Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harold And Grace Upjohn Community Care Center during CMS and state inspections, most recent first.
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.
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.
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.
The facility failed to maintain a sanitary environment for a resident and shared medical equipment, leading to potential cross-contamination and infections. Observations revealed unsanitary conditions on broda chairs, a recliner seat, a hoyer lift machine, and other equipment. Staff interviews indicated inconsistencies in cleaning responsibilities and schedules, contrary to the facility's policy on cleaning and disinfection.
A resident with cognitive impairment and multiple diagnoses, including second-degree burns, experienced significant harm due to delayed treatment after spilling hot tea on her lap. The staff did not promptly apply cool liquid to the affected area, leading to additional skin breakdown, prolonged healing, infection requiring IV antibiotics, and ongoing pain. The incident highlights the importance of immediate intervention following a burn to prevent further complications.
The facility failed to ensure proper catheter tubing securement for a resident with severe cognitive impairment and multiple medical conditions, despite a physician's order. Observations revealed the absence of a securement device, leading to potential risks. Staff acknowledged the issue, citing unavailable devices and delays in ordering alternatives.
A resident with severe cognitive impairment and second-degree burns experienced significant pain during wound care due to the facility's failure to adhere to physician orders for applying lidocaine ointment 10-15 minutes prior to treatment. Staff did not consistently wait the required time, causing the resident distress during dressing changes.
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 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 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.
Failure to Maintain Sanitary Conditions for Resident and Shared Medical Equipment
Penalty
Summary
The facility failed to ensure a sanitary environment for Resident #6 and the shared medical equipment, leading to potential cross-contamination and infections. During observations, a broda chair outside of room [ROOM NUMBER] was found with dried liquid, dirt, and debris on various parts, including the armrest, back pad, footrest, and seat cushion. Similar unsanitary conditions were noted on another broda chair and a recliner seat located between rooms [ROOM NUMBER] and 25, with dirt, debris, and dried material on different parts of the chairs. Additionally, a hoyer lift machine was observed with dried red spillage on the bottom frame, and a broda chair had significant dirt and grime around the wheels and casters. The fall mat and light blue wedges in Resident #6's room were also found to be soiled and in need of cleaning. Interviews with staff revealed inconsistencies in the cleaning responsibilities and schedules. Certified Nursing Assistant (CNA) Y reported that wheelchairs were cleaned during the night shift according to a schedule, while CNA JJ mentioned that housekeeping usually cleaned the fall mats, but she would clean them if something was spilled. Licensed Practical Nurse (LPN) E confirmed that wheelchairs and broda chairs were cleaned on the third shift and that it was everyone's responsibility to ensure the fall mats were cleaned. The Infection Preventionist (IP) H stated that shared equipment should be cleaned before and after each use. The facility's policy on Cleaning and Disinfection of Resident Care Equipment, approved on 05/08/2024, mandates that reusable resident-care equipment be cleaned and disinfected according to CDC recommendations to prevent the transmission of pathogens. The policy specifies that direct care staff are responsible for cleaning single-resident equipment when visibly soiled and according to a routine schedule. However, the observations and interviews indicate that these guidelines were not consistently followed, resulting in unsanitary conditions for Resident #6 and shared medical equipment.
Delayed Treatment of Hot Liquid Burn Resulting in Complications
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to immediately treat a hot liquid burn per professional standards of practice for a resident (Resident #103) who spilled a cup of hot liquid on her lap. Despite the incident occurring on 2/22/24, where Resident #103 spilled hot tea on her lap resulting in burns to both her legs and buttocks, the facility staff did not promptly apply cool liquid to the affected area to stop the burn process. This lack of immediate intervention led to additional skin breakdown, prolonged healing, infection requiring IV antibiotics, and ongoing pain for Resident #103. The report details how Resident #103, a female with pertinent diagnoses including second-degree burn of thigh, skin infection, stroke with left-sided weakness, peripheral vascular disease, dementia, and anxiety, experienced significant harm due to the delayed treatment of her burn. Despite Resident #103's severe cognitive impairment, the staff's response to the hot liquid spill was inadequate, as they only applied cream to the affected area without utilizing cool liquid to stop the burning process. This failure to adhere to professional standards of practice resulted in the development of blisters and extensive burns on Resident #103's thighs, leading to a cascade of complications requiring hospital evaluation, wound clinic treatment, IV antibiotics, and ongoing wound management. The deficiency was further highlighted by the accounts of family members, staff, and healthcare providers involved in Resident #103's care. Family members expressed distress over the staff's lack of knowledge on how to respond to the hot liquid spill, emphasizing Resident #103's ongoing pain and suffering as a result of the delayed treatment. Healthcare providers noted the severity of Resident #103's burns, the need for IV antibiotics, and the challenges in managing the wounds due to the delayed initial intervention.
Failure to Secure Catheter Tubing as Ordered
Penalty
Summary
The facility failed to ensure that catheter tubing was properly secured for a resident with an indwelling catheter, as per the physician's order. This deficiency was observed in a resident with severe cognitive impairment and multiple medical conditions, including second-degree burns, a skin infection, and stroke-related weakness. During multiple observations, it was noted that the resident's Foley catheter was not secured with a device to prevent pulling or tugging, which could lead to potential dislodgement and urethral damage. The catheter tubing was observed to be taut, and the securement device was missing on several occasions, despite a physician's order to change the securement device every Sunday night shift for trauma prevention. Staff interviews revealed that the securement device was not available on the unit, and a different style of device was ordered but not yet received. The facility placed an order for the securement devices only after the deficiency was noted by surveyors. The resident's medical records indicated that the Foley catheter was initially placed for wound management due to burns on the thighs and buttocks. Despite the physician's order and the resident's need for proper catheter care, the securement device was not consistently used. Staff members, including the Assistant Director of Nursing and Unit Manager, acknowledged the absence of the securement device and reported that the resident had previously complained about skin irritation from the strap-style device. However, no alternative securement device was provided in a timely manner, leading to the observed deficiency. The facility's failure to maintain proper catheter care as per the physician's order was documented in the Medication Administration Record and Health Status Notes, highlighting the lack of available securement devices and the delay in ordering a new style of device.
Failure to Implement Pain Management Protocol During Wound Care
Penalty
Summary
The facility failed to implement physician orders for pain management during wound care for a resident with second-degree burns, resulting in pain during wound care. The resident, who had severe cognitive impairment, suffered burns from a hot tea spill and required wound care twice daily. Despite physician orders to apply lidocaine ointment 10-15 minutes prior to wound care, staff did not adhere to this protocol, causing the resident significant pain during dressing changes. Observations revealed that nursing staff did not wait the required 10-15 minutes for the lidocaine to take effect before proceeding with wound care. During one instance, the staff waited only a few minutes before applying new dressings, and in another instance, they waited approximately one minute. The resident expressed pain during these procedures, indicating that the lidocaine was not given sufficient time to numb the area. Interviews with staff and family members confirmed that the resident experienced significant pain during wound care. The nurse practitioner and other staff members acknowledged the need to wait 10-15 minutes for the lidocaine to take effect, but this protocol was not consistently followed. The facility's pain management policy emphasized the importance of providing pain management consistent with professional standards and the resident's care plan, which was not adhered to in this case.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 345 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
A prioritized, do-first checklist
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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 | ★★★★★ | 45 | 0 |
| Medilodge Of Portage | 4.5 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Kalamazoo | 4.5 mi | ★★★★★ | 0 | 0 |
| Friendship Village | 4.8 mi | ★★★★★ | 15 | 0 |
| Medilodge Of Westwood | 5.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.