resident was being discharged from the hospital, contrary to facility policy requiring timely notification of emergency contacts.
A resident with multiple comorbidities developed stage II pressure ulcers that were not consistently documented or addressed in care plans. Staff interviews revealed confusion about the presence and staging of the wounds, and wound logs were incomplete or missing key information. Facility policies for wound assessment and documentation were not followed, leading to inadequate monitoring and care for the resident's pressure ulcers.
A resident's medical record lacked complete and accurate documentation of ADL care, with only half of the required showers or bed baths recorded and no evidence to support late entries made after family concerns were raised. The facility was unable to verify whether the resident received or refused care as required by policy.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment posed risks, and supervision protocols were not sufficient to ensure resident safety.
Construction equipment, materials, and resident room furniture were stored in a main corridor and adjacent open spaces during ongoing room renovations, obstructing exit access. The construction area was not separated from the corridor, and glue vapors were present, indicating poor ventilation. Some rooms in the affected corridor remained occupied by residents not under renovation.
The facility failed to comply with food safety standards, as observed during a survey. Improper cooling and storage of food items were noted, with chicken and rice not logged for cooling, and several items improperly dated or expired. Cleanliness issues were found with food contact surfaces, including debris on scoops and dispensers. Additionally, ice coolers did not allow for proper drainage, violating FDA guidelines.
Several residents experienced long wait times for call light responses, affecting their dignity and well-being. A resident with diabetes waited nearly an hour for assistance after a bowel movement, while another with an overactive bladder felt neglected due to frequent delays. A resident with dementia waited 45 minutes for a response, and a resident with a urinary catheter had a bleeding wound unattended for over an hour. The facility lacked evidence of recent staff education on call light response times.
An LPN at the facility repeatedly left her medication cart unattended with the computer screen open, displaying sensitive resident information, including that of a resident with type 2 diabetes. This occurred multiple times, with the LPN away for 5 to 10 minutes, allowing staff and others to view the exposed information. The LPN acknowledged knowing the requirement to lock the screen but admitted to forgetting.
A resident with a history of falls and a recent femur fracture experienced a fall, resulting in abrasions and bruises. The facility failed to adequately assess and document the resident's knee wounds, leading to a delay in treatment. Despite bleeding through bandages, the knee injuries were not addressed promptly due to their omission in the post-fall documentation. Interviews revealed a lack of adherence to expected assessment protocols by the nursing staff.
A resident with type 1 diabetes and moderate cognitive impairment did not receive necessary vision services due to a failure in scheduling an optometrist appointment. Despite an order from the Medical Director and documentation of broken glasses, the Medical Records Assistant was unaware of the need for an appointment, and the Unit Manager missed the progress note. As a result, the resident's vision needs were unmet, impacting their ability to perform daily tasks.
A resident with a Foley catheter experienced repeated UTIs due to the facility's failure to change the catheter as ordered. The resident, with a history of obstructive and reflux uropathy and neurogenic bladder, had an order for catheter change that was not completed, leading to continued infections. Observations showed improper catheter management, and staff interviews revealed a lack of awareness and communication about the order, resulting in additional UTIs.
A resident with multiple diagnoses experienced a delay in physician response to a pharmacist's medication regimen review recommendations. The recommendations included insulin dosage adjustments, discontinuation of montelukast, reevaluation of Miralax dosages, and reduction of Doxepin Hydrochloride. The physician's response was delayed by over a month, contrary to the facility's policy requiring timely action on such recommendations.
Two residents, both legally blind, were not provided with necessary adaptive dining equipment while in isolation, leading to difficulties in eating and drinking. The facility's policy of using disposable items during isolation conflicted with the residents' care plans, causing frustration and decreased independence.
The facility failed to ensure the Medical Director attended QAPI meetings quarterly, as required. The interim NHA reported a change to quarterly meetings with ad hoc sessions as needed. While the Medical Director attended some meetings, they missed the November session, and the sign-in sheet for that meeting was missing. This led to the potential for the Medical Director to be unaware of quality deficiencies.
The facility failed to follow infection control protocols for residents under transmission-based and enhanced barrier precautions. Staff did not use appropriate PPE for droplet precautions, and gowns were not worn during high-contact care for a resident at risk of spreading MDROs. Additionally, improper hand hygiene and glove use were observed during catheter care for a resident with an indwelling catheter.
A facility failed to obtain and document COVID-19 vaccination consent or declination for a resident with severe cognitive impairment, resulting in the resident's family not being informed about the vaccination and its risks and benefits. The resident's immunization record did not list the COVID-19 vaccine, and there was no documentation of communication with the resident's guardian. The facility's policy requires such documentation, which was not followed.
The facility failed to follow infection control protocols for two residents, leading to potential infection spread. A resident with dementia did not receive care under enhanced barrier precautions, and another resident on contact isolation for a UTI was exposed to staff not wearing PPE. Additionally, the facility did not notify staff and visitors of confirmed COVID-19 cases, resulting in improper mask usage and lack of signage on the affected unit.
The facility failed to maintain an agreement with the dialysis provider for four residents requiring dialysis services, leading to potential disruptions in care. Despite efforts to locate the agreement, it was not found, impacting residents with serious health conditions.
The facility failed to implement proper infection control protocols, including Enhanced Barrier Precautions (EBP), for residents with indwelling medical devices. Observations and staff interviews revealed a lack of appropriate signage and PPE, and the EBP program had not been initiated. Additionally, infection control policies had not been reviewed or updated annually, leading to outdated practices.
The facility failed to ensure timely care and services during meal times for three residents, leading to long call light wait times, incontinence, and meals left unattended. These deficiencies resulted in feelings of frustration, embarrassment, and diminished self-worth among the residents.
A resident with multiple health conditions reported only receiving a shower once a week despite preferring baths to help with body pain. Interviews with CNAs revealed that while they generally asked residents about their bathing preferences, this resident's preference for a bath was not accommodated, resulting in the resident not achieving his highest practicable level of well-being.
The facility failed to provide a written transfer notice for a resident who was hospitalized. The resident and his daughter did not receive any notice before the transfer, and staff interviews revealed a lack of awareness and training regarding the requirement to provide such a notice. The facility was unable to provide documentation of a written transfer notice by the time of the survey exit.
A resident with Type 2 diabetes, bipolar disorder, and insomnia was transferred to a hospital without receiving a written bed hold policy. The facility staff confirmed that the policy was undated, unsigned, and not properly documented. Interviews revealed that the policy should be completed and signed before transfer, but this procedure was not followed.
The facility failed to accurately complete MDS assessments for two residents, resulting in an inaccurate reflection of their health status. One resident's PTSD diagnosis was not recorded, and another resident's injury was incorrectly documented as a Stage 2 pressure ulcer.
The facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including dementia and stroke. Observations revealed that specific interventions, such as keeping the bed in a low position and ensuring glasses were within reach, were not consistently followed. Interviews with staff indicated a lack of adherence to the care plan, resulting in inadequate service for the resident's well-being.
The facility failed to ensure residents received care according to professional standards, resulting in potential delays in treatment. One resident had a contaminated urine sample with no follow-up actions documented, while another resident was observed self-administering Biofreeze gel without a current order or assessment.
A facility failed to ensure timely review and response to a pharmacist's medication regimen review recommendations for a resident with a pulmonary artery embolus. The recommendations to discontinue diphenhydramine and low-dose aspirin were delayed by 17 days before being reviewed and declined by the nurse practitioner, due to a breakdown in the facility's process.
Pressure Ulcer Prevention and Wound Monitoring Failures
Penalty
Summary
The facility failed to maintain an effective pressure ulcer prevention and wound monitoring program for multiple residents reviewed for pressure ulcers. Resident #41 had severe cognitive impairment, was completely dependent for toileting and transfers, and was assessed as being at moderate risk for pressure injury with a Braden score of 13. Although the resident had multiple wounds, including a sacral wound, right foot wounds, and a urinary catheter ordered to support wound healing, the record lacked consistent documentation of wound measurements, progression, or timely assessment. Facility staff could not determine when the sacral and right foot wounds were last formally measured, and weekly skin checks were repeatedly duplicated rather than reflecting current wound status. During observations, the resident remained in bed for prolonged periods in the same position, was not promptly cleaned after vomiting, and staff reported delaying repositioning until later in the day. Hospice documentation described the sacral wound as a stage 4 pressure wound with pain and drainage, showing worsening from earlier documentation of a stage 3 sacral wound. Resident #53 also had significant wound care and monitoring failures. The resident was cognitively intact but required substantial assistance for bed mobility and was completely dependent for toileting, with a Braden score of 12 indicating high risk. The care plan did not reflect the resident’s pressure injury risk factors, bowel and bladder incontinence, or need for enhanced barrier precautions. Facility documentation showed repeated weekly skin checks marked as normal despite known heel and coccyx wounds, and the wound management plan was not updated. A wound communication log noted purulent drainage and new wounds, but there was no documentation that the concern was assessed or monitored. When surveyors observed the resident, the coccyx wound was heavily draining and measured much larger than previously documented, with slough and eschar present, and new discoloration was noted on the thigh and toes. Staff were unaware of some of these wounds, and direct care was provided without the PPE expected for enhanced barrier precautions. The report also identified that the facility failed to effectively assess and monitor additional residents with pressure injuries or skin breakdown concerns, including residents #61, #45, #7, #18, and #4, contributing to the overall deficiency. For Resident #41, the sacral wound worsened to a stage 4, and for Resident #53, the stage 3 sacral pressure ulcer deteriorated with new tissue exposure and additional wounds identified. The report states that Resident #61 developed a new facility-acquired pressure ulcer, and that the remaining residents had the potential for skin breakdown or continued skin breakdown. Across the reviewed records, the facility lacked consistent wound assessments, accurate documentation, and timely recognition of worsening skin conditions.
