Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Woods Manor during CMS and state inspections, most recent first.
Food Storage and Dating Deficiency: Surveyors found multiple unlabeled, undated, and expired food items in the kitchen, nourishment room refrigerators/freezers, and dining room reach-in refrigerator, including open meats, dairy items, juices, and ice cream past use-by dates or with no discard dates. The DM stated resident foods were good for 3 days and noted the facility had many new staff and was working to educate them on proper labeling, dating, and discarding practices.
Delayed Call Light Response: A resident with Parkinson’s disease and cognitive impairment had a call light left unanswered for nearly 30 minutes while staff talked in the hallway and a CNA walked past the room. Other residents reported staff shutting off call lights and not returning, with waits of 30 minutes to an hour, especially on weekends and third shift. Resident council notes, concern forms, and a confidential resident meeting showed repeated complaints about delayed call light response and short staffing.
Cold food and cold plates were served to residents during meal service. Residents reported that meals eaten in rooms were often cold, including eggs and French toast, and one resident said kitchen staff had to warm items constantly. Surveyors observed a resident receiving a breakfast tray on a cold ceramic plate, and staff were seen stacking plates outside the warmer during tray prep. The DM/CDM acknowledged complaints about temperature loss from the service area to resident rooms and confirmed that plates should remain in the plate warmer until use.
Unclean Rooms and Damaged Dining Furniture: A wall-mounted TV in one resident room was loose, and resident room floors were observed stained, scuffed, and dirty, including food on the floor in one room. Dining areas also had multiple chairs with peeling vinyl and damaged armrests, and residents reported the chairs needed repair or replacement.
Medication storage areas and carts were found unsecured, cluttered, and improperly maintained. An unlocked medication cart contained expired meds, snacks were stored with cleaner, and a loose tablet was found in the hallway near where the cart was parked. In medication rooms, staff stored personal items with meds, food was kept in a med refrigerator, an open undated TB vial was present, and expired medications and other items were stored on the floor.
Incomplete UTI surveillance and failure to use EBP PPE. The facility’s infection surveillance records showed many suspected UTIs without culture results identifying the organism, and the ICP stated the facility could track the number of infections but not the organisms or resistant organisms involved. In addition, an RN provided direct care to a resident with a PEG tube and Foley catheter without a gown or handwashing, and no EBP sign was posted outside the room during repeated observations.
Failure to obtain informed consent for psychotropic medication use was identified for a resident with major depressive disorder and Alzheimer's disease. Record review showed Ativan orders changed in dose and frequency over time, but the only consent on file did not match the current scheduled Ativan regimen. SW stated consent is obtained when a psychotropic is started and when there is any change in dose or frequency, and believed prior consents may have been missed.
A resident with diagnoses including borderline personality disorder, mild intellectual disabilities, opioid dependence, PTSD, and dialysis dependence was found to be not capable of making medical treatment decisions, yet the resident still signed an AD form that was witnessed by two staff. No DPOA or legal guardian was documented in the EMR, and the form section for a resident without decision-making capacity and without legal representation was not used.
Failure to Provide Complete Medicare Non-Coverage Notices: The facility did not consistently provide complete NOMNC and ABN documentation when skilled Medicare Part A coverage was ending. Two residents reviewed did not receive proper notice: one had an incomplete ABN with no option selected, and another received a NOMNC but no ABN at all. The Business Office Manager stated she was not consistent with issuing ABNs, and review of other residents showed additional cases where ABNs were not provided.
Failure to update the care plan for repeated weight loss. A resident with HF, edema, steroid use, Cymbalta use, and loose dentures had multiple significant weight changes over several weeks, but the nutrition care plan was not revised and progress notes did not address the losses. The resident remained on a regular or mechanically altered diet with thin liquids, and RD notes documented weight loss without adding new interventions.
Failure to provide ADL care to a dependent resident resulted in poor oral and nail hygiene. The resident had dementia, was rarely or never understood, and required max-to-total assistance for ADLs except eating. During observation, the resident’s teeth had a heavy gray/green buildup with thick strands visible between the teeth, and a black unknown substance was seen under the nails. The RN stated the lack of oral care was unacceptable, and the chart contained no documentation of oral care completion.
The facility failed to complete timely skin assessments for a resident with dehydration, diarrhea, heart disease, and weakness who had a sore on the left side of the nose that the resident said was a cancerous lesion and sometimes picked at. Record review showed a gap in weekly skin assessments, and the DON could not explain why they were missed even though the resident was in the building.
Restorative Nursing services were not provided for a resident with heart disease, kidney disease, diabetes, hypothyroidism, and arthritis whose MDS showed declining mobility and increasing assistance needs. The resident said she no longer walked and wanted to walk, but the EMR had no documentation of restorative ROM, splint/brace assistance, or ambulation services, and the UM confirmed the resident was listed for restorative ambulation but was not receiving those services.
Failure to monitor significant weight loss and update nutrition interventions for a resident with repeated rapid weight changes. The resident had multiple large weight losses over short periods, but the care plan was not updated and progress notes did not address the losses. The RD stated another RD had been covering the building earlier, and the resident remained on the original nutrition plan without new interventions.
Respiratory equipment was not maintained in a sanitary manner and oxygen was not administered as ordered for multiple residents. A resident with CPAP and O2 had a mask left uncovered on a soiled blanket and reported staff had not cleaned the equipment, while two residents with COPD were observed with nebulizer equipment left connected or stored with fluid still in the medication chamber; one resident also had O2 tubing that was not dated and another had O2 running at a rate that did not match the order.
A resident with dementia, depression, and difficulty walking was repeatedly observed yelling out, grimacing, and sitting in a wheelchair with poor positioning while staff passed by without meaningful intervention. Staff could not identify effective non-pharmacological approaches, the care plan lacked individualized dementia interventions, and the facility had no dementia management policy. The resident’s record showed ongoing behavioral issues, medication changes for agitation and pain, incomplete behavioral documentation, and later improvement when placed in a Broda chair and given personalized comfort measures such as gospel music and family-related cues.
Medication administration errors exceeded the allowed rate when an LPN omitted a resident’s Voltaren gel because it was not available, and during another med pass for a second resident, crushed an ER med that should not have been crushed and failed to properly prime an insulin pen before administration. The DON and Clinical Support RN confirmed that ER meds should not be crushed and insulin pens should be primed.
