Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Grand Blanc during CMS and state inspections, most recent first.
A facility failed to keep clean linens consistently available, and multiple linen closets were found with very limited supplies. Staff said they often had to borrow from other halls or use towels in place of washcloths, and laundry staff acknowledged ongoing shortages and delayed deliveries. A resident with DM, malnutrition, weakness, and dependence for bathing and toileting was unable to get a shower because no washcloths were available, was offered towels instead, and reported waiting over two hours in a dirty brief and feeling dirty until the next scheduled shower day.
A resident who was cognitively intact and dependent on staff for ADLs reported that a CNA made rude, disrespectful comments while helping reposition him, including questioning how he got into certain positions and saying that was not how she left him. The resident said the comments upset him and made him nervous about the care he needed. A family grievance and staff interviews confirmed the CNA was unprofessional during care and that the facility’s dignity policy required respectful, resident-centered communication.
Care plan implementation failed for a cognitively intact resident with trach/vent dependence and muscular dystrophy who was dependent for ADLs. The resident said staff were not shaving his face or clipping his nails as planned on shower days, and he was observed with overgrown facial hair outside his preferred goatee and long, unkempt fingernails. Although the TAR showed grooming tasks as completed and staff said the resident often refused care, no refusals were documented, and the ADON and DON/NHA both verified the mismatch between the charting and the resident’s actual condition.
A resident with a history of bilateral femur fractures and repeated falls fell out of bed during a bed bath after one aide left and the remaining CNA continued the bath alone. The resident said he was sliding off the bed before hitting the floor and later reported fractures to both legs and a chipped tooth. Records showed he was a 2-person total assist for bed mobility, while bathing was listed as 1-person total assist at the time of the fall.
Food Safety and Sanitation Deficiencies in Dietary Area: Kitchen observations found a loose dishwasher backflow preventer cap, an ice machine drain line sitting directly in a drain, gravy held on the counter at improper temps for lunch, and cooked chicken on the steam table at 101 degrees F. A staff member handled raw breaded chicken, changed gloves, and then prepared ready-to-eat food without washing hands. Surveyors also observed hallway ice coolers lined with trash can liners, a dirty sink with a used pitcher and lemonade stored in it, soiled prep equipment, damaged pans, and expired food items in the refrigerator.
The facility failed to operationalize a comprehensive infection control program. The IC RN and DON reported that infection surveillance data were tracked with a mapping tool and line listing, but the counts did not match, a skin infection was missed from the line list, and the monthly analysis did not include trend analysis. The facility also did not track potential infections that did not receive antimicrobials, and symptom documentation was incomplete or inconsistent for residents with HAIs, including a UTI with mismatched specimen and onset dates.
Failure to monitor and analyze antibiotic use: The facility did not operationalize its antibiotic stewardship program for all residents. During review with the IC RN and DON, the line listing did not document whether infection or antibiotic criteria were met, several symptom fields were blank, and the RN could not verify criteria without reviewing each resident EMR. The monthly antibiotic summary and analysis had not been completed, the antibiogram review entry was unexplained, and staff could not explain how the facility monitored for unnecessary antibiotic use or appropriate duration.
Multiple residents reported and were observed experiencing delayed responses to call lights, inaccessible call light devices, and undignified staff interactions. Several residents with intact cognition described waiting 30 minutes or longer for assistance, including while on the toilet and when requesting pain medication, with staff sometimes turning off call lights and not returning. Other residents with impaired cognition, hemiplegia, ventilator dependence, and limited hand use were observed with call lights on the floor, covered by items, or otherwise out of reach, requiring them to yell or throw objects to get help. A confidential group of residents and a family member agreed that call lights are often out of reach, response times are long, staff may become upset when call lights are reactivated, and staff engage in personal conversations and talk about other residents within earshot instead of addressing the resident directly.
Surveyors identified that multiple dependent residents did not receive consistent ADL and hygiene care, including bathing, nail trimming, shaving, and routine personal hygiene. Several residents with cognitive impairment, ventilator dependence, stroke‑related deficits, and other serious conditions were observed with long, jagged or unkempt fingernails (sometimes digging into the skin), greasy or debris‑filled hair, unkempt beards despite stated preference for shaving, dried secretions on the face, mucous in the eyes, and pervasive offensive odors in a room. EMR review showed missed or undocumented scheduled baths, lack of documentation of nail care, and no progress notes describing reapproach attempts after refusals or reasons for incomplete bathing. Care plans often lacked specific interventions for refusals of care or grooming needs such as facial hair, demonstrating that ADL care and related documentation were not consistently implemented for these residents.
Nebulizer equipment for multiple residents with trachs and ventilator dependence was observed stored assembled in bags with visible dried residue, crystals, or moisture in the medication chambers. The RT described emptying and shaking the equipment before placing it back in the bag, while the DON stated it should be rinsed and air dried; one resident’s equipment was later inspected with the DON and still showed moisture and whitish crystals.
A resident with multiple chronic conditions and documented cognitive impairment had a DNR order entered, but the care plan still stated that the resident had chosen not to complete advance care planning. The chart showed conflicting cognitive assessments, including a BIMS score indicating severe impairment, yet there was no documentation of a code status discussion with the resident or responsible party and no competency form in the record.
Improper Use of Bed Rails as a Physical Restraint: A resident with stroke-related hemiplegia, dementia, dysphagia, trach/vent dependence, and total ADL dependence was observed in bed with three and at times four side rails raised. Staff said the extra rails were left up because the resident "wiggles" and to keep the resident from moving off the bed, while RN and DON stated only two rails should be raised and that three or four rails would be a restraint. The care plan did not specify the number of rails to use, and there was no documentation about side rail use.
Inaccurate MDS Assessment for Insulin Use: A resident with dementia, sciatica, and a history of falls had an MDS that documented 7 days of injections and 7 days of insulin injections, but record review and observation showed no insulin orders, no insulin on the MAR, and no insulin administered. The MDS nurse reviewed the assessment, orders, progress notes, and MAR and confirmed the MDS was not accurate.
A resident with bilateral knee contractures, impaired ROM, tracheostomy, and ventilator dependence was observed in bed without ordered splints or braces in place. The care plan called for a restorative splinting program with a leg and knee abductor wedge, left hand splint, and left elbow support, but EMR documentation showed the splint/brace task was repeatedly marked not completed or left blank on multiple shifts. The DON stated staff should complete the task and document it as completed.
A resident with a gastrostomy tube was observed receiving enteral feeding while lying in bed with the HOB at 17 degrees, below the care plan requirement for HOB >30 degrees during tube feeding. RN Z was unable to state the current elevation and only estimated the needed angle, and the DON later confirmed that the HOB should be elevated to at least 30 degrees. The resident had diagnoses including cerebrovascular disease, gastrostomy, and colostomy.
A resident with severe cognitive impairment and multiple medical conditions was found with a padded full side rail in use without a care plan, physician order, informed consent, or required assessments. Facility staff confirmed that no assessment, consent, or entrapment measurements were completed, and the use of side rails was not documented in the care plan, contrary to facility policy.
Two residents requiring Enhanced Barrier Precautions due to complex medical conditions and infection risks did not have proper signage posted or adequate PPE available as required by their care plans and facility policy. Staff were unable to locate necessary PPE or signage, and care activities were not conducted in accordance with established infection control protocols.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
Two residents with complex medical conditions experienced repeated episodes of constipation, with extended periods without bowel movements, despite care plans and a facility bowel protocol intended to address such issues. Documentation showed that interventions were not consistently implemented in a timely manner, and both residents exhibited symptoms such as emesis, restlessness, and resistance to care during these episodes. Both also experienced falls during periods of constipation, and staff interviews confirmed that the bowel protocol was not always followed as required.
A resident with multiple medical conditions experienced a significant change in condition, including increased fatigue, refusal to eat, and decreased responsiveness, leading to interventions such as oxygen therapy, CPAP, IV fluids, and Narcan administration. Despite facility policy requiring prompt notification, the resident's representative was not informed of these changes until the following day, and documentation of notification was missing. Staff interviews confirmed that the required notification did not occur in a timely manner, resulting in the family being unaware of the resident's status and interventions.
