Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marvin & Betty Danto Health Care Center during CMS and state inspections, most recent first.
A resident with osteoarthritis and quadriplegic CP was repeatedly observed with the call light out of reach or inaccessible, and the resident stated they could not find or use it because of hand difficulty and poor vision. The resident reported having to yell for help when staff were not nearby. The record showed dependence for most ADLs, and the NM observed the resident could not demonstrate use of the current call button; facility procedure stated call lights should be positioned conveniently and placed on the bed or preferred location before staff leave the room.
Unsafe wall-mounted shelf unit in resident room: A resident with diabetes, heart disease, anxiety disorder, and moderately impaired cognition reported concern that a [NAME] above her dresser might fall and break her belongings. Surveyors observed the unit was not properly attached on one side, with visible pegs, a disconnected back, and a gap at the bottom corner; the resident said she had reported it to Maintenance weeks earlier, but it was still in place. The Maintenance Director said he had not been aware of the issue until shown the unit, and the DON stated all staff could report needed repairs to Maintenance.
Improper Use of Wheelchair Seat Belt Without Adequate Clinical Justification: A resident with muscular dystrophy and Friedreich ataxia was observed in a wheelchair with a seat belt that the resident could not unlatch and did not understand. The DON said the belt was used for safety and positioning at the mother/guardian’s request, but the UM reported there was no prior physician order and could not provide documentation of clinical justification, staff training, or alternatives tried.
A resident with a J-tube was observed receiving enteral formula at 45 mL/hr even though the active MD order specified 40 mL/hr. The formula bottle had blank documentation fields and no label information such as the name, rate, or date/time hung. Nursing staff stated they were unaware of the updated order, and the NM confirmed the nurse should have followed the MD order and that the bottle should have been labeled with required details.
Unsafe Resident Equipment Not Maintained: A resident's footboard was observed broken and leaning, and the low air mattress unit attached to it showed a continuous flashing Power Fail light. A nurse and the Maintenance Director observed the same issues, and the Maintenance Director stated the unit sometimes had to be reset and later found broken screws in the footboard. The facility's policy required equipment to be kept in safe, operable condition at all times.
Surveyors found unsanitary conditions in shared shower and rehabilitation areas, including sewage odors, uncovered drains, dirty equipment, soiled linens on floors, and improper storage of personal care products. Facility leadership acknowledged the presence of these issues, which affected the cleanliness and safety of areas used by residents and staff.
A resident with no cognitive impairment reported that their personal belongings were searched by the NHA without consent after staff suspected them of hoarding and selling prescribed Oxycodone. The resident noticed their paperwork was disturbed and felt compelled to purchase a safe due to loss of trust. The NHA confirmed the search was conducted based on a rumor and without consent, in violation of facility policy guaranteeing privacy and confidentiality.
A resident with vascular dementia who required staff assistance for dressing and transfers waited approximately one hour and 45 minutes to be dressed and transferred out of bed after requesting help. Staff cited the need for two people for a mechanical lift and unavailability of the assigned CNA as reasons for the delay, despite other staff being available to assist. The DON confirmed the wait time was excessive.
A resident with vascular dementia and an indwelling catheter developed a new skin impairment on the right thigh that was not promptly identified or assessed, and no clear interventions were implemented to prevent recurrence. Staff were uncertain about the cause, and documentation did not show timely notification of a medical provider or effective preventive actions, despite facility policy requiring daily skin inspections and ongoing review.
A resident dependent on staff for mobility and skin care developed a deep tissue injury to the heel after inconsistent repositioning, incomplete skin assessments, and lack of documentation regarding the use of pressure-relieving boots. Staff did not consistently perform or document required interventions, and the wound was not identified until weeks after admission.
The facility failed to maintain a clean and homelike environment, with observations of dirty and cluttered rooms, inconsistent housekeeping, and inadequate laundry services. Residents reported issues with obtaining clean linens and towels, and the facility's maintenance practices were found lacking, with unreported repairs and improper use of extension cords for medical devices.
The facility failed to properly administer and document medications for two residents, leading to complaints of delayed pain relief and inaccurate records. One resident did not have their as-needed narcotic pain medication documented on the MAR, while another resident's medication administration was not recorded at all. The DON confirmed that medications should be documented at the time of administration, as per policy.
