Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Life Care Center Of Plainwell during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was treated with quetiapine and clonazepam without clear, valid consent from his co‑guardians, despite one guardian’s explicit statements that he did not want the resident sedated or given these medications. Hospital discharge orders for quetiapine were continued, and clonazepam was initiated and later increased for anxiety and behavioral issues, based on verbal consents that were poorly documented, lacked identification of the consenting party, omitted dosage information, and were not physically signed by the guardians. Progress notes and interviews revealed conflicting accounts between staff and the guardians about whether consent was obtained, late documentation of a purported verbal consent at the DON’s direction, and a facility practice of relying on undocumented or incomplete verbal consents instead of securing proper guardian signatures, resulting in psychotropic treatment that did not adhere to the legal guardian’s right to direct the resident’s medication choices.
A resident with severe cognitive impairment and multiple comorbidities was found on his knees by the bed with oxygen and tube feeding tubing wrapped around him, exhibiting restlessness and self‑transferring despite staff encouragement to wait for assistance. He was assessed, assisted back to bed, and the physician and DON were notified, but there was no documentation that his co‑guardians were informed. In interviews, the RN could not recall notifying the guardians, and both guardians reported they were unaware of the fall, despite facility policy and federal regulations requiring immediate notification of resident representatives after such accidents.
A resident with severe cognitive impairment, dysphagia, and NPO status exhibited frequent behaviors including yelling out, repeatedly requesting water, drinking from inappropriate sources, pulling out a G‑tube, and removing O2. The care plan identified behavioral problems related to unsafe drinking but contained only generic statements and no specific, individualized interventions. Nursing staff and the SSD reported daily behaviors and limited interventions beyond checking on the resident, while the family stated they were not asked for input on non‑pharmacologic strategies and had expressed a desire to avoid sedation. Despite a facility policy requiring thorough assessment and trial of person‑centered non‑drug approaches before psychotropic use, the resident was maintained on Seroquel for behavior and later started on clonazepam, which was then increased for restlessness, anxiety, and behavioral issues without documented comprehensive assessment or clear evidence that individualized non‑pharmacologic interventions had been implemented and evaluated first.
A cognitively intact resident with heart failure, morbid obesity, and fragile skin sustained bilateral upper arm skin tears and other injuries after becoming dizzy during CNA-assisted toileting. Although the resident had a care plan for skin tears, the new skin tear from the fall was not timely addressed in weekly skin and wound assessments, and the dressing on the left forearm remained unchanged for an extended period until a family member alerted nursing staff. When the provider later evaluated the arm, the dressing had not been changed since initial treatment, removal of the dressing caused the tear to reopen with moderate bleeding, and the entire forearm was reddened and bruised, indicating that necessary skin care and dressing changes were not properly implemented or monitored.
Staff failed to follow required PPE for a resident on contact and droplet precautions for RSV. Orders and progress notes documented that the resident was RSV-positive and required contact and droplet isolation, and signs on the door instructed staff to perform hand hygiene and wear gown, gloves, and appropriate face protection. An IP entered the resident’s room wearing only a mask, did not don gown or gloves, and then exited and walked down the hallway with the same mask. In interviews, the IP and DON confirmed that RSV required contact and droplet precautions including gown, gloves, and mask, showing that the PPE used did not comply with the posted precautions and physician orders.
Multiple residents with significant care needs experienced extended call light wait times, negative staff comments, and lack of respectful interactions, leading to unmet care needs and emotional distress. Staff and resident council interviews confirmed widespread delays, particularly during night shifts, and the facility had not provided recent staff education on dignity and respect.
A facility failed to maintain a comfortable, clean, and homelike environment when multiple residents reported freezing or needing extra layers and blankets because their rooms and hallways were cold, with staff confirming ongoing low temps and cold air blowing from vents. Surveyors also observed dirt, debris, cobwebs, dead insects, dead ants in bathrooms, and fecal-soiled items left in a bathtub, while housekeeping said she was told not to clean one room at that time.
A facility failed to ensure physician follow-up on pharmacist MMR recommendations for several residents. Pharmacy reports for residents with diagnoses including anxiety, depression, dementia, anemia, and muscle weakness contained blank provider response sections or missing documentation for medication changes and lab monitoring, including recommendations involving alprazolam, omeprazole, ferrous sulfate, insulin glargine, and TSH, B12, magnesium, and lipid testing. The DON and MD stated they were responsible for reviewing the MMRs, but the record showed multiple recommendations without documented physician response.
Kitchen Plumbing and Equipment Maintenance Deficiencies: Surveyors observed a walk-in cooler floor that buckled when walked on and had cracks where water could accumulate, a two-door refrigeration unit with heavy black staining on the gasket seals, and an automatic hand sink that ran only 4 to 5 seconds before needing to be reactivated. Surveyors also found stagnant capped water lines at the garbage grinder area and an AVB that was not 6 inches above the sink overflow rim.
Pest Control Program Failed to Control Ant Infestation: Surveyors observed live ants in multiple resident rooms and a resident common area, including on floors, in bathrooms, and in bathtubs, with dead ants also present in one room. A resident and family member reported seeing numerous ants earlier that morning and said the issue had been reported to staff on numerous occasions. Housekeeping reported ants were seen throughout the building, and most residents in a council interview said the facility had an ant problem in rooms and hallways.
Advance directive information was not kept current for a cognitively intact resident with heart failure. The care plan and ACP note listed the resident as Full Code, but care management notes and the resident’s interview showed she wanted DNR and had told staff and her family this several months earlier. The NHA confirmed there was no documentation of follow-up to revise the advance directive, and staff would still be expected to provide CPR if the resident’s heart stopped.
Delayed Podiatry Services for a Diabetic Resident: A resident with DM, chronic pain, toe fungus, and foot pain reported requesting podiatry care since admission but not being seen or assessed. Records showed a podiatry consult request and an MD note documenting diabetic neuropathy and a diabetic ulcer, but no documentation that the facility ensured the resident was actually evaluated by the podiatrist; the podiatrist later said he had not received a prior consult request.
Improper urinary catheter maintenance was found for two residents with indwelling drainage devices. One resident’s Foley leg bag was overfilled with dark urine and sediment while staff were not readily available, and family reported increased agitation and concern for UTI. Another resident’s suprapubic catheter system had cloudy urine and heavy sediment coating the tubing and bag connection, with staff unable to say when the tubing was last flushed and records showing no recent catheter or bag change during the reviewed period.
Missing Pre- and Post-Dialysis Assessments: Two residents who required hemodialysis did not have documented pre- and post-dialysis nursing assessments. One resident reported that staff often skipped the assessments and did not check vital signs after returning from dialysis, and the LPN confirmed she did not assess the resident or complete the dialysis communication form. A second resident’s chart also lacked dialysis communication forms, and the DON and NHA confirmed the required documentation was not present.
Medical Director Did Not Ensure Medication Regimen Reviews Were Completed. The facility failed to ensure the MD implemented MRR policies and coordinated care with the consulting pharmacist/pharmacy for 4 of 5 residents reviewed for medications. The DON said Unit Managers were supposed to provide Monthly Medication Reviews to the MD, but he could not say how many were missed or whether audits had been done. The NHA said the issue had only recently been identified and MMRs were not being reported in QAPI. The MD said he was responsible for reviewing and responding to MMRs, but did not know how often they were due or whether any had been missed.
QAPI did not effectively address repeat deficiencies involving resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives. The NHA stated these issues were not being worked on as PIPs, and the facility only brought survey deficiencies to QAPI until the compliance date in the POC was met. The MD attended QAPI but did not describe an active role, and resident council minutes showed ongoing concerns about dietary staff not following meal tickets.
A resident with a history of aggressive behavior, including schizophrenia and autism, physically assaulted another cognitively intact resident using a wheelchair. Despite multiple prior incidents of aggression, the facility did not implement new interventions or increase supervision, and staff were not present to prevent the assault. Required 15-minute checks were not consistently documented, contributing to the failure to protect residents from abuse.
A CNA who had not completed required dementia care and other annual trainings responded inappropriately to a resident with dementia by covering the resident's mouth with a gown and spraying aroma therapy mist in the resident's face, escalating the resident's distress. Facility leadership confirmed that staff training completion was not monitored, and the CNA had not attended in-person dementia care training beyond orientation, resulting in the potential for inadequate care.
