Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge At The Shore during CMS and state inspections, most recent first.
The facility did not follow its pressure injury prevention and wound management policies, resulting in missed skin assessments, delayed provider notifications, incomplete wound documentation, and failure to update care plans for residents with pressure injuries. Several residents did not receive wound treatments as ordered, and staff interviews revealed issues with communication, care plan adherence, and timely response to resident needs.
Two cognitively intact residents were involved in a physical altercation, with one resident observed by a CNA to be hitting the other. Although staff intervened and separated the residents, the incident was not reported to the state survey agency within the required timeframe, as the NHA was initially informed it was only a verbal argument. The delay in reporting and lack of clear documentation led to a deficiency for not timely reporting suspected abuse.
A resident with multiple complex diagnoses did not have her care plan updated to reflect new physician orders, changes in condition such as new onset seizures, or deterioration of a pressure injury. The care plan also failed to include specific dietary orders, individualized food preferences, and effective pain management interventions. Staff were observed using inappropriate feeding utensils and not consistently following the care plan, resulting in incomplete and inaccurate care.
Staff failed to follow Enhanced Barrier Precautions and infection control protocols during care for two residents with complex medical needs, including not wearing required PPE, improper glove use, inadequate hand hygiene, and mixing clean and soiled linens. Additionally, the facility did not properly track or document staff illnesses, omitting key information needed for infection surveillance.
The facility did not establish or follow required policies and procedures for administering flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
Three residents experienced medication administration errors, including controlled pain medications given at incorrect intervals without documented rationale and a cardiac medication administered without required pre-dose vital sign assessments. Facility records lacked appropriate documentation to justify these deviations from physician orders and facility policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with hemiplegia and cognitive impairment did not receive prescribed splint therapy for the left upper extremity as ordered, with multiple missed applications and lack of follow-up documentation or re-approach by licensed staff. The splint was found unused in the resident's drawer, and staff interviews confirmed the care plan was not consistently followed.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A resident with severe cognitive impairment and multiple medical conditions did not receive a required face-to-face visit from a physician or non-physician practitioner within the mandated 60-day interval after the initial 90 days post-admission. Review of records and staff interviews confirmed a gap of over 90 days without a documented visit, despite the resident receiving care from an outside provider and experiencing a hospitalization during this period.
A pharmacist made a medication regimen review recommendation for a resident with severe cognitive impairment and multiple diagnoses, but the facility failed to document the recommendation or show that a physician reviewed or acted on it. Required documentation was missing from the EMR, and attempts to retrieve it from an outside provider were unsuccessful, resulting in noncompliance with facility policy.
Surveyors found that individual medication containers, such as a nasal spray and a diskus, were not labeled with resident names inside the medication cart, even though the outer boxes were labeled. Nursing staff confirmed that the usual practice is to label each container to prevent mix-ups, but this was not done in these cases.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple complex medical conditions was started on a new Clonidine transdermal patch, but the facility failed to remove the old patch when applying a new one and did not initiate monitoring for side effects after starting the medication. The resident was later found unresponsive with two patches still in place and was sent to the ER, where staff confirmed the medication administration error.
Two residents receiving tube feeding did not have their feeding equipment properly labeled or maintained according to standards of practice. Feeding solution bottles lacked required information such as initiation date, time, and ordered rate, and syringes were not separated, rinsed, or dried between uses. The DON confirmed these lapses and noted the absence of a facility policy addressing these practices.
The facility failed to meet the needs of two residents by not ensuring timely response to call lights. A resident with Alzheimer's had her call light out of reach, while another with multiple sclerosis experienced delays in response, especially during the third shift. Staff interviews confirmed similar complaints from other residents.
The facility failed to provide quality care to two residents. A resident with a feeding tube had incorrect wound care orders followed, leading to pus and a foul smell at the site. Another resident with Alzheimer's had outdated nursing notes, and a low blood pressure reading was not promptly addressed. These deficiencies highlight lapses in following care orders and timely documentation.
An unattended medication cart was found unlocked with resident information visible and contained loose unidentified pills and an unsecured metal box with controlled substances. An LPN acknowledged the oversight, and another LPN confirmed that medication carts and narcotic boxes should always be locked when unattended. The facility's policy requires all medications to be stored securely.
The facility failed to provide adequate supervision and timely root cause analysis for fall incidents involving three residents, leading to significant injuries. Despite having care plans identifying them as at risk for falls, interventions were not effectively implemented, and residents were often left unsupervised. This resulted in multiple falls, with one resident sustaining a wrist fracture and another requiring emergency treatment for a laceration.
