Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Frankenmuth during CMS and state inspections, most recent first.
Food service staff failed to follow basic food safety practices, including storing expired yogurt and milk, leaving cut watermelon without date marking, and holding foods such as egg salad, ranch, cut tomato, and cream of mushroom at unsafe temperatures. Surveyors also observed a visibly soiled coffee machine, mixer, and ice machine with an outdated filter, and a staff member was seen gloving without washing hands first. The CDM and MD gave statements that conflicted with Food Code requirements cited in the report.
A resident with a trach, PEG, and Foley catheter was observed receiving high-contact care without EBP PPE, while suction and nebulizer equipment in the room were left out, uncovered, or improperly stored. Infection control rounding and surveillance documentation was missing for multiple facility areas and months, and a nurse disinfected a glucometer with an alcohol swab instead of the facility’s purple-top disinfectant.
Plumbing and housekeeping deficiencies were observed in multiple areas of the facility. A hand sink in the laundry room was missing a sewer line and was draining wastewater into a trash bin, which the Housekeeping Manager said had been occurring for about two months. In addition, utility sinks in several housekeeping closets had backflow prevention concerns involving AVBs, hoses, and chemical feeders, and a soiled towel was observed on the floor of a shower room.
Failure to maintain resident dignity, privacy, and timely assistance: residents reported staff turning off call lights and not returning, cold meals, rude comments, and loud staff gatherings at the nurses’ station. One resident with stroke, aphasia, trach, PEG, epilepsy, and severe cognitive impairment had a call light out of reach and was observed receiving brief care with the privacy curtain open. Another resident with MS and quadriplegia reported long call wait times and being left in a dirty brief for hours after requesting help.
A confidential group of residents reported frustration with the facility’s HS snack process because they had to complete a blue form by 2 PM to receive a bedtime snack, and some said they did not get a snack if they did not submit the form. The RD Q confirmed the form-based process for specific snack requests, and the DON stated she had a problem with requiring residents to fill out the sheet by 2 PM. Residents also reported seeing staff take snacks from the cart, leaving fewer options for them.
Antibiotic stewardship and infection criteria were not followed for 4 residents who received antibiotics for UTIs that did not meet McGeer criteria. The IP could not locate supporting UA, culture, or organism documentation for Macrobid, Cipro, levofloxacin, and Bactrim DS use, and stated there was no urine dipstick policy or McGeer procedure available; the computer program flagged criteria, but the NP decided whether antibiotics were stopped.
Failure to provide timely grooming and shaving assistance was cited for two residents. One resident repeatedly had visible chin whiskers and said staff only shaved her on shower days, while another resident with dementia and severe cognitive loss was repeatedly observed unshaven despite needing supervision or touch assistance with hygiene tasks including shaving. The UM said she did not know why the male residents were not shaved, and the care plan did not address shaving or refusal of care.
Inconsistent wound care and undated dressings. Two residents receiving wound care had missed or undocumented dressing changes, including repeated blanks on the MAR/TAR for one resident’s coccyx, sacral, and gluteal wounds and an old, undated dressing on another resident’s right great toe wound that was saturated with drainage. One resident reported treatments were not always done daily and that the wounds seemed to be getting bigger, while the DON acknowledged blank documentation and that staff were not using the MAR/TAR coding key.
A nurse was observed working independently on the dementia unit before completing required competencies, in-services, and orientation topics. Records showed the nurse had completed only PPE and hand hygiene training while other required items, including abuse, neglect, behavioral health, dementia, resident rights, and medication pass, were still incomplete when reviewed by the DON and Administrator.
Medication administration was not performed according to standards when an LPN carried two medication cups into a room, handled a dropped pill, placed one resident’s cup into a used cup containing the dirty pill, and then gave the medications to another resident. A resident with ALS, dysphagia, PEG tube use, COPD, diabetes, sleep apnea, heart disease, GERD, and PTSD reported that medications given through the PEG sometimes squirted out and were not replaced. In a group interview, residents said meds were sometimes left at the bedside while staff left the room, and one resident said meds were occasionally forgotten until the resident spoke up.
A resident with ALS and dysphagia did not consistently receive the full ordered amount of tube feeding, with MAR documentation showing multiple days below the prescribed 1000 ml and some days with no documentation or excessive amounts; the resident reported late starts, early discontinuation, and improper flushing. Another resident with a PEG tube was observed with an enteral feeding bag that remained dated from the prior day, and a nurse was unsure about the bag date and initials, indicating the feeding equipment was not properly maintained.
Unsanitary Storage of Respiratory Equipment: A resident with ALS, COPD, sleep apnea, and other diagnoses had AVAPS, cough assist, and suction equipment at the bedside, but the AVAPS mask was uncovered and appeared soiled, the cough assist tubing was kinked and pinched in a drawer, and distilled water jugs were left undated and one was labeled with another resident’s name. Orders required cleaning, drying, and covered storage of the respiratory equipment, but the care plan did not address the AVAPS or cough assist devices.
Inaccurate daily staffing postings failed to show RN hours. Record review showed CNA, LPN/LVN, and med tech hours, but no RN coverage, and HR acknowledged the posting format was inaccurate and did not display RN hours.
A nurse failed to follow insulin pen administration and needle safety practices for a resident. The nurse attached the needle without cleaning the insulin pen with an alcohol swab and administered the insulin without priming the needle with the required 2 units; the DON was later alerted to the error.
Medication Storage and Labeling Deficiencies: Multiple opened topical meds in treatment carts were found without dates, and several discontinued or unused meds remained stored for residents, including one resident who had already been discharged. A medication refrigerator also had repeated temperatures below the required range, and the log showed no documented corrective action despite staff awareness and DON validation of the deviation.
A resident with Alzheimer’s disease and vascular dementia repeatedly wandered into other residents’ rooms and slept in their beds, with documentation of 31 such episodes in one month and staff acknowledging this as an ongoing behavior. The care plan contained only a minimal intervention to redirect the resident if another resident was upset, without detailing consistent redirection strategies, environmental modifications, or linen-changing and cleaning practices after the resident used another’s bed. Another resident and that resident’s spouse were directly affected, with the spouse reporting ongoing incidents of the wandering resident in her husband’s bed and expressing frustration that staff said they could not consistently monitor the behavior. The Social Worker and other staff confirmed that no additional individualized interventions had been developed or trialed despite persistent intrusive behaviors, room changes, and complaints, contrary to the facility’s policy requiring comprehensive, person-centered care planning.
The facility failed to ensure dignity and privacy for residents during meal service and personal care. Two residents were left without meals while others were served, and a resident was exposed without clothing due to an open privacy curtain. Additionally, residents reported unmet needs and unresponsive staff regarding call lights. A resident's room had a persistent urine odor, and another resident was unable to reach their call light, highlighting issues in maintaining a dignified environment.
The facility failed to assess and obtain informed consent for the use of bed rails for several residents, leading to a deficiency. Observations showed residents using siderails without proper documentation or consent. Care plans did not address siderail use, and consent forms were incomplete. Staff interviews revealed a lack of awareness and compliance with the facility's policy on bed rails.
The facility failed to ensure proper labeling, storage, and discard of medications across four medication carts, leading to deficiencies in medication management. Observations revealed that multi-dose medications were not dated with either an open date or expiration date, and ampules were found outside of their foil packets. Interviews with staff confirmed the lack of adherence to medication labeling and storage policies, and the Nursing Home Administrator admitted to the absence of a multi-dose medication policy.
The facility failed to maintain sanitary conditions in the kitchen and did not follow proper thawing procedures for hamburger meat. Observations included equipment with dried food, improper thawing of meat in a pool of blood, and a small brush on the handwashing sink that could transfer bacteria. The facility's policies on food preparation and service were not adhered to, leading to potential cross-contamination issues.
The facility failed to ensure a clean environment for residents, with observations of dusty fans and improperly stored oxygen tubing. A resident with Guillain-Barre Syndrome had a dusty fan blowing on him, and another resident's oxygen tubing was not stored in a bag to prevent contamination. Additionally, a resident receiving respiratory treatments had a dusty fan and a urine catheter bag improperly placed. The facility lacked specific policies for cleaning fans and storing respiratory equipment.
The facility failed to update care plans for residents with changing needs, including those with a history of falls and specific code status preferences. Several residents were observed with siderails, but their care plans lacked documentation on their use and monitoring. The DON was unaware of the siderails, indicating a gap between policy and practice.
The facility failed to ensure accurate weight measurements for two residents, leading to incorrect documentation in their medical records. One resident was recorded to have gained 16 pounds in one day, which was later corrected to a 1.7-pound loss after reweighing. Another resident was documented with an implausible weight gain of 1,643.5 pounds in one day. These errors were not addressed until surveyor intervention, and the RD confirmed that weights were not routinely checked for accuracy.