A resident with severe dementia did not receive individualized care as required, when a CNA, lacking dementia care training, used unauthorized aroma therapy mist and covered the resident's mouth with a gown during an episode of agitation. This non-care planned intervention caused increased distress for the resident, and was not approved by nursing or medical staff.
A resident reported a missing wedding ring, but the facility failed to thoroughly investigate and resolve the grievance. The cognitively intact resident reported the loss to the Social Services Director, who documented the concern. The investigation, led by the Central Supply Director, did not find the ring, and the grievance process was incomplete as the Executive Director did not ensure follow-up. This resulted in the resident's grievance remaining unresolved.
The facility failed to maintain food safety and sanitation standards, with issues including improper cooling of beef roasts, expired sanitizing test strips, and cleanliness problems in the kitchen. The dish machine was also found to be operating below the required temperature, and the physical facilities showed signs of neglect.
A long-term care facility was found deficient in its infection control program, with staff failing to perform proper hand hygiene and glove changes during resident care, leading to potential cross-contamination. Equipment cleaning was inadequate, as tube feeding pumps and poles were visibly soiled. Enhanced Barrier Precautions were not consistently implemented, with staff failing to wear required protective gear and maintain sterile environments during wound care.
A facility failed to accurately document a resident's advance directives, leading to inconsistencies in their code status. Despite the resident's medical record indicating no advance directives, an order summary and care plan showed a DNR status. However, a physical chart incorrectly displayed 'Full Code'. Staff interviews revealed a lack of proper documentation and validation processes for code status changes.
The facility failed to provide bed-hold notifications to two residents who were transferred to the hospital, as required by policy. One resident, with diagnoses including surgical aftercare and shoulder pain, was hospitalized without receiving a bed-hold form. Another resident, with conditions such as Parkinson's and schizophrenia, was transferred to the hospital six times without receiving the necessary notification. Staff confirmed the absence of these forms in the residents' medical records.
A resident with a stage 3 pressure ulcer and cognitive intactness had an outdated care plan that included an indwelling catheter, despite its discontinuation. Observations and interviews confirmed the resident was incontinent and without a catheter, highlighting the facility's failure to update the care plan to reflect current needs.
A resident with hemiplegia following a stroke did not consistently receive restorative exercises as recommended, receiving them only 6 times out of 24 opportunities. This was due to the Restorative Aide's absence and reassignment to CNA duties, with no coverage for her restorative responsibilities. The facility identified the inconsistency during an audit, but corrective actions were not yet fully implemented.
A resident with an indwelling Foley catheter experienced leakage, resulting in saturated briefs and bedding with dark red urine. Despite staff awareness, the catheter was not changed, and the Director of Nursing was unaware of the issue. The facility's catheter care procedures, which include monitoring for complications and replacing the catheter when leakage occurs, were not followed.
A resident with PTSD and severe cognitive impairment did not have a care plan addressing PTSD triggers, leading to potential re-traumatization when another resident verbally threatened them. Staff were unaware of the resident's PTSD triggers, and no trauma-informed care assessment was conducted after the PTSD diagnosis.
A facility failed to protect residents from abuse, as one resident with severe cognitive impairment physically restrained another resident, causing emotional distress. Despite a policy against abuse, the facility did not manage the aggressive behavior, leading to a deficiency.
A facility failed to protect residents from verbal abuse by staff, involving three residents who reported incidents of intimidation and neglect by CNAs during night shifts. One resident, who was cognitively intact, was left on a bedpan all night and verbally intimidated. Another resident, who was cognitively impaired, experienced rude behavior and neglect in incontinence care. A third resident reported feeling uncomfortable due to dismissive and intimidating behavior by CNAs. The facility's inadequate response and lack of timely action contributed to the deficiency.
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, leading to potential continued mistreatment. A cognitively intact resident reported being left on a bedpan all night by a CNA who made inappropriate comments. Another resident, who was cognitively impaired, reported rude and unresponsive behavior from night shift CNAs. A third resident expressed dread about the night shift due to dismissive comments from a CNA. Despite these complaints, the facility did not conduct thorough investigations or report the concerns to the State Agency.
A facility failed to investigate and protect residents after abuse allegations involving three residents. A cognitively intact resident reported rough treatment and neglect by a CNA, while a cognitively impaired resident experienced rudeness and neglect. Another resident reported intimidation and annoyance from CNAs. The facility did not suspend the CNA immediately, delayed the investigation, and failed to report to the State Agency, resulting in an incomplete investigation and potential for future mistreatment.
A resident at moderate risk for pressure ulcers developed a Stage 2 ulcer and a deep tissue injury due to the facility's failure to implement necessary care plan interventions. Despite being cognitively intact and having limited mobility and incontinence, the resident's care plan lacked interventions for skin integrity and pressure ulcer prevention. The resident was reportedly left on a bedpan overnight, contributing to skin damage, and the care plan was not updated to reflect these conditions.
Two residents in a LTC facility developed moisture-associated skin disorder (MASD) due to inadequate incontinence care. One resident, immobile and at moderate risk for pressure wounds, lacked a care plan for skin integrity, resulting in MASD and a pressure ulcer. Another resident reported a painful open area on her buttocks after her incontinence brief was not changed all day, with staff unaware of her MASD concerns. Interviews revealed a lack of awareness and response to residents' incontinence care needs, highlighting systemic failures in care provision.
A facility failed to monitor the weight of a newly admitted resident at risk for malnutrition, resulting in a significant weight loss of 6.8% over three weeks. The resident's care plan required weekly weight monitoring, but this was not done due to unclear responsibilities among staff. The RD was aware of the risk but did not ensure weekly monitoring, and the LPN and DON confirmed that the necessary orders were not in place.
A resident with Parkinson's disease and dementia was not provided with the necessary assistive devices and positioning support as outlined in their care plan. Observations revealed the resident leaning in bed and in a Geri chair without proper alignment aids, leading to discomfort. The facility staff did not follow the care plan interventions or repositioning policies, resulting in a deficiency.
A resident with Parkinson's disease and dementia was observed multiple times without accessible fluids, leading to signs of dehydration such as dry and cracked lips. Despite the care plan requiring drinks in sip cups, staff failed to provide them, and the resident's over-the-bed table was consistently out of reach. The facility's policy to ensure fluid availability at all times was not followed.
A resident with Parkinson's disease and dementia did not receive prescribed assistive devices, such as sip cups and plate guards, during meals, leading to potential issues with oral intake. Observations showed the resident in positions that hindered effective eating and drinking, and staff interviews confirmed the lack of necessary devices. The water pass census required a sip cup, but a styrofoam cup was provided instead, which the resident could not use effectively.
A resident with Parkinson's disease and dementia required enhanced barrier precautions due to a foley catheter and g-tube. Despite clear signage and facility policy, staff failed to consistently wear gowns and gloves during personal care, as observed in multiple instances. Interviews with staff confirmed the expectation to use PPE, but adherence was lacking.