Failure to Follow Policy for Resident Food Storage
Penalty
Summary
The facility failed to fully implement its policy regarding the use and storage of foods brought in by family or other visitors. On 4/14/26 at 10:06 AM, observation of the East Nourishment room found a plastic bag containing leftover dinner and dessert items labeled with a resident's name and dated 4-6-26, as well as an unopened package of yogurt labeled with a resident's name and a best by date of March 23, 2026. During the same observation, the Dietary Manager stated that staff come to the room in the morning and after lunch to check snack items but probably get used to only looking at the items dietary regularly stocks. On 4/14/26 at 10:18 AM, observation of the [NAME] Nourishment room found three four-packs of yogurt with best by dates of [DATE] and March 6, 2026. Record review of the facility policy stated that food brought in by family or other visitors is permitted if handled properly for safe and sanitary storage and consumption, and that foods should be consumed or used by 72 hours or per facility food storage policy, with residents and families informed that food not consumed within the designated storage time will be discarded for food safety concern.
Failure to Use QAPI for Repeat Deficiencies
Penalty
Summary
The facility failed to effectively identify quality deficiencies, develop, and implement appropriate actions to correct deficiencies, and failed to sustain a system to ensure corrective measures related to resident rights, bowel/bladder incontinence/catheter care, infection control, monthly medication reviews, pressure ulcers, and quality of care. Based on interview and record review, these repeat deficiencies had been cited on the past three surveys, but they were not being addressed through the facility's QAPI process as performance improvement projects. During an interview on 4/17/2026 at 1:01 PM, the NHA stated the facility was currently working on performance improvement projects related to resident falls and new employee orientation, but was not working on any PIPs related to the repeat deficiencies from the last three recertification and abbreviated surveys. The NHA confirmed that resident rights, bowel/bladder incontinence/catheter care, infection control, monthly medication reviews, pressure ulcers, and quality of care were repeat deficiencies and high priority areas, yet these issues had not been brought to QAPI as PIPs for the facility to work on. Review of the facility's QAPI Committee policy dated 3/11/26 stated that the facility would maintain an ongoing and active QAPI program and set priorities for PIPs focused on high-risk, high-volume, or problem-prone areas.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to effectively implement its infection prevention and control program by not consistently applying Enhanced Barrier Precautions (EBP), Contact Precautions, and standard infection control measures for multiple residents with wounds, indwelling devices, or multidrug-resistant organism (MDRO) concerns. The report also identified deficiencies in the facility’s active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing, including observations of stagnant or disused water fixtures and a water management program that did not reflect complete monitoring of the domestic hot water system. Resident #41 had a stage 4 sacral pressure wound, a Foley catheter, and a recent wound culture that led to ciprofloxacin being ordered for pseudomonas. Although the care plan indicated EBP was initiated because of the resident’s wound and indwelling device, a hospice nurse performing wound care was observed without a gown while the resident’s room had EBP signage posted. Family reported the resident had been hospitalized for the wound and was receiving antibiotics for a bad sacral wound infection. The resident’s wound clinic note documented that the sacral wound had declined and that increased repositioning and dressing changes were needed when soiled. Resident #45 had a chronic open wound on the chin/neck area that was observed as large, deep, beefy red, and crusted at the edges, with dried blood on the gown and blood under the fingernails. The resident’s skin care plan did not address the open wound or infection prevention, and there was no EBP signage in place during observation. Staff later acknowledged the chronic open wound and that EBP would be added, while another CNA reported being unaware of any infection control precautions. Resident #53 had bilateral heel wounds and a coccyx pressure ulcer with no EBP care plan or signage initially in place. During wound and incontinence care, multiple staff provided direct care without proper PPE related to EBP, and the coccyx wound was observed with drainage, slough, and eschar while the resident was incontinent of stool and urine. Resident #61 had a urine culture positive for MDRO E. coli and was placed on Contact Precautions, with orders for staff to wear gown and gloves before entering the room. Despite this, staff were observed entering the room, delivering a meal tray, and providing incontinence care without gown, gloves, or hand hygiene as required by the care plan. For Resident #5, who had a Foley catheter and EBP orders, the catheter bag was repeatedly observed partially on the floor while the resident sat in a recliner. In addition, the facility’s water management observations found removed faucet handles, discolored water from unused fixtures, nonoperable hoppers and sprayers, and water lines that were not being regularly used, while the facility stated it only tested free chlorine in the cold-water system even though its water management program included monitoring water leaving the boiler.
Failure to Track CNA Annual In-Service Education
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) employed by the facility received at least 12 hours of annual in-service education. During interviews, the Staff Scheduler reported she was not familiar with CNA in-service hour requirements, the DON stated that CNAs were assigned monthly trainings through an online platform and that HR tracked them, and the Interim-CEO reported he was not able to provide tracking information for CNA in-service hours. The Interim-CEO also stated that the Infection Preventionist was responsible for staff education but that the task was not being completed. Review of the CNA in-service reports provided by the facility did not confirm that all CNAs employed by the facility received the required 12 hours of annual in-service, and numerous CNAs listed did not complete the assigned monthly trainings.
Failure to Provide Consistent ADL Bathing and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including bathing, grooming, and nail care, for multiple residents who were dependent on staff. One resident with an ADL deficit care plan specifying assistance with daily care and scheduled showers on Thursdays and Saturdays was observed with greasy hair, an unwashed face, and uncombed hair. Review of shower sheets showed that from admission through mid-April, this resident had 16 opportunities for showers or bed baths but received only 5. The resident reported that staff had not offered a basin or washcloth for face washing on the day of observation and stated that her hair had not been washed for at least a couple of weeks, despite documentation of a bed bath earlier that day. Another resident with dementia and physical debility was repeatedly observed seated in a reclining chair with fingernails that extended far beyond the fingertips, were jagged and broken, and had dark dried material accumulated under the nails on multiple days. A unit manager reported that nurses could cut fingernails when asked but that nail clippers were stored downstairs in supply rather than on the medication cart, and that CNAs could use a wooden nail cleaning tool during scheduled showers. Despite these capabilities, the resident’s nails remained long, dirty, and unkempt over several observations. A cognitively intact resident with schizoid personality disorder, depression, morbid obesity, and a documented ADL deficit had a care plan goal to maintain a neat, clean, well-groomed appearance and a preference for bed baths. The MDS indicated dependence for bathing, yet the resident reported only being assisted with getting cleaned up about once a week and felt this was insufficient. Shower sheets showed only four showers or bed baths over a two‑month period, and the CEO confirmed there were no additional shower sheets for that timeframe. Another resident with congestive heart failure, major depressive disorder, moderate cognitive impairment, and an ADL deficit, who often refused showers and preferred bed baths, was scheduled for bathing twice weekly but was documented as offered or receiving bathing on only 10 of 17 opportunities. This resident appeared disheveled, reported not being cleaned up as often as desired, and stated she was not offered bathing twice a week. A CNA reported that when staffing fell below scheduled levels, staff were sometimes unable to offer shower or bathing assistance, and the unit manager confirmed that CNAs were expected to complete shower sheets for each bathing offer, with nurses and the unit manager to review them.