The facility failed to properly assess and implement advanced directives for two residents. One resident, not her own responsible party, had an advanced directive signed by herself instead of her Durable Power of Attorney. Another resident, who was her own responsible party, had an advanced directive incorrectly signed by her husband.
A facility failed to complete timely PASARR Level I and II evaluations for a resident with multiple diagnoses, including dementia and schizophrenia. The social worker did not follow up with the OBRA Coordinator to ensure the Level II Evaluation was scheduled, assuming the coordinator would see the need in the system. The Director of Nursing acknowledged the delay and lack of a tracking system, noting the social worker's failure to act promptly.
A resident with multiple health issues, including dysphagia and cognitive deficits, was observed eating alone without staff assistance, contrary to his care plan requiring one-person assistance. Despite being on a puree diet and receiving speech therapy, the resident was left unattended during meals, highlighting a failure in following the prescribed care plan.
A resident with multiple health issues, including dysphagia, was not adequately assessed for hydration and food intake. The resident repeatedly requested cold water but was not provided with appropriate thickened liquids due to a shortage. Discrepancies in fluid intake documentation were noted, with staff recording incorrect amounts. Observations showed the resident consumed minimal food and fluids, and staff assistance was inconsistent.
A facility failed to follow up on dialysis concerns for a resident with end-stage renal disease. The resident experienced issues such as cramping and hypotension during dialysis, but the facility did not complete necessary documentation or address these concerns. Interviews revealed a lack of clarity on responsibility and policy regarding dialysis communication.
A facility failed to ensure a pharmacist reported drug regimen irregularities to a physician for a resident with multiple diagnoses, including chronic kidney disease and bipolar disease. Despite medication reviews noting irregularities, the reports were not documented in the resident's medical record, and the DON could not obtain the necessary documentation from the pharmacist, leading to a potential lack of physician awareness.
A resident with chronic respiratory issues received Oxycodone five hours earlier than prescribed, contrary to the physician's order for 12-hour intervals. The facility failed to document the medication error or notify the physician, and no monitoring occurred post-administration. The DON confirmed the deviation from the policy, which allows a one-hour window for scheduled medications.
The facility failed to maintain complete medical records for three residents, missing hospice visit notes and a medication irregularity report. The DON struggled to locate hospice notes for two residents, eventually obtaining them from the hospice company. For another resident, a medication irregularity report was not documented in the electronic health record, contrary to facility policy.
A resident with an IV line was not provided with proper Enhanced Barrier Precautions (EBP) as required. Two CNAs were observed providing care without gowns, despite instructions to wear them for high-contact activities. The Infection Control Preventionist confirmed the oversight and noted the absence of PPE supplies in the resident's room.
A facility failed to offer a pneumococcal vaccine to a resident with diabetes, heart failure, and COPD, as required by their policy. The resident, who was cognitively intact, had previously received a PCV23 vaccine but was not offered the PCV20 vaccine upon admission. The oversight was identified during an immunization audit by the Infection Control Preventionist.
A resident with a history of stroke was admitted with existing wounds, but the facility failed to assess, monitor, and document these wounds accurately. The facility did not notify the physician or DPOA of new and worsening pressure injuries, and treatments were not completed as ordered. The resident was later hospitalized with severe sepsis due to an infected ulcer, highlighting the facility's inadequate wound management and communication.
The facility failed to ensure routine monitoring of patient care equipment, potentially affecting the safety of all residents. The DON reported no log for monitoring equipment, and while mechanical lifts are checked by an external company, other equipment like wheelchairs and bed rails are not routinely monitored. An electronic communication program exists for repairs, but no formal preventative maintenance system is in place.
The facility failed to ensure proper hand hygiene during meal tray delivery and incontinence care, leading to potential cross-contamination. Staff were observed not washing hands before or after entering resident rooms, and a CNA did not change gloves or perform hand hygiene during incontinence care for a resident with colitis.