Failure to Honor Legal Guardian’s Medication Decisions and Obtain Valid Psychotropic Consents
Penalty
Summary
The deficiency involves the facility’s failure to honor a legal guardian’s right to make medication treatment decisions for a resident who was severely cognitively impaired and unable to make his own decisions. The resident was admitted with multiple diagnoses including legal blindness, heart failure, dysphagia, alcohol abuse, and kidney disease, and had a BIMS score of 6/15 indicating severe cognitive impairment. Guardianship paperwork identified two family members as co‑guardians. Despite this, the resident was started on quetiapine 50 mg twice daily via tube for behavior following hospital discharge, based on a hospital discharge summary that noted quetiapine had been started for agitation with good response. A medication informed consent form for quetiapine dated shortly after admission documented verbal consent “on the phone” without listing any name under resident/legal representative, left the reason for the prescription blank, and was signed only by a facility representative. The facility also obtained and implemented orders for clonazepam without clearly documented, valid consent from the co‑guardians and in conflict with one guardian’s stated wishes. A medication informed consent form dated several days after admission documented verbal consent from one guardian for clonazepam 0.25 mg BID for anxiety, with side effects including sedation and drowsiness, and was signed only by an RN. Another consent form dated later listed both guardians’ names for an increased clonazepam dose but did not include a dosage, and again lacked the guardians’ signatures. Progress notes show that clonazepam 0.25 mg BID was ordered by the medical director and later increased to 0.5 mg BID for anxiety due to restlessness and behavioral issues. A behavior note documented that a guardian was initially apprehensive about increasing clonazepam due to concern about sedation but, after discussion about the care plan and behaviors, stated they would follow the doctor’s recommendations and that a psychotropic consent was signed and filed, although the form itself did not contain the guardians’ signatures. Interviews with the co‑guardians and staff further demonstrated inconsistencies and lack of reliable consent practices. The co‑guardians stated they were clear that they did not want the resident sedated and specifically did not consent to quetiapine or clonazepam, and that they were not contacted on the dates the facility documented consents for these medications. One guardian reported telling the facility at a care conference that he did not want the resident sedated or “drugged,” while the SSD stated the guardians did not mention not wanting psychotropic medications. RN C reported he obtained verbal consent from one guardian for clonazepam but acknowledged the other guardian opposed the medication and that he entered a late progress note about the consent at the DON’s direction weeks later. RN F reported he completed the consent form for the clonazepam dose increase and that the guardian was reluctant due to fear of sedation. The DON stated that verbal consents were documented on forms and that physical signatures were not obtained because the guardians did not visit often, and confirmed that once verbal consent was obtained, they did not pursue physical signatures. The visitor log showed the guardians did visit on at least two dates during the relevant period, but no signed consents from them were present in the record.
Failure to Notify Resident Guardians of Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal guardians of a fall and change in condition. The resident was admitted with diagnoses including legal blindness, heart failure, dysphagia, alcohol abuse, and kidney disease, and had a BIMS score of 6/15 indicating severe cognitive impairment. Guardianship paperwork identified two family members as co‑guardians. A progress note documented that the resident was found on his knees facing his bed at 0640 with oxygen and tube feeding tubing wrapped around him. He was assessed for injuries with none noted, assisted back to bed, tubing straightened, and vital signs and neuro checks initiated. The note also indicated the resident continued with fast breathing, initially high blood pressures that decreased throughout the day, frequent calling out, and no complaints of pain or bruising to the knees. A fall report for the same event described the resident as observed on his knees leaning over the bed with tube feeding and Foley catheter in place and without his nasal cannula. The resident was described as restless, dressing, and exhibiting compulsive behavior of calling out and self‑transferring between chair and bed despite staff encouragement to allow assistance. The fall report listed the physician and DON as notified but did not document family notification. In interview, the RN who worked that day stated she assumed the resident fell, notified the physician and DON, but could not remember if she notified the guardians. In a separate interview, both co‑guardians stated they were unaware of the fall and had not been contacted about it. The facility’s policy, reflecting federal regulations on notification of changes, requires immediate notification of the resident representative when there is an accident involving the resident that results in injury and has potential for requiring physician intervention.
Failure to Implement Non‑Pharmacologic Interventions Before Initiating Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to manage a resident’s behaviors with individualized, non‑pharmacological interventions before initiating and escalating psychotropic medications. The resident was admitted with legal blindness, heart failure, dysphagia, alcohol abuse, kidney disease, and severe cognitive impairment (BIMS score 6/15). Upon admission, the resident was prescribed Seroquel 50 mg twice daily via tube for behavior, and later clonazepam was added and increased to manage behaviors. The facility’s own psychotropic medication policy required a thorough assessment of underlying causes of behaviors, use of person‑centered non‑drug interventions, and involvement of the resident or representative in discussions of non‑pharmacologic and medication interventions prior to psychotropic use. Behavior documentation over a 30‑day lookback showed only two days of disruptive sounds, while progress notes described frequent behaviors including yelling out "hey" repeatedly, persistent requests for water despite NPO status, drinking from the sink, toilet, and urinals, pulling out the G‑tube multiple times, and removing oxygen. The care plan identified a behavioral problem related to drinking water from his and his roommate’s urinals and from the toilet, and noted a history of non‑compliance with fluid restriction. The listed interventions were generic statements such as anticipating and meeting needs and educating the resident/family on coping and interaction strategies, but no specific, individualized intervention strategies were documented for this resident. Progress notes described staff reminding the resident about NPO status and attempting to orient him, but did not document a range of individualized non‑pharmacologic approaches trialed and evaluated prior to starting or increasing psychotropic medications. Interviews with multiple RNs indicated that the resident had daily behaviors such as yelling out, non‑compliance with NPO and oxygen, and pulling out his feeding tube, and that staff did not know of effective interventions beyond checking on him. The Social Services Director and DON acknowledged the resident’s frequent calling out and impulsive behaviors, and the DON stated that multiple interventions such as activities and regular checks were tried, but these were not reflected as specific interventions in the care plan. The family/guardians reported that although the facility called them about behaviors and held a care conference, they were not asked about non‑pharmacologic interventions and one guardian stated he told the facility he did not want the resident sedated despite behavior problems. The psychotropic medication policy required that psychotropic medications be used only after non‑drug approaches were attempted and that the prescriber conduct and document a comprehensive assessment demonstrating the necessity of the medication; the record showed initiation and dose increase of clonazepam for behaviors and anxiety without documented evidence of such comprehensive assessment or of systematic, individualized non‑pharmacologic interventions preceding the psychotropic use.
Failure to Implement and Monitor Skin Tear Treatment and Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor ordered and needed skin care for a cognitively intact resident with fragile skin and multiple comorbidities, including morbid obesity, difficulty walking, heart failure, and chronic pain. The resident had an existing care plan problem for skin tears and fragile skin with an intervention to use caution during transfers and bed mobility. On 3/9/2026, during CNA-assisted toileting in preparation for going to the hospital, the resident reported dizziness, was lowered to the floor, and sustained skin tears to both upper arms and injuries to the backs of both hands and the right elbow. Nursing documentation noted hypotension and bradycardia, that the resident was assisted back to bed with a Hoyer lift, and that the physician would be notified of the low blood pressure. However, the weekly skin assessment and wound observation documentation did not address the new skin tear from 3/9/2026 in a timely manner. Subsequent provider and family reports showed that the dressing applied to the left arm skin tear was not changed for an extended period. The resident’s family member observed on 3/21/2026 that the bandage on the left arm was still dated 3/10/2026 and reported it had not been changed until she brought it to the nurse’s attention, by which time the arm was worse and weeping. A provider note on 3/21/2026 documented that the resident had sustained a fall the prior week, that the left forearm skin tear had been treated, but the dressing had not been changed since, and that when the dressing was removed the tear reopened with moderate bleeding, with the area reddened and bruised throughout the entire forearm. A later progress note on 3/25/2026 described the wound as a skin tear from blisters opening on the forearm due to fluid overload in the left arm related to heart failure, with the arm dependent and requiring elevation. These findings demonstrate that ordered and necessary skin care and dressing changes were not consistently implemented or monitored for this resident’s skin tear.
Failure to Use Required PPE for Resident on Contact and Droplet Precautions
Penalty
Summary
Facility staff failed to follow the ordered infection prevention and control precautions for a resident diagnosed with RSV. The resident had physician orders for contact and droplet isolation precautions starting 4/7/2026, and progress notes documented RSV-positive results with isolation per policy. On 4/8/2026, signage outside the resident’s room indicated Enhanced Barrier Precautions and Droplet Precautions, instructing that staff must clean their hands before entering and leaving, and that providers and staff must wear gloves and a gown for specified high-contact resident care activities, as well as ensure eyes, nose, and mouth are fully covered before room entry and remove face protection before room exit. Despite these posted precautions and the resident’s RSV diagnosis, the Infection Preventionist entered the resident’s room wearing only a mask and did not don a gown or gloves, and then exited the room and continued down the hallway wearing the same mask. In an interview, the Infection Preventionist acknowledged being new to the role, confirmed awareness that the resident had RSV and that the signs were posted to direct staff on appropriate PPE, and stated that she should have worn a gown, gloves, and changed her mask but did not think about PPE because she was only in the room briefly. In a subsequent interview, the Infection Preventionist and the DON both stated that RSV required contact and droplet precautions, including gown, gloves, and mask, with eye protection described as optional, confirming that the PPE actually used by the Infection Preventionist did not meet the required precautions for this resident.