A resident with multiple health conditions did not receive Hospice services as per the plan of care, which required skilled nursing and nurse aide visits twice a week. The facility's DON was unaware of the oversight, and the facility's policy on Hospice service coordination was not followed.
The facility failed to ensure proper storage and security of medications across multiple medication carts. Medications were found unpackaged and without patient identifiers, and a medication cart was observed unlocked and unattended. The Director of Nursing acknowledged the issue, which violated the facility's medication storage policy.
A resident was found with medical ointments and treatments in their room without an order for self-administration. The facility's policy requires an order and secure storage of medications. The resident, moderately cognitively impaired, reported applying the medications themselves or with staff assistance. The medications were removed by staff after the deficiency was noted.
The facility failed to ensure accurate and timely implementation of advanced directives for two residents. One resident had conflicting documentation regarding their code status, with a signed DNR form and an electronic record indicating FULL CODE. Another resident's son, acting as DPOA, made medical decisions without proper authorization, as the resident was cognitively intact and not deemed incompetent. The facility's policy requires prompt documentation and discussions regarding health status and treatment options, which were not adequately followed.
A resident with a history of stroke and aphasia was unable to effectively communicate their needs due to the facility's failure to provide alternative communication methods. Despite being non-verbal and expressing distress with their modified diet, the resident had no access to communication boards or assistive devices. Staff confirmed the communication challenges, and the facility lacked a policy to address these needs, leading to the resident's ongoing frustration.
A resident with multiple diagnoses was observed receiving two liters of oxygen via nasal cannula without a physician's order, as required by the facility's policy. The DON confirmed the absence of the necessary order, highlighting a failure in ensuring proper documentation for oxygen therapy.
A facility failed to provide trauma-informed care for a resident with PTSD, depression, and anxiety. The resident struggled to adjust to the LTC setting and was dissatisfied with their psychological provider. Despite requests for a different provider and additional support, no changes were made. The care plan lacked specific interventions for PTSD, and no triggers were identified. Staff were unaware of the PTSD diagnosis, affecting their ability to provide appropriate support.
A resident in an LTC facility experienced three medication errors, resulting in a 7.32% error rate. An LPN inaccurately measured MiraLAX, administered Metoprolol against ordered parameters, and failed to administer Flonase as documented. The DON acknowledged these errors.
A facility failed to maintain resident dignity and respect when a CNA entered rooms without knocking or announcing themselves, addressing a resident in a gruff tone. The CNA acknowledged the oversight, citing numerous call lights as a distraction. The DON confirmed awareness of the issue.
A resident with multiple skin issues, including an open wound on the sacrum and a blister on the right heel, experienced delayed and conflicting wound care interventions. Despite being identified on admission, appropriate treatment for the right heel was delayed, and there was no physician assessment of the wounds until weeks later. The facility's DON acknowledged the concerns and indicated a review of the medical record for assessments.
A resident was found with their feet and legs tied in a knot with blankets, indicating a failure to ensure freedom from physical restraints. Staff members observed the resident in this condition, but the facility's response was inconsistent, with discrepancies in staff accounts and a lack of proper investigation. The facility suggested the resident tied themselves, despite evidence to the contrary, and failed to provide a restraint policy when requested.
A resident with dementia and other health issues was found with blankets tied around their legs, suggesting possible abuse. Despite observations by staff, the incident was not reported as an abuse allegation to the appropriate authorities. The facility's investigation was inadequate, and the Administrator dismissed the incident as a rumor, failing to comply with reporting guidelines.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that a resident with osteoarthritis and quadriplegic cerebral palsy had an appropriate call button provided and placed within reach for use. The resident was observed multiple times in their room with the call light either hanging off the side of the bed on the floor, lying on the bed out of reach, or positioned up by the resident’s neck and inaccessible. During these observations, the resident stated they could not find the call button, could not reach it, and did not think they could use it because of trouble with their hands and poor vision. The resident also reported that they had to yell for help and that sometimes staff did not hear them if they were not walking by. The resident’s record showed dependence on staff for most activities of daily living and a care plan identifying an ADL self-care performance deficit related to weakness, cerebral palsy with quadriplegia, and osteoporosis. When the Nurse Manager assessed the resident’s ability to use the call button, the resident was unable to demonstrate use of the current device. The Nurse Manager stated a touch pad or bell might work better, and acknowledged that the call button should be placed within reach of residents for use. The facility’s call light procedure also stated that call lights should be positioned conveniently for the resident to use and placed on the bed or preferred location before staff leave the room.
