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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Imperial, A Villa Center during CMS and state inspections, most recent first.
The facility failed to timely reorder and provide ordered pain medications for two residents with chronic pain, resulting in multiple missed doses of methadone and pregabalin (Lyrica). One resident with a history of opioid abuse and PTSD went three days without methadone, with MAR entries showing the drug as “on order” or “awaiting pharmacy delivery,” while the resident reported pain, irritability, sweating, and feeling they were going into withdrawal. Another resident with osteoarthritis and back pain missed several scheduled doses of Lyrica over multiple days, with MAR notes again indicating the medication was “on order.” The residents reported lying in pain and going days without medications, and staff interviews revealed delays related to obtaining new prescriptions and failures to utilize available backup medication.
A resident with dementia and impaired cognition did not receive proper meal assistance during a meal service. The resident was served thick meat and asked for a knife to cut it, but staff said knives were not available on the unit and gave a spoon instead, leaving the resident to try to cut the meat with the spoon. Record review and staff interviews also showed standing order items were missing from the tray, and the DON stated staff should have provided or supervised use of a knife or assisted with cutting the food.
Failure to provide a bed hold notice during a hospital transfer. A resident with impaired cognition, shortness of breath, hypertension, and assistance needs for bed mobility and transfers was sent to the hospital after family reported concern for a possible stroke. The transfer paperwork did not show that the bed hold form was provided to the resident or representative, and the DON could not locate the form. Facility staff stated the bed hold form should be given when a resident transfers to the hospital.
Nonfunctional Wheelchair Brake: A resident who required total assist with mechanical lift transfers reported that the wheelchair brakes were broken and the left brake did not stop the wheel from rolling. The resident said staff had been told about the problem previously, but it was never repaired. The resident was later transferred into the wheelchair with the mechanical lift while the brake remained non-functional, and the DON confirmed the chair should not be used until repaired.
A resident with stroke, dysphagia, severe cognitive impairment, and dependence on staff for eating was observed receiving TF at 70 ml/hr even though the physician order specified 75 ml/hr. The lower rate was documented on the night report sheet, and the UM and RD were not aware of any reason for the discrepancy. Record review also showed significant weight loss, poor PO intake, and repeated meal refusal or lack of response during mealtimes.
A resident with a PICC line for IV ABX had a transparent dressing observed dated earlier than the documented change date, and the dressing was rippled and partially pulled away from the skin. The resident had cellulitis and sepsis, and the order required PICC dressing changes every 7 days; the TAR documented a later dressing change date than the one seen on the dressing.
A facility failed to ensure enough nursing staff to timely administer meds to three residents. One resident with iron deficiency anemia and seizures, another with HTN and diabetes, and a third with HTN, a sacral pressure ulcer, and lumbar disc degeneration all reported or were found to have 9:00 AM meds delayed by several hours, with MARs showing multiple meds not documented until early afternoon. Staff reported a nurse call-off and only two nurses on the unit instead of three, and the DON acknowledged the late med concerns.
Three residents at high risk for falls did not receive required fall prevention interventions, including proper wheelchair positioning, use of nonskid socks, and locking wheelchair brakes. These lapses occurred despite individualized care plans and facility policy specifying these safety measures for residents with cognitive impairment, mobility issues, and recent fall history.
A resident with severe cognitive impairment and behavioral issues exited the facility on two occasions without staff awareness after being incorrectly assessed as low risk for elopement. Staff failed to update the resident's elopement risk assessment or care plan following the first incident, and communication lapses led to further unawareness among staff, resulting in the resident being found outside the facility by chance.
A resident with End Stage Renal Disease and Obstructive Sleep Apnea had care plan interventions for oxygen therapy and fluid restriction entered without corresponding physician orders. Staff interviews confirmed that these interventions were implemented based on standard practice and admission communication, rather than actual physician directives, and the facility's policy did not address how interventions should be implemented.
