Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Marshall Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
Missing Annual Competency Evaluations for Licensed Nurses: The facility failed to ensure five of five licensed nurses had the competency evaluations identified in the facility assessment. The assessment listed resident needs including wounds, wound vac, trach care, catheters, enteral nutrition, and ostomy care, and the facility had residents with indwelling catheters, a tracheostomy, enteral nutrition, and parenteral nutrition. When annual competency records were requested, only a trach care in-service for two LPNs was provided, along with an older competency checklist for one LPN and an education acknowledgement for an RN from another facility.
A resident with dementia and anxiety repeatedly refused a scheduled shower, but a CNA proceeded after being told by an RN that the shower had to occur regardless of the resident’s objections. During transfer with a mechanical lift and use of a shower chair, the resident became combative, and one CNA held the resident’s wrists down while the other completed the shower, which a second CNA later characterized as abuse. The resident kicked or struck a shower bar or lift bar, developed bruising, swelling, and an abrasion from the knee to the ankle on the right leg, and an X-ray confirmed an acute transverse fibular neck fracture. The resident’s guardian was informed of a bruise and that the resident had been combative, and later learned of the resident’s unexpected death.
A resident with dementia and other psychiatric diagnoses was scheduled for a shower and repeatedly stated she did not want it, but CNAs proceeded after being told by an RN that the shower had to be given. During the transfer with a mechanical lift and while on the shower chair, the resident became combative, was held down by the wrists, kicked wall and equipment bars, and subsequently developed bruising, swelling, and an abrasion of the right lower leg; an X‑ray later showed an acute fibular neck fracture. One CNA later stated that holding the resident’s wrists and forcing the shower constituted abuse, and both CNAs documented that the resident did not want the shower. The DON documented the injury and notified the guardian of a bruise and ordered X‑ray, and the resident later died. The Administrator, despite having CNA statements describing the incident, concluded abuse could not be substantiated and did not report the suspected abuse incident to the state agency, resulting in a failure to report as required.
A resident with dementia and other psychiatric diagnoses was given a shower using a mechanical lift and shower chair after repeatedly refusing, per CNAs who reported they were instructed by an RN that the shower had to be done. During the shower, the resident became combative, kicked a wall or lift bar, and staff held the resident’s wrists to prevent hitting, resulting in bruising, swelling, and fingertip marks, with later X-ray confirming an acute fibular neck fracture. One CNA stated that holding the resident’s wrists and forcing the shower was abuse and violated the resident’s rights. Although the DON documented notifying the guardian of a shin bruise and staff documented the incident on a shower sheet, the facility did not complete or provide an incident report or a thorough investigation of the alleged abuse and injury when requested by surveyors.
Surveyors determined that the facility did not follow its own policy and professional standards for managing food brought in by families and visitors and stored in resident refrigerators. During observations with the DON, surveyors found outside delivery pizza boxes without any labeling, dates, expiration dates, or resident names; a bag of tacos from an outside restaurant that was past the facility’s allowed holding time; and a salad with no date or resident identification. They also observed several opened 2L bottles of soda with no dates or resident names. The DON acknowledged that all such items were required to be labeled, dated, and marked with the resident’s name, and policy review confirmed that refrigerated cooked foods must be date-marked and discarded after a set time, and undated foods discarded.
Surveyors found that two residents with indwelling urinary catheters had drainage bags repeatedly observed resting on the floor rather than being properly secured to the bed and kept off the ground, as required by the facility’s infection control expectations and one resident’s care plan. Despite the ICP’s and DON’s stated expectations that catheter bags hang below the resident and never touch the floor, staff allowed the bags to remain on the floor on multiple observations, indicating a failure to maintain appropriate infection prevention and control practices for catheter management.
A resident with severe cognitive impairment, overactive bladder, and an indwelling urinary catheter had a care plan intervention requiring documentation of catheter output, but staff recorded urine output only a few times during the resident’s stay instead of at least once per shift. CNA staff reported they were supposed to document amounts when emptying catheter bags, and the DON confirmed that catheter output should be recorded every shift. Nursing notes later described the catheter not draining, unsuccessful flushing attempts, and the need to replace the Foley, after which a significant amount of dark yellow urine with sediment was immediately drained, demonstrating that the ordered monitoring intervention was not consistently carried out.
Food service equipment and storage areas were found with debris, dried residue, and damaged surfaces. Clean pitchers, the ice scoop holder, the meat slicer, the scoop drawer, cooler gaskets, and cutting boards all had visible soil or wear, and two hydration pass coolers were not self-draining, allowing ice to mix with meltwater. Freezer #3 also had torn door gaskets, and the plate warmer had only one working side.
Inadequate Legionella and OPPP Water Management: Surveyors found multiple plumbing fixtures and water lines that were disconnected, unused, or not being flushed, including kitchen and pantry dish machines, washer hookups, spa room walk-in tubs, and a commode valve in a converted room. The CFM stated the pantry dish machines were not used, and the MD said several fixtures were not included in the facility’s flushing schedule. The MD also stated free chlorine sampling for hot and cold water had not yet started, and the facility’s Legionella plan only identified vacant resident rooms as potential stagnant water areas.
Two residents with moderate cognitive impairment reported boredom and a lack of meaningful activities, while staff confirmed there had been no weekday activity programming for about a month after the Activity Director resigned. One resident with dementia, blindness, diabetes, and multiple chronic conditions said he was not invited to activities and wanted more options, and another resident with depression and dementia said there was nothing fun to do. Activity calendars were missing or outdated, the hallway activity board was blank, and planned interests such as bingo, crafts, exercise, manicures, intellectual programs, and outdoor time were not observed.
Unqualified Activity Director and Inadequate Activity Program: The facility failed to ensure the Activity Director met qualification criteria for the role. The activity board was blank when first observed, the monthly calendar was posted later, and no activities were observed during the survey week. The calendar was sparse, ended by mid-afternoon, and the Clinical Regional Director could not explain the listed activities. Review of the Activity Director/CNA's file showed no required licensure, certification, recent recreational-program experience, or State-approved training.
Failure to complete monthly pharmacist drug regimen reviews and respond to pharmacy recommendations affected multiple residents. One resident on hospice had missing monthly med reviews and an unaddressed recommendation to reduce omeprazole, while another resident with schizophrenia, dementia, DM, and HF had unsigned pharmacy recommendations for pantoprazole and hyoscyamine. Two additional residents had drug regimen review forms referencing irregularities, but the actual pharmacy recommendations were not found in the chart; the DON and Regional Nurse Consultant acknowledged missing documents and that pharmacy reviews were not being tracked and addressed as required.
QAPI Program Failed to Identify and Correct Multiple Care and Documentation Deficiencies: The facility did not maintain an effective QAPI process, with failures in discharge and bed hold documentation, activity tracking, wound care, advance directive accuracy, and audit oversight. Surveyors found a resident sent to the hospital without documented bed hold/transfer/discharge paperwork, another resident with dementia lacking activity documentation and participation records, a resident with a facility-acquired stage 3 pressure ulcer receiving wound care that did not follow MD orders, expired wound supplies in the med room, and advance directive forms with missing or incorrect witness information that were still marked accurate on audit tools.
Unsafe and Unsanitary Environmental Conditions: Multiple spa rooms, utility rooms, a resident bathroom, the laundry room, supply room, oxygen storage room, and an HVAC unit were observed with environmental and sanitation issues. Findings included missing or poorly placed call light pull cords, call lights that did not activate properly, exposed clean linens, debris and staining in shower areas, gloves and trash bags stored in hand sinks, leaking AVBs, sewer gas odor from an uncovered floor drain, a gap under the oxygen storage door, no bathroom exhaust suction, an unshielded light fixture, briefs stored on the floor, and debris buildup in an AC inverter.
Failure to Honor Guardian-Signed DNR Order: A resident with severe communication and cognitive limitations, trach and PEG status, and multiple chronic conditions was listed as Full Code in the chart and on the physician order, even though the scanned record contained a Michigan DNR order signed by the legal guardian. The SW stated the guardian had requested DNR status, but the prior NHA said a guardian could not determine code status in Michigan, and the DNR was rescinded without documentation of the guardian discussion in the medical record.
The facility failed to give a resident or the resident's representative written notice of the bed-hold policy and the reason for transfer after the resident was sent to the hospital and did not return. The facility also failed to notify the Ombudsman of discharges/transfers for two residents, and leadership acknowledged that written transfer notifications were not being completed.
A resident with aphasia, vascular dementia, quadriplegia, and bilateral hip pressure ulcers developed an open area on an old left hip wound that was later documented as a Stage 3 pressure ulcer. Record review showed wound care was not ordered and implemented until later, and the MDS Coordinator confirmed that a significant change MDS was not completed when the Stage 3 pressure wounds were discovered.
Inaccurate MDS Weight Loss Coding: A resident with multiple chronic conditions, including Parkinsonism, dementia, and dysphagia, had an MDS coded to show significant weight loss and severe cognitive impairment. The RD later stated the weight loss entry was inaccurate and that the weight variance report did not support the coded loss, indicating the MDS was completed incorrectly.
Inconsistent Shower Scheduling and Documentation: A resident with major depression, obesity, and dementia, and moderate cognitive impairment, did not receive showers on a routine twice-weekly schedule as care planned. The resident reported missing showers, the record showed only intermittent showers over several months, and staff interviews confirmed the resident was generally compliant with care while shower tracking had not been routinely monitored.
