Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Grand Rapids during CMS and state inspections, most recent first.
A hospice resident with heart disease and lung cancer, who was cognitively intact and had clearly chosen DNR status, had that wish documented by hospice and on facility DNR forms completed at admission and again several days later. The facility lost or could not locate the initial DNR paperwork, and when a new DNR form was completed and sent to the physician, the signed form was returned but remained in the DON’s inaccessible email inbox and was never entered into the EHR. Because the resident’s orders still showed FULL CODE, an LPN and other staff initiated CPR, used an AED, and called EMS when the resident was found pulseless, leading to extensive resuscitative efforts that directly contradicted the resident’s documented end-of-life wishes.
A hospice resident with a history of atherosclerotic heart disease and unstable angina, who was cognitively independent, requested and signed DNR paperwork, but the facility failed to complete and implement advance directive and DNR documentation at admission and did not update the EMR code status from "Full Code" after the physician signed the DNR. The DON received the signed DNR via email but did not access it, and no other staff had access to that inbox, so the resident’s record continued to show "Full Code." When the resident was later found unresponsive, an LPN verified the code status in the orders as "Full Code" and staff initiated CPR, used an AED, and EMS provided advanced resuscitative measures, contrary to the resident’s expressed DNR wishes, as also reported by the family and hospice documentation.
A resident with a history of cerebral infarction and other conditions exhibited signs of a stroke, but the LTC facility staff failed to recognize and act on the change in condition. Despite being aware of the symptoms, the staff did not transfer the resident to the emergency room until the family intervened, leading to a 27-day hospitalization. The facility's lack of communication, documentation, and adherence to protocols contributed to the deficiency.
A resident with moderate cognitive impairment and a history of falls experienced multiple falls due to inadequate supervision in an LTC facility. Despite a care plan to reduce injury risk, the resident fell several times, resulting in a head laceration and hematoma. Interviews revealed that the facility was understaffed, unable to provide the necessary 1:1 supervision, and failed to meet the resident's supervision needs, leading to repeated falls and injuries.
The facility failed to ensure proper PPE use and cleaning of shared equipment, risking infection spread. Two residents under enhanced barrier precautions were not provided appropriate care, as staff, including the DON, did not wear required PPE during care activities. Shared equipment was also found heavily soiled, indicating poor cleaning practices. Staff interviews revealed a lack of understanding and implementation of infection control measures.
A long-term care facility failed to provide sufficient staffing, resulting in falls and unmet care needs for residents. One resident, who was at risk for falls, experienced multiple unwitnessed falls due to inadequate supervision, leading to head injuries and emergency room visits. Another resident was unable to receive proper grooming and assistance with daily activities due to staffing shortages. Staff and family members reported concerns about the lack of supervision and care, highlighting the impact of insufficient staffing on resident safety and well-being.
The facility failed to maintain dignity and privacy for two residents. A resident with cerebral palsy and other conditions was not shaved daily as per her care plan, leading to concerns about her appearance. Another resident was transferred with a mechanical lift while her room door was open, compromising her privacy. These actions were contrary to the facility's policy on resident dignity.
A resident with a history of cerebral infarction and other conditions experienced a change in condition, including decreased consciousness, which was not communicated to the family by the facility staff. Despite the facility's policy requiring notification of significant changes, the family only learned of the situation upon visiting the resident, resulting in a delay in transferring the resident to the emergency room for evaluation.
A resident received wound care and compression stockings without physician orders, despite having a care plan indicating a risk for skin integrity issues. The resident had a cut on their hand and was observed receiving care without proper medical direction. The DON confirmed the absence of orders, noting the resident's spouse requested the stockings without medical necessity.
A resident with dysphagia was given the wrong meal tray, leading to choking and death. A new CNA, unsupervised and unfamiliar with residents, delivered a regular diet instead of the prescribed pureed diet. The facility was short-staffed, and the CNA lacked access to verify diet orders, contributing to the incident.