A resident with end stage renal disease and obstructive sleep apnea was not properly assessed prior to dialysis treatment. The dialysis communication form was incomplete, missing vital signs, code status, pain assessment, changes in condition, and staff identification, contrary to facility policy and expectations confirmed by the DON.
A resident with multiple medical conditions experienced severe, unresolved abdominal pain for over 12 hours. Despite repeated complaints, unsuccessful interventions, and involvement of family and medical staff, nursing staff did not transfer the resident to a higher level of care. The resident ultimately called 911 and was hospitalized with ischemic bowel. The facility's transfer policy did not address the right to contact EMS.
The facility failed to ensure call lights were within reach for four residents, leading to a deficiency in accommodating resident needs. A resident's call light was missing and later found on the floor, while another's was out of reach behind a table. Two other residents had call lights that were inaccessible, with one reporting frequent issues with certain CNAs. The facility's policy required call lights to be within easy reach, but this was not consistently followed.
The facility failed to maintain a safe and homelike environment for residents, with multiple deficiencies observed in ten rooms on Unit D, including missing handrail end caps, damaged baseboard heaters, and crumbling sheetrock. A resident reported a long-standing issue with a broken nightstand drawer, despite repeated requests for repair. The facility's policy emphasizes a homelike environment, but the observed conditions and resident experiences indicate a failure to meet these standards.
A resident experienced a lack of dignified care when left wet and exposed due to a leaking catheter and insufficient staff assistance. The resident, who required a two-person approach for care, was initially attended by a single nursing assistant unfamiliar with the care orders, leading to feelings of shame and distress.
A resident with Cerebral Palsy and Anxiety Disorder was observed self-administering medications, including a narcotic, without staff supervision. The facility failed to assess the resident's ability to self-administer medications, as required by their policy. The ADON confirmed that a nurse should have been present, highlighting a deficiency in medication management.
The facility failed to maintain a clean and homelike environment for two residents, resulting in a deficiency. Both residents, who were cognitively impaired and dependent on staff, were observed with soiled tube feeding poles and dried tube feed formula on the floor. Despite multiple observations, these issues remained unaddressed. The Maintenance Director acknowledged the ongoing issue with exposed heat vents, and the Nursing Home Administration was informed of the observations.
A resident with severe cognitive impairment and multiple diagnoses was found to have a low air loss mattress set incorrectly at 400 pounds, despite weighing 180.2 pounds. The facility's records showed the setting was checked multiple times, yet the error persisted. The Unit Manager and an LPN acknowledged the mistake, and wound care staff confirmed the correct setting should have been 200 pounds.
A resident with significant cognitive impairment and total dependence on staff developed a new unstageable pressure ulcer due to the facility's failure to document and implement prescribed interventions. Despite having a care plan that included using a low air loss mattress and foam boots, these interventions were not documented as completed for 12 days, leading to the development of a new pressure injury.
The facility failed to ensure proper labeling and dating of resident inhalers in two medication carts. Observations revealed that inhalers lacked open dates and resident identifiers, which was acknowledged by the LPNs involved. The facility's policy and manufacturer guidelines require inhalers to be dated upon opening and discarded after six weeks or when the counter reads zero.
A facility failed to ensure proper PPE use for a COVID-19 positive resident. An NP was observed in the resident's room without PPE, despite precautionary signs. The resident required isolation due to COVID-19 and muscle weakness. The ADON confirmed the oversight, and the facility's PPE policy lacked guidance on droplet precautions.
A facility failed to serve food at the preferred temperature, leading to resident dissatisfaction. Residents reported receiving cold food, and an observation confirmed that staff left food cart doors open while distributing trays. A dietary manager found food temperatures below the expected range, and a surveyor confirmed the food was lukewarm, affecting its palatability. The resident involved had a history of COPD and rectal cancer.
