Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at King Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
Insufficient CNA Annual Training Hours: The facility failed to ensure CNAs completed at least 12 hours of annual training for three of five CNAs reviewed. The BOM said the annual requirement was based on hire date and that online training was used. Record review showed one CNA had 3.87 hours, another had 8.75 hours, and another had 3.25 hours during their respective annual periods, and the NHA acknowledged that CNAs did not receive their required training hours.
A resident with intact cognition and multiple chronic conditions reported missing a scheduled shower and being told there were no towels or washcloths available for resident care. Surveyors found limited clean linen supplies, staff cutting up facility towels to make washcloths, and laundry left sitting in dryers overnight. Shower documentation was missing, and staff acknowledged the facility had been having difficulty maintaining enough towels and washcloths for resident hygiene needs.
A medication storage refrigerator was found unlocked, without a readily available temperature log, and with the thermometer placed among medications on a shelf. The refrigerator temperature was observed at 34 degrees F and later 32 degrees F, below the facility’s stated storage range. The refrigerator contained insulin, dulaglutide, an IV antibiotic, nebulizer solution, a pneumococcal vaccine, and pharmacy back-up boxes, all of which required refrigeration between 36 and 46 degrees F and should not be frozen.
Cold Food Served Below Required Temperature: Dietary staff served hamburgers and french fries below the facility’s required hot-food temperature, with items measured at 119 to 131 degrees F for hamburgers and 122 degrees F for french fries. Multiple residents reported that their meals were cold or room temperature, including one resident who said she did not want to eat because the food was cold and another who described the hamburger, fries, and coffee as cold. The DM was also observed placing french fries back in the oven for reheating while they still measured 122 degrees F.
Food temperatures were not monitored during meal service, and both hot and cold items were found outside safe holding ranges. Hamburgers and French fries were below the minimum hot holding temperature, while pickle spears, milk, lemonade, pudding, and strawberries were above the maximum cold holding temperature. A Dietary staff member confirmed temperatures had not been checked at the steam table, and the Dietary Mgr stated staff are expected to check and document food temps before and during meal service.
Failure to protect confidential medical records: A facility laptop was observed open on a med cart near the nurse's station with a resident's PHI visible on the screen and no staff present nearby. The NHA stated staff often have to close laptop screens because the same issue happens repeatedly and acknowledged it is a problem.
The facility failed to provide a bed hold notice to one resident transferred to the hospital and failed to send written transfer notices to the Ombudsman for two residents sent out for changes in condition. The NHA stated the facility was not sending the Ombudsman a discharge list, and staff reported that residents or their representatives were not given a bed hold notice when transferred.
A facility failed to revise care plans for two residents after a diet order change and after a fall with major injury. One resident with DM and other chronic conditions was on a therapeutic diet, reported receiving inadequate food, and had a physician order for a regular diet with double protein and thin liquids that was not added to the care plan; another resident with severe cognitive impairment fell, fractured a hip, and had no care plan interventions or revisions documented after the event.
Failure to implement a restorative nursing program for ROM affected two residents with hand weakness and decreased function. One resident with intact cognition reported difficulty using a hand, feeding self, and losing hand strength without restorative help, while another resident with moderate cognitive impairment reported weak hands and no participation in a restorative nursing program. Staff stated there was no formal restorative program, no restorative charting, no restorative aide, and no one implementing the program.
A resident with DM and intact cognition was ordered a regular diet with double protein and thin liquids, but meals were served without the ordered double protein. The resident reported receiving only one hamburger patty for dinner and later was observed eating lunch that did not appear to include a double portion of protein. The DM acknowledged the tray card showed only regular with extra protein and stated the resident had not received double protein as ordered for about 2 months.
Failure to Ensure Understanding of Arbitration Agreement: Two residents with documented clear comprehension signed the facility’s arbitration agreement shortly after admission, but later reported they did not understand what they were signing and felt the paperwork was rushed or not explained. One resident said she was in pain after surgery and trusted staff, while the other said she had just had a heart attack and did not recall the arbitration terms. The BOM stated all residents signed, and the NHA referenced the need to explain the agreement and the right to refuse.