Failure to Implement Pressure Ulcer Prevention and Treatment Protocols
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management and did not ensure that treatments were completed as ordered for multiple residents with skin integrity issues. One resident, a female with dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, was identified as high risk for pressure injuries but did not receive consistent skin assessments or timely notification to the provider or responsible party when a pressure injury developed. Documentation showed missed skin assessments, delayed notification of a new pressure injury, and incomplete wound assessments. The care plan for this resident did not include specific interventions such as a turning/repositioning schedule, and interventions were not updated in response to wound deterioration. Staff interviews revealed that the resident was often left wet and not repositioned as required, with communication gaps and staffing issues contributing to missed care. Other residents with wounds or pressure injuries also did not receive wound treatments as ordered, with documentation showing missed treatments on several occasions. Staff interviews indicated that some CNAs did not follow care plans, and there were reports of staff not assisting with care, leaving residents waiting for extended periods, and not responding promptly to call lights. Cognitively intact residents reported waiting so long for assistance that they became incontinent, and observed staff ignoring call lights or engaging in personal conversations instead of providing care. Review of facility policy and nursing standards highlighted the requirement for individualized care plans, timely provider notification of wound changes, and consistent implementation of interventions based on risk assessments. The facility did not consistently document or communicate interventions, modify care plans in response to wound deterioration, or ensure that all staff were aware of and followed the required interventions. These failures resulted in residents not receiving appropriate pressure ulcer care and prevention as required by facility policy and professional standards.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two cognitively intact residents who were involved in a physical altercation. According to the records, one resident was observed by a Certified Nursing Assistant (CNA) to be hitting another resident in the upper chest and collarbone area while the other resident was lying in bed in a defensive posture. The CNA immediately intervened and separated the residents. Statements from multiple staff members, including the CNA and a Registered Nurse (RN), confirmed that the incident involved physical contact, with the CNA consistently stating she witnessed one resident hitting the other. Despite these observations, the Nursing Home Administrator (NHA) was initially informed that the incident was only a verbal argument. The NHA did not receive or document clear information about the physical nature of the altercation until after further investigation the following day. The facility's own policy requires that allegations of abuse be reported to the Administrator, state agency, and other required authorities immediately, but no later than two hours after the allegation is made. However, the incident was reported to the state survey agency approximately 17 hours after it occurred. The delay in reporting was compounded by inconsistent communication and documentation. The NHA did not document a follow-up conversation with the CNA, who maintained her original statement about witnessing physical abuse. Additionally, the NHA did not have the CNA revise her statement to reflect any uncertainty, as claimed during the investigation. The facility's failure to promptly and accurately report the abuse allegation as required by policy resulted in a deficiency.
Failure to Update and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed, revised, and implemented according to the resident's changing needs and physician orders. The resident, an elderly female with diagnoses including dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, had multiple care needs that were not accurately reflected or updated in her care plan. For example, her care plan did not address the need for a geri chair with direct supervision as ordered, nor did it reflect the restriction against using a broda chair. Additionally, the care plan failed to include the administration of pain medication one hour prior to wound dressing changes, despite a physician's order for this intervention. The resident experienced new onset seizures, but her care plan did not include this diagnosis or interventions for seizure precautions and injury prevention. There was also a lack of updated interventions following the deterioration of her unstageable pressure injury, such as specific positioning or offloading measures. The care plan did not reflect the need for frequent repositioning as documented in provider notes, nor did it address the significant weight loss the resident experienced over a three-month period. Dietary orders for pureed food and nectar thick liquids by teaspoon were not fully incorporated into the care plan, and the use of inappropriate feeding utensils, such as straws, was observed during meal assistance. Furthermore, the care plan lacked individualized details regarding the resident's food preferences, dislikes, and effective non-pharmacological pain interventions. Staff interviews and observations confirmed that the care plan was not consistently referenced or followed, leading to discrepancies between the resident's documented needs and the care provided. These omissions and failures to update the care plan resulted in incomplete and potentially inappropriate care measures for the resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and proper infection control practices. In one instance, two certified nurse aides provided a bed bath to a resident with a feeding tube and severe cognitive impairment without wearing the required gowns, despite clear signage indicating EBP was necessary. The aides also failed to change gloves between soiled and clean activities, left the room with soiled gloves without performing hand hygiene, and continued care after inadequate handwashing. Both aides acknowledged awareness of the EBP requirements but admitted to not following them during care. Another resident, who was cognitively intact but nonverbal and dependent on staff for care, was observed receiving morning care from a certified nursing assistant who did not use any PPE, despite signage indicating EBP was required. The assistant used the same gloves and washcloths for both clean and soiled areas, mixed clean and dirty linens, and failed to perform hand hygiene when leaving and re-entering the room. A registered nurse assisted in transferring the resident but did not ensure the assistant donned appropriate PPE, even though the nurse was aware of the requirements and the assistant's noncompliance. Additionally, the facility's infection surveillance system was found lacking in tracking and documenting staff illnesses. The call-in log for staff absences due to illness did not consistently record essential information such as the unit worked, specific symptoms, onset dates, or return-to-work dates. The infection control preventionist confirmed these gaps, and there was no documentation of follow-up or analysis to identify potential clusters or prevent the spread of infection, contrary to facility policy and procedures.