Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Lenawee Medical Care Facility during CMS and state inspections, most recent first.
Failure to Protect Resident from Staff Abuse: A resident with dementia, severe cognitive impairment, and hospice status was physically and mentally abused by CNAs during care. Surveyors found staff routinely held him down for brief changes, did not follow the resident’s behavior approaches, and one CNA made and carried out an inappropriate “Titty Twister” act while another witness observed the resident being restrained and laughed at. Video footage and staff interviews confirmed the abuse, and management agreed abuse had occurred.
Physical restraint used during resident care. A resident with dementia, severe cognitive impairment, and hospice care was held down by CNAs during brief care despite a behavior plan that used non-restraint approaches. Witness statements and video review showed staff pushing the resident down, restricting his arms and legs, and engaging in inappropriate physical contact, while the CNAs stated this was routine practice for managing his combative behavior.
A resident with dementia, severe cognitive impairment, and hospice care was physically restrained by CNA E and CNA F during personal care after he resisted and refused care. CNA G reported that CNA E pushed the resident down, held his arms, and CNA F held his legs, while both CNAs said this was routine and did not seek nurse assistance or reapproach later. The report also documented CNA E laughing and performing a “Titty Twister” on the resident’s breast at the nurses’ station, with video review and witness statements confirming the inappropriate touching and management acknowledging that abuse had occurred.
Failure to report substantiated abuse as a suspected crime. A severely cognitively impaired, hospice resident was reportedly held down during brief care by CNAs, and one CNA later made and performed a “Titty Twister” comment/action at the nurses’ station. Witness statements and the facility’s own investigation substantiated physical abuse, but the incident was marked as not a suspected crime and law enforcement was not contacted.
Failure to Protect a Resident from Abuse: A resident with dementia and severe cognitive impairment was reportedly held down during care by two CNAs and later subjected to a humiliating sexualized act at the nurses' station. Witness statements, staff interviews, and video review showed the CNAs routinely used force to manage the resident's combative behavior, did not seek RN assistance, and did not follow available behavior approaches; facility management acknowledged physical and humiliation/mental abuse occurred.
The facility did not maintain required documentation showing that all paid feeding assistants had successfully completed a State-approved training course. Review of facility records showed 12 staff functioning as paid feeding assistants and 9 residents approved for the paid feeding assistant program, but the DON reported that documentation of completed training could only be found for 6 staff. The DON stated that a Life Enrichment Coordinator and several Dining Room Assistants had completed the training and assisted with feeding, yet the facility was unable to locate records verifying their training completion.
Failure to Assess Resident for Self-Administration of Medications: A resident with COPD, HF, anxiety, depression, and a BIMS of 15 was observed during med pass with the RN leaving meds and an inhaler at the bedside, not performing hand hygiene, and allowing the resident to use her inhaler on her own without a documented assessment permitting independent self-administration. The RN also did not provide water to rinse and spit after the inhaler, and the DON stated bedside medication administration was not expected unless an assessment allowed it.
Protected resident information was left visible during medication administration when an RN walked into a resident’s room with the med cart computer screen open and a resident list and daily report face up on the cart. The RN also left meds and an inhaler at the bedside, left the room to get a BP machine, and was observed without hand hygiene before giving meds. The DON confirmed the expectation was to close the screen and not leave resident names visible on the cart.
Delayed Significant Change in Status MDS for a resident enrolled in hospice. A resident with MS and moderate cognitive impairment was enrolled in hospice, triggering an SCSA requirement, but the MDS was completed after the required timeframe. The MDS nurse stated the assessment should have been locked earlier, and the record showed the ARD and completion dates did not meet CMS timing requirements.
Failure to implement a restorative ROM program for a resident with left lower extremity impairment and limited mobility. The resident was observed seated in a wheelchair with the legs extended and the left leg bent outward, while PT and OT discharge summaries recommended restorative services including lower extremity strengthening, passive ROM, AAROM, AROM, and restorative ROM. Staff reported a referral had been made, but the resident was not yet on the restorative program because the caseload was too large and the resident was on a waiting list.
Medication administration errors exceeded the allowed rate when an RN failed to perform hand hygiene, left meds and an inhaler at the bedside while leaving the room, did not provide water for rinsing after the resident self-administered a budesonide-formoterol inhaler, and attempted to apply a discontinued Lidoderm patch instead of the active lidocaine cream order. The DON stated meds should not be left at the bedside unless the resident has an assessment allowing self-administration, and the resident had no such assessment in the record.