A resident who wandered frequently exited through a west hall door after the exit alarm failed to alert staff. Staff did not immediately check outside when the alarm activated, and the resident was later found outside by a neighbor and returned to the facility. Investigation showed the door could be opened without properly alarming, and weekend staff were not aware they were responsible for testing the exit doors.
The facility did not conduct or document the required annual full-scale or community-based emergency preparedness exercises, nor did it provide evidence of a qualifying actual event or tabletop exercise within the past year. This deficiency was confirmed during record review and interview with the Facility Administrator, potentially affecting all occupants in the event of a disaster.
The facility did not provide documentation that the fire alarm system was fully tested and maintained according to NFPA 70 and NFPA 72, with 28 devices left untested and no records of required semiannual visual inspections. These deficiencies were confirmed during a record review and interview with the Maintenance Assistant.
The facility did not provide documentation that deficiencies from the annual sprinkler system inspection were corrected, failed to show evidence of a completed quarterly flow test, and had undated or outdated sprinkler gauges with no records of their installation or manufacture dates. These issues were confirmed by facility staff.
The facility did not provide complete documentation for the required 4-year testing of fire dampers in its HVAC system, with records showing that only a portion of the dampers were inspected or tested according to NFPA standards. This was confirmed during a review of records and an interview with the Maintenance Assistant.
The facility did not provide documentation of required weekly generator inspections for the past year, instead only documenting one inspection per month. This failure to maintain proper records and conduct inspections as required by NFPA standards was confirmed during a record review and interview with a maintenance staff member.
A resident with dementia, stroke, and hyponatremia had a physician order for a daily fluid restriction, but staff failed to monitor or document fluid intake as required. The resident was served more fluids than planned, and staff interviews confirmed that fluid intake was not being tracked. The care plan and facility policy lacked specific procedures for fluid distribution and documentation, resulting in the potential for fluid imbalance.
A resident with cancer did not receive a scheduled dose of hydrocodone, leading to a medication discrepancy. An LPN retroactively documented an unscheduled dose, which the resident denied receiving. The DON was informed, and local law enforcement suggested the LPN may have stolen the medication. Facility policies on controlled substances were not followed.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, potentially resulting in foodborne illness among 42 residents. Observations revealed expired and unlabeled food items in the activity room refrigerator, and the temperature log was initially found blank, indicating a lack of monitoring.
The facility failed to implement enhanced barrier precautions (EBP) for seven residents with conditions such as indwelling catheters, PEG tubes, and wounds. Observations revealed a lack of EBP signage and PPE carts, and the Director of Nursing admitted to not maintaining EBP protocols after a recent COVID outbreak.
The facility failed to implement interventions for a resident with severe cognitive impairment and ROM deficits, leading to the potential for extreme pain and worsening of contractures. Despite recommendations for palm protectors, the devices were not consistently used or documented, and staff could not confirm their application.
Insufficient CNA Annual Training Hours
Penalty
Summary
The facility failed to ensure Certified Nurse Aide (CNA) training of no less than 12 hours per year was completed for three of five CNAs reviewed for nurse aide training hours. During an interview, the Business Office Manager stated that the 12 hours of training in a year was based on the CNA hire date and acknowledged that the facility used online training. Review of facility documents showed that CNA H, hired on 1/18/22, had 3.87 hours of training from 1/18/25 to 1/18/26; CNA I, hired on 7/25/19, had 8.75 hours of training from 7/25/24 to 7/25/25; and CNA J, hired on 6/29/23, had 3.25 hours of training from 6/29/24 to 6/29/25. The NHA stated that there were educational issues and that CNAs did not receive their 12 hours of training in a year.