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for three residents. For one resident, a controlled pain medication (Norco) was administered at intervals shorter than the physician-ordered four hours, with doses given three hours apart and no documentation providing a rationale for this deviation. Another resident received Percocet doses at intervals of 2 to 2.5 hours instead of the ordered four hours, with no documentation explaining the early administration. In both cases, the medication administration records and electronic medical records lacked required documentation to justify the timing discrepancies. A third resident, prescribed Metoprolol with specific parameters to hold the medication if blood pressure or heart rate were below set thresholds, did not have vital signs assessed prior to several evening doses. Instead, morning vital sign results were inappropriately documented as if they were taken before the evening doses. The facility's own medication administration policy requires obtaining and recording vital signs when applicable or as ordered by the physician, and to hold medication for vital signs outside prescribed parameters. The Nursing Home Administrator confirmed these errors and reported no additional documentation to refute the findings.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Follow Physician Orders and Care Plan for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the care plan for a resident with hemiplegia, hemiparesis, vascular dementia, and pseudobulbar affect, who required a splint for the left upper extremity. The physician's order specified that the splint should be applied upon rising, removed for lunch, reapplied after lunch, and removed at bedtime, as tolerated by the resident. Multiple observations revealed that the resident was not wearing the splint at the required times, and the resident reported that the splint was never applied and was unaware of its location. The splint was later found in the resident's drawer, and the resident allowed it to be applied without resistance. Documentation showed that there were 21 instances where the splint application did not occur, with no follow-up documentation by licensed staff to address refusals or investigate the root cause. The care plan indicated that if the resident refused, staff should encourage compliance and document refusals, but there was no evidence that this was consistently done. Interviews with staff confirmed that the care plan was not followed, and communication regarding refusals was lacking.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Ensure Timely Face-to-Face Physician Visits
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or non-physician practitioner conducted a face-to-face visit with a resident at least once every 60 days after the initial 90 days post-admission, as required. The resident in question was admitted with multiple diagnoses, including dementia, diabetes, bipolar disorder, depression, and hepatic encephalopathy, and was assessed as being severely cognitively impaired. Review of the resident's electronic medical record showed no documentation of a physician or non-physician practitioner visit between late February and early June, a period of 93 days, which exceeded the required interval for such visits. The Director of Nursing confirmed that there was no evidence in the facility's records of a face-to-face visit during this time frame. Although the resident received physician services from an outside company and had been hospitalized for part of the period in question, there was still a significant gap where no documented visit occurred. The deficiency was identified through both record review and staff interview, with the DON agreeing that a visit should have taken place within the required timeframe.
Failure to Document and Communicate Pharmacy Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacist's medication regimen review recommendation was properly documented and communicated for one resident. The resident in question was admitted with multiple diagnoses, including dementia, bipolar disorder, and depression, and was assessed as being severely cognitively impaired. On a specific date, the pharmacist indicated that a comment or recommendation had been made regarding the resident's medication regimen, as noted in the progress note. However, a review of the resident's electronic medical record did not reveal any documentation of what the pharmacist's recommendation or comment was, nor any evidence that the physician had reviewed or acted upon it. Interviews with the DON confirmed that the expected documentation, which should have been scanned into the resident's EMR, could not be located. Further attempts to obtain the report from an outside company providing physician services were unsuccessful, as they also did not have a copy of the relevant pharmacy report. The facility's policy requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and DON, and that the physician document their review and any actions taken in the resident's medical record. In this case, there was no documentation to confirm that these steps were followed.
Failure to Properly Label Individual Medication Containers
Penalty
Summary
During an inspection of the Southwest Medication Cart, surveyors observed that medications were not appropriately labeled in accordance with professional standards. Specifically, a box of Desmopressin Nasal Spray and a box of fluticasone and salmeterol were found with the respective residents' names on the outer boxes, but the individual nasal spray container and diskus inside the boxes were not labeled with any identifying information. This created a situation where, if the medication containers became separated from their boxes, it would not be possible to identify which resident they belonged to. Interviews with nursing staff confirmed that the standard practice is to label individual medication containers with the resident's name, either using pharmacy-provided labels or by writing the name directly on the item. Staff members acknowledged the importance of this practice, especially when multiple residents are prescribed the same medication, to prevent mix-ups. However, in these instances, the labeling procedure was not followed, resulting in a failure to ensure that all drugs and biologicals were properly labeled as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Remove Old Clonidine Patch and Monitor After New Medication Initiation
Penalty
Summary
The facility failed to follow professional standards for medication administration for one resident. A male resident with a history of recent brain bleed, left-sided weakness and paralysis, chronic kidney disease stage 4, morbid obesity, insulin-dependent diabetes mellitus, and a feeding tube was admitted and started on a new order for a Clonidine transdermal patch. The electronic medication administration record showed that the patch was to be applied weekly, but there was a delay in administration due to the patch not being available, resulting in it being placed two days late. Additionally, there was no new monitoring ordered to assess for side effects after starting this new medication. On a later date, the resident was found unresponsive with labored breathing and was sent to the emergency room. Upon arrival, two unidentified Clonidine patches were found on each of his upper arms, one from the initial application and one from the later application, indicating that the old patch had not been removed as required. Nursing home staff confirmed that the patches were old and should have been removed. The presence of multiple patches was noted as concerning by the ER staff, and the resident exhibited symptoms including extreme drowsiness, difficulty arousing, and periods of apnea.