Unsafe wall-mounted shelf unit in resident room
Penalty
Summary
The facility failed to ensure a safe, homelike environment for one resident who was observed lying in bed and expressing concern that a [NAME] attached above the dresser might fall and break the items displayed on its shelves. Observation showed the pegs that normally connect the shelf to the upright support were completely visible and not attached on the right side, the back of the [NAME] was not connected to the upright support, and there was an approximately 1 1/2 inch gap on the bottom right-hand corner. Various personal and decorative items were on the shelves, many of which would have been broken if the [NAME] fell apart. The resident stated she had told Maintenance about the condition approximately three weeks earlier and was told it would be removed, but it remained in place. The resident had been admitted with diagnoses including diabetes, heart disease, and anxiety disorder, and her MDS assessment indicated moderately impaired cognition. The Maintenance Director stated he was not aware of the concern until shown the [NAME], then said it should be removed immediately and that he would have expected staff to report the condition. The Administrator and DON stated all staff members could report needed repairs to Maintenance. The facility policy titled Homelike Environment stated residents are provided with a safe, clean, comfortable and homelike environment.
Improper Use of Wheelchair Seat Belt Without Adequate Clinical Justification
Penalty
Summary
The facility failed to ensure that one resident was free from the use of a physical restraint unless needed for medical treatment. The resident was observed sitting in a wheelchair in the dining room with a seat belt in place while playing bingo. When asked, the resident stated they could not unlatch the belt themselves and did not know why it was being used. The resident’s record showed diagnoses of muscular dystrophy, Friedreich ataxia, and mood disorder due to a known physiological condition with depressive features, and a BIMS score of 15 indicating no cognitive impairment. Interviews and record review showed the seat belt had been used without appropriate clinical justification and documentation. The DON stated the resident’s mother requested the seat belt for safety and poor trunk control, and later said the belt was used for positioning and safety because the resident had no trunk control and slid from the chair. The UM reported there was no physician order prior to the order entered on 3/17/26 and could not provide information about staff training, clinical justification, or alternatives tried. The record also showed an assessment completed on 12/18/24 that noted a restraint might be considered if the resident had balance issues while sitting and could not recover balance under their own power, but no additional supporting information was documented.
Enteral Feeding Not Administered or Documented per Order
Penalty
Summary
The facility failed to ensure enteral feeding was documented correctly and administered according to the physician’s order for one resident receiving tube feeding through a J-tube. On 3/16/26, the resident was observed in bed with enteral formula infusing at 45 mL per hour. The bottle of formula hanging on the pole had no information on it, including the name, rate, or date/time it was hung, and all documentation fields were blank. Later that same day, the resident was again observed with formula infusing at 45 mL per hour, and the bottle still had the rate field left blank. The resident had been admitted with diagnoses including disorders of bilirubin metabolism and severe protein-calorie malnutrition. The MDS indicated the resident needed assistance from facility staff with activities of daily living and had a feeding tube. The care plan included tube feeding for digestive pancreatic cancer and gastric outlet obstruction, with interventions for tube feeding per orders. A physician’s order dated 3/6/26 directed Pivot 1.5 at 40 mL per hour starting at 2:00 p.m. and continuing until 800 mL had infused, with use of the JT port and specified water flushes. When the enteral feeding order was reviewed with nursing staff, the nurse indicated they were unaware the order had been changed earlier the previous week and stated they would change the pump setting to the active order of 40 mL per hour. The nurse manager stated the resident’s goal was to get to 45 mL per hour, but the nurse should have been following the physician’s order. The nurse manager also stated the bottle of formula should have included the name, room number, date, and rate.
Unsafe Resident Equipment Not Maintained
Penalty
Summary
The facility failed to ensure resident care equipment was maintained in safe operating condition for one resident, R116. Multiple observations of R116's room from 3/16/26 through 3/17/26 showed the resident's footboard appeared broken, was tilted sideways, and leaned down on the left side. During the same observations, the low air mattress electrical panel secured to the footboard had a continuous flashing red light for the indicator labeled Power Fail. On 3/17/26 at 11:10 AM, the Maintenance Director observed the room with a nurse present while R116 was seated in a gerichair recliner and having vital signs obtained. The flashing red light was still present and the footboard remained leaning down on the right side. The Maintenance Director stated the unit sometimes had to be reset and that the facility had power surges at times. The nurse reported no concerns had been identified, despite acknowledging the flashing light and leaning footboard. The Maintenance Director then removed the footboard and found the screws were broken and needed to be replaced. The Administrator and DON were later informed that staff had been in-serviced multiple times about reporting concerns when identified, and the facility policy stated equipment was to be maintained in a safe and operable manner at all times.