Insufficient linens interfered with resident hygiene care
Penalty
Summary
The facility failed to ensure adequate supplies, care, and services were available to meet the personal hygiene needs of one resident who required staff assistance. The resident had diagnoses including renal failure, diabetes mellitus, hyperlipidemia, anxiety disorder, depression, and psychotic disorder, and scored 15 out of 15 on the BIMS, indicating intact cognition. The resident reported that staff said there were no towels or washcloths available to wash up all residents, and also stated the resident did not receive the scheduled shower and had not refused it. Surveyor observation and interviews found the clean linen room contained limited supplies, including 15 washcloths, 16 bath towels, 12 fitted sheets, 5 flat sheets, 3 pull sheets, and 17 pillowcases, and staff confirmed these were not adequate for all residents. A staff member stated they routinely did laundry at night to have linens available and that facility towels were being cut up to make washcloths for residents. The same staff member said blue/grey microfiber cloths had been placed in the linen room the previous day and that they did not know what they were for. Observation of the laundry rooms showed clean laundry sitting in dryers overnight and dirty laundry containing only one washcloth and no other towels or washcloths. Staff stated laundry was only done by laundry staff from 6:00 a.m. to 2:00 p.m. Another staff member confirmed the facility had been having difficulty maintaining enough washcloths and towels for resident care and acknowledged staff were cutting up towels to make washcloths. Review of the resident’s care plan showed showers were scheduled for Friday mornings, but the shower documentation for the expected shower was not present in the EMR or the shower binder.
Medication Refrigerator Temperature Not Maintained
Penalty
Summary
The facility failed to ensure the medication storage refrigerator was maintained at acceptable temperatures. During observation of the medication storage room, the refrigerator was found unlocked and no refrigerator medication log was present in the medication room. The thermometer was located on the second shelf toward the back of the refrigerator, between stored medications, and was difficult to read. It appeared to show 34 degrees F, then 36 degrees F when held up, and later 38 degrees F when removed into room air. No temperature log for the medication storage refrigerator was found inside the locked medication room. When the refrigerator logs were requested, only June 2026 logs were located in a binder at the nurses’ station, with temperatures monitored once daily. Logs for January 2026 through May 2026 could not be located prior to survey completion. The facility’s policy stated that medications and biologicals should be stored at appropriate temperatures according to USP guidelines, with refrigeration at 36 to 46 degrees F, and another policy stated refrigerators used for medication storage must have a thermometer monitoring ideal temperatures of 35 to 46 degrees F. Later observation found the medication storage refrigerator at 32 degrees F. RN G stated the temperature was too low and confirmed that checking the refrigerator only once a day would not show when the excursion occurred. The refrigerator contained three pharmacy back-up boxes, an intravenous antibiotic, nebulizer solution, a pneumococcal vaccine, fast-acting and long-acting insulin, and dulaglutide injection. The instructions for these medications and the vaccine stated they should be stored refrigerated between 36 and 46 degrees F and should not be frozen.
Cold Food Served Below Required Temperature
Penalty
Summary
The facility failed to provide palatable food served at a safe and appetizing temperature for 8 of 12 residents reviewed for food palatability. During an initial kitchen tour, dietary staff were observed serving food from the steam table, and temperature checks showed hamburgers at 119 degrees F on the top of the pan and 131 degrees F on the bottom of the pan, with french fries at 122 degrees F. Later, a resident in her room was observed moving french fries and a hamburger around on her plate and stated she was doing so because the food was cold and she did not want to eat it since it was cold. During a group meeting, a resident stated that the food was always cold and that a microwave was needed in the rooms so residents could warm their food. In the main dining room, a resident told the surveyor that everything was cold, including the hamburger, french fries, and coffee, and handed the surveyor a french fry that was cold, greasy, and limp to the touch. Four residents interviewed during dinner all said their hamburgers and french fries were served cold, and two of those residents said the food was not cold but was room temperature. In the kitchen, the Dietary Manager was observed removing french fries from the tray line and placing them in the oven for reheating, and the temperature of the fries measured 122 degrees F while partially in the oven. Review of the facility policy showed hot foods should be greater than 135 degrees F before meal service and food should not remain on the steam table longer than 30 minutes before resident meal service.