A resident with dysphagia and other conditions was mistakenly served a regular meal tray, leading to a choking incident and subsequent death. Despite attempts to resuscitate, the resident did not survive. The facility failed to report the incident to the State Agency, as advised by corporate, believing it was the hospital's responsibility.
The facility failed to maintain sanitary conditions in the kitchen, risking foodborne illness spread. Improper cooling of breakfast sausage, open raw hamburgers in the freezer, and encrusted saucepans were observed. The dish machine's wash temperature was below the required minimum, and food items lacked proper date labeling, violating food safety protocols.
The facility failed to honor resident privacy and dignity, as reported by eight residents during a Resident Council meeting. Residents felt frustrated and disrespected due to staff entering rooms without knocking and being distracted by phones during the third shift. Previous concerns about staff not introducing themselves were also noted. The Activities Director was unaware of recent issues, and the Nursing Home Administrator believed improvements had been made.
The facility failed to resolve grievances reported in Resident Council Meetings, as seven residents expressed ongoing issues with showers, cold food, and call light response times. Despite the Activities Director's awareness and communication of these concerns to department heads, the facility did not effectively address them, leading to unresolved issues over several months.
The facility failed to maintain adequate supplies of bath linens and incontinence products, leading to unsanitary conditions and frustration among residents. A resident with multiple sclerosis and another with heart failure reported frequent shortages of washcloths and preferred briefs, confirmed by staff who resorted to makeshift solutions. Observations revealed a lack of washcloths and unsanitary conditions in common areas, with management acknowledging the issue but failing to resolve it.
The facility failed to provide routine showers for several residents, leading to frustration and embarrassment. A resident with multiple sclerosis missed 7 out of 25 scheduled showers, while another missed 10 out of 24. A cognitively impaired resident was observed with poor hygiene, missing 11 out of 24 showers. A cognitively intact resident reported going 11 days without a shower. Staffing shortages were cited as a reason for missed showers, and the issue was raised in a resident council meeting.
The facility failed to provide adequate staffing, resulting in long wait times for resident assistance, missed showers, and insufficient supervision. Residents with conditions like multiple sclerosis and cognitive impairments experienced delays in daily activities due to staffing shortages. Staff confirmed the lack of sufficient CNAs and the challenges in providing timely care. Despite concerns from residents and staff, the facility had not effectively addressed the staffing issues.
The facility failed to serve food at palatable temperatures, as observed during a survey. Test trays showed food temperatures below the expected level, and residents consistently reported receiving cold meals and drinks. Despite concerns raised in Resident Council meetings, the issue persisted, affecting residents' dining experiences.
The facility failed to provide nourishing nighttime snacks to eight residents, leading to a potential 13-14 hour gap between dinner and breakfast. Residents reported limited snack options and suspected staff consumption of their snacks. Despite a policy requiring nursing staff to offer and document snacks, issues with availability and variety persisted.
A facility failed to ensure accurate advanced directive information for a resident, whose advance directive indicated no resuscitation, but the EHR listed them as full resuscitation. Staff relied on the EHR for code status, and the error was missed during care planning reviews.
A facility failed to complete a Level II PASARR evaluation for a resident with mental health diagnoses, including schizoaffective disorder and major depressive disorder. The resident's screening indicated the need for further evaluation, but the process was incomplete due to a lack of communication and access issues. The Regional Social Worker completed the screening, but it awaited the medical doctor's review, who was unaware of her responsibility and lacked login credentials.
The facility failed to develop comprehensive care plans for two residents, one with hand stiffness requiring splints and another undergoing dialysis. The first resident needed assistance with splints due to non-compliance, but this was not included in her care plan. The second resident's dialysis care plan was delayed, lacking coordination with the dialysis provider. These oversights resulted in incomplete care plans, potentially affecting the residents' care.