The facility failed to ensure clean and dry storage of respiratory equipment for three residents, leading to unsanitary conditions. A resident's nebulizer mask was found uncovered on a nightstand, another's CPAP mask was stored improperly, and a third's treatment mask was not stored as expected. The IC Nurse and DON acknowledged the improper storage practices.
A facility failed to monitor and update the antibiotic line listing for a resident receiving Gentamycin through a suprapubic catheter. The medication was administered less frequently than prescribed, and the resident was omitted from infection control line listings. The RN Infection Control nurse was unaware of this omission and acknowledged the lack of monitoring since 2023, noting the treatment's ineffectiveness based on lab results.
A group of residents expressed dissatisfaction with the facility's evening snack provision, citing limited variety and insufficient quantities. Observations revealed that snack carts were not restocked regularly, and available items were repetitive, with minimal protein options. Dietary staff confirmed the limited stocking of snack carts and lack of kitchen access after hours, contributing to residents' frustration.
A resident in a LTC facility experienced poor skin conditions due to inadequate ADL care. Despite being cognitively intact, the resident reported delays in staff assistance after episodes of fecal incontinence, leading to sores on the buttocks. The resident's skin issues were attributed to frequent urinal spills and loose stools, as well as potential shearing from a Hoyer sling. The facility's ADL policy was not adequately followed, resulting in the deficiency.
The facility failed to provide timely and available physician-ordered medications for two residents. One resident, admitted with fractures and cancer, did not receive pain medications for 24 hours, leading them to leave the facility for relief. Another resident experienced a delay in receiving both pain and general medications, including Eliquis. The facility's policy did not address backup medication availability, contributing to the deficiency.
The facility failed to maintain a clean, safe, and homelike environment, with issues such as a non-functional exit door, foul odors, unsecured windows, and furniture in disrepair. Call lights were often out of reach for residents, compromising their ability to call for assistance. Unsanitary conditions, including urine odors and maintenance issues, were prevalent, and a visitor expressed concerns about a resident's clothing and room conditions.
The facility failed to maintain residents' rights and dignity by not addressing grievances and not responding to call lights in a timely manner. A resident reported issues with a nurse not properly changing his wound dressing and touching his medication with her fingers. Despite voicing these concerns, no grievance form was filled out, and the issues persisted. Additionally, residents experienced long wait times for call light responses, leading to discomfort, pain, and incontinence. The facility's policies on call light accessibility and timely response, as well as the procedure for filing grievances, were not adhered to.
A facility failed to properly assess and monitor a resident after a fall with a head injury and did not complete an incident report for another resident with an injury of unknown origin. The first resident, with severe cognitive impairment, was not given the required neuro checks after returning from the hospital. The second resident, also cognitively impaired, was found with a skin tear and bruise, but the incident was not reported due to a nurse's incorrect assumption about the resident's care plan.
The facility failed to provide adequate respiratory care for three residents, leading to potential health risks. A resident's nebulizer equipment was not properly maintained, with moisture and no replacement date. Another resident's oxygen tank was nearly empty, risking respiratory health. A third resident's nebulizer equipment was improperly stored, with moisture and debris present, and the oxygen concentrator was left on. Facility policies for equipment maintenance were not followed.
The facility failed to properly store medications and needles on the East Wing Unit, with unattended medications and needles found at the nurses' station and on a medication cart. The area was accessible to residents, and the facility's policy requires all drugs and biologicals to be stored in locked compartments.
A resident who required a two-person assist for bed mobility and toileting fell off the bed and sustained a femur fracture when a CNA attempted to change the resident's brief alone. The CNA admitted to knowing the resident's care plan but proceeded alone because other staff were busy.
The facility failed to follow policies for medication labeling and storage, with multiple instances of improperly labeled and unattended medications found in medication carts and the medication room. This included insulin pens, eye drops, nasal sprays, and inhalers without open or expiration dates, indicating systemic issues in medication management.
The facility failed to maintain sanitary conditions in the kitchen, with several expired food items found in storage and improper cleaning of the walk-in cooler fan. This increased the potential for cross-contamination and foodborne illness, potentially affecting 45 residents.
The facility failed to follow standards of practice for administering oral Coumadin and intravenous Vancomycin for two residents, leading to the administration of incorrect dosages despite elevated lab results. This resulted in the likelihood of prolonged illness and/or hospitalization.
The facility failed to ensure timely completion and assessment of diagnostic/laboratory testing and comprehensive monitoring following a change in condition for two residents. One resident experienced a decline in condition and death without proper medical intervention, while another resident's PT/INR levels were not adequately monitored, risking inappropriate Coumadin dosing.
A resident developed an unstageable coccyx pressure ulcer due to the facility's failure to implement timely interventions despite being identified as at risk upon admission. The resident's care plan did not address their pressure ulcer history, and the facility did not follow its clinical protocol for pressure ulcer prevention, leading to the development of the ulcer.
The facility failed to timely assess, investigate, and notify practitioners and the dietitian of a resident's significant weight loss of 32.3 pounds (12.52%) over one month. The reweight was requested but not completed until 11 days later, contrary to the facility's weight monitoring policy.
The facility failed to properly assess and monitor the PICC lines for two residents, resulting in missed dressing changes, flushes, and end cap changes. One resident had a 3.5 cm inward migration of the catheter that was not reported to the physician, while another resident had no documented PICC line care for four days after admission. Both residents had significant medical histories, and the lack of appropriate care posed a risk of complications.
A resident received an unnecessary dose of Coumadin despite elevated PT/INR levels due to the facility's failure to monitor these levels as required. The facility lacked specific policies for Coumadin or PT/INR monitoring, leading to the administration of the medication without appropriate safeguards.
The facility failed to maintain a medication error rate below 5%, resulting in a 30% error rate. Two residents experienced late medication administrations and incorrect dosing, including a stronger dose of Vancomycin given to a resident despite the need for a dose adjustment.
The facility failed to prevent significant medication errors for two residents. One resident received an anticoagulant despite elevated INR levels, and another received the wrong strength of Vancomycin despite elevated trough levels. These errors were due to inadequate documentation, failure to adhere to updated orders, and poor communication among staff.
The facility failed to implement a comprehensive infection control program, leading to inconsistent and incomplete data collection, lack of tracking for potential infections, and inadequate monitoring of antimicrobial stewardship. The IC RN admitted to not having completed training and being unaware of reporting guidelines. Additionally, employee illness tracking and vaccination status monitoring were insufficient, and the laundry and utility rooms were found to be in poor condition.
The facility failed to ensure call lights were within reach and responded to in a timely manner for three residents, and one resident was left exposed. Multiple residents reported long wait times for call light responses, and specific observations confirmed call lights being out of reach and delayed responses, leading to resident frustration and potential mental anguish.
The facility failed to obtain informed consents for non-psychotropic medications used to treat mood and behavior disorders and/or hypnotic medications for seven residents. This resulted in residents receiving medications without the necessary consents, leading to the potential for unnecessary and undesired medication use.
Food Storage, Temperature Control, Equipment Cleanliness, and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain food service best practices in the kitchen and nourishment areas during observation, interview, and record review. Surveyors observed yogurt in the walk-in cooler with a best-by date of April 22, 2026, and milk in the three-door refrigerator with a use-by date of 5/3/26. The Certified Dietary Manager stated milk was good for seven days once opened, but the report cited the 2022 Food Code requirement that refrigerated ready-to-eat time/temperature control for safety foods be consumed, sold, or discarded by the expiration date. Surveyors also observed the coffee machine visibly soiled with buildup near the nozzles, the mixer soiled with residue inside the bowl and on the interior ceiling, and the ice machine filter dated 8/24/23 with cups on the floor behind the machine and a brown splotch on the interior wall of the ice machine. The Maintenance Director stated the ice machine was cleaned monthly, the filter needed to be changed now, and it was usually changed yearly. Additional observations showed cut watermelon in the memory care unit refrigerator without date marking, despite the facility policy requiring foods stored in the refrigerator or freezer to be covered, labeled, and dated. During lunch, boiled egg on salad was temped at 54 F and ranch at 53 F while sitting on a cart behind the steam table without ice. The Certified Dietary Manager stated cold food should be held at 40-41 F. Surveyors also observed cut tomato at 65 F at the prep sink and cream of mushroom at 75 F sitting out of its original container near the prep sink; the Certified Dietary Manager stated the cream of mushroom should be refrigerated after opening. In addition, a staff member was observed gloving one hand after going to the fridge and returning to the prep area without washing hands, and the Certified Dietary Manager stated staff are supposed to wash hands before gloving. The report cited the 2022 Food Code requirements for date marking, cold holding, equipment cleanliness, and handwashing before donning gloves.