Two residents experienced neglect and abuse by a nurse aide who failed to respond to call lights and provide necessary care. One resident, dependent on a ventilator, was left soiled for hours, leading to distress and suicidal thoughts. Another resident was denied assistance with oral secretions and subjected to inappropriate language, causing discomfort and stress. The facility's policies on abuse and dignity were not followed, and care plans were not adhered to.
The facility's kitchen was found to have unsanitary conditions, including debris in refrigerator handles, soiled floors, and improper dish sanitization due to a malfunctioning dishwasher. Cleaning logs showed incomplete tasks, and expired food items were found in storage. The facility's cleaning schedule was not adhered to, and a boiler issue was identified as affecting water temperature.
The facility failed to promptly act on positive influenza results for two residents, who attended a Resident Council meeting without masks, exposing others. The DON and Infection Preventionist acknowledged the residents should not have been invited. Delays in receiving test results prevented timely precautions and interventions, and the facility did not offer alternative activities for the residents in isolation.
The facility's activities program was found to be monotonous and unoriginal, failing to meet the interests and needs of residents. Nine residents expressed dissatisfaction with the repetitive and poorly organized activities, which were often gender-biased and did not cater to cognitively intact individuals. The Activities Director admitted to copying and pasting activities from month to month and did not address the lack of resident-specific programming. Additionally, the facility's bus could not accommodate more than one resident with a specialty wheelchair, limiting participation in outings.
The facility failed to maintain a clean and safe environment, with soiled privacy curtains, improperly stored respiratory equipment, and unclean common areas. Residents' call lights were not within reach, posing safety risks. Respiratory equipment was found next to unsanitary items, lacking proper labeling and dating. The Infection Control Preventionist acknowledged improper storage of personal items, and the Maintenance Director was unaware of a ceiling tile issue causing a draft in a shared bathroom.
A facility failed to develop and implement a comprehensive activity care plan for a resident on mechanical ventilation, who expressed a desire to participate in activities outside their room. The resident reported staff unresponsiveness to requests for assistance and insufficient staffing to facilitate their participation in desired activities. The resident's electronic medical record lacked an activity care plan, contrary to facility policy, and the DON confirmed this oversight without explanation.
A resident with a history of COPD, influenza, and sepsis experienced a delay in treatment for pneumonia due to lapses in the facility's processes. Despite showing symptoms such as a cough and high temperatures, there was a delay in reviewing lab results and administering appropriate antibiotics. The resident's condition was not promptly addressed, leading to a potential exacerbation of their illness.
A resident returned from the ER with a urinary catheter, but the LTC facility failed to document its presence or provide necessary care. The resident's medical record lacked any mention of the catheter, and staff were unaware of its existence, leading to inadequate assessment and monitoring. The facility's policy on catheter care was not followed, resulting in a deficiency.
A facility failed to ensure proper head of bed elevation during tube feeding for a resident, resulting in a deficiency. The resident, with a complex medical history and requiring mechanical ventilation and tube feeding, was observed with the bed elevated at 24 degrees, below the recommended 30-degree minimum. The facility's policy lacked specific guidance on head elevation during feeding.
A facility failed to flush a PICC line after administering IV Cefepime to a resident with ALS and other complex medical conditions. The RN acknowledged the oversight, and the DON confirmed the requirement to flush PICC lines post-medication. The resident's care plan lacked PICC line monitoring, and the facility's policy required flushing before and after infusions.
A resident with serious health conditions did not receive prescribed medications Bumetanide and Spironolactone on multiple occasions due to delays in obtaining them from the pharmacy. The DON and ADON were unaware of the issue, and the facility failed to utilize available back-up medication. No documentation of communication with the pharmacy or practitioner was found.
A resident with multiple health conditions did not receive prescribed doses of Bumetanide and Spironolactone on several occasions due to delays in pharmacy delivery. The DON and ADON were unaware of the issue, and there was no documentation of communication with the practitioner about the missed doses, leading to significant medication errors.
A resident with multiple health issues, including influenza, was not documented as having been offered or received the influenza vaccine, nor was there a record of refusal. The ICP could not find the resident's immunization information, and the resident's name was missing from the audit report. Facility policies require annual offering and documentation of influenza vaccinations, which was not adhered to in this case.
The facility failed to provide dignified and respectful care, resulting in deficiencies for several residents. A resident dependent on a ventilator experienced delayed staff response, leading to incontinence and feelings of embarrassment. Another resident with dysphagia was left unsupervised during meals, contrary to their care plan. In the dining area, residents used towels instead of proper shirt protectors due to a shortage, and a resident was exposed during a transfer due to inadequate privacy measures.
The facility failed to provide timely ADL care and supervision for three residents, leading to discomfort and frustration. A resident was left in a broken bed without incontinence care, another experienced long call light wait times resulting in incontinence, and a third resident with swallowing precautions ate unsupervised, risking aspiration.
A facility failed to implement care-planned safety and supervision interventions for three residents, leading to potential and actual harm. A resident with multiple sclerosis was transferred by a single CNA instead of two, another resident with severe cognitive impairment lacked accessible call light and fall mats, and a resident with dysphagia ate unsupervised despite needing meal supervision.
A facility failed to dispose of oxycodone and maintain accurate medication records for a resident. The Controlled Substance Log was disorganized, with missing nurse initials and a missing pill from the blister pack. The resident's oxycodone order had been discontinued months prior, and there was no documentation of administration. The DON and Unit Manager revealed the pill was meant to be wasted due to blister pack damage, but this was not documented. The facility's policy on controlled substances was not followed.
A resident with cognitive decline and multiple health issues was verbally abused by a staff member in the dining room. The staff member, who had a history of inappropriate behavior, told the resident to "shut your mouth," which was overheard by other staff. The facility's policy on preventing abuse was not effectively implemented.
The facility failed to prevent an overdose for a resident with a history of substance abuse by not informing practitioners of the history and applying a fentanyl patch in an accessible area. Additionally, the facility did not ensure a safe environment or conduct thorough investigations for falls involving two residents, leading to potential harm and a decline in their conditions.
A nurse failed to properly secure her PPE gown during PEG tube care for a resident with complex medical needs, leading to potential contamination. The gown was not tied at the neck and waist, resulting in it tearing and falling off during the procedure, contrary to the facility's PPE policy.
A resident with an acute displaced fracture of the right ankle did not consistently receive pain assessments or medication as ordered, leading to prolonged periods of unmanaged pain. Despite reporting high pain levels, there were significant delays in administering prescribed pain medication. Interviews with the DON acknowledged the concerns, but no satisfactory explanation was provided for the inconsistencies, which were contrary to the facility's pain management policy.
Inconsistent Linen Availability Delayed Resident Hygiene Care
Penalty
Summary
The facility failed to ensure that clean linens were consistently available to meet residents’ needs. Survey observations and interviews showed multiple linen closets on different halls with very limited supplies, including closets with no pillowcases, no gowns, no blankets, and only a few washcloths and towels for the residents assigned to those areas. Staff on several halls stated that when linens ran out, they borrowed from other halls, used towels or other linens in place of washcloths, or searched the building for supplies. Laundry staff and management acknowledged that linen shortages were an ongoing problem and that staff had complained about not having enough linen supplies. Resident #103 was admitted with diagnoses including diabetes mellitus, failure to thrive, muscle weakness, protein calorie malnutrition, bipolar II disorder, and difficulty walking. The resident’s MDS showed cognitive intactness with a BIMS score of 15/15 and dependence for toileting and showering/bathing. The resident’s care plan and physician orders required showers on Wednesday and Saturday, incontinence care as needed, and assistance with bathing and hygiene. On the night of the incident, staff documented that a washcloth was unavailable and that the resident was offered a shower using clean towels, which the resident refused. The resident stated that she wanted a shower but there were no washcloths or towels available and that she did not want to use a sheet. Interviews with CNA and nursing staff confirmed that linen shortages affected resident care on the unit. A CNA stated that on the shift in question she could not find washcloths on any hall and told the nurse, who then went to the basement laundry area but found no one there. Another nurse stated that linen shortages were happening regularly over the prior weeks and that CNAs had complained about not having enough linens for incontinence care. The resident reported waiting over two hours in a dirty brief because linens were unavailable, feeling dirty, and not receiving the shower until the next scheduled shower day several days later. Laundry staff also stated that deliveries were inconsistent, that some shifts were late, and that there was a gap between deliveries that contributed to the shortage of linens available on the halls.