A resident experienced dysuria for two weeks due to a facility's mishandling of a lab specimen, which was sent to the wrong lab following a switch in lab providers. The nursing staff failed to monitor pending lab results, and the resident's reports of pain were not communicated to the provider, resulting in delayed treatment for vulvovaginitis.
A facility failed to reassess a resident's preference for using therapy-recommended hand splints, leading to potential complications. The resident, with a history of hand stiffness and cognitive intactness, needed assistance to apply the splints but reported staff did not remind her. Therapy staff had set a schedule for alternating hand use, but no sign was found in the resident's room, and there was no physician's order or care plan documentation for the splints, contributing to the deficiency.
A resident with an indwelling urinary catheter was at risk for infection due to inadequate catheter care. Despite the presence of dark, sediment-filled urine and a strong odor, the catheter had not been changed since May. Interviews revealed that staff were unaware of the catheter change schedule, and the medical director noted the increased risk of infection due to prolonged catheter use.
A facility failed to provide adequate care for a resident receiving enteral nutrition. The resident, with a history of dysphagia following a stroke, required continuous tube feeding and specific bed elevation. Observations revealed the bed was not elevated as required, and the feeding formula lacked proper labeling. Interviews confirmed these deficiencies, which contradicted the facility's Feeding Tube policy.
A facility failed to obtain physician orders for a resident's oxygen use, leading to potential risks. The resident, admitted with weakness, was observed receiving oxygen without corresponding orders or a care plan. Staff interviews confirmed the absence of a physician's order, and the MD was unaware of the oxygen use.
A resident experienced delayed treatment due to the facility's failure to ensure timely completion of a urinalysis. The urine sample was sent to the wrong lab following a switch in lab providers, leading to confusion among staff. The facility had not provided necessary training on the new lab process, resulting in a lack of tracking and monitoring of lab orders.
The facility failed to implement proper infection control practices, leading to unsanitary conditions and the potential for the spread of infection among residents. A resident with a urinary catheter did not receive care with the required PPE, another resident with psoriatic arthritis had blood-stained linens and soiled skin, and a third resident with a pressure ulcer was assisted without proper PPE. Shared equipment was also found to be heavily soiled and not sanitized between uses.
The facility failed to respect residents' private space, leading to feelings of embarrassment and potential negative psychosocial outcomes for three residents. Incidents included staff entering rooms without proper knocking and exposing residents during personal care activities.
The facility failed to accommodate resident choices and preferences for three residents, leading to issues with hygiene, care routines, and responsiveness. One resident was left in a soiled brief, another did not receive daily bed baths or clean linens, and a third had issues with urinals not being emptied by night staff.
The facility failed to prevent the misappropriation of a resident's narcotic medications when an LPN altered the narcotic count sheet and inadvertently threw away four Oxycodone tablets. The resident, who was cognitively intact and had multiple sclerosis, reported no issues with receiving pain medications. The facility conducted audits and training to ensure compliance with protocols for handling controlled substances.
The facility failed to provide palatable food for three residents, resulting in dissatisfaction with meal quality, portion size, taste, and temperature. Observations and interviews revealed issues such as repetitive menus, cold and unappetizing food, and instances of raw or frozen food being served. The Regional Registered Dietician acknowledged these problems, attributing them to staff turnover and menu planning focused on Assisted Living residents rather than those in Long Term Care.
The facility failed to maintain a clean and sanitary environment, resulting in strong odors and increased infection risk. Residents reported uncleaned floors and overflowing trash cans. Observations confirmed soiled furniture and dirty floors. Housekeeping staff admitted that cleaning was not always completed due to being short-staffed.