Failure to Follow EBP, Store Respiratory Equipment, Perform Surveillance, and Disinfect Glucometer Properly
Penalty
Summary
Enhanced barrier precautions were not followed for a resident with a tracheostomy, PEG tube, and Foley catheter who also had severely impaired cognition and was dependent on staff for care. During observation, staff provided high-contact care including Foley catheter care, PEG site dressing care, and cleaning of loose stool from the resident’s buttocks while no gowns or masks were worn. The resident was observed lying in bed with eyes closed and remained lethargic and non-responsive to his name while staff continued direct care without using the enhanced barrier precautions identified in the resident’s care plan. The resident’s room also contained respiratory and suction equipment that was not properly stored or maintained. A suction canister with straw-yellow drainage was observed on the nightstand with tubing attached, and the open end of the suction tubing was left in or near a trash can with visible debris or uncovered on the nightstand during different observations. A nebulizer mask and chamber were also observed out in the open on the bedside table or resting on a paper towel rather than being stored clean and dry. Staff interviews reflected that suction and nebulizer equipment not in use should be stored dry, clean, bagged, and labeled, but the equipment remained out of proper storage during the observations. Infection control surveillance and rounding data were not being performed for all residents and areas of the facility. Review of the infection surveillance binder from August 2025 through March 2026 showed missing rounding/audit documentation for areas such as the kitchen, laundry, medication rooms, dining rooms, therapy gym, resident rooms, and enhanced barrier precaution rooms, with only limited audits found in some months. The Infection Preventionist stated that housekeeping rounding had not yet been completed for May 2026, and computer review did not locate additional surveillance documentation or analysis. In addition, a nurse disinfected a blood glucose meter with an alcohol swab and placed it in a medication cart drawer, while the DON stated the meter should be disinfected with a purple-top product. The facility’s infection prevention and control program policy required surveillance, monitoring of infection prevention practices, and proper storage and maintenance of supplies, but the observed practices did not match those requirements.
Plumbing and Housekeeping Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and ensure appropriate backflow prevention at plumbing fixtures. On 05/04/2026 at 2:12 PM, the hand sink near the washers in the laundry room was observed without a sewer line, and wastewater was going directly into a trash bin below the sink. The trash bin beneath the hand sink was approximately half full of wastewater. When asked how long the sink had been broken, the Housekeeping Manager stated it had been that way for about two months and that the trash can was emptied into the mop bucket sink. Additional observations on 05/04/2026 identified plumbing and housekeeping concerns in multiple areas. At 2:18 PM, a utility sink in the east hall housekeeping closet was observed without an atmospheric vacuum breaker, with an attached hose and a chemical feeder downstream. At 2:21 PM, 2:22 PM, and 2:27 PM, chemical feeds downstream of an AVB were observed on utility sinks in the main hall, central hallway, and west hall housekeeping closets. At 2:28 PM, a soiled towel was observed on the floor of the shower area in the west hall shower room. The report also cites the State of Michigan's 2008 Cross Connection Manual regarding AVBs and chemical feeder backflow prevention.
Failure to Maintain Resident Dignity, Privacy, and Timely Assistance
Penalty
Summary
The facility failed to ensure residents were treated in a respectful and dignified manner, including timely assistance with care, call lights within reach, privacy during care, and a homelike environment. During interviews, a confidential group of residents reported that staff would enter rooms to answer call lights, turn them off, say they would return, and then not come back. They also reported late meal trays, cold food, being laughed at when they complained, being awakened at 4:30 AM for toenail care, hearing staff use words that were not very nice, and hearing loud staff gatherings and food runs at the nurses’ station during evenings, nights, and weekends. Resident #6 had diagnoses including stroke, aphasia, tracheostomy, PEG tube, epilepsy, muscle weakness, and right above-knee amputation, with severely impaired cognition and a BIMS score of 0/15. On observation, the resident’s call light was hung over the headboard and out of reach, and Hospice CNA A confirmed it was not within the resident’s reach even though the resident was not verbal and relied on the call light for help. The same resident was also observed during brief care with the privacy curtain tucked behind the tube feed pole and open to the roommate and hallway side while CNA D completed care, despite the facility policy requiring resident privacy. Resident #83 had progressive multiple sclerosis, quadriplegia, encephalopathy, and depression, and was cognitively intact with a BIMS score of 15/15. The resident reported call wait times of 30 minutes or more, especially on 2nd and 3rd shifts, and stated that after requesting brief care following a bowel movement, a CNA turned off the call light and left, and no one returned for several hours, leaving the resident embarrassed in a dirty and malodorous brief. Resident #17 was observed pulling at facial whiskers during a skin assessment and stated that they had a razor somewhere, and the task list review showed bathing/shower documentation was being reviewed as part of the record.
HS Snack Process Limited Resident Access
Penalty
Summary
The facility failed to ensure that HS snacks were provided on a regular basis in accordance with residents’ needs, preferences, and requests. During a meeting with a confidential group of residents, they stated they were upset about the process for receiving an evening snack at bedtime. Residents reported they had to complete a blue form that came on their meal tray and return it to the kitchen by 2:00 PM in order to receive a snack, and they said this process was problematic because they might change their minds later, the selected item might no longer be available, and some residents could not ask for or fill out the form. Some residents also said they did not receive a snack if they did not complete the form. During interview, the RD Q confirmed that residents who wanted a specific snack were expected to complete the blue form titled, “Please Select a Snack for Tonight,” and return it by 2 PM so the request could be honored. The RD Q stated there was a snack cart filled by kitchen staff and distributed by clinical staff, usually a nurse aide, and acknowledged that if a resident could not fill out the form or say what they wanted, staff could offer a snack. The DON was shown the blue sheet and stated she had a problem with requiring residents to fill it out by 2 PM to receive a snack, and said they would work on that. Residents also reported feeling upset that they observed staff taking snacks from the carts for themselves, leaving residents with fewer options.
Antibiotic Stewardship and Infection Criteria Not Followed
Penalty
Summary
The facility failed to follow its antibiotic stewardship program and standards of practice for 4 residents, resulting in antibiotics being given without appropriate clinical rationale. The facility’s policy stated that it uses McGeer criteria to define infections, that laboratory testing shall follow current standards of practice, that narrow-spectrum antibiotics should be used when possible, and that antibiotic orders on admission or readmission should be reviewed for appropriateness with monitoring of response and lab results. During review of monthly infection tracking forms for January through April 2026, the Infection Preventionist could not locate supporting cultures, urine analyses, or other documentation for the antibiotic use identified for the residents. Resident #18 was started on Macrobid for a facility-acquired UTI that did not meet McGeer criteria, and the Infection Preventionist stated there was no culture or UA and that treatment may have been based on a dipstick urine test, but no dipstick policy or results could be produced. Resident #4 received Cipro for a UTI that did not meet McGeer criteria after readmission, and the Infection Preventionist stated no culture or UA was found and that the former IP should have obtained the culture and lab results for documentation. Resident #59 received levofloxacin for a facility-acquired UTI that did not meet McGeer criteria, and no culture or UA for an organism was found. Resident #40 received Bactrim DS for a facility-acquired UTI that did not meet McGeer criteria, and again no culture or UA for an organism was found. When asked for the urine dipstick policy and the McGeer policy, the Infection Preventionist stated that no policy or procedure could be located and that the infection control computer program automatically tells staff whether symptoms meet McGeer criteria, while the nurse practitioner decides whether antibiotics are stopped.
Failure to Provide Timely Grooming and Shaving Assistance
Penalty
Summary
The facility failed to provide timely assistance with ADLs, including grooming and shaving, for two residents reviewed for ADLs. Resident #9 was observed on multiple occasions with visible chin whiskers, and the resident stated that staff only shaved her on shower days and that she wanted it more often. The resident was seen outside in the courtyard, in the dining room, and in the hallway over several days with chin whiskers still visible. Resident #12 had diagnoses including dementia, PTSD, back pain, diabetes, and depression, and the MDS showed severe cognitive loss with a BIMS score of 3/15. The MDS indicated the resident needed supervision or touch assistance with hygiene tasks including shaving. During several observations, Resident #12 was repeatedly seen unshaven with whiskers approximately 1/2 to 1 inch long, including while sleeping at an activities table and later sitting in the day room after breakfast. The unit manager stated she did not know why the male residents were not shaved and said that if they refused, nurse aides would chart the refusal when documenting showers. The care plan for Resident #12 included showering on Monday and Thursday evenings and bathing assistance, but it did not mention shaving or refusal of shaving, and the behavior charting did not show aggressive behaviors or rejection of care.
Inconsistent wound care and undated dressings
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to date dressings and provide consistent dressing changes for two residents receiving wound care. For one resident with coccyx and left gluteal wounds, the record review of the treatment administration record for January through May 2026 showed multiple missed treatments each month, including missed treatments to the coccyx, sacrum, and left gluteal area. During interview, the resident stated the treatments and dressings were not always done every day and said the wounds seemed to be getting bigger. The resident was observed in bed with an air mattress in place and later declined offloading measures, including pressure-relief boots and a pillow to elevate the feet. For another resident with a right great toe wound, the surveyor observed an undated bandage that appeared old, with the inside pad completely saturated with dark red and black drainage that appeared old and odorous. The resident stated the bandage had been put on two days earlier. Record review showed an order for daily cleansing, collagen Ag, and foam dressing to the right great toe. The DON acknowledged blank spots on the MAR/TAR and stated staff were not using the documentation key at the bottom of the forms; the DON also stated there should have been a progress note if the treatment was left blank.