Failure to Assess Wounds, Manage Infections, and Follow Orders for Blood Glucose and Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment, monitoring, and treatment in accordance with physician orders and professional standards for multiple residents. One resident with a history of diabetes, mild cognitive impairment, and absence of the left eye was observed with thick, dried green discharge matting the eyelashes of the left eye, with moist, stringy green material between the lashes and swollen, irritated eyelids. The resident stated he believed it was a blocked tear duct and reported that the nurse sometimes put drops in his eye. His MAR showed ordered artificial tears administered three times daily, but there was no documentation of any assessment of the abnormal drainage, no physician communication note, and no provider progress note addressing a potential eye infection. The Infection Preventionist confirmed the resident was not on the infection tracking log and that there was no documentation indicating concern for infection, and the DON confirmed there was no progress note or physician communication regarding the eye. Another resident, cognitively impaired and requiring assistance with hygiene, had a long-standing basal cell carcinoma on the left chin/neck area. Observations showed a large, deep open wound on the chin/neck with crusted blood on the gown and blood under the fingernails, and no signage indicating Enhanced Barrier Precautions. Weekly skin checks documented that skin was within normal limits and that no new skin issues were identified, while simultaneously noting an open wound on the chin that had not been evaluated; these weekly assessments were repeated verbatim over several weeks. Staff interviews revealed there were no orders for wound care, no dressing orders, and no monitoring orders for this wound, and that the wound was not being accurately documented in weekly skin checks, with assessment details copied from prior weeks. Direct care staff reported they did not perform any wound care or cleansing of the open chin wound. For residents with diabetes, the facility failed to recognize and act on critical blood glucose values. One resident with type 2 diabetes and hyperglycemia, who received daily insulin and was care planned for diabetes with a goal to remain free of signs and symptoms of hyperglycemia, had blood sugar readings over 500 mg/dL on three occasions. Blood sugar summaries documented values of 523 mg/dL, 547 mg/dL, and 541 mg/dL, yet progress notes contained no evidence that the physician was notified or that further action was taken, despite facility expectations that blood sugars below 70 mg/dL or above 350 mg/dL required physician contact. Another resident with type 2 diabetes and severe cognitive impairment, also receiving daily insulin, experienced hypoglycemia on multiple dates, with blood sugars below 70 mg/dL documented on four separate days. Progress notes for those dates contained no documentation that a physician was notified, even though nursing staff and the nurse practitioner stated that blood sugars below 70 mg/dL or above specified thresholds required immediate provider notification and documentation of the contact and guidance. A further deficiency involved medication administration outside ordered parameters for a resident with Alzheimer’s disease and hypotension who was prescribed midodrine 10 mg before meals, to be held if systolic blood pressure was above 130. Review of the MAR showed that midodrine was administered on multiple occasions when the resident’s blood pressure was outside the ordered parameters, and on one date the medication was documented as given without any vital signs recorded to show whether administration was appropriate. These findings collectively demonstrate failures to assess and monitor non-pressure wounds, recognize and assess symptoms of infection, follow physician orders for medication use, and recognize and report episodes of hypo- and hyperglycemia as required by professional standards and facility expectations.
Failure to Maintain Cleanliness of Shared Transfer Equipment
Penalty
Summary
The facility failed to maintain the cleanliness of shared resident transfer equipment, including hoyer lifts and sit-to-stand devices, as observed on multiple occasions. On 04/14/2026 at 9:57 AM, a hoyer lift located in the hallway outside a resident room had dried white material on the footrest base area and dried brownish/tannish splattered spots on the base. Later that morning at 10:31 AM, a sit-to-stand device outside another resident room was observed with dirt and debris on the base and footboard area, and its knee pads had white dried smeared material on the inner curved surfaces. A gait belt was present on the device and slung over the top, and a plastic bag attached to the equipment contained no wipes. A second hoyer lift next to this sit-to-stand also had white dried material on the base on both sides, resembling residue from someone stepping on it, and its attached plastic bag likewise contained no wipes. On 04/15/2026 at 2:22 PM, the same sit-to-stand device outside two resident rooms remained soiled as on the previous day, with white dried material still present on the knee pads and dirt and debris on the footrests, although purple wipes were now present in the plastic bag. At 2:24 PM that same day, another hoyer lift between two resident rooms was again observed with dried white material on the footrest base area and dried brownish/tannish splattered spots on the base. In an interview on 04/16/2026 at 9:18 AM, the Infection Preventionist reported that staff had recently received customer service training that included re-education and reminders to sanitize shared resident equipment after each use to prevent the spread of potential infection.
Failure to Develop Individualized Care Plans Based on Comprehensive Assessments
Penalty
Summary
The facility failed to develop and implement resident-focused care plans based on comprehensive assessments for 5 of 18 residents reviewed, including residents with pressure ulcers, incontinence, wounds, and cognitive impairment. The record review showed that several care plans were generic or outdated and did not reflect current diagnoses, wound status, mobility limitations, toileting needs, or device use. In multiple cases, the care plans did not include the specific risks and interventions documented elsewhere in the medical record, and direct care staff reported they did not rely on the care plans to know what care was needed. For one resident with severe cognitive impairment, bedfast status, incontinence, a Foley catheter, and multiple pressure injuries, the skin, wound, and infection control care plans did not identify why the resident was at risk for skin breakdown, did not address incontinence or catheter use, and did not include the right foot wound, blue protective boot, or the indwelling urinary catheter. Observations showed the resident lying in bed for prolonged periods, with wound dressings in place, a Foley catheter bag hanging from the bed frame, and catheter tubing pulled tight without a securement device. Hospice documentation described a stage 4 sacral wound, right heel and right lateral foot pressure wounds, and pain rated 8/10, while staff interviews indicated the resident was not repositioned for hours and direct care staff were not using the care guide to direct care. For another resident with cognitive impairment and a large open wound on the chin/neck, the skin care plan only stated that the resident was at risk for skin breakdown and did not address the chin/neck wound, buttocks breakdown, incontinence, or pressure ulcer prevention. The resident was observed with a soiled gown and a large open wound, and staff reported the wound was a skin cancer lesion without wound care orders. A third resident with heel and coccyx pressure ulcers, toe discoloration, gangrene, incontinence, and limited bed mobility had a wound care plan that did not include the toe wounds, the need for blue protective boots, or enhanced barrier precautions. Staff reported the resident was incontinent, had toe pressure points, and required constant monitoring to keep the feet from pressing against the bed, but these needs were not reflected in the care plan. A fourth resident had a skin care plan that was not individualized to current toileting and pressure injury needs despite being bedfast, dependent for toileting, and having buttock excoriation and pressure-related skin changes. During observation, the resident had bright red buttocks and upper thighs, crusted areas near the gluteal crease, and pain when touched, while staff applied antifungal powder even though the record showed orders for wound cleanser and A&D ointment for excoriation. For the resident with dementia and behavioral symptoms, the care plan remained a standard dementia plan and behavior plan that did not address the resident’s broader medical, nursing, mental, or psychosocial needs identified in the comprehensive assessment. The administrator acknowledged that resident care plans needed improvement because many were not individualized and person-centered.
Care Plan Did Not Reflect Heel Protector Order
Penalty
Summary
The facility failed to revise Resident #18’s care plan interventions for pressure ulcer prevention. Resident #18 was admitted with diagnoses including unspecified dementia and heart failure, and the MDS assessment indicated the resident was severely cognitively impaired and at risk for developing pressure ulcers. The care plan dated 10/9/25 identified the resident as at risk for skin breakdown related to dependence on staff for assistance with bed mobility and included interventions to float heels on a pillow as tolerated and apply skin prep to the right heel, but it did not include the use of heel protector boots. A physician order dated 4/2/26 directed that heel protectors be used at all times, every day and night shift, for prevention of skin impairment. The Kardex used by CNAs reflected only the care plan interventions and did not include the heel protector order. During interview, a CNA stated she relied on the Kardex for resident care needs and believed the resident no longer needed heel protector boots. During serial observations, Resident #18 was lying supine in bed with both heels resting directly on the mattress, and the heel protector boots were observed in a chair by the roommate’s bed.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, with repeated examples of wound assessments and related documentation being incomplete, duplicated, or not reflective of the residents’ actual conditions. For Resident #41, the record showed multiple pressure injuries and open lesions involving the sacrum and gluteal areas, but weekly skin checks repeatedly stated that wounds had “not been evaluated,” copied prior entries, or failed to include all wounds listed in hospital and wound clinic records. The wound clinic note on 4/6/26 stated the sacral wound had declined and that culture results supported starting ciprofloxacin for pseudomonas, yet the facility record did not contain corresponding current assessments or documentation showing regular measurement and monitoring of the wounds. Similar documentation problems were identified for Resident #45, whose record contained weekly skin checks that were duplicated from prior weeks and did not reflect current findings. The resident was observed with a soiled gown and a large open wound on the left chin/neck, but the weekly skin check did not mention the wound as an active assessed condition. Staff later observed and measured a large deep open wound on the chin/neck, and the UM reported there were no orders for wound care, dressing, or monitoring. The resident’s skin care plan also did not address the buttocks breakdown, chin wound, or pressure ulcer prevention, despite documentation showing buttocks redness, a chronic open wound, and a small open area on the genitals/testicles. For Resident #53, the record showed pressure ulcers of the sacrum and heels, but weekly skin checks repeatedly stated wounds had not been evaluated or failed to document toe wounds that were observed and treated. The facility’s wound communication log documented purulent drainage from the sacral wound and a new wound near the current wound, but there was no documentation in the log for dressing orders or risk management. Later observation showed a large coccyx wound measured by the NP, a purple discolored wound on the right upper thigh, and discolored toes on the left foot, including a great toe with a thick scab and black discoloration of the 2nd and 3rd toes. The physician note from 2/9/26 documented bilateral heel stage 3 pressure injuries and gangrene concerns in the toes, but the weekly skin checks still did not consistently reflect those findings. Additional record failures were identified for Resident #61, whose weekly skin check documented a rear right thigh pressure ulcer, a scratch on the right lateral thigh, and coccyx redness, yet the nurse later stated she had not completed the skin check and was unaware it had already been documented. Resident #7 had a physician communication note and orders for a new slit in the intergluteal cleft with barrier cream, but the weekly skin check did not mention the buttocks wound. Resident #81’s record also lacked the NP assessment that reportedly led to urgent transfer for stroke-like symptoms, and the facility could not provide that documentation. The report also references Resident #18 as part of the group of residents reviewed for complete and accurate documentation, but the excerpt provided ends before the specific findings for that resident are fully described.