Failure to Maintain Sanitary Conditions in Common and Rehabilitation Areas
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's residential common areas, including a shared shower room, tub room, and rehabilitation area. In the shared shower area, there was a strong sewage odor, an uncovered floor drain, exposed sharp metal fasteners, broken tiles with debris, and a dirty tub with a thick brown ring. The tub room was being used for storage, containing a bedside commode and floor mat, and the shower bed had cracked foam padding with visible black hairs. Both shower rooms contained used wet towels and washcloths on the floor, with puddled water, soap residue, and additional black hairs present. The private toilet room was found locked, restricting access for residents. A Hoyer lift was observed with food crumbs on its base, and both the DON and NHA acknowledged the unsanitary conditions upon inspection. In the rehabilitation area, the training bathroom was found to have opened, partially used peri care spray bottles, a container of multiuse sanitation wipes, and an unidentified blue liquid stored on the toilet tank. The perimeter of the rehab area had dusty, dirty floors and equipment stored on the floor, with dead plant debris on the windowsill and floor. The Director of Rehab Services confirmed the unsanitary storage of supplies and the need for cleaning. These conditions were directly observed and acknowledged by facility leadership, indicating a failure to maintain a sanitary healthcare environment in areas used by residents and staff.
Failure to Obtain Consent Before Searching Resident's Personal Belongings
Penalty
Summary
The facility failed to obtain consent before searching a resident's personal belongings. A resident, who was cognitively intact as indicated by a perfect BIMS score, reported that after staff suspected them of hoarding and possibly selling their prescribed Oxycodone, the Nursing Home Administrator (NHA) searched their room and personal items without seeking or obtaining the resident's consent. The resident noticed their personal paperwork had been disturbed and subsequently felt compelled to purchase a safe due to a loss of trust in the facility. The NHA later confirmed during an interview that the search was conducted based on a rumor and without the resident's consent, and could not provide further justification for not involving local authorities if illegal activity was suspected. Facility policy reviewed during the investigation stated that residents are guaranteed rights to privacy and confidentiality under federal and state law. Despite this, the NHA and DON acknowledged that only verbal consent is typically obtained for room searches, and in this case, no consent was obtained at all. The incident was triggered by staff suspicion and a rumor, rather than direct evidence or proper procedure, resulting in a violation of the resident's rights to privacy and dignity.
Delay in Assistance with Activities of Daily Living
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for dressing and transfers requested assistance to get dressed and out of bed. The resident, who had vascular dementia and moderately impaired cognition, expressed her desire to choose her own outfit and notified a CNA of her request. Despite this, the resident remained in bed wearing a hospital gown for approximately one hour and 45 minutes after her initial request. During this period, staff interactions included a CNA changing her brief and putting on pants, and another CNA indicating that assistance was delayed due to the need for two staff members for a mechanical lift transfer and the other CNA being occupied with another resident. The resident's care plan specified the need for assistance with dressing and a mechanical lift with two staff for transfers. Observations confirmed that the resident was not assisted in a timely manner, as she remained in bed for an extended period after her request. The DON acknowledged that the wait time was excessive and noted that additional staff, including nurses and managers, could have assisted with the transfer. The delay in providing assistance was directly observed and confirmed through staff interviews.
Failure to Promptly Identify and Address New Skin Impairment
Penalty
Summary
A deficiency occurred when staff failed to promptly identify and implement interventions for a new skin impairment in a resident with vascular dementia, who was at risk for pressure ulcers and required substantial assistance with mobility. The resident was observed with an indwelling urinary catheter and a black area on the right lateral thigh, which was first noted as a skin tear by staff on 3/20/25. Documentation showed that a daily body audit was in place, and the new wound was recorded on 3/20/25. However, the wound was not assessed by the wound nurse until the following day, and there was no documentation that a medical provider was notified at the time of discovery. The wound was described as a blister, but photos indicated a flat black area rather than a fluid-filled lesion. Interviews with the wound nurse and DON revealed uncertainty about the cause of the wound, with possible explanations including friction from a wheelchair or mechanical lift. The DON stated that no specific interventions were implemented to prevent recurrence, and the facility's skin management policy required daily skin inspections and ongoing review of interventions for effectiveness. The lack of timely identification, assessment, and implementation of preventive measures contributed to the deficiency.