Resident Was Spoken to Rudely During Repositioning Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during care. Resident #102 was cognitively intact with a BIMS score of 15/15 and was dependent on staff for ADLs, including bed mobility, dressing, toileting, and transfers. The resident had diagnoses including acute respiratory failure with a tracheostomy, cardiac arrest, dependence on renal dialysis, diabetes mellitus, muscle weakness, and obesity. During interviews, the resident and a family member reported that a CNA made rude comments when the resident needed help repositioning, including statements such as, "I don't know how you get yourself in these positions" and "that is not how I left you." The resident stated that the comments upset him and made him nervous about the level of care he needed. The record also showed a grievance filed by the family regarding the CNA's care and family notification concerns. The NHA documented that the CNA and nurse were interviewed and that customer service education was needed for the CNA. During interviews, the CNA acknowledged that the resident had been upset and said she apologized, while the NHA stated that the CNA was unprofessional during care, received a verbal write-up for customer service issues, and was re-educated. The facility policy required staff to protect and promote resident rights, treat each resident with respect and dignity, keep conversation resident-focused and resident-centered, and speak respectfully to residents.
Care Plan for Grooming and Hygiene Not Followed as Documented
Penalty
Summary
The facility failed to ensure that a comprehensive, resident-centered care plan was implemented as written for a resident with chronic respiratory failure with tracheostomy and ventilator dependence, muscular dystrophy, muscle weakness, depression, and anxiety. The resident was cognitively intact with a BIMS score of 15/15 and was functionally dependent for care. During interview, the resident stated that staff were not following the care plan for grooming, explaining that his face was supposed to be shaved and his nails clipped on shower days, Saturdays and Wednesdays, and that he had not been shaved in about a week and was unsure when his nails were last clipped. The resident was observed with extra facial hair outside of his preferred goatee area and with visibly long, unkempt fingernails extending past the free edge of the fingers. He stated that the long nails made it uncomfortable to use the control shifter on his automated wheelchair and that he had repeatedly raised the issue with the ADON. The care plan directed staff to offer grooming and personal hygiene care, including nail care and shaving on shower days, and the TAR for May 2026 documented showering, shaving, and nail care as completed on multiple dates with no refusals or incompletes recorded. During interview, the ADON stated the resident often refused care and complained that it took too long, but after reviewing the TAR she verified there were no documented refusals and that the grooming tasks were marked complete. She also observed the resident’s nails and facial hair and agreed they were not as documented. The NHA likewise reviewed the TAR and agreed that all May shower, facial hair, and nail care tasks had been marked completed, while noting the resident’s concerns about grooming and stating the tasks would be separated in documentation going forward.
Failure to Follow Care Plan During Bed Bath Led to Fall With Fractures
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a history of right femur fracture, left femur fracture, muscle wasting, and repeated falls, resulting in a fall with multiple fractures. The resident stated that while receiving a bed bath, one staff member left the room and another staff member rolled him in bed to dry his back; he told the staff member he was sliding off the bed and then fell to the floor. The resident reported that he broke both legs, chipped a tooth, and was hospitalized. The incident report documented that the resident fell out of bed during care and sustained injuries, with x-rays showing a comminuted impacted supracondylar/intercondylar fracture of the left femur and an impacted supracondylar fracture of the right femur. Record review showed the resident was a two-person total assist for bed mobility at the time of the fall, but was a one-person total assist for bathing. The resident’s care plan was later updated to a two-person total assist for bathing. A CNA stated that another aide was present initially, but left, and the CNA then gave the bed bath alone. The CNA also stated that another person should have been with them to perform the bed bath and that residents are often rolled away from the caregiver during care. The DON stated there was no deficient practice identified and that the facility believed it was following the care plan.
Food Safety and Sanitation Deficiencies in Dietary Area
Penalty
Summary
The facility failed to maintain best practices in the food service area during observations of the kitchen and dietary storage areas. During the kitchen tour, a loose cap was observed on the atmospheric vacuum breaker on the water line to the dishwasher, and the drain line to the ice machine was observed sitting directly inside a drain. The Certified Dietary Manager stated that a contractor had repaired the backflow preventer a couple of weeks earlier because it had been spewing water. The observations were cited as not meeting FDA Food Code requirements for systems to be maintained in good repair and for proper air gaps to prevent backflow. Food handling and temperature control concerns were also observed. Two pans of gravy were found covered with aluminum foil on the counter, and both were temped at 130 degrees F and 135 degrees F; the Certified Dietary Manager stated the gravy had been sitting there since 8:00 a.m. and was being used for lunch. A pan of cooked breaded chicken was later observed sitting on top of the steam table at 101 degrees F. In addition, a staff member handled uncooked breaded chicken while wearing gloves, removed the gloves, put on new gloves, and then proceeded to prepare and temp ready-to-eat food without washing hands. When interviewed, the Certified Dietary Manager stated hands should be washed whenever needed and before moving onto the next thing, while the facility policy required handwashing before putting on gloves and after removing gloves. Additional observations showed improper storage and sanitation issues in the kitchen and hall coolers. Two hallway coolers had interiors lined with bags used to hold ice, and the Certified Dietary Manager identified the bags as Sysco Classic can liners, which the product sheet described as trash can liners with no indication they were food-contact safe. The back sink was dirty and contained a used pitcher, and a prepared lemonade container dated 02/21/2026 with an expiration of 02/27/2026 was stored in the same sink. The cook prep area had a large used food scoop and dirty knife on the counter, the sink had food particles present, and the clean equipment rack held two sauté pans with peeled Teflon coating and a vegetable mandolin slicer with a soiled handle and mold in the groove. The refrigerator also contained expired items, including chicken rice soup, cooked ground beef, yogurt, and ham lunchmeat slices with discard or expiration dates that had passed, and the Certified Dietary Manager verified the expired items and removed them for discard.
Infection Control Surveillance and Documentation Deficiencies
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection control program, including outcome surveillance and accurate data documentation and analysis. During review of January 2026 infection control data, the Infection Control RN and DON stated they used a mapping tool and a line listing for surveillance, but the number of infections on the line listing did not match the number on the mapping tool. A resident with a skin infection was included on the mapping tool but not on the line listing, and the RN stated the infection was missed. The RN also stated an analysis had not been completed, and the DON provided a monthly analysis form that listed total infections but did not include analysis of trends. The total number of infections on that form also differed from both the line listing and the mapping tool. The line listing showed each infection listed received antimicrobial treatment, but the RN stated the facility did not maintain a line list of infections or potential infections that did not receive treatment. The DON stated the facility had respiratory surveillance documentation because of a COVID outbreak in January 2026, but when asked how infections or potential infections were tracked when there was not an outbreak, both the DON and RN stated the facility did not have a method in place to clearly track potential infections. The line listing also had a section for symptoms, but signs and symptoms of infection were not specified. For one resident listed with a HAI, the infection site was documented as other and no signs or symptoms were listed. Another resident was treated for a HAI UTI, with the onset date and treatment start date listed as 1/14/26, while the urine sample was obtained on 1/9/26. When asked about the inconsistency, the RN stated it did not make sense and said they had noticed that previously. Other residents were listed as having treatment initiated on the same day symptoms began, and the RN stated they would need to review each chart to determine whether signs or symptoms were documented before antimicrobial treatment began. The RN stated they had stepped into the Infection Control Nurse role within the last few weeks and had not completed the January 2026 infection control tracking data, and the DON and RN stated the prior Infection Control nurse had left abruptly.
Failure to Monitor and Analyze Antibiotic Use
Penalty
Summary
The facility failed to implement and operationalize a comprehensive antibiotic stewardship program for all 126 residents. During an interview and record review with the Infection Control RN and the DON, the facility’s January 2026 infection control data was reviewed and the RN stated that McGeer criteria were used to assess residents for infection and initiation of antibiotics. However, the line listing documentation did not show whether infection or antibiotic use criteria had been met, and the symptoms section was blank for several residents who had received antibiotics. When asked whether criteria had been met for each antibiotic or antimicrobial medication on the line list, the RN stated that each resident’s EMR would need to be reviewed. The monthly summary and analysis for antibiotic use for January 2026 had not been completed. Although the DON provided a two-page Monthly Analysis and Summary/QAPI Committee Infection Prevention/Control Report, the antibiotic stewardship section only indicated that antibiotic use was reported to providers and that the annual antibiogram review date was marked “Yes,” without explanation. The RN could not explain what the “Yes” entry meant, did not have a copy of the antibiotic report provided to providers, and could not explain how the facility monitored to ensure antibiotics were not used unnecessarily or that residents who required antibiotics received the appropriate antibiotic for the correct duration. The RN stated they had recently assumed the Infection Control Nurse role and had not completed the January 2026 infection control and antibiotic stewardship data because the prior Infection Control Nurse had left the position.
