Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Lakeside Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cerebral infarction, lymphedema, and polyarthritis, who had a physician order for transfers using a mechanical lift with 2-person assist, was initially moved from bed to wheelchair with the lift. After repositioning in the wheelchair caused the sling to slip out of place, two CNAs were unable to use the sling for the return transfer and instead manually transferred the resident by lifting and attempting to stand them, contrary to the ordered transfer method. The resident reported experiencing pain during this manual transfer and later informed the DON, who acknowledged that the CNAs were expected to follow the resident’s plan of care. A requested transfer policy was not provided to surveyors.
Food storage and sanitation practices were not maintained in the kitchen and food service areas. Surveyors observed opened ready-to-eat meats in the walk-in refrigerator, residue inside two ice machines, a utility sink hose connected downstream of an AVB, and a cafe refrigerator that had been off for months with leftovers and yogurt warm to the touch.
Improper Exterior Trash Refuse Area Maintenance: The exterior trash refuse area had 2 dumpsters with both doors left open, and garbage was spilling onto the ground along with several used disposable gloves. The enclosure also contained 2 large empty boxes, a grill unit, and a wood pallet. The Dietary Manager stated that maintenance of the area was shared among Maintenance, Housekeeping, and Dietary, while the facility policy required dumpsters to be covered when not being loaded and the surrounding area to be kept clean.
Staff failed to follow PPE requirements for a resident on EBP when a CNA provided morning care without a gown and PPE was missing from multiple EBP room carts. A CNA was also observed handling resident bedding without gloves or a gown. Surveyors additionally found plumbing and water-use concerns, including an unused hydrotherapy tub with no flushing record, an out-of-order toilet left open to the environment, an unused plumbed fountain machine, and an ice machine filter dated over a year earlier.
Failure to Apply Ordered Heel Boots: Three residents were observed in bed without their ordered heel protectors in place, despite active physician orders for heel boots while in bed. One resident with retention of urine and adjustment disorder, one resident with dementia and a prior femur fracture, and one resident with functional quadriplegia and chronic venous hypertension were each found without the boots on multiple occasions; staff reported refusals or that the boots were kicked off, but the TAR, progress notes, and care plans did not document any refusals.
Failure to implement a planned fall intervention for a resident with a prior major fall and hip fracture. The care plan included floor mats next to the bed, but observations found no mats in place while the resident was in bed. The DON stated the mats should have been in place for the resident, who also required staff assistance with bed mobility and transfers.
Care Plan Not Updated to Reflect Transfer Status: A resident with urinary retention and adjustment disorder, who had a fall and required staff assistance with bed mobility and transfers, had conflicting care plan interventions for transfer status. The record listed both one-person pivot transfer and two-person assist, while a CNA said the resident no longer gets out of bed and staff were unsure how the resident transfers. The DON stated the resident was made a two-person assist after the fall and the care plan needed to be updated to reflect the resident’s accurate transfer status.
Full Foley Drainage Bag Not Emptied: A resident with an indwelling catheter was observed multiple times with a full drainage bag while lying in bed. The resident had urinary retention, could not complete the BIMS, and needed staff help with bed mobility and transfers. An LPN said the bag should have been emptied, a CNA was unsure when it was last emptied, and the DON stated it should be emptied when half full and at the end of a shift.
Failure to provide ordered adaptive eating equipment and utensils for a resident with a left femur fracture and dementia. The resident had an order for meal setup assistance, padded foam utensils, and a divided plate with a guard, but was observed with regular utensils and a regular plate while on a pureed diet. A CNA said the meal ticket listed the padded utensils but not the divided plate, and the DM said padded utensils were unavailable because staff kept them in rooms and did not return them for cleaning and reuse.
Failure to supervise two cognitively impaired residents led to repeated overnight hallway wandering and an incident where both residents were found together in one room, with one resident unclothed and the other without a shirt. One resident had dementia, HTN, and failure to thrive; the other had vascular dementia with agitation, anxiety, and COPD and was ordered continuous O2 at 2 L via NC. Staff documented that the residents remained in the hallway after being told to go to sleep, and later found them in the room during morning rounds.
Unsanitary Exterior Trash Refuse Area: Surveyors observed two dumpsters with both doors open, greasy liquid leaking from one dumpster and pooled on the concrete, and a strong garbage odor in the area. The Dietary Manager stated Maintenance was responsible for cleaning the area, and the facility did not provide the requested policy by the end of the survey.
Failure to hold required quarterly QA meetings was identified after interview and record review showed no evidence of active QA committee meetings for 2024, no PIPs for that year, and no action plans for ongoing 2025 PIPs. The new Administrator reported no handoff of QA projects from the prior Administrator, while current survey concerns included infection control, falls, physician order implementation, and daily care needs.
A facility failed to keep resident rooms and hallway carpets clean and in good repair. Observations found multiple stained, soiled, rippled, and damaged carpet areas in the north and south hallways, plus peeling wallpaper in the multipurpose room. In resident rooms, staff observed an uncased cracked pillow, missing dresser drawers, wall damage with holes and exposed wires, a wound drainage canister left on a dresser, and dried tube feeding residue on a pump and pole.
A resident with intact cognition and a history of Schizoaffective Disorder and Alzheimer's repeatedly reported discomfort and inadequate coverage due to being provided with incontinence briefs that were too small. Despite informing staff and the availability of larger briefs in the facility, the resident's preference was not honored, resulting in ongoing discomfort and improper fit. The DON acknowledged the issue and the presence of bariatric briefs, but the resident continued to receive briefs that did not meet their needs.
The facility failed to administer Heparin as ordered for a resident, did not follow hospital discharge instructions for catheter removal and bladder scans for another, and did not complete required vital sign monitoring for a third resident. These deficiencies were due to medication unavailability, overlooked discharge orders, broken equipment, and incorrect order entry in the electronic medical record.
A resident receiving Medicare Part A skilled services had a NOMNC that stated coverage would end, but the guardian did not sign it until after services were set to stop. The facility had no documented proof that the guardian was notified at least 2 days before the end of skilled services, and the BOM said the notice was faxed without fax confirmation or a follow-up call to verify receipt.
PRN antipsychotic order lacked required stop date. A resident with cerebral infarction, vascular dementia, anxiety disorder, severe cognitive impairment, and hospice services had an open-ended PRN Haloperidol order for agitation. The record lacked physician or hospice documentation supporting continued use beyond the 14-day limit, and the pharmacist review only supported use for up to 60 days without further follow-up documentation.
A resident was found wet and soiled with urine odor, a yellow-stained sheet, and reports that staff had not changed the brief since the prior shift; the DON stated wet residents should be changed and checked at least every 2 hours, and only one aide was on the hall until 11 PM. Another resident’s bed was observed with a draw sheet smeared with what appeared to be BM and a brief left on the bed, with the dirty linen seen again later; RN A acknowledged the condition was not good. Both residents had care plans requiring assistance with incontinence care, and one had intact cognition while the other had severe cognitive impairment.
Inhalers in a medication cart were found without the date opened, including a Fluticasone Furoate/Vilanterol inhaler and a fluticasone/salmeterol inhaler for a resident, while another inhaler was dated. The DON stated inhalers should be dated as soon as they are opened, and the facility policy required medications and biologicals to be labeled in accordance with current regulations.
Failure to maintain an active WMP and ensure proper EBP PPE use. The facility had only a 2022 WMP policy and blank forms, but no water system diagram, risk assessment, identified Legionella hazard areas, control points, limits, or evidence of routine monitoring or team meetings. The Administrator said only Maintenance was on the team and the team had not met, and the IP stated she had no real involvement beyond assessing residents for signs and symptoms.
A facility failed to prevent verbal abuse by a CNA towards a resident, leading to feelings of disrespect. The incident began when the CNA insisted on giving the resident a shower despite their refusal, escalating into a verbal altercation with threatening language. The resident, with a traumatic brain injury and multiple fractures, felt disrespected by comments related to their wheelchair use. The CNA resigned after the incident was reported to the administrator.