Nursing Staff Worked Independently Before Completing Required Competencies
Penalty
Summary
The facility failed to ensure that nursing staff were reviewed for competency before caring for residents, affecting one of five staff reviewed for staffing education and competency. Nurse J was hired around March 11, 2026, and was assigned multiple SNF competencies, in-services, and trainings with due dates in March, April, and May 2026. The record showed she completed only 2 of 30 assigned items, both on PPE donning and doffing and hand hygiene, while the remaining assignments were not marked complete. Despite the incomplete competency record, Nurse J was observed working independently on the dementia unit on May 4, May 5, and May 6, 2026, and was not identified as being on orientation. During interview, the DON stated staff were not supposed to be on the floor independently if they had not completed initial competencies, in-services, and training, and confirmed Nurse J had worked independently as a nurse. A later record review with the Administrator showed Nurse J’s education document still listed General Orientation topics such as abuse, neglect, behavioral health, dementia, resident rights, and medication pass as not completed, although an updated document provided the next day stated those trainings had been completed on May 5, 2026.
Medication Administration Errors and Unsafe Handling of Medications
Penalty
Summary
The facility failed to follow standards of practice during medication administration for three residents and a confidential group of residents. On 5/05/2026 at 8:29 AM, Nurse K was observed at the medication cart outside room five with two medication cups filled with medications. Nurse K carried both cups into the room, gave one cup to Resident #28, and when a pill fell from the resident’s mouth, picked it up and placed it into the used medication cup. Nurse K then went to Resident #43, who was struggling to adjust oxygen tubing into the nose, placed the full medication cup into the used cup that contained the dropped pill, donned gloves to assist with oxygen, then removed the full cup from the dirty cup and handed the medications to Resident #43, who consumed them. Nurse K then left the room, discarded the dropped pill into the drug buster bottle, and obtained a new blood pressure pill for Resident #28. Resident #3 was admitted and readmitted with ALS, dysphagia, need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD, and PTSD, and had a BIMS score of 15/15. The resident stated that medications given through the PEG tube were sometimes not fully received because medication would squirt out, and said the medication was not replaced when that happened. The care plans included interventions to administer medications as ordered. During a confidential group interview, several residents said nurses left medications in cups at the bedside and exited the room before the residents took them, including times when residents were in the bathroom. One resident also stated that a nurse had forgotten to give medication on a few occasions and the resident had to speak up about it.
Tube feeding not administered as ordered and enteral equipment not properly maintained
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered as ordered for a resident with ALS, dysphagia, COPD, diabetes, sleep apnea, heart disease, GERD, and PTSD who had full cognitive abilities and required some assistance with all care. The resident was ordered Nutren 2.0 at 100 ml/hr for 10 hours overnight, with instructions to start at 8:00 PM and stop at 6:00 AM so the full 1000 ml would be delivered. During interview, the resident stated the tube feeding was sometimes started late, taken down early, and not always flushed properly, and he reported that the feeding sometimes did not finish and the tube would spray him in the face during flushing. Record review showed the documented amounts of tube feeding often did not match the ordered volume. In March 2026, multiple days were below 1000 ml and some were above 1000 ml; in April 2026, there were two days with no documentation of tube feeding and many days below the ordered amount; in May 2026, documented amounts included 700 ml, 997 ml, 997 ml, and 2000 ml. The registered dietitian stated the resident should receive one full container daily and that if it was not finished, the nurse should let it continue to run until completed. The resident and a confidential person also stated that on one day the resident did not receive his tube feeding and his stomach became upset the next morning when he received medications. The facility also failed to properly maintain enteral feeding equipment for another resident with traumatic brain injury, dysphagia, and PEG tube placement who required extensive assistance with all ADLs and had severely impaired cognition. The resident was observed with an enteral feeding bag attached and running, and the bag was dated 5/3 0200 with initials written on it; the same dated bag was still observed later that day. A nurse who was asked about the bag date stated it may have been a mistake and was unsure whose initials were on the bag. The record showed the resident was NPO with PEG tube placement and receiving nutritional supplements as ordered, and the report cited guidance that feeding bags should be replaced every 24 hours to prevent bacterial buildup.
Unsanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure sanitary storage of respiratory equipment for a resident with ALS, dysphagia, a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD, and PTSD. The resident had full cognitive abilities with a BIMS score of 15/15 and required some assistance with all care. During observation, the resident was in bed with an AVAPS machine, a cough assist machine, and a suction machine at the bedside. The cough assist hose was bent and pinched in the nightstand drawer, and the AVAPS mask was lying uncovered in a basket on the cart and buried beneath other items. The room also contained three one-gallon distilled water jugs, including one partially full jug that was not dated when opened and two empty jugs on the floor, one of which had another resident’s name written on it. The physician orders required the cough assist mouthpiece and AVAPS mask to be cleaned after use, dried well, and covered with a plastic bag or stored completely enclosed when not in use. The care plan referenced CPAP but did not refer to the AVAPS machine, and there was no mention of caring for or cleaning the AVAPS equipment or the cough assist machine. The facility policy stated delivery devices should be kept in a plastic bag when not in use and cleaned according to facility policy.
Inaccurate Daily Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily staff posting was accurate for all staff who provided care for residents. A record review of the daily staffing postings showed CNA, LPN/LVN, and med tech hours, but no RN hours were displayed. During interview, the scheduler stated she was new and that the posting was completed by HR. HR later stated the information was pulled from the scheduling system and may not have been pulling RN information, and she agreed that the posted format did not show RN hours and was inaccurate. The facility also provided paper copies of the postings after they were requested for review.
Insulin Pen Administration and Needle Safety Error
Penalty
Summary
The facility failed to follow standards of practice for insulin administration and needle safety for Resident #29, one of three residents reviewed for insulin administration. On 5/06/2026 at 11:49 AM, Nurse L gathered the resident’s insulin pen for administration, attached a needle to the pen without first cleaning the pen with an alcohol swab, turned the dial to 8 units, and entered the resident’s room. Nurse L then administered the insulin pen without priming the needle with the required 2 units. At 12:32 PM the same day, the DON was alerted that Nurse L had not cleaned the insulin pen with an alcohol swab before attaching the needle and had not primed the required 2 units before administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled or stored in accordance with accepted principles. During observation of two treatment carts, multiple topical medications were found opened and used without dates on the boxes or tubes, and several discontinued medications remained in the carts. These included clotrimazole-betamethasone cream for Resident #7, hydrocortisone acetate with pramoxine for Resident #3, clotrimazole-betamethasone cream and nystatin powder for Resident #40, nystatin cream for Resident #39, and nystatin powder for Resident #96, who had already been discharged from the facility. In the east unit treatment cart, nystatin powder for Resident #5 was opened without a date, and mupirocin ointment for Resident #68 was opened without a date; a second tube of triamcinolone cream with no resident name or date was also found in the box. The facility also stated there were no treatment cart policy and no discontinued medication policy. Medication refrigerator temperature logs showed repeated out-of-range readings in February 2026, including 34 degrees F and multiple readings of 32 degrees F, with no documented corrective action in the column designated for action when temperatures were outside 36 to 46 degrees F. The DON observed and validated that staff recognized the temperature deviation but did not document or initiate corrective steps. The record review found no evidence of corrective action, including no recalibration, maintenance, replacement, or staff re-education, and the facility policy required refrigerated products to remain within 36 to 46 degrees F and to be reported promptly to maintenance if malfunctioning.