Failure to Timely Reorder and Provide Ordered Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pain medication by not reordering controlled substances in accordance with its own policy, resulting in multiple missed doses for two residents with chronic pain. One resident, admitted with diagnoses including opioid abuse and PTSD, had a physician’s order for methadone 10 mg, eight tablets once daily for pain. The MAR for April showed methadone was not administered for three consecutive days, with EMAR notes indicating the medication was “on order” or “awaiting pharmacy delivery.” During this period, the resident reported not receiving methadone for three days, stated this had happened before, and described being irritable, in pain, sweating, and feeling they were going into withdrawal, and that they felt the facility did not care. Facility staff later acknowledged awareness that the resident had been out of methadone and attributed delays to fax issues, despite having a second fax machine available, and records showed that backup methadone tablets were available but no backup medication removal requests were made for the days doses were missed. Another resident, admitted with primary generalized osteoarthritis and back pain and with intact cognition, had an active order for pregabalin (Lyrica) 75 mg twice daily. The April MAR documented multiple missed doses over several days, with notes stating the medication was “on order.” The resident reported lying in pain all night, only recently receiving some pain relief, and stated they had gone days without medications and were told the medication was on order, and that they had not had Lyrica in days and that this occurred often. An LPN reported that the Lyrica was not available during a scheduled medication pass, stated a new script was needed and had been placed in the doctor’s log days earlier, and that the pharmacy still had not received it. The DON later reported that the pharmacy indicated a new script was needed and that there was authorization to pull from backup, but at the time of the missed doses, the medication had not been obtained or administered as ordered.
Failure to Provide Proper Meal Assistance and Ordered Tray Items
Penalty
Summary
The facility failed to accommodate a resident’s needs during meal service by not providing proper utensils and not ensuring ordered meal items were present. During observation, the resident, who had a diagnosis of dementia and was assessed as having impaired cognition and needing some assistance with ADLs, received a meal with thick pieces of meat, carrots, pudding, juice, and a fork. The resident asked staff for a knife to cut the meat, but staff stated the resident could not have a knife and brought a spoon instead. The resident then attempted to cut the meat with the spoon by pushing it into the meat multiple times. Record review and staff interviews showed the resident’s meal ticket included standing orders for 8 fl oz apple juice and 8 fl oz whole milk, and the dietician stated standing order items were to be on the tray every meal. The dietician also reported the unit did not have knives and that the meal ticket would note if the resident needed meal setup assistance, including cutting food items. The DON later stated that if the resident needed meat cut, staff should have given the knife, observed the resident with it and removed it when done, or assisted by cutting the items. The facility policy on ADLs stated care and services should be based on the resident’s assessment and choices, including dining.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to one resident, R232, when the resident was transferred to the hospital. R232 was admitted on 1/6/2026 with diagnoses of shortness of breath and hypertension, and a MDS assessment showed a BIMS score of 9/15, indicating impaired cognition. The resident also required staff assistance with bed mobility and transfers. On 3/6/2026, the resident’s son and daughter reported concerns that the resident may have had a stroke, and the nurse documented that the resident’s vital signs were within normal limits and that the NP was notified. The nurse received an order to send the resident to the hospital for a CT of the head to rule out a possible stroke. The transfer evaluation form showed that the “Bed Hold Form” was not checked under documents sent, indicating the bed hold form had not been provided to the resident or resident representative before the hospital transfer. During interviews, the DON stated the facility was looking for the bed hold form but could not find one, and the UM stated staff should complete the transfer form and provide a bed hold form when someone transfers to the hospital. The facility policy stated that residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave.
Nonfunctional Wheelchair Brake
Penalty
Summary
The facility failed to maintain care equipment in working order for one resident who used a wheelchair and required total assistance for transfers with a mechanical lift. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease and an Anxiety Disorder and whose cognition was intact, reported that the wheelchair was old and that the brakes were broken. During interview, the resident demonstrated that the left brake was loose and did not apply pressure to the wheel or stop it from rolling, and stated they had previously told staff about the problem but it was never repaired. The resident was observed sitting in the wheelchair after staff had transferred them there using the mechanical lift, and the resident stated they could feel the chair moving and that it made them nervous. The left brake remained non-functional during the observation. On a later interview with the DON present, the resident again reported that the wheelchair had not been repaired or replaced and that they felt the chair slipping while being lowered into it. The DON confirmed that if staff were setting up the wheelchair for a mechanical lift transfer, they would be aware the brake was not working and the chair should not be used until repaired. The facility policy stated the intent was to provide an environment free from hazards under facility control and to ensure staff were properly trained with facility equipment.