Failure to Accommodate Visually Impaired Resident’s Environmental and Accessibility Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident with legal blindness and a right leg amputation by not individualizing his physical environment. The resident was cognitively intact, had highly impaired vision, and no behavioral issues. His care plan for impaired visual function only addressed arranging consultations with an eye care practitioner and did not include any interventions related to environmental modifications, accessibility, or low-vision supports in his room. Surveyors observed that the resident’s room furniture and electrical access were not arranged in a functional manner. There was only about two feet of space between the end of his bed and his chest of drawers, where his stereo was placed, requiring him to maneuver his powerchair backwards into the narrow space and lean forward to see the stereo dials. He had access to only one electrical outlet with two sockets on his side of the room, which were occupied by his laptop and phone charger, leaving his talking book machine unplugged. The resident reported frustration with the room setup, stating he felt like he was in a cage, could not charge and use his devices as desired, and was unable to use his braille writer or have adequate workspace. He stated he had repeatedly asked staff for a power strip and an LED bulb to reduce glare and adjust lighting, but reported that staff told him power strips were illegal and did not follow up on his requests. The resident also reported difficulty seeing the overhead light cord because it was white against a white wall, with only a small piece of glow-in-the-dark tape at the end, and he stated he needed contrast to see such items. He further reported that a bright yellow privacy curtain he could see well had been replaced without asking him, with a dull-colored curtain that appeared depressing and without a visible pattern to him. Documentation from a Caring Partners form showed he had voiced concerns about the accessibility and limited space in his room weeks earlier, and interviews with the unit manager and CNA confirmed he had complained about room layout, need for a larger room, and poor lighting. The facility’s own Accommodation of Needs policy required reasonable accommodation of residents’ physical environments based on individual needs to assist in maintaining independence, but the resident’s expressed concerns and needs for accessibility and low-vision modifications were not acted upon or incorporated into his care plan.
Failure to Assess Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess and ensure the safe self-administration of medication for one resident who had been approved to self-administer acetaminophen at the bedside. The resident had diagnoses including schizoid personality disorder and depression, and a MDS assessment showed a BIMS score of 15/15, indicating cognitive intactness. The care plan identified acetaminophen at the bedside as a self-administered medication and directed staff to evaluate the continued appropriateness of self-administration per facility policy. The physician order for acetaminophen specified unsupervised self-administration. During an observation and interview, the resident was found in bed with a clear medication cup on the bedside table containing what appeared to be chocolate pudding with flecks of a white substance throughout it, and the resident reported that unknown medications had been left for her in the pudding mixture. No staff were present in the room at that time. The most recent medication self-administration assessment in the record had been completed on 6/20/24, while the nursing home administrator stated that a self-administration assessment should be completed annually and with a change of condition. The facility policy stated that each resident has the right to self-administer medications unless the interdisciplinary team determines it is unsafe, and that the resident's ability should be assessed on admission, annually, or with significant change.
Delayed Response to Call Light Led to Loss of Resident Dignity
Penalty
Summary
The facility failed to provide an environment that promoted resident dignity for Resident #29, a male resident with diabetes, mild cognitive impairment, acquired absence of the left eye, strep group B infection in the left knee, and arthritis due to bacteria in the left knee. His care plan, revised on 3/24/26, identified that he was at risk for falls due to impaired safety awareness and directed staff to anticipate his needs, round to his room frequently, ask if he needed anything, and remind him to use the call light and wait for assistance. During an interview on 04/14/2026 at 9:58 AM, Resident #29 stated that when he pressed his call light, staff took too long to respond even though he pressed it before he needed help. He reported that because of the delay, he would end up having a bowel movement in his pants, which he found embarrassing and upsetting because staff then had to clean him up. In an interview on 04/16/2026 at 8:49 AM, CNA MM reported that recent staffing levels had made it challenging to meet resident needs. The facility policy on Accommodation of Needs stated that the facility would treat each resident with respect and dignity and evaluate and make reasonable accommodations for individual needs and preferences.
Failure to Honor Resident Preference for Shower Timing
Penalty
Summary
The facility failed to allow resident choice regarding personal care for one resident who had an ADL deficit and needed assistance with daily care related to weakness/debility. The resident’s care plan directed ADL care to meet her needs, and the kardex listed bathing assistance as one assist extensive on Thursday and Saturday, with personal hygiene independent after set-up. During interview, the resident stated she did not receive her shower on Saturday because staff came at 10:00 PM and the shower was not offered the next day; she declined at that late hour because she was tired and not up to taking a shower then. Shower sheet documentation showed the resident had repeatedly requested showers be changed to day shift, including entries noting her preference and nurse acknowledgment of the requested change. A CNA reported that when a resident refused a shower, staff documented it after multiple attempts to encourage the resident, and the completed shower sheet was submitted to the nurse for review and signature. Another CNA stated the resident had requested day-shift showers and that the Unit Manager was aware of the preference, while the Unit Manager stated nurses were expected to enter an alert in the medical record to notify her of requested shower-day changes.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to provide and document evidence of prompt resolution of grievances for two residents who voiced concerns about their care and living environment. One resident, who had legal blindness, diabetic retinopathy, and a right leg amputation, reported frustration with the layout of his room, including limited space between his bed and chest of drawers, difficulty seeing and reaching his stereo, and not having enough accessible electrical outlets to charge devices and use a talking book machine at the same time. He also reported asking several staff members for a power strip and an LED bulb, but said nothing had been done and he felt the room was set up like a cage. During interviews, facility leadership and staff confirmed that the resident had voiced concerns about room accessibility in weekly Caring Partners check-ins, but a grievance was never filed and there was no follow-up. A Caring Partners form documented that the resident wanted items in his room moved because space was limited. A CNA and an UM also confirmed they did not complete grievance forms for the resident’s concerns about lighting and room layout, and the UM stated she did not do so because she felt the facility could not accommodate the request. An OT reported placing glow-in-the-dark tape on the overhead light cord but was not aware of the resident’s accessibility and low-vision concerns in the room. A second resident reported that her pajama tops were missing and that no one had spoken to her about replacing them. Staff interviews showed that missing-item concerns were handled informally, with laundry searches, sticky notes, or concern forms depending on the situation, but no concern form was completed for this resident’s missing pajama tops. The NHA stated that when staff could not locate a missing item, the grievance process was circumvented. The facility’s grievance policy required concern forms to be reviewed in morning meeting, assigned for investigation, resolved, documented, and returned within 7 days, with residents entitled to a written decision regarding the grievance.
Falls, Unsafe Transfers, and Unsafe Wheelchair Transport
Penalty
Summary
The facility failed to provide adequate supervision and implement care planned interventions to prevent falls for a resident with dementia, physical debility, anxiety, seizures, stroke, and hearing loss. The resident’s care plan identified him as at risk for falls due to generalized weakness, impaired mobility, and physical limitations, with interventions including routine visual checks, frequent rounding, a bed in the lowest position, bolsters on the bed, Dycem on the broda chair cushion, and a mat at bedside when in bed. The record noted that the care plan was not updated after falls on 3/15/26 and 3/16/26. The resident was found on the floor in his room on 1/31/26 lying on his left side with his head partially resting on a chair after stating he needed to use the bathroom. The post-fall documentation stated the fall was unwitnessed, no injury was noted, and the resident’s brief was dry. The incident report documented no immediate intervention to ensure the resident’s safety. On 3/15/26, the resident was found on his knees between the bed and a heater after being observed in bed earlier that morning. The incident report again documented no immediate intervention to ensure the resident’s safety, and the post-fall evaluation noted the resident was sitting on his knees keeping himself upright between the bed and heater. On 3/16/26, staff heard the resident yelling and found him on the floor next to his bed after he had rolled out of bed. The note stated he had pushed wedges off the bed when he rolled out of bed. The post-fall evaluation documented the fall as unwitnessed and bedside, with the resident using incontinence supplies and being barefoot. Later observations on 4/16/26 showed the resident in bed with the bolster sideways under the bed or removed from the bed entirely, the wedge on the floor, and no bolsters or pillows placed on the bed. Staff interviews stated fall interventions should be in place and that immediate intervention for safety was expected after a fall. The facility also failed to ensure safe transfer for a resident with diabetes, peripheral vascular disease, dementia, and muscle weakness who required a 2-assist Hoyer transfer. A bruise was observed on the resident’s right shin, and a home care aide reported it was not present at the end of the prior shift and believed it may have occurred during Hoyer transfers because the resident’s feet were not tucked in and could hit the base of the Hoyer. During an observed transfer, the resident’s legs were held straight out, her feet rested on the Hoyer footrests, and as staff moved her toward the bed, her lower leg and feet were caught on the Hoyer base and she yelled in pain. Neither CNA had a hold of her legs or feet to guide them around the base. The facility also failed to ensure safe wheelchair transport for a resident with vascular dementia, severe cognitive impairment, legal blindness, and dependence for wheelchair mobility. The care plan identified the resident as at risk for falls and directed that she be kept in line of sight with non-skid material in the seat of the chair. During observations, the resident was transported in a wheelchair with her feet hanging unsupported above the floor and no footrests present, and later was pushed down the hall with the wheelchair footrests folded up and her feet unsupported throughout the transport. The CNA confirmed she did not place the resident’s feet on the foot pedals, and the OT stated transporting residents without footrests placed them at significant risk for injury, including falls with major injury.