A resident with Alzheimer's disease and severe cognitive loss signed a binding arbitration agreement even though the medical record showed the resident was not capable of understanding the Bill of Rights or making medical treatment decisions. The Admissions Director said the agreement was reviewed with the resident or representative after admission and that confusion might prompt a nurse or SW review, but the facility policy did not address assessing competence before signing. In a group interview, 10 residents said they did not know what the arbitration agreement was or whether they had signed one.
A resident admitted with stroke, pneumonia, dysphagia, and type 2 DM, and ordered NPO with PEG tube feeding and insulin, experienced neglect when staff changed the ordered Glucerna formula to Jevity without rationale and significantly delayed initiation of tube feeding and water flushes. Facility staff failed to enter and follow discharge insulin orders on admission, did not start oral DM medication and basal insulin until nearly two weeks later, and did not consistently act on repeated BG readings over 300–500+ despite a policy to notify a practitioner for BG >400. Therapy staff and CNAs reported progressive lethargy, weakness, and increased dependence for transfers, while the record lacked nursing assessments of change in condition, respiratory assessments or monitoring for pneumonia, documentation of antibiotic use for pneumonia, or PEG site assessments. EMS later documented that staff reported the resident had been in an altered mental status with BG levels above 500 for several days before transfer, and hospital records showed admission for altered mental status, severe hypernatremia, hyperglycemia, AKI, and sepsis, demonstrating that the resident’s change in condition went unrecognized and undocumented by facility nursing staff.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident who was fully dependent and non-ambulatory exhibited increased pain and abnormal behaviors over several days, which were observed and reported by multiple CNAs to nursing staff. Despite these reports and visible signs such as an externally rotated leg, nursing staff did not conduct or document a thorough assessment, and no timely pain management was provided. The resident was only sent to the hospital after family intervention, where bilateral femoral neck fractures were discovered. The facility lacked a pain management policy and did not follow its change in condition notification policy, resulting in delayed recognition and treatment.
The facility failed to maintain appropriate hot water temperatures and chlorine levels, crucial for preventing Legionella growth. Despite policies for daily temperature checks, records showed inconsistent monitoring, with many readings below recommended levels. Maintenance staff acknowledged issues with a mixing valve and inconsistent temperature checks, creating potential risks for residents.
The facility failed to document and make accessible the code status of six residents, leading to potential miscommunication of treatment preferences. For one resident, the EMR lacked clear code status information, and the care plan did not reflect their wishes. Similar issues were found for other residents, with staff relying on a cumbersome binder system not part of the official medical record. The facility's policy did not ensure easy access to code status information.
The facility failed to conduct timely assessments and maintenance checks for enabler bars for several residents, leading to a deficiency in care. A resident had enabler bars without a care plan, and maintenance logs were incomplete. Another resident's assessments were delayed, and maintenance documentation was unclear. A third resident had no follow-up assessments after the initial one. The facility's policy required quarterly evaluations, which were not followed, indicating a systemic issue.
A facility failed to include a resident and his representative in the care planning process. Despite the resident having full cognitive abilities, he was not involved in any care planning meetings, and his wife, who is his representative, was not asked to participate in a care conference. The Clinical Care Coordinator confirmed that no interdisciplinary team members were present during the meeting with the wife, and there was no documentation of the meetings. This oversight contradicts the facility's policy on collaborative care planning.
The facility failed to update care plans for two residents, one with a suspected deep tissue injury and another with significant weight loss. The care plans did not reflect the current conditions or interventions, leading to deficiencies in care management.
A resident with multiple diagnoses, including paraplegia and heart failure, was observed with a hand brace provided by her daughter, but the facility failed to document, assess, or monitor its use. Despite an order for the brace, there was no documentation in the EMR, MAR, TAR, or care plans, and staff interviews confirmed the absence of a restorative nursing department. This lack of documentation and monitoring constitutes a deficiency in care.
A resident experienced new visual hallucinations and delusions, reporting seeing cats and rats in her room. Despite these symptoms being noted by staff on multiple occasions, the facility failed to act promptly, with no immediate assessment or monitoring conducted. The issue was only addressed during a survey process, highlighting a deficiency in the facility's response to the resident's change in mental status.
A facility failed to prevent a pressure ulcer for a resident and ensure timely skin assessments for another. One resident's pressure ulcer worsened due to a delay in replacing a worn wheelchair cushion, while another resident's skin issues were not promptly identified due to missed assessments. The facility did not adhere to its skin care protocols, contributing to these deficiencies.
A resident's enteral nutrition was administered at an incorrect rate, contrary to physician orders, and the DPOA was not informed of the change. Additionally, there were no documented orders for the routine care of the resident's PEG tube site. The facility's policy on resolving discrepancies before medication administration was not followed.
A facility failed to follow policies for skin and wound assessments, resulting in pressure ulcers in three residents. One resident developed a Stage III ulcer and multiple deep tissue injuries due to inconsistent repositioning and lack of documentation. Another resident developed Stage II and IV ulcers, with inadequate care plans and infection control breaches during dressing changes. A third resident's skin assessments were not conducted regularly. The facility's policies for weekly assessments and documentation were not followed, leading to these deficiencies.
Food Storage and Dating Deficiency
Penalty
Summary
The facility failed to store food in a sanitary manner and to appropriately label and date food products in the kitchen, nourishment rooms, and dining room refrigerator. During observation of the walk-in refrigerator, surveyors found open bacon and eggs with no open date or expiration date, chopped lettuce and tomatoes past their use-by dates, oranges with no open date or expiration date, and cream cheese cups past their use-by date, including an additional full box of 100 cream cheese cups that was discarded because it had no date on the box. In the walk-in freezer, chicken patties and sausage links were open with no open date or expiration date. The dish machine also had no air gap on the drain. In the East Nourishment room refrigerator and freezer, surveyors observed apple juice and orange juice past their use-by dates, hot dogs in the freezer past their use-by date, and open ice cream with no receipt date or discard date. In the [NAME] Nourishment room refrigerator and freezer, orange juice was past its use-by date, open ice cream had no receipt date or discard by date, and styrofoam containers were dated 5/27/26 with a discard date of 5/30/26. In the [NAME] Dining Room reach-in refrigerator, grape juice, orange juice, and multiple juices were all past their use-by dates. The Dietary Manager stated resident items were good for three days and discarded the undated or expired items, and stated the facility had many new staff and was working to educate them on labeling, dating, and discarding items properly.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for multiple residents, including a resident with Parkinson’s disease, a left hand contracture, and diabetes mellitus who was moderately cognitively impaired and required set up to total assistance with ADLs. During observation, this resident pressed the call light at 12:08 PM, while two staff members were seen talking in the hallway near the room at 12:10 PM. The staff continued talking and walked away without answering the call light, and a CNA later walked past the room without acknowledging or answering it. The call light remained on and unanswered for almost 30 minutes. Resident interviews and record review showed similar concerns from other residents. One resident reported that staff would shut the light off and say they would return but did not come back, and that weekends were the worst because lights took a long time to be answered. The resident also demonstrated that the call light worked outside the room and stated that third shift was lazy and did not check on residents. Another resident reported that call lights were taking 30 minutes to an hour to be answered, that staff shut off the light and did not return, and that it took too long to get help, including assistance to the bathroom. Resident council and confidential group interviews documented that call light delays were a repeated concern. Concern forms from the last 6 months showed multiple complaints that call lights took 30 minutes to an hour to receive staff response. In a confidential resident meeting, 6 of 10 residents said they had waited an hour or longer for call light assistance, and 4 of 10 said they had waited 20 to 30 minutes to use the restroom or get help. Most residents also reported short staffing, especially on weekends, with call-ins and no-shows, and stated that weekends were the worst for delayed call light response.