Failure to Implement Individualized Dementia Interventions for Wandering and Bed-Hopping
Penalty
Summary
The deficiency involves the facility’s failure to implement individualized dementia care interventions for a resident with Alzheimer’s disease and vascular dementia who persistently wandered into other residents’ rooms and slept in their beds. During a tour of the locked memory care unit, surveyors observed this resident asleep in another resident’s bed, with no nursing staff visible in the hallway at the time. Staff, including CNAs and the Infection Preventionist, acknowledged that the resident frequently wandered into multiple rooms and beds and was generally easily redirectable, but also reported that they had only basic measures such as visual stop signs on doors and informal redirection, with no stop sign inside the shared bathroom that connected the rooms involved. Record review showed that in the prior 30 days, the resident had been documented 31 times as sleeping or resting in other residents’ beds. The care plan focus noted that the resident liked to sleep in other residents’ beds, and the only listed intervention was to gently redirect him to his own bed if the other resident was upset, with no mention of consistent redirection, environmental modifications, or cleaning and linen-change practices when he used another resident’s bed. Practitioner notes documented staff reports that the resident often wandered, went into other people’s rooms, and lay in their beds, and that staff “let him” do so when he was not agitated. Additional notes described persistent intrusive behaviors, poor boundaries, repeated episodes of grabbing and violating personal space, frequent entry into other residents’ rooms, and urinating in other residents’ closets. Another resident, who also had dementia and other medical conditions, was directly affected by this behavior. Concern forms and progress notes documented that this resident’s wife repeatedly complained that the wandering resident was sleeping in her husband’s bed and that she was “tired of it.” She reported to surveyors that she continued to find the wandering resident in her husband’s bed during her visits, that staff told her they could not consistently monitor the wandering resident, and that the bed was not being stripped every time this occurred. The Social Worker acknowledged that the wandering and bed-hopping behavior had become more prominent over the year, that a room change had not resolved it, that they had not considered the impact of shared bathrooms, and that no additional interventions beyond redirection had been implemented or trialed. The facility’s comprehensive care plan policy required a person-centered care plan consistent with resident rights, but the documented plan and staff responses did not reflect individualized, comprehensive interventions for this resident’s dementia-related behaviors.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity and privacy for several residents during meal service and personal care. During a lunch meal service, two residents were left without meals while others at their table were served and finished eating. This delay in meal service was not in accordance with the posted mealtime schedule, and the staff failed to communicate effectively with the kitchen to address the issue. Resident #9, who is legally blind and has severely impaired cognition, and Resident #37, with moderate cognitive impairment, were among those affected by this oversight. In another incident, Resident #27 was exposed without clothing while lying in bed, as the privacy curtain was not closed during care. This resident, who has severe cognitive impairment and requires assistance with bed mobility and dressing, was left in a vulnerable position visible from the hallway. The staff's failure to maintain privacy during care compromised the resident's dignity. Additionally, a group of residents expressed concerns about the responsiveness of staff to call lights, reporting that their needs were often unmet, and call lights were turned off without follow-up. Resident #35's room was noted to have a strong urine odor despite cleaning efforts, indicating a persistent issue with maintaining a dignified living environment. Resident #24 was observed unable to reach their call light, which was on the floor, further highlighting the facility's failure to ensure residents' ability to communicate their needs effectively.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments and obtain informed consent for the use of bed rails for several residents, leading to a deficiency in care. Observations revealed that residents were using silver metal bilateral half siderails without proper documentation or consent. For instance, Resident #8, who has severe cognitive impairment and multiple medical conditions, was observed with siderails in use, but there was no consent or assessment found in their records. Similarly, Resident #14, who is cognitively intact, was using siderails without a physician's order or documented consent, and there was no monitoring for entrapment risks. The facility's care plans for the residents did not address the use, consent, assessment, or monitoring of the siderails. For Resident #19, the 'Informed Consent for Use of Bed Rails' form was incomplete, lacking documented assessments of medical needs, benefits, risks, and alternatives. Resident #43 also had an incomplete consent form, with no identification of the type or location of siderails to be used. These omissions indicate a systemic failure to adhere to the facility's policy on the proper use of bed rails, which requires thorough assessments and informed consent before installation. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, revealed a lack of awareness and compliance with the facility's siderail policy. The staff referred to the siderails as assist bars, and there was confusion about their proper use and documentation. The Director of Maintenance acknowledged that the silver siderails had been in use for a long time without proper evaluation or replacement. This lack of oversight and adherence to policy contributed to the deficiency in ensuring resident safety and compliance with regulatory standards.
Deficiencies in Medication Management and Labeling
Penalty
Summary
The facility failed to ensure proper labeling, storage, and discard of medications across four medication carts, leading to deficiencies in medication management. Observations revealed that multi-dose medications, such as Trelegy Ellipta and insulin pens, were not dated with either an open date or expiration date. Additionally, ampules of Ipratropium Bromide and Albuterol Sulfate were found outside of their foil packets, and a nitroglycerin bottle was missing its red sealed tape and lacked proper dating. Blood glucose strips were also found without an open date, and a loose white tablet was observed in a medication cart drawer. Interviews with staff, including LPNs and RNs, confirmed the lack of adherence to medication labeling and storage policies. The facility's policies on medication storage and labeling were reviewed, revealing that multi-use vials should be labeled with the date they were opened and discarded within 28 days unless otherwise specified. However, the Nursing Home Administrator admitted to the absence of a multi-dose medication policy and an open medication and expiration date policy. The infection control preventionist also confirmed the lack of an ophthalmic medication policy, and no further documentation was provided to address these concerns.
Sanitation and Thawing Procedure Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as to follow correct thawing procedures for hamburger meat. During a kitchen walkthrough, several issues were identified, including a large can opener with dried food on the blade, a small toaster with excessive crumbs, a large mixer with dried batter, and a plate warmer with dried food drippings. Additionally, a black food cart and plastic bowls were found with dried food, and a gray plastic food tray cart had dried food and drippings. A small brush was observed on the handwashing sink, which could transfer bacteria between staff. The facility also failed to maintain proper thawing procedures for hamburger meat. A log of hamburger was observed sitting in a pool of blood in the freezer, which was acknowledged as incorrect by the Infection Control Nurse and the registered dietitian. The facility's Food Preparation and Service policy requires potentially hazardous foods, such as raw meats, to be prepared in specified areas to prevent cross-contamination. However, the facility's Infection Control walk-through checklist previously marked meat thawing as satisfactory, indicating a discrepancy in practice. The dietary staff received education on proper thawing techniques after the observation.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a clean environment for residents, as evidenced by observations of dusty fans and improperly stored oxygen tubing. Resident #41, who has a history of Guillain-Barre Syndrome and other health issues, was observed with a fan blowing directly on him that was covered in dust. Despite multiple observations over consecutive days, the fan remained uncleaned, and the resident confirmed that no one had cleaned it. The Director of Nursing and the Administrator acknowledged the lack of a specific policy for cleaning fans, and the facility's generalized cleaning policy did not specify who was responsible for this task. Resident #42, who is oxygen-dependent, was found with oxygen tubing hanging over a wheelchair without being stored in a bag to prevent cross-contamination. The Director of Nursing admitted there was no policy for storing respiratory equipment properly. Additionally, Resident #54, who requires respiratory treatments, was observed with a dusty fan blowing on him and a urine catheter bag improperly hanging on a trash bin. The Infection Control Nurse indicated that the nurse should have addressed the urinal immediately, but this was not done.
Deficiencies in Care Plan Updates and Safety Measures
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect changing care needs for several residents. Resident #28, who had severe cognitive loss and a history of falls, did not have an updated care plan addressing toileting needs despite multiple falls. Similarly, Resident #47, with severe dementia and a history of falls, had care plans that were not revised after several falls, indicating a lack of proactive measures to prevent future incidents. Resident #60's care plan did not specify the resident's code status preferences, despite the resident choosing to be a Full code. This lack of specificity in the care plan could lead to confusion regarding the resident's advance care planning. Additionally, residents #8, #14, and #19 were observed with bilateral half siderails in use, but their care plans did not address the use, consent, assessment, and monitoring of these siderails, which is a critical oversight in ensuring resident safety. The Director of Nursing was unaware of the siderails' presence, indicating a disconnect between policy and practice. The facility's policy requires comprehensive person-centered care plans, but the observed deficiencies highlight a failure to adhere to this policy, resulting in inadequate care planning and potential safety risks for the residents.
Inaccurate Weight Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate weight measurements for two residents, resulting in incorrect documentation in their medical records. Resident #35 was recorded to have gained 16 pounds in one day, which was later corrected to a 1.7-pound loss after a reweighing prompted by surveyor inquiry. The resident had severe cognitive loss and required assistance with all care. The error was not identified or corrected by the staff until the surveyor's intervention, and the Registered Dietitian (RD) confirmed that weights were not routinely checked for accuracy. Similarly, Resident #47 was documented to have an implausible weight gain of 1,643.5 pounds in one day. This error was also not addressed until the surveyor's involvement. The resident had severe dementia and required assistance with all activities of daily living. The RD stated that she reviewed weights three days a week and would request reweighs if she noticed any abnormal readings. The Director of Nursing acknowledged the issue with weight accuracy in the facility.
Unsanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure the clean and dry storage of respiratory equipment for three residents, leading to unsanitary conditions. Resident #25's nebulizer mask was found face down on their nightstand, uncovered and without a barrier. This resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness, confirmed the use of the nebulizer. Infection Control (IC) Nurse A stated that nebulizer masks should be cleaned, dried, and stored in a bag, which was not followed in this case. Resident #44's CPAP face mask was stored uncovered inside a metal basket, and their coughing machine mouthpiece was in direct contact with the back of the oxygen concentrator. This resident, with diagnoses including Amyotrophic Lateral Sclerosis (ALS), COPD, and Obstructive Sleep Apnea, required assistance with their respiratory equipment. IC Nurse A acknowledged that the storage of Resident #44's equipment was unacceptable. Resident #54's respiratory treatment mask was observed sitting on a window sill on top of a clear plastic bag, contrary to the IC Nurse's statement that it should be placed on a paper towel to dry before being stored in a plastic bag. The Director of Nursing confirmed the absence of a specific policy for storing respiratory equipment in plastic bags, although it was expected practice.