Failure to Ensure Accessible Call Lights, Timely Responses, and Dignified Interactions
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity, self-determination, communication, and timely assistance by not ensuring call lights were accessible and responded to promptly. One resident with chronic obstructive pulmonary disease, chronic pain, respiratory failure, a history of falls, and intact cognition reported that when she activated her call light, it sometimes took 30 minutes to an hour for staff to respond, especially at night. She stated that this delay also affected her ability to receive pain medication, as she first had to wait for staff to answer the call light and then wait longer to actually receive the medication. Another resident with intact cognition who required substantial/maximal assistance with toilet transfers and toileting hygiene reported being left on the toilet for about 30 minutes and stated that he sometimes had to wait more than 30 minutes for assistance, mostly on night shift. He described that nurses would answer the call light, turn it off, say they would notify someone, and then not return, requiring him to turn the call light back on after about 10 minutes when no one came. The facility also failed to ensure that call lights were consistently within reach for several residents with significant functional and cognitive impairments. One resident with moderately impaired cognition who required substantial/maximal assistance with personal hygiene, rolling, and was dependent for transfers, dressing, and toileting was observed lying in bed with the bed in a high position and the call light placed on a Geri chair, covered by items, and out of his sight and reach. He reported that the call light often fell on the floor and that he resorted to throwing objects at the door to get staff attention. A nurse, when alerted, acknowledged that the resident should have had the call light in reach and then repositioned it and lowered the bed. Another resident with severe cognitive impairment, hemiplegia and hemiparesis, muscle wasting, atrophy, and attention and concentration deficits was observed with the call light lying on the floor at the head of the bed and not within reach; a CNA confirmed it should not have been on the floor and then clipped it to the resident’s blanket. The resident’s care plan specifically included an intervention to place the call light within reach. Additional concerns were identified through a confidential group meeting with residents and a family member, as well as with a resident dependent on a ventilator. The group reported that they all wait a long time for call lights to be answered and that staff often enter the room, turn off the call light without completing the requested task, or say they will return and do not, then become upset if residents turn the call light back on. The group also agreed that call lights are frequently on the floor or out of reach. They reported that staff have personal conversations that can be overheard, talk about other residents or their own personal lives, and talk to each other rather than to the resident while providing care, and that staff sometimes visit in rooms instead of completing tasks timely. A family member stated she has had to call the facility to get help for her brother, who needs suctioning and cannot reach his call light, particularly on weekends or after 7:00 p.m. Another resident with chronic respiratory failure, ventilator dependence, muscular dystrophy, and limited use of his hands reported that his press-pad call light, designed to be activated by his head, is sometimes out of reach, forcing him to yell for help. The unit manager stated that call lights should be answered as soon as they go off and should be clipped within residents’ reach, indicating a discrepancy between facility expectations and observed practice.
Failure to Provide and Document ADL and Hygiene Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate ADL and hygiene care, including bathing, nail care, shaving, and personal hygiene, for multiple dependent residents. One resident with metabolic encephalopathy, dementia, muscle weakness, and difficulty walking had long, broken, and jagged fingernails and facial hair extending beyond the goatee style he preferred. His MDS showed moderately impaired cognition and a need for substantial to maximal assistance with bathing and dressing and partial to moderate assistance with personal hygiene. His shower schedule showed only three showers documented over a 30‑day period, and there was no documentation of nail care or refusals of nail care, nor any care plan focus addressing refusals of care. Another resident with bilateral above‑knee amputations, diabetes, cognitive communicative deficit, and end‑stage renal disease on dialysis was observed in a room with a pervasive, rank odor that intensified near the resident. The resident required moderate to total assistance with ADLs and had a care plan calling for two‑person total assist for bathing. The bathing task record showed missed or undocumented scheduled baths and documented refusals on some days, but there was no progress note documentation of reapproach attempts after refusals or explanations for why bathing was not completed on specific dates. The DON attributed the odor to a recent UTI and stated the room would be cleaned, but the record showed only antibiotic courses and did not document hygiene interventions related to the odor. A ventilator‑dependent resident with severe cognitive impairment and total dependence for ADLs was observed with long, dark chin hairs and dark, unknown material under the fingernails. The care plan addressed ADL self‑care deficits and nail trimming behavior but did not include any focus or intervention for chin hair care. Another ventilator‑dependent resident, fully dependent for ADLs, was observed with dry, cracked lips, dried substance around the mouth and cheek, brownish areas on pillow and blankets, and mucous in the corners of both eyes, with similar findings of dried and moist mucous around the mouth on a later observation. The DON acknowledged this lack of hygiene was not acceptable. A resident with heart disease, oxygen dependence, stroke with dysphagia and aphasia, and right‑sided hemiplegia and hemiparalysis, who required moderate to total assistance for most ADLs, was observed with long, greasy hair containing visible chunks of an unknown substance and a long, unkempt beard, despite stating a preference to be shaved and an inability to shave independently. The resident’s right hand was flaccid and clenched in a fist, with long, unkempt fingernails digging into the palm, and the resident reported hand pain from the nails. The care plan called for extensive assist with personal hygiene but did not prevent this condition. Another resident with a history of cerebral infarction, cognitive communication deficit, and acute respiratory distress syndrome, requiring extensive assistance for personal hygiene, was observed with long fingernails. This resident reported disliking the nail length, stated they had asked staff to cut their nails without the request being fulfilled, and that staff did not offer nail care; the EMR contained no documentation of nail care being completed. Across these residents, surveyors found repeated failures to provide scheduled bathing, nail trimming, shaving, and routine hygiene, as well as failures to document refusals and to incorporate refusals and specific grooming needs into care plans. Observations included offensive odors, visibly unclean or unkempt hair and beards, long and jagged fingernails (sometimes causing discomfort), dried secretions on the face, and soiled linens. The records lacked consistent documentation of ADL care completion, reasons for missed care, or follow‑up after refusals, demonstrating that the facility did not implement and operationalize procedures to ensure dependent residents received necessary ADL and hygiene care.
Nebulizer equipment stored with dried residue and moisture
Penalty
Summary
The facility failed to maintain nebulizer equipment in a sanitary manner for four residents receiving respiratory care and ventilator/tracheostomy care. During observations, connected nebulizer administration sets were found stored in clear plastic bags behind ventilators or on oxygen supply equipment, and the medication administration chambers contained visible dried, crystalized, or whitish substance. The equipment remained in this condition across repeated observations for several residents. Resident #16 was observed in bed with a tracheostomy and mechanical ventilation, and a connected nebulizer administration set dated 1/25 was hanging behind the ventilator in a clear bag with a visible dried, crystalized substance in the medication chamber. The same condition was observed again on later visits. Resident #84 was also in bed receiving respiratory support via tracheostomy and mechanical ventilation, and the connected nebulizer set behind the ventilator remained in a clear plastic bag with a dried, whitish substance in the medication chamber during repeated observations. Resident #118 was observed in bed receiving mechanical ventilation via tracheostomy, with a connected nebulizer administration set in a clear bag behind the ventilator and a visible dried substance in the medication chamber on repeated observations. Resident #119, who was alert and engaged in conversation and had a tracheostomy and ventilator dependence, had nebulizer equipment stored assembled in a bag hanging on oxygen supply on the wall, with the medication chamber observed moist; when the DON later inspected it, the chamber contained moisture and multiple whitish crystals. The DON stated the chamber should be cleaned out and set on a barrier to dry, and the RT stated the equipment was emptied, shaken, and placed back in the bag.