Delayed CPR initiation for a resident with Full Code status. An LPN found the resident on the floor appearing purplish and left the room to verify code status because the most recent Advance Directive was not readily available in the Code Status binder. CPR was delayed for about 4 to 5 minutes until the LPN returned and began compressions, while an RN remained in the room and did not start CPR.
Delayed Wound Treatment Orders for a Resident With Pressure Ulcers: A resident with aphasia, vascular dementia, quadriplegia, and pressure ulcers of both hips had an open area on an old left hip wound noted in a progress note, but wound care orders were not implemented until later. The left hip wound was then documented as an open old surgical wound and later classified as a Stage 3 PU, with the RCD confirming there was a delay in treatment orders.
Open inhalers in two medication carts were found without dates showing when they were opened, including Trelegy, Albuterol Sulfate, and Combivent inhalers. In the medication room, temperature logs for two medication refrigerators were missing entries on two dates even though temperatures were expected to be recorded twice daily; one refrigerator held controlled meds and another stored refrigerated meds such as vaccines and insulin. The DON stated that open medications should be dated and refrigerator temperatures recorded twice per day.
Failure to provide dental services for a resident with no teeth and missing dentures. The resident, who was cognitively intact and had multiple chronic conditions, said she had dentures at home before admission but did not have them in the facility and had not received updates about getting replacements. The record lacked documentation of a dental referral, and although consent and a physician order were present, the SW could not confirm a referral was sent or why the resident was not scheduled; the dental provider reported no referral had been received and the resident had not been seen.
Failure to offer influenza immunization to a resident with severe cognitive impairment and multiple diagnoses, including aphasia, vascular dementia, quadriplegia, and bilateral hip pressure ulcers. Record review showed no documentation that the flu vaccine was offered for the prior year, although the resident had accepted and received it in earlier years; the RCD could not locate vaccine documentation.
Failure to Offer COVID-19 Vaccine and Document Immunization Status: A resident with aphasia, vascular dementia, quadriplegia, and pressure ulcers had severe cognitive impairment on MDS review and was observed sleeping in bed, unable to participate in an interview. Record review showed no documentation that the COVID-19 vaccine was offered for the prior year, despite the resident having consented to and received the vaccine in earlier years. The RCD could not locate vaccine documentation for that year.
A resident with multiple comorbidities and a MRSA-infected wound did not consistently receive physician-ordered daily wound treatments, as evidenced by over 30 missed treatments and incomplete documentation in the MAR. Weekly wound assessments were also missing on several occasions. Staff interviews confirmed that wound care and documentation were not performed as required, and the resident reported inconsistent dressing changes to wound clinic staff.
Staff failed to keep a resident's controlled medication, Lorazepam 0.5mg, in its original pharmacy packaging and instead repackaged the tablets into multiple unlabeled clear bags and a cup. The repackaged medication lacked required labeling such as resident name, medication name, and directions, and staff could not identify the tablets by appearance. Nursing staff and the DON confirmed the improper storage and labeling, and the individual responsible for the repackaging could not be identified.
The facility did not ensure proper calibration of glucometers or compatibility between glucometers and glucose test strips for residents needing blood glucose monitoring. Staff were unclear about calibration procedures, logs were incomplete or missing, and at least one control result was out of range without documented follow-up. Multiple types of glucometers and test strips were used interchangeably, and the correct control solutions were not always used, leading to improper monitoring practices.
Staff used a ReliOn Premier BLU glucometer, intended for single-patient use only, on multiple residents and cleaned it with unapproved disinfectant wipes, contrary to manufacturer instructions. The DON was unaware of the single-patient restriction, and staff wrapped glucometers in wipes for disinfection, which was not in line with manufacturer guidelines. These practices failed to meet infection prevention and control requirements.
The facility failed to maintain documentation for glucometer calibration, affecting 17 diabetic residents. An LPN stated that glucometers were tested every 24 hours, but the logbook was missing, raising concerns about the accuracy of blood glucose readings. The Regional Nurse confirmed the absence of the logbook, which should have been available for monitoring.
A facility failed to disinfect glucometers between uses, affecting four residents. An LPN was observed performing blood glucose tests without proper disinfection, placing the device on various surfaces without barriers. The LPN cited a lack of germicidal wipes and a hectic environment as reasons for not following protocol. The DON and a Regional Nurse confirmed the risk of infection control breaches, and audits were not available to ensure compliance.
A resident with cognitive impairment and multiple medical conditions developed additional pressure injuries due to the facility's failure to implement proper care interventions. The resident was not repositioned regularly, and pain management was inadequate, leading to severe discomfort and reluctance to move. The pressure-reducing mattress was found unplugged, and a medical device-related pressure injury was identified, indicating a lack of proper care and monitoring.
A resident with multiple pressure ulcers and severe pain did not receive prescribed pain medication consistently, particularly before wound care, leading to uncontrolled pain. Despite having a care plan for pain management, the facility failed to administer Oxycodone as needed, resulting in the resident experiencing severe discomfort and anxiety during care procedures.
The facility did not send notifications of emergency transfers for 41 residents to the State LTC Ombudsman over the past year. The Ombudsman confirmed not receiving any notifications despite inquiries. The RCD could not provide evidence of sent notifications, only a list of transferred residents.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 49 residents. Observations included peeling shrink wrap on cooler doors, soiled kitchen appliances, and inadequate air gaps in plumbing. Kitchenettes also had soiled ventilation grills and light covers. These issues indicate a failure to adhere to food safety standards, increasing the risk of cross-contamination.
The facility failed to maintain the outdoor waste receptacle, affecting 49 residents. The receptacle was missing a rear sliding door and had a cracked swinging door, increasing pest attraction. The Dietary Manager planned to contact the waste removal company for repairs. Facility policy requires regular cleaning and sanitizing of garbage cans, reporting damage for replacement, and maintaining dumpsters covered and clean.
The facility failed to maintain a clean and sanitary environment, affecting 49 residents. Observations included soiled flooring, stained ceiling tiles, and non-functional light bulbs in resident rooms. Common areas had missing vacuum breakers, damaged chairs, and soiled ventilation grills. Maintenance logs lacked documentation of these issues, indicating inadequate follow-up. Policies for housekeeping and maintenance were not effectively implemented, leading to potential cross-contamination and decreased air quality.
The facility failed to secure medication and treatment carts, with two carts found unlocked and containing prescribed medications. Additionally, an RN left a medication cart unlocked and a computer with a resident's medical record exposed while administering medications, compromising security and confidentiality.
The facility failed to provide palatable and temperature-controlled food, affecting 49 residents. Observations showed food temperatures outside safe ranges, and residents reported dissatisfaction with taste and lack of alternative options. The dietary staff acknowledged these issues, and plans for an alternative menu were not yet implemented.
A resident with severe cognitive impairment was observed in a wheelchair with a torn and cracked arm cushion, which was not reported for repair by the LPN. The ADON confirmed no report was made, highlighting a lapse in communication and protocol adherence, posing an infection control issue.
A facility failed to accurately complete an MDS assessment for a resident regarding the use of restraints. The resident, with multiple medical conditions, used side rails for assistance, which were incorrectly coded as restraints in the MDS. Interviews revealed that the side rails were intended as assistive devices, and the MDS Coordinator acknowledged the coding error, indicating a lapse in accurate assessment and documentation.
A resident admitted with complex medical conditions did not receive a baseline care plan within 48 hours as required. Despite being cognitively intact, the resident was unaware of her care plan. Facility staff acknowledged the oversight, noting the plan was completed but not uploaded to the medical record in time, and a crucial part of the plan was incomplete.
A resident with multiple contractures was not provided with necessary splints and braces as per their care plan, potentially worsening their condition. Observations showed the splints were left on a chair instead of being applied. Staff interviews revealed confusion about responsibilities, with CNAs lacking access to printed care plans, leading to inconsistent care delivery.
A facility failed to obtain weights per policy for a resident, leading to potential inaccuracies in assessing the resident's nutritional status. The resident, with multiple diagnoses, experienced significant weight loss and expressed dissatisfaction with the facility's food, often refusing meals. The resident's menu ticket lacked information on food preferences, and the Registered Dietician's request for a reweigh was not completed, contributing to the deficiency.
The facility failed to properly store, clean, and label oxygen and respiratory equipment for two residents, leading to potential cross-contamination and respiratory illnesses. One resident was observed with undated oxygen tubing and unbagged nebulizer equipment, while another had a nasal cannula lying on bed linens. The ADON/ICN noted that equipment should be changed and stored correctly, highlighting a lapse in infection control practices.
A facility failed to maintain effective communication with a contracted dialysis center, resulting in incomplete documentation of a resident's dialysis care and weight tracking. The resident, with end-stage renal disease, had an order for weekly weights, but inconsistencies in weight documentation were noted. The dialysis center did not consistently complete communication forms, leading to a deficiency in monitoring the resident's condition.
A facility failed to assess and measure bed rails for a resident, risking entrapment. The resident, with multiple health issues, used side rails for mobility. Staff admitted to not measuring the rails, despite policy requirements for assessments at installation and quarterly.
A facility experienced a 16% medication error rate due to improper administration practices. An RN gave a sublingual medication orally mixed with pudding, and another RN administered Flomax before breakfast and failed to ensure a resident swallowed their medication. Additionally, the RN did not prime an insulin pen before use, citing unfamiliarity with the facility's procedures as a travel nurse.