Failure to Promote Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by extended call light wait times, negative staff comments, and lack of appropriate staff education. One resident with critical illness myopathy and end stage renal disease reported frequent delays of 30-45 minutes for call light responses, overheard staff referring to him as 'cranky,' and felt staff were retaliating against him after voicing concerns. The resident expressed feelings of anger, frustration, and being dehumanized, and stated that previous complaints to management were not addressed, leading him to stop reporting issues. Another resident with hemiplegia following a stroke, who required assistance with bed mobility and personal hygiene, reported waiting at least 30 minutes for staff to answer her call light. She described experiencing pain while waiting to be repositioned and discomfort from remaining in a soiled brief for extended periods. This resident stated that the delays made her feel sad and angry. A third resident with anxiety and depression also reported long call light wait times, particularly at night and on weekends, sometimes waiting so long that her needs went unmet and she fell asleep without assistance. Staff interviews confirmed that residents had complained about long call light wait times, especially during the night shift. Resident council meeting minutes and a confidential group interview further corroborated that multiple residents experienced extended wait times, with reports of waiting over 45 minutes during evening hours across several facility halls. The facility's own dignity policy emphasized the importance of treating residents with respect and enhancing their self-worth, but the lack of recent staff education and the ongoing issues with staff-resident interactions contributed to the deficiency.
Cold, Unclean Resident Rooms and Hallways
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents by allowing multiple resident rooms and hallways to remain cold and by leaving several rooms unclean. During observations, cold air was felt blowing from hallway ceiling vents between resident rooms and outside resident rooms on multiple occasions, and the hallway temperature was described as cold. Several residents who were cognitively intact reported that their rooms were cold, that they were freezing, and that they had to wear coats, hoodies, or extra blankets to stay warm. One resident reported sleeping in a zip-up hoodie sweatshirt to stay warm, another said she was freezing and had to wear a coat in the hallway, and another said she could not comfortably expose her arm while eating because it was so cold. The temperature concern was also confirmed by staff and a confidential resident council meeting. A confidential informant who worked in the building reported that the coldness had been brought to the facility multiple times and had been ongoing since the weather turned cold. Staff members reported that residents on the 200 hall commonly complained of being cold, that maintenance had been made aware of the complaints, and that the unit was really cold in the winter. The thermostat for the 200 hall was observed set at 69 degrees, and the maintenance director confirmed the common areas felt cool. A maintenance assistant reported recording ambient temperatures as low as 68 degrees in resident rooms and hallways. The report also documented unclean resident rooms and bathrooms. One room was observed with dirt and debris at the threshold, under the heat register, along the wall-floor junctions, and in the corners of the room and bathroom. Cobwebs with dead winged insects and ants were observed in corners, inside closets, and on ceilings. Multiple dead ants were seen in bathtubs and on bathroom floors, a dead ant was floating in a toilet, and one bathroom contained fecal-soiled men’s underwear and toilet paper in the bathtub. In another room, housekeeping staff stated she had been told not to clean the room at that time and instead to make another bed because family was coming to visit soon. One resident with critical illness myopathy and end stage renal disease reported that his room remained cold and that he had used a heated blanket for warmth, but the facility took it away because it was against fire safety code.
Missing Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews were timely reviewed by the physician and that pharmacy recommendations were documented with a provider response for multiple residents. Surveyors identified missing or blank physician response sections on pharmacy consultation reports, along with missing documentation showing that some monthly medication regimen reviews were completed or reviewed by the Medical Director. The deficiency involved residents whose medication regimens included medications such as alprazolam, omeprazole, ferrous sulfate, insulin glargine, and orders for laboratory monitoring that were not documented as addressed in the record. For one resident with diagnoses including adjustment disorder, major depressive disorder, anxiety disorder, and vascular dementia, pharmacy consultation reports repeatedly recommended changes to alprazolam and omeprazole, including consideration of alternative insomnia therapy and reevaluation of long-term PPI use. The physician response sections were blank, and no response from the physician was documented. The DON stated it was important for the physician to follow pharmacist recommendations to avoid residents receiving unnecessary medications and/or experiencing avoidable medication side effects. For another resident with anxiety and depression, the EMR showed monthly medication regimen reviews on some dates, but surveyors could not verify reviews for several months and the facility did not provide requested documentation before survey exit. Pharmacy recommendations for lipid panel monitoring and later B12 and magnesium monitoring were left blank in the provider response section and were not signed by the Medical Director. For a resident with major depressive disorder and muscle weakness, pharmacy recommendations for omeprazole discontinuation, TSH monitoring, and insulin glargine dose reduction also had blank provider response sections, and the facility could not provide documentation showing that the Medical Director reviewed the recommendations. For a resident with anemia, pharmacy reports recommended decreasing ferrous sulfate from twice daily to every other day, but the physician response sections were blank on multiple reports, and the facility was unable to produce documentation showing what the irregularity was, what the pharmacist recommended, or whether the physician responded.
Kitchen Plumbing and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain kitchen plumbing equipment and surfaces in a manner that would allow for safe, clean, and consistent operation. On 12/17/25 at 8:35 AM, the walk-in cooler floor was observed to move and buckle when walked on, and cracks were seen in portions of the floor where water could accumulate. The Food Service Director stated it was something the facility had plans to repair. On 12/17/25 at 8:44 AM, the two-door Traulsen refrigeration unit was observed with heavy black staining on the rubber gasket seals. The Food Service Director stated staff clean the gaskets, but the staining does not come off, and said they were in the process of getting new gaskets. On 12/17/25 at 8:46 AM, the automatic hand sink next to the drink station was observed to run only four to five seconds before needing to be reactivated, and the Food Service Director stated this was how it normally runs. On 12/17/25 at 1:43 PM, the left side of the garbage grinder area at the end of the cook line was observed with stagnant hot and cold-water lines capped off with no way to properly flush the domestic water, and the garbage grinder had a submerged inlet water line with an Atmospheric Vacuum Breaker that was not six inches above the overflow rim of the sink. The Food Service Director stated this area had plumbing work done about a year earlier and the facility was looking to renovate the area further.
Pest Control Program Failed to Control Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program for ants and winged-insects in five resident rooms and one resident common area. Surveyors observed live ants crawling on the floors of multiple resident rooms, including both bed areas, bathroom floors, and bathtubs, with dead ants also present in one bathtub and on the floor. One room with a current resident and family member had at least 15 ants observed crawling on the floor, and the family member reported that ants had been counted earlier that morning and had been reported to staff on numerous occasions. Housekeeping staff stated that ants had been seen throughout the building, usually by resident room doors. Review of closed work orders showed a prior report of ants in a resident room, identified by the facility as a medium concern. During a resident council interview, 4 out of 5 residents reported the facility had an ant problem and that ants were seen in their rooms and hallways. The facility policy stated that it would maintain an effective pest control program with frequent treatment and environmental monitoring, and that pest control problems would be reported promptly to the Director of Maintenance.
Advance Directive Not Updated to Reflect Resident’s DNR Preference
Penalty
Summary
The facility failed to ensure updated and accurate advance directive information was in place for one resident who was cognitively intact with a BIMS score of 15/15 and had a diagnosis of hypertensive heart disease with heart failure. The resident’s care plan and an advance care planning note documented the resident as Full Code, and the care plan stated the resident had decided to remain Full Code. However, care management progress notes documented that the resident and family stated she wanted to be a DNR, and another note stated the resident wanted to be a DNR and that staff would work on her becoming a DNR. During interview, the resident stated she had decided several months earlier that she did not want CPR if her heart stopped and had told staff this during care conferences. She reported that her spouse, who was her DPOA, needed to sign an advance directive reflecting her wishes, but she had not received further information. The NHA confirmed the resident had asked to change her code status to DNR several months earlier and that the facility had no documentation of follow-up on revising her advance directive; the NHA also confirmed staff would currently be expected to provide CPR if the resident’s heart stopped.