Failure to Prevent Pressure Ulcer and Ensure Accurate Skin Assessments
Penalty
Summary
A resident with a history of joint replacement surgery, macular degeneration, and a right shoulder rotator cuff tear was admitted to the facility and was dependent on staff for activities of daily living. The resident was care planned to require extensive assistance for bed mobility and to have pressure-relieving boots applied while in bed, as well as to be turned and repositioned every two hours. Despite these interventions, documentation revealed inconsistent completion of required skin assessments and repositioning, with multiple days lacking evidence that these tasks were performed, particularly on the midnight shift. The resident developed a deep tissue injury (DTI) to the left heel, which was not identified until more than two weeks after admission. Initial skin assessments and daily body audits failed to document any issues with the left heel, and the majority of daily skilled assessments inaccurately reported no skin issues, despite the resident having both a surgical wound and a sacral pressure injury requiring daily treatment. Staff interviews indicated that the resident did not routinely wear the prescribed foam boots prior to the development of the wound, and there was no documentation of refusal or non-compliance until after the DTI was identified. Further, the resident reported difficulty repositioning themselves and stated that staff only assisted with turning when asked, with particular difficulty obtaining assistance at night. The facility's policy required daily skin inspections and accurate documentation, but these were not consistently followed. The Director of Nursing acknowledged gaps in both the frequency and accuracy of skin assessments and agreed that refusals of interventions such as heel boots should have been documented.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident complaints. During a survey, several rooms were found in disarray, with dried tube feeding formula on equipment, missing paint, and gouged drywall. Floors were littered with food debris, dirty clothing, and trash, and some rooms had open garbage bags containing linens and clothing. Residents reported inconsistent housekeeping services, particularly on weekends, and expressed dissatisfaction with the cleanliness of their living spaces. Residents also raised concerns about the facility's laundry services. They reported issues with obtaining clean linens and towels, with some staff allegedly hoarding these items, making them difficult to access. The change in the laundry process, which involved placing dirty laundry in plastic bags without proper labeling, led to residents not receiving their clothes back. Additionally, the mixing of dirty linens with clothing was noted as a potential infection control issue. The facility's laundry staff struggled to manage the workload, resulting in delays in returning clean laundry to residents. The facility's maintenance practices were also found lacking. A nebulizer was improperly plugged into an extension cord, and large gouges in the walls of some rooms had not been reported or repaired. The maintenance director was unaware of these issues, indicating a failure in the facility's reporting system for needed repairs. The laundry room was observed to have collected dust and clean linen racks exposed to potential contaminants. These deficiencies highlight the facility's failure to provide a safe and homelike environment for its residents.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to ensure medications were administered and documented according to professional standards for two residents, resulting in complaints of delayed pain medication and inaccurate medical records. Resident 47, who has intact cognition and medical conditions including heart failure, diabetes, and chronic kidney disease, reported delays in receiving as-needed narcotic pain medication. A review of the CONTROLLED SUBSTANCE RECORD and Medication Administration Record (MAR) revealed multiple instances where oxycodone was signed out but not documented on the MAR. Nurse 'A' admitted to not documenting the administrations on the MAR, relying instead on the CONTROLLED SUBSTANCE RECORD for timing and administration. Resident 104, with diagnoses including hypertension, heart failure, and prostate cancer, was observed receiving medications from LPN A, but the administration was not documented on the MAR. Despite multiple attempts to reconcile the MAR, no documentation was found for the medications administered to Resident 104. The Director of Nursing confirmed that medications should be documented at the time they are administered, as per the facility's policy. The lack of documentation for both residents indicates a failure to adhere to the facility's medication administration policy.