Failure to perform hand hygiene during medication administration: An RN entered a resident’s room with medications, handed them to the resident, left the meds and inhaler on the over-bed table, returned with a BP machine, and continued care without hand hygiene before or after these actions. The resident had COPD, HF, AKF, anxiety, depression, and SOB, and the DON stated the expectation was for the medication pass nurse to perform hand hygiene before and after passing medications.
A deficiency occurred when the facility failed to thoroughly investigate and report a substantiated incident of sexual abuse between two cognitively impaired residents, both with multiple comorbidities and requiring one-person assistance with ADLs. Video footage and a CNA witness confirmed that a male resident in a wheelchair repeatedly touched a female resident’s breasts near the nurse’s station before being separated by staff. Despite this, the facility did not interview other residents or staff on the unit about the resident’s ongoing inappropriate sexual comments and behaviors, did not provide staff education related to the incident, and moved the alleged perpetrator to another hallway with other vulnerable female residents. The facility also did not notify law enforcement of the witnessed and recorded sexual abuse, with leadership citing the residents’ cognitive impairment as the reason for not calling the police.
A CNA recorded a video of a resident with moderate cognitive impairment in her room without consent while the resident was on the phone, then shared the video via social media. The resident was unaware of being recorded, and the video was further disseminated, violating facility policy and the resident's right to privacy.
A resident with a history of right femur fracture and Multiple Sclerosis, dependent for transfers, was injured when a CNA attempted a transfer alone using a sit-to-stand lift, contrary to the care plan requiring two-person assistance. The resident's leg gave out during the transfer, resulting in a fall and subsequent femur fracture, which was confirmed after ongoing pain and further imaging.
A resident's personal property was misappropriated when a CNA removed and discarded colored pictures from the resident's room without permission, leading to the resident's distress. The facility's investigation confirmed the incident, which was reportedly due to competition between CNAs.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical and mental abuse by staff. The resident was an older male admitted with diagnoses including dementia, heart failure, and adult failure to thrive, had a BIMS score of 99, and was receiving hospice care. His behavior care plan identified that he could be resistant to care and combative, and it directed staff to approach slowly, identify themselves, use calming sensory interventions, and communicate calmly and respectfully. The resident’s hospice care plans and notes did not indicate that physical restraint was to be used during care. The incident began when a CNA in training reported witnessing two CNAs hold the resident down during brief care. The trainee stated one CNA pushed the resident’s shoulders, another held his arms and legs, and the resident became combative during the interaction. The trainee also reported hearing one CNA say “Titty Twister” and later seeing that CNA perform the action on the resident while the resident appeared surprised. Another witness reported hearing laughter and overhearing the same comment at the nurses’ station. Video footage reviewed by surveyors showed the CNA fondling the resident’s right breast, and the QAM stated the facility confirmed that abuse had occurred and identified it as physical and humiliation/mental abuse. During interviews, the involved CNAs acknowledged that they routinely restrained the resident during care and said they did so because he was combative and for staff safety. One CNA stated this was how everybody took care of him and that staff had no other choice, while another said they held him down because he fought, kicked, and spit. Both CNAs stated they did not seek nurse assistance and did not use the resident’s behavior interventions as written. One CNA denied touching the resident at first, then said the act was a joke after being told the surveyor had viewed the video. Surveyor interviews also documented that the resident’s behavior tracking for that day had no recorded behaviors, and management staff, including the DON, HR, QAM, and NHA, agreed that abuse had occurred.