Failure to Follow Standards of Practice for Tube Feeding
Penalty
Summary
The facility failed to follow standards of practice for tube feeding for two residents. For one male resident with paraplegia and protein-calorie malnutrition, observations revealed that the irrigation container and syringe used for tube feed flushes were left on the bedside table with the plunger inside the syringe, and the syringe was sitting in a graduated container containing clear liquid dated from the previous day. Additionally, the bottle of tube feed did not have the time it was initiated as required. The resident's electronic medication administration record indicated an order to change and label the feeding syringe and/or container every night shift, but this was not followed. For a female resident with spastic quadriplegic cerebral palsy who is dependent on tube feeding, the tube feed solution bottle did not have the ordered rate or the date the feed was initiated written on it. The syringe and plunger were not separated and were left together in a cylinder with clear liquid on the bedside table. During an interview, the DON confirmed that the tube feed bottles should be labeled with the date, time, and ordered rate, and that syringes and plungers should be separated, rinsed, and allowed to dry between uses. The DON also reported that the facility did not have a policy addressing these standards of practice.
Failure to Ensure Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure that residents' needs were met in a timely manner and that call lights were within reach for two residents. Resident #6, a female with Alzheimer's and rheumatoid arthritis, was observed multiple times with her call light out of reach and covered by a hat, making it inaccessible. Despite being in bed and needing assistance, she was unable to notify staff due to the call light's placement. The facility's policy requires staff to ensure resident access to call lights, but this was not adhered to in the case of Resident #6. Resident #9, a male with multiple sclerosis and difficulty speaking, reported delays in staff responding to his call light, particularly during the third shift. His roommate corroborated these delays, noting that staff would sometimes dismiss the urgency of the call. Confidential staff interviews revealed similar complaints from other residents about the third shift staff being rough, rushed, and slow to respond to call lights. The facility's policy states that any staff member who sees or hears an activated call light is responsible for responding, yet this was not consistently practiced, leading to unmet needs for Resident #9.
Failure to Provide Quality Care for Residents
Penalty
Summary
The facility failed to provide quality care to two residents, leading to deficiencies in their treatment. Resident #1, a female with a history of cerebral aneurysm, stroke, and other medical conditions, was admitted with a feeding tube. The hospital discharge orders specified that the tube feed site should be cleaned with a dermal wound cleanser. However, the facility's electronic medication administration record indicated that normal saline was used instead. This discrepancy in care led to the resident's daughter observing pus and a foul smell from the tube site, which was confirmed by an observation showing pus-like drainage and a saturated drain sponge. Resident #6, a female with Alzheimer's and rheumatoid arthritis, exhibited severely impaired cognition. The facility's nursing progress notes for this resident were outdated, with the last entries made over a month apart. A low blood pressure reading was recorded on 11/17/24, but there was no documentation of physician notification or a timely re-check of the blood pressure until four days later. This lack of timely documentation and follow-up on the resident's condition indicates a failure to provide appropriate care according to the resident's needs.
Unsecured Medication Cart with Controlled Substances
Penalty
Summary
The facility failed to secure an unattended medication cart, which was observed on 01/08/25 at 7:20 AM. The cart, designated for rooms 1-15, was found with resident information displayed on the computer screen and was unlocked. Inside the cart, 14 different loose unidentified pills were found in the second drawer on the left side, and an unsecured metal box containing controlled substances was found in the second drawer on the right side. During an interview shortly after the observation, an LPN acknowledged the oversight, expressing regret. Another LPN confirmed that medication carts and narcotic boxes are required to be locked at all times when not attended by a nurse. The facility's policy on medication storage, last reviewed on 01/30/24, mandates that all medications be stored in locked compartments, with controlled substances requiring double lock and key.