Cold food and cold plates served during meal service
Penalty
Summary
The facility failed to ensure food was palatable and served at an appetizing temperature for residents receiving meals in their rooms and dining rooms. Resident #106, who had diagnoses including COPD, chronic respiratory failure, and cerebral infarction without residual deficits, stated that the food was cold and that kitchen staff had to warm items for her constantly at all meals. Resident #6 also stated that food eaten in rooms was cold, including cold eggs in the morning, and that the alternate menu was tiresome. Resident #49 stated that the food was cold and mushy and that the alternate menu took too long to arrive during mealtime. During dining observations, surveyors saw breakfast trays being prepared and sent on rolling carts from the kitchen to the nursing units and resident rooms. In the East dining room, a resident received a breakfast tray in her room, and the surveyor touched the bottom edge of the ceramic plate and found it cold with no heat felt in the plate. The resident stated that the food is always cold, that she eats in her room most of the time, and that the cold plate and cold syrup over French toast made the meal worse. In the West dining room, the plate warmer was observed on, but the cook stacked thermal bottoms with ceramic plates on top of each other instead of keeping them in the warmer until ready for use. Interviews with the Dietary Manager/Certified Dietary Manager confirmed complaints about cold food, especially for residents in rooms and on the west end and part of the central unit. The manager stated that temperature is lost from the service area to the room and acknowledged that the plates should remain in the plate warmer until ready to be used. Residents in the East dining room also reported that the food was cold, the plates were cold, and the mashed potatoes had dry clumps from instant mix. The observations and interviews showed that the facility’s meal service process resulted in cold food and cold plates being served to residents.
Unclean Rooms and Damaged Dining Furniture
Penalty
Summary
The facility failed to provide a clean, comfortable, and home-like environment by allowing resident room floors to remain dirty and in poor condition and by leaving a wall-mounted television unsecured in one resident room. In room [ROOM NUMBER]-2, a wall-mounted television was observed coming loose, with the top screw out of the wall and the mount moving freely when touched. In the same room, the floor in front of the resident's bed had a large rectangular brown stain approximately 3 feet by 2 feet, and the remainder of the floor was scuffed and stained as if it needed to be rewaxed. In room [ROOM NUMBER]-1, the floor was observed to be scuffed and stained and had food on it, and it was not clean. The dining environment also showed poor upkeep: the [NAME] dining room had 26 chairs with peeling vinyl on the seats, backs, or arms, including one chair with a missing padded armrest piece that remained in use. In the East dining room, 4 chairs were observed with peeling vinyl, and resident council attendees stated that the chairs needed repair or replacement, with 8 of 10 residents reporting that the [NAME] dining room chairs were in even worse condition.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to keep medication storage areas clean, secure, and properly organized, and failed to ensure medications and biologicals were stored and labeled according to policy. In the East Hall medication storage room, an oxygen tank was sitting on the floor without a holder, and multiple items were stored directly on the floor, including a wheelchair storage bag, wheelchair cushion, portable oxygen container holder, wound vac tubing, an open box of Boost supplements, and an open box of piston syringes for tube feedings. Food was also present in the medication refrigerator, and an unknown live bug was observed moving across the floor in the room. The East Hall medication room also contained expired medications, including two packs of Narcan spray 4 mg, Bacitracin Zinc Ointment packages, Bisacodyl 10 mg suppositories, and Tylenol 650 mg suppositories. In the Central Hall medication room, an open and undated vial of TB PPD 5 TU/0.1 mL antigen solution was found in the medication refrigerator, and personal items belonging to nursing staff, including bags, clothing, and beverages, were stored in a cabinet containing medications and medical supplies. The infection control LPN stated that food should not be stored with medications and that the TB antigen solution should have been dated when opened. The Central Short Hall medication cart was observed unlocked and unattended, and it contained expired Bisacodyl 10 mg suppositories, expired Tylenol 650 mg suppositories, and an expired tube of Lidocaine 4%. The bottom drawer of the cart also contained snacks stored with a container of cleaner. In addition, a white tablet was found on the floor in the hallway near where the medication cart was parked, and staff later observed the cart in that same area while medications were being administered elsewhere. A resident stated he had seen the loose pill in the hallway overnight, and an RN picked up the tablet but did not know what it was or where it came from.