A facility failed to monitor and timely initiate treatment orders for a new wound on a resident's left baby toe, identified by an LPN. Despite documentation of the wound, no physician or medical staff was contacted for treatment orders, and the resident's MAR and TAR lacked documentation for the wound's treatment. The care plan did not address the new wound, and the Nurse Practitioner did not assess it until eight days later. The Director of Nursing confirmed the nurse should have entered the order into the record, but it was not added, resulting in potential wound deterioration.
The facility failed to maintain comfortable room temperatures, with two resident rooms recorded at 65 and 66 degrees Fahrenheit, leading to resident complaints of cold conditions. The Maintenance Supervisor was unsure of the standard for comfortable temperatures, and the Administrator acknowledged issues with heating units in the area. Facility policy requires temperatures between 71 and 81 degrees Fahrenheit.
The facility failed to provide bed hold policy notifications to three residents during hospital transfers, as required. Interviews and record reviews revealed that the responsibility for issuing these notices was unclear among staff, and the Social Service Director could not locate the necessary documentation. The residents involved had various medical conditions, and one reported not receiving a notice during an emergency transfer.
A resident with multiple medical conditions refused all medications and vital sign checks since readmission, but the facility failed to notify the physician or document these refusals as required by policy. The resident had not had vital signs recorded since August, and the attending physician was unaware of the refusals, indicating a lapse in communication and adherence to care standards.
A resident with moderately impaired cognition was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents and redirection by staff, the facility did not implement sufficient protective measures, such as separating the residents or providing continuous monitoring, to prevent the abuse.
The facility failed to maintain the carpet in a clean, sanitary, and safe condition, affecting all 58 residents. Observations showed stained, worn, and buckled carpet, with missing spots. Housekeeping staff indicated the need for deep cleaning and replacement, but lacked a floor technician. Residents expressed concerns about the carpet's dangerous condition, with one almost tripping. The DON acknowledged the issue, having tripped on the carpet themselves.
The facility has been without a full-time Activities Director for months, affecting all 58 residents. A resident and an Activities Aide confirmed the lack of activities, especially on weekends. The Regional Nursing Home Administrator acknowledged the absence and mentioned a new hire is expected soon. The facility's policy on activities did not include the role of an Activities Director.
The facility failed to maintain RN coverage for at least 8 consecutive hours daily, as required. Staff postings showed multiple dates without RN coverage, confirmed by interviews with the scheduler and DON. The facility's staffing policy did not address RN coverage requirements.
The facility failed to post and maintain required nurse staffing information, affecting all 58 residents. During a survey, it was found that the facility did not have complete staff posting data for RNs and CNAs. Interviews with staff confirmed the absence of required postings, and the Director of Nursing was unaware of the missing logs. The facility's policy required daily posting of staffing information, but they failed to comply with this requirement.
The facility did not provide adequate meal portion sizes to meet residents' nutritional needs. The Dietary Supervisor served a small piece of baked chicken, estimated at 2 ounces, instead of the required 4 ounces. The RD confirmed the portion was insufficient, and residents reported feeling that the food portions were too small.
A facility failed to serve food at the preferred temperature, leading to dissatisfaction among residents. A resident reported the food was cold and unappealing, and observations showed staff serving meals with food cart doors open. A Registered Dietician confirmed the food was below the preferred temperature, and the facility's policy on serving hot foods was not followed.
The facility failed to serve meals on time, leading to resident dissatisfaction. Breakfast and lunch were served significantly later than the scheduled times due to insufficient kitchen staffing. Residents complained about hunger and the consistent lateness of meals.
A survey revealed multiple sanitation and food safety deficiencies in the kitchen of an LTC facility. Observations included a soiled trash can, improper thawing of pork chops, undated food items, and unsanitary conditions such as grime buildup and a mold-like substance in the ice machine. Additionally, the dish machine's temperature log was not maintained, and equipment like the ventilation hood lights and garbage grinder were non-functional.
The facility failed to manage its operations effectively, leading to deficiencies in maintaining a safe environment and equipment. The carpet in hallways remained stained and unsafe, and there was a lack of documentation and awareness regarding the mechanical lift's repair status. The Nursing Home Administrator was unavailable, leaving no documentation on these issues, and no Quality Assurance activities were documented to address them.
The facility failed to implement an active water management plan, lacking team member lists and water flow diagrams, and did not conduct required inspections. Additionally, staff did not consistently don and doff PPE for residents on enhanced barrier precautions, as observed in multiple instances. Interviews revealed a lack of awareness and adherence to infection control protocols, increasing the risk of infections.
The facility failed to respond promptly to call lights for four residents, resulting in significant delays in care. One resident waited over 13 minutes for pain medication, while another experienced prolonged waits in soiled conditions. A third resident reported waiting up to an hour and a half for hygiene assistance, and a fourth resident's call light was ignored for 30 minutes despite needing help with a mechanical lift. The facility lacked documentation on call light response times, and staff did not adhere to the policy requiring prompt response to call lights.
The facility failed to provide adequate activities for four residents, leading to dissatisfaction and boredom. One resident expressed having nothing to do but ride in circles in their wheelchair, while another wandered the facility seeking bird-watching opportunities. A third resident reported a lack of engagement in activities for months, and a fourth noted the absence of an activities director and weekend activities. The Activities Aide confirmed working alone during weekdays without weekend coverage, highlighting staffing and scheduling challenges.
The facility failed to provide a 14-day stop date for PRN antianxiety medications or adequate documentation to justify their use beyond 14 days for two residents. One resident with anxiety and rheumatoid arthritis had Alprazolam orders without a stop date, while another nonverbal resident with severe cognitive impairment had a Xanax order without a stop date. The facility's policy requiring a 14-day limit on PRN orders was not followed.
A facility failed to maintain essential equipment, leading to safety hazards and discomfort for residents. One resident was injured by a damaged wheelchair, while another faced issues with an unstable mechanical lift and ill-fitting wheelchair cushions. Additional maintenance oversights included a broken dresser and inadequate shower pressure, highlighting a lack of attention to resident needs and safety.
The facility failed to provide a mechanical lift for two residents, leading to unsafe conditions. One resident, with muscular dystrophy, was unable to get out of bed for days, requiring fire department assistance. Another resident, with cerebral infarction, faced manual lifting by staff, which was dangerous. Staff interviews revealed a lack of documentation and awareness about the lift's repair status.
A facility failed to report an abuse allegation involving a resident attempting to touch another resident inappropriately. The incident was observed by staff but was reported to the State Agency 14 days later due to the administrator's absence and the DON's uncertainty about the reporting process. Facility policy requires immediate reporting, but this was not followed.
The facility did not provide the necessary written transfer notification to a resident and the Ombudsman when a resident was transferred to an acute care hospital due to a worsening bruise that developed into a wound. The EMR lacked documentation of the transfer notification, and the facility's administrative staff could not produce the required documentation during the survey.
A resident with respiratory issues was observed with an oxygen concentrator running but the nasal cannula was on the floor, and no active physician's order or care plan for oxygen was documented. The resident had diagnoses including Acute Respiratory Failure and COPD, and their MDS assessment indicated moderately impaired cognition. The facility's policy requires a baseline care plan, which was not implemented.
A resident with encephalopathy and type 2 diabetes experienced multiple falls without updates to their fall care plan. Despite having moderately impaired cognition and requiring supervision for ADLs, the care plan's last intervention was dated months prior. Interviews with staff confirmed the lack of updates, which contradicted the facility's policy requiring care plan revisions after status changes.
A resident in an LTC facility did not receive consistent, scheduled showers as per their preference and facility policy. Despite requiring maximal assistance with bathing due to medical conditions, the resident only received four baths in a month, with no showers documented. The resident expressed frustration over the lack of personal cleanliness, and the DON acknowledged the difficulty in accommodating the resident's preferred shower time.
The facility failed to schedule follow-up appointments for a resident with a fracture and hip replacement, leading to missed chemotherapy treatments. Additionally, another resident with respiratory issues had no active physician orders for oxygen, despite being observed with an oxygen concentrator running and reporting difficulty breathing.