Failure to Provide Hospice Services Per Plan of Care
Penalty
Summary
The facility failed to ensure that Hospice services were provided according to the plan of care for a resident who was under Hospice care. The resident, who had multiple diagnoses including multiple sclerosis, pressure ulcers, osteomyelitis, anxiety disorder, dementia, and contractures, was supposed to receive skilled nursing visits twice a week and nurse aide visits twice a week as per the Hospice plan of care. However, the review of hospice staff notes revealed that the first skilled nursing visit occurred two weeks after the resident signed on for services, and subsequent visits did not meet the twice-weekly requirement. Additionally, there were no documented visits from a Hospice nurse aide. During an interview, the facility's Director of Nursing (DON) was unaware of who was responsible for ensuring that the Hospice company conducted visits per the plan of care. The DON initially believed the resident was to receive skilled nursing visits once a week and nurse aide visits twice a week, but upon reviewing the Hospice plan of care, it was confirmed that the services had not been provided as outlined. The facility's policy requires that Hospice providers have a written agreement with the facility and are responsible for meeting professional standards and timeliness of service, which was not adhered to in this case.
Improper Medication Storage and Security
Penalty
Summary
The facility failed to ensure proper storage of medications across four medication carts, as observed on January 8, 2024. During the inspection, various medications were found unpackaged and without patient identifiers in the 700-1, 600, and 500 medication carts. Specific medications, such as white round tablets, peach round EP102, and insulin pens, were noted to be improperly stored. Additionally, an insulin pen was labeled only with a room number, lacking a patient identifier. The Director of Nursing acknowledged that medications should not be stored without secured packaging and patient identifiers. Furthermore, on January 7, 2024, a medication cart located next to a resident's room was observed to be unlocked and unattended. A nurse, identified as Nurse S, was seen coming from a resident's room and confirmed that the cart should have been locked. The facility's policy on medication storage, dated April 2019, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, in the packaging or containers in which they are received. The observations indicate a failure to adhere to this policy, leading to the deficiency.
Failure to Obtain Order for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain an assessment and physician's order for a resident to self-administer medications. During an observation, a resident was found with several medical ointments and treatments on their shelf and tray table. The resident, who was alert and able to answer questions, reported that they could apply some of the medications themselves or have staff assist them. However, it was noted that the resident did not have an order to self-administer medications, and the medications were not secured as required by the facility's policy. Further investigation revealed that the medications should not have been left in open areas in the resident's room. The nurse assigned to the hall confirmed the lack of an order for self-administration and removed the medications. The Unit Manager and the Director of Nursing both confirmed that the facility's policy requires an order for self-administration and that medications should be locked up when not in use. The resident's clinical record showed a moderate cognitive impairment, with a BIMS score of 11/15, and diagnoses including cerebral infarction and type II diabetes.
Failure to Implement and Document Advanced Directives
Penalty
Summary
The facility failed to ensure timely and accurate advanced directives information was in place and implemented for two residents, R66 and R2. R66 was observed to be severely cognitively impaired and had conflicting documentation regarding their code status. The electronic face sheet indicated R66 was a FULL CODE, while an Advance Directives form signed by the resident and a legal representative indicated a Do Not Resuscitate (DNR) status. Social Worker F, assigned to R66, claimed the resident had changed their wishes to FULL CODE, but no supporting documentation was provided. Additionally, a hospital record indicated the resident did not want CPR or intubation, further complicating the situation. R2, who was cognitively intact, was noted as a FULL CODE in their clinical record. However, their son, who was activated as the Durable Power of Attorney (DPOA), was making medical decisions without the resident being deemed incompetent. The DPOA document did not authorize the son to make decisions regarding code status or medical treatments, yet consent forms for medications and infection control were signed by the son. Social Worker F acknowledged the unusual nature of the DPOA but did not ensure proper documentation or discussions regarding R2's end-of-life wishes. The facility's policy on Advance Directives/Advance Care Planning requires that advance directives be respected and documented promptly in the medical record. The policy also mandates that the attending physician provide information to the resident and legal representative regarding health status and treatment options. The discrepancies in the documentation and lack of proper discussions with the residents or their legal representatives led to the deficiencies identified in the survey.