Food Temperatures Not Monitored During Meal Service
Penalty
Summary
The facility failed to ensure that hot and cold food items were maintained at safe temperatures during dinner meal service. During observation of the steam table, hamburgers measured 119 F on the top of the pan and 131 F on the bottom of the pan, and French fries measured 122 F, all below the required minimum hot holding temperature of 135 F. At the same time, several cold items were above the recommended maximum cold holding temperature of 41 F, including pickle spears at 63.5 F, a glass of milk not stored in an ice bath at 47.2 F, a glass of lemonade at 44.8 F, a cup of vanilla pudding at 50.8 F, and a cup of strawberries at 44 F. During interview, Dietary Staff member Q confirmed that food temperatures had not been monitored at the steam table. The Dietary Manager E stated that staff are expected to check and document food temperatures before and during meal service to ensure compliance with food safety standards. The facility policy titled Tray and Dining Room Meal Service stated that items not meeting the minimum hot or cold temperature requirements should be removed and brought to the correct temperature, that cold or frozen foods should remain in the refrigerator/freezer until needed, and that milk should be stored in an ice bath during meal service.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to protect the privacy of medical records for one resident when a facility laptop was observed open on a medication cart near the nurse's station with the resident's personal health information visible on the screen and no facility staff present near the cart. During interview, the Nursing Home Administrator stated that staff often have to close laptop screens because the same issue occurs repeatedly and acknowledged that it is a problem. The facility policy titled Resident Rights states that residents have the right to privacy and confidentiality.
Failure to Provide Bed Hold Notice and Ombudsman Transfer Notifications
Penalty
Summary
The facility failed to provide a bed hold notice for one resident who was transferred to the hospital Emergency Department, and there was no documentation in the EMR showing that the resident or responsible party received the notice. During interview, the Nursing Home Administrator stated the facility did not provide a bed hold notice upon transfer to the hospital, and a Registered Nurse reported that residents or their representatives were not given a copy of the bed hold notice when sent out, even though the policy stated it should be provided at admission and again with any emergency transfer from the facility. The facility also failed to send written notices of transfer to the Office of the State Long Term Care Ombudsman for two residents who were sent out to the hospital for changes in condition. For one resident, the EMR documented that the resident was sent out via EMS for slurred speech and a change in condition, and the NHA stated she was unaware of the requirement to notify the Ombudsman of discharges. For the other resident, the EMR showed transfer to the hospital ED, and an email from the Ombudsman indicated the facility had not been sending a list of discharges; the NHA confirmed the facility had not been sending the Ombudsman a list and was unable to provide an Ombudsman list from March to verify the resident was included.
Care plans not revised after diet order change and fall with injury
Penalty
Summary
The facility failed to update and implement care plans for two residents after changes in care needs and after an incident. One resident had diagnoses including renal failure, diabetes mellitus, and hyperlipidemia, scored 15/15 on the BIMS, and was documented as receiving a therapeutic diet. The resident stated that not enough food was being served and reported receiving only one hamburger patty for dinner, with bun and French fries, despite having diabetes and not eating bread or fries. The nutritional care plan remained dated 2/9/2021 and included general interventions such as diet as ordered, honoring food preferences, monitoring food acceptance, and offering substitutions if less than 50% of a meal was consumed. A physician order dated 3/30/26 for a regular diet with double protein and thin liquids was signed on 4/5/26 and appeared in the EMR, but it was not added to the care plan. The Dietary Manager stated the resident’s tray card showed a regular diet with extra protein and acknowledged the resident had not received double protein on the lunch tray for approximately 2 months. For the second resident, the MDS showed admission with a hip fracture diagnosis and severe cognitive impairment with a BIMS score of 3/15. A safety event record documented that the resident took herself to the bathroom, tripped while returning to the wheelchair, complained of severe right hip pain, and stated she thought she broke her hip; EMS was called and the hospital confirmed a fractured right hip. The resident’s care plan did not include interventions or revisions after the fall. An RN/MDS nurse stated there was no revision or intervention to the care plan following the fall, and the NHA acknowledged the care plan should have been reviewed and revised with interventions after a fall with major injury.
Failure to Implement Restorative Nursing Program for ROM
Penalty
Summary
The facility failed to implement a restorative nursing program to maintain or improve range of motion (ROM) for two residents reviewed for ROM concerns. Resident #26 was admitted to the facility and had a BIMS score of 15 out of 15, indicating intact cognition. During interview, the resident reported difficulty using a hand, difficulty feeding self, loss of strength in the hand, and stated that no one in restorative therapy was helping with ROM or improving hand strength. Resident #42 was admitted to the facility and had a BIMS score of 8 out of 15, indicating moderate cognitive impairment. During interview, the resident reported problems with losing strength in the hands and that the hands felt weak, and stated that the resident did not work with a restorative nursing program at the facility. RN M reported that the DON was in charge of the restorative therapy program, but there was no formalized program, no charting regarding restorative therapy notes, and no restorative aide. PTA O reported being unaware of any restorative therapy program, and the NHA stated that the DON was supposed to be in charge of the restorative nursing program and that no one was implementing the program at that time.