Physical restraint used during resident care
Penalty
Summary
The facility failed to ensure a resident with dementia and severe cognitive impairment was free from physical restraint during care. Resident #2 was an older male admitted with diagnoses including dementia, heart failure, and adult failure to thrive, and he was receiving hospice services. His behavior care plan identified that he could be resistant and combative with care and listed non-restraint interventions such as approaching slowly, identifying staff, using calming sensory items, calm communication, non-verbal cues, and simple one-step directions. The hospice care plans and hospice notes did not identify any intervention that physical restraint was to be used during care. On 4/18/26, a facility-reported incident alleged that CNA E and CNA F held the resident down and gave him “Titty Twisters” during care. Witness statements described the resident lying in bed for a brief change when staff attempted care, after which CNA E pushed on his shoulders, restricted his arms, and CNA F held his legs while the resident became combative and refused care. CNA G, who was in orientation and observing, stated she saw CNA E forcefully push the resident down on the bed and then saw CNA E hold his arms while CNA F held his legs. CNA E and CNA F both stated that holding the resident down was routine and was how staff provided care to him because he was combative. During the investigation, the QAM stated the facility confirmed abuse had occurred and identified it as physical and humiliation/mental abuse. Video footage reviewed by the facility showed CNA E fondling the resident’s right breast while the resident was seated at the nurses’ station. CNA E later admitted it was routine practice to restrain the resident during care and stated staff had to hold him down because of his behaviors. CNA F also stated staff had to hold him down because he fought, kicked, and spit. The facility policy defined physical restraint to include holding down a resident during care if the resident is resistive or refusing care, and the report states the staff involved failed to apply or demonstrate understanding of professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without force or restraint.
Failure to Preserve Resident Dignity and Right to Refuse Care
Penalty
Summary
The facility failed to preserve a resident’s dignity and right to make choices, including the right to refuse care, when staff physically restrained him during personal care and later mocked him with inappropriate touching and joking. The resident was an older male with dementia, heart failure, adult failure to thrive, severe cognitive impairment on BIMS, and was receiving hospice services. His behavior care plan identified that he could be resistant to care and combative, and directed staff to approach slowly, identify themselves, use calming sensory interventions, communicate calmly and respectfully, use non-verbal cues, and give short, simple directions. During the reported incident, CNA E and CNA F were caring for the resident while CNA G was in orientation. CNA G reported that CNA E pushed on the resident’s shoulders to position him, after which the resident became combative and refused care. CNA G stated CNA E restricted the resident’s arms while CNA F held his legs down. CNA E and CNA F both described holding the resident down as routine practice because he fought care, kicked, spit, and was combative, and both stated they did not ask the nurse for assistance or stop and reapproach later. CNA E also stated staff had to provide care and that leaving him alone would be neglect. The report further described an incident at the nurses’ station where CNA E said “Titty Twister” and performed the action on the resident’s breast while laughing, with CNA G and a housekeeper reporting that the resident appeared surprised and that laughter followed the act. The facility’s video review confirmed CNA E touching and tickling the resident’s breast, and management acknowledged that the conduct was humiliating and that abuse had occurred. Interviews also reflected that CNA E used profanity toward the resident when taking items from him, and that CNA E and CNA F failed to demonstrate understanding of professional boundaries, abuse prevention, resident rights, and appropriate management of combative residents without force or restraint.
Failure to Report Substantiated Abuse as a Suspected Crime
Penalty
Summary
The facility failed to develop and/or implement policies and procedures to ensure reporting of a reasonable suspicion of a crime under section 1150B of the Act for one resident. Resident #2 was an elderly male with dementia, heart failure, adult failure to thrive, severe cognitive impairment on the BIMS, and hospice care, so the reasonable person standard was used. A reported incident dated 4/18/26 documented that an LPN notified the QAM by phone about an allegation of abuse involving CNA G, who was in training and paired with CNA E and CNA F. According to witness statements, CNA G reported that CNA E and CNA F held Resident #2 down during brief care and that CNA E later said “Titty Twister” and performed the action on the resident while at the nurses’ station. CNA E acknowledged holding the resident down during care because the resident was combative, but denied physical contact and said the comment was a joke. CNA F stated the resident was held during care because he became combative. Housekeeper H reported overhearing laughter and the “Titty Twister” comment at the nurses’ station. The facility’s investigation concluded that physical abuse had occurred and the incident was substantiated as abuse, but the reported incident form indicated “Suspected Crime: No” and “Was law enforcement contacted: No.” When asked why police were not notified, the NHA and QAM did not respond.