Failure to Provide Communication Aids for Non-Verbal Resident
Penalty
Summary
The facility failed to assess and provide alternative or augmentative communication methods for a resident with significant communication challenges due to medical conditions. The resident, who had a history of stroke, aphasia, hemiplegia, seizure disorder, and depression, was observed to be non-verbal and unable to effectively communicate their needs. Despite being able to eat independently, the resident expressed distress and frustration with their modified diet and had difficulty communicating their needs to staff. During observations, the resident used gestures to indicate dissatisfaction with their meal and pointed to a sore in their mouth, indicating pain. The resident also pointed to their clenched right hand and foot, suggesting a need for assistance with a hand splint and foot brace. However, there were no communication boards or assistive devices available in the resident's room to facilitate communication. Staff members confirmed the resident's communication challenges and acknowledged the absence of tools to aid in communication. The facility's failure to provide appropriate communication aids was further highlighted by the lack of a communication policy and the absence of speech therapy addressing communication needs. Although the resident had been evaluated for dysphagia, their communication needs were not initially addressed. The resident's care plan noted their non-verbal status but did not include alternative communication methods. This deficiency in providing necessary communication support led to the resident's ongoing frustration and inability to fully express their needs.
Lack of Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure a physician's order for supplemental oxygen for a resident who was observed receiving oxygen therapy. On multiple occasions, the resident was seen in their wheelchair and bed with two liters of oxygen being delivered via nasal cannula from an oxygen concentrator. Despite the ongoing administration of oxygen, a review of the resident's clinical records revealed no physician's order for supplemental oxygen. The resident, who has diagnoses including spastic hemiplegic cerebral palsy, adjustment disorder, dysphagia, high blood pressure, and chronic pain, was unable to communicate verbally during an attempted interview. The Director of Nursing confirmed that there should have been an order for the supplemental oxygen, as per the facility's policy on oxygen administration, which requires verification of a physician's order for the procedure.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate trauma-informed care for a resident diagnosed with PTSD, depression, and anxiety. The resident, who was cognitively intact, expressed difficulty adjusting to the long-term care setting and dissatisfaction with their current psychological provider. Despite the resident's requests for a different provider and additional social services support, no changes were made. The resident's care plan lacked specific interventions for PTSD, and no triggers were identified or addressed. The resident's medical records indicated a history of trauma, including night terrors and past family abuse, yet the facility did not conduct a formal trauma assessment or provide supportive visits from social services. The social worker assigned to the resident was unaware of the PTSD diagnosis and acknowledged the lack of supportive visits and care planning. The facility's policy on trauma-informed care was not followed, as there was no individualized care plan addressing the resident's past trauma or identifying potential triggers. Interviews with facility staff revealed a lack of awareness and action regarding the resident's PTSD diagnosis and care needs. The social worker and activity director were not informed of the diagnosis, which affected their ability to provide appropriate support and activities. The facility's failure to implement trauma-informed care and address the resident's psychosocial needs resulted in ongoing distress and care refusals by the resident.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.32% during a medication administration observation. This deficiency was identified when three medication errors were noted for one resident, R104, out of 41 opportunities. R104, who was admitted with medical conditions including hypertension, heart failure, prostate cancer, thyroid disorder, and renal insufficiency, was observed to have received an incorrect dose of MiraLAX due to inaccurate measurement by LPN A. Additionally, LPN A administered Metoprolol to R104 despite the resident's heart rate being below the ordered parameter of 60 beats per minute, with a documented heart rate of 57 beats per minute. Furthermore, during the medication administration observation, it was documented that R104 was given Flonase, an allergy relief medication, but it was not actually administered. The Director of Nursing was informed of these findings and acknowledged the errors, including the incorrect measurement of MiraLAX, the failure to adhere to Metoprolol administration parameters, and the discrepancy in the documentation and administration of Flonase. These actions and inactions led to the identified deficiency in medication administration practices at the facility.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of residents R805, R806, and R807, as observed during a survey. On the morning of November 19, 2024, call lights were activated and sounding at the nursing desk for the rooms occupied by these residents. Certified Nursing Assistant (CNA 'A') was observed entering the room of residents R806 and R807 without knocking or announcing themselves, and addressed R807 in a gruff, rushed tone. Additionally, CNA 'A' entered R805's room without knocking or announcing themselves, despite not being assigned to that resident. During an interview, CNA 'A' acknowledged the oversight but attributed it to the overwhelming number of call lights ringing. The Director of Nursing (DON) confirmed being informed of the dignity concerns by Unit Manager 'B' and acknowledged that such actions should not have occurred. These observations and interviews highlight the facility's failure to provide an environment that promotes and enhances residents' dignity, as required by regulations.