Failure to Provide Ordered Double Protein Diet
Penalty
Summary
The facility failed to meet the increased protein needs of one resident with diabetes mellitus who was cognitively intact and documented as receiving a therapeutic diet. The resident’s physician order, dated 3/30/26 and signed on 4/5/26, specified a regular diet with double protein and thin liquids, but the resident’s nutritional care plan listed only diet as ordered. During an interview, the resident stated that not enough food was being served and reported receiving only one hamburger patty for dinner, served with a bun and French fries, which she said she did not eat because she was diabetic and does not eat bread or fries. At lunch, the resident was observed eating spaghetti with meat sauce, garlic bread, and zucchini, and she stated she would not be eating the pasta or garlic bread. The dietary manager reviewed the tray card and identified it as regular with extra protein, then acknowledged that the resident was supposed to receive double protein but did not receive it because the diet was not documented on the meal tray card as regular/double protein/thin liquids. The dietary manager also acknowledged the resident had not received double protein as ordered for approximately 2 months.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents or their representatives understood the purpose of the binding arbitration agreement and their right to refuse it for two residents reviewed. Resident #43 was admitted after surgery and, according to the MDS, had clear comprehension and could make herself understood. She signed the facility’s arbitration agreement the day after admission, but later stated that she did not believe in binding arbitration, did not remember signing it, and felt the paperwork was presented quickly without explanation while she was in pain, overwhelmed, and trying to get rehab so she could go home. Resident #22 was also admitted with clear comprehension documented on the MDS and signed the arbitration agreement the day after admission. She later stated that she did not remember much when she first came to the facility, recalled signing papers, but had no idea what she was signing and did not recall signing anything regarding arbitration after having a heart attack. The Business Office Manager stated that all residents or their representatives had signed the arbitration agreement and that no one had refused to sign. The NHA stated that the BOM had been asked to explain the arbitration agreement and ensure residents understood what they were signing, and the facility policy required residents or representatives to be explicitly informed that signing was not a condition of admission or continued care and that the agreement be explained in a manner they understood.
Elopement Due to Malfunctioning Exit Door and Inadequate Response
Penalty
Summary
The facility failed to prevent, detect, and respond to an elopement for one resident who was independently ambulatory and routinely walked around the room and facility as desired. The resident’s care plan identified wandering behavior and stated the goal was that he would not injure or harm himself secondary to wandering, with an approach to remove him from other residents’ rooms and unsafe situations. The resident was also described as agitated and busy, touching items such as fire extinguishers and door keypads, and staff reported they usually walked with him and were instructed to keep an eye on him. On the evening of the incident, the resident exited through the west hall door and went outside. Staff accounts showed that the alarm did not sound overhead as expected, and one CNA reported hearing someone say to turn off the alarm while another stated she never heard any alarm. Staff did not go outside to look for the resident when the alarm was activated, and one CNA later acknowledged she should have checked the outside perimeter. The resident was later found outside on the grass down the hill from the building and was brought back by a neighbor who had seen him in the wooded area behind the facility. The investigation found the west hall exit door was malfunctioning and could be opened without properly alarming when the key portion was moved out from the door bar. The NHA and LPN later tested the door and confirmed it could be opened without an alarm when the key spot was toggled. The maintenance director stated he tested exit doors Monday through Friday and housekeeping was responsible on weekends, but weekend staff interviewed said they did not know they were supposed to test the doors and did not check the alarms. The resident’s BIMs assessment completed after the incident showed a significant decline in cognitive status.
Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required exercises to test its emergency preparedness plan as mandated by federal regulations. Specifically, there was no documentation provided for an annual full-scale facility-based exercise or a full-scale community-based exercise. Additionally, there was no evidence of an actual event that would qualify as a test of the emergency plan, nor was there documentation of a tabletop exercise within the last year. During the survey, a review of the facility's emergency preparedness records revealed the absence of records demonstrating compliance with the annual testing requirements. The surveyor noted that the facility did not provide any documentation of having conducted the necessary drills, exercises, or actual emergency events that would satisfy the regulatory requirements for emergency preparedness testing. These findings were confirmed through an interview with the Facility Administrator at the time of record review. The lack of documentation and failure to conduct the required exercises constituted a deficiency in the facility's emergency preparedness program. This deficiency was noted to potentially affect all 61 occupants in the event of a facility-wide or community disaster, as stated in the report.
Plan Of Correction
E0039 #1 Facility failed to conduct exercises to test the Emergency Preparedness Plan at least annually. #2 Facility Maintenance Director was educated on putting Emergency Preparedness Drill copies into the Life Safety Book when completed. #3 Maintenance Director retrieved and made copies of both the Table Top Drill and an actual Emergency Drill. #4 Any further Table Top drills and/or conducted Emergency Preparedness Drill exercises will be conducted at least annually, and paperwork will be kept in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director to continue to conduct Emergency Plan Exercises at least annually.
Failure to Test and Maintain Fire Alarm System per NFPA Standards
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to the requirements of NFPA 70 and NFPA 72. During a record review, it was found that documentation was missing to show that the fire alarm inspection was conducted as required, with a vendor report indicating that 28 devices remained untested. Additionally, there was no documentation provided to confirm that the semiannual visual inspection of the fire alarm initiating devices had been completed, as required by NFPA 72. These deficiencies were confirmed through an interview with the Maintenance Assistant during the record review. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K345#1 All current reports were placed in the Fire Safety Manual. The documentation for the semiannual visual inspection of the fire alarm system was completed on 3/13/25, and reports were obtained and placed in the Fire Safety Manual. Any items that need to be addressed will be corrected by Summit Fire Protection on 5/22/25. #2 A review of all reports was completed to ensure accuracy and completeness. #3 Maintenance Director was educated on following up on making sure all Fire Alarm System tests have been completed and complete paperwork is in the Life Safety Manual. #4 Any further Fire Alarm System tests will be followed up on to make sure all are completed and all paperwork is received and placed in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director and the Administrator to ensure sustained compliance.
Failure to Maintain and Document Sprinkler System Testing and Maintenance
Penalty
Summary
The facility failed to comply with NFPA 25 requirements for the inspection, testing, and maintenance of its automatic sprinkler system. During record review, it was found that the facility did not provide documentation showing that deficiencies identified during the annual sprinkler system inspection were corrected. Additionally, there was no documentation available to confirm that the required quarterly flow test of the automatic sprinkler system was completed for the first quarter of the year. Observation in the basement revealed three sprinkler gauges, one of which was dated from several years prior and two that were undated, with no documentation available regarding their installation or manufacture dates. These findings were confirmed through interviews with the Maintenance Assistant and Housekeeping/Laundry Manager.
Plan Of Correction
K353 #1 All items identified during the annual sprinkler testing of 12/23/2024 will be corrected by Summit Fire Protection on 5/22/25. A quarterly flow test was completed on 4/29/25 with no concerns. The gauges that were identified as requiring replacement will be replaced on 5/22/25 by Summit Fire Protection. #2 All residents have the potential of being affected by the deficient practice. All reports were reviewed and a corrective action repair visit was scheduled for 5/22/25. #3 Maintenance Director was educated to provide all paperwork and proof of Sprinkler System Testing in the Life Safety Manual. #4 Any further Sprinkler System Maintenance and Testing paperwork will be kept in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director and Administrator to ensure sustained compliance.
Incomplete Fire Damper Testing Documentation in HVAC System
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) systems were in compliance with National Fire Protection Association (NFPA) standards. During a review of facility records, it was found that documentation for the required 4-year testing of fire dampers, as specified by NFPA 80, was incomplete. A vendor report dated March 14, 2025, showed that only 15 out of 30 fire dampers had been inspected or tested. An additional vendor report from August 9, 2022, indicated that only 8 fire dampers were inspected and all passed. These findings were confirmed through an interview with the Maintenance Assistant during the record review.