Incomplete UTI Surveillance and Failure to Use EBP PPE
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when its infection surveillance line listings for suspected urinary tract infections were incomplete and often did not identify the infectious organism. Review of the June 2025 through June 2026 infection surveillance records showed 99 suspected UTIs, and 54 of them did not have culture results identifying an organism. The missing organism information was noted on most of the UTI entries, including 37 of 61 suspected UTIs from June 2025 through December 2025 and 17 of 38 suspected UTIs from January 2026 through June 2026. The Infection Control Practitioner stated that some antibiotics were started before urinalysis and culture testing, and that some residents were admitted already diagnosed with UTI and the organism information was not available to the facility. The Infection Control Practitioner also stated that the facility could track the number of suspected UTIs but could not identify the organisms responsible for the infections or determine whether they were resistant organisms, including MDROs. The facility document titled Infection Prevention and Control Assessment Tool for Long-term Care Facilities indicated that the facility had a process for reviewing infection surveillance data and a written surveillance plan, but the surveillance line listings reviewed by the surveyor were incomplete and did not consistently include culture and sensitivity results for the UTI cases. The facility also failed to ensure PPE was worn when indicated for a resident in Enhanced Barrier Precautions. During observation of a resident with a PEG tube, colostomy bag, and Foley catheter, an RN handled the PEG site and emptied the Foley urometer without wearing a gown or performing handwashing during the care. The surveyor also observed that there was no EBP sign posted outside the room on multiple observations. The facility’s EBP policy stated that gown and glove use was required during high-contact care for residents with wounds or indwelling medical devices such as PEG tubes and Foley catheters.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication use for one resident, R76, who was admitted with diagnoses including major depressive disorder and Alzheimer's disease. Record review showed a physician's order for Ativan 0.5 mg by mouth four times daily for anxiety with a start date of 3/26/26, but the only informed consent found for Ativan was dated 9/16/25 and referenced Ativan 0.5 mg every six hours as needed. Additional discontinued Ativan orders were reviewed, including Ativan 0.5 mg twice daily starting 9/17/25 and Ativan 0.5 mg three times daily starting 12/25/25. During interview, the Social Work staff member stated informed consent is obtained when a psychotropic medication is started and whenever there is a change in the medication, including changes in dose or frequency, and suggested the prior SW may have missed the consents.
Advance directive signed by resident deemed incapable
Penalty
Summary
The facility failed to ensure that an advance directive form was completed and signed by a competent individual for one resident. Resident #2 was admitted with diagnoses including borderline personality disorder, mild intellectual disabilities, opioid dependence, PTSD, and dependence upon dialysis. The MDS assessment identified the resident as cognitively intact and needing set-up to no assistance with ADLs, but the EMR also contained a Physician Determination of Decision-Making Capability form stating the resident was not capable of participating in and/or making medical treatment decisions. That form was signed by a physician/licensed psychologist and the attending physician. Despite the determination of incapacity and no documentation of a DPOA or legal guardian in the EMR, the resident signed an Advance Directive Resident Preferred Treatment Option form, which was also witnessed by two facility staff. The form included an option indicating the resident was not capable of making decisions and had no legal representation, but that section was not used. During interview, the SW acknowledged that when the resident signed the forms, they had been deemed incompetent and stated that this was not appropriate. The SW also stated the facility was trying to obtain public guardianship, but no legal guardian was documented in the record.
Failure to Provide Complete Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide documentation of adequate notice of Medicare Part A non-coverage for 2 of 3 residents reviewed, including an Advance Beneficiary Notice of Non-Coverage (ABN), which affected the residents’ ability to exercise the right to file an appeal in a timely manner. The Administrator stated that the Business Office Manager was responsible for providing Notice of Medicare Non-Coverage (NOMNC) letters and ABNs to residents receiving skilled Medicare Part A benefits when skilled care was ending, but the Business Office Manager said she did not know she was supposed to track the ABN/NOMNC and was compiling a list of residents she had notified. She also stated she was assigned the task in November 2025 and did not know she was supposed to issue an ABN until March 2026. Resident #20 was admitted after a fall with fracture, and the last covered day of skilled care was 5/20/26. The NOMNC and ABN were signed by the resident’s representative on 5/15/26, but the ABN was incomplete because none of the available options were selected, including the option related to appealing discontinuation of services and beginning resident payment for care. Resident #101 was admitted to the facility and had a NOMNC signed by the representative on 2/20/2026 acknowledging the last covered day of Medicare skilled care coverage was 2/23/2026, but no ABN was provided to inform the resident/representative of the cost of services if they agreed to pay for them or to appeal the decision. The Business Office Manager later stated she issued NOMNCs but was not consistent with providing ABNs, and review of residents who received Medicare Part A skilled care from January 2026 through May 2026 showed 10 residents/representatives did not receive an ABN when Medicare Part A skilled care benefits were ending.
Failure to Update Care Plan for Repeated Weight Loss
Penalty
Summary
The facility failed to develop and update the comprehensive care plan within 7 days of the comprehensive assessment for Resident #49, specifically failing to add interventions related to repeated weight loss. The resident’s weight log showed multiple significant fluctuations, including a 13.1-pound loss in 7 days in January 2026, a 24-pound loss in 7 days in February 2026, a 10.8-pound loss in 7 days in March 2026, and a 17.4-pound loss in 6 days in May 2026. For each of these weight changes, the nutrition care plan had no additional interventions added, and progress notes did not address the weight losses on the dates identified in the record review. Resident #49’s nutritional care plan, initiated on 1/19/2026, included interventions such as assessing hydration, evaluating lab values, monitoring significant weight change, providing nutritional supplements per dietary assessment, and serving the diet as ordered. The resident had diagnoses and conditions noted in the record including heart failure, steroid use, Cymbalta use, bilateral lower leg edema, and loose dentures. A dietary note dated 3/22/2026 documented weight loss in less than 30 days and stated the resident was on a regular diet with thin liquids, fed self, and ate 100% of an alternate meal requested during lunch. A quarterly update dated 4/23/2026 noted a general mechanically altered diet with thin liquids and that the resident was consuming 75% of most meals, but it also stated no significant weight changes were noted and recommended continuing the current diet as ordered.
Failure to Provide Oral and Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide ADL care to a dependent resident who required maximum-to-total assistance with all ADLs except eating. The resident was admitted with diagnoses including heart failure, weakness, and dementia, and the MDS indicated the resident was rarely or never understood and needed extensive assistance. During an observation, the resident was confused, did not provide meaningful verbal responses, and did not follow instructions. The resident’s teeth had a visible and significant accumulation of gray/green thick, viscous substance, with strands of the substance stretching from the top to bottom teeth when the mouth was opened. At the same observation, a black unknown substance was seen under the resident’s nails. The RN present stated the resident was confused and did not understand, which made care more difficult, but also said the lack of oral care was unacceptable. Review of the resident’s documentation for the month showed no documentation of oral care completion. During interview, the DON and a clinical support RN confirmed dependent residents should receive assistance with oral care, and the DON was informed of the observed condition of the resident’s teeth and nails.
Missed Skin Assessments for Resident With Nose Lesion
Penalty
Summary
The facility failed to perform timely skin assessments for one resident, R17, who was admitted with diagnoses including dehydration, diarrhea, heart disease, and weakness. During observation, R17 was noted to have a sore on the left side of the nose, and the resident stated it was a cancerous lesion that she sometimes picks at. Record review showed that skin assessments were not completed for R17 from 3/26/26 to 5/4/26. The DON stated that skin assessments are done once weekly, could not explain why the assessments were missed, and confirmed that R17 was present in the building during that time. The DON also stated that the facility keeps a list at the nurse's station of skin assessments that need to be completed weekly. The facility policy titled, Skin at Risk Assessment, Documentation, Staging and Treatment, states that daily skin inspections with am and pm care are reviewed and implicated as indicated for each individual risk factor.