Delayed Podiatry Services for a Diabetic Resident
Penalty
Summary
The facility failed to ensure timely provision of podiatry services for one resident with type 2 diabetes mellitus and chronic pain. The resident’s care plan identified diabetes mellitus and noted risk for infections. During interview, the resident stated she had requested to see the podiatrist since admission but had not yet been seen or assessed, and reported toe fungus and a need for nail care. Record review showed an attending physician request for podiatry services for foot pain and a physician order for a podiatry consult, along with a medical director note documenting diabetic neuropathy and a diabetic ulcer with a plan for podiatry consult. When surveyors requested all podiatry documentation for the resident, the facility provided only the medical director note. No additional documentation was produced to show the facility took further action to have the resident seen and assessed by a podiatrist. The NHA confirmed there was only one podiatrist arranged to treat residents, and the podiatrist later reported the resident had only been added to his list by an email request from the facility a few hours before the surveyor interview and that he had not received any prior consult or request.
Improper Urinary Catheter Maintenance
Penalty
Summary
The facility failed to maintain urinary catheters appropriately for two residents with indwelling urinary drainage devices. One resident had an indwelling Foley catheter with a leg bag and was cognitively impaired, with family reporting increased agitation, restlessness, and concern for a possible UTI. During observation, the resident’s leg bag was found full of dark orange urine with a large amount of darker red-orange sediment at the bottom, and staff were not immediately available in the hall when assistance was needed. A nurse later documented that the Foley leg bag had been overfilled and that more than 1500 cc had been drained. The second resident had a suprapubic catheter for neurogenic bladder and a history of recurrent UTI. Observation showed the urinary collection bag holding cloudy yellow urine, with white sediment in the tubing and heavy white, dark yellow, almost orange sediment at the connection between the tubing and bag. The sediment was significant enough that the surveyor could not see inside the tubing/connection. The resident stated the catheter had been changed about a month earlier, while the MAR showed the catheter and bag had not been changed during the reviewed period. The care plan called for catheter care every shift and monitoring for signs and symptoms of UTI, including cloudiness and deepening urine color. Record review and interviews showed the sediment and catheter condition were not documented in progress notes, and staff were unable to state when the tubing had last been flushed. One RN stated the resident gets sediment all the time and did not know when the tubing was last flushed, and the UM stated the same. The report also noted that staff had not reported the first resident’s dark urine and increased confusion and agitation to the physician as a possible UTI. The findings showed two residents with catheter systems that were overfilled or heavily sedimented and not maintained as documented in the records reviewed.
Missing Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure pre- and post-dialysis assessments were completed for two residents who required hemodialysis. One resident had diagnoses including critical illness myopathy and end stage renal disease, with a care plan noting risk for complications related to renal failure and hemodialysis, a left arm fistula, and interventions to assess the shunt site, observe for bleeding, and monitor for signs and symptoms of renal insufficiency. The resident reported that nursing staff commonly skipped pre- and post-dialysis assessments and did not take vital signs when he returned from dialysis. For that resident, the electronic medical record did not contain documentation of pre- or post-dialysis assessments or refusals of assessments, and the most recent blood pressure documented was several weeks earlier. The LPN caring for the resident on the day he returned from dialysis confirmed that she did not assess him after he returned and did not complete a dialysis communication form. She also stated that nurses were supposed to complete pre-assessment notes with weight and vital signs before dialysis and document the post-dialysis assessment on the dialysis communication form placed in the dialysis binder. A second resident was admitted with dependence on renal dialysis, and the order summary identified the resident as a dialysis patient. Review of that resident’s chart did not contain any dialysis communication forms. The facility policy stated that dialysis transfer forms were to be maintained in the medical record and that pre/post dialysis communication forms were to be completed. The DON confirmed that nurses were required to complete pre- and post-dialysis assessments and document them on the dialysis communication forms, and the NHA stated there were no dialysis communication forms available for the resident.
Medical Director Did Not Ensure Medication Regimen Reviews Were Completed
Penalty
Summary
The facility failed to ensure the Medical Director implemented Medication Regimen Review (MRR) policies and procedures, including coordination of care between the facility and the consulting pharmacist/pharmacy, for 4 of 5 residents reviewed for medications. During interviews, the DON stated the Unit Managers were responsible for making sure Monthly Medication Reviews (MMR) were provided to the Medical Director and said he had only recently learned this may have been occurring, but he could not say how many MMRs were missed or whether any audits had been completed to identify missed reviews. The NHA stated the facility had only recently identified that the Medical Director had not been reviewing and responding to resident MMRs, and that MMRs were not being reported on during monthly QAPI meetings. The Medical Director stated he was responsible for reviewing and responding to MMRs, that he completed them when the facility provided them, but that he did not know how often he was supposed to review them, how often reviews were missed, or whether any reviews had been missed.
QAPI Did Not Address Repeat Deficiencies
Penalty
Summary
The facility failed to effectively identify quality deficiencies and develop and implement appropriate actions to correct them, and it did not sustain a system to ensure corrective measures related to resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives. During an interview, the Nursing Home Administrator reported the facility was working on PIPS related to staff education and had closed a PIP about meal tickets not matching what was served after audits reached 100%, but stated the facility was not currently working on any PIPS related to the repeat deficiencies cited on the last two recertification surveys. The NHA also stated the facility would bring survey deficiencies to QAPI and remove them once the compliance date in the plan of correction was met. The NHA confirmed that repeat deficiencies involving resident rights, dialysis, bowel/bladder incontinence/catheter care, and advance directives had not been brought to QAPI as PIPs for the facility to work on, even though these were high priority areas. The facility was reviewing monthly medication reviews at QAPI, but it had just identified that the Medical Director's review of MMRs was missing in November 2025. The Medical Director reported he attended QAPI meetings but, when asked about his role and participation, stated he was the doctor and had no other information to provide. Resident council minutes showed that residents expressed concerns in October 2025 and again in November 2025 about dietary staff not following meal tickets, and the facility's QAPI policy stated the program must be ongoing, comprehensive, and address all systems of care and management practice.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from physical abuse, resulting in one resident physically assaulting another. The incident involved a male resident with schizophrenia and autism, who had a documented history of aggressive behaviors, including hitting, biting, and throwing objects at both staff and other residents. Despite multiple documented episodes of aggression in the weeks leading up to the incident, no new interventions or increased supervision were implemented to address the escalating behaviors. On the day of the incident, the aggressive resident exited his room and struck another male resident, who was cognitively intact and using a wheelchair, in the face. Staff interviews confirmed that there was no staff present in the hallway or at the nurses' station at the time of the assault, and that the aggressive resident was able to approach and hit the other resident without intervention. The assaulted resident sustained redness to his cheek, and the aggressor incurred a minor laceration from contact with the wheelchair. Prior to the assault, the aggressive resident had also thrown a drink at another resident, but the facility did not increase supervision or implement additional safety measures following this event. The care plan for the aggressive resident noted his history of physical aggression but was not updated with new interventions after repeated incidents. Documentation also revealed that required 15-minute checks, which were eventually added to the care plan, were not consistently performed or documented.
Plan Of Correction
Resident #102 still resides in the facility. The resident has not had any further encounters with other residents and continues to show no signs of distress from the 5/12/25 and 6/17/25 incidents. Resident #101 still resides in the facility and has not had any further issues of aggression with other residents. Facility residents have the potential to be affected by the alleged deficient practice. The Social Services Director/designee completed facility-wide interviews with residents to ensure there were not any unaddressed concerns on 7/1-7/3/25. Any discrepancies noted with the interviews were addressed at that time. The Staff Development Coordinator/Designee will provide re-education to all staff on the facility abuse prevention policy and de-escalation tips for challenging behaviors on or before 7/14/25. Staff will not be allowed to work until education is completed. The IDT will review 24-hour reports for resident-to-resident encounters for potential abuse. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. The Social Service Director/Designee will audit resident concerns to review for potential abuse allegations during IDT meetings. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Executive Director is responsible for ongoing compliance.