A resident with limited range of motion and mobility needs did not receive restorative services as per physician orders. Despite having a care plan for restorative therapy, there was no documentation of participation in the program. The resident, who was cognitively intact and experienced occasional pain, expressed a desire for exercise to maintain and improve mobility. The Director of Nursing was unaware of the issue, and the facility's policy on providing restorative programs was not followed.
The facility did not ensure a timely physician response to Pharmacist Medication Regimen Reviews (MRR) recommendations for a resident. Despite pharmacy progress notes indicating irregularities, the complete MRR and physician follow-up were unavailable. The DON suggested the MRRs might be in a binder, but they were not provided, and a policy for MRRs was not received before the survey ended.
Failure to Follow Ordered Mechanical Lift Transfer for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s ordered transfer method and provide safe transfer assistance. A cognitively intact resident with diagnoses including cerebral infarction, lymphedema, and polyarthritis was admitted on 9/4/25 and required staff assistance with ADLs. The resident had an active physician order dated 1/22/26 specifying transfers with a named mechanical lift and 2-person assist. On 3/23/26, two CNAs transferred the resident from bed to wheelchair using the mechanical lift. After the resident was in the wheelchair, they were readjusted, which caused the sling to slip too far up the resident’s back, making it unusable for the return transfer to bed according to the CNAs. When it was time to transfer the resident back to bed, instead of using the ordered mechanical lift, the two CNAs decided to perform a manual transfer. The resident reported that the CNAs, one on each side, lifted them from the wheelchair and attempted to stand them on their feet, which caused pain that the resident stated they communicated to the CNAs. One CNA stated they were unable to reposition and connect the sling due to the resident’s size and confirmed that a manual transfer was performed. The other CNA reported that the resident was informed of the manual transfer, appeared agreeable, and was able to bear some weight, and stated the resident did not complain of pain. The resident later reported the incident to the DON, who acknowledged that the CNAs should not have transferred the resident in that manner and that they were supposed to follow the plan of care. A transfer policy was requested from the facility during survey but was not provided by the end of the survey.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area. During the initial kitchen tour, an opened bag of turkey dated 2/3 with a discard date of 2/10 and an opened bag of salami dated 2/3 with a discard date of 2/10 were observed in the walk-in refrigerator. The Dietary Supervisor stated that food is kept for 7 days, and the facility's date marking policy and the 2022 Food Code both require refrigerated ready-to-eat time/temperature control for safety food held at 41 F or less to be marked for a maximum of 7 days, with the day of preparation counted as Day 1. Additional observations in the kitchen and related food areas showed an ice machine with dark brown residue on the interior walls, and the Dietary Supervisor stated it is cleaned every month. A utility sink had an attached hose to a chemical feeder downstream of an atmospheric vacuum breaker. In the cafe, a refrigerator had a strong odor, and a black box of leftovers and a cup of yogurt were warm to the touch; Housekeeping Supervisor C stated the refrigerator had been off for several months. A second ice machine in the nourishment room had yellow residue on the interior wall, and the Director of Facilities stated it is cleaned and sanitized monthly.
Improper Exterior Trash Refuse Area Maintenance
Penalty
Summary
The facility failed to maintain the exterior trash refuse area in a sanitary manner. On observation of the outside garbage area, there were 2 dumpsters with both doors on each dumpster left open. Garbage was spilling onto the ground surface, including several used disposable gloves, and the enclosure also contained 2 large empty boxes, a grill unit, and a wood pallet. Prior to the observation, the Dietary Manager stated that maintenance of the outside garbage area was shared among Maintenance, Housekeeping, and Dietary. Record review of the facility's Disposal of Garbage and Refuse Policy dated 11/1/2022 stated that refuse containers and dumpsters kept outside the facility shall have tightly fitting lids, doors, or covers, shall be kept covered when not being loaded, and the surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.
Infection Control: PPE Not Available for EBP Rooms and Plumbing Fixtures Not Managed for Legionella Risk
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not use personal protective equipment as required for a resident on Enhanced Barrier Precautions. On 2/4/2026, R5 was observed receiving morning care from a CNA who was not wearing a gown, and the CNA stated they never wear a gown when getting this resident out of bed. Gowns and masks were not available in the EBP cart at R5’s room door, and the CNA stated the scheduler fills the containers in the morning. During the same survey, four rooms with EBP signs on the doors (119, 203, 218, and 226) were found to have no gowns or masks available. Additional observations showed staff handling resident care and bedding without PPE. On 2/4/2026, a CNA was observed delivering a tray and then moving resident bedding without gloves or a gown. The facility’s ICP and DON stated that supplies should be in containers inside the room with gowns, and that masks were not in drawers because there were no residents on transmission-based precautions. The ICP also stated a supply person fills the containers on the night shift with help from the night supervisor, and that staff know where to obtain PPE if a container needs restocking. The facility also failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. Surveyors observed an ice machine filter dated 8/14/2023 in the nourishment room, an unused fountain pop machine wrapped in plastic and plumbed into the wall in the dining area, an out-of-order toilet with the water line left open to the environment in a shower room on the 200 hall, and an unused hydrotherapy tub with dirt accumulation at the bottom. The Director of Facilities stated the hydrotherapy tub is flushed monthly, but the flushing logs reviewed did not show the tub being flushed. The Administrator stated the hydrotherapy tub had not been used the entire time she had been there and no residents were care planned to use it.
Failure to Apply Ordered Heel Boots
Penalty
Summary
The facility failed to apply ordered heel boots for three residents reviewed for skin conditions. R2 was observed in bed multiple times with heels on the mattress and heel boots left in a chair across the room, despite an active physician order to apply soft heel protector boots when in bed up to 12 hours a day. R2 had diagnoses of retention of urine and adjustment disorder, required staff assistance with bed mobility and transfers, and had a BIMS score of 99 indicating inability to complete the assessment. The DON stated R2 refused to wear the heel boots and that refusals should be documented, but the progress notes, TAR, and care plan did not show any refusals. R4, who had diagnoses of fracture of left femur and dementia and required staff assistance with bed mobility and transfers, was observed in bed without heel boots on multiple occasions even though there was an active order to wear proactive heel boots while in bed up to 12 hours. UM B stated R4 refuses the boots and often kicks them off, and that refusals or removal should be documented, but no refusals were documented in the progress notes, TAR, or care plan. R13, who had diagnoses of functional quadriplegia and chronic venous hypertension and required staff assistance with bed mobility and transfers, was also observed in bed several times without heel boots, with the boots found in the wheelchair. R13 stated they took off their oxygen cannula and that no one offered to place the heel boots on them, and the record contained no refusals for the ordered heel protectors.
Failure to Implement Planned Fall Intervention
Penalty
Summary
The facility failed to implement the fall intervention listed in R4’s care plan, which identified floor mats next to the bed. R4 was admitted on 1/21/2021 with diagnoses of fracture of the left femur and dementia, and the MDS showed a BIMS score of 15/15 indicating intact cognition. R4 also required staff assistance with bed mobility and transfers. During observation on 2/4/2026, 2/5/2026, and 2/6/2026, R4 was seen lying in bed and no fall mats were observed next to the bed, despite the DON stating that the mats should be in place for R4 because of a prior major fall and hip fracture. The facility policy stated that each resident’s risk factors and environmental hazards would be evaluated when developing the comprehensive plan of care, interventions would be monitored for effectiveness, and the plan of care would be revised as needed.
Care Plan Not Updated to Reflect Transfer Status
Penalty
Summary
The facility failed to revise R2’s care plan to reflect the resident’s accurate transfer status after a fall. R2 was admitted with diagnoses of Retention of Urine and Adjustment Disorder, and the most recent MDS showed a BIMS score of 99, indicating the resident was unable to complete the assessment. The record also showed that R2 required staff assistance with bed mobility and transfers. An incident and accident report dated 1/14/2026 documented a fall with no injuries noted. R2’s care plan contained conflicting transfer interventions, including “Transfer: One assist; pivot transfer” on the self-care deficit care plan and “Transfer: Two person assist” on the fall care plan. On 2/5/2026, a CNA stated that R2 used to be a one-person assist and could help get to the chair, but now does not get out of bed and staff are unsure how the resident transfers. The DON stated on 2/6/2026 that R2 was made a two-person assist for transfers following the fall and that the care plan would need to be updated to reflect the resident’s accurate transfer status. The facility policy for the Fall Prevention Program stated that each resident’s risk factors and environmental hazards are to be evaluated when developing the comprehensive plan of care, interventions are to be monitored for effectiveness, and the plan of care is to be revised as needed.