Restorative Nursing Services Not Provided
Penalty
Summary
The facility failed to ensure that Restorative Nursing services were provided for Resident #95, who had diagnoses including heart disease, kidney disease, diabetes, hypothyroidism, and arthritis. The resident’s MDS assessments showed a decline in mobility over time, with the resident needing supervision or touch assistance with ambulation in 2024 and partial to moderate assistance with ambulating 10 and 50 feet and being dependent for 150 feet in 2025. On observation, the resident was sitting in a wheelchair and stated she no longer walked and that the walking program had been discontinued, although she said she would like to walk and believed it would take two people to assist her. Record review showed Restorative-ROM and Restorative-Splint/Brace Assistance tasks in the EMR, but there was no documentation that either task had been provided during the prior 30 days. There was also no Restorative-Ambulation entry. The Therapy Manager stated the resident had an ambulation plan and that restorative services were typically developed after therapy and placed in the chart for Nurse Aides to follow, while the Unit Manager confirmed the resident was listed for restorative ambulation but was not receiving restorative ROM or splint/brace services and that no ambulation plan was on the care plan. The DON stated he was not sure about the restorative program and was still learning about it.
Failure to Monitor Weight Loss and Update Nutrition Interventions
Penalty
Summary
The facility failed to assess and monitor weights and failed to ensure that interventions to promote nutrition and prevent weight loss were in place for one resident. The facility’s Weight Management policy stated that resident weights would be monitored by the IDT in accordance with the nutritional plan of care, and that patterned significant unplanned weight loss or gain required the IDT to assess and implement individualized interventions. The policy defined significant unplanned weight loss as 5% in 30 days, 7.5% in 90 days, or 10% in 180 days, or insidious loss over a prolonged period. Resident #49 had multiple documented weight fluctuations, including a 13.1-pound loss in 7 days, a 24-pound loss in 7 days, a 10.8-pound loss in 7 days, and a 17.4-pound loss in 6 days. Record review showed no additional interventions added to the nutrition care plan after these losses and no progress notes addressing the weight losses. The resident’s nutritional care plan, initiated on 1/19/2026, included interventions such as hydration assessment, lab review, routine weight monitoring, supplements per dietary assessment, and RD evaluation as needed, but the record review and interview with the RD showed no updated interventions since the original plan. The RD stated she began at the facility on 4/6/2026 and that an agency or corporate RD had been covering the building before then.
Respiratory equipment not maintained in sanitary condition and oxygen not provided as ordered
Penalty
Summary
The facility failed to store and maintain respiratory equipment in a sanitary manner and failed to ensure oxygen was administered as ordered for three residents receiving respiratory care. Resident #5, who was cognitively intact and required assistance with ADLs, was observed with a CPAP mask left exposed and uncovered on top of a visibly soiled blanket on the recliner in the resident’s room while oxygen was in place via nasal cannula at 3.5 L per minute. The resident stated they removed the mask and did not have a specific place to store it, and also reported they had not seen staff clean the CPAP equipment. The resident’s orders included oxygen at 2 L via nasal cannula to maintain SpO2 of 91% or greater and daily CPAP cleaning instructions for the mask, humidifier chamber, tubing, and headgear. Resident #116, who had COPD, pulmonary embolism, and pneumonia, was observed with oxygen via nasal cannula and a nebulizer machine on the dresser with the administration set connected, exposed, and visible fluid present in the medication chamber; the oxygen tubing was not dated. The resident stated they used oxygen continuously and had not yet received a breathing treatment that morning. Resident #106, who had COPD, chronic respiratory failure, and a history of cerebral infarction, was observed with a nebulizer mask stored next to the bed with fluid still in the medication chamber, and the nebulizer tubing was dated 5/15/26. The resident stated they had last received a breathing treatment around 10:00 AM. Interviews with the DON and unit manager confirmed that nebulizer equipment should be rinsed and allowed to air dry after treatment, and the facility policy stated oxygen delivery would be according to physician order and nebulizer tubing and delivery systems were to be cleaned, dried, and stored between uses.
Failure to Provide Individualized Dementia Care and Comfort Measures
Penalty
Summary
The facility failed to develop and operationalize policies and procedures to ensure comprehensive assessment and care of dementia for a resident with dementia with behavioral disturbances, depression, and difficulty walking. The resident was rarely or never understood, required maximum to total assistance with ADLs except eating, and had no behaviors documented on the MDS despite later observations of persistent yelling out, crying, and distress. The facility also did not have a policy or procedure pertaining to dementia management, and staff were unable to identify individualized non-pharmacological interventions for the resident’s dementia-related behaviors. The resident was observed in a wheelchair with the legs positioned behind the footrests, feet not touching the floor, and the back not against the wheelchair back. The resident was tense, grimacing, and yelling continuously in the hallway for an extended period while staff walked past without acknowledging or assisting the resident. When asked about the yelling, an RN stated the resident likely had pain and was due for medications, but was unaware of non-pharmacological interventions. A CNA attempted to reposition the resident’s legs, which increased yelling and grimacing, and the resident continued to yell while being taken to the room and while medications were being prepared. The resident’s record showed care plans for psychosocial distress and grief, but the interventions were general and not individualized to the resident’s current cognitive status or behaviors. Documentation showed a history of agitation and yelling beginning in 2025, with medication changes over time for mood swings, agitation, and pain concerns. Behavioral documentation for May 2026 included multiple instances of crying, disruptive sounds, verbal aggression, and negative statements, with many blank entries. Staff interviews showed uncertainty about the resident’s preferences and effective interventions, and the resident was not receiving restorative nursing services related to limited ROM. Later, therapy determined a Broda chair was more appropriate, and the resident was observed calmer and not yelling while seated in it. Family input later identified specific preferences such as gospel music, hugs, and pictures of grandchildren, but these individualized comfort measures had not been incorporated earlier into the resident’s dementia care approach.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication administration error rate of less than 5% when three medication errors were observed during 25 medication pass observations, resulting in a 12% error rate. During observation of an LPN administering medications, Resident #104’s Voltaren 1% topical gel was not available in the medication room, and the medication was not administered and was omitted. The resident had their knee brace down and was waiting for the gel to be applied when the LPN informed them the medication was not available. During another medication pass observation for Resident #19, the LPN removed Humalog insulin from the cart, selected 5 units, and did not prime the insulin pen before initially preparing it. The LPN also crushed all of the resident’s oral medications together, including mirabegron 25 mg extended-release, despite the medication being an extended-release product that should not be crushed. The LPN later prepared the insulin pen again, primed it with the original needle, discarded that needle, attached a new needle, and administered the insulin after holding the dose injector knob down for two seconds and then holding the pen in place for seven additional seconds. The DON and Clinical Support RN confirmed that extended-release medications should not be crushed and that insulin pens should be primed prior to administration.