Failure to Ensure Nursing Staff Competency and Completion of Required Dementia Training
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a Certified Nursing Assistant (CNA), had the appropriate skill sets and completed required annual trainings, as mandated by facility policy and federal regulations. The facility's policy required all staff to receive training on dementia care upon hire, annually, and as needed, with the Staff Development Coordinator responsible for maintaining training records. However, review of training records revealed that one CNA had not completed 60 out of 62 required trainings over a 13-month period, including essential topics such as dementia care, challenging behaviors, and mental health in LTC. The facility assessment indicated that dementia and cognitive impairment were prevalent among residents, with 19 residents diagnosed with dementia in the previous two quarters, and all staff were expected to be trained in these areas. An incident occurred in which a resident with dementia began yelling in the hallway. The CNA in question, who had not completed the required dementia care training, responded by pulling the resident's gown up to cover his mouth and then spraying an aroma therapy mist toward the resident's face, which also affected another CNA present. This action caused the resident to become more agitated. The CNA later admitted to being stressed by the resident's behaviors and confirmed she did not recall receiving any dementia care training from the facility. The other CNA present reported that the actions taken by the untrained CNA escalated the resident's distress. Interviews with facility leadership, including the Staff Development Coordinator, Human Resources Director, and Nursing Home Administrator, confirmed that staff completion of required trainings had not been monitored until recently. Staff were only able to complete computer-based trainings while in the facility, and there were reported difficulties accessing available computers. The facility had no documentation of the CNA attending any in-person dementia care training during her employment, aside from initial orientation. This lack of training and oversight resulted in the potential for delivery of care that did not support the resident's highest practicable well-being.
Plan Of Correction
Resident #103 no longer resides at the facility. CNA S no longer works at the facility. Facility residents have the potential to be affected. The DON/Designee conducted an audit to identify CNAs who have not completed Dementia training on 7/2/25. The Staff Development Coordinator/Designee will educate licensed nurses and certified nursing aides on education and training requirements and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. CNA s will be required to have completed at least 2 dementia-related training courses within the past 12 months prior to 7/14/25. The DON/Designee will conduct weekly audits of CNA education assignments to ensure that education is being completed. The audit will be conducted one time per week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.
Failure to Provide Individualized Dementia Care and Unauthorized Use of Aroma Therapy
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia did not receive individualized care interventions as outlined in their care plan. The resident, who had a BIMS score indicating severe cognitive impairment and a history of dementia and cognitive communication deficit, was subjected to actions by a CNA that were not authorized or tailored to their needs. The care plan specified approaches such as allowing extra time for responses, using simple instructions, and providing cues, but these were not followed during the incident. On the night in question, the resident became agitated and began yelling in the hallway. A CNA responded by pulling the resident's gown up over their mouth and spraying an aroma therapy mist directly at the resident's face, actions which were not part of the resident's care plan and had no physician order. This intervention caused the resident to become further agitated, resulting in physical resistance and distress. Other staff members witnessed the incident and reported that the resident only calmed down after alternative, individualized calming strategies were used. Interviews with staff revealed that the CNA had not received required dementia care training and had independently brought the aroma therapy spray into the facility without authorization from nursing or medical staff. Multiple staff members confirmed that the use of aroma therapy mist was not approved or ordered for any residents, and the facility's policy required individualized, person-centered interventions for dementia care. The facility also had not been monitoring staff compliance with required dementia care training at the time of the incident.
Plan Of Correction
Resident #103 no longer resides in the facility. Facility residents with a diagnosis of dementia have the potential to be affected. The DON/Designee conducted an audit to identify those residents who have been diagnosed with dementia and were reviewed by the Interdisciplinary Team for appropriate interventions. Their personalized care plans will be reviewed for accuracy on or by 7/11/25. The SDC/Designee will educate nurses and CNAs on the Caring for Dementia policy, creating and following individualized care plan interventions, 10-Tips to De-Escalate Challenging Situations, and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. The DON/designee will complete audits three times a week for eight weeks or until substantial compliance is achieved of newly admitted and readmitted residents with a dementia diagnosis to ensure their care plan includes individualized interventions. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.
Failure to Resolve Resident's Grievance on Missing Item
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for a resident who reported a missing wedding ring. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported the loss of his wedding ring several months ago. The concern was documented by the Social Services Director, who noted that the resident had reported the missing item to her. The investigation was assigned to the Central Supply Director, who conducted a search in the resident's room but did not find the ring. However, the investigation was incomplete as the actions taken to resolve the concern, the date and time of findings, and the executive director's signature were left blank on the concern form. Interviews with the Social Services Director and the Executive Director revealed that the facility's grievance process was not followed through to completion. The Social Services Director stated that the concern forms are initially handled by her and then passed to the appropriate department head, who is responsible for resolving the issue before it is reviewed and signed off by the Executive Director. However, in this case, the completed concern form was not returned to the Social Services Director, and the Executive Director acknowledged that there was no follow-up completed on the missing ring. This lack of follow-through resulted in the resident's grievance remaining unresolved.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a kitchen tour. A full pan containing two beef roasts was found in the walk-in cooler with a vented top, and the Food Service Director (FSD) was unable to provide a cooling log for the item, stating it was erased during cleaning. The roast was cooked the previous day and placed in the cooler at a temperature between 160F and 170F, but the FSD was unaware of the required time and temperature for proper cooling. The roast was eventually discarded due to uncertainty about its cooling process. Additional issues were noted with expired quaternary ammonium test strips, which are necessary for measuring sanitizing solution concentrations. The FSD acknowledged that both the current and backup test strips were expired. Furthermore, the kitchen was found to have cleanliness issues, including crumb debris in utensil drawers, debris on muffin tins, and black debris on can openers. A bus tub with kitchen equipment contained a dead moth and sticky debris, indicating a lack of regular cleaning and maintenance. The dish machine area also presented problems, with the machine running below the required 160F for the wash cycle, as indicated by the manufacturer's data plate. The dish log showed that 19 out of 24 logged wash temperatures were below the required minimum. Additionally, the physical facilities, such as the floor juncture under the dish machine and the dry storage room, were found to have accumulations of dirt and grime, further highlighting the facility's failure to maintain a clean and safe food service environment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies in hand hygiene and glove use during resident care. In one instance, a cognitively intact resident with a pressure ulcer and catheter care orders was observed receiving care from a hospice RN and CNAs who repeatedly failed to perform hand hygiene between glove changes. The RN handled soiled briefs and bed linens, touched the resident's urinary catheter, and managed wound care without proper hand hygiene, increasing the risk of cross-contamination and infection. Additionally, the facility did not ensure the proper cleaning and disinfecting of resident equipment. Observations revealed that tube feeding pumps, poles, and bases for two residents were splattered with dried formula and debris, indicating a lack of routine cleaning. Housekeeping staff confirmed that these items were part of a monthly deep clean list, but the visible dirt and debris suggested that cleaning protocols were not being followed consistently. The facility also failed to implement Enhanced Barrier Precautions (EBP) as required. A resident with a stage 3 pressure ulcer and a history of multidrug-resistant organisms was observed receiving care without the CNA wearing a gown, despite signage indicating the need for such precautions. Furthermore, during wound care, an LPN placed soiled dressing supplies into a clean field and failed to perform hand hygiene before applying gloves, compromising the sterile environment necessary for wound care. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation of advance directives for a resident with multiple sclerosis, who was cognitively intact. The resident's medical record contained a document indicating no advance directives were chosen at the time, yet an order summary and care plan indicated a DNR status with comfort measures was active. However, a physical chart at the nurse's station incorrectly displayed a 'Full Code' status. Interviews with nursing staff revealed inconsistencies in the process of updating and validating code status changes, with a lack of proper documentation and signatures from witnesses and the physician. Further investigation showed that during a hospital readmission, a conversation about the resident's code status change was reportedly held, but no documentation was found to support this. The Social Services Director indicated that the nursing department handles advance directives, but no documentation was found in the resident's medical record to confirm the resident's DNR wishes. The facility's policy requires review and documentation of advance directives upon admission, quarterly, and when there is a change in the resident's condition, but this was not adhered to in this case.