Tube Feeding Administered Below Ordered Rate
Penalty
Summary
The facility failed to ensure tube feeding was administered at the ordered rate for one resident who was reviewed for tube feeding. On 04/22/2026, the resident was observed in bed with the head of the bed elevated about thirty degrees and was connected to tube feeding that was actively infusing at 70 ml/hr through an electronic pump. The resident did not respond to any query during the observation. A physician order dated 03/25/26 directed Glucerna 1.5 Cals at 75 ml/hour for 18 hours, starting at 4 PM and stopping at 10 AM the next day. On 04/23/2026, the resident was again observed with tube feeding infusing at 70 ml/hr. An LPN reviewed the night nurse’s report sheet, which documented the tube feeding rate as 70 ml/hr, and the Unit Manager stated the ordered rate should have been 75 ml/hr and was not aware of any reason for the lower rate. The RD reported the resident had been placed on tube feeding due to significant weight loss and poor food acceptance and was not aware of any reason the rate was set lower. The resident’s record showed diagnoses of stroke and difficulty swallowing, severe cognitive impairment, dependence on staff for eating and all ADLs, and RD notes documenting weight loss, poor PO intake, declining meals, and not responding to staff during mealtimes.
Delayed PICC Dressing Change
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident with a PICC line in the right upper arm. On 04/22/2026, the resident was observed at the entry to the room with a transparent PICC dressing dated 4/11; the dressing was rippled and pulled away from the skin in places. The resident stated they had a post-surgical foot wound and were receiving an antibiotic through the IV PICC line for an infection. Record review showed the resident was admitted with diagnoses including cellulitis of the right lower limb and sepsis. The physician order dated 04/08/26 directed that the PICC line dressing be changed every seven days, and the care plan included IV antibiotics and dressing changes to the IV site as ordered. The April 2026 TAR documented a dressing change on 04/14, which did not match the 4/11 date observed on the dressing. The facility policy stated that site care is to be performed at established intervals and immediately if the dressing integrity is compromised, and that transparent dressings are to be changed at least every seven days.
Late Medication Administration Due to Staffing Shortage
Penalty
Summary
The facility failed to ensure sufficient staff to timely administer medications to three residents. On 04/21/26, R90 was observed lying in bed and reported that morning medications due at 9:00 AM had not been given. Review of the MAR confirmed multiple medications were not documented as administered at the scheduled time, including ferrous sulfate, polyethylene glycol, multivitamin, spironolactone, verapamil, docusate sodium, Keppra, potassium chloride, and pregabalin. Four of the nine medications were scheduled twice daily. R90’s record showed diagnoses of iron deficiency anemia and seizures, and the MDS documented intact cognition with a BIMS score of 13/15 and dependence or substantial/maximal staff assistance for most ADLs. R240 was observed in bed and reported not receiving 9:00 AM medications, stating this happens about once a week, and also reported sharp leg and back pain rated 9/10. The MAR showed the morning medications were not documented until 2:04 PM, including loratadine, sertraline, and tamsulosin; hydrocodone PRN pain medication had not been documented as provided at the time of interview. R209 was also asked whether 9:00 AM medications had been given and no response was provided; the MAR showed the medications had not been documented until 2:07 PM, including amlodipine, aspirin, polyethylene glycol, dronabinol, and magnesium, with dronabinol and magnesium scheduled twice daily. R209’s record showed diagnoses of high blood pressure and diabetes, impaired cognition with a BIMS score of 6/15, and substantial/maximal assistance or dependence for all ADLs. Facility staff reported a nurse call-off and that only two nurses were assigned for the unit instead of three on the day shift, and the DON reported hearing about late medication concerns and that additional staff attempted to help out.