Failure to Protect a Resident from Abuse
Penalty
Summary
The facility failed to ensure protection of a resident from abuse. Resident #2 was an older male admitted with diagnoses including dementia, heart failure, and adult failure to thrive, had severe cognitive impairment on the BIMS, and was receiving hospice care. Because of his cognitive status, the reasonable person standard was used for the citation. The resident was involved in an incident in which staff members were alleged to have physically restrained him during care and later subjected him to a humiliating act described as a "Titty Twister," which was identified as pinching and twisting a person's nipple roughly to inflict pain. During the investigation, a CNA in training reported that two CNAs held the resident down during brief care while he was combative, with one CNA restricting his arms and the other holding his legs. The same CNA reported that later at the nurses' station, one CNA said "Titty Twister" and performed the action on the resident, and that the resident appeared surprised. A housekeeper also reported overhearing the comment and laughter at the nurses' station and confirmed the phrase when asked. Facility video reviewed by surveyors showed the CNA fondling the resident's right breast, although there was no audio and the resident's facial expression was difficult to read. Interviews with the involved CNAs showed they routinely restrained the resident during care and believed this was normal practice because he was combative. One CNA stated staff had to hold him down for safety and said the resident had no behavior interventions in place, although a Kardex with approaches was later found in the resident's closet. The CNAs also stated they did not seek nurse assistance, did not reapproach later after allowing the resident time to settle, and did not use listed interventions. The facility's management acknowledged that abuse had occurred and identified it as physical and humiliation/mental abuse, and surveyor interviews showed the involved CNAs did not demonstrate understanding of professional boundaries, abuse prevention, resident rights, or appropriate management of combative residents without force or restraint.
Missing Documentation of State-Approved Training for Paid Feeding Assistants
Penalty
Summary
The facility failed to maintain records of successful completion of a State-approved paid feeding assistant training course for 6 of 12 staff members functioning as paid feeding assistants. Surveyors reviewed facility lists showing 12 staff designated as paid feeding assistants and 9 residents approved for the paid feeding assistant program. During an interview, the DON stated the facility could only locate documentation of completed State-approved training for 6 of the 12 paid feeding assistants. The DON identified specific staff, including the Life Enrichment Coordinator and multiple Dining Room Assistants, who had reportedly completed the paid feeding assistant training and had assisted residents with feeding, but the facility was unable to locate documentation verifying that these individuals had completed the required training. No additional clinical details or medical histories of the 9 residents approved for the paid feeding assistant program were provided in the report, and the deficiency centers on the absence of required training documentation for staff who assisted with feeding.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess one resident, R121, for permission to self-administer medications safely and independently. R121 was admitted with diagnoses including COPD, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. Her most recent MDS showed a BIMS score of 15 out of 15, and she required minimum assistance with showering, personal care, dressing, and putting on footwear, although that section of the assessment was not completed at the time. During a medication pass observation, an RN removed medications from the cart, left the computer screen open with resident information visible, and did not perform hand hygiene before handling and giving medications to R121. The RN left the medications and inhaler on the over-bed table and stepped out of the room to get a blood pressure machine. After returning and obtaining a BP of 151/92, the RN allowed R121 to state that she used her inhaler on her own, then handed her a blood pressure pill without observed hand hygiene before returning to the cart or before giving the medication. The inhaler was Budesonide-Formoterol Fumarate Inhalation Aerosol, ordered for COPD with instructions to rinse the mouth after use, but no water was provided for rinse and spit. R121 stated nurses usually stayed in her room while she took medications and that she could not always take them all at once. Record review did not show an assessment authorizing self-administration, and the DON stated the nurse should not leave medications at the bedside unless there was an assessment permitting self-administration and should provide water to rinse and spit after inhaler use.
Protected Resident Information Left Visible During Medication Administration
Penalty
Summary
The facility failed to protect personal, private, and confidential information for one resident, R121. R121 was admitted with diagnoses including chronic obstructive pulmonary disease, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. The most recent MDS showed a BIMS score of 15 out of 15 and indicated the resident needed minimum assistance with showering, personal care, dressing, and putting on footwear, though that section was not completed at the time referenced in the report. During an observation, an RN was seen pulling medications from the medication cart to administer to R121 and walked into the resident’s room with the medications while leaving the computer screen open with R121’s personal and protected information visible. The screen also showed a list of resident names and a daily report face up on the cart. The RN did not perform hand hygiene before handing medications to the resident, left medications and an inhaler on the over-bed table, left the room to get a blood pressure machine, and later returned to give the blood pressure medication without observed hand hygiene before accessing the cart or after handing the medication to the resident. The DON stated the expectation was to close the computer screen before leaving the medication cart unattended and that the same expectation applied to leaving the resident list face up on the cart.