Full Foley Drainage Bag Not Emptied
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with an indwelling catheter when R2’s drainage bag was observed full on multiple occasions. On 2/4/2026 at 10:21 AM, R2 was lying in bed with an indwelling catheter in place and the drainage bag was full. R2 was admitted with diagnoses of Retention of Urine and Adjustment Disorder, and the most recent MDS showed a BIMS score of 99, indicating R2 was unable to complete the assessment. R2 also required staff assistance with bed mobility and transfers. The physician’s order directed staff to change the foley bag/tube/anchor as needed. The drainage bag was again observed full on 2/4/2026 at 1:13 PM and on 2/5/2026 at 8:45 AM, 9:28 AM, and 9:52 AM. At that time, an LPN stated the bag was full and should have been emptied, and reported it should be emptied every two hours and as needed. A CNA stated they were unsure when the bag was last emptied and had not emptied it on their shift. The DON stated the drainage bag should be emptied when half full and at the end of a shift.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who had an order for assistance with meals, padded foam utensils, and a divided plate with a guard. The resident was admitted with diagnoses of left femur fracture and dementia, and the MDS showed a BIMS score of 15/15 with intact cognition. The resident also required staff assistance with bed mobility and transfers, and the diet order directed staff to help with meal setup and use padded foam utensils and a divided plate with a guard. During observation, the resident was seen in their room with a lunch tray, on a pureed diet, and had not eaten much. The resident stated they did not want any more because their stomach was hurting. The resident was observed using regular utensils and a regular plate. A CNA stated the meal ticket showed the resident was supposed to have padded foam utensils, but the divided plate was not listed. The Dietary Manager stated the facility ran out of padded utensils when staff kept them in rooms and did not return them to be cleaned and reused, and that the divided plate was not on the meal ticket because the order had not been received to update the ticket. The Director of Rehab stated the resident was on therapy and the order came from that department to increase the resident's independence with eating.
Failure to Supervise Two Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for two cognitively impaired residents, R38 and R44. R38 was admitted with diagnoses including dementia, hypertension, and failure to thrive, and the MDS indicated the resident required assistance with activities of daily living. R44 was admitted with diagnoses including vascular dementia with agitation, anxiety, and chronic obstructive pulmonary disease, and the MDS showed the resident required extensive assistance with activities of daily living. R44 also had a physician order for 2 liters of continuous oxygen via nasal cannula. Nursing documentation showed that R38 and R44 spent most of the night talking in the hallway in front of room 114 after staff educated them to go to sleep, but they continued talking in the hallway on the north side of the facility. A later note stated that during morning rounds, staff found R38 seated on the bed in a room without clothing while R44, who was not wearing a shirt, was standing about four feet away and engaged in conversation. The nurse escorted R44 back to their room and then assessed R38. During interviews, the RN on duty stated the residents were outside their rooms talking most of the night and that R44 was not in their room when rounds were being prepared, while the CNA stated that when they entered R38's room both residents were there with R38's bra on and brief pulled down to the ankles and R44 standing near the bed with his shirt off.
Unsanitary Exterior Trash Refuse Area
Penalty
Summary
The facility failed to maintain the exterior trash refuse area in a sanitary manner. On 08/04/2025 at 9:00 AM, surveyors observed two dumpsters with both doors on each dumpster in the open position. A greasy liquid was leaking from the bottom corner of one dumpster, and a large area of greasy liquid was pooled on the concrete near the dumpsters. A strong garbage odor was present in the area. When the Dietary Manager was asked about the dumpster area at 10:30 AM, she stated that Maintenance was responsible for cleaning that area. The policy for maintaining the exterior trash refuse area was requested from the Administrator at 11:00 AM but was not provided by the end of the survey.
Failure to Hold Required Quarterly QA Meetings
Penalty
Summary
The facility failed to ensure quarterly Quality Assurance (QA) meetings were held in 2024 for 59 residents in a census of 59. During an interview and record review on 08/06/2025 at 1:01 PM, the Administrator stated that evidence of the required quarterly QA meetings for 2024 could not be found and that no performance improvement plans or projects (PIPs) were identified for 2024. The Administrator, who had taken the role in March 2025, reported that no handoff of QA projects or quality improvement plans was provided by the previous Administrator. The Administrator also reported that no action plans had been developed for ongoing 2025 PIPs. Current survey concerns included infection control, falls, physician order implementation, and daily care needs for residents.
Unsafe and Poorly Maintained Resident Rooms and Hallways
Penalty
Summary
The facility failed to ensure resident rooms and the north and south resident hallway carpets were clean and in good repair for four residents in a census of 59. Observations showed multiple areas of soiled, stained, and damaged carpet in both hallways, including red and pink dried spills, blackened and gray soil, bleached areas, ripples, raised seams, and a raised metal floor cover near the nurse’s station. The multipurpose room carpet also had a red dried spill and a pink/red stain, and the wallpaper was peeled away at one corner under a window. The Life Safety Director reported the south hall carpet was not cleanable and the red areas would not come up, and the Maintenance Director acknowledged the need for additional carpet repairs. Resident room conditions were also observed to be in poor repair and not maintained in a clean condition. One resident had an uncased pillow with multiple cracks and splintered cracks in the plastic covering, and the resident was later observed seated on that pillow in a wheelchair. Another resident’s room had three linear gouges in the wallboard behind the bed and patched holes on the opposite wall that had not been painted. Two residents had dresser drawers missing from their dressers. One resident’s wall thermostat had been removed, leaving a hole with wires hanging out, and a canister for wound drainage with a brown and white crystallized substance was sitting on the dresser; the resident stated it had been there for a while. Another resident’s feeding pump and tube feeding pole had dried tube feeding residue on them, and the DON and Unit Manager observed the residue and stated their expectation was that housekeeping or nursing would clean the equipment.
Failure to Honor Resident's Incontinence Brief Size Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for incontinence brief size, despite repeated requests and clear evidence that the provided briefs were too small and uncomfortable. The resident, who had diagnoses of Schizoaffective Disorder and Alzheimer's but was cognitively intact, reported that the briefs did not cover the thigh or buttocks area, were too tight, and caused discomfort. The resident stated they had informed staff about the issue, but was told that the current size was all that was available. Observations confirmed that the briefs were stretched thin and did not fit properly, and the resident continued to be placed in briefs that were too small over several days. Further review of the facility's supply showed that larger briefs were available in the storage room, but the correct size was not provided to the resident. The Director of Nursing acknowledged the existence of bariatric briefs for larger residents and noted that shipments had been delayed, but staff had purchased appropriate sizes as needed. The resident's care plan documented the need for assistance with incontinence care, and the facility's admission contract guaranteed reasonable accommodation of resident needs and preferences. Despite this, the resident's preference for a larger brief was not honored, resulting in discomfort and inadequate care.
Failure to Follow Physician Orders for Medication, Catheter Care, and Vital Signs
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with a history of traumatic secondary hemorrhage, seroma, and high cholesterol, Heparin doses were missed on 18 occasions due to the medication being unavailable. Documentation showed that staff did not notify the physician of the missed anticoagulant doses, as required by facility policy. The resident reported that the facility frequently ran out of Heparin, and the Director of Nursing (DON) confirmed the missed doses and lack of physician notification. Another resident, admitted with urinary retention and nephritis, was re-admitted after a hospital stay for a urinary tract infection. Hospital discharge instructions required discontinuation of an indwelling catheter and a trial of voiding with bladder scans and specific documentation. These orders were not followed, as the catheter was not discontinued, bladder scans were not performed, and there was no documentation of the required procedures. The DON and a registered nurse acknowledged that the discharge orders were overlooked, and it was revealed that the facility's bladder scan machine had been broken for months. A third resident had physician orders for regular vital sign monitoring, which were not completed as required. The electronic medical record did not prompt staff to take vital signs due to incorrect order entry, and the last recorded vitals were from the resident's admission several months prior. Staff confirmed that vital signs were not taken as ordered, and the DON stated that vital signs should be completed per physician orders and on admission for baseline.