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall care plan interventions for three residents who were identified as being at risk for falls. For one resident with metabolic encephalopathy and multiple comorbidities, staff did not properly secure the resident in their wheelchair after toileting, resulting in the resident sliding out of the chair and falling to the floor. The care plan for this resident included interventions such as monitoring for poor positioning and using a nonskid pad, but these were not properly followed at the time of the incident. Another resident with impaired cognition due to alcohol withdrawal delirium was observed walking barefoot and later with non-grip socks, despite a care plan intervention to encourage the use of nonskid socks. This resident had a recent history of falls, including an incident where they tripped over a phone cord while attempting to get out of bed. The care plan specified the need for cues, prompting, and appropriate footwear to reduce fall risk, but these interventions were not consistently implemented. A third resident with dementia and epilepsy was observed sitting in a wheelchair with the wheels unlocked and leaning forward, despite care plan interventions requiring wheelchair brakes to be locked. The unit manager confirmed that both this resident and the previously mentioned resident were at risk for falls and that proper safety measures, such as locking wheelchairs and using gripper socks, should have been in place. The facility's own fall safety policy emphasizes the need for consistent implementation of individualized interventions to prevent falls, which was not adhered to in these cases.
Failure to Identify and Address Elopement Risk Resulting in Resident Exiting Facility Unnoticed
Penalty
Summary
The facility failed to identify and address the elopement risk of a resident with severe cognitive impairment and a history of behaviors requiring constant redirection. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease and Schizophrenia, was initially assessed as low risk for elopement upon admission. Despite exhibiting behaviors such as wandering, loud vocalizations, and hallucinations, no updated elopement risk assessment or care plan interventions were completed after the resident exited the facility on one occasion. On two separate occasions, the resident was able to leave the facility without staff awareness. The first incident occurred when the resident followed staff out the front door after it was unlocked by a receptionist. The second incident involved a newly hired receptionist who mistakenly identified the resident as a visitor and allowed them to exit. In both cases, staff were unaware of the resident's absence until after the fact, and the resident was found outside the facility, once by a staff member driving to work and once by facility supervisors. Interviews with staff revealed a lack of communication and awareness regarding the resident's previous elopement and ongoing behaviors. Key personnel, including the assigned nurse and other staff, were not informed of the prior incident or the need for reassessment. The DON confirmed that no reassessment or new interventions were implemented after the initial elopement, and the administrator stated that only the receptionists were in-serviced following the incidents. The facility's policy required reassessment and intervention upon changes in resident behavior or condition, which was not followed in this case.
Removal Plan
- Resident wander assessment completed for the at-risk resident.
- Resident care plan reviewed by the interdisciplinary team and updated.
- Resident monitored by psychiatry for behaviors and medication management.
- All residents in the facility reassessed for risk of elopement to identify those at risk.
- Audit completed by the facility's clinical management team on all residents who trigger for elopement risk.
- Care-plan review for residents deemed at risk for elopement to ensure appropriate interventions are in place.
- Residents deemed at risk for elopement are included in all facility elopement binders, which are located on the nurse's unit and at the reception area.
- In-servicing for staff initiated by DON/Designee on the elopement guideline.
- Signage made visible throughout the building for staff and visitors to be aware of residents who may be around when walking through doors.
- In-servicing for licensed nurses initiated by the DON/Designee on ensuring a resident is reassessed for wandering when showing behaviors to ensure accuracy of care plan and interventions.
- The DON/Designee will review residents who are at risk for elopement to ensure wander/elopement assessments are current and interventions are accurate.
- Results reported to the QA committee for monitoring and follow-up.