Failure to Provide Bed-Hold Notifications for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed-hold notifications to residents who were transferred to the hospital, as required by their policy. This deficiency was identified for two residents, Resident #41 and Resident #2, who were hospitalized without receiving the necessary bed-hold forms. Resident #41, who was readmitted to the facility with diagnoses including surgical aftercare and shoulder pain, was sent to the emergency room due to a leaking abscess and deep vein thrombosis. However, there was no evidence in the medical record that a bed-hold notice was provided for this hospitalization. The Director of Nursing confirmed that the facility was unable to locate the form for Resident #41's hospitalization. Similarly, Resident #2, who was cognitively intact and had diagnoses including Parkinson's, seizures, bipolar disorder, and schizophrenia, was transferred to the hospital six times in 2024 without receiving a bed-hold form. During interviews, both the Director of Nursing and the Unit Manager acknowledged that bed-hold notifications should be provided with each hospital transfer. However, the forms were not found in the resident's medical records or the facility's filing system. Medical Records staff also confirmed that no bed-hold forms were uploaded into the electronic medical records for Resident #2.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to revise a person-centered care plan for a resident, resulting in an inaccurate reflection of the resident's current care needs. The resident, who was cognitively intact with a BIMS score of 15/15, had a diagnosis of a stage 3 pressure ulcer in the sacral region. Initially, the care plan included an intervention for an indwelling catheter, which was initiated on 9/4/2024. However, observations and interviews revealed discrepancies in the care plan. On 10/8/2024, the resident was observed without a urine drainage bag, and subsequent notes indicated that the wound vac and foley catheter had been discontinued by 9/20/2024. Further observations and interviews confirmed that the resident was incontinent of bowel and bladder and did not have a foley catheter at the time of the survey. Despite these changes, the care plan still included an intervention for an indwelling catheter, which was no longer applicable. The Licensed Practical Nurse Unit Manager confirmed that the care plan should have been updated to reflect the resident's current condition, indicating a failure in maintaining an accurate and up-to-date care plan for the resident.
Inconsistent Restorative Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to consistently provide restorative exercises as recommended for a resident with hemiplegia and hemiparesis following a stroke, resulting in the potential for pain, stiffness, and avoidable decline. The resident, who was cognitively intact, reported receiving therapy initially but was now dependent on restorative exercises due to insurance limitations. The restorative program was developed by therapy and was supposed to be administered by a Restorative Aide and overseen by a Restorative Program Nurse. However, the resident received restorative exercises only 6 times out of 24 opportunities over an 8-week period. This inconsistency was attributed to the Restorative Aide having days off and being reassigned to work as a CNA, with no coverage for her restorative duties. The Restorative Program Nurse confirmed the inconsistency and acknowledged that the facility had identified the issue during an audit, but a plan to address it was not yet fully implemented.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, resulting in the potential for urinary tract injury and/or infection. The resident, who was cognitively intact and dependent on staff for activities of daily living due to obstructive uropathy, had an indwelling catheter that was observed to be leaking. During observations, the resident's brief and bedding were found saturated with urine, and the urine collection bag contained dark red urine. Certified Nursing Assistants reported that the catheter had been leaking for some time and had not been changed, despite the knowledge of the nursing staff. The Director of Nursing was unaware of the catheter leakage issue, and the Unit Manager mentioned discussions about removing the catheter to allow the resident to urinate naturally, but no action had been taken. A previous progress note indicated that the catheter had been changed due to leaking several months prior. The facility's procedure for catheter care emphasized monitoring for complications, maintaining a sterile closed system, and replacing the catheter when leakage occurs, but these protocols were not followed, leading to the deficiency.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address Post Traumatic Stress Disorder (PTSD) triggers for a resident, leading to a lack of trauma-informed care. The resident, who had a diagnosis of PTSD, dementia with psychotic disturbance, adjustment disorder, and obsessive-compulsive disorder, did not have a care plan that included focus, goals, or interventions related to PTSD or any possible triggers. Despite the resident's severe cognitive impairment and history of abuse, there was no trauma-informed care assessment conducted after the PTSD diagnosis, and staff members, including LPNs and the Social Services Director, were unaware of the resident's triggers. An incident occurred where another resident verbally threatened the resident with PTSD, which could have been re-traumatizing. The threatening behavior was reported, but repeated attempts to contact the witness were unsuccessful. Observations of the resident showed signs of distress, such as yelling out monosyllable noises, but staff interviews revealed a lack of awareness and documentation regarding the resident's PTSD and potential triggers. The Social Services Director confirmed that trauma assessments should be completed at admission and with new diagnoses, but this was not done for the resident in question.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, as evidenced by incidents involving two residents. Resident #80, who was severely cognitively impaired, exhibited aggressive behavior towards her roommate, Resident #61. On one occasion, Resident #80 pulled her roommate from her wheelchair and restrained her on the floor, causing physical and emotional distress. This incident was witnessed by a Certified Nursing Assistant (CNA), who reported that Resident #80 was confused and believed Resident #61 was trying to leave the room for inappropriate reasons. Resident #61, who was moderately cognitively impaired and used a wheelchair for mobility, experienced fear and emotional distress following the altercation with Resident #80. The incident report and interviews indicated that Resident #61 was unable to comment on the event due to her cognitive communication deficit but expressed feelings of being stuck at the facility. The CNA described Resident #61 as being in shock and fearful after the incident, highlighting the emotional impact of the physical restraint. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse, including physical restraint by other residents. Despite this policy, the facility did not adequately prevent or address the aggressive behavior of Resident #80, resulting in a failure to protect Resident #61 from abuse. The report indicates that the facility's inaction in managing Resident #80's behavior and ensuring the safety of Resident #61 contributed to the deficiency.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse by staff, specifically involving three residents. Resident #102, who was cognitively intact, reported being verbally intimidated by a CNA who told her not to wet the bed while placing her on a bedpan. The resident's daughter corroborated this account, stating that the resident had been left on the bedpan all night. The resident had a history of stroke and was incontinent, which made her dependent on staff for toileting assistance. The facility's care plan for Resident #102 lacked specific interventions for toileting and skin integrity, which may have contributed to the incident. Resident #103, who was cognitively impaired, reported that CNAs on the night shift were rude and unhelpful. He recounted an incident where a CNA refused to change his brief after multiple bowel movements, telling him he would have to wait for the next shift. This resident also reported that another CNA was stern and restrictive about his choice of sleepwear. The facility's documentation showed that a concern form was completed but not promptly addressed, and the CNA involved was eventually terminated. Resident #105, who was cognitively intact, expressed dread about the night shift due to the CNAs' behavior. She reported that a CNA was dismissive and intimidating, making her feel uncomfortable when requesting incontinence care. The facility's response to these complaints was inadequate, as there was no evidence of follow-up interviews with other residents or staff, and the concerns were not reported to the State Agency. The lack of timely and appropriate action by the facility's administration contributed to the deficiency in protecting residents from abuse.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for continued violations involving mistreatment, neglect, or abuse going undetected, unreported, or without thorough investigation. Resident #102, who was cognitively intact, reported that a CNA had left her on a bedpan all night and made inappropriate comments. This incident was documented by RN D after being informed by the resident's daughter and the resident herself. However, the report was not immediately escalated to the State Agency. Resident #103, who was cognitively impaired, reported that CNAs on the night shift were rude and unresponsive to his needs. He specifically mentioned an incident where a CNA refused to change his brief after multiple requests. This concern was documented by the Director of Rehabilitation but was not interpreted as an allegation of abuse or neglect by the DON, and thus, was not reported to the State Agency. Resident #105, who was cognitively intact, expressed dread about the night shift due to the behavior of the CNAs, particularly CNA G, who made dismissive comments. Despite multiple complaints from residents about CNA G, the Nursing Home Administrator did not conduct further interviews with other residents or staff, nor did they report the concerns to the State Agency. The lack of timely reporting and thorough investigation of these allegations constitutes a deficiency in the facility's handling of potential abuse cases.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to adequately investigate and protect residents following allegations of abuse involving three residents. Resident #102, who was cognitively intact, reported that a CNA had been rough, yelled at her, and left her on a bedpan all night. Despite the report being made, the CNA was not immediately suspended, and the investigation was incomplete. The facility's response was delayed, and the incident was not reported to the State Agency. Resident #103, who was cognitively impaired, reported that a CNA was rude and refused to change his brief during the night, telling him he would have to wait for the next shift. A complaint form was filled out, but the investigation and response were incomplete. The Director of Nursing (DON) did not interpret the complaint as an allegation of abuse or neglect and did not report it to the State Agency. The CNA was eventually terminated, but the process was delayed, and the investigation was not thorough. Resident #105, who was cognitively intact, reported that the night shift CNAs were not nice, with one CNA being intimidating and another acting annoyed when asked for assistance. The facility did not follow up with the residents or report the concerns to the State Agency. The Nursing Home Administrator admitted to not interviewing other residents or staff and not reporting the concerns, resulting in an incomplete investigation and potential for future mistreatment.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions to prevent the development of pressure ulcers for a resident, resulting in a Stage 2 pressure ulcer on the right buttock and a deep tissue injury on the coccyx. The resident, who was admitted with a history of stroke and was cognitively intact, was identified as being at moderate risk for pressure ulcers due to limited mobility, incontinence, and other factors. Despite these risks, the resident's care plan did not include necessary interventions for skin integrity and pressure ulcer prevention. The resident developed moisture-associated skin damage (MASD) and subsequently a Stage 2 pressure ulcer, which were not addressed in the care plan or assessed by a physician before the resident's discharge. Interviews with facility staff revealed that the resident was left on a bedpan overnight, which may have contributed to the skin damage. The resident's family member reported that the resident was immobile and incontinent, and had been treated roughly by a CNA. The Director of Nursing was unable to provide additional information on why appropriate interventions were not in place. The lack of documentation and failure to update the care plan contributed to the development of the pressure ulcers.