The facility failed to offer alternative food choices, leading to dissatisfaction among residents. A resident reported refusing meals due to unappealing food, with only a peanut butter and jelly sandwich as an alternative. Another resident was unaware of other options, and a third resident noted the absence of an alternative menu despite promises. Observations confirmed the unappetizing nature of meals served.
A facility failed to coordinate hospice services for a resident with COPD and dementia, resulting in potential inadequate care. The resident was not provided with a hospice calendar, and the facility's hospice notebook lacked a complete plan of care and visit schedule. The ADON could not provide necessary documentation, and the SW confirmed a delay in documenting a care conference with the hospice agency.
Missing Annual Competency Evaluations for Licensed Nurses
Penalty
Summary
The facility failed to ensure five of five licensed nurses had the competency evaluations identified in the facility assessment. The facility assessment, updated and reviewed with the QAA/QAPI committee, listed resident needs including wounds, wound vacuum, tracheostomy, catheters, enteral nutrition, and ostomy care, and it identified annual competencies for staff in specialized care areas such as catheter care, tracheostomy care/suctioning, tube feedings, and wound care/dressings. The facility's CMS 802 showed residents with indwelling catheters, a tracheostomy, enteral nutrition, and parenteral nutrition. On 5/13/26, annual competency evaluations were requested for five licensed nurses, but the document provided was only a tracheostomy care education/in-service record for two LPNs. The DON stated the facility had previously identified missing skills competencies and had scheduled a skills fair for the following week, and also reported that agency staff verified competency by signing an attestation. The NHA later stated the facility had identified that annual competency evaluations had not been completed and that a skills fair had been scheduled, and the only additional documents located were an older competency checklist for one LPN and a nurse education acknowledgement signed by an RN for another facility.
Failure to Prevent Physical Abuse and Honor Refusal of Shower Leading to Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to refuse care during a shower. The resident was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety, who had been reported by her guardian as being in her normal state prior to the incident and without prior reports of a change in condition. On the day in question, the resident was scheduled for a shower. According to interviews and documentation, when CNAs entered the resident’s room with a mechanical lift and shower chair and placed the sling under her, the resident became combative, yelled that she was not supposed to receive a shower, and repeatedly stated she did not want the shower. Despite the resident’s repeated refusals, CNA F reported that she proceeded with the shower because RN H told her that the resident had to be showered or she would be written up, and that “no matter what” the resident was going to get a shower. Both CNAs described the resident as combative, digging into their skin, hitting, and kicking. CNA F stated she held the resident’s arms down by the wrists while CNA G washed the resident, and CNA G confirmed she saw CNA F holding the resident’s wrists to prevent the resident from hitting her. CNA G later stated that holding the resident’s wrists down and forcing the shower despite the resident’s refusal constituted abuse and that the shower should not have been given once the resident clearly refused. During the course of this forced shower, the resident sustained an injury to her right lower leg. Accounts from staff varied slightly, with CNA F and CNA G reporting that the resident kicked a bar on the wall in the shower room and/or the mechanical lift bar, and RN H reporting that the resident hit her leg on the mechanical lift bar when being transferred. Post-incident documentation by RN H described bruising, swelling, and an abrasion to the right shin, with swelling from the knee to the ankle, guarding of the leg, yelling out with touch, and refusal of range of motion of the knee. A progress note by the DON documented that the resident became aggressive during the shower and hit her leg on the shower chair, resulting in a bruise, and an X-ray subsequently showed an acute transverse fibular neck fracture of the lower leg. The resident’s guardian was notified of the bruise and told that the resident had been combative during the shower, and later learned of the resident’s death, which she described as a shock given that she had not been informed of any change in condition prior to that day.
Failure to Report Suspected Abuse Related to Forced Shower and Resulting Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to report to the state agency an allegation of abuse related to a resident who was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety. The resident had been admitted and later returned to the facility, and subsequently expired with a physician-documented time of death of 3:34 PM (actual time 2:34 PM). On the day of death, a progress note documented that the ADON was on the phone with the resident’s guardian discussing a change in condition and an assessment by the Medical Director when two CNAs reported they believed the resident had passed away. The ADON assessed the resident and found her unresponsive, with fixed eyes, no visible breathing, no lung sounds, and no apical pulse after a full 60‑second check, and the Medical Director then confirmed death at 2:34 PM. Prior to the resident’s death, there was an incident during a scheduled shower in which the resident, who repeatedly stated she did not want a shower, became combative. CNA F and CNA G reported that the resident was yelling, digging into their skin, hitting, and kicking while being transferred with a mechanical lift and placed on a shower chair. Both CNAs documented that the resident did not want the shower and that she kicked bars in the shower area, resulting in bruising. CNA F stated she was told by RN H that the resident had to receive a shower or she would be written up, and that she held the resident’s arms down by the wrists while CNA G washed the resident. CNA G confirmed that the resident was very irate, kicking, and that she saw CNA F holding the resident’s wrists down while the resident continued to say she did not want the shower, and later stated she considered both the forced shower and the wrist‑holding to be abuse. Clinical documentation and staff statements showed that after the shower incident the resident had bruising, swelling, and an abrasion to the right shin, with swelling from knee to ankle, guarding of the leg, yelling out with touch, and refusal of ROM of the knee. An X‑ray later revealed an acute transverse fibular neck fracture of the lower leg. The DON’s progress note to the guardian indicated that during the shower the resident became aggressive and hit her leg on the shower chair, causing a bruise, and that an X‑ray was ordered. The guardian reported being told that the resident had been hostile during the shower and had kicked a bar on the wall, and that she was later notified of a bruise and then of the resident’s death, without prior calls about a change in condition. Despite CNA F’s written statement and CNA G’s characterization of the incident as abuse, the Administrator stated she was not able to substantiate abuse and therefore did not report the incident to the state agency, resulting in the failure to report suspected abuse as required.
Failure to Investigate Alleged Abuse and Injury During Forced Shower
Penalty
Summary
The deficiency involves the facility’s failure to investigate and report an alleged abuse incident and injury involving one resident. The resident was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety, who later expired at the facility. According to staff interviews and documentation, two CNAs attempted to provide a shower using a mechanical lift and shower chair after being directed by an RN that the resident had to receive a shower. The resident repeatedly stated she did not want a shower and became combative, yelling, kicking, hitting, and digging into staff skin. During the shower process, the resident kicked a shower bar on the wall and/or the mechanical lift bar, and staff documented bruising to the right shin and fingertip bruising on the arms from efforts to control the resident’s movements. One CNA admitted to holding the resident’s wrists down while the other CNA washed the resident, and another CNA stated that forcing the resident to shower against her will and holding her wrists down constituted abuse and violated the resident’s rights. Subsequent nursing documentation and a written statement by the RN indicated the resident developed bruising, swelling, and an abrasion to the right shin, with swelling from the knee to the ankle, guarding of the leg, and yelling out with attempts at touch or range of motion. An X-ray later showed an acute transverse fibular neck fracture of the lower leg. The DON documented notifying the resident’s guardian about a bruise to the right shin and indicated the injury occurred when the resident hit her leg on the shower chair during aggression in the shower. Despite the documented injury, staff statements describing actions they considered abusive, and the resident’s expressed refusal of the shower, the facility did not provide an incident report or evidence of a thorough investigation when requested by surveyors. The report states that the facility did not perform an investigation regarding the incident.
Failure to Label and Date Outside Food Stored in Resident Refrigerators
Penalty
Summary
Surveyors found that the facility failed to ensure that food brought in by families and visitors and stored in resident refrigerators was labeled and dated in accordance with facility policy and professional standards. During an observation of the south unit refrigerator with the DON, surveyors observed a large and a small box of outside delivery pizza with no labeling, no date, no expiration date, and no resident name. On another hall, surveyors observed in the refrigerator a bag of tacos from an outside restaurant with a receipt date indicating it had been received several days earlier and was past the facility’s allowed holding time, as well as a salad with no date and no resident name. Additionally, multiple opened 2-liter bottles of soda (blood orange, grape, and another flavor) were present without dates or resident names. The DON acknowledged that these items should have been labeled, dated, and identified with the resident’s name. Review of the facility’s written policy on foods brought in for residents showed that refrigerated cooked food items must be discarded after three days, all opened packages must have an open date and use-by date clearly marked, and foods found without dates are to be discarded, which was not followed in these instances. No specific resident medical histories or conditions were described in the report related to these observations.
Failure to Maintain Proper Positioning of Catheter Drainage Bags
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of indwelling urinary catheter drainage bags for two residents. One resident was observed on multiple occasions lying in bed with a catheter bag that was 100% on the floor and not attached to the bed, despite a care plan intervention dated 9/11/2025 specifying that tubing or any part of the drainage system should not touch the floor. Another resident was repeatedly observed in bed with a catheter bag hanging from the bed but with the bottom of the bag resting on the floor, including after the bag had been moved and attached to a different part of the bed. In interviews, the Infection Control Preventionist stated that catheter bags should always hang on the side of the bed, below the resident and not touching the ground, and the DON confirmed that catheter bags should not be on or hanging on the floor and that this was an infection control concern. These observations and interviews demonstrate that staff did not consistently follow established infection control practices and the resident’s care plan interventions regarding proper positioning of catheter drainage bags, resulting in catheter systems resting on the floor for two of three residents reviewed with catheters.