Advance Directive and Code Status Not Updated
Penalty
Summary
The facility failed to ensure advance directives were completed appropriately and that the care plan for advance directives was updated for one resident, R130, who had diagnoses including peripheral vascular disease, heart disease, hypertension, and cognitive communication deficit and later expired at the facility. Record review showed a physician order for DNR dated after a prior Full Resuscitate order, but the care plan still stated, "Resident has chosen not to formulate advanced care planning" and had not been updated to reflect the change in code status. The resident's MDS later showed a BIMS score of 3, indicating severe cognitive impairment, while a psychiatry note also documented a BIMS of 3 and a progress note described the resident as confused at baseline. During interview, the Social Worker stated that if a resident is cognitively impaired, the facility would obtain a competency from the physician, but no competency form was in the chart for this resident. The Social Worker also stated that the resident was able to sign her own DNR paperwork based on staff judgment that she was cognitively intact, and acknowledged that a competency check should have been completed before deciding on code status. The EMR contained no documentation of a conversation with the resident or responsible party about code status, and the facility policy required periodic assessment of decision-making ability and review of advance directives as part of the comprehensive care planning process.
Improper Use of Bed Rails as a Physical Restraint
Penalty
Summary
The facility failed to ensure that physical restraints were not used for staff convenience for one resident, resulting in restriction of mobility. Resident #118 had diagnoses including cerebral infarction with right-sided hemiplegia, dementia, dysphagia, gastrostomy, neuromuscular dysfunction of the urinary bladder, respiratory failure with tracheostomy placement, and dependence on a mechanical ventilator. The resident was rarely or never understood and was dependent on staff for all ADLs, including bed mobility. Observations showed the resident in bed with side rails raised. On one observation, both upper side rails were raised; on later observations, three side rails were elevated, and at another time all four side rails were raised. The resident was also noted to have fall mats on both sides of the bed and a contracture in the left upper extremity/hand. The care plan addressed fall risk, low bed use, fall mats, and a bed rail intervention, but it did not specify how many side rails should be raised. Progress notes contained no documentation about side rail use. The EMR included an informed consent form for bed rails that described immobility and mobility loss as assessed needs and recommended full side rails on the right and left at all times when the resident was in bed. During interviews, CNA staff stated that three rails were left up because the resident "wiggles" and to keep the resident from wiggling off the bed or putting a leg over the side. RN staff and the DON stated that two side rails should be raised and that three or four side rails would be a restraint, but the DON also stated there was no explanation for why staff were raising three to four rails. Facility policy stated restraints are only to be used for the resident's safety and well-being after alternatives have failed, and the bed rail policy required person-centered use and ongoing monitoring documentation.
Inaccurate MDS Assessment for Insulin Use
Penalty
Summary
The facility failed to ensure that a resident’s MDS assessment accurately reflected the resident’s status. The resident was admitted with diagnoses including dementia, sciatica, and a history of falling, and the MDS documented a BIMS score of 3/15, indicating severe problems with memory or thinking. In section N of the MDS, the assessment recorded 7 days of injections and 7 days of insulin injections, with 0 days of changed insulin orders, indicating the resident had received insulin during the assessment period. Record review and observation did not support those MDS entries. During medication pass, no insulin was administered and no insulin was ordered on the MAR. The resident’s orders contained no insulin orders, and the medical chart did not include a diagnosis indicating the need for insulin. During interview, the MDS nurse reviewed the assessment, the resident’s diagnoses, the orders, the progress notes, and the MAR, and confirmed that no insulin had been administered and that the MDS assessment for the resident was not accurate.
Failure to Implement Ordered Splinting and Contracture Care
Penalty
Summary
The facility failed to implement planned interventions for contracture management for Resident #16, who had diagnoses including heart failure, bilateral knee contractures, gastrostomy, and respiratory failure with tracheostomy and mechanical ventilator dependence. On observation, the resident was in bed, nonresponsive to verbal stimulation, with both hands bent toward the inner arms at the wrists and the legs bent at the knees. No splints or braces were in place on the upper or lower extremities during the observation. Record review showed the resident had impaired ROM in both upper and lower extremities and a care plan for a restorative splinting program related to contracture, decreased strength, and limited ROM. The plan included use of a leg and knee abductor wedge, left hand splint, and left elbow support, along with positioning and daily skin checks. Documentation for February 2026 showed the splint/brace assistance task was not completed on multiple days, including several day shifts and 22 of 24 night shifts, and there were also blank entries where the task was not documented as completed. The DON stated staff should complete the task and document it as completed.
Tube Feeding Administered With Head of Bed Below Ordered Elevation
Penalty
Summary
Tube feeding was not administered per professional standards of practice and the resident’s plan of care for one resident with a gastrostomy tube. On 2/23/26 at 10:40 AM, Resident #40 was observed lying in bed on their back while receiving tube feeding through an infusion pump at 43 mL per hour. The head of the bed was measured at 17 degrees with a protractor tool, which was below the care plan intervention requiring the head of bed to be greater than 30 degrees when tube feeding was being administered. During the observation, RN Z was asked how high the head of the bed was elevated and stated they did not know, estimating “20 or 30 degrees” and then, when asked what the head of bed should be during tube feeding, replied “30 degrees” in a questioning tone. RN Z then elevated the head of the bed and left the room. Record review showed Resident #40 had diagnoses including cerebrovascular disease, skin transplant, gastrostomy, and colostomy, and the care plan specifically directed head of bed elevation greater than 30 degrees during tube feeding. The DON later stated the head of the bed should be elevated to a minimum of 30 degrees and identified RN Z as new.
Failure to Assess, Obtain Orders, and Care Plan for Side Rail Use
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease, dependence on renal dialysis, gastrostomy feeding, difficulty walking, and muscle weakness, was observed in bed with a padded full side rail in place. The resident was restless and appeared to be attempting to get out of bed, with the side rail preventing a fall. The bed was in the lowest position and a floormat was placed on the floor, but there was no documentation or evidence of appropriate assessment or authorization for the use of the side rail. Review of the resident's electronic medical record revealed the absence of a care plan addressing the use of side rails, no mention of side rails in the fall prevention care plan, and no informed consent or assessment for side rail use. Additionally, there were no initial entrapment measurements or grids for the bed/side rails, and no physician orders authorizing the use of side rails. Interviews with facility staff, including the DON and Unit Manager, confirmed that these required steps were not completed for this resident. Facility policy requires that side rails, considered a form of physical restraint when they restrict movement and cannot be easily removed by the resident, must only be used after a written physician order, informed consent, and a thorough assessment. The policy also mandates documentation of the medical reason for side rail use, compatibility checks, entrapment measurements, and inclusion in the resident's care plan. None of these procedures were followed for the resident in question, resulting in the cited deficiency.