Failure to Verify Competence Before Arbitration Agreement Signing
Penalty
Summary
The facility failed to ensure that residents were competent to sign a binding arbitration agreement before signing it for one resident. Resident #36 was admitted with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, diabetes, heart disease, hypothyroidism, anxiety, depression, and arthritis. The admission MDS assessment showed severe cognitive loss with a BIMS score of 6/15. The resident signed the arbitration agreement on 5/4/2026, and the medical record also contained a Physician Determination of Decision Making Capability signed by two medical providers. The Medical Director documented on the same day that the resident was no longer capable of understanding the Bill of Rights and participating in medical treatment decisions, and another provider later documented that the resident was no longer capable of making medical treatment decisions. During interview, the Admissions Director stated the arbitration agreement was reviewed with the resident or representative by the next day after admission or Monday if admitted on a Friday, and that if a resident sounded confused she would ask a nurse or social worker, or contact a POA if one existed. When the resident's signed arbitration agreement was reviewed with her, she said the resident had signed it and was not aware that the physician had determined the resident was not capable of making medical decisions on the same day. The facility policy titled Voluntary Binding Arbitration Agreement stated the agreement was to be presented to the resident or resident's legally authorized representative after admission paperwork was completed, but it did not mention assessing the resident's competence before signing. In a group interview, 10 of 10 residents stated they did not know what the arbitration agreement was or whether they had signed one.
Neglect in Enteral Nutrition, Diabetes Management, and Infection Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to enteral nutrition, diabetes management, and monitoring for infection and respiratory status. The resident was admitted with diagnoses including cerebral infarction, pneumonia, dysphagia, and type 2 diabetes, and was NPO with orders for PEG tube feeding using Glucerna 1.5 at a specified rate, along with insulin lispro on a sliding scale. Upon admission, the facility changed the ordered Glucerna to Jevity 1.5 without documented rationale and did not initiate tube feeding until many hours after admission, with documentation showing Jevity first administered approximately 23 hours after admission and water flushes about 6 hours after admission. The resident’s insulin from the hospital discharge orders was not entered and administered on admission; instead, the facility delayed ordering and starting diabetic medications, with oral Jardiance initiated about 13 days after admission and Lantus insulin about 14 days after admission. The facility did not consistently follow its own parameters and standing orders for hyperglycemia management and failed to timely intervene or notify practitioners despite numerous critically elevated blood glucose readings. Facility policy required notifying the practitioner when blood sugar exceeded 400, yet the resident’s blood sugars were above 300 on at least 29 occasions and repeatedly above 400, including readings of 435, 455, 509, and 510, without documented timely intervention or consistent communication to the practitioner. Progress notes show that on one day a blood sugar of 510 led to an order for 20 units of regular insulin and that the resident’s wife reported noticing a change in condition days earlier and requested transfer to the emergency room. However, there was no documentation of ongoing nursing assessments addressing the persistently elevated blood sugars, no A1C results despite being ordered, and the DON acknowledged that the facility could not identify who was closely monitoring these levels or provide other interventions implemented during the period of sustained hyperglycemia. The facility also failed to assess and document the resident’s pneumonia, respiratory status, and PEG tube site, and did not maintain adequate documentation of changes in condition leading up to the resident’s transfer to the hospital. The resident was admitted on an antibiotic for pneumonia, but the record lacked respiratory assessments, monitoring of pneumonia progression or improvement, documentation of antibiotic use related to pneumonia, or a short-term care plan for this diagnosis. Therapy staff and CNAs reported that over time the resident became increasingly lethargic, weak, and more dependent for transfers, with observations of posterior lean, difficulty with transfers, dizziness, and appearing as “dead weight,” and a speech therapist documented concern for a change in status that was communicated to nursing and the NP. Despite these reports, there were no corresponding nursing assessments or transfer forms in the record. EMS documentation indicated that staff reported the resident had been in an altered mental status with blood glucose levels sustained above 500 for several days prior to transfer, and hospital records described admission for altered mental status, hypernatremia, hyperglycemia, acute kidney injury, and sepsis. The DON and Administrator were unable to locate documentation of PEG site assessments or explain the lack of pneumonia-related assessments and monitoring, confirming gaps in required nursing assessment and documentation. The combination of delayed initiation and inappropriate change of enteral nutrition, failure to follow discharge insulin orders or timely implement diabetes treatment, lack of timely intervention and communication regarding persistently elevated blood glucose levels, and absence of documented respiratory and PEG site assessments for an admitted pneumonia diagnosis constituted neglect of the resident’s care needs. These inactions and omissions led to an unnoticed and undocumented change in condition that ultimately required hospitalization, as evidenced by EMS and hospital records describing the resident’s deteriorated state at the time of transfer.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Assess and Document Change in Condition Resulting in Delayed Pain Treatment
Penalty
Summary
A deficiency occurred when staff failed to promptly assess and document a change in condition for a fully dependent, non-ambulatory resident with multiple comorbidities, including dementia, schizoaffective disorder, and heart failure. The resident exhibited increased pain and abnormal behaviors, such as intense rocking, grimacing, and vocalizations, which were observed by several CNAs and reported to nursing staff. Despite these observations, nursing staff attributed the behaviors to the resident's baseline diagnoses and did not conduct or document a thorough assessment or follow-up, even when the resident's leg was noted to be externally rotated and he displayed pain upon touch. Multiple staff members, including CNAs and nurses, reported noticing the resident's increased discomfort and abnormal leg positioning over several days. These changes were communicated during shift reports and to the responsible nurse, but no progress notes or assessments were completed to address the resident's change in condition. Pain assessments documented a score of zero on the day the leg abnormality was discovered, and pain medication was administered only twice in the days preceding the event. The resident's family member ultimately insisted on hospital transfer, where imaging revealed acute, complete bilateral femoral neck fractures. The facility's investigation did not identify abuse or neglect but concluded that the injuries were likely subacute and possibly pathological in nature. However, the lack of timely assessment, documentation, and communication with the medical director regarding the resident's increased pain and change in condition resulted in a delay in treatment and recognition of the fractures. The facility did not have a specific pain management policy, and staff failed to follow the existing policy for change in resident condition, which required physician and family notification for significant changes.