Foley Catheter Care and Timely Incontinence Care Not Provided
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a Foley catheter. Resident #41 had severe cognitive impairment, was completely dependent on staff for toileting, and had a sacral pressure ulcer. The resident returned to the facility with a Foley catheter in place for sacral wound healing after a hospitalization for UTI. The care plan did not identify the indwelling device as a urinary catheter, and there was no care plan related to incontinence and/or urinary catheter use. During observation, the Foley catheter bag was seen hanging from the bed frame while a hospice nurse performed wound care, and the nurse was not wearing a gown. On a later observation, the resident’s catheter tubing was pulled tight across the right leg, and no catheter securement device was observed to anchor the tubing in place. The unit manager reported the resident had been hospitalized for UTI and returned with the Foley catheter in place. The physician order for the Foley catheter did not include the catheter size or balloon size, and the bowel and bladder task record showed the resident was incontinent and/or not rated due to the indwelling catheter every day over the past 30 days. The facility also failed to provide timely incontinence care for another resident. Resident #7 had a history of stroke with right-sided paralysis, cognitive impairment, and complete dependence on staff for toileting. The resident’s care plan directed staff to check and assist with incontinence care, wash and dry the perineum, change clothing as needed, and monitor for signs and symptoms of UTI. The resident reported that staff did not come timely when the call light was used and stated she was sitting in a wet brief during the observation. A CNA later reported the resident had not received incontinence care since about 6:00 AM, more than 5 hours earlier, and noted a new thin open wound in the crease of the buttocks during care.
Failure to Ensure Physician Supervision of Wound Care
Penalty
Summary
The facility failed to ensure a physician supervised the medical care of a resident with multiple wounds and participated in wound assessments and treatment planning. Resident #53 was admitted with diagnoses including pressure ulcers of the sacral region and heel, had a BIMS score of 13 indicating cognitive intactness, and was identified as high risk for pressure ulcers with a Braden Scale score of 12. The resident’s skin care plan noted risk for skin breakdown, and the wound management care plan listed bilateral heels and coccyx, but the record contained no updates to that plan and no documentation related to pressure ulcer risk interventions beyond the listed wound care measures. Facility staff interviews and record review showed that wound assessment documentation was incomplete and inconsistent. The unit manager reported there was no dedicated wound nurse or provider and that floor nurses were expected to complete wound assessments during weekly skin checks and notify management or a provider if there was a concern. The wound communication log documented a sacral wound with purulent drainage, a new bruise to the right upper thigh/hip, and a new wound near the current wound, but there was no documentation in the log for dressing orders or risk management. The unit manager also stated she was not aware of that note and could not explain why there were no progress notes or physician notes showing the wound concern had been assessed and monitored. During observation, the resident was found with multiple wounds that had not been fully assessed in prior documentation. The NP measured bilateral heel wounds and identified them as deep tissue injuries, and the coccyx wound was observed as a large open wound with slough and eschar, measuring 8 cm by 9.5 cm and described as a Stage 3 pressure ulcer that was deteriorating. A large purple wound on the right upper thigh was also observed and appeared consistent with shearing. The resident’s toes were discolored and scabbed, and later nursing staff identified the left great toe as an unstageable pressure injury. The physician note from an earlier visit documented bilateral heel stage 3 pressure injuries, discoloration and gangrene of the toes, concern for gangrene, and orders for x-rays and vascular referral, but the record contained no additional provider visits, assessments, or plans after that note. Weekly skin checks repeatedly documented wounds as not evaluated, and the resident’s toes were not documented on those checks.
Delayed Physician Response to Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure timely physician follow-up with pharmacy recommendations for 3 residents reviewed for medications. The report states that the pharmacist completed monthly medication regimen reviews and identified irregularities, but the physician response was not documented for Resident #3 and Resident #10, and documentation could not be verified for Resident #57. The facility’s Medication Regimen Review policy required the pharmacist to communicate irregularities in writing and for facility staff to act upon recommendations according to procedure. Resident #3 had diagnoses including insomnia and a BIMS score of 12/15, indicating moderate cognitive impairment. The pharmacy consultation report noted that Zolpidem Tartrate 10 mg at bedtime was above the maximum recommended dose for older adults and recommended decreasing the dose to 5 mg at bedtime. No physician response was documented, and the active order remained Zolpidem Tartrate 10 mg daily for insomnia. Resident #10 had diagnoses including Alzheimer’s disease and anxiety disorder. The pharmacy consultation report stated that the resident received Quetiapine Fumarate ER, Clonazepam, and Trintellix and had a diagnosis of dementia, and it recommended documentation of risk-versus-benefit assessment, dose reduction history, target behaviors, desired outcomes, and monitoring. The physician response section was empty, and the facility could not provide documentation that the medical director reviewed the report. Resident #57 had diagnoses including dementia, age-related debility, and mild cognitive impairment. The pharmacy report noted clotrimazole topical had been used for greater than 4 weeks without a documented stop date and recommended discontinuation or documentation of a stop date, but the facility could not locate documentation showing the monthly medication review report had been reviewed by the provider.
Medical Director Did Not Complete Monthly Pharmacy Review Documentation
Penalty
Summary
The facility failed to ensure the Medical Director fulfilled responsibility for implementing Medication Regimen Review (MRR) policies and coordinating medical care between the facility and the consulting pharmacist/pharmacy for 3 residents reviewed for medications. During interview, the Interim CEO confirmed that the facility did not have documentation showing that the Medical Director had completed monthly pharmacy recommendation reviews for the three residents, and confirmed that the Medical Director was responsible for ensuring all resident pharmacy reports were reviewed and signed. The report also states that the Medical Director did not return the surveyor’s telephone call before survey exit. Review of the facility’s MRR policy dated 4/24/24 showed that each resident’s drug regimen is to be reviewed at least monthly by a licensed pharmacist and that the review includes the resident’s medical chart, with staff acting on recommendations according to facility procedures.
Survey Results Binder Not Updated
Penalty
Summary
The facility failed to ensure that the most recent survey results were available for residents, family members, legal representatives, and visitors to review. On 5/27/26, a survey results binder located on a table near the elevator and kitchen entry in a hallway leading to the main dining room contained survey results from a survey completed in September 2025, rather than the most recent survey results. On 5/28/26, the Manager of Case Management reviewed the binder and stated she did not know the binder existed or that survey results were supposed to be available for resident and guest review, and she confirmed the binder contained outdated survey results. Later that day, she added the facility’s most recent life safety survey results, but stated she did not know how to obtain survey results and that updating the binder was not her responsibility. The Nursing Home Administrator stated he had not updated the binder and had not received notification that his plan of correction was approved and complete, but he accessed the most recent survey results online and confirmed that the survey results and plan of corrections were available.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted each day. On 5/27/26 at 8:30 am, 12:30 pm, and 4:45 pm, the staffing hours posted in the glass enclosure to the right inside the main entrance were still dated 5/22/26. The same outdated posting remained in place on 5/28/26 at 7:45 am, 12:15 pm, and 4:35 pm, and again on 5/29/26 at 7:45 am. In interview, the Scheduler reported she was responsible for posting staffing hours, had been absent from 5/23/26 through 5/26/26, returned on 5/27/26, and should have posted the staffing hours but had not done so; she also stated she did not know who would post them when she was absent. The NHA stated the Scheduler was responsible for daily posting and that the DON would be responsible when the Scheduler was absent. The DON stated any manager could post the staffing hours, including herself, and reported there was no management staff in the building on weekends or holidays, so the hours did not get posted.
Failure to Notify Family of Resident's Fall, Injury, and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's emergency contact following a series of emergency incidents involving a resident with severe cognitive impairment, including dementia, repeated falls, anxiety, and depression. The resident experienced a fall resulting in a head injury with bleeding, which required immediate transfer to an acute care hospital for evaluation and treatment. Although the physician was notified shortly after the incident, the resident's family was not informed of the fall, injury, or hospital transfer at the time these events occurred. Documentation and interviews revealed that the family only became aware of the incident when the resident was being discharged from the hospital, several hours after the initial event. The facility's policy required notification of the resident's representative in such situations, especially for residents incapable of making decisions. The lack of timely communication left the family unaware of the resident's condition and hospital transfer until after medical intervention had already taken place.
Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
A resident with a history of morbid obesity, edema, venous insufficiency, and hypothyroidism was found to have quarter-sized, healing stage II pressure ulcers on both buttocks during an observation. The resident reported having the ulcer for many months, and there was no pain or drainage noted at the time of observation. Despite the presence of these wounds, the resident's care plans did not address the risk for pressure ulcers or document a history of pressure ulcers. Physician orders for wound care were in place, but documentation in the medical record was inconsistent and incomplete, with missing weekly wound notes and lack of detailed wound assessments. Multiple staff interviews revealed confusion and lack of awareness regarding the resident's pressure ulcers. Some staff, including the nurse practitioner and LPNs, were unsure if the resident had a pressure ulcer, and there was disagreement about the staging and nature of the wounds. The wound log was incomplete, with missing measurements, staging, and inconsistent entries. The interdisciplinary team, including the registered dietitian and director of health and wellness, were unaware of the wound log and the resident's wound status. Additionally, there was no incident report or clear documentation of when the pressure ulcer was first identified, and weekly skin assessments were not consistently performed as required by facility policy. Facility policies required thorough documentation of skin assessments, regular wound monitoring, and interdisciplinary care planning for pressure ulcers. However, these procedures were not followed, as evidenced by the lack of detailed wound documentation, incomplete care plans, and inconsistent communication among staff. The failure to provide necessary care and services consistent with professional standards resulted in the potential for worsening or recurrence of pressure injuries for the resident.
Failure to Accurately Document Resident ADL Care
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical record of a resident regarding activities of daily living (ADLs), specifically related to showers and bed baths. During the resident's stay, only 6 out of 12 possible showers or bed baths were documented, with records showing 4 completed and 2 refused. There was no documentation for the remaining 6 instances, making it unclear whether the resident received or refused care on those occasions. This lack of documentation was identified after concerns were raised by the resident's family member about whether the resident was receiving appropriate hygiene care and skin checks. Further review revealed a late entry progress note written by a nurse after a family meeting, stating that the resident received a bed bath on one date and refused care on another. However, there were no supporting shower sheets or other documentation to verify these claims. When questioned, the Nursing Home Administrator could not explain where the information in the late entry note originated, as it was not supported by existing records. The facility's own policy requires that documentation be completed at the time of service or by the end of the shift, but this standard was not met in this case.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Obstructed Exit Access Corridors During Construction
Penalty
Summary
During an observation conducted between 12:00 PM and 1:00 PM, construction equipment, materials, and resident room furniture were found stored in the 100 corridor and in spaces open to that corridor, obstructing the exit access corridors. The construction room door was blocked open, and there was no separation between the construction work area and the corridor. Additionally, glue vapors were present in the corridor, indicating improper ventilation. At the time of the survey, a floor renovation was ongoing in residents' rooms, with some rooms still occupied by residents not under renovation. Construction materials were also stored in a resident day area open to the corridor.
Plan Of Correction
1. All exit access corridors were cleared of all obstructions, including construction equipment/materials and resident furniture, in accordance with LSC 19.2.2 and chapter 7. 2. Actively scheduled staff requiring education will be identified to receive education on keeping exit corridors clear of obstructions. 3. The Director of Plant Operations and/or designee will conduct a weekly audit, and results of the audits will be brought to the Quality Assurance Performance Improvement Committee monthly for review. Any changes to the auditing process will be made by the QA Committee. The Administrator is responsible for attaining and maintaining compliance. 4. The completion date for compliance will be 05/1/2025
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. In the walk-in cooler, a 3-gallon container of chicken breast and two single-gallon containers of rice and gravy were found with condensation and a temperature of 42F, indicating improper cooling. Staff interviews revealed that cooling logs were not maintained, and food was left out on the counter before being placed in the cooler. The facility's Kitchen Policy requires a Cooling Log for potentially hazardous food items, but this was not followed, violating the 2017 FDA Food Code's cooling requirements. Additional deficiencies were noted in the cleanliness and maintenance of food contact surfaces and equipment. Mechanical scoops were found with dried food debris, and the juice and pop dispensers had accumulations of debris. The microwave in the east Nourishment room also had food and dried debris. These observations contravene the FDA Food Code, which mandates that food-contact surfaces and equipment be clean to sight and touch, free of encrusted grease deposits, and other soil accumulations. The facility also failed to properly date and store food items. An open container of grape jelly was left unrefrigerated, and hard-boiled eggs were improperly dated. Nutritional shakes and thickened water were not dated, and several expired food items were found in various locations, including fruit cups and nutritional supplement puddings. The FDA Food Code requires that ready-to-eat, time/temperature control for safety food be clearly marked with a date for consumption or disposal. Additionally, ice coolers used in the facility did not allow for self-draining, leading to water mixing with ice, which is against FDA guidelines for storing food in contact with water or ice.
Delayed Call Light Responses Affect Resident Dignity
Penalty
Summary
The facility failed to respond timely to call lights, affecting the dignity and well-being of several residents. Resident #4, who has type 1 diabetes and moderate cognitive impairment, reported waiting almost an hour for assistance after a bowel movement, leading to frustration. Resident #10, with an overactive bladder and moderate cognitive impairment, also experienced long wait times, feeling neglected by the staff. Resident #22, cognitively intact, expressed frustration over frequent long wait times for call light responses. Resident #36, with dementia and moderate cognitive impairment, was observed waiting 45 minutes for a response to his call light, during which he became hungry and attempted to find assistance independently. Two staff members were noted at the nurses' desk during this time, but did not respond to the call light. Resident #237, cognitively intact, had a urinary catheter and was observed with a blood-soaked bandage on his forehead. Despite the call light being activated, it went unanswered for over an hour, during which the resident's family member expressed concerns about the resident's care. The facility's Unit Manager was aware of past concerns regarding call light response times and believed improvements had been made through staff education. However, the Nursing Home Administrator admitted that recent education on call light response times had not occurred. The facility was unable to provide maintenance orders or evidence of staff education on call light response times, indicating a lack of follow-through on addressing the issue.
LPN Leaves Computer Screen Unattended, Exposing Resident Information
Penalty
Summary
The facility failed to ensure the confidentiality of resident health information, specifically for Resident #71, as required by HIPAA regulations. During multiple observations on March 12, 2025, it was noted that an LPN repeatedly left her medication cart unattended with the computer screen open, displaying sensitive resident information. This occurred at various times throughout the morning and early afternoon, with the LPN leaving the cart for periods ranging from 5 to 10 minutes. During these times, the computer screen was visible to anyone passing by, including other staff members, compromising the privacy of the residents' medical information. Resident #71's medical information was specifically noted to be exposed during one of these instances, with several staff members walking past the open screen. The LPN admitted in an interview that she was aware of the requirement to lock the computer screen when not in attendance but stated that she sometimes forgets to do so. This repeated oversight led to a breach of confidentiality for Resident #71 and potentially other residents whose information was visible on the screen.
Inadequate Assessment and Delayed Treatment for Resident's Fall Injuries
Penalty
Summary
The facility failed to ensure adequate assessment and timely treatment for a resident, identified as R237, who experienced a fall resulting in abrasions. The resident, who was cognitively intact with a BIMS score of 13/15, had a history of falling and a recent fracture of the left femur. On the day of the incident, the resident was found on the floor after sliding off a wheelchair, sustaining a skin tear on the forehead and abrasions on both knees, along with bruises on the face, neck, and chest. Despite these injuries, the post-fall documentation did not include the knee wounds, leading to a delay in treatment. Observations revealed that the resident's knee wounds were bleeding through the bandages, staining the sheets and blanket with blood. The RN initially assessed and changed the bandage on the resident's head but did not address the knee wounds due to their absence in the post-fall documentation. Interviews with the Director of Nursing and Unit Manager highlighted expectations for thorough fall assessments, which were not met in this case. The CNA who found the resident confirmed the presence of scrapes on the knees and a bleeding head wound, indicating a lack of comprehensive assessment and documentation by the nursing staff.
Failure to Provide Vision Services for a Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities, resulting in the resident's inability to attain or maintain the highest practicable level of well-being. Resident #4, who was moderately cognitively impaired and had type 1 diabetes, had a care plan intervention to arrange a consultation with an eye care practitioner due to impaired visual function. An order was placed by the Medical Director for Resident #4 to consult a visiting optometrist because of low vision and a clouded magnifier on his glasses, but this order did not have a completion date and was not acted upon. Despite the resident's broken glasses being documented in progress notes, the Medical Records Assistant did not schedule an appointment as she was unaware of the order. The Unit Manager, who typically reviews progress notes daily, missed the note about the broken glasses and was unaware of the need for an optometrist consultation. Consequently, Resident #4 did not see an eye doctor and had no appointment scheduled, despite the Medical Director's order and the resident's expressed difficulty in completing daily tasks due to the broken glasses.
Failure in Catheter Care Leads to Repeated UTIs
Penalty
Summary
The facility failed to provide proper coordination of care and services for a resident with a Foley catheter, leading to repeated urinary tract infections (UTIs). The resident, who was admitted with obstructive and reflux uropathy and had a neurogenic bladder, had an order for the catheter to be changed after 48 hours due to a UTI. However, this order was not completed, and the resident continued to experience UTIs. Observations revealed that the catheter bag was improperly placed on the floor, and there was heavy sediment in the tubing, indicating poor catheter management. Interviews with facility staff, including the Unit Manager, Assistant Director of Nursing, and Hospice Nurse, revealed a lack of awareness and communication regarding the catheter change order. The Medical Director confirmed placing the order, but it was not executed due to incorrect order entry and lack of follow-up. This oversight resulted in the resident experiencing additional UTIs, highlighting a significant deficiency in catheter care and communication within the facility.