Failure to Implement Physician-Ordered Care Plan Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions for a resident with End Stage Renal Disease and Obstructive Sleep Apnea. The resident was dependent on staff for bed mobility and transfers and had an intact cognition. The care plan included interventions for oxygen via nasal cannula at 3 LPM as needed and a 1500 ml fluid restriction, with specific allocations for dietary and nursing staff, due to edema, diuretic use, and hospital dietary orders. However, a review of the current physician's orders revealed that there were no orders for either the fluid restriction or oxygen for this resident. Interviews with facility staff confirmed that the fluid restriction was entered into the care plan without a corresponding physician's order, despite it being a standard practice for dialysis patients. The Registered Dietitian stated that a physician's order should have been obtained before including the intervention in the care plan. The DON was unsure why the oxygen intervention was included and acknowledged that it was not supported by a physician's order, even though it was communicated on the admission notice form. The facility's care plan policy did not address the implementation of interventions.
Failure to Complete Pre-Dialysis Assessment and Documentation
Penalty
Summary
The facility failed to properly assess a resident with end stage renal disease and obstructive sleep apnea prior to dialysis treatment. The resident, who was dependent on staff for bed mobility and transfers and had intact cognition, was admitted to the facility and required dialysis services. Review of the dialysis communication form for the resident showed that only the patient's name, date, and pre-dialysis weight were completed, while critical sections such as vital signs, code status, pain assessment, changes in condition, and the staff member's name and title were left blank. The Director of Nursing confirmed that the expectation was for residents to be assessed before going to dialysis and for the communication form to be fully completed, which did not occur in this instance. Facility policy also required communication of daily weights and any changes in condition or mood between the dialysis provider and the facility.
Failure to Transfer Resident with Severe Abdominal Pain
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease, alcohol-induced pancreatitis, anxiety, and diaphragmatic hernia experienced severe, unresolved abdominal pain over a 12-hour period. The resident initially reported pain after dinner, which was treated unsuccessfully with a laxative, famotidine, and Zofran. Despite ongoing complaints of pain, vomiting, and diarrhea, the resident remained in the facility, and the physician was notified multiple times. Orders were given for an enema, abdominal X-ray, and pain medication, but the interventions did not alleviate the resident's symptoms. Throughout the night, the resident continued to express severe pain, including screaming out and requesting additional pain medication. The resident's family was involved, with the daughter arriving at the facility and discussing the possibility of hospital transfer or leaving against medical advice (AMA). Nursing staff and supervisors did not facilitate a transfer to a higher level of care, and at one point, EMS was called but reportedly sent away. Staff interviews indicated that the nurse supervisor did not agree that hospital transfer was necessary, and there was confusion regarding communication with emergency services. Ultimately, the resident called 911 independently and was transferred to the hospital, where they were diagnosed with ischemic bowel with bowel infarction. The facility's transfer and discharge policy did not address the resident's right to contact emergency medical services. The failure to transfer the resident in a timely manner, despite persistent and severe symptoms, resulted in a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, leading to a deficiency in accommodating resident needs. Resident #86's call light was initially missing and later found on the floor, indicating it was not accessible. The resident, who had severe cognitive impairment and required supervision for daily activities, was unaware of the call light's location. Similarly, Resident #115's call light was not present in the room initially, and when it was installed, it was placed out of reach behind a table. This resident also had severe cognitive impairment and required assistance for most activities. Resident #71's call light was found on the floor, out of reach, and the resident was unable to locate it. This resident had severe cognitive impairment and needed extensive assistance. Resident #83's call light was draped over the bed, out of reach, and the resident reported that it was often inaccessible with certain CNAs. This resident had intact cognition but required extensive assistance. The facility's policy stated that call lights should be within easy reach, but observations and interviews revealed that this was not consistently followed, leading to the deficiency.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain room furnishings in a safe and homelike condition for ten resident rooms on Unit D and for one resident reviewed for a homelike environment. Observations revealed multiple deficiencies, including missing end caps for handrails, missing vertical trim, baseboard heater covers hanging or missing, crumbled sheetrock, open windows, dusty fans, missing edge molding, cracked and unpainted ceilings, and visible nails behind crown molding. These issues were acknowledged by the Maintenance Director during an inspection, and a review of maintenance logs showed only one heating register repair on a different unit, indicating a lack of attention to the identified problems on Unit D. A specific resident, identified as R47, was observed with a nightstand missing the covering for the drawer, leaving all items inside visible. The resident reported that the nightstand had been in this condition for a long time and despite numerous requests for repair or replacement, no action had been taken. The resident, who has muscle weakness and a contracture in the left wrist, was assessed with an intact cognition and required staff assistance with bed mobility and transfers. The facility's policy emphasizes creating a homelike environment, but the resident's experience and the observed conditions suggest a failure to meet these standards.