Delayed Delivery of Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to ensure timely delivery of the Medicare Notice of Non-Coverage (NOMNC) for one resident, R55, who was receiving Medicare Part A skilled services. R55 was admitted with diagnoses including heart disease, rheumatoid arthritis, and high blood pressure. The NOMNC dated 05/30/2025 stated that services would end on 06/04/2025, but R55's guardian did not sign the notice until 06/09/2025. There was no documented evidence that the guardian was notified at least two days before the end of skilled services. During an interview on 08/06/2025, the Business Office Manager reported that the NOMNC was faxed to the guardian, but fax confirmation showing successful transmission was not available, and no follow-up call was made to verify receipt of the notice.
PRN Antipsychotic Order Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure a 14-day stop date for a PRN antipsychotic medication for one resident reviewed for unnecessary medications. The resident had diagnoses including cerebral infarction with left hemiplegia, vascular dementia, and anxiety disorder, had a BIMS score of 5/15 indicating severe cognitive impairment, and was receiving hospice services. During observation, the resident was primarily non-responsive and non-communicative. Review of the resident’s record showed an active PRN Haloperidol order for agitation with a start date of 05/13/25 and an end date listed as open-ended. The record did not contain documentation from the prescribing physician or hospice service showing follow-up, ongoing monitoring, or support for extending the medication beyond 14 days. The pharmacist’s MRR associated with the order indicated the medication could be used for up to 60 days, but after that period expired there was no further documentation supporting continued use. The DON stated the expectation was that an antipsychotic medication would have a 14-day stop date, and reported hospice said the medication was the only thing that was effective and therefore they did not implement a 14-day stop date. The facility policy stated PRN antipsychotic orders are limited to 14 days with no exceptions.
Delayed Incontinence Care and Soiled Bedding
Penalty
Summary
The facility failed to ensure timely incontinence care for one resident who was observed wet and soiled, with a yellow area behind the resident, a sheet that appeared yellow in spots, and an odor of urine in the room. The resident reported being wet since the last shift, said the brief had overflowed because an aide left and did not return to change them, and stated they had not been changed when breakfast was served and had not refused care. The resident also reported shortages of briefs and concerns with staff attitudes. A CNA later reported not changing the resident earlier in the morning before another staff member changed them after the call light was on. The DON stated that if a resident is wet, they should be changed and checked at least every two hours, and confirmed only one aide was on the hall until 11:00 PM. The resident’s record showed diagnoses of diabetes and intestinal obstruction, a care plan requiring one-person assistance for incontinence care, and an MDS documenting intact cognition and dependence or substantial/maximal assistance for most ADLs. The facility also failed to ensure bedding was changed timely for another resident. A cloth draw sheet was observed with light brown smears that appeared to be bowel movement, and an incontinence brief was turned inside out in the middle of the linen draw sheet. A CNA entered the room to deliver a breakfast tray and left the dirty linen and brief on the bed. On a later observation, the bed again had a cloth draw sheet with light brown smears that appeared to be bowel movement. The Unit Manager, RN A, was shown the dirty cloth draw sheet and stated, "that is not good." The resident’s record showed diagnoses of dementia, osteoarthritis, and heart disease, with an MDS documenting severe cognitive impairment and an ADL care plan identifying the resident as needing one-person assistance as needed and assistance with incontinence care.
Inhalers Not Dated When Opened
Penalty
Summary
The facility failed to ensure resident inhalers were labeled with the date opened in one of four medication carts. During an observation of the 200-back medication cart with an LPN, a Fluticasone Furoate/Vilanterol inhaler for a new admit that had not been added to the sample was found not dated when opened, and a fluticasone/salmeterol 250/50 inhaler for R18 was also not dated when opened. A Fluticasone/Salmeterol 250/50 inhaler for R56 was observed dated opened 04/14. On interview, the DON stated the inhalers should be dated as soon as they are opened. The facility policy titled, Labeling of Medications and Biologicals, stated medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations, and labels for medications designed for multiple administrations, such as inhalers, will identify the specific resident for whom it was prescribed. The prescribing information reviewed for the Fluticasone/Salmeterol inhaler stated it should be discarded 1 month after opening the foil pouch or when the counter reads 0, whichever comes first, and the prescribing information for the Fluticasone Furoate/Vilanterol inhaler stated the date the tray is opened should be written on the inhaler label.
Failure to Maintain an Active Water Management Program and EBP PPE Oversight
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP), and it also failed to ensure nursing staff used appropriate PPE for Enhanced Barrier Precautions (EBP). On 08/04/2025 at 10:00 AM, the Corporate Life Safety Director stated that the Building Maintenance Supervisor had resigned the prior week and that he was trying to locate documents related to the facility’s Water Management Program (WMP). He produced a binder containing a 2022 policy and blank monitoring forms. Review of the binder showed there was no diagram or text description of the building water system, no risk assessment, no identified areas where Legionella could grow and spread, and no listed control points, measures, or limits. There was no evidence of control point monitoring, no evidence that the water management team was meeting routinely, and the last water temperatures documented in the book were from 8/2/24. The facility’s WMP policy, dated 2022, stated that an infection control risk assessment should be conducted, a Water Management Team should meet quarterly, potentially hazardous areas or devices should be identified, control points and limits should be established, activities and corrective actions should be documented in meeting minutes, and the program should be reviewed annually. The Administrator stated that only Maintenance was on the team and that the team had not met since she arrived in March. The Infection Preventionist stated she had no involvement in the WMP other than assessing residents for signs and symptoms.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to prevent verbal abuse by a staff member towards a resident, resulting in the resident feeling disrespected. The incident involved a verbal altercation between a Certified Nurse Assistant (CNA) and a resident, where the CNA insisted on giving the resident a shower despite the resident's refusal. The situation escalated when the CNA used threatening language, implying harm, which was witnessed by another staff member. The resident, who had a traumatic brain injury and multiple bone fractures, reported feeling disrespected by the CNA's comments, particularly those related to their use of a wheelchair. The incident was reported to the facility's administrator, who confirmed the details of the altercation and the threatening language used by the CNA. The CNA voluntarily resigned after suspecting termination. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury or intimidation, which includes verbal abuse. The report highlights the failure of the facility to protect the resident from verbal abuse, as required by their policy.