Failure to Implement Timely Wound Care Interventions
Penalty
Summary
The facility failed to timely implement effective wound interventions and ensure physician follow-up, assessment, and monitoring of a worsening wound for a resident identified as R502. Upon admission, R502 had several skin issues, including an open wound on the sacrum and an open blister on the right heel. Despite these conditions being identified on admission, there was a delay in implementing appropriate treatment for the right heel, which was not addressed until six days later. Additionally, there were conflicting treatment orders for the sacral area, with no clarification or explanation provided in the medical record. The medical record review revealed that multiple treatments were prescribed by medical doctors and nurse practitioners for R502's wounds, but there was no evidence of assessment or documentation of these wounds by the physician team until more than three weeks after admission. The first documented assessment of the resident's heels by the physician team occurred on 5/29/24, and the sacral wound was not acknowledged until 6/2/24. Furthermore, there was no documentation of the resident's noncompliance with turning and positioning, despite it being mentioned in a physician's note. The facility's Director of Nursing (DON) acknowledged the concerns regarding the sacral and right heel skin impairments and the delayed implementation of treatment. The DON indicated that the nursing staff and interdisciplinary team were following the resident's wounds but would review the medical record for physician/nurse practitioner assessments. The report highlights the lack of timely and effective wound care interventions and inadequate physician follow-up, which contributed to the worsening of the resident's pressure ulcers.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a resident, identified as R503, who was found with their feet and legs tied in a knot with blankets. The incident was reported to have occurred on the afternoon shift, and multiple staff members, including a Certified Nurse Aide (CNA) and a nurse, observed the resident in this condition. The resident, who had a history of dementia and was receiving hospice services, was unable to respond appropriately during an attempted interview. The clinical record review did not indicate any behavior consistent with self-restraining, contrary to the facility's suggestion that the resident might have tied themselves. Interviews with staff members revealed discrepancies in the facility's response to the incident. CNA 'G' reported finding the resident with their legs bound and expressed doubt that the resident could have tied the blankets themselves. Nurse 'H' confirmed the observation and attempted to identify the responsible party among the staff, but no one admitted to restraining the resident. Unit Manager 'I' was informed of the situation but claimed to have only been told that the resident was tangled in blankets, not tied. Despite reports of an in-service education on restraints, the Unit Manager did not provide such training at the time of the incident. The Director of Nursing (DON) and the facility's Administrator were also involved in the aftermath of the incident. The DON was not fully aware of the details and relied on the Unit Manager's account, which downplayed the severity of the situation. The Administrator conducted an investigation but concluded that the resident had tied themselves, despite evidence to the contrary. The facility failed to provide a restraint policy when requested, further indicating a lack of proper procedures and documentation regarding the use of restraints.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged abuse incident involving a resident, identified as R503, to the abuse coordinator and the State Agency. The incident involved R503 being found with blankets tied around their legs, which was initially observed by a Certified Nurse Aide (CNA) and a nurse. Despite the observations, the incident was not reported as an allegation of abuse to the appropriate authorities in a timely manner. R503, a resident with diagnoses including moderate protein calorie malnutrition, heart disease, adjustment disorder with anxiety, falls, and dementia, was receiving hospice services at the time of the incident. On the day of the alleged incident, a CNA found R503 with their legs bound by blankets, which they believed the resident could not have done themselves. The nurse on duty confirmed the observation and reported it to the Unit Manager, who did not take immediate action to report the incident as abuse. The facility's investigation into the incident was inadequate, as it was based on the assumption that R503 had tied the blankets themselves, despite evidence suggesting otherwise. The Administrator, who was also the Abuse Coordinator, did not consider the incident as an allegation of abuse, labeling it as a rumor instead. This led to a failure in reporting the incident to the State Agency as required by the facility's abuse and neglect procedural guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Notting Hill Of West Bloomfield | 0.5 mi | ★★★★★ | 23 | 0 |
| West Bloomfield Health And Rehabilitation Center | 0.5 mi | ★★★★★ | 2 | 0 |
| Medilodge Of West Bloomfield | 1.5 mi | ★★★★★ | 21 | 0 |
| Fox Run Village | 3.2 mi | ★★★★★ | 0 | 0 |
| Maple Manor Rehab Center Of Novi Inc | 3.2 mi | ★★★★★ | 2 | 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.