Inadequate Incontinence Care Leads to Skin Disorders
Penalty
Summary
The facility failed to maintain professional standards of care and provide adequate incontinence care for two residents, resulting in moisture-associated skin disorder (MASD). Resident #102, who was cognitively intact but immobile due to a recent stroke, was admitted without a care plan addressing her incontinence and skin integrity needs. Despite being at moderate risk for pressure wounds, no interventions were in place, leading to the development of MASD and a Stage 2 pressure ulcer. Reports indicated that Resident #102 was left on a bedpan overnight, which may have exacerbated her condition. Resident #106, also cognitively intact, reported developing a painful open area on her buttocks due to her incontinence brief not being changed throughout the day. Despite having a care plan indicating a risk for skin breakdown, there were no person-centered interventions for her incontinence care needs. The resident's call light was reportedly ignored by CNAs, and her incontinence task record showed frequent incontinence episodes. A physician's order for MASD treatment was incomplete, lacking a medication name, and staff were unaware of the resident's MASD concerns until the surveyor's intervention. Interviews with facility staff revealed a lack of awareness and appropriate response to the residents' incontinence care needs. The LPN responsible for Resident #102's admission failed to develop a baseline care plan, and the Director of Nursing could not provide additional information on why interventions were not in place. For Resident #106, the LPN was unaware of the MASD issue and had to correct the treatment order after the surveyor's inquiry. These deficiencies highlight a systemic failure in providing adequate incontinence care and maintaining skin integrity for residents at risk.
Failure to Monitor Weight of Resident at Risk for Malnutrition
Penalty
Summary
The facility failed to ensure timely monitoring of weight for a newly admitted resident, Resident #105, who was at risk for malnutrition. According to the facility's policy, a resident's weight should be recorded at the time of admission, weekly for four weeks, and then monthly. However, Resident #105's weight was not monitored weekly as required. The resident was admitted with a diagnosis of malnutrition and adult failure to thrive, and the care plan included monitoring for significant weight loss. Despite this, there was no record of weights taken between the initial weight of 144.1 pounds on 6/9/24 and a subsequent weight of 134.3 pounds on 7/1/24, indicating a 6.8% weight loss in three weeks. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for ordering and monitoring weekly weights. The Registered Dietician (RD) was aware of the resident's risk for malnutrition but did not know if weights were monitored weekly. The Licensed Practical Nurse (LPN) stated that newly admitted residents are weighed weekly, but this was not done for Resident #105. The Director of Nursing (DON) confirmed that the nurse responsible for the resident's admission should ensure weight monitoring orders are in place, but this was not done for Resident #105, leading to a delay in identifying significant weight loss.
Failure to Implement Resident Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with Parkinson's disease, dementia, muscle weakness, and lack of coordination. The resident was observed multiple times in positions that did not align with the care plan interventions, such as leaning to the right side in bed without assistive devices or pillows for proper body alignment. The resident's care plan included the use of a lateral wedge cushion and assistance with eating and drinking, but these measures were not observed during the surveyor's visits. Additionally, the resident was seen in a Geri chair in positions that were uncomfortable and lacked proper support, such as a hyper-extended neck and leaning to the left without adequate positioning aids. Despite the care plan's directives, the staff did not utilize assistive devices or reposition the resident to ensure comfort and alignment. Interviews with the Director of Nursing revealed that the staff did not adhere to the facility's policies and procedures for repositioning residents, which contributed to the deficiency.
Failure to Provide Accessible Hydration to Resident
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as Resident #102, had access to fluids for hydration, resulting in the potential for dehydration. Resident #102 had diagnoses including Parkinson's disease, dementia, muscle weakness, and lack of coordination, and was cognitively intact with a BIMS score of 13/15. Observations on multiple occasions revealed that Resident #102's over-the-bed table, which held water and meal trays, was consistently placed out of reach, leading to dry and cracked lips, a sign of dehydration. During one observation, Resident #102 was found with a wet shoulder and an empty styrofoam cup, indicating an attempt to drink water that resulted in spillage. Interviews with staff revealed that the CNA responsible for water pass did not provide Resident #102 with the appropriate sip cup, despite the care plan indicating that all drinks should be in sip cups. The Director of Nursing stated that water should be passed to every resident at least twice a day and that residents should always have access to drinkable water. However, the facility's policy on hydration and nutrition, which mandates that fluid is available to residents at all times, was not adhered to, as evidenced by the repeated observations of Resident #102 without accessible fluids.
Failure to Provide Assistive Devices for Resident
Penalty
Summary
The facility failed to provide assistive devices as ordered for a resident with Parkinson's disease, dementia, muscle weakness, and lack of coordination, which resulted in the potential for a decline in oral intake of food and fluids. The resident was cognitively intact and had specific physician orders for a regular diet with all drinks in sip cups and a plate guard. However, during multiple observations, the resident was found without the necessary assistive devices, such as sip cups and plate guards, during meals. The resident's care plan also indicated a risk for dehydration and required assistance with eating and drinking, which was not adequately provided. Observations revealed that the resident was often in positions that compromised her ability to eat and drink effectively, such as leaning to one side in bed or in a reclined Geri chair without proper support or positioning aids. Interviews with staff, including a registered dietician and certified nurse assistants, confirmed that the resident was not receiving the prescribed assistive devices. The water pass census indicated that the resident required a sip cup, but staff provided a styrofoam cup instead, which the resident could not use effectively. These failures in providing the necessary assistive devices and positioning support contributed to the deficiency identified by the surveyors.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control enhanced barrier precautions for a resident, leading to the potential for the spread of infection. The resident had diagnoses including Parkinson's disease, dementia, muscle weakness, and lack of coordination, and was cognitively intact. The resident's care plan and physician orders required enhanced barrier precautions, including the use of gowns and gloves during personal care due to the presence of a foley catheter and g-tube. However, during observations, staff members were noted not adhering to these precautions. Specifically, a CNA was observed providing personal care without wearing the required personal protective equipment (PPE), and another CNA performed catheter care without donning a gown, despite the signage indicating the need for such precautions. Interviews with staff, including CNAs, an LPN, the RN/Infection Preventionist, and the Director of Nursing, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents requiring enhanced barrier precautions. The facility's policy on enhanced barrier precautions, reviewed on a specific date, also outlined the necessity of using gowns and gloves during high-contact care activities for residents with indwelling medical devices. Despite these guidelines, the staff did not consistently follow the required infection control measures, as evidenced by the observations and interviews.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 258 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plainwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alamo Nursing Home Inc | 4.8 mi | ★★★★★ | 11 | 0 |
| Plainwell Pines Nursing And Rehabilitation Communi | 5.6 mi | ★★★★★ | 12 | 1 |
| Medilodge Of Westwood | 8.6 mi | ★★★★★ | 2 | 0 |
| Friendship Village | 9.4 mi | ★★★★★ | 15 | 0 |
| Villa At Borgess Place | 10.3 mi | ★★★★★ | 45 | 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.