Failure to Timely Initiate Wound Care Orders
Penalty
Summary
The facility failed to monitor and timely initiate treatment orders for a new wound on a resident's left baby toe, which was identified on 01/07/2025. Despite the wound being noticed and documented by an LPN, there was no indication that the physician or medical staff was contacted for wound care treatment orders. The resident's Medication Administration Record (MAR) and Treatment Administration Records (TAR) did not show any documentation for treatment of the left baby toe or foot. The resident's care plan also did not address the new wound, and the Nurse Practitioner did not document an assessment of the left baby toe or foot until 01/15/2025, eight days after the wound was first identified. The Director of Nursing confirmed that the nurse should have entered the order into the record, but no order or treatment was added into the physician orders or onto the January MAR or TAR. The facility's policy requires accurate documentation of wound assessments and treatments, but this was not followed in this case. The lack of timely treatment and documentation resulted in the potential for wound deterioration, as the wound care orders were not initiated until after the resident was seen by the wound care Nurse Practitioner on 01/15/2025.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures in two resident rooms, resulting in resident complaints of cold conditions. On the morning of January 21, 2025, the air temperature in one resident's room was measured at 66 degrees Fahrenheit, and the resident was observed in bed with a blanket pulled over his head. Another resident's room was measured at 65 degrees Fahrenheit, and the resident expressed feeling cold. A nearby vacant room was found to have a temperature of 48 degrees Fahrenheit. During an interview, the Maintenance Supervisor was uncertain about the facility's standard for comfortable ambient air temperature, initially suggesting anything under 60 degrees was too low, then reconsidering to under 70 degrees, but ultimately was unsure. The Administrator was unaware of the issues in one of the rooms but acknowledged that the other room was in an area with vacant rooms and broken heating units. The facility's policy stated that temperatures in common resident areas should be maintained between 71 and 81 degrees Fahrenheit.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a bed hold policy notification for three residents during their transfer to a hospital, as required by regulations. The deficiency was identified through interviews and record reviews, which revealed that the facility did not issue written notices specifying the duration of the bed-hold policy to the residents or their representatives. The Director of Nursing stated that the responsibility for bed holds lies with the Business Office and Social Work, while the Nursing Home Administrator indicated that nurses should provide the bed hold policy upon the resident's departure, or communicate it by phone the next day in emergency situations. However, the Social Service Director, who recently assumed the role of contacting families for bed holds, was unable to locate the bed hold notice for one of the residents. The residents involved in this deficiency included one with altered mental status and metabolic encephalopathy, another with muscular dystrophy, chronic kidney disease, and high blood pressure, and a third with diabetes and high blood pressure. The records showed that these residents were transferred to the hospital for various medical reasons, but there was no documentation of bed hold notifications being provided. One resident, who was transferred in an emergency, reported not receiving a bed hold notice. The facility's policy requires that a written notice be given at the time of transfer, but this was not adhered to, leading to the deficiency noted in the report.
Failure to Notify Physician of Resident's Refusal of Care
Penalty
Summary
The facility failed to notify the physician of a resident's refusal of vital signs and medication, which is a deficiency in meeting professional standards of quality. The resident, identified as R904, was observed in bed and appeared pleasant and conversant, with no signs of distress. R904 had a history of multiple medical conditions, including muscular dystrophy, chronic kidney disease, and diabetes mellitus, and was dependent on staff for various activities of daily living. Despite these needs, the facility did not record any vital signs for R904 since August 17, 2023, and failed to take vital signs upon the resident's readmission on September 3, 2024. The facility's records indicated that R904 had refused all medications since readmission and frequently refused care, medications, and treatments since July 8, 2023. The attending physician was not informed of these refusals, as evidenced by the lack of documentation in the physician's progress notes. The Director of Nursing confirmed that the facility's policy required documentation of refusals and physician notification, which was not adhered to in this case. The facility's policy on residents' rights regarding treatment and advance directives outlined specific documentation and notification procedures that were not followed, contributing to the deficiency.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with moderately impaired cognition who was sexually abused by another resident with a history of inappropriate sexual behavior. The abusive resident had been observed attempting to touch other residents inappropriately on multiple occasions prior to the incident. Despite these observations, the facility did not implement sufficient protective measures to prevent the abuse from occurring. The facility's investigation revealed that the abusive resident had been redirected multiple times by staff for inappropriate behavior, including attempts to touch other residents and staff. However, the facility did not provide adequate evidence of protective interventions to prevent further incidents. The abusive resident's room was located directly across the hall from the victim's room, and the facility failed to take timely action to separate the two residents or provide continuous monitoring to ensure the victim's safety.
Facility Fails to Maintain Safe and Clean Carpet Conditions
Penalty
Summary
The facility failed to maintain the carpet throughout the building in a clean, sanitary, and safe condition, affecting all 58 residents. Observations revealed that the carpet on the 200 unit was stained, worn, and had missing spots next to the walls. Further inspection showed large stains and buckling in some areas. Interviews with housekeeping staff indicated that the carpet needed a deep clean and replacement, but there was no floor technician available, and the owner had been informed about the issue. The Maintenance Director confirmed the lack of staff to operate the carpet cleaning machine and mentioned that replacing the carpet would be costly. Residents expressed concerns about the carpet's condition, describing it as dangerous and dirty, with buckling and unraveling in several places. One resident reported almost tripping while using a walker. The Director of Nursing acknowledged the issue, having personally experienced tripping on the carpet. A review of the facility's policy on providing a safe and homelike environment highlighted the requirement to ensure a safe physical layout that does not pose a safety risk, which the current carpet condition failed to meet.
Absence of Full-Time Activities Director
Penalty
Summary
The facility failed to employ a full-time Activities Director, a deficiency that potentially affects all 58 residents. During an interview, a resident reported that the facility has been without an Activities Director for months, resulting in a lack of activities, especially on weekends. The Regional Nursing Home Administrator confirmed the absence of an Activities Director and mentioned that a new hire is expected to start soon. An Activities Aide, who has been working alone in the activities department, corroborated this information, stating they have been in the role for the past year, both part-time and full-time, after previously serving as a receptionist and a certified nursing aide. Additionally, the facility's policy on activities did not mention the role of an Activities Director.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which is a requirement for adequate coordination of care. This deficiency was identified through a review of daily staff postings, which revealed multiple dates across January, March, June, and July where RN coverage was not provided. Interviews with the scheduler and the Director of Nursing (DON) confirmed the inconsistency in RN coverage, particularly when the DON joined in March. The facility's policy on Nurse Staffing Posting Information did not address the requirement for RN coverage, contributing to the deficiency.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to record and post necessary staffing information as required by regulatory guidance, which had the potential to affect all 58 residents. During a survey, it was found that the facility did not have staff posting data showing the number and hours of the staff working, particularly for RNs and CNAs. The survey team requested staff postings for specific periods, but the facility was unable to provide complete records. The facility's policy required daily posting of nurse staffing information, including the facility name, current date, resident census, and the total number and hours worked by nursing staff per shift. However, the facility did not consistently track or maintain these records. Interviews with facility staff, including the Unit Manager and the Regional Nursing Home Administrator, confirmed the absence of required staff postings. The Director of Nursing, who started in March 2024, was unaware of the missing logs. The facility's policy stated that nurse staffing information should be readily available and maintained for a minimum of 18 months. Despite this, the facility failed to provide complete staffing records for the requested periods, indicating a lack of compliance with their own policy and regulatory requirements.
Inadequate Meal Portion Sizes
Penalty
Summary
The facility failed to provide residents with meal portion sizes that met their nutritional needs, specifically regarding protein intake. During an observation, the Dietary Supervisor was seen preparing lunch trays with a small piece of baked chicken, approximately 2 1/2 inches by 2 1/2 inches, which was estimated to weigh around 2 ounces. This portion size was confirmed by the Registered Dietitian (RD) to be insufficient, as the diet spreadsheet indicated that a 4-ounce portion was required for a regular diet. A group of residents also reported that they felt the food portions were too small, leading to inadequate food intake.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for one resident and a group of seven confidential residents, leading to dissatisfaction during meals. On multiple occasions, a resident expressed dissatisfaction with the food, stating it was cold and unappealing, which resulted in them not eating most of it. During an observation, staff were seen serving lunch trays to residents' rooms with the food cart doors left open, which likely contributed to the food being served at inadequate temperatures. A Registered Dietician (RD) checked the temperature of a random food tray and found the baked chicken, cooked mixed vegetables, and orzo pasta to be significantly below the preferred temperature of 165 degrees Fahrenheit. The RD acknowledged the temperature issue, although they noted the chicken tasted good. The surveyor also taste-tested the meal and found it to be lukewarm, negatively impacting the food's palatability. The facility's policy on food preparation, which emphasizes serving hot foods hot, was reviewed and found to be inconsistent with the observed practices.