Plan Of Correction
K521 #1 The missing report was obtained and placed in the Life Safety Manual to ensure all 30 items were tested. #2 All residents have the potential to be affected by this deficiency. Any deficiencies identified will be corrected by Summit Fire Protection on 5/22/25. #3 The Maintenance Director was educated on providing all paperwork as proof that the heating, ventilation and air conditioning is in compliance with NFPA and paperwork will be kept in the Life Safety Manual. #4 Any further heating, ventilation and air conditioning shall continue to stay in compliance with NFPA and paperwork will be provided and put in Life Safety Manual. #5 It will be the responsibility of the Maintenance Director and Administrator to insure sustained compliance.
Failure to Document and Complete Required Weekly Generator Inspections
Penalty
Summary
The facility failed to ensure compliance with required maintenance and testing protocols for its emergency generator system as outlined by NFPA 110, NFPA 99, NFPA 111, and NFPA 70. Specifically, during a review of facility records, it was found that documentation for weekly generator inspections over the past 12 months was incomplete. Only one weekly inspection per month was documented, rather than the required weekly inspections for each month. This deficiency was confirmed during an interview with the Maintenance Assistant at the time of the record review. The lack of proper documentation and completion of weekly generator inspections means the facility did not meet the standards necessary to ensure the emergency power system would function as required in the event of an electrical failure. The deficiency could potentially affect all occupants who rely on the emergency power source for safety and essential services during power outages, as the facility could not demonstrate that the generator was being properly maintained and inspected according to regulatory requirements.
Plan Of Correction
K918 #1 Based on record review and interview, the facility failed to ensure generators or other alternative power sources are in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70. This deficient practice could affect all occupants in the event of electrical failure requiring emergency generator power. #2 Facility Maintenance Director was educated that there must be weekly generator inspections and that there needs to be a monthly load test as well. #3 The Maintenance Director immediately corrected his inspections to weekly and will continue his monthly load test as well. Proof will be kept in the Life Safety Manual. #4 All further weekly and monthly logs will be kept in the Life Safety Manual. #5 It will be the responsibility of the Maintenance Director to ensure sustained compliance.
Failure to Monitor and Document Fluid Restriction for Resident with Hyponatremia
Penalty
Summary
The facility failed to monitor and document fluid intake as ordered for a resident with a physician-ordered fluid restriction due to hyponatremia. The resident was admitted with diagnoses including dementia, stroke, and hyponatremia, and had a physician order for a daily fluid restriction of 1.5 liters. Observations showed that the resident was served more fluids than planned at meals, and the resident reported not limiting fluid intake. The tray card and care plan indicated the fluid restriction, but there was no individualized plan for fluid distribution. Record review revealed that no fluid intake was documented in the medical record for the resident over a one-month period. Interviews with staff, including a CNA and an LPN, confirmed that fluids were not being documented, and the DON acknowledged there was no process in place to total or analyze fluid intake for residents on restriction. The facility's policy only required staff to be aware of residents on fluid restrictions, with no further procedures for monitoring or documentation. This lack of monitoring and documentation resulted in the potential for fluid imbalance for the resident.
Plan Of Correction
#1 Resident 6 remains in the facility and does not appear to have been affected by this deficient finding. Documentation of fluid intake has been added to the EMAR for completion each shift. Night shift will complete 24-hr totals and update the provider PRN for concerns. Care plan has been reviewed and updated regarding fluid restriction. #2 All facility residents requiring fluid restriction had the potential to be at risk for the same deficiency. No other residents were found to be affected by this deficient practice. #3 Licensed nurses, CNA's, activity staff, and therapy staff have been educated by the DON or designee regarding residents requiring fluid restriction and necessary documentation. #4 The DON or designee will audit residents requiring fluid restriction for intake documentation 3X a week for 4 weeks, then weekly for 4 weeks. Any identified concerns will be addressed immediately by the DON or designee. Finding will be submitted to the facility QA committee for further recommendations.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident with malignant cancer of the colon and rectum, who was under hospice care. The resident was prescribed hydrocodone acetaminophen to be administered four times a day. On the morning of November 27, 2024, a discrepancy was discovered in the medication count by a Registered Nurse (RN) during a shift change. The Controlled Substance Proof of Use form indicated that the resident should have had three remaining pills, but only two were found in the medication cart. A Licensed Practical Nurse (LPN) claimed to have administered an additional dose at 5:00 AM, which was not scheduled, and retroactively documented this on the form. The Director of Nursing (DON) was notified of the discrepancy and attempted to investigate the situation. The LPN involved left the facility and refused to return for further investigation. The resident confirmed that they did not receive the medication at 5:00 AM, contradicting the LPN's claim. An incident report from local law enforcement suggested that the LPN may have stolen the medication. The facility's policies on abuse prevention and controlled substances documentation were not followed, as the LPN failed to properly document the administration of the narcotic medication.