Failure to Implement Enhanced Barrier Precautions and Provide PPE
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to the care plans for two residents who were at high risk for infection transmission due to their medical conditions and devices. For one resident with end-stage renal disease, a gastrostomy, and a hemodialysis port, the care plan required the use of gowns and gloves during high-contact care activities and the posting of EBP signage to alert staff and visitors. However, during observation, there was no EBP signage posted inside or outside the resident's room, and no personal protective equipment (PPE) was available in the room or nearby hallway. The nurse interviewed was unaware of the proper location for PPE and admitted to retrieving PPE from other residents' rooms, which was not in accordance with protocol. The Infection Control Nurse confirmed that signage and PPE should have been present and accessible as per the care plan. Another resident with a history of traumatic brain injury, chronic stage IV pressure ulcer, thoracic spine wound infection, and an indwelling urinary catheter also required EBP per the care plan and physician orders. Observations revealed that there was no EBP signage posted for this resident, and the available PPE in the room was insufficient, consisting of only a couple of gowns. The nurse caring for this resident was unable to locate the required signage and acknowledged that it should have been present. The resident's medical records confirmed recent hospitalization for wound infection and ongoing orders for EBP during high-contact care activities. Facility policy required the use of isolation signs to alert staff, family, and visitors of transmission-based precautions, and specified the use of gowns and gloves for high-contact care activities for residents with certain risk factors. Despite these policies and individualized care plans, the facility did not ensure that EBP signage was posted and that adequate PPE was available and accessible for staff, resulting in a failure to follow established infection prevention and control protocols for the residents reviewed.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Prevent and Address Constipation in Two Residents
Penalty
Summary
The facility failed to implement adequate measures to prevent constipation for two residents who were reviewed for this issue. Both residents had complex medical histories, including diagnoses such as diabetes, end-stage renal disease, renal dialysis, cardiac arrest, seizures, and feeding tubes, and required assistance with all care. Documentation showed that both residents experienced multiple episodes of constipation, with extended periods of no bowel movements, sometimes lasting up to ten days. During these periods, there were also documented episodes of emesis, restlessness, combativeness, and resistance to care. For one resident, the care plan included monitoring for no bowel movement in three days and administering medications as ordered. However, records indicated that there were several instances where the resident went longer than three days without a bowel movement, and interventions were not consistently documented or implemented in a timely manner. The resident experienced repeated episodes of emesis and behavioral changes during these periods of constipation. Additionally, the resident had a fall during a time when constipation was present and had received interventions for bowel elimination. The second resident also had a care plan to observe for no bowel movement in three days and to administer medications as ordered. This resident experienced multiple episodes of constipation, with several periods of four or more consecutive days without a bowel movement. The resident received interventions such as Polyethylene glycol and Bisacodyl suppositories, but these were not always administered according to the facility's bowel protocol. The resident also experienced falls during periods of constipation. Interviews with nursing staff and the DON confirmed that the facility's bowel protocol was not always followed as intended, and that both residents had patterns of repeated constipation that were not adequately addressed.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition. The resident, who was cognitively intact and had a history of cerebrovascular disease, hypertension, apnea, and peripheral vascular disease, experienced unusual fatigue, refused breakfast, and would not get out of bed or speak as usual. Medical interventions were initiated, including oxygen therapy, CPAP, IV fluids, and administration of Narcan, with the provider and nurse manager involved in the resident's care. Despite these significant changes and interventions, there was no documentation that the resident's family was notified at the time of the change. Interviews with facility staff revealed that the nurse manager assumed the floor nurse would notify the family, but could not find any documentation to confirm this. The nurse who provided care during the initial change stated that she attempted to call the resident's daughter but only reached voicemail and did not document the attempt or pass the information to the oncoming nurse. The nurse who took over the next shift believed the family had already been notified and only contacted them at the end of her shift, at which point the family expressed upset at not being informed sooner about the resident's condition and interventions. The facility's policy requires prompt notification of the resident's representative in the event of significant changes in condition, including the initiation of new treatments or clinical complications. In this case, the responsible party notification section in the electronic medical record was left blank, and staff interviews confirmed that the required notification did not occur in a timely manner, resulting in the family not being informed of the resident's change in condition until the following day.
Neglect and Abuse of Residents by Nurse Aide
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically involving two residents. One resident, who was dependent on a ventilator and required significant assistance with activities of daily living, was left unattended and in a soiled state for over two hours during the midnight shift. The resident's call light was ignored by a nurse aide, who expressed that her foot hurt and she was tired of responding to the call light. This neglect led to the resident feeling disrespected, anxious, and expressing suicidal thoughts. The resident's wife had to intervene by calling the facility multiple times to ensure her husband received the necessary care. Another resident, who also had respiratory needs and was dependent on assistance for daily activities, experienced neglect when the same nurse aide refused to assist with oral secretions, stating it was not her job. The aide also used inappropriate language and displayed a lack of professionalism, which made the resident feel uncomfortable and intimidated. The resident had to swallow secretions due to the lack of assistance and felt stressed by the aide's behavior. The facility's policies on abuse, neglect, and maintaining resident dignity were not followed, as evidenced by the staff's failure to respond to call lights promptly and provide necessary care. The social services staff did not assess or refer the first resident for psychological evaluation despite the resident's expressed distress and suicidal thoughts. The care plans for both residents were not adhered to, contributing to the neglect and abuse experienced by the residents.
Sanitation and Equipment Failures in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a tour with Registered Dietitians. The inspection revealed debris inside the handles of the reach-in refrigerator, dried food residue and burnt particles on the toaster, and a speaker placed atop clean dishware. Additionally, wet sheet pans were found on a storage rack meant for dry items, and the kitchen floors were soiled with debris and dried substances. The ice machine's bottom lip yielded a black residue when wiped, and the walk-in cooler had a dusty fan cover and expired food items. The facility's dishwasher was not reaching the required sanitization temperatures, with the temperature gauge failing to move beyond 140 degrees during multiple cycles, despite the requirement for a wash temperature of 150-165 degrees. It was noted that using the sprayer simultaneously with the dishwasher could prevent the water from reaching the necessary temperature. The cleaning logs showed numerous blanks, indicating that daily cleaning tasks were not being completed as required, with several areas such as floors, trash cans, and equipment not being cleaned. The facility's cleaning schedule from late December to early January showed that many deep cleaning tasks were not completed, and there was no coverage when the porter responsible for these tasks was absent. The PM Diet Aide and PM Cook also failed to complete their cleaning tasks during their shifts. The Senior Maintenance Director reported a possible supply and demand issue with the boilers, and a contracted company was addressing a malfunctioning stage controller. The Dietary Manager acknowledged the issues and noted that the dishwasher gauge had been replaced, restoring proper temperature function.
Failure to Timely Act on Influenza Outbreak
Penalty
Summary
The facility failed to act promptly on positive influenza laboratory results and did not operationalize policies and procedures for an influenza outbreak involving two residents. During a Resident Council meeting, two residents who tested positive for influenza attended without masks, exposing other residents. The facility staff, including the Director of Nursing (DON) and Infection Preventionist, acknowledged that these residents should not have been invited to the meeting and that alternative arrangements could have been made to address their concerns. The residents had shown symptoms of influenza, including high temperatures and cough, but were not placed on transmission-based precautions until several days after the positive test results were received. The facility's Infection Control Preventionist was unaware of the positive results until two days after they were faxed to the facility. This delay in receiving and acting on the test results prevented the timely initiation of precautions, facility-wide testing, and acquisition of prophylactic medication for residents. The facility's policy required transmission-based precautions for residents suspected or confirmed to have infectious diseases, but these were not implemented in a timely manner. The residents continued to participate in communal activities despite being on droplet precautions, and the facility did not offer alternative activities in their rooms. The lack of monitoring of the fax machine for pending laboratory results contributed to the delay in initiating necessary precautions and interventions.
Inadequate Activities Program Fails to Meet Resident Needs
Penalty
Summary
The facility failed to provide an activities program that met the interests and needs of its residents, resulting in a monotonous and unoriginal schedule. During a Resident Council meeting, nine residents expressed their dissatisfaction with the current activities, citing that they were boring, poorly organized, and repetitive. They also noted that the activities did not cater to the interests of cognitively intact residents and were often gender-biased, with prizes and activities skewed towards women. Additionally, the residents were frustrated with the lack of space for specialty wheelchairs on the bus for outings, which limited participation to the same group of residents each time. A review of the Resident Council notes from April 2024 to December 2024 showed low attendance, with some months having only one or two residents attending, and one month with no attendees. The activity calendars from July 2024 to January 2025 revealed a lack of variety, with many activities being repeated each month. For example, Sundays consistently featured the same schedule, and many weekdays had identical activities across different months. The Activities Director admitted to copying and pasting activities from month to month without much variation and did not have a substantial response when questioned about the lack of resident-specific programming. The Activities Director also acknowledged that the facility's bus could not accommodate more than one resident with a specialty wheelchair, and the same residents typically attended outings. Despite recognizing the gender bias in BINGO prizes, the director had not taken steps to gather input from residents on desired items. The facility's policy on activities emphasized the importance of designing programs to meet the interests and well-being of residents, but the current programming did not reflect these goals. The Activities Director's job description also highlighted the need for a comprehensive assessment to develop meaningful activities, which was not being fulfilled.
Deficiencies in Cleanliness and Safety in LTC Facility
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, as evidenced by multiple observations of soiled privacy curtains, improperly stored respiratory equipment, and unclean common areas. Privacy curtains in several rooms were noted to have stains of varying colors, and the residents were unable to recall when they were last laundered. The Laundry/Housekeeping Manager confirmed that some curtains could be laundered while others needed to be discarded, but the housekeeping routine did not include checking the privacy curtains. In the common area/dining room on the 300-Hall, wheelchairs and Geri chairs were stored with visible debris and stains, and a walker was found filthy with rips in the seat cushion. Residents' call lights were not within reach, posing a risk to their safety. For instance, a resident with severe cognitive impairment was observed struggling to reach her call light, which was found on the floor without a clip to secure it. Another resident was found eating alone with food debris scattered on her chest and bed, and her call light and TV remote were also on the floor. Additionally, respiratory equipment such as nebulizers and CPAP machines were not stored properly, with some found next to unsanitary items like urinals. The equipment lacked proper labeling and dating, indicating a lapse in infection control practices. The facility's Infection Control Preventionist acknowledged the improper storage and labeling of personal items like wash basins and denture cups, which were found without resident identification. The Maintenance Director was unaware of a ceiling tile issue causing a draft in a shared bathroom, highlighting a communication gap in reporting maintenance concerns.