Delayed Meal Service and Resident Dissatisfaction
Penalty
Summary
The facility failed to serve meals in a timely manner and in accordance with the scheduled mealtimes, leading to resident dissatisfaction. The documented meal times were breakfast from 7:30 am to 8:30 am and lunch from 11:30 am to 12:30 pm. However, on the morning of July 14, 2024, kitchen staff were observed preparing to start breakfast service at 9:15 am, and breakfast trays were still being delivered at 10:30 am. Dietary Aide K attributed the delay to insufficient staffing, with only one or two staff members available to manage meal preparation and delivery. Additionally, lunch trays were observed being delivered at 3:07 pm, well past the scheduled lunch time, prompting complaints from residents about hunger and late meals. A confidential group of residents confirmed that meals were consistently served late, not aligning with the facility's documented meal times.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. A trash can near the handwashing sink was found without a liner and heavily soiled with a mold-like substance. The handwashing sink near the ice machine contained food debris and lacked paper towels. Additionally, raw pork chops were improperly thawed in a sink with water, reaching unsafe temperatures, and were left unattended for an extended period. Several food items in the kitchen's walk-in cooler and reach-in refrigerator were opened and undated, violating food safety standards. The kitchen's physical environment was also found to be unsanitary. The flooring throughout the kitchen had a heavy buildup of grime and food debris, and the dry storage room had food debris under the racks. The ventilation cover above the clean dishware rack was soiled with dust. The dish machine's temperature log had not been updated since earlier in the month, and staff were unsure how to monitor the machine for adequate sanitation. The interior lights for the ventilation hood were non-functional, and the garbage grinder was broken and full of old food, attracting gnats. The ice machine in the pantry was observed with a black mold-like substance on the interior sides of the ice bin. The Facilities Director confirmed the presence of the mold-like substance and noted that the cleaning solution used did not reach the sides of the machine. These observations indicate a failure to adhere to the 2017 FDA Food Code, which outlines necessary cleaning and maintenance practices to prevent contamination and ensure food safety.
Deficiencies in Facility Maintenance and Equipment Management
Penalty
Summary
The facility failed to effectively manage its daily operations, resulting in deficiencies related to the maintenance of the facility's environment and equipment. Specifically, the facility did not address the unsafe condition of the carpet throughout the hallways, which remained stained despite cleaning efforts. The Housekeeping/Laundry Supervisor acknowledged the need for carpet replacement and indicated that the issue had been communicated to the owner. Additionally, the facility did not maintain or timely replace resident care equipment, as evidenced by the lack of documentation and awareness regarding the mechanical lift's repair status. The Maintenance Supervisor and Director of Nursing were unable to provide details or documentation about the lift's repairs or the duration it was unavailable. The Nursing Home Administrator, who was on vacation, left the facility without documentation or information regarding the mechanical lift repairs or carpet plans. During a Quality Assurance review meeting, it was found that there were no documented QA activities related to the worn carpet or mechanical lift repairs in the Quality Assurance Binder. The facility's policy on providing a safe and homelike environment was not adhered to, as the facility failed to ensure that residents could receive care and services safely due to these unresolved issues.
Deficiencies in Water Management and PPE Use
Penalty
Summary
The facility failed to implement an active water management plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. During the survey, it was found that the Water Management binder lacked a list of team members and a water flow diagram. The policy outlined daily, weekly, and quarterly inspections, but there was no evidence of these being conducted. The kitchen dish machine had a heavy buildup of lime scale, and the dish machine log had not been completed since early July. Interviews with the Maintenance Supervisor, Director of Nursing/Infection Preventionist, and Administrator revealed a lack of involvement and awareness regarding the water management program, and no evidence of testing was provided by the end of the survey. The facility also failed to ensure proper donning and doffing of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). For three residents, staff were observed not wearing the required PPE during care activities. One resident reported that staff only wore gloves when emptying a catheter bag, and another resident stated that staff never wore gowns, only gloves. Interviews with staff, including a CNA and an LPN, confirmed the absence of PPE outside the residents' rooms and a lack of adherence to PPE protocols. The Director of Nursing stated that staff were expected to wear PPE when providing care to residents on EBP. The facility's infection prevention and control program policy, reviewed and revised in March 2024, emphasized the need for staff education and competence in resident care procedures. However, observations and interviews indicated that staff did not consistently follow the established procedures for infection control, particularly in relation to the use of PPE for residents on EBP. This failure to adhere to infection control protocols increased the risk of communicable diseases and infections among residents.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights in a timely manner for four residents, leading to significant delays in care. Resident R50's call light was activated for over 13 minutes before being addressed, during which time they requested a pain pill. R50 reported that it sometimes takes 30 minutes to an hour for their call light to be answered. R49 expressed that it takes 20 to 30 minutes for their call light to be initially answered, and they have experienced waiting in soiled conditions for 2 to 3 hours. R49's call light logs were unavailable for review. Resident R24 reported waiting up to an hour and a half for their call light to be answered, particularly when needing assistance with hygiene. R24 described a pattern of staff turning off the call light without providing the needed help, causing frustration and distress. R24 was cognitively intact and able to accurately report the time they waited. The facility did not have call light logs available for R24, indicating a lack of documentation on response times. Resident R9's call light was activated for 30 minutes while a CNA was observed using their cell phone at the nurse's station. R9 required assistance with a mechanical lift to get out of bed and had informed staff of their need two hours prior. CNA E turned off R9's call light without providing assistance, stating they informed the assigned aide. The facility's policy requires all staff to respond to call lights, but this was not adhered to, resulting in prolonged wait times for residents.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities to meet the needs of four residents, as observed during a survey. Resident 9 expressed dissatisfaction with the lack of activities, stating that there was nothing to do except ride in circles in their wheelchair. Resident 19 was observed wandering around the facility, expressing boredom and a desire to bird watch, but no activities were provided. Resident 20 reported that they used to be offered activities but had not been engaged in any for the past few months, relying on their family for leisure materials. Resident 32 mentioned the absence of an activities director and a lack of weekend activities, expressing a desire for off-site trips. The Activities Aide, working alone Monday through Friday, confirmed the lack of weekend coverage and the challenges in providing a comprehensive activities program. The facility's policy states that activities should support residents' choices based on their assessments, care plans, and preferences, aiming to enhance their physical, mental, and psychosocial well-being. However, the facility's current staffing and scheduling limitations have resulted in a failure to meet these standards, as evidenced by the lack of activity notes for the residents in question.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a 14-day stop date for PRN antianxiety medications or adequate documentation to justify their use beyond 14 days for two residents. Resident 21, who was admitted with diagnoses of anxiety and rheumatoid arthritis, had physician orders for Alprazolam without a stop date. Despite having intact cognition, as indicated by a Brief Interview for Mental Status score of 15/15, the orders lacked the necessary stop date. Interviews with the Social Service Director and the Director of Nursing revealed that there was an expectation for all PRN anti-anxiety medications to have a 14-day stop date unless otherwise noted, but this was not implemented. Resident 44, who was nonverbal and had severely impaired cognition due to conditions such as encephalopathy, depression, and vascular dementia, also had a PRN order for Xanax without a stop date. The facility's policy on the use of psychotropic medications, which requires a 14-day limit on PRN orders unless justified by a physician, was not followed. Interviews with the Social Service Director and other staff indicated a lack of adherence to this policy, as there was no documentation justifying the continued use of the medication beyond the 14-day period.
Deficiencies in Equipment Maintenance and Resident Safety
Penalty
Summary
The facility failed to ensure that essential patient equipment was in safe operating condition, leading to potential hazards and discomfort for several residents. One resident was observed with blood seeping from a bandage on her arm, which was attributed to cracked and worn wheelchair armrests that exposed sharp plastic edges. Despite the resident's complaints to staff about the discomfort and injury caused by the wheelchair, the issue was not addressed until it was brought to the attention of the surveyor. Another resident experienced multiple issues with their power wheelchair and the facility's mechanical lift. The resident reported discomfort and improper seating due to an ill-fitting air cushion, which caused them to slide out of the wheelchair frequently. The mechanical lift used for transfers was described as unstable and worn, with chipped paint and a loose anchor post, raising concerns about its safety. Despite these issues being known to staff, including the unit manager and CNAs, no corrective actions were taken to address the equipment's condition. Additional deficiencies were noted in the facility's maintenance of resident rooms and equipment. One resident's dresser was in disrepair, with missing and collapsed drawers, which had been reported to maintenance staff months prior without resolution. Another resident faced issues with their room's shower pressure and was told to purchase their own clock batteries, as the facility did not provide them. These maintenance oversights contributed to an environment where residents' needs and safety were not adequately prioritized.