Inadequate Supervision and Fall Risk Management
Penalty
Summary
The facility failed to provide adequate supervision and timely root cause analysis for fall incidents involving three residents, leading to significant injuries. Resident R48, a female with a history of bipolar disorder, epilepsy, and muscle weakness, experienced multiple falls resulting in a wrist fracture. Despite having a care plan that identified her as at risk for falls, interventions such as bed height adjustments and non-skid footwear were not effectively implemented. Observations revealed that R48's bed was often at an unsafe height, and she was left unsupervised, contributing to her falls. Resident R102, diagnosed with congestive heart failure, Alzheimer's disease, and muscle weakness, also suffered from multiple falls, one of which resulted in a laceration requiring emergency treatment. Her care plan included interventions like wheelchair anti-rollback and non-skid footwear, but these did not address her cognitive deficits or history of unsafe transfers. The facility failed to conduct thorough investigations or root cause analyses for her falls, and there was no evidence of increased supervision despite her known safety issues. Resident R465, a male with dementia and visual problems, was found sitting on the floor after an unwitnessed fall. His care plan included interventions for fall risk, but there were no specific measures for supervision. Observations showed that R465 was often left alone and did not know how to use his call light, indicating a lack of adequate supervision. The facility did not conduct a root cause analysis or implement new interventions following his fall.
Failure to Implement Advanced Directives
Penalty
Summary
The facility failed to accurately assess and implement advanced directives for two residents upon admission. Resident R102, a female with multiple diagnoses including congestive heart failure and Alzheimer's disease, was not her own responsible party. The facility did not have a signed advanced directive from R102's son, who was her Durable Power of Attorney. Instead, an advanced directive form was signed by R102 herself, despite her not being her own responsible party. The Director of Nursing confirmed the absence of contact with R102's son regarding the advanced directive. Resident R110, who was her own responsible party, also had issues with her advanced directive. Although R110 was listed as her own clinical responsible party, the facility had an advanced directive signed by her husband. The Director of Nursing acknowledged that R110 should have signed her own advanced directive. The advanced directive on record incorrectly had the husband's signature, indicating a failure in the process of obtaining and verifying the correct responsible party's signature.
Failure to Complete Timely PASARR Evaluations
Penalty
Summary
The facility failed to ensure timely completion of the Pre-Admission Screening and Resident Review (PASARR) Level I and Level II evaluations for a resident. The resident, who was admitted with multiple diagnoses including dementia, depression, anxiety, and schizophrenia, was identified as needing a PASARR Level II Evaluation by a specific date. However, the PASARR Level I Screening was completed late, and the Level II Evaluation was not completed at all. The social worker responsible for coordinating these evaluations did not follow up with the OBRA Coordinator to ensure the Level II Evaluation was scheduled, assuming instead that the coordinator would automatically see the need for it in the system. Interviews revealed that the social worker did not have a system in place for tracking and following up on PASARR evaluations, relying instead on the OBRA Coordinator to notify her of necessary actions. The Director of Nursing acknowledged the delay and the lack of a tracking system, noting that the social worker had not heard from the OBRA Coordinator for over 30 days after the Level I Screening was completed. Despite receiving an email from the OBRA Coordinator about the need for the Level I Screening, the social worker delayed its completion by 35 days, contributing to the overall deficiency in the resident's care assessment process.
Failure to Assist Resident with Eating as per Care Plan
Penalty
Summary
The facility failed to follow the care plan for a resident, identified as R465, who required assistance with eating. R465, a male resident with diagnoses including kidney failure, dementia, macular degeneration, dysphagia, and cognitive communication deficit, was observed eating independently on multiple occasions without staff assistance, despite his care plan indicating he needed one-person assistance for eating. On one occasion, R465 was observed eating lunch alone and requesting cold water, but he was unable to use the call light to request help. A CNA briefly entered the room to get thickened cold water but left R465 alone with his meal tray. Further observations revealed R465 eating breakfast alone in his room on two separate occasions. During an interview, the Registered Dietitian confirmed that R465 was on a puree diet with thickened fluids and was receiving speech therapy for swallowing problems. The Speech Therapy Progress note indicated that R465 had impaired cognitive-communication and swallowing functioning, which affected his ability to safely complete activities of daily living and meet his nutrition and hydration needs independently.