Failure to Implement Care Plan for Catheter Output Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention to document urinary catheter output for a resident with an indwelling catheter. The resident was admitted with diagnoses including overactive bladder and intellectual disabilities, and a Discharge MDS indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The resident’s catheter/ostomy care plan, dated 10/9/25, included an intervention to document urinary output, yet the output record showed only four entries over a nine-day admission, despite the expectation that catheter output be documented at least once per shift. Nursing documentation later noted that the resident’s catheter was not draining, attempts to flush with sterile water were unsuccessful, and the Foley catheter was removed and replaced, after which 500 mL of dark yellow urine with sediment immediately drained. Interviews confirmed that CNAs were expected to empty catheter bags multiple times per day and document the amount under urine output, and the DON confirmed that urinary catheter output should be documented minimally every shift. The DON acknowledged that the resident had only four documented outputs during the entire admission, demonstrating that the care plan intervention to document catheter output was not consistently implemented.
Food Service Equipment and Storage Areas Not Kept Clean or in Good Repair
Penalty
Summary
The facility failed to maintain food service equipment and storage areas in accordance with professional standards. During observation, a beverage pitcher stored with other clean containers under the prep table had brown and white dried liquids on it, the kitchen ice scoop holder had an increased accumulation of white and brown crusted debris at the bottom inside, and the meat slicer had dried meat debris on the back blade and back top portion of the unit. The clean mechanical scoop drawer also had excess crumb debris in the back corners, and the drawer only opened halfway, making it difficult to clean effectively. The two-door Horizon cooler had increased debris on the top side of the door gaskets. The hydration pass stations on the Forest Unit and the [NAME] Unit each had coolers for ice that were not fitted with a means to self-drain, allowing ice for consumption to comingle with melted ice water. At the [NAME] Unit station, the cooler contents were observed to be half water and half ice. The kitchen cutting boards were also observed to be stained with orange and brown debris and had deep cut marks, and the white cutting board was identified by the CFM as needing resurfacing or removal from use. The CFM also stated that the plate warmer only had one side working and staff had to work off the one side while keeping a cover on the nonworking side to keep plates hot. Freezer #3 had ripped and torn gasket seals in the middle of both doors.
Inadequate Legionella and OPPP Water Management
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation, surveyors found a water line to the left of the hand sink at the drink station in the kitchen that was not connected to anything and indicated a stagnant water line. In the Forest Pantry, surveyors observed a dish machine that was not connected to a wastewater line and water lines where a stackable washer and dryer would go, with nothing connected to the water fixtures at that time, indicating a stagnant water line. In the [NAME] Pantry, surveyors observed a dish machine and a washer with accumulation of debris on the inside, indicating they had not been used or flushed and indicating a stagnant water line. The Certified Food Manager stated the dish machines in the pantries are not used. Surveyors also observed the Forest Unit spa room and the [NAME] South spa room, where walk-in tubs were holding stored items and had debris accumulated in the bottoms of the tubs. The Maintenance Director stated the facility has flushing Fridays for some fixtures, but the pantry dish machines, washer water lines, spa room tubs, and a commode valve in the converted Central Supply room were not part of the flushing schedule. The Maintenance Director also stated the tubs were not being used to his knowledge, the facility had not started collecting free chlorine samples for hot and cold water supply, and the facility's Legionella plan overview stated only vacant resident rooms more than 30 days old were identified as possible stagnant water areas.
Lack of Meaningful Activity Programming and Resident Engagement
Penalty
Summary
The facility failed to provide meaningful and engaging activities of interest for two residents reviewed and failed to provide activity programming during the week. One resident was admitted with diagnoses including type 2 diabetes, frontotemporal neurocognitive disorder, legal blindness, polyosteoarthritis, diabetic polyneuropathy, obesity, lymphedema, tachycardia, bradycardia, chronic kidney disease, and anemia, and had a BIMS score of 11 indicating moderate cognitive impairment. During observation and interview, the resident was sitting at the side of the bed and stated the facility did not have enough activities to keep his interest, that he wanted more options and more activities, and that no one had invited him to activities in a very long time. An activity calendar posted over the bed was not current at one point and later the resident could not answer when the September activity calendar was provided. Another resident with diagnoses including major depression, obesity, and dementia had a BIMS score of 12 indicating moderate cognitive impairment. During interview, the resident reported there was nothing fun or entertaining to do and that he was very bored. The main hallway activity board was blank and the activity calendar was not posted until later. A CNA stated the former Activity Director had resigned about a month earlier, the new person had not started, and there had been nobody doing activities during the week, with only a part-time person sometimes coming on weekends. The resident’s care conference notes documented a request for more activities and new items such as dye and sand art, while the activity care plan listed bingo, manicures, crafts, exercise programs, intellectual programs, and time outside, none of which were observed during the survey dates. The last activity assessment was dated April 2021.
Unqualified Activity Director and Inadequate Activity Program
Penalty
Summary
The facility failed to ensure the Activity Director met the criteria as a qualified activities professional for a current census of 46 residents. On observation of the main hallway on 09/02/25, a large board intended to post the weekly activities was blank, and the activity calendar was not posted until 09/04/2025. The September activity calendar listed activities 7 days a week, with the latest activity ending at 3:30 PM, and included titles such as Morning News, Church Packets, and Conversation ball. During the survey week of 9/02-09/08/25, zero activities were observed. On 09/08/2025, the NHA reported being new to the facility and directed the surveyor to the Clinical Regional Director because the Activity Director/CNA Z now worked as a CNA. The Clinical Regional Director stated the facility had hired a new Activity Director whose first day was to be 9/08/25, and reviewed the September activity calendar, which had been made by Activity Director/CNA Z. The Clinical Regional Director could not explain what was entailed in the listed activities and agreed the calendar was sparse and offered nothing in the late afternoon or early evening. Review of Activity Director/CNA Z's personnel file showed that when hired for the Activity Director position, she did not have a license, registration, or certification as a recreation specialist or activity professional by a recognized accrediting body, did not have two years of experience in a recreational program within the last 5 years, and had not completed a training course approved by the State Agency.
Failure to Complete and Respond to Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews in accordance with its policies and procedures and failed to implement or respond to pharmacy recommendations for multiple residents. For Resident #5, who was readmitted to the facility and received hospice care, the record showed no documentation of monthly medication reviews for December 2024, January 2025, April 2025, and May 2025. A pharmacy review dated 2/12/25 recommended decreasing omeprazole 40 mg twice daily to 20 mg twice daily 30-60 minutes before meals, tapering as tolerated, but there was no documentation that the recommendation was acted upon, agreed with, disagreed with, or signed by the provider. For Resident #3, who had diagnoses including paranoid schizophrenia, dementia, diabetes, and heart failure, pharmacy recommendations dated 11/20/24 and 12/10/24 were not signed by the provider. One recommendation was to consider gastroprotection with pantoprazole 20 mg once daily, and another was to evaluate whether hyoscyamine was still needed and consider discontinuing it due to lack of use. For Resident #28, who had diagnoses including end stage renal disease, diabetes, morbid obesity, depression, gastro-esophageal reflux, chronic kidney failure, and peripheral vascular disease, and for Resident #46, who had diagnoses including need for assistance with personal care and a BIMS score of 12, the medical record contained pharmacist drug regimen review forms stating to see the report for irregularities and/or recommendations, but no copies of the pharmacy recommendations were found scanned into the records. During interview, the Regional Nurse Consultant and DON stated they were aware of missing documents and unanswered pharmacy recommendations, and reported that pharmacy reviews were not being tracked and addressed as required.