Failure to Maintain Safe Water Temperatures and Chlorine Levels
Penalty
Summary
The facility failed to monitor and respond to abnormally low hot water temperatures, which is crucial for the prevention and management of Legionella. The Infection Prevention and Control (IPC) Nurses and the Maintenance Director were responsible for reviewing the water management program and monitoring water for Legionella. However, there was a lack of communication and awareness about any issues with the water system, as the IPC Nurse was not informed of any problems. The water management program book showed outdated testing, with the last test conducted in 2023, and the Administrator provided conflicting information about the testing dates. The facility's water testing results indicated that the chlorine levels in certain areas were significantly below the required minimum, and the hot water temperatures were not maintained at the recommended levels. The Corporate Maintenance Director acknowledged that the water temperatures were often below 110 degrees Fahrenheit, which is below the recommended range of 114-118 degrees Fahrenheit due to low chlorine levels. Despite the facility's policy to test water temperatures daily, there were many days without recorded temperatures, and the facility did not consistently test on weekends. The facility's water temperature records revealed numerous instances of temperatures below the recommended levels, with some readings even below 100 degrees Fahrenheit. Maintenance staff admitted to not taking daily temperature checks consistently and acknowledged issues with a mixing valve. The facility's failure to maintain appropriate water temperatures and chlorine levels, as well as the lack of consistent monitoring, created conditions conducive to the growth of Legionella, posing a potential risk to the residents.
Deficiency in Documenting and Accessing Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of six residents was documented and accessible in their medical records, which could lead to miscommunication regarding their treatment preferences. For Resident #12, the electronic medical record (EMR) did not clearly indicate the resident's code status, and the physician's order only referred to a Preferred Treatment Option without specifying the details. Additionally, the care plan for Resident #12 did not mention the code status, and similar issues were found for Residents #21, #53, #79, and #158, where the EMR contained forms with options but lacked specific orders or care plans reflecting the residents' wishes. Resident #92, who had moderate cognitive loss and was receiving hospice services, also had no clear documentation of code status in the medical record. The Clinical Care Coordinator acknowledged the absence of specific orders or care plans for code status and mentioned that staff would need to search through the EMR or refer to a binder at the nurse's desk to find this information. However, the binder was not part of the official medical record, and the process of locating a resident's code status was cumbersome due to the binder's organization. During interviews, it was revealed that the binders containing code status information were difficult to navigate, and some documents, like the one for Resident #92, were of poor quality and unreadable. The facility's policy on Advanced Directives did not provide a clear process for ensuring that residents' code status was easily accessible in the medical record, contributing to the deficiency in maintaining accurate and accessible documentation of residents' treatment preferences.
Failure to Conduct Timely Assessments and Maintenance for Enabler Bars
Penalty
Summary
The facility failed to complete necessary assessments and maintenance checks for enabler bars for four residents, leading to a deficiency in care. Resident #2 was observed with bilateral enabler bars affixed to her bed, but her care plan did not include any information related to these bars. The maintenance logs for Resident #2 were incomplete, with no record of the initial four-day monitoring after installation. The Maintenance Director confirmed that the resident needed the enabler bars, but there was no documentation to support this need. Resident #71 had a care plan for assist rails to enhance mobility, but the quarterly assessments for the continued use of enabler bars were not completed on time. The last assessment was five months late. The maintenance logs were unclear, with an 'X' next to the room number, making it uncertain whether the enabler bars were inspected for safety and functionality. Similarly, Resident #76's assessments were not completed at the appropriate intervals, and the maintenance logs showed lines through the initial monitoring days, indicating a lack of clarity in the documentation. Resident #75 had an initial assessment for enabler bars, but no subsequent assessments were completed. The facility's policy required quarterly evaluations of residents' need for rails, which was not adhered to. The Clinical Care Coordinator acknowledged the responsibility of unit managers to ensure assessments were completed, but the last monthly audits of enabler bars were conducted months prior, indicating a systemic issue in maintaining compliance with the facility's policies.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to include and document the participation of a resident and his representative in the care planning process. The resident, who had been at the facility for nearly three weeks, was not involved in any care planning meetings. His wife, who is his representative, reported that she had not been asked to participate in a care conference or care planning meeting with the resident and the facility. The resident confirmed that he had not been included in any care planning meetings. The resident's medical history includes dementia, heart failure, kidney failure, an intestinal disorder, sepsis, a history of falls, rib fractures, and gait and mobility abnormalities. Despite having full cognitive abilities, as indicated by a BIMS score of 13/15, the resident was not involved in the care planning process. The Clinical Care Coordinator (CCC) responsible for conducting care conferences stated that a meeting was held with the resident's wife over the phone, but no other staff from the interdisciplinary team was present. The CCC also confirmed that the resident was not included in the meeting and that there was no documentation of the meetings with the resident or his wife. A review of the facility's policy on the care planning process emphasized the importance of a collaborative partnership with the interdisciplinary team, resident, and/or resident representative, and the need to provide an opportunity for the resident to participate in planning care and treatment changes. However, this policy was not followed in the case of this resident.
Failure to Update Care Plans for Skin and Nutrition
Penalty
Summary
The facility failed to timely revise and update care plans for two residents, resulting in care plans not reflecting the current status and needs of the residents. Resident #33, who has a history of dementia, major depressive disorder, chronic systolic heart failure, anxiety, and hypertension, was found to have a suspected deep tissue injury (SDTI) on her right heel and ankle. Despite this, the care plan for skin impairment had not been revised since February and did not mention the current skin conditions. The Unit Manager acknowledged that the care plan should have been updated to include a short-term care plan for the SDTI and the actual skin issue, but it was only revised after being notified of the oversight. Resident #63, with diagnoses including dementia, major depressive disorder, encephalopathy, and hypertension, experienced a significant weight loss of 17% over six months. Despite being started on supplement shakes to aid in weight gain, the care plan for nutrition had not been updated since 2021 and did not include a specific plan for addressing the weight loss. The Certified Dietary Manager admitted to not creating a specific care plan for weight loss, instead incorporating it into the general nutritional care plan. This lack of timely updates and specific care plans for the residents' changing conditions led to deficiencies in their care management.