Failure to Provide Adequate Hydration and Nutrition Assessment
Penalty
Summary
The facility failed to adequately assess and provide for the hydration and food intake needs of a resident, identified as R465, who was reviewed for nutrition. R465, a male resident with kidney failure, dementia, macular degeneration, dysphagia, and cognitive communication deficit, required assistance with eating. On multiple occasions, R465 was observed requesting cold water but was unable to use the call light to alert staff. The Certified Nurse Aide (CNA) L was unable to provide cold thickened water due to a shortage in the kitchen and instead offered thickened milk, which R465 refused. The Registered Dietitian (RD) K later provided thickened Pepsi, which R465 accepted in small sips, but he continued to request thin liquids, which were not provided due to his swallowing problems. There were discrepancies in the documentation of R465's fluid intake. CNA L and CNA J provided conflicting accounts of the amount of fluid R465 consumed, with CNA J initially recording an incorrect amount due to a misunderstanding of the cup size. The Director of Nursing (DON) confirmed the error in the recorded fluid intake. Additionally, observations showed that R465 consumed minimal food and fluids during meals, and staff were not consistently present to assist or accurately document his intake. These issues highlight a failure in the facility's processes to ensure accurate assessment and documentation of R465's nutritional and hydration needs.
Failure to Follow Up on Dialysis Concerns
Penalty
Summary
The facility failed to provide appropriate follow-up care for a resident requiring dialysis services. The resident, who had multiple diagnoses including end-stage renal disease and diabetes, experienced issues during dialysis sessions, such as intradialytic cramping and symptomatic hypotension. Despite these concerns being documented by the dialysis center, the facility did not complete the necessary sections of the hemodialysis communication records upon the resident's return. This included missing vital signs, site observations, and documentation of the resident's response to pain. Interviews with the Unit Manager and the Director of Nursing revealed a lack of clarity regarding who was responsible for addressing the dialysis communication and what the facility's policy was. The Director of Nursing confirmed the absence of documentation addressing the resident's concerns and acknowledged that education for staff on completing dialysis forms had just begun. Additionally, there was no evidence that the facility was applying lidocaine cream as directed by the dialysis center.
Failure to Report Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist reported identified drug regimen irregularities to the physician for a resident reviewed for monthly pharmacist Medication Regimen Reviews. The resident, who was admitted to the facility with multiple diagnoses including chronic kidney disease, diabetes, visual hallucinations, and bipolar disease, had medication reviews conducted by the pharmacist on two occasions. However, the reports and recommendations from these reviews were not documented in the resident's electronic medical record, as required by the facility's policy. During the survey, the Director of Nursing (DON) was unable to locate the pharmacist's reports or notes detailing the irregularities found on the specified dates. Despite attempts to contact the pharmacist for copies of the recommendations, the facility did not provide any documentation related to the pharmacist's findings by the completion of the survey. This lack of documentation and communication resulted in the potential for the physician to be unaware of drug irregularities, which is a violation of the facility's policy on addressing medication regimen review irregularities.
Early Administration of Oxycodone
Penalty
Summary
The facility failed to adhere to the physician's ordered time frame for administering a controlled substance, Oxycodone, to a resident. The resident, who was admitted with chronic respiratory failure with hypoxia, asthma, and dementia, had a physician's order for Oxycontin to be administered every 12 hours. However, the medication was administered five hours early, at 7:00 AM, instead of the scheduled time. This deviation from the prescribed schedule was not documented as a medication error, and there was no evidence that the physician was contacted or that any incident or monitoring occurred following the early administration. The Director of Nursing (DON) acknowledged that medications with a scheduled time frame should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. Despite this policy, the facility's documentation did not reflect any identification or explanation of the medication error. The facility's policy on medication administration, which emphasizes adherence to professional standards and verification of medication details, was not followed in this instance. As of the survey exit, no additional information or explanation was provided regarding the incident.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete medical records for three residents, which could potentially hinder providers from having an accurate and complete picture of the residents' stay. For one resident, the electronic medical record lacked hospice aide visit notes from a specified period. Despite the Director of Nursing's (DON) efforts to locate these notes, they were initially unavailable in the facility's system and had to be obtained from the hospice company. Another resident's electronic medical record also lacked hospice visit notes, including those from hospice aides and nurses, for a specific timeframe. The DON acknowledged the absence of these notes and indicated that the facility's medical records person was unable to locate them. Eventually, the hospice visit notes were retrieved from the hospice company and added to the resident's electronic medical record. For a third resident, the facility failed to document a medication irregularity report in the electronic health record. The surveyor could not find evidence of the irregularity report or the physician's response to it. The DON provided a document with recommendations but admitted that the final report, which should include the physician's signature, was not available. The facility's policy requires the attending physician to document any irregularities and actions taken, but this was not done in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident, identified as R5, who was under infection control practices due to an IV line. R5 was admitted with diagnoses including sepsis, diabetes, and a right femur fracture, and was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance with activities of daily living. During an observation, it was noted that a stop sign on R5's door instructed staff to wear gloves and gowns for high-contact care activities. However, two Certified Nurse Assistants (CNAs) were observed providing personal care to R5 while wearing gloves but not gowns, contrary to the posted instructions. When questioned, one of the CNAs stated that they believed gowns were not necessary for R5, as the precaution was only for her IV. Additionally, there was no personal protective equipment (PPE) stand or supplies found in R5's room. The Infection Control Preventionist (ICP) confirmed that the CNAs should have been wearing gowns and acknowledged the absence of PPE supplies in the room. The ICP indicated that re-education of the CNAs and placement of a PPE stand in R5's room would be necessary.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that immunizations were offered and provided to a resident, identified as R29, who was reviewed for immunizations. R29 was admitted to the facility with diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, and was cognitively intact with a BIMS score of 15 out of 15. According to the facility's Pneumococcal Vaccine policy, adults aged 19-64 with such diagnoses should be offered the pneumococcal vaccine upon admission. However, a review of R29's immunization record revealed that although R29 had received a PCV23 vaccine in 2011, they were not offered the PCV20 vaccine upon admission in 2023, as required by the policy. The Infection Control Preventionist acknowledged the oversight during an interview and record review, noting that an immunization audit had revealed several residents, including R29, were missed for the PCV20 vaccine offer.