Failure to Provide Dignified Care for Resident
Penalty
Summary
The facility failed to uphold the dignity of a resident, identified as R216, during care. On one occasion, R216 was observed lying in bed, wet from a leaking indwelling catheter, and expressed feelings of shame and distress due to being unable to help themselves. The resident was waiting for staff assistance to get dressed and was concerned about being late for therapy. The resident's medical record indicated a need for a two-person approach during care, which was not initially followed. On another occasion, R216 reported that a nursing assistant attempted to change them without the required assistance, which made the resident feel unsafe and exposed. The resident insisted that the nursing assistant stop and seek additional help, resulting in the resident being left partially exposed until two nursing assistants returned to complete the task. The Director of Nursing confirmed that the nursing assistant was new and unfamiliar with the care orders, highlighting a lapse in staff awareness of resident care requirements.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess a resident for self-administration of medications, leading to a deficiency. The resident, who has diagnoses of Cerebral Palsy and Anxiety Disorder, was observed self-administering medications without staff supervision. The resident was seen taking a gas pill and a narcotic pain pill, Norco, without any staff present. The resident mentioned that staff usually leave the medications with them, indicating a lack of oversight in medication administration. A review of the resident's medical record showed no assessment or care plan for self-administration of medications, despite the facility's policy requiring a licensed nurse to evaluate the resident's ability to self-administer medications. The Assistant Director of Nursing confirmed that a nurse should have been present during the administration of medications, especially for a narcotic. This oversight in following the facility's policy and ensuring proper supervision during medication administration led to the identified deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, leading to a deficiency. One resident was observed with a visibly soiled tube feeding pole and dried tube feed formula caked on the floor. The resident's bed was positioned next to a heat vent with a damaged baseboard exposing the coils. Despite multiple observations over several days, the dried tube feed formula and the damaged baseboard remained unaddressed. The resident was severely cognitively impaired and totally dependent on staff for activities of daily living. Another resident was also observed with a soiled tube feeding pole and dried tube feed formula on the floor. This resident was significantly cognitively impaired and totally dependent on staff for daily activities. The Maintenance Director acknowledged the ongoing issue with exposed heat vents, and the Nursing Home Administration was informed of the observations. The facility's guideline stated that the resident's environment should be maintained in a homelike manner with appropriate housekeeping, which was not adhered to in these cases.
Improper Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure the proper setting for a specialty low air loss mattress for a resident, leading to a deficiency. The resident, who was observed multiple times over several days, was found to have the mattress power unit set at 400 pounds, despite not appearing to weigh that much. The resident, who had diagnoses including dementia, stroke, and diabetes, was severely cognitively impaired and dependent on staff for movement and hygiene. The resident's actual weight was documented as 180.2 pounds, and a physician's order specified that the mattress pump should reflect the resident's weight. The facility's records indicated that the mattress setting had been checked by nursing staff on several occasions, yet the incorrect setting persisted. The Unit Manager and an LPN acknowledged the setting was likely too high and consulted with wound care staff, who confirmed the mattress should have been set at 200 pounds. The facility's Skin Protection Guideline emphasized the importance of individualized support surfaces to prevent skin breakdown, but this was not adhered to in this case, resulting in a failure to provide appropriate care according to the resident's needs and physician's orders.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to document interventions and prevent the development of a pressure ulcer for a resident, identified as R165, who was admitted with significant cognitive impairment and total dependence on staff for activities of daily living. Upon admission, R165 had a stage 2 pressure sore on the left buttock and dry, cracked heels. The care plan included interventions such as applying barrier cream, elevating heels, and using a low air loss mattress. However, the Treatment Administration Record (TAR) showed that orders for monitoring the mattress and applying foam boots were not documented as completed for 12 days. Subsequently, R165 developed a new unstageable pressure injury on the coccyx, which was initially documented as a deep tissue injury (DTI) but later identified as an unstageable wound. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the documentation errors and the compromised state of the resident's skin upon admission. The facility's Skin Protection Guideline aims to provide evidence-based standards for skin care, but the lack of documentation and follow-through on prescribed interventions contributed to the development of the new pressure ulcer.