Failure to Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive activity care plan for a resident, resulting in the potential for lack of meaningful activities and decreased quality of life. The resident, who was observed in their room wearing a hospital gown and receiving mechanical ventilation via a tracheostomy, was able to communicate by mouthing words and indicated they could write or type. However, no method for written communication was present in the room. The resident expressed a desire to participate in activities outside their room, such as going to the small lounge to read or do puzzles, but reported that staff were not responsive to call lights or requests for assistance, and there was insufficient staff to facilitate their participation in these activities. A review of the resident's electronic medical record revealed that they did not have a care plan in place for activities, despite being cognitively intact and having specific activity preferences. The Director of Nursing confirmed the absence of an activity care plan for the resident and was unable to provide an explanation for this oversight. The facility's policy requires that each resident's interests and needs be assessed routinely and incorporated into a care plan, which was not adhered to in this case.
Delay in Treatment for Resident with Pneumonia
Penalty
Summary
The facility failed to provide timely treatment for a resident who experienced a change in condition, resulting in a potential exacerbation of pneumonia and sepsis. The resident, who had a history of chronic obstructive pulmonary disease, influenza, and sepsis, was admitted to the facility and later readmitted with these diagnoses. The resident began exhibiting symptoms such as a cough and elevated temperatures, which were documented in the progress notes. Despite these symptoms, there was a delay in obtaining and acting upon laboratory results and in administering appropriate medication. The resident's medical record indicated that a chest x-ray was ordered after the resident showed signs of a high temperature and wheezing. However, there was a delay in receiving and reviewing the results of a respiratory panel, which eventually revealed the presence of influenza and Staphylococcus aureus. The facility staff did not become aware of these results until several days after they were faxed to the facility. Additionally, there was a delay in the administration of antibiotics due to an allergy to the initially prescribed medication, Levaquin, and a subsequent delay in ordering an alternative antibiotic, Doxycycline. Interviews with the Infection Control Preventionist and the Director of Nursing revealed that the facility did not promptly act on the laboratory results or the resident's need for a change in medication. The Director of Nursing acknowledged the delay in treatment and the failure to promptly address the resident's condition. This deficiency highlights a lapse in the facility's processes for managing changes in residents' conditions and ensuring timely medical interventions.
Failure to Document and Provide Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who returned from the emergency room with a urinary catheter. The resident, who is cognitively intact but dependent on staff for daily care, was observed with a catheter drainage bag upon return from the emergency room. However, there was no documentation in the resident's medical record indicating the presence of the catheter, nor were there any physician orders, nursing notes, or care plans addressing the catheter. The facility's policy requires catheter care to be provided in accordance with current clinical standards, including regular emptying and monitoring, but these procedures were not documented or followed. The deficiency was further highlighted when a CNA reported providing catheter care without any charting prompts indicating the presence of a catheter. The Unit Manager was unaware of the catheter and could not find any additional information or documentation regarding its placement or removal. This lack of documentation and communication resulted in the resident not receiving the necessary assessment, monitoring, and ongoing care for the urinary catheter, as required by the facility's policy.
Improper Head of Bed Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure proper administration of enteral tube feeding for a resident, resulting in insufficient head of bed elevation during tube feeding administration. The resident, who was receiving mechanical ventilation via a tracheostomy and tube feeding via pump, was observed with the head of their bed at a 24-degree angle, which is below the minimum 30-degree elevation recommended by the Director of Nursing (DON) and professional standards of practice. The resident did not have a care plan or Health Care Provider (HCP) order specifying the required degree of head elevation during tube feeding. The resident involved had a complex medical history, including gastrostomy, end-stage renal disease with dialysis dependence, heart disease, tracheostomy, respiratory failure with ventilator dependence, and pneumonia. The resident was moderately cognitively impaired and required maximum to total assistance for Activities of Daily Living (ADLs). The facility's policy on feeding tubes did not specify the necessary head of bed elevation during tube feeding, contributing to the deficiency observed.
Failure to Flush PICC Line After IV Medication Administration
Penalty
Summary
The facility failed to properly manage and care for a Peripherally Inserted Central Catheter (PICC) line for a resident, resulting in a deficiency. During an observation, a Registered Nurse (RN) was found to have not flushed the PICC line after administering IV Cefepime, an antibiotic, to the resident. The medication was administered the previous day, and the IV pump was found turned off with an empty bag still connected to the resident's PICC line. The RN acknowledged that PICC lines should be flushed after medication administration but did not provide an explanation for the oversight. The resident involved had a complex medical history, including Amyotrophic Lateral Sclerosis (ALS), anarthria, a tracheostomy, and ventilator dependence, and was severely cognitively impaired. The resident's care plan did not include monitoring and care for the PICC line. The Director of Nursing (DON) confirmed that PICC lines should be flushed following IV medication administration. The facility's policy on flushing guidelines for peripheral venous catheters was reviewed, which stated that IV catheters should be flushed before and after each infusion.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident, resulting in the non-administration of prescribed medications Bumetanide and Spironolactone. The resident, who had multiple serious health conditions including congestive heart failure and chronic obstructive pulmonary disease, was not given Bumetanide on several occasions and Spironolactone on multiple days as the medications were not available. The Medication Administration Record (MAR) indicated that the medications were on order from the pharmacy, but there was no documentation of communication with the pharmacy or the resident's practitioner regarding the missed doses. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the issue until the survey. The DON acknowledged that the medications should have been obtained from the back-up supply if available, and the pharmacy should have been contacted for follow-up. The facility's back-up medication list confirmed that Spironolactone was available, but it was not utilized. Additionally, there was no facility policy provided regarding medication administration and acquisition, which was requested during the survey.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the practitioner for a resident, resulting in significant medication errors. The resident, who had multiple diagnoses including congestive heart failure and acute kidney failure, was not administered Bumetanide and Spironolactone on several occasions. The Medication Administration Record (MAR) indicated that Bumetanide was not given on six different days, and Spironolactone was not administered on six different days as well. The progress notes consistently cited waiting on medication from the pharmacy as the reason for non-administration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the issue until it was brought to their attention. The DON acknowledged that the nurse should have contacted the provider and arranged for an alternative until the medication arrived. There was no documentation in the medical record that the practitioner had been notified of the missed doses, and the practitioner confirmed that they had not received any communication regarding the missed medications. The lack of communication and documentation led to the resident not receiving critical diuretic medications, which could potentially exacerbate their medical conditions.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to ensure that immunizations were reviewed and offered to a resident, resulting in a deficiency related to infection control. During a survey, it was found that a resident, who had been diagnosed with influenza, did not have documentation of being offered or receiving the influenza vaccine, nor any record of refusal. The resident's medical history included significant health issues such as congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, diabetes, and dependence on supplemental oxygen, which could increase the risk of complications from influenza. The Infection Control Preventionist (ICP) acknowledged the lack of immunization information in the resident's medical record and was unable to find any documentation of the resident being offered or refusing vaccinations. The ICP noted that the resident's name did not appear on the audit report, which was supposed to include all residents. Facility policies require that residents be offered influenza vaccinations annually and that documentation should reflect whether the resident received the immunization or refused it. However, this process was not followed for the resident in question, leading to the deficiency.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure dignified and respectful care for several residents, leading to multiple deficiencies. Resident #61, who is dependent on a ventilator and has a tracheostomy, experienced significant delays in staff response to call lights, resulting in unnecessary incontinence and feelings of embarrassment and frustration. The resident also reported discourteous and unprofessional behavior from staff, including a nurse accusing them of disconnecting their ventilator tubing for attention. Additionally, the resident lacked access to adaptive communication devices, such as a whiteboard or paper and pen, which hindered their ability to communicate effectively with staff. Resident #39, who has a history of stroke and dysphagia, was observed eating alone in their room without supervision, despite having swallowing precautions posted on the wall. The resident was not provided with a clothing protector and was found with food on their chest and bed. The care plan for Resident #39 indicated the need for supervision during meals, but no staff was present to assist or monitor the resident while eating, which is contrary to the care plan requirements. In the dining area, several residents were observed using towels instead of proper shirt protectors, which failed to adequately protect their clothing from food spills. This was attributed to a shortage of shirt protectors due to issues with the facility's laundry service. Additionally, Resident #4 was exposed during a transfer to a shower chair, as the privacy curtain was not closed, and the door to the room did not stay shut, compromising the resident's dignity and privacy. These observations highlight the facility's failure to maintain resident dignity and privacy as per their policy.