Failure to Store and Label Food Properly
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially resulting in a foodborne illness among the 42 residents. During an observation, three individual take-out containers in the activity room refrigerator were found without resident names or dates. One container had a Styrofoam cup with a milkshake that had mold growing on it, two packages of expired hot dogs, hot dog buns with an expired date, and a large Styrofoam container with crab Rangoon without a label or date. Additionally, the Record of Refrigeration Temperatures log for the specified date range was found blank, indicating a lack of temperature monitoring for the refrigerator during that period. The Nursing Home Administrator (NHA) initially did not notice any expired or unlabeled foods and later produced a previously blank temperature log with recorded values, suggesting falsification of data. The NHA stated that the dietary department was responsible for the cleaning and maintenance of the resident refrigerator. The facility's policy on labeling and dating food brought in by visitors was reviewed, which mandates that food items must be checked by a nurse, labeled with the resident's name and date of delivery, and disposed of after three days if refrigerated. Suspicious or contaminated food must be discarded immediately, and any food found without dates must also be discarded.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for seven residents who required such measures due to their medical conditions. Observations revealed that Resident #3, who had an indwelling urinary catheter, did not have any EBP signage or a cart for personal protective equipment (PPE) outside her room. Similar deficiencies were noted for other residents with conditions such as PEG tubes, wounds, and PICC lines, all of whom lacked EBP signage and PPE carts. The Director of Nursing (DON) admitted to not maintaining EBP protocols after a recent COVID outbreak, resulting in the removal of PPE supplies about a month prior to the surveyor's visit. Review of physician orders and care plans for the affected residents showed no orders or interventions related to EBP. The facility's policy, dated 4/5/24, mandates the implementation of EBP for residents with wounds or indwelling medical devices, including the availability of gowns and gloves near or outside the resident's room. However, this policy was not followed, leading to the observed deficiencies in infection control practices.
Failure to Implement ROM Interventions for Resident
Penalty
Summary
The facility failed to implement interventions to address range of motion (ROM) for a resident with severe cognitive impairment and multiple diagnoses, including epilepsy and dementia. The resident's medical record indicated functional limitations due to ROM deficits in both upper and lower extremities, and the resident was observed multiple times without the recommended palm protectors or any other devices to prevent discomfort or worsening of contractures. Despite recommendations from therapy in June 2023 to use palm protectors, there were no physician orders in the resident's electronic medical record, and staff were unable to confirm the consistent use of these devices. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that they were aware of the resident's contractures but could not confirm the last time the resident used the recommended devices. The Therapy Director also confirmed that staff had been educated on applying the palm protectors but could not verify their usage or documentation since the resident was no longer receiving therapy services. The resident's care plan included encouragement for the use of bilateral palm protectors, but this intervention was not being implemented, leading to the potential for extreme pain, discomfort, and worsening of contractures.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houghton Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Intersect Healthcare Of Roscommon | 16.9 mi | ★★★★★ | 9 | 0 |
| Gladwin Nursing And Rehabilitation Community | 23.8 mi | ★★★★★ | 14 | 0 |
| Autumnwood Of Mcbain | 23.9 mi | ★★★★★ | 7 | 0 |
| Grayling Nursing & Rehabilitation Community | 24.4 mi | ★★★★★ | 13 | 0 |
| Munson Healthcare Crawford Continuing Care Center | 25.5 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.