Delayed Significant Change in Status MDS for Resident Enrolled in Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment timely for one resident. The resident was admitted and later readmitted to the facility with a diagnosis that included Multiple Sclerosis, and the Significant Change in Status MDS reflected moderate cognitive impairment on the BIMS and that the resident received hospice services. The MDS had an ARD of 2/5/26 and was completed on 2/19/26. Record review showed the resident was admitted to hospice services on 1/30/26, and the MDS nurse reported that the significant change in status occurred on that date when the resident enrolled in hospice. In a follow-up interview, the MDS nurse stated the Significant Change in Status MDS should have been locked by 2/12/26. The CMS LTC Facility Resident Assessment Instrument 3.0 User’s Manual states that an SCSA is required when a terminally ill resident enrolls in hospice, with the ARD within 14 days of the hospice election and the MDS completion date no later than 14 days from the ARD and no later than 14 days after the determination that the criteria were met.
Failure to Implement Restorative ROM Program
Penalty
Summary
The facility failed to implement a restorative maintenance program for one resident who had been admitted with diagnoses including a non-pressure chronic ulcer of the left thigh with necrosis of muscle, a displaced intertrochanteric fracture of the left femur, and a left artificial knee joint. The admission MDS dated 2/1/26 showed the resident scored 8 out of 15 on the BIMS and had lower extremity impairment on one side that interfered with daily functions or placed the resident at risk of injury in the last 7 days. On 3/17/26 and 3/18/26, the resident was observed seated in a wheelchair in the room, watching TV and later minimally self-propelling with the arms. On both observations, the wheelchair footrests were elevated to approximately seat level height, the legs were extended, and the left leg was bent laterally at the knee. Therapy documentation showed the resident was discharged from PT and OT on 2/18/26, with recommendations for restorative services including lower extremity strengthening, passive ROM, active assisted ROM, active ROM, and restorative ROM. In interviews, the Therapy Director and RN reported a referral had been made for restorative services, but the resident was not yet on the restorative program because the caseload was too large and there was a waiting list; staff also stated the facility had two restorative aides plus one as-needed aide and about 25 residents on restorative services at the time.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent when two medication errors were observed during 30 medication administration opportunities for one resident, resulting in a 6.67 percent error rate. The resident involved had diagnoses including COPD, heart failure, acute kidney failure, anxiety, depression, shortness of breath, and pain in both shoulders, and the most recent MDS showed a BIMS score of 15. During observation, an RN did not perform hand hygiene before giving the resident medications, left the medications and inhaler on the over-bed table while leaving the room to obtain a blood pressure machine, and did not provide water for the resident to rinse and spit after self-administering Budesonide-Formoterol inhalation aerosol. During the same medication pass, the RN also pulled a Lidoderm 4% patch to apply to the resident’s shoulders even though the record showed that the patch had been discontinued the prior evening and a new order had been written for Lidocaine 4% external cream instead. The resident stated nurses usually stay in the room during medication administration and that she was not offered water to rinse and spit after using her inhaler. The DON stated the expectation was to verify the medication order, check allergies, and triple-check the medication against the order and resident, and confirmed that if an order was discontinued the nurse should notice it and that medications should not be left at the bedside unless the resident had an assessment allowing self-administration.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was not followed during medication administration for one resident. During observation, the RN pulled medications from the medication cart and went into the resident’s room without performing hand hygiene. The RN handed the resident her medications without hand hygiene, then left the medications and inhaler on the over-bed table while leaving the room to get a blood pressure machine. The RN returned with the BP machine, again without performing hand hygiene, and took the resident’s vital signs with a BP of 151/92. The resident was admitted with diagnoses including COPD, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. The most recent MDS showed a BIMS score of 15 out of 15 and indicated the resident needed minimum assistance with showering, personal care, dressing, and putting on footwear. During interview, the DON stated it was the expectation for the medication pass nurse to perform hand hygiene before and after passing medications.