Failure to Provide Timely ADL Care and Supervision
Penalty
Summary
The facility failed to provide necessary services for timely response and assistance with Activities of Daily Living (ADL) care for three residents, resulting in discomfort and feelings of frustration and embarrassment. Resident #43 was found in bed with a strong odor of urine and bowel movement, indicating a lack of incontinence care since the previous night. The resident's bed was stuck in a high-seated position, causing neck and back pain, and staff failed to address the issue or provide care. The bed was later found to be unplugged, and once reconnected, the resident expressed increased comfort. Resident #61 reported long wait times for call light responses, leading to incontinence due to delayed assistance with toileting. The resident, who was dependent on a ventilator, expressed embarrassment and frustration over the situation. Despite having a bedside commode, the resident was unable to use it without assistance, and staff were observed turning off the call light without addressing the resident's needs. Resident #39, who had swallowing precautions due to a history of stroke, was observed eating alone without supervision or assistance, resulting in food spillage. The resident's care plan required supervision during meals, but no staff were present to assist or monitor the resident while eating. This lack of supervision posed a risk given the resident's swallowing difficulties and need for assistance with meal setup.
Failure to Implement Safety and Supervision Interventions
Penalty
Summary
The facility failed to implement care-planned interventions for safety and supervision for three residents, leading to potential and actual harm. Resident #4, who has multiple sclerosis, dementia, and Alzheimer's disease, was transferred using a mechanical lift by a single CNA, contrary to the care plan that required two-person assistance. The CNA admitted to transferring the resident alone due to being behind in work and lack of available staff, which was against facility policy. Resident #35, with severe cognitive impairment and multiple physical disabilities, was found without a call light within reach and with only one fall mat in place, despite care plan interventions requiring bilateral floor mats and the call light to be accessible. The resident had previously been observed sliding off the bed, and the care plan included interventions to prevent falls, which were not fully implemented. Resident #39, who has hemiplegia and dysphagia, was observed eating alone without supervision, despite care plan requirements for supervision during meals due to swallowing precautions. The resident's care plan specified the need for assistance with meal setup and monitoring while eating, which was not provided, as no staff were present in the hallway to assist or supervise the resident during the meal.
Failure to Dispose and Document Controlled Substances
Penalty
Summary
The facility failed to promptly dispose of 24 pills of oxycodone and maintain accurate and legible controlled medication reconciliation records for a resident. During an observation of the Vent Medication Cart, it was found that the Controlled Substance Log for Oxycodone IR 5 MG Tab had disorganized entries with multiple witnessed initials that were difficult to match to specific rows. The log indicated that the resident was administered oxycodone on a specific date, but there were no nurse initials, and the blister pack showed a missing pill with a circled bubble. The resident's medical records revealed that the oxycodone order had been discontinued months prior, and there was no documentation of administration on the date in question. Further investigation with the Director of Nursing and Unit Manager revealed that the pill was intended to be wasted due to damage to the blister pack, but this was not properly documented. The disorganization of the narcotic form made it unclear whether the nurse signatures corresponded to the correct entries. The facility's policy on controlled substances requires accurate inventory and proper documentation of disposal, which was not adhered to in this case. The resident involved had a medical history including respiratory failure, end-stage renal disease, atrial fibrillation, hypotension, and polyneuropathy.
Failure to Prevent Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse involving a resident with paranoid schizophrenia, hypothyroidism, heart failure, anxiety, depression, and intellectual disabilities. The resident, who had moderate cognitive decline and required assistance with all care, was subjected to verbally abusive language by a staff member. The incident occurred in the main dining room after an activity, where the staff member told the resident to "shut your mouth," which was overheard by other staff members. The staff member involved had a history of inappropriate verbal interactions with co-workers, having been reprimanded three times prior to this incident. Despite these previous incidents, the staff member continued to work at the facility until the verbal abuse towards the resident occurred. The facility's policy on abuse, neglect, and exploitation, which was in place to protect residents' health, welfare, and rights, was not effectively implemented to prevent this incident.
Deficiencies in Resident Safety and Care Management
Penalty
Summary
The facility failed to adequately assess, monitor, and implement interventions to prevent an overdose for a resident with a long-standing history of polysubstance abuse. The resident, who had been admitted with a history of substance abuse and various medical conditions, was prescribed a fentanyl patch for pain management. However, the facility did not inform the prescribing practitioners of the resident's substance abuse history, nor did they obtain informed consent from the resident's guardian for the administration of fentanyl. The patch was applied in an accessible area, leading to the resident ingesting it and experiencing an overdose, which required multiple doses of Narcan to reverse. Additionally, the facility failed to ensure a safe environment and adequate supervision to prevent falls for two residents. One resident fell while taking a shower, resulting in minor injuries, but the incident report was incomplete, lacking details about the nursing assistant's location during the fall. Another resident, who was quadriplegic and unable to move independently, was found on the floor after an unwitnessed fall. The facility did not conduct a thorough investigation or update the care plan to address the root cause of the fall, which was attributed to aggressive coughing. The facility's failure to conduct complete investigations and implement appropriate interventions for both residents highlights deficiencies in ensuring resident safety and preventing accidents. The lack of documentation and communication regarding the residents' conditions and care needs contributed to these incidents, resulting in potential harm and a decline in the residents' medical conditions.
Improper PPE Use During PEG Tube Care
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube, leading to a potential risk of contamination and infection spread. During an observation, Nurse D was seen performing PEG tube site care for a resident who was on Enhanced Barrier Precaution due to tracheostomy and gastrostomy status. Nurse D did not properly secure her gown, as it was not tied at the neck and the waist belt was not securely fastened. During the procedure, the gown tore and fell off her shoulders, exposing her clothing and potentially contaminating the care area. The resident involved was admitted with multiple complex medical conditions, including quadriplegia, tracheostomy, gastrostomy, and chronic respiratory failure with hypoxia. The resident was bedridden, had contractures, and was unable to communicate or request assistance, relying entirely on staff for care. The facility's policy on PPE, which mandates the use of appropriate protective gear to prevent pathogen transmission, was not adhered to during this incident, as evidenced by the improper gowning technique observed.
Inconsistent Pain Management for Resident with Ankle Fracture
Penalty
Summary
The facility failed to consistently complete pain assessments and administer medication as ordered for a resident with an acute displaced fracture of the right ankle. The resident, who was admitted for short-term skilled nursing and rehabilitation services, had a history of cellulitis and heart failure and had fallen at home prior to admission. Despite having intact cognition, the resident reported worsening pain after admission, which was confirmed by an x-ray showing a right ankle fracture. However, the resident did not consistently receive their prescribed pain medication, leading to prolonged periods of unmanaged pain. The resident's electronic medical record revealed inconsistencies in pain assessments and medication administration. On several occasions, the resident's pain levels were documented as high, yet there were significant delays in administering the next dose of pain medication. For instance, on one day, the resident reported a pain level of 8/10 in the morning but did not receive medication until nearly 12 hours later. Similarly, on another day, the resident reported a pain level of 8/10 in the evening, but there was no follow-up assessment or medication administration for approximately 18 hours. Interviews with the Director of Nursing (DON) indicated an awareness of the concerns but did not provide a satisfactory explanation for the inconsistencies. The facility's pain management policy emphasized the importance of systematic recognition, assessment, treatment, and monitoring of pain, yet these protocols were not followed in the case of this resident. The failure to adhere to the facility's pain management policy resulted in inadequate pain control for the resident, as evidenced by the documented gaps in pain assessment and medication administration.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 302 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Blanc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Woodfield | 2.9 mi | ★★★★★ | 2 | 0 |
| Wellbridge Of Grand Blanc | 4 mi | ★★★★★ | 14 | 0 |
| Regency At Grand Blanc | 4.1 mi | ★★★★★ | 3 | 0 |
| Briarwood Nursing And Rehabilitation | 8 mi | ★★★★★ | 7 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 9.5 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.