QAPI Program Failed to Identify and Correct Multiple Care and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven QAPI program, as shown by multiple deficiencies involving discharge documentation, activity programming, wound care, advance directives, and audit accuracy. The report states that the facility policy required the QAPI plan to address data collection, monitoring, analysis of quality deficiencies, corrective actions, and evaluation of effectiveness, but the facility did not demonstrate ongoing documentation or accurate completion of its audits and related processes. For one resident who was hospitalized and readmitted after surgery for a displaced left tibia fracture, the record did not show that bed hold, transfer, or discharge notices were discussed or documented when the resident went out to the hospital. The DON stated staff were supposed to report these events, but also stated he did not know how the issue did not show up in audits and that he did not write a progress note when the resident was sent out. The resident stated he did not receive bed hold, transfer, or discharge paperwork before going to the hospital or when he returned. For another resident with dementia and multiple chronic conditions, the activity director stated she did not track or document who participated in activities, did not have an October calendar because the computer crashed, and could not provide an activity calendar or activity involvement record for the resident. The resident stated he had nothing to do and was not taken to activities. The record showed the resident had preferences for cooking, movies, music, and radio, but there was no documentation supporting participation in preferred activities or whether he was asked to participate. The report also documented wound care and audit failures for a resident with a facility-acquired stage 3 coccyx pressure ulcer. The resident was ordered repositioning every 2 to 3 hours, a low air loss mattress, and specific wound care including wound cleanser, skin prep, Medi-honey, hydrogel, collagen, and a foam border dressing. Surveyors observed that the resident was on a regular mattress, had no heel protective boots, and the wound care performed did not follow the physician’s orders because the wound was not cleaned with wound wash and Medi-honey and skin prep were not applied. Expired wound care supplies were also found mixed with non-expired supplies in the medication room. Additional deficiencies involved advance directives and bed hold audits. One resident’s DNR order lacked witness signatures and dates, yet the facility’s audit tool marked the advance directive as completed accurately. Another resident’s DNR form had incorrect witness information and missing date information, but the audit tool again marked it as accurate. A separate resident’s bed hold policy was not found in the record, and the resident was not included in the facility’s discharge and bed hold audits because the DON was not aware of the discharge. The report also noted that two hydration pass coolers were not self-draining even though the facility had alleged compliance that they were fixed, and maintenance could not provide documentation showing the coolers had been repaired or replaced.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, including spa rooms, utility rooms, resident bathrooms, the laundry room, supply room, oxygen storage room, and a unit HVAC unit. Observations found call lights in spa rooms with pull cords positioned 18 to 28 inches off the ground, one far shower call light with no pull cord, and another shower call light that did not activate on first pull. In the Forest Unit spa room, a nickel-sized snowflake sticker remained on the shower wall and three clean washcloths were left open and exposed on the rack outside the first shower stall. In the [NAME] South spa room, the shower bed had increased debris on the mat and dark brown staining and dirt accumulation underneath the mat surface. In the [NAME] North spa room, clothes and towels were set up for the next resident and a large amount of hair was found in the shower drain. Additional observations showed two boxes of gloves and two rolls of trash bags stored in hand sinks in soiled utility rooms, leaking atmospheric vacuum breakers in the Forest Unit janitors closet and the [NAME] janitors closet, an uncovered floor drain in the central supply room with sewer gas odor and air movement from the drain, and a 1/4 inch gap under the oxygen storage room access door. A resident bathroom call light had no pull cord, and the bathroom exhaust ventilation in resident room [ROOM NUMBER] had no audible or visual suction when tested with a paper towel. The laundry room had one main light fixture without a protective shield, the [NAME] South clean utility room had eight packages of briefs stored on the floor under shelving, and the AC inverter on the [NAME] South unit had increased accumulation of black spotted debris on the inside fan mechanism. The Maintenance Director stated CNAs should clean up between residents and housekeeping staff tidy and clean daily, and also stated he had not recently been on the roof to check exhaust ventilation.
Failure to Honor Guardian-Signed DNR Order
Penalty
Summary
The facility failed to honor a resident's/guardian's advance directive for Do Not Resuscitate (DNR) status for Resident #4. The resident was admitted with multiple complex diagnoses including cerebral palsy, epilepsy, dysphagia, cognitive communication deficit, chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. The most recent MDS indicated a BIMS could not be completed because the resident was rarely or never understood. During observation, the resident was lying in bed, appeared well groomed, and did not respond to verbal questions. The medical record banner and physician order both listed the resident as Full Code, with an order for CPR. However, the resident's scanned medical record contained a Michigan Do-Not-Resuscitate Order signed by the legal guardian. A progress note stated the physician was aware of the code status change to full code. In interview, the Social Worker explained the guardian had requested the Michigan DNR order and that the resident had been a DNR, but the previous Nursing Home Administrator stated a guardian could not determine code status in Michigan, after which the DNR order was rescinded. The Social Worker was unable to provide documentation in the medical record showing the conversation with the guardian or documentation of the guardian's wishes.
Failure to Provide Required Transfer, Discharge, and Bed-Hold Notices
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of the facility bed-hold policy and the written reason for transfer for one resident who was transferred to the hospital and did not return. The clinical record for that resident contained no documentation that the resident or representative was provided a written explanation, in a language they would understand, for the transfer and no documentation that bed-hold information was provided. The facility also failed to provide notice of discharges and transfers to the representative of the Office of the State Long-Term Care Ombudsman for two residents. One resident was admitted with chronic kidney failure and heart failure and was transferred to the hospital, while another resident was admitted and later discharged home against medical advice; during interviews, facility leadership acknowledged that transfer notification in writing was not being done and that the Ombudsman had not been notified of discharges/transfers in July 2025.
Failure to Complete Significant Change MDS After New Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to submit a significant change MDS for one resident when a significant change in condition occurred. The resident was admitted and later readmitted with diagnoses including aphasia, pressure ulcers of both hips, vascular dementia, and quadriplegia, and the MDS with an ARD of 06/27/2025 showed severe cognitive impairment with a BIMS score of 4 out of 15. Record review showed a progress note on 03/12/2025 documenting that the resident’s left hip had an open area on an old wound, and physician orders showed wound care for the left hip was not ordered and implemented until 04/05/2025. A later progress note on 04/05/2025 stated the old surgical wound on the left hip had opened up, treatment was in place, and the wound doctor would evaluate the resident that week; additional documentation identified the left hip open area as a Stage 3 pressure ulcer. In interview on 09/08/2025, the MDS Coordinator confirmed that a significant change MDS was not completed when the resident’s Stage 3 pressure wounds were discovered.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident, identified in the report as Resident #25, out of 12 residents reviewed for accurate assessments. The resident was admitted with multiple diagnoses including Parkinsonism, seizures, type 2 diabetes, anemia, anxiety, bipolar disorder, hypothyroidism, peripheral vascular disease, gastro-esophageal reflux disease, constipation, Parkinson's disease, malnutrition, dementia, and dysphagia. The MDS with an ARD of 03/18/2025 showed a BIMS score of 00, indicating severe cognitive impairment, and section K0300 was coded to indicate weight loss of 5% or more in the last month or 10% or more in the last 6 months. A progress note dated 03/20/2025 documented a current weight of 109.2 lbs, BMI 17, and stated the resident had lost 17 lbs (13.6%) over 32 days, with a puree diet, honey thick liquids, and supplements in place. However, the Registered Dietician later stated that the weight loss information was not accurate, that the weight variance report did not show the resident had actually lost weight, and that the MDS had been coded incorrectly. The facility's Weight Variance Report dated 01/01/2025 showed the resident did not have weight loss greater than 3.5% during that period.
Inconsistent Shower Scheduling and Documentation
Penalty
Summary
The facility failed to ensure showers were provided on a routine, regularly scheduled basis and as preferred for one resident. Resident #6 was admitted with diagnoses including major depression, obesity, and dementia, and had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The resident reported being displeased about not receiving showers twice a week and stated that showers were supposed to be provided on the afternoon shift, but this did not happen consistently. Review of the clinical record showed the resident received 3 showers in April, 3 in May, 3 in June, and 5 in July 2025. There was no evidence in the record that the resident refused any showers. The care plan dated 6/3/24 stated the resident would receive showers twice a week on the afternoon shift. A CNA familiar with the resident stated the resident never refuses care and occasionally complains about not getting a shower the night before. An LPN/Unit Manager stated the resident was compliant with care and showers but was new to the position and did not realize the resident was not getting showers routinely. The interim DON stated she had recently implemented shower documentation to be tracked on the treatment record in order to monitor showers.
Delayed CPR Initiation for a Full Code Resident
Penalty
Summary
The facility failed to initiate CPR in a timely manner for one resident who had orders for Full Code and CPR. The resident had diagnoses including COPD and respiratory failure and expired at the facility. The medical record contained a physician order for Full Code, Give CPR, but there was no documentation describing the events surrounding the resident’s change in condition and death. During interview, an LPN stated she was alerted that the resident was on the floor in his room, lying on his stomach and appearing purplish. She stepped out to call for help and then left the room to confirm the resident’s code status, but could not readily locate the most recent Advance Directive in the Code Status binder at the nurses station. She found an Advance Directive from a prior admission that indicated Full Code, and said the process of locating the document and making phone calls took about 4 to 5 minutes. When she returned, staff had not initiated CPR, so she turned the resident onto his back and began CPR. An RN confirmed she remained in the room while the LPN was checking code status and that CPR was not started until the LPN returned. The RCD stated CPR should be initiated immediately and confirmed the resident’s most recent Advance Directive was not readily available, which led to the delay.
Delayed Wound Treatment Orders for a Resident With Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not maintained when the facility failed to implement wound treatment orders in a timely manner for Resident #13. The resident had diagnoses including aphasia, pressure ulcers of the right and left hip, vascular dementia, and quadriplegia. The MDS dated 06/27/2025 reflected severe cognitive impairment with a BIMS score of 4 out of 15. On 03/12/2025, a progress note documented that the resident’s left hip had an open area on an old wound. The physician orders showed that wound care for the left hip was not ordered and implemented until 04/05/2025. A progress note on that date documented that the old surgical wound on the left hip had opened up, treatment was in place, and the wound doctor would evaluate the resident that week. Further documentation identified the left hip open area as a Stage 3 pressure ulcer with full-thickness skin loss. The Regional Clinical Director stated that the facility had identified a delay in treatment for pressure ulcers and confirmed there was a delay in treatment orders for this resident.
Medication Labeling and Refrigerator Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to label open medications with the date they were opened in two medication carts reviewed. During inspection of the North medication cart with an LPN, three inhalers were observed open without an open-date recorded on the container: Trelegy 100 mcg/62.5 mcg/25 mcg inhalers and two Albuterol Sulfate 90 mcg inhalers. The LPN stated it was the facility practice to date medications when opened but could not explain why these inhalers were not dated and said she would call pharmacy to replace the undated inhalers. The facility also failed to record refrigerator temperatures for two medication refrigerators. In the medication room, three refrigerators were observed, including one containing locked controlled medications and another containing refrigerated medications such as vaccinations and insulins. Review of the temperature logbook showed no recorded temperatures for 09/06/2025 and 09/02/2025 for refrigerators #1 and #2, even though temperatures were expected to be recorded twice daily. Current observations showed refrigerator #1 at 36 degrees Fahrenheit and refrigerator #2 at 46 degrees Fahrenheit. During inspection of the second medication cart, an open Combivent 20 mcg/100 mcg inhaler was also found without an open date. The DON stated it was her expectation and policy that all medications be dated when opened and that refrigerator temperatures be recorded twice per day.