Failure to Assess and Treat Pressure Injuries
Penalty
Summary
The facility failed to adequately assess, monitor, and document pressure injuries and wounds for a resident, leading to incomplete and inaccurate wound assessments and a delay in treatment. The resident, a male with a history of stroke and other medical conditions, was admitted with existing wounds documented by the hospital. However, the facility did not identify or document these wounds accurately during the admission assessment, and there was a lack of treatment orders for certain areas, such as the reddened area on the right outer ankle and bilateral heels. The facility also failed to notify the physician and the Durable Power of Attorney (DPOA) of new and deteriorating pressure injuries. There were multiple instances where wound treatments were not completed as ordered, and there was no documentation of a rationale for the lack of wound care. The resident's care plans were not updated to reflect the multiple pressure injuries following skin assessments, wound assessments, or hospitalization. Additionally, the facility's wound management program was found to be lacking, with late and incomplete assessments and inconsistent documentation. The resident was eventually admitted to the hospital with severe sepsis due to an infected sacral decubitus ulcer, and multiple pressure ulcers were identified. The facility's failure to provide timely and appropriate wound care, along with inadequate communication and documentation, contributed to the deterioration of the resident's condition. Interviews with staff and family members confirmed the lack of notification and communication regarding the resident's worsening condition and new wounds.
Lack of Routine Monitoring of Patient Care Equipment
Penalty
Summary
The facility failed to have a system in place to ensure routine monitoring of patient care equipment for safe and functional condition, potentially affecting the safety of all residents. During an interview, the Director of Nursing (DON) reported that there is no log of resident care equipment being monitored. Mechanical lifts are checked once or twice a year by an external company, but the maintenance department does not maintain a log for routine monitoring of other patient care equipment such as wheelchairs, shower chairs, mechanical lifts, and bed rails. Although an electronic communication program exists to report equipment needing repairs, there is no formal system for preventative maintenance and monitoring. A review of the facility's Preventative Maintenance Program policy, last revised in March 2022, revealed that a program should be developed and implemented to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Failure to Follow Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during meal tray delivery and incontinence care, leading to potential cross-contamination and the spread of illness. During observations on the Northwest Hallway, staff members, including a Registered Dietitian, Certified Nursing Aides, and a Social Worker, were seen delivering meal trays without performing hand hygiene before or after entering resident rooms. This was confirmed by the Director of Nursing, who stated that staff are expected to wash their hands after resident contact and before handling another resident's tray. Additionally, a Certified Nursing Assistant was observed providing incontinence care to a resident with generalized weakness and colitis without changing gloves or performing hand hygiene between handling soiled items and clean surfaces. The CNA admitted in an interview that she should have changed her gloves and performed hand hygiene when transitioning from dirty to clean tasks.
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 218 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Nursing Centre | 1.1 mi | ★★★★★ | 36 | 0 |
| Heartwood Lodge Trinity Health | 3 mi | ★★★★★ | 1 | 0 |
| Roosevelt Park Nursing And Rehabilitation Communit | 10.6 mi | ★★★★★ | 3 | 0 |
| Optalis Health & Rehabilitation Of Muskegon | 11.3 mi | ★★★★★ | 40 | 0 |
| Christian Care Nursing Center | 11.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.