Inhaler Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that resident inhalers were properly dated when opened and labeled with resident identifiers, as observed in two of six medication carts. During an observation on Unit C, a Breo Ellipta inhaler and an Incruse inhaler were found without open dates and resident identifiers. Licensed Practical Nurse (LPN) J acknowledged the absence of these details on the inhalers. Similarly, on the Unit C Front cart, two Trelegy inhalers and one Incruse inhaler were also found without open dates and resident identifiers. LPN K confirmed that an open date was required on the inhalers. The facility's policy on medication storage, dated April 2018, states that drugs dispensed in the manufacturer's original container should carry the manufacturer's expiration date, and once opened, they should be used until the expiration date unless specified otherwise. The prescribing information from the manufacturers of Incruse, Breo, and Trelegy inhalers indicates that these inhalers should be discarded six weeks after opening or when the counter reads zero, whichever comes first, and the date of opening should be written on the label. The failure to adhere to these guidelines resulted in the deficiency noted during the survey.
Failure to Use PPE for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident who was positive for COVID-19 and under isolation precautions. On the morning of February 26, 2025, a Nurse Practitioner (NP) was observed in the room of a COVID-19 positive resident without wearing any PPE, despite the presence of PPE and precautionary signs on the door. The resident had been admitted with diagnoses of COVID-19 and muscle weakness and required staff assistance for mobility and transfers. A Licensed Practical Nurse (LPN) confirmed that the resident was still positive for COVID-19 and required precautions. The NP admitted to not noticing the precaution signs and was unaware of the resident's status. The Assistant Director of Nursing (ADON), who also serves as the Infection Control Preventionist, confirmed the resident's status and acknowledged that the NP should have been wearing full PPE. The facility's policy on PPE did not address droplet precautions.
Failure to Serve Food at Preferred Temperature
Penalty
Summary
The facility failed to serve food at the preferred temperature for a resident, resulting in dissatisfaction during meals. The resident council meeting minutes from March to May 2024 indicated that residents complained about receiving cold food, with trays not being passed in a timely manner. On May 30, 2024, a resident expressed dissatisfaction with the temperature of the food, stating that it was frequently cold and that they relied on their children to bring them food. An observation on the same day revealed staff passing out food trays while leaving the food cart doors open, which likely contributed to the food cooling down. A dietary manager tested the temperature of a random food tray and found the Chicken Alfredo to be 112 degrees Fahrenheit and the Broccoli/Carrot mix to be 100.4 degrees Fahrenheit, both below the expected range of 125-130 degrees Fahrenheit. The surveyor also taste-tested the food and found it to be lukewarm, negatively impacting its palatability. The resident involved had a medical history of chronic obstructive pulmonary disease and rectal cancer, with intact cognition as per their most recent assessment. The facility's policy on food palatability, issued in September 2021, stated that food should be served at a safe and appetizing temperature to ensure resident satisfaction.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dearborn Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Wayne | 3.3 mi | ★★★★★ | 10 | 0 |
| Maple Manor Rehab Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation Of Dearborn Heig | 3.8 mi | ★★★★★ | 20 | 0 |
| Pine Creek Manor Skilled Nursing & Rehab Center | 4 mi | ★★★★★ | 0 | 0 |
| Regency, A Villa Center | 4.3 mi | ★★★★★ | 16 | 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 July 2026) and official state health department websites.