Failure to Arrange Dental Services for an Edentulous Resident
Penalty
Summary
Provide or obtain dental services for each resident was not met for one resident who was admitted with diagnoses including bipolar disorder, type 2 diabetes, hypertension, hyperlipidemia, GERD, restless leg syndrome, paranoid schizophrenia, chronic pain, anxiety, depression, and obesity. The resident’s most recent MDS showed a BIMS of 15, and during observation she was edentulous. She stated that she had dentures at home before coming to the facility, but she did not have them after admission and had told someone she wanted dentures, though she had not received updates about obtaining them. The resident’s record did not contain documentation of a referral for dental services. Her care plan identified impaired oral/dental status because she had no natural teeth or tooth fragments and did not currently have her dentures. Although a consent for dental services and a physician order for dental service were later found in the record, the social worker could not explain whether a referral had been sent or why the resident had not been placed on the list to be seen. The third-party dental receptionist stated that the facility had not provided a referral document for the resident, and the resident had not received dental services when the provider last visited the facility.
Failure to Offer Influenza Immunization
Penalty
Summary
The facility failed to offer the influenza immunization to one resident out of five reviewed for immunizations. The resident was admitted and later readmitted with diagnoses including aphasia, a pressure ulcer of the right hip, a pressure ulcer of the left hip, vascular dementia, and quadriplegia. The Minimum Data Set with an ARD of 06/27/2025 reflected a BIMS score of 4 out of 15, indicating severe cognitive impairment. On 9/02/2025, the resident was observed in bed sleeping and did not respond to an interview request. During immunization record review, there was no documentation showing that the influenza vaccine was offered for 2024, although the resident had consented to and received the influenza vaccine in prior years. On 9/08/2025, the Regional Clinical Director stated that she was unable to locate any documentation for the resident's 2024 vaccines.
Failure to Offer COVID-19 Vaccine and Document Immunization Status
Penalty
Summary
The facility failed to offer the COVID-19 immunization to one resident out of five reviewed for immunizations. Resident #13 was admitted and later readmitted with diagnoses including aphasia, pressure ulcers of the right and left hip, vascular dementia, and quadriplegia. The Minimum Data Set with an ARD of 06/27/2025 showed the resident scored 4 out of 15 on the BIMS, indicating severe cognitive impairment. On 9/02/2025, the resident was observed in bed sleeping and did not respond to an interview request. During immunization record review, there was no documentation that the COVID-19 vaccine had been offered for 2024, although the resident had consented to and received the vaccine in prior years. On 9/08/2025, the Regional Clinical Director stated that she was unable to locate any documentation for the resident's vaccines for 2024.
Failure to Provide and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to assess, monitor, follow physician orders, and document wound care for a resident with non-pressure skin conditions. The resident, a 65-year-old male with diagnoses including hypertension, peripheral vascular disease, wound infection, and diabetes, was admitted with an unstageable wound infected with MRSA. Despite physician orders for daily wound treatments, review of the Medication Administration Record (MAR) revealed over 30 missed treatments without supporting documentation or valid reasons. Weekly wound assessments were also incomplete, with missing documentation on several dates. Interviews with staff confirmed that wound treatments and assessments were not consistently performed or documented as required. Further, the resident reported to wound clinic staff that dressings were not changed daily as ordered, and he often arrived at the clinic with dressings dated more than 24 hours prior. The wound clinic also verified that the resident was not seen for a scheduled appointment on one occasion, contradicting facility staff's belief. The Director of Nursing acknowledged the missed treatments and lack of documentation, and staff interviews confirmed that missed treatments were not always communicated to the physician or documented in progress notes as required by facility policy.
Improper Labeling and Storage of Controlled Medications
Penalty
Summary
Facility staff failed to ensure that controlled medications were properly labeled and stored according to professional standards. A resident, an 84-year-old female with diagnoses including chronic obstructive pulmonary disease, pneumonia, weakness, and depression, was admitted on hospice services and brought Lorazepam 0.5mg tablets from home. Instead of keeping the medication in its original pharmacy packaging, staff repackaged the tablets into nine unlabeled clear plastic bags and a cup, with no resident name, medication name, directions, or description on the packaging. The repackaging was done to facilitate counting at shift change, but staff were unable to identify the tablets by appearance, and the original labeled bottle was empty. Both the RN and DON confirmed the presence of the repackaged, unlabeled controlled medication and were unsure who authorized the repackaging. Interviews with nursing staff revealed that the standard practice was to keep all narcotic medications in their original, clearly labeled pharmacy packaging. However, in this instance, the controlled medication was divided into multiple unlabeled bags, and the staff responsible for this action could not be identified. The facility's documentation showed the medication was received from a home supply and that counts were being performed at shift changes, but the lack of proper labeling and storage did not meet professional standards or regulatory requirements.
Failure to Calibrate Glucometers and Ensure Test Strip Compatibility
Penalty
Summary
The facility failed to ensure that glucometers were calibrated according to manufacturer recommendations and did not ensure compatibility between glucometers and glucose test strips for residents requiring blood glucose monitoring. Observations revealed that calibration logs did not specify the brand of glucometer being calibrated, and several logs had blank columns for control ranges, making it impossible to determine if control results were within acceptable parameters. Multiple types of glucometers and test strips were found on medication carts, with some staff using backup devices and being uncertain about calibration procedures or the frequency of calibration. Interviews with nursing staff, including RNs and LPNs, indicated inconsistent knowledge and practices regarding when and how to calibrate glucometers, particularly when opening new bottles of test strips. Staff often believed calibration was the responsibility of the night or third shift, and some were unsure if calibration was necessary with new test strips. The Director of Nursing also demonstrated uncertainty about calibration requirements and acknowledged that incorrect test strips could result in false blood sugar readings. There was also confusion about which control solutions should be used for calibration, with the DON admitting to using the wrong brand of control solution for a particular glucometer. Documentation showed that at least one control result for a ReliOn Premier BLU glucometer was outside the acceptable range, with no follow-up actions documented. Additionally, calibration logs were missing for some glucometers in use, and there was a lack of clarity about which devices and test strips were being used together. The facility was also found to be out of the correct test strips for certain glucometers, leading to further confusion and improper practices.
Improper Use and Disinfection of Glucometers
Penalty
Summary
The facility failed to follow manufacturer recommendations for the sanitary use and disinfection of glucometers, which potentially affected 17 residents requiring blood glucose monitoring. Observations revealed that staff, including an RN and an LPN, used a ReliOn Premier BLU glucometer for multiple residents, despite the device's user manual specifying it is for single-patient use only and not intended for use in healthcare or LTC settings. Staff reported using Super Sani-Cloth Germicidal Disposable Wipes for cleaning and disinfecting glucometers, although the manufacturer had only validated Clorox Healthcare Bleach Germicidal Wipes for this purpose and warned against using other chemicals. Additionally, the practice of wrapping the glucometer in a disinfecting wipe for two minutes was observed, which contradicted the instructions for both the ReliOn Premier BLU and the Arkray Assure Platinum glucometers. The Director of Nursing was unaware that the ReliOn Premier BLU glucometer was intended for single-patient use only and confirmed that glucometers should not be wrapped in disinfecting wipes unless specified by the manufacturer. The facility's Plan of Correction education record also included a tip to wrap the glucometer in a wipe for the required contact time, which was inconsistent with manufacturer instructions. These actions and inactions resulted in the facility not meeting the requirements for infection prevention and control as outlined in §483.80.
Failure to Document Glucometer Calibration
Penalty
Summary
The facility failed to maintain documentation indicating that glucometer calibration was being performed, potentially affecting all 17 residents diagnosed with diabetes who required blood glucose monitoring. During an interview, an LPN stated that glucometers were quality control tested every 24 hours by the night shift. However, when the glucometer calibration logbook was requested, it could not be found by the Assistant Director of Nursing, the Director of Nursing, or the Regional Nurse, despite searching through various locations including the nurse's station and medication cart. The Regional Nurse confirmed the absence of the logbook and acknowledged that it should be available for monitoring the glucometer's accuracy. The lack of documentation for the glucometer's calibration raised concerns about the potential for inaccurate blood glucose readings and incorrect treatment for diabetic residents. The facility used the Assure Platinum glucometer model, and the manufacturer's manual provides a template for a Quality Control Record, which was not being utilized as required.
Failure to Disinfect Glucometers Between Uses
Penalty
Summary
The facility failed to maintain proper disinfection protocols for glucometers, which are used for blood glucose testing, affecting four residents. During observations, an LPN was seen performing blood glucose tests without disinfecting the glucometer between uses. The LPN placed the glucometer on various surfaces without using a barrier and did not sanitize the device before or after testing. This practice was observed with multiple residents, and the glucometer was not disinfected before being stored back in the medication cart. Interviews with the LPN revealed that while she was aware of the disinfection protocol, she did not consistently follow it due to the unavailability of germicidal wipes. The LPN admitted to not requesting the wipes regularly, citing a hectic work environment as a reason for not obtaining them. The Director of Nursing and a Regional Nurse confirmed that the LPN's actions were incorrect and posed an infection control risk. They also noted that audits to ensure compliance with the disinfection process were not readily available. The facility's records showed that none of the residents tested had a blood-borne pathogen diagnosis, but the lack of proper disinfection still posed a risk of pathogen transmission. The facility used Assure Platinum glucometers, and the manufacturer's guidelines clearly stated the need for cleaning and disinfecting the device after each use. Despite this, the facility's documentation of staff training on glucometer disinfection was incomplete, with only a few competency checklists available for review.