Failure to Provide Mechanical Lift for Residents
Penalty
Summary
The facility failed to ensure the availability of a total assistance mechanical lift for two residents, resulting in their inability to safely get in and out of bed as desired. Resident R2, who has muscular dystrophy and anxiety disorder, was unable to get out of bed for four consecutive days in June 2024 due to the facility's lift being out for repairs. The fire department was called to assist R2 back into bed when the lift was unavailable. Interviews with staff, including the Maintenance Supervisor and the Director of Nursing, revealed a lack of documentation and awareness regarding the lift's repair status and duration of unavailability. Resident R9, who has cerebral infarction, hypoxia, and morbid obesity, also experienced issues due to the lack of a functioning mechanical lift. R9 reported that approximately two weeks prior, the facility did not have a working lift, which prevented them from attending a family event. Staff attempted to manually lift R9, which was deemed dangerous by the resident. The facility's policy on providing a safe and homelike environment was not adhered to, as the residents could not receive care and services safely due to the lift's unavailability.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner to the State Agency (SA) for one resident involved in an incident. The incident involved a resident, R45, who was observed by staff attempting to touch another resident, R4, inappropriately on the chest. This incident occurred on June 11, 2024, but was not reported to the SA until June 25, 2024, which is 14 days after the incident took place. The Director of Nursing (DON) acknowledged during a phone interview that all abuse investigations should be reported to the Abuse Coordinator and the SA promptly. However, the incident was delayed in reporting because the administrator was on vacation, and the DON was unsure of the reporting process in their absence. The facility's policy mandates that such incidents should be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. The failure to adhere to this policy resulted in the delayed reporting of the incident.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide the required written transfer notification to a resident and the Ombudsman when the resident was transferred to an acute care hospital. The deficiency was identified during an interview and record review, where the resident confirmed they were recently hospitalized due to a worsening bruise that developed into a wound. A review of the resident's census indicated hospitalization and subsequent return to the facility. However, the Electronic Medical Record (EMR) lacked documentation of the written transfer notification. Upon request, the facility's corporate administrative staff could not provide the written transfer notification or the Ombudsman monthly notification list by the time of the survey exit.
Failure to Implement Respiratory Care Plan for Resident
Penalty
Summary
The facility failed to implement a care plan for a resident requiring respiratory care. The resident, identified as R15, was observed on multiple occasions with an oxygen concentrator running, but the nasal cannula was found lying on the floor instead of being used by the resident. Despite the resident reporting difficulty breathing, there was no active physician's order for oxygen, and no care plan for oxygen or respiratory care was documented in the resident's medical record. R15 was admitted with diagnoses including Acute Respiratory Failure, Pneumonia, Adjustment Disorder with Anxiety, and Chronic Obstructive Pulmonary Disease. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition. During an interview, the MDS/Registered Nurse acknowledged that all orders should be transcribed and care plans written for each resident, but this was not done for R15. The facility's policy requires a baseline care plan to be developed and implemented for each resident, which was not adhered to in this case.
Failure to Update Fall Care Plan Interventions
Penalty
Summary
The facility failed to update the fall care plan interventions for a resident following multiple falls. The resident, who was observed with bruising on their forehead, reported a recent fall. A review of the resident's incidents and accidents from April to July revealed multiple falls, yet no new interventions were added to the care plan after these incidents. The last intervention on the care plan was dated in April, despite the resident experiencing several falls thereafter. The resident, admitted with diagnoses including encephalopathy and type 2 diabetes, had moderately impaired cognition and required supervision for all activities of daily living. Interviews with the MDS/RN and the DON confirmed that the care plan had not been updated with new interventions following each fall, contrary to the facility's policy. The policy requires the care plan to be reviewed and revised as necessary when a resident experiences a status change, with the interdisciplinary team collaborating on intervention options.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to provide consistent and scheduled showers for a resident who required assistance with activities of daily living (ADL), specifically bathing care. The resident expressed a desire to receive regular showers, stating that they were not being provided as scheduled, which was twice a week. The resident reported feeling upset and frustrated due to the lack of showers, as personal cleanliness was important to them. A review of the resident's ADL bath logs indicated that they received only four baths in a one-month period, with six instances where the activity did not occur, and no explanation was provided. Additionally, there was no documentation of any showers during the 30-day period, and the baths that were provided did not align with the resident's preference for evening or night showers. The resident's medical history included limb amputation, peripheral vascular disease, stroke, anxiety, and depression, requiring maximal assistance with toileting and bathing/showers. The Director of Nursing acknowledged the resident's concerns and mentioned the difficulty in accommodating the resident's preferred shower time. The facility's policy on Activities of Daily Living, implemented in November 2022, stated that care and services should be provided based on the resident's comprehensive assessment and consistent with their needs and choices. However, the facility did not adhere to this policy, resulting in the resident's dissatisfaction with their bathing care.
Failure to Schedule Follow-Up Appointments and Ensure Oxygen Orders
Penalty
Summary
The facility failed to set up follow-up appointments for a resident, resulting in a delay of care. The resident, who had a fracture in their left knee and a left hip replacement, was observed with a swollen knee and a surgical dressing on the hip that had not been changed since the previous month. The resident reported missing four chemotherapy treatments since admission. The medical record indicated the need for follow-up with orthopedic and oncology physicians, but no appointments were scheduled until much later. The receptionist, responsible for scheduling, was unaware of the need for these appointments until recently, and the Director of Nursing was not familiar with the resident's situation. Additionally, the facility failed to ensure appropriate physician orders were in place for oxygen for another resident. This resident, with a history of acute respiratory failure, pneumonia, and COPD, was observed with an oxygen concentrator running but the nasal cannula on the floor. The resident reported difficulty breathing, and upon checking, there were no active physician orders for oxygen. The facility's policy required oxygen to be administered under physician orders, except in emergencies, but this was not followed. The MDS/RN indicated that all orders should be transcribed and care plans written, but this was not done for the resident's oxygen needs.
Failure to Provide Restorative Services for Resident with Limited ROM
Penalty
Summary
The facility failed to provide restorative services to a resident with limited range of motion and mobility needs. The resident, who was observed in a power wheelchair with a bent right arm and a tightly closed right hand, expressed a desire for exercise and range of motion therapy to maintain and improve mobility. Despite having physician orders for restorative therapy to maintain upper extremity strength and range of motion, the resident reported not receiving any restorative therapy or being enrolled in a therapy program. The resident's care plan indicated they were on a restorative program with specific exercises outlined, but there was no documentation in the electronic medical record of participation in a restorative exercise program. The resident's Minimum Data Set assessment revealed a history of limb amputation, peripheral vascular disease, stroke, anxiety, and depression, requiring varying levels of assistance with daily activities. The resident was cognitively intact and experienced occasional pain. During an interview, the Director of Nursing was unaware of the resident not receiving restorative services and stated that the issue would be addressed. The facility's policy on Activities of Daily Living emphasized the provision of maintenance and restorative programs to assist residents in achieving the highest practicable outcomes, which was not adhered to in this case.
Failure to Ensure Timely Physician Response to MRR Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to Pharmacist Medication Regimen Reviews (MRR) recommendations for a resident. The medical record review revealed pharmacy progress notes indicating irregularities on specific dates, but the complete MRR and pharmacy recommendations with physician follow-up were not available. An email request for these documents was made, but the facility was unable to provide them. The Director of Nursing (DON) indicated that the MRRs might be in a binder in the office, but they were not sure why they were not provided. Additionally, a policy for MRRs was requested but not received before the survey concluded.
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.
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What surveyors actually found near you
We read the 927 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sterling Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Shoreline | 0.8 mi | ★★★★★ | 8 | 0 |
| Shelby Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Shelby Crossing Health Campus | 1.4 mi | ★★★★★ | 0 | 0 |
| Regency Manor Nursing & Rehabilitation Center | 2.4 mi | ★★★★★ | 9 | 0 |
| Optalis Health And Rehabilitation Of Sterling Heig | 3.1 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.