Failure to Monitor Antibiotic Use and Update Line Listings
Penalty
Summary
The facility failed to adequately monitor the antibiotic use for a resident who was receiving Gentamycin sulfate through a suprapubic catheter. The medication was prescribed to be administered three times a week, but the resident only allowed it to be administered twice a week during showers. This discrepancy was known to the resident's mother and physician. However, the facility did not update the antibiotic line listing to reflect this resident's use, and the resident was not included in the infection control line listings for several months. The RN Infection Control nurse was unaware of the omission of the resident from the line listings and acknowledged that the resident's Gentamycin use had not been monitored or tracked since 2023. Despite the urologist's indefinite order for the medication, the RN noted that the treatment appeared ineffective based on the resident's lab results. The lack of monitoring was recognized as a potential issue for the growth of MDROs, and the RN confirmed that the resident's antibiotic use should have been included in the monthly line listings.
Inadequate Evening Snack Provision
Penalty
Summary
The facility failed to provide an adequate amount and variety of evening snacks for a group of residents, leading to dissatisfaction and frustration among them. Residents reported that the snack carts were not restocked regularly, and the available snack items were limited and repetitive. Complaints included the absence of snack distribution at night, the removal of the snack cart, and a lack of variety in the snacks provided, such as limited fruit choices and insufficient protein options. Residents expressed a desire for more diverse snacks, including different types of sandwiches, chips, and cookies. Observations and interviews with dietary staff revealed that the snack carts were stocked with a limited number of items, such as peanut butter and jelly sandwiches, chips, cookies, and a few fruit options. The nourishment refrigerator contained minimal protein snacks, primarily cottage cheese, and a small number of other items like puddings and meat sandwiches. The dietary staff indicated that the snack carts were stocked with about 4 or 5 of each item, and there was no access to the kitchen after staff left for the night. The Resident Council Minutes also highlighted ongoing concerns about the lack of snack distribution, indicating that the issue had been persistent over time.
Failure to Provide Adequate ADL Care Leads to Skin Issues
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident who was dependent on staff assistance, resulting in poor skin conditions and insufficient help with bed mobility and peri-care. The resident, who is cognitively intact with a BIMS score of 15, reported issues with staff response times when needing assistance after episodes of fecal incontinence. The resident experienced delays in being cleaned up and repositioned, leading to being left in urine or feces for extended periods. This neglect contributed to the development of sores on the resident's buttocks, which were noted to be improving. Upon admission, the resident did not have any skin conditions, but later developed moisture-associated skin damage (MASD) on the coccyx, as documented in a wound evaluation form. Interviews with the Wound Nurse and the Director of Nursing revealed that the resident's skin issues were attributed to frequent urinal spills and loose stools, which kept the skin wet, as well as potential shearing from a Hoyer sling. The facility's policy on ADLs emphasizes the importance of maintaining residents' functional abilities, including personal hygiene, which was not adequately upheld in this case.
Medication Availability and Timeliness Deficiency
Penalty
Summary
The facility failed to ensure the availability and timely administration of physician-ordered medications for two residents. Resident #1, who was admitted with a pathological fracture, rib fracture, and cancer, did not receive prescribed pain medications, Hydromorphone and Morphine, upon admission. The complainant reported that the pain medications were unavailable for approximately 24 hours, leading the resident to call 911 and leave the facility to obtain pain relief. The Director of Nursing (DON) confirmed that the medications were not available onsite and explained that the process for obtaining pain medication was delayed due to the need for physician orders to be entered into the electronic medical record (EMR) before medications could be accessed. Resident #2, admitted with spinal stenosis, a history of falling, atrial fibrillation, and chronic obstructive pulmonary disease, also experienced a delay in receiving medications. The resident reported a delay of over 24 hours in receiving both pain medications and general medications, including Eliquis. The electronic medical record revealed that doses of Eliquis were missed on two consecutive days. The facility's medication administration policy, which requires medications to be administered within 60 minutes of the scheduled time, did not address the availability of medications in backup, contributing to the deficiency.
Environmental and Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by multiple observations of environmental deficiencies across two units. On the Central Unit, an exit door was improperly latched shut, rendering it non-functional in case of an emergency. Additionally, there were foul odors, unsecured windows, and furniture in disrepair. On the East Wing Unit, call lights were consistently found out of reach for residents, compromising their ability to call for assistance when needed. Several specific instances highlighted these deficiencies. In one room, a resident was unable to reach their call light, which was positioned almost on the floor. Another resident's call light was clipped to the wall, out of reach, and a nurse had to reposition it. Observations also noted call lights on the floor in multiple rooms, indicating a systemic issue with ensuring residents' access to call lights. Furthermore, a resident reported that call light response times could exceed half an hour, suggesting inadequate staffing or response protocols. The facility's environment was further compromised by unsanitary conditions, including urine odors in rooms and bathrooms, dried substances on walls, and broken furniture. Maintenance issues were prevalent, such as missing outlet covers, non-functional cold water taps, and holes in bathroom walls. The Maintenance Director acknowledged these issues but indicated a lack of communication from staff regarding environmental concerns. A confidential visitor also expressed concerns about a resident's clothing and room conditions, further underscoring the facility's failure to provide a safe and homelike environment.
Failure to Address Grievances and Timely Call Light Response
Penalty
Summary
The facility failed to maintain residents' rights and dignity by not addressing grievances and not responding to call lights in a timely manner for four residents. Resident #2, who had intact cognition, reported issues with a nurse not properly changing his wound dressing and touching his medication with her fingers. Despite voicing these concerns to Nurse B, no grievance form was filled out, and the issues persisted. Additionally, Resident #2 experienced long wait times for call light responses, leading to discomfort and pain when left on a bedpan for an extended period. Resident #3, with moderately impaired cognition, was observed in a wheelchair without foot pedals and with a stained gown, indicating possible neglect. The resident's call light was not within reach, and she reported long wait times for staff response. Resident #6, who had intact cognition, also reported long wait times for call light responses, resulting in incontinence. Resident #9, who was independent in cognitive skills, confirmed similar issues with call light response times, particularly during the night shift. The facility's policies on call light accessibility and timely response, as well as the procedure for filing grievances, were not adhered to. Staff interviews revealed a lack of consistent documentation and follow-up on resident complaints. The facility's failure to address these issues resulted in unmet needs and compromised resident dignity.
Deficiencies in Fall and Injury Management
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident, identified as Resident #11, after a fall that resulted in a head injury. The resident, who had severe cognitive impairment due to dementia and seizures, was involved in an incident where another resident pushed her, causing her to fall and hit her head. Although she was sent to the hospital for evaluation, upon her return, the facility did not conduct the necessary neuro checks as per their policy, which should have been done every 12 hours. This oversight was acknowledged by the Director of Nursing (DON), who admitted that the follow-up assessment for the fall was missed. Another deficiency involved Resident #12, who also had severe cognitive impairment and was found with a skin tear and a bruise, suggesting a possible fall. The incident was not reported immediately because a nurse mistakenly believed the resident was care planned to sit on the floor. This assumption led to a delay in completing an incident report and conducting a thorough investigation. The DON confirmed that the resident was not care planned to be on the floor, and the failure to report the skin tear as an injury of unknown origin delayed the necessary investigation and assessment. The facility's deficiencies in handling these incidents resulted in potential risks for the residents involved. The lack of timely reporting and assessment could have led to undetected injuries or abuse, particularly for Resident #12, whose injuries were not immediately investigated. These failures highlight significant lapses in the facility's procedures for managing falls and injuries of unknown origin, as well as in their communication and documentation practices.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to potential health risks. Resident #2's nebulizer equipment was not properly maintained, as it was observed with moisture in the medication chamber and lacked a replacement date. Despite being informed, the nurse did not replace the equipment, and the resident reported not receiving new equipment over the weekend. This negligence in maintaining the nebulizer equipment could lead to respiratory infections. Resident #5 was observed with an oxygen tank that was nearly empty while sitting in a common area. The resident's oxygen order required continuous oxygen at 2 L/min, but the tank's dial was in the red zone, indicating a lack of oxygen. The CNA responsible for the resident's care reported checking the tank earlier, but it was not adequately monitored, risking the resident's respiratory health. Resident #8's nebulizer equipment was improperly stored, with moisture and debris present in the mask and medication chamber. The oxygen concentrator was left on, and the nasal cannula was visibly soiled without a replacement date. The facility's policy required weekly changes and proper drying of equipment, which was not followed, increasing the risk of mold or mildew formation and potential respiratory issues for the resident.