Failure to Prevent Pressure Injuries and Inadequate Pain Management
Penalty
Summary
The facility failed to prevent the development of pressure injuries for a resident who was admitted with a sacral pressure ulcer and later developed additional facility-acquired ulcers. The resident, who had cognitive impairment and multiple medical conditions, was observed lying in bed without proper positioning aids such as pillows to offload pressure or elevate heels. Despite having a care plan that included interventions like repositioning every two hours and using a pressure-reducing mattress, these measures were not consistently implemented. The resident reported severe pain from the ulcers, which hindered his ability to move, and staff did not assist with repositioning or offer pain management effectively. The resident's care plan was not adequately followed, as evidenced by the lack of regular skin assessments and the failure to document any refusals for repositioning. The resident's pressure-reducing air mattress was found unplugged on multiple occasions, and staff did not provide necessary equipment like pillows or wedges to float the resident's heels. Additionally, a medical device-related pressure injury was identified, caused by the wound vac tubing pressing into the resident's skin, further indicating a lack of proper care and monitoring. Pain management was insufficient, as the resident was not offered prescribed pain medication before wound dressing changes, leading to significant discomfort and reluctance to reposition. The staff did not regularly assess the resident's pain levels or offer appropriate pain relief, contributing to the resident's fear of falling and resistance to repositioning. The facility's failure to adhere to the care plan and manage the resident's pain effectively resulted in the development of additional pressure injuries and significant distress for the resident.
Inadequate Pain Management for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R26, who was admitted with multiple serious medical conditions including sepsis, osteomyelitis, and a Stage 4 sacral pressure ulcer. The resident also developed additional pressure ulcers after admission. Despite having a care plan that included administering pain medication as ordered, the facility did not consistently provide the prescribed pain relief, particularly before wound care procedures, which resulted in the resident experiencing severe pain. R26's medical records indicated an order for Oxycodone to be administered as needed and before dressing changes, but this was not consistently followed. The resident reported severe pain during wound care, rating it as high as 9 or 10, and expressed that the pain was excruciating, preventing him from wanting to be moved in bed. Despite the presence of a physician's order for pain management, the medication was only sporadically administered, and the resident was unaware of the availability of stronger pain relief options beyond Tylenol. Interviews with nursing staff confirmed that R26 often refused wound care and repositioning due to pain, and it was verified that no as-needed pain medication was administered prior to dressing changes. The inconsistency in pain assessments and the lack of regular pain medication offerings contributed to the resident's ongoing pain and anxiety, highlighting a significant deficiency in the facility's pain management practices.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to ensure that notifications of emergency transfers for 41 residents were sent to the State Long-Term Care Ombudsman over the past year. During an interview, the Ombudsman confirmed that she had not received any notifications of resident emergency transfers and had inquired about them several times without receiving a response or copies. The Regional Clinical Director (RCD) was unable to provide evidence that the notifications were sent, despite being requested to do so. A list of residents who were emergency transfers was provided, but no documentation proving that the notifications were sent to the Ombudsman was available.
Deficiencies in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 49 residents. During an initial tour of the food service area, several deficiencies were observed, including peeling packing shrink wrap on the doors of two coolers, and various kitchen appliances such as a can opener, microwave oven, stand mixer, stove/oven/griddle, and garbage disposal were found with accumulated and encrusted food residue. Additionally, the broom waste caddies and dry storage room light assembly were heavily soiled with dust, dirt, and dead insect carcasses. The mechanical dish machine ventilation hood was also observed with corroded moisture stains and grime. Further inspection revealed that the three-compartment sink waste lines were heavily soiled and direct plumbed without an effective air gap, violating the 2017 FDA Model Food Code. The facility's kitchenettes also exhibited similar issues, with soiled ventilation grills and light assembly covers containing dead insect carcasses and dust. These observations indicate a failure to adhere to professional standards for food safety and sanitation, increasing the risk of cross-contamination and bacterial harborage. Record reviews of the facility's policies and procedures showed that there were established guidelines for cleaning and sanitizing equipment such as hoods, filters, ranges, ovens, and grills. However, the observed conditions suggest that these policies were not effectively implemented or followed, leading to the noted deficiencies in maintaining a clean and safe food service environment.
Improper Maintenance of Outdoor Waste Receptacle
Penalty
Summary
The facility failed to effectively maintain the outdoor waste receptacle, impacting 49 residents. During an environmental tour, it was observed that the outdoor waste receptacle was missing the rear sliding door and had one of its two swinging doors cracked and broken. This condition increased the likelihood of pest attraction and harborage. The Dietary Manager acknowledged the issue and indicated plans to contact the waste removal company for necessary repairs. A review of the facility's policy and procedure on sanitizing garbage cans and dumpsters revealed that garbage cans should be thoroughly cleaned and sanitized regularly, and any damage to the containers should be reported to the Dietary Manager for replacement. Additionally, dumpsters provided by the local refuge vendor should be maintained by the facility and kept covered at all times, with the area around the dumpster kept clean and free of debris, foul odors, and pests.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting 49 residents, as observed during an environmental tour. The laundry service area was found with heavily soiled flooring and light covers with dead insect carcasses. In the common areas, missing atmospheric vacuum breakers, damaged chairs, and soiled ventilation grills were noted. Additionally, the dining room had tables with missing leg support levelers and light bulbs secured with zip ties. In the resident rooms, several deficiencies were observed, including soiled flooring, stained ceiling tiles, and non-functional light bulbs. Restrooms were found with etched and stained caulking, malodorous conditions, and missing toilet tissue. Some rooms had damaged drywall and frayed electrical wires, posing potential safety hazards. The maintenance request logs did not reflect these issues, indicating a lack of proper documentation and follow-up. The facility's policies and procedures for housekeeping and maintenance were reviewed, revealing a lack of specific dates and inadequate monitoring for compliance. The policies stated the importance of maintaining a safe and sanitary environment, but the observed conditions contradicted these guidelines. The failure to adhere to these policies resulted in an increased likelihood of cross-contamination and decreased air quality, compromising the residents' living conditions.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medications and treatment carts were secured, as observed during a survey. On multiple occasions, two treatment carts located in the resident's dining room were found unlocked, with drawers open revealing wound treatment supplies and prescribed topical medications. This was observed on two consecutive days, with the carts remaining unsecured at various times, indicating a lack of adherence to protocols for securing medication and treatment supplies. Additionally, during a medication administration observation, a registered nurse was seen leaving a medication cart unlocked and a computer open with a resident's medical record exposed. This occurred while the nurse administered medications to a resident in the dining area, with the cart only partially in view and the nurse's back turned towards it. These actions demonstrate a failure to maintain the security of medications and the confidentiality of resident records.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food products, affecting 49 residents. Observations revealed that food trays were delivered from the kitchen in insulated transport carts, but the food temperatures did not meet the standards set by the 2017 FDA Model Food Code. For instance, the corn served to Resident #1 was recorded at 126.2°F, and the milk was at 49.7°F, both outside the safe temperature range. Additionally, the food was described as unappetizing, with the beef burrito being semi-tough and dry, and the Spanish rice starchy and dry. Interviews with residents highlighted dissatisfaction with the food quality and lack of alternative meal options. Resident #22 reported not eating any food since admission, and Resident #26 mentioned refusing meals due to poor taste. Residents expressed that the only alternative offered was a peanut butter and jelly sandwich, and there was no discussion of their food preferences. The absence of an alternative menu was confirmed during observations, and residents expressed frustration over the lack of variety and the facility's unfulfilled promises to implement an alternative menu. The dietary staff, including the Dietary Manager, acknowledged the issues with the meal service. The Dietary Manager indicated that an alternate meal choice was assigned only for the main entree and mentioned plans to implement an always-available menu option. However, at the time of the survey, no such menu was in place, and the food delivery schedule contributed to the temperature issues, as trays were delivered to different dining rooms sequentially, potentially affecting the food's temperature and palatability.
Deficiency in Wheelchair Maintenance and Infection Control
Penalty
Summary
The facility failed to ensure safe and clean medical equipment for a resident, specifically regarding the condition of a wheelchair. The resident, who has severe cognitive impairment and multiple medical conditions including Alzheimer's Disease and dysphagia, was observed on two separate occasions sitting in a wheelchair with a torn and cracked right arm cushion. This condition was noted during observations in the common area of the unit, and the resident was unable to participate in an interview due to their cognitive impairment. The Licensed Practical Nurse (LPN) responsible for the resident acknowledged the issue upon observation but had not reported it to the Assistant Director of Nursing (ADON) as required. The LPN confirmed that the damaged cushion posed an infection control issue because it could not be adequately cleaned. The ADON also confirmed that no staff had reported the need for repair of the wheelchair, indicating a lapse in communication and protocol adherence within the facility.