Failure to Thoroughly Investigate and Report Substantiated Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an alleged and substantiated incident of sexual abuse between two cognitively impaired residents. One resident (R2), with CHF, stroke, traumatic brain injury, dysphagia, major depression, hypertension, bipolar disorder, weakness, and unsteady gait, had a BIMS score of 7 indicating moderate to severe cognitive impairment and required one-person assistance with ADLs. Another resident (R3), with CHF, adjustment disorder, vascular dementia without behavioral disturbance, unsteady gait, and gait abnormalities, had a BIMS score of 3 indicating severe cognitive impairment and also required one-person assistance with ADLs. Camera footage and staff observation documented that R3, while in his wheelchair near the nurse’s station, touched R2’s face, rubbed her back, and then repeatedly touched both of R2’s breasts before being separated by a CNA. The facility verified the incident by reviewing the hallway camera footage and obtaining a witness statement from the CNA who intervened, confirming that R3 touched both of R2’s breasts. However, the investigation was limited to these immediate observations and did not include interviews with other residents on the same household regarding R3’s inappropriate behaviors, comments, or touching of female residents. The record also did not show interviews with other staff working on that household about R3’s prior or ongoing inappropriate behaviors or comments toward female residents or staff, despite staff later reporting that R3 was flirty with female residents and staff, made sexually suggestive comments, and had been “a little hands on” with staff. The facility moved R3 from one alert hallway to another where other vulnerable female residents lived, but records showed no evidence of staff education related to this sexual abuse incident, even though this was not the first time R3 had exhibited inappropriate behaviors and comments. The facility did not contact law enforcement regarding the witnessed and video-recorded sexual abuse, with the Nursing Home Administrator stating that police were not called because both residents were cognitively impaired and providing no other explanation. The record review and interviews confirmed that the facility failed to conduct a thorough investigation, failed to interview potentially affected residents and staff, failed to provide education to staff regarding the incident, and failed to report the substantiated sexual abuse to the police as required by regulation.
Resident Privacy Violated by Unauthorized Video Recording
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) recorded a video of a resident in her room without her knowledge or consent. The resident, who had diagnoses including Parkinson's Disease, vascular dementia, and major depressive disorder, was moderately cognitively impaired according to her most recent assessment. The video was taken from behind the resident while she was sitting in her wheelchair, watching television, and talking on the phone. The CNA then turned the camera on herself at the end of the video. The resident was unaware that she had been recorded and, when asked, stated her feelings about being recorded would depend on the circumstances, but she had no knowledge of this specific incident. The video was sent via social media messenger to another CNA, who shared a social media account with a third party, allowing the video to be further disseminated. Facility investigation confirmed that the video was recorded and shared without the resident's awareness, violating the facility's policy prohibiting photography or video recordings on the property and the resident's right to privacy. The CNA involved admitted to recording the video as a form of personal documentation related to workplace allegations, not for any resident care purpose.
Failure to Follow Transfer Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent for transfers and had a history of right femur fracture and Multiple Sclerosis, was not transferred according to their care plan. The care plan and Kardex specified that two-person assistance was required for transfers using a sit-to-stand lift. However, a CNA attempted the transfer alone, relying on outdated information from a report sheet that did not reflect the updated care plan requirements. During the transfer, the resident's right leg gave out, and although the wheelchair was locked, it moved backward, causing the resident's legs to slide out and resulting in the resident being lowered to the floor and landing hard on their buttocks. The resident immediately began experiencing significant pain in the right thigh, which persisted and worsened over the following days. Initial x-rays did not reveal a fracture, but ongoing pain and subsequent imaging confirmed a femur fracture with callus formation, necessitating surgical intervention. The incident was further complicated by the resident's continued reports of severe pain during movement and care, as documented in multiple progress notes and medication administration records. The failure to follow the care plan for transfer assistance directly led to the resident being injured during the transfer process.
Misappropriation of Resident's Personal Property
Penalty
Summary
The facility failed to protect the personal property of a resident, leading to feelings of sadness and potential mistrust. The resident, who was cognitively intact, had colored pictures on her wall that were created by a favorite CNA. Another CNA, without the resident's permission, removed and discarded these pictures, which upset the resident. The incident was observed by the resident's family member, who noted a possible competition between the two CNAs as a reason for the removal of the pictures. The facility's investigation, which included reviewing camera footage, confirmed that the CNA entered the resident's room when she was absent and discarded the pictures. The CNA admitted to removing the pictures, claiming they caused the resident distress. The social worker and nursing home administrator were informed, and the incident was reported and substantiated as misappropriation of property.
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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 Adrian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springcreek Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 22 | 0 |
| Lynwood Manor Healthcare Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Adrian Bay Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 5 | 0 |
| Otterbein Sunset Village | 20 mi | ★★★★★ | 5 | 0 |
| Lakes Of Sylvania, The | 21 mi | ★★★★★ | 9 | 0 |
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