Improper Storage of Medications and Needles
Penalty
Summary
The facility failed to properly store medications and needles on the East Wing Unit, which was observed during a survey. At the nurses' station, a bag of multiple antibiotic IV medications, a tube of Derma fungal cream, Assure glucometer control solution, a vial of Ertapenem, and Assure ID Pen needles were found unattended on the counter. The area was accessible to residents, and there were no staff present at the time of observation. The Nursing Home Administrator was informed of the unattended medications and needles and subsequently retrieved the nurse responsible for the area, who acknowledged that the medications should not have been left unattended. Additionally, an observation of a nurse's medication cart in the East Wing hallway revealed an open box of needles on top of the cart while the nurse was administering medications to residents. The nurse confirmed that the needles should not have been left on top of the cart and removed them. The facility's policy on medication storage, which was reviewed and revised earlier in the year, mandates that all drugs and biologicals be stored in locked compartments to ensure security and proper conditions. The failure to adhere to this policy resulted in the potential for medication ingestion, diversion, and injury.
Failure to Follow Care Plan Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to abide by a resident's assessed level of assistance during incontinence care, resulting in the resident rolling off her bed and sustaining a preventable femur fracture. The resident, who is cognitively intact and able to make her needs known, required a two-person assist for bed mobility and toileting. However, a CNA attempted to change the resident's brief alone, leading to the resident falling off the bed and requiring surgical intervention for a femur fracture. The incident occurred when the CNA placed the resident on a bedpan and then attempted to change the brief alone. The resident was already close to the edge of the bed, and the CNA was not paying sufficient attention to her positioning. As the CNA was changing the brief, the resident rolled toward the right side and fell off the bed. The CNA admitted to knowing that the resident required a two-person assist but proceeded alone because other staff were busy. Interviews with the CNA and nursing staff confirmed that the resident's care plan and Kardex indicated a two-person assist for bed mobility and toileting. The CNA acknowledged that she did not follow the proper procedure and that she had been trained on turning and repositioning just days before the incident. The facility conducted a sweep of like residents and provided additional training and competency checks for CNAs to ensure compliance with care plans.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to follow policies and procedures for medication labeling and storage, as observed in two medication carts and one medication room. Specifically, the East Unit Medication cart was found unlocked and unattended, allowing the state surveyor to access medication drawers. The responsible RN admitted to leaving the cart unattended while attending to other tasks. Additionally, multiple instances of improperly labeled medications were found, including insulin pens, eye drops, nasal sprays, and inhalers without open or expiration dates. These deficiencies were observed across multiple residents' medications, indicating a systemic issue in medication management and storage practices. Further observations in the medication room revealed additional labeling and storage issues. For example, a multi-dose Novolog insulin bottle and a tuberculin multi-dose bottle were found without open dates. The medication refrigerator also contained improperly labeled medications, including a COVID-19 injection and a multi-dose Novolog insulin bottle. These findings suggest a failure to adhere to the facility's policies on medication storage and labeling, potentially compromising medication efficacy and resident safety.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During a tour of the kitchen, several expired food items were found in the dry storage room, cook refrigerator, and walk-in cooler. These items included expired packets of sugar-free raspberry gelatin, hard shell tacos, a 5-pound bag of corn muffin mix, a 50-pound container of rice, and 3-gallon containers of various cereals. Additionally, a 5-quart container of salad mix in the cook refrigerator and several gallon-sized bags of frozen meats in the walk-in cooler were either expired or lacked proper date marking. The facility's staff, including the Dietary Cook and Certified Dietary Manager, acknowledged that it was the responsibility of all kitchen staff to discard expired food items, but this was not being adequately performed. Furthermore, the walk-in cooler fan was observed to be soiled, indicating a lack of proper cleaning and maintenance. The Certified Dietary Manager confirmed that kitchen staff are responsible for discarding expired food as they access these areas daily for meal preparation. The facility's failure to adhere to the 2013 FDA Food Code section on date marking and proper food storage practices was evident, as expired and improperly dated food items were found throughout the kitchen. This deficiency potentially affected 45 residents who consume meals prepared in the kitchen.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to follow the standards of practice for the administration of oral Coumadin and intravenous Vancomycin medications for two residents. For Resident #100, the facility did not consistently document PT/INR levels on the Medication Administration Record (MAR) and administered Coumadin despite elevated INR levels. Specifically, the MAR showed blank entries for PT/INR on several dates, and Coumadin was given on a date when the INR was significantly elevated, contrary to the standard practice of holding the medication in such cases. Interviews with the Nurse Practitioner and Licensed Practical Nurse confirmed that the medication should not have been administered without knowing the PT/INR levels, highlighting a lapse in following the nursing standard of practice for high-risk medications like Coumadin. For Resident #200, the facility failed to properly adjust the dosage of Vancomycin based on elevated trough levels. The MAR indicated that the Vancomycin dosage was changed from 750 mg/250 ml to 500 mg/100 ml due to elevated trough levels. However, the night shift nurse administered the higher dose despite the change in orders. Interviews with the LPN and Unit Manager revealed that the elevated trough levels were known, and the incorrect dosage was still administered, indicating a failure to adhere to the updated medication orders and proper monitoring protocols. These deficiencies in medication administration practices for both residents resulted in the likelihood of prolonged illness and/or hospitalization. The facility's failure to document and act on critical lab results and medication orders demonstrates a significant lapse in adhering to professional standards of quality care, as outlined in the facility's policies and nursing standards of practice.
Failure to Monitor and Assess Residents' Conditions
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure timely completion and assessment of diagnostic/laboratory testing as well as comprehensive assessment, monitoring, and treatment following a change in condition for two residents. For Resident #49, the facility did not conduct necessary laboratory tests, failed to reassess abnormal vital signs, and did not involve the resident in care decisions despite the resident being cognitively intact and capable of making their own medical decisions. The resident experienced a decline in condition, including symptoms of pneumonia and hypoxia, but the facility did not adequately monitor or respond to these changes, leading to the resident's death without proper medical intervention or transfer to a hospital as needed. Resident #49 was admitted with diagnoses including Covid-19, pneumonia, congestive heart failure, and diabetes mellitus. Despite being on a course of oral steroid therapy and antibiotics, the resident's condition worsened, showing signs of pneumonia and hypoxia. The facility's documentation revealed inconsistencies in oxygen administration and a lack of follow-up on abnormal vital signs, such as hypotensive blood pressure readings. Additionally, there was no documentation of a urinalysis that was indicated in the nursing notes, and the resident's decreased intake and output were not adequately monitored. For Resident #100, the facility failed to monitor PT/INR levels as required for a resident on Coumadin therapy for atrial fibrillation. The Medication Administration Record (MAR) showed blank entries for scheduled PT/INR tests, and there was no documentation of the nurses monitoring these critical lab results. This lack of monitoring could have led to inappropriate dosing of Coumadin, as evidenced by an elevated INR level that was not addressed in a timely manner. The facility's failure to adhere to its own policies for monitoring high-risk medications resulted in a significant deficiency in the care provided to Resident #100.
Failure to Implement Timely Interventions for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement timely interventions to prevent an unstageable coccyx pressure ulcer for a resident, resulting in the development of a new unstageable pressure ulcer. The resident, admitted with diagnoses including diabetes, anemia, and heart failure, required extensive assistance with activities of daily living and had intact cognition. Despite being identified as at risk for impaired skin integrity upon admission, there was no care plan implemented for the resident's pressure ulcer history and Braden scale score. The resident's electronic medical record indicated no skin issues upon admission, but a new skin problem was observed ten days later, leading to the development of an unstageable pressure ulcer on the coccyx, which was in-house acquired and measured 5.42 cm by 3.02 cm initially and later 5.68 cm by 1.88 cm, showing some improvement by May 1st. The facility's clinical protocol for pressure ulcer prevention, revised in January 2022, emphasizes the importance of an admission evaluation to identify residents at risk and implement prompt interventions. However, the facility did not adhere to this protocol, as evidenced by the lack of a care plan for the resident's pressure ulcer history and the delayed response to the resident's skin issues. The Director of Nursing and Unit Manager acknowledged the deficiency but suggested the ulcer was unavoidable, without providing additional documentation to support their claim. This failure to follow established protocols and timely implement preventive measures led to the resident developing a new unstageable pressure ulcer, highlighting a significant lapse in care and oversight.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to timely assess, investigate, implement appropriate interventions, and notify practitioners and the dietitian of significant weight loss for one resident. Resident #13 experienced a significant weight loss of 32.3 pounds (12.52%) over one month, which was not promptly addressed by the facility. The resident's care plan included notifying the dietitian and physician of significant weight changes, but this was not done in a timely manner. The resident's weight dropped from 257.9 lbs on 12/05/2023 to 225.6 lbs on 01/09/2024, yet there were no nursing progress notes regarding the weight loss or notifications to the dietitian or practitioners during this period. The Registered Dietitian requested a reweight on 1/11/2024, but it was not completed until 1/22/2024, 11 days after the request and 13 days after the initial weight was recorded. The facility's policy on weight monitoring, revised on 10/26/2023, states that significant changes in weight should be promptly addressed and the physician and dietitian should be informed. However, this policy was not followed, resulting in delayed assessment and intervention for Resident #13's significant weight loss.