Inaccurate MDS Assessment for Restraint Use
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident #33, regarding the use of restraints. The resident was admitted with multiple diagnoses, including cerebral infarction, hemiparesis, hemiplegia, aphasia, and other conditions. During an observation, the resident was seen using side rails on the bed for positioning and assistance with getting up. However, the MDS assessment inaccurately coded these side rails as restraints, despite the facility's policy that side rails used for assistance and not restricting movement should be considered assistive devices. Interviews with the Assistant Director of Nursing (ADON) and the MDS Coordinator revealed discrepancies in the coding of the MDS. The ADON confirmed that the side rails were not considered restraints and that the facility did not measure these devices to prevent potential entrapment. The MDS Coordinator admitted to mistakenly coding the side rails as restraints and acknowledged the need to correct and resubmit the MDS. This error highlights a failure in accurately assessing and documenting the resident's use of assistive devices, leading to an incorrect MDS assessment.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete and provide a baseline care plan within 48 hours of admission for a resident, identified as Resident #22. The resident was admitted with multiple complex medical conditions, including iron deficiency anemia, end-stage renal disease, and severe protein-calorie malnutrition, among others. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident was unaware of any details regarding her plan of care and denied receiving a copy of the baseline care plan within the required timeframe. Interviews with facility staff revealed that the baseline care plan was completed but not uploaded into the resident's medical record until after the surveyor's inquiry. The Assistant Director of Nursing and the Regional Clinical Director acknowledged the oversight, with the latter noting that the second page of the care plan, which would have shown the resident's review and agreement, was incomplete. The facility's policy mandates the completion and implementation of a baseline care plan within 48 hours to ensure continuity of care and communication, which was not adhered to in this case.
Failure to Apply Splints for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with multiple contractures received appropriate care to maintain or improve their range of motion. The resident, who had contractures in both upper and lower extremities, was observed multiple times without the necessary splints and braces that were supposed to be applied daily. Despite instructions posted in the resident's room and outlined in the care plan, the splints were consistently found on a chair rather than on the resident. This lack of adherence to the care plan potentially contributed to the worsening of the resident's contractures. Interviews with staff revealed inconsistencies in the understanding and execution of the resident's care plan. Certified Nurse Aides (CNAs) provided conflicting information regarding who was responsible for applying the splints, with some stating that therapy staff applied them, while others indicated it was the CNAs' responsibility. Additionally, CNAs reported not having access to printed care plans, relying instead on computer access to review care instructions, which may have contributed to the oversight. The Physical Therapist Assistant confirmed that the resident was supposed to have knee splints applied daily, further highlighting the discrepancy in care delivery.
Failure to Obtain Resident Weights and Address Nutritional Preferences
Penalty
Summary
The facility failed to adhere to its policy of obtaining weights for a resident, leading to potential inaccuracies in assessing the resident's nutritional status. Resident #26, who was admitted and later readmitted with multiple diagnoses including sepsis, osteomyelitis, a sacral pressure ulcer, muscle weakness, and type 2 diabetes, was not weighed weekly for four weeks following admission as required. The resident's medical record showed an admission weight of 240 lbs, a readmission weight of 259 lbs, and a subsequent weight of 210.3 lbs, indicating a significant weight loss of 48.7 lbs (18%) over 28 days. There were no documented refusals for the missed weights, and the Registered Nurse confirmed the absence of documentation for the weekly weights. Additionally, the resident expressed dissatisfaction with the facility's food, often refusing meals, which may have contributed to the weight loss. The resident reported that no one had discussed his food preferences with him, and his menu ticket lacked information on his likes and dislikes. The Registered Dietician noted the weight loss and requested a reweigh to verify accuracy, but it had not been completed by the time of the report. The failure to document weights and address the resident's nutritional preferences contributed to the deficiency identified by the surveyors.
Improper Storage and Cleaning of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage, cleaning, and labeling of oxygen and respiratory equipment for two residents, leading to potential cross-contamination and respiratory illnesses. Resident #18, a cognitively intact female with multiple health conditions including chronic lung disease and heart failure, was observed with undated oxygen tubing and unbagged nebulizer equipment. Her CPAP mask was found lying on her pillow, and the oxygen tubing was dated over two weeks prior to the observation. The resident had been diagnosed with facility-acquired pneumonia in July 2024, and her physician orders required the use of CPAP during sleep and oxygen therapy for comfort or low oxygen saturation levels. Resident #37, also a cognitively intact female with similar health conditions, was observed with her oxygen concentrator running and the nasal cannula lying directly on bed linens. Additionally, her nebulizer equipment was found on the cushion of her wheelchair. The Assistant Director of Nursing/Infection Control Nurse stated that oxygen tubing should be changed every seven days and nebulizer equipment should be rinsed and stored in a bag after use. These observations indicate a failure in maintaining proper infection control practices for respiratory equipment, increasing the risk of cross-contamination and respiratory complications.
Failure in Dialysis Communication and Weight Tracking
Penalty
Summary
The facility failed to ensure effective communication and collaboration with the contracted dialysis facility for a resident requiring dialysis care, leading to issues in tracking the resident's weight. The resident, who has end-stage renal disease and a binge eating disorder, was admitted and readmitted to the facility with an active physician's order for weekly weight monitoring. However, the medical record showed inconsistencies in weight documentation, with significant gaps between recorded weights and no documented refusals for the weekly weights. The Dialysis Communication Binder, which should have contained completed forms from the dialysis facility, was found to have several incomplete forms. These forms were meant to document vital information, including pre- and post-dialysis weights. An RN at the facility acknowledged that the resident had an order for weekly weights but stated that the resident was refusing to be weighed at the facility, leading to an agreement to use weights obtained at the dialysis center. However, the dialysis facility did not consistently complete and return the necessary communication forms, contributing to the deficiency in tracking the resident's weight as per the physician's order.
Failure to Assess and Measure Bed Rails for Entrapment Risk
Penalty
Summary
The facility failed to ensure that bed rails were properly assessed and measured to prevent possible entrapment for a resident using bed rails. The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiparesis, hemiplegia, and moderate cognitive impairment, was observed using side rails for positioning and assistance with bed mobility. Despite the resident's medical record indicating the use of bed rails and a trapeze to promote independence, the facility did not complete the necessary measurements of the side rails to prevent potential entrapment. Interviews with facility staff revealed that the Assistant Director of Nursing acknowledged the use of side rails but admitted that the facility did not measure these devices to prevent entrapment. The Regional Clinical Director and Nurse confirmed that bed rail assessments with measurements were supposed to be completed at installation and quarterly, but no such measurements for the resident could be found. The facility's policy required maintenance staff to install bed rails according to manufacturer's recommendations and to initiate a bed rail assessment prior to installation, but these procedures were not followed for the resident in question.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate. During an observation, a Registered Nurse (RN) administered a Hyoscyamine 0.25 mg tablet to a resident by mixing it with pudding, despite the medication being ordered for sublingual administration. This error was observed as the resident swallowed the medication instead of allowing it to dissolve under the tongue as prescribed. Another RN was observed administering Flomax to a resident before breakfast, contrary to the order specifying it should be given after breakfast. Additionally, the RN did not ensure the resident swallowed the medication, resulting in pills falling to the floor. The same RN also failed to prime an insulin pen before administering insulin, which is against the facility's policy. The RN attributed this oversight to being a travel nurse and unfamiliar with the facility's procedures.
Failure to Provide Alternative Food Choices
Penalty
Summary
The facility failed to provide alternative food choices for three residents, leading to dissatisfaction and a non-pleasurable dining experience. Resident #26 expressed dissatisfaction with the taste of the food and reported that he often refused meals, with only a peanut butter and jelly sandwich available as an alternative. He also mentioned that no one had discussed his food preferences with him. Resident #41 also found the food unappealing and was only aware of the option to make a peanut butter and jelly sandwich if she did not like the meal provided. Resident #13 described the food as gross and noted that there was no alternative menu available, despite promises from the facility to create one. Observations during meal times revealed that the food served was not appetizing, with specific mention of a lunch consisting of a beef burrito, Spanish rice, and corn, which did not appear appealing. The Spanish rice was served in a scoop form, and a taste test by the surveyor found the spaghetti sauce to be overly salty and the meatballs unappetizing. The Dietary Manager acknowledged the lack of an alternative menu and stated that the current practice was to substitute only the main entree with an alternate choice, with plans to implement an always-available menu option in the future.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to coordinate hospice services for a resident, resulting in the potential for inadequate care and lack of information regarding hospice services. The resident, who was admitted with multiple diagnoses including COPD and dementia, was receiving hospice care but was not provided with a hospice calendar detailing the schedule of services. During an interview, the resident was unable to specify when hospice services were provided, indicating a lack of communication and coordination. Further investigation revealed that the facility's hospice notebook, which should have contained a calendar of hospice services and a plan of care, was incomplete. The Assistant Director of Nursing could not provide documentation of the hospice plan of care or a comprehensive calendar of visits. Additionally, the Social Worker confirmed that a care conference with the hospice agency had occurred but had not been documented in the resident's medical record in a timely manner, highlighting a delay in the coordination of hospice services.
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 151 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marshall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Marshall | 0.9 mi | ★★★★★ | 14 | 0 |
| Calhoun County Medical Care Facility | 8.8 mi | ★★★★★ | 5 | 0 |
| Pinnacle Care Of Battle Creek | 10.5 mi | ★★★★★ | 15 | 0 |
| The Oaks At Battle Creek | 12.1 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Battle Creek | 12.3 mi | ★★★★★ | 12 | 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 July 2026) and official state health department websites.