Failure to Document and Monitor Hand Brace for Resident
Penalty
Summary
The facility failed to ensure proper documentation, assessment, and monitoring of a hand brace/splint for a resident who was reviewed for rehab and restorative services. The resident, who was observed with a splint/brace on her right hand, reported that her daughter had provided the brace and staff assisted her in putting it on and off. However, the resident did not perform any exercises for her right hand or arm. The resident's medical records, including the Face sheet, Minimum Data Set (MDS) assessment, and physician orders, indicated that she had multiple diagnoses, including paraplegia, heart failure, COPD, diabetes, and others. Despite an order allowing the use of a soft brace, there was no documentation of restorative services or assistance with the brace in the electronic medical record (EMR), Medication Administration Record (MAR), Treatment Administration Record (TAR), or care plans. Interviews with facility staff, including the Therapy Director and Clinical Care Coordinator, revealed that the facility did not have a dedicated restorative nursing department, but nurse aides were trained to perform restorative functions. The Clinical Care Coordinator acknowledged the existence of an order for the brace but confirmed the absence of further documentation or a care plan related to the brace. The facility's policy on the Restorative Nursing Program emphasized evaluating residents individually to maintain their highest functional level, yet there was no evidence of such evaluation or documentation for the resident's hand brace. This lack of documentation and monitoring represents a deficiency in the facility's care for the resident.
Delayed Response to Resident's Change in Mental Status
Penalty
Summary
The facility failed to act timely on a change in mental status for Resident #11, who was observed experiencing visual hallucinations and delusions. On 4/9/2025, the resident reported seeing cats on her dresser, which she described as resembling wolves. This was a new onset for the resident, who had no prior history of delusions or visual hallucinations. Despite the resident's ability to communicate her needs and the presence of a major depressive disorder among her diagnoses, the facility did not address these symptoms promptly. The resident's hallucinations were first noted on 3/31/2025, when a CNA reported the resident talking about seeing live rats, but no immediate action was taken. The delay in addressing the resident's change in condition was further highlighted by the Nurse Practitioner's documentation on 4/1/2025, which noted the resident's confusion and visual hallucinations but did not result in further assessment or monitoring. It was not until the survey process on 4/9/2025 that the facility began to take steps to address the issue, including initiating a behavior log and planning a medical workup. This lack of timely intervention represents a deficiency in the facility's response to a significant change in the resident's mental status.
Failure to Prevent Pressure Ulcers and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to implement meaningful interventions to prevent the development of a pressure ulcer for Resident #83 and ensure timely skin assessments for Resident #33. Resident #83, who was admitted with multiple diagnoses including a Stage 3 pressure ulcer, was observed to have a worsening condition of her pressure ulcer on the left buttock. Despite being reliant on staff for assistance with turning and repositioning, the facility did not replace her worn wheelchair cushion for over a month, which was a significant factor in the development and progression of her wound. The facility's care plan lacked proactive measures to prevent further skin breakdown, and interventions were only added after the wound had developed. Resident #33, who was admitted with conditions such as dementia and heart failure, had a suspected deep tissue injury on her right heel and ankle. The facility failed to conduct timely skin assessments, as there was a gap between assessments from March 14 to March 28, during which no skin assessment was completed. This oversight was acknowledged by the unit manager, who stated that skin assessments should have been conducted twice weekly in conjunction with shower days. The lack of timely skin assessments contributed to the failure to identify and address skin issues promptly. The facility's policy on skin risk assessment and treatment was not adequately followed, as evidenced by the lack of daily skin inspections and timely reporting of abnormal skin conditions. The deficiencies in both cases highlight a failure to adhere to established protocols for skin care and prevention, leading to the development and progression of pressure ulcers in the residents.
Failure to Follow Enteral Nutrition Orders and Notify DPOA
Penalty
Summary
The facility failed to adhere to a physician's order for enteral nutrition for Resident #95, who was observed with an incorrect infusion rate of 50 mL/hour instead of the prescribed 60 mL/hour. This discrepancy was noted on 4/8/2025, despite the physician's order being updated on 4/1/2025. The nurse responsible for Resident #95 was unaware of the change in the infusion rate, and the error was not corrected until later in the day when the rate was temporarily increased to compensate for the missed volume. Additionally, the facility did not notify Resident #95's Durable Power of Attorney (DPOA) about the change in the tube feed rate from 50 mL/hour to 60 mL/hour. The resident's daughters, who are frequently present at the facility, were not informed of this change or the temporary increase in the infusion rate to make up for the missed volume. This lack of communication with the resident's responsible party was confirmed by both the daughters and the Registered Dietitian. Furthermore, there were no documented orders for the routine cleansing, assessment, and monitoring of Resident #95's PEG tube site following her readmission on 3/21/2025. The Clinical Care Coordinator and Corporate Nurse confirmed the absence of such orders, which are essential for maintaining the site. The facility's policy on medication administration emphasizes resolving any discrepancies before proceeding, yet this was not adhered to in the case of Resident #95.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to operationalize policies and procedures for skin and wound assessments, leading to the development of pressure ulcers in three residents. Resident #1 developed a Stage III pressure ulcer on the coccyx and multiple suspected deep tissue injuries on the feet. The resident was severely cognitively impaired, dependent on staff for repositioning, and had a poor appetite. Despite being on a pressure-relieving mattress, there was a lack of documentation regarding repositioning and the application of protective boots. The care plans lacked specific interventions for each wound, and skin assessments were not conducted consistently. Resident #2 developed a Stage II pressure ulcer on the right buttock and a Stage IV pressure wound on the right ischium. The resident had moderately impaired cognition and was dependent on staff for mobility. The care plan did not include specific positioning guidelines, and wound assessments were not conducted regularly. During a dressing change, infection control protocols were not followed, as the nurse used the same 4x4 gauze to clean multiple wounds without changing gloves or performing hand hygiene. Resident #3's skin assessments were not completed consistently, with gaps of up to 14 days between assessments. The Director of Nursing acknowledged the lack of consistent documentation and indicated that the air mattress settings were incorrect. The facility's policy required weekly skin assessments and documentation of wound characteristics, but these were not adhered to, leading to the deficiencies observed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Montrose Inc | 6.7 mi | ★★★★★ | 27 | 0 |
| Medilodge Of Frankenmuth | 9.6 mi | ★★★★★ | 20 | 0 |
| Wellspring Lutheran Services | 9.6 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Flushing | 9.8 mi | ★★★★★ | 8 | 0 |
| Kith Haven | 11.1 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.