Failure to Properly Monitor and Document PICC Line Care
Penalty
Summary
The facility failed to properly assess and monitor the PICC lines for two residents, resulting in significant deficiencies in care. Resident #39 had a PICC line inserted for IV antibiotics but did not have any documented PICC line assessments or care orders until 13 days after admission. This lack of documentation included missed dressing changes, flushes, and end cap changes. Additionally, a 3.5 cm inward migration of the catheter was noted but not reported to the physician, which could lead to further complications. The Director of Nursing and Unit Manager confirmed the absence of PICC assessments prior to the 13th day of admission. Resident #200 also experienced deficiencies in PICC line care. Upon admission, the resident's PICC line dressing was not occlusive, dated, or initialed, and there were no orders for PICC line care until four days after admission. The resident's MAR/TAR did not include any documented measurements for arm circumference or catheter length, and the first documented PICC line treatment was recorded 11 days after admission. Nurse D confirmed that the admission assessment should have prompted the input of PICC line orders, but this did not occur. Both residents had significant medical histories, including osteomyelitis, diabetes, mood disorder, atrial fibrillation, dementia, and sepsis. The lack of timely and appropriate PICC line care and documentation posed a risk of complications such as infection, thrombosis, and further catheter migration. The facility's failure to adhere to standards of practice for PICC line care was evident in the observations, interviews, and record reviews conducted by the surveyors.
Failure to Monitor PT/INR Levels Before Administering Coumadin
Penalty
Summary
The facility failed to ensure that a resident was free from an unnecessary dose of Coumadin, an anticoagulant, despite elevated laboratory Protime (PT) and International Normalized Ratio (INR) levels. The resident, who had multiple medical diagnoses including atrial fibrillation and heart failure, was supposed to have PT/INR levels monitored three times a week. However, the Medication Administration Record (MAR) showed blank entries for several scheduled PT/INR checks, and the medication was administered without proper monitoring of these levels. Specifically, the resident received Coumadin on a day when their PT/INR levels were significantly elevated, which was against the standard practice of holding the medication in such cases. This oversight was confirmed through interviews with the Nurse Practitioner and Licensed Practical Nurse, who both acknowledged that the medication should not have been given under these circumstances. Further review revealed that the facility's medication administration policy did not include instructions for nurses to monitor therapeutic laboratory levels prior to administering high-risk medications like Coumadin. The Director of Nursing confirmed that the facility lacked specific policies for Coumadin or PT/INR monitoring. This deficiency in policy and practice led to the administration of a high-risk medication without appropriate safeguards, increasing the likelihood of excessive bleeding and potential hospitalization for the resident.
High Medication Error Rate Due to Late Administration and Incorrect Dosing
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5%, resulting in a medication error rate of 30%. This was observed through 7 late administrations of medications and 2 medication errors out of 30 opportunities for two residents. Specifically, Resident #200 experienced a medication error when a stronger dose of Vancomycin was administered by the night shift, despite the need for a dose adjustment due to elevated lab values. Additionally, the resident's morning medications were administered significantly later than the policy's 60-minute requirement. Resident #100 also received their 8:00 AM medications at 9:26 AM, which is beyond the allowed time frame. During the survey, it was observed that the call light for Resident #200 was left out of reach, and the resident's PICC line dressing was dated incorrectly. The pharmacy had sent four doses of Vancomycin 500 mg/100 ml, but none were administered as ordered. Both LPNs D and E were still passing morning medications well past the scheduled time. These observations and record reviews highlight the facility's failure to adhere to its medication administration policy, leading to a high medication error rate and potential risks for the residents involved.
Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. For Resident #100, a nurse administered Coumadin, an anticoagulant, despite an elevated INR level of 3.58, which increased the likelihood of bleeding or hospitalization. The facility's policy required PT/INR levels to be checked three times a week, but the results were not consistently documented in the Medication Administration Record (MAR). The nurse administered the medication without verifying the elevated INR level, contrary to the facility's guidelines and professional standards of practice. For Resident #200, a nurse administered the wrong strength of Vancomycin, an antibiotic, despite elevated Vancomycin trough levels. The resident was initially prescribed 750 mg of Vancomycin twice daily, but due to elevated trough levels, the dose was adjusted to 500 mg. However, the night nurse administered the previous higher dose of 750 mg, ignoring the updated order. This error was identified when the new dose was found in the medication storage room, indicating that none of the new doses had been administered as ordered. Both incidents highlight a failure in the facility's medication administration process, including inadequate documentation, lack of adherence to updated medication orders, and insufficient communication among staff. These deficiencies resulted in significant medication errors that could have led to prolonged illness and hospitalization for the affected residents.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection control program, which included outcome and process surveillance, accurate data collection, documentation, and analysis. The infection control data for March 2024 was inconsistent and incomplete, with discrepancies in the number of infections reported on different documents. The Infection Control (IC) Registered Nurse (RN) V, who started in February 2024, admitted to not having completed their organizational training and being unaware of reporting guidelines related to communicable diseases. The line listing did not include essential details such as carry-over infections, room numbers, isolation precautions, diagnostic testing results, and antimicrobial treatment duration. Additionally, the facility was not reporting Covid-19 or other communicable diseases to the Health Department, and there was a lack of tracking for potential infections and symptoms among residents not receiving antimicrobial treatment. The facility's infection control program also failed to track and monitor antimicrobial stewardship effectively. RN V was unable to quickly access and verify if infections met the criteria for treatment, and the monthly summary for March 2024 did not address residents who received treatment without meeting the criteria. Specific cases, such as Resident #26 and Unsampled Residents A and B, highlighted issues with documentation and tracking of infection onset dates, diagnostic testing, and antibiotic administration. RN V admitted to not tracking potential infections and contagious microorganisms, which is crucial for mitigating the spread of illness. Employee call-in and illness tracking were also inadequate, with the list for March 2024 lacking details related to infection tracking. RN V was unaware of how contracted staff call-ins and illnesses were reported and tracked. The facility did not have a comprehensive system for tracking resident vaccination status for influenza and pneumococcal vaccines. Additionally, process surveillance and rounding were minimal, and the laundry and utility rooms were found to be in poor condition, with issues such as dirty and cluttered environments, improper storage of PPE, and uncovered oxygen concentrators. The Director of Nursing (DON) acknowledged the concerns but did not provide a clear plan for addressing the deficiencies.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure call lights were within reach and responded to in a timely manner for three residents, and one resident was left exposed. During a Resident Council meeting, multiple residents reported waiting over 30 minutes for call light responses, with some waiting over an hour. Specific observations included Resident #15's call light being out of reach on multiple occasions, Resident #100 being left exposed in a wet brief with the door open, and Resident #200's call light being placed out of reach. Additionally, Resident #6's call light was activated for nine minutes without staff response, and further delays were noted in assisting the resident out of bed. The facility's policies on promoting resident dignity, resident rights, and call light accessibility were not adhered to, as evidenced by the observations and resident reports. Staff members were observed not placing call lights within reach and not responding promptly, leading to residents experiencing frustration and potential mental anguish. The deficiencies were noted across different shifts and involved multiple staff members, indicating a systemic issue in the facility's adherence to its policies and procedures.
Failure to Obtain Informed Consents for Mood Stabilizers and Hypnotics
Penalty
Summary
The facility failed to ensure that informed consents were obtained for non-psychotropic medications used to treat mood and behavior disorders and/or hypnotic medications for seven residents. This resulted in residents receiving medications without the necessary consents, leading to the potential for unnecessary and undesired medication use. The facility's policy stated that psychotropic drugs should only be given when necessary to treat a specific condition and must be documented in the clinical record. However, the facility did not obtain consents for medications such as Lamictal, Depakote, Topamax, and Ramelteon, which were used as mood stabilizers or hypnotics for various residents with mood disorders, bipolar disorder, and dementia with behavioral features. During the survey, it was found that the social services designee was unaware that consents were needed for mood stabilizers. Upon realizing the oversight, the designee conducted an audit and identified seven residents who required consents for their medications. The residents involved had conditions such as bipolar disorder, mood disorders with psychotic features, and dementia with behavioral disturbances, and were prescribed medications like Depakote, Lamictal, and Topamax without the proper consents. This lack of informed consent was a significant deficiency in the facility's medication administration process.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 320 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Frankenmuth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellspring Lutheran Services | 0.2 mi | ★★★★★ | 0 | 0 |
| Avista Nursing And Rehabilitation | 8.3 mi | ★★★★★ | 23 | 0 |
| Maple Woods Manor | 9.6 mi | ★★★★★ | 26 | 0 |
| Medilodge Of Montrose Inc | 12.6 mi | ★★★★★ | 27 | 0 |
| Hoyt Nursing & Rehab Centre | 13.1 mi | ★★★★★ | 16 | 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 October 2026) and official state health department websites.