Delayed Physician Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely physician review and response to a licensed pharmacist's monthly medication regimen review recommendations for a resident. The resident, a male with diagnoses including diabetes, insomnia, anxiety, and depression, was subject to several medication regimen recommendations that were not addressed promptly. These recommendations included adjustments to insulin dosages, discontinuation of montelukast due to potential neuropsychiatric side effects, reevaluation of Miralax dosages, and reduction of Doxepin Hydrochloride due to risks associated with its use in older adults. The physician did not respond to these recommendations until more than a month later, with some responses delayed by over two months. The Director of Nursing reported that pharmacy consultation reports should be reviewed by the physician to agree or disagree with the recommendations, and necessary orders should be placed based on these recommendations. The facility's policy on Medication Regimen Review requires that any irregularities identified by the pharmacist be communicated in writing within 10 working days, and facility staff are expected to act upon these recommendations. However, in this case, the physician's delayed response to the pharmacist's recommendations resulted in a failure to address potential medication interactions and adverse side effects in a timely manner.
Failure to Provide Adaptive Dining Equipment During Isolation
Penalty
Summary
The facility failed to provide adaptive dining equipment to two residents, both of whom were legally blind and required such equipment to eat and drink independently. Resident #3, who was on droplet precautions due to suspected influenza, did not receive a dual-handled cup and scoop plate as specified in her care plan. Instead, she was given a can of cola and a disposable foam container, which did not meet her needs. The CNA confirmed the absence of the required adaptive equipment, and the LPN explained that the facility's policy was not to provide such equipment to residents on transmission-based precautions. Resident #4, who was moderately cognitively impaired and also legally blind, was similarly affected. His care plan required the use of adaptive silverware and bowls to assist with his visual deficits. However, while in isolation, he was not provided with these items and struggled to eat using plastic utensils and styrofoam containers. The resident expressed frustration over the situation, and the Occupational Therapist confirmed that the adaptive equipment was necessary for his self-feeding. The facility's policy during isolation was to use disposable dining items to prevent infection spread, as stated by the Dining Services Manager and the Infection Preventionist. However, the Infection Preventionist also noted that adaptive equipment should be sent with a plastic bag for cleaning after use. The CDC guidelines referenced in the report indicate that no special precautions are needed for dishware and eating utensils, suggesting that the facility's policy may not align with these guidelines.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director was a mandatory attendee at the Quality Assessment and Process Improvement (QAPI) meetings at least quarterly. During an interview, the interim Nursing Home Administrator (NHA) reported that the facility had recently changed their QAPI meetings to a quarterly schedule with additional ad hoc meetings as needed. Although the Medical Director attended an ad hoc meeting in March 2025, the NHA could not initially provide documentation of the Medical Director's attendance at the quarterly meetings over the past year. Upon further review, it was confirmed that the Medical Director attended meetings in July and August 2024, and February 2025, but did not attend the November 2024 meeting. Instead, a Nurse Practitioner attended the November meeting, but the sign-in sheet for this meeting was not located. This deficiency resulted in the potential for the Medical Director to be unaware of quality deficiencies occurring in the facility.
Infection Control Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control practices, as evidenced by multiple observations involving residents under transmission-based precautions and enhanced barrier precautions. For Resident #27, a hospice registered nurse entered the room, which was under droplet precautions, wearing only a surgical mask without the required eye protection. Additionally, a hospice aide entered the same room wearing personal eyeglasses instead of approved eye protection. The facility's infection control policy and CDC guidelines were not followed, as both staff members failed to don the necessary personal protective equipment (PPE) for droplet precautions. Resident #38 was under enhanced barrier precautions due to the risk of spreading multidrug-resistant organisms (MDROs). Despite the requirement for staff to wear gowns and gloves during high-contact care activities, certified nursing assistants and a registered nurse were observed providing care without gowns. This included bed mobility and brief changes, during which the staff's clothing came into contact with the resident's bed linens. The infection preventionist confirmed that gowns and gloves were required for any high-contact resident care, contradicting the staff's understanding and practice. For Resident #42, who had an indwelling catheter, the facility failed to maintain proper infection control during catheter care. A registered nurse was observed placing supplies on a visibly soiled tray table and administering medications without washing hands or changing gloves. The nurse also failed to change gloves or wash hands before handling the catheter and the resident's genital area. The infection preventionist acknowledged that no recent catheter care education or audits had been conducted, and emphasized the expectation for nurses to wash hands and change gloves when necessary during care.
Failure to Document COVID-19 Vaccination Consent for a Resident
Penalty
Summary
The facility failed to obtain COVID-19 vaccination consents or declinations for a resident, identified as Resident #71, who was reviewed for immunizations. This deficiency resulted in the resident's family members not being informed about the vaccination and the associated risks and benefits. Resident #71 was admitted to the facility with diagnoses including type 2 diabetes and had undergone surgery of the digestive system. The resident was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15, and had a guardian due to this cognitive status. The review of Resident #71's immunization record showed that the COVID-19 vaccine was not listed, making it unclear whether the resident received or refused the vaccine. The facility's COVID Vaccine Resident List indicated a refusal, but there was no documentation that the resident's guardian was contacted for consent or declination, nor was there evidence of education provided on the vaccine's risks and benefits. During an interview, the Assistant Director of Nursing, who also served as the Infection Preventionist, confirmed the absence of documentation regarding the consent or declination and the lack of communication with the guardian. The facility's COVID-19 Vaccination Policy requires education and documentation of consent or declination, which was not adhered to in this case.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to adhere to enhanced barrier and contact precautions for two residents, leading to potential transmission of infections. Resident #104, diagnosed with dementia, had orders for enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs). However, during an observation, a registered nurse (RN) was seen administering care without wearing the required gown, despite acknowledging the necessity of such precautions. The RN admitted to not following the protocol due to being busy, which increased the risk of spreading MDROs. Resident #105, with a diagnosis of heart failure, was on contact isolation for a urinary tract infection caused by Enterococcus. Despite clear signage indicating the need for gloves and gowns before room entry, multiple staff members, including a life enrichment aide and a certified nursing assistant, entered the room without the necessary protective equipment. The staff members either were unaware of the contact precautions or chose not to follow them, further risking the spread of infection. Additionally, the facility failed to notify staff and visitors of confirmed COVID-19 infections within the facility. Observations revealed that staff on the affected unit were not consistently wearing masks, and there was a lack of signage indicating the presence of COVID-19 and the required precautions. Interviews with staff, including the infection preventionist, revealed a lack of communication and enforcement of infection control measures, contributing to the potential spread of COVID-19 within the facility.
Failure to Maintain Dialysis Service Agreement
Penalty
Summary
The facility failed to ensure that an agreement between themselves and the dialysis provider was established and maintained for four residents requiring dialysis services. This deficiency was identified during interviews and record reviews, revealing that the facility could not provide a contract or agreement with the dialysis provider. The lack of such an agreement resulted in the potential for disruption in the continuity of care and interruption of dialysis treatments for the affected residents. Resident #61, a male with diagnoses including stroke, dialysis, dementia, and diabetes, was one of the residents affected. Similarly, Resident #28, a female with conditions such as stroke, heart failure, and end-stage renal disease, also required dialysis services. Resident #20, a male with acute kidney failure, heart failure, and dependence on renal dialysis, and Resident #75, a female with heart failure, renal insufficiency, and dependence on renal dialysis, were also impacted. Despite efforts by the Nursing Home Administrator to locate the agreement, it was not found, and no contact was made with the dialysis provider before the survey exit.
Failure to Implement Enhanced Barrier Precautions and Update Infection Control Policies
Penalty
Summary
The facility failed to implement proper infection control protocols and practices, including Enhanced Barrier Precautions (EBP) per national standards of practice for eight residents reviewed for infection control. Observations revealed that residents with indwelling medical devices, such as catheters and PICC lines, did not have appropriate signage or personal protective equipment (PPE) available. Staff interviews confirmed that EBP was not being utilized, and the Infection Preventionist reported that the EBP program had not yet been initiated, pending upper management approval. This lack of implementation was observed in multiple instances, including residents with catheters and wounds, where staff only used gloves and did not don additional PPE as required by EBP guidelines. Additionally, the facility failed to ensure that infection control policies were reviewed and updated on an annual basis. The review of facility policies, such as the Antibiotic Stewardship, Influenza Vaccination, and COVID-19 Vaccination policies, revealed that they had not been updated for several years. Interviews with the Infection Preventionist and the Nursing Home Administrator confirmed that the policies were outdated and in the process of being revamped. The lack of timely review and update of these policies could result in the facility not adhering to current standards of practice for infection control. Specific instances of non-compliance included residents with diagnoses such as benign prostatic hyperplasia, osteomyelitis, dementia, and neurogenic bladder, who had indwelling medical devices but no EBP signage or PPE available. Staff members, including Certified Nursing Assistants and Licensed Practical Nurses, were observed providing care without the required PPE. Interviews with staff indicated a lack of awareness or implementation of EBP, further highlighting the facility's failure to adhere to infection control protocols. This deficiency increased the potential for the spread of infection, cross-contamination, and disease transmission among residents in the facility.
Failure to Ensure Timely Care and Dignified Environment During Meal Times
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity and ensure a dignified environment during meal times for three residents. Resident #10, who was cognitively intact, reported long call light wait times, sometimes up to an hour, resulting in bowel incontinence. This made her feel diminished and as though she was nothing. Resident #331, who was mildly cognitively impaired, experienced a similar issue. Her family member reported a 20-minute wait for assistance, leading to an incontinent episode of stool, causing the resident to feel angry and embarrassed. Observations confirmed that call lights were often left unanswered due to staff shortages and technical issues with the call light notification system, which did not always work properly on the mobile phones carried by CNAs. Additionally, the display screen for call light notifications was not visible to staff when they were away from the nurses' station, further delaying response times. The Director of Nursing and other staff acknowledged these issues, noting that the system was unreliable and that CNAs often did not use the phones as intended. Resident #6, who had multiple diagnoses including dementia and required assistance with meals, was observed lying in bed with his lunch tray left unattended for over 15 minutes. This delay in assistance was confirmed by staff interviews, which revealed that residents needing help with meals received their trays last, and the assigned CNA was responsible for providing the necessary assistance. The Quality Improvement Coordinator confirmed that meal trays for residents requiring assistance should not be left in the room without immediate help. These deficiencies in timely care and assistance during meal times led to feelings of frustration, embarrassment, and diminished self-worth among the residents involved.
Failure to Honor Resident's Bathing Preference
Penalty
Summary
The facility failed to accommodate a resident's right to make choices consistent with their assessment and plan of care. Resident #61, a male with diagnoses including stroke, dialysis, dementia, anxiety, peripheral vascular disease, aphasia, apraxia, diabetes, and high blood pressure, reported that he only received a shower once a week and preferred to take a bath to help with his body pain. Despite the facility having two bathtubs available, Resident #61 was not offered a bath, which he expressed a preference for during an interview. His family member also confirmed his preference for baths over showers. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that while they generally asked residents about their bathing preferences, Resident #61's preference for a bath was not accommodated. The CNAs reported that they usually followed the residents' preferences and documented them in the kardex, but in this case, Resident #61's preference for a bath was overlooked. This failure resulted in the resident not achieving his highest practicable level of well-being, as his preference for a bath to alleviate body pain was not honored.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide written notice of transfer for Resident #15, who was hospitalized. Resident #15, who had diagnoses including Type 2 diabetes mellitus, bipolar disorder, and insomnia, was cognitively intact with a BIMS score of 15/15. On the day of the transfer, the resident was sent to a hospital without receiving a written notice of transfer. The resident and his daughter reported that they did not receive any notice before the transfer. Interviews with various staff members, including the Manager of Case Management, Registered Nurses, and the Director of Nursing, revealed that the standard paperwork for a transfer did not include a transfer notice. Additionally, the Medical Records Assistant confirmed that there was no transfer notice in the resident's electronic medical record for the transfer date in question. The staff interviews indicated a lack of awareness and training regarding the requirement to provide a written transfer notice. One RN specifically mentioned that she had never been informed about the need to send a transfer notice and did not know what it was. The facility was unable to provide documentation of a written transfer notice for Resident #15 by the time of the survey exit, highlighting a systemic issue in the facility's transfer procedures and communication protocols.
Failure to Provide Written Bed Hold Policy During Resident Transfer
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to a resident and their representative during a transfer to a hospital. Resident #15, who had diagnoses including Type 2 diabetes mellitus, bipolar disorder, and insomnia, was transferred to a hospital without receiving a written bed hold policy. The resident, who was cognitively intact with a BIMS score of 15/15, reported that neither he nor his daughter received the bed hold policy before the transfer. The facility staff, including the Manager of Case Management and the Medical Records Assistant, confirmed that the bed hold policy was undated, unsigned, and not properly documented in the resident's medical record. Interviews with the Director of Nursing and a Registered Nurse revealed that the bed hold policy should be completed and signed by the resident before transfer, but this procedure was not followed. The facility's policy required that the bed hold policy be provided in writing at the time of transfer, specifying the duration and return process. However, the staff were unable to provide documentation of a written bed hold policy for Resident #15's transfer, leading to the deficiency noted in the survey.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for two residents, resulting in an inaccurate reflection of their health status. For Resident #41, who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), the MDS assessment did not indicate the presence of PTSD. The MDS Coordinator (MDSC) acknowledged that the PTSD diagnosis should have been checked but was not, due to an error in the electronic medical record system. The MDSC admitted that not every diagnosis was reviewed for accuracy before submission to CMS, leading to the oversight. For Resident #43, the MDS assessment inaccurately documented a Stage 2 pressure ulcer. The resident had an open area on the right ankle caused by repeatedly hitting the ankle on the wheelchair, which was not a pressure ulcer. The Assistant Director of Nursing (ADON) confirmed that the wound was not a pressure ulcer, and the MDSC admitted to mistakenly coding it as such. Both MDS assessments were acknowledged as inaccurate and required correction and resubmission.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident #6, who had multiple pertinent diagnoses including dementia, stroke, muscle weakness, dysphagia, pigmentary retinal dystrophy, repeated falls, anxiety, and monoplegia. The care plan, revised on 7/19/22, included specific interventions such as keeping the bed in a low position, ensuring glasses were within reach, and using hipsters and blue wedges for fall prevention. However, multiple observations revealed that these interventions were not consistently implemented. For instance, the resident's bed was not in a low position, glasses were out of reach, and blue wedges and hipsters were not in place as required by the care plan. Interviews with staff, including a CNA and the DON, indicated a lack of adherence to the care plan interventions. The CNA reported placing the call light by the resident's legs but did not ensure other interventions were in place. The DON relied on unit managers and staff to implement and monitor the care plan but acknowledged that the interventions were not consistently followed. This failure to implement the care plan resulted in a lack of service for Resident #6 to maintain his highest practicable physical, mental, and psychosocial well-being.
Deficiencies in Nursing Practice and Documentation
Penalty
Summary
The facility failed to ensure residents received care in accordance with professional standards of nursing practice for two residents. Resident #6, who had a history of recurrent urinary tract infections (UTIs), was found to have a contaminated urine sample. Despite the contamination, there was no documentation of follow-up actions or communication with the provider to obtain a new sample. The resident's medical record lacked documentation of the conversation between the provider and the nurse regarding the contaminated sample, and the resident continued to exhibit symptoms of a UTI without appropriate intervention or documentation of care provided. Resident #61 was observed self-administering Biofreeze gel without a current physician's order or an assessment to determine his ability to self-administer medications. The resident's medical record showed that previous orders for Biofreeze had been discontinued, and there was no documentation of a new order or assessment. Staff provided the Biofreeze to the resident without proper authorization, and the facility's Quality Improvement Coordinator confirmed that an order and assessment were required for self-administration of medications. These deficiencies highlight a lack of adherence to professional standards of nursing practice, including proper documentation, communication with healthcare providers, and ensuring that residents receive care according to physician orders. The failure to follow established protocols for urine sample collection and medication administration resulted in potential delays in treatment and inadequate care for the residents involved.
Failure to Timely Address Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure the attending physician reviewed and responded to the registered pharmacist's monthly medication regimen review recommendations in a timely manner for one resident. Resident #41, who had a pertinent diagnosis of a saddle embolus of the pulmonary artery, had two pharmacist recommendations dated 05/06/2024. The first recommendation was to discontinue diphenhydramine due to its strong, sedating anticholinergic properties and to consider initiating PRN loratadine. The second recommendation was to discontinue low-dose aspirin due to the increased risk of serious, potentially fatal bleeding when used concomitantly with Eliquis. Both recommendations were not addressed until 05/23/2024, resulting in a delay of 17 days before the nurse practitioner reviewed and declined the recommendations, citing the need for diphenhydramine for rash with itching and the history of pulmonary embolism for the continued use of aspirin. The delay in addressing the pharmacist's recommendations was attributed to a breakdown in the facility's process. The Director of Nursing (DON) reported receiving the pharmacist's consultation reports on 05/08/2024 but failed to ensure they were promptly reviewed by the medical provider. The reports should have been printed and placed in the medical provider's mailbox for review, but this step was not completed in a timely manner. The Nursing Home Administrator (NHA) acknowledged the issue, indicating a need to review and address the process to prevent future delays.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 362 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kalamazoo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa At Borgess Place | 3.6 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Portage | 4.5 mi | ★★★★★ | 17 | 0 |
| Medilodge Of Kalamazoo | 4.5 mi | ★★★★★ | 4 | 0 |
| Friendship Village | 4.8 mi | ★★★★★ | 15 | 0 |
| Medilodge Of Westwood | 5.3 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.