Failure to Honor DNR Resulting in Unwanted CPR and Life-Sustaining Measures
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact hospice resident’s clearly expressed wish to be Do Not Resuscitate (DNR), resulting in CPR and other life-sustaining interventions being performed. The resident was admitted on hospice services with diagnoses including atherosclerotic heart disease with unstable angina, lung cancer, heart failure, and a history of malignant neoplasm of the bronchus and lung. Pre-admission hospice documentation faxed to the facility and uploaded into the electronic medical record before admission indicated the resident’s care type as hospice and explicitly listed “DO NOT RESUSCITATE” in the clinical information. The resident’s hospice care plan also stated that the goal was for the resident’s end-of-life wishes to be honored. On the day of admission, the resident, who was documented as cognitively independent and responsible for her own decisions, completed the facility’s DNR form expressing that no one should attempt resuscitation if her heart and breathing stopped. Family members present at admission confirmed that the resident completed and returned the DNR paperwork to the nurse doing the admission, and that hospice had already communicated the resident’s DNR status to the facility. However, the facility later could not locate any advanced directive or DNR forms for the resident during an admission audit. The DON confirmed that consent forms, including advanced directives and DNR, were supposed to be completed on day 1, but for this resident the DNR was not found and was not in place as required. Several days after admission, when the missing DNR was discovered, the DON and an LPN again completed a DNR form with the resident, who remained her own responsible party. This DNR form was signed by the resident and two witnesses and then emailed by the DON to the medical director for physician signature. The physician signed the DNR and returned it electronically to the DON’s individual email inbox approximately seven hours before the resident experienced a code event. The DON, who was not working and was the only person with access to that inbox, did not retrieve the signed DNR, and the resident’s electronic physician orders were never updated from “FULL CODE” to DNR. As a result, when the resident was later found unresponsive on the bathroom floor without a pulse, the LPN checked the physician orders, saw “FULL CODE,” and initiated CPR, used an AED, and called EMS. EMS continued resuscitative efforts, including defibrillation, airway placement, and intraosseous access, until the resident was pronounced deceased. The facility’s own documentation and family interviews confirmed that CPR and other life-sustaining measures were performed despite the resident’s documented and repeatedly communicated wish to be DNR, and that the failure to timely complete, retain, and implement the DNR documentation led directly to the provision of unwanted resuscitative care.
Removal Plan
- Completed a blanket audit of residents to ensure the medical record accurately reflects each resident’s code status and that a signed copy of the advance directive is uploaded into PCC; no concerns or corrections noted.
- Reviewed the CPR and Advanced Directive policy by the NHA and DON and determined it remains appropriate.
- Had the Social Service Director audit all residents to ensure proper code status is in place; no changes required.
- Completed a DON audit of admissions to ensure proper code status is in place for new admissions; no discrepancies noted and no corrections made.
- Reviewed the admission policy and deemed it appropriate.
- Educated all licensed nurses on completing advanced directives paperwork on admission with the designated responsible party and notifying the physician to obtain orders and place into PCC.
- Implemented a process requiring the admitting nurse to meet with the resident/responsible party immediately upon admission to address code status wishes, complete the paperwork, and immediately communicate with the physician to obtain orders for entry into PCC.
- Implemented a process for immediate action on code status documentation: the admitting nurse faxes the document to a preprogrammed fax number that transmits to the provider email; the provider signs and returns via provider phone to facility fax; nurses also call the provider to alert them of the incoming document.
- Initiated weekly DON audits to ensure new admissions’ code status documentation is obtained/completed by the admitting nurse and that facility procedure/policy is followed, continuing until QAPI determines substantial compliance is achieved.
Failure to Implement and Honor Resident DNR Order Resulting in Full Resuscitation
Penalty
Summary
The deficiency involves the facility’s failure to obtain, process, and implement a resident’s advance directive and DNR order in a timely manner, and the subsequent failure to honor the resident’s DNR status during a cardiac arrest. The resident was admitted on hospice services with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris and was cognitively independent, able to make consistent and reasonable decisions. On admission, the facility did not complete consent forms, including advance directives and DNR paperwork, as confirmed by the DON during an admission audit conducted days later. The facility’s own policy required determination of advance directives on admission and completion of a DNR order form signed by the attending physician and resident, to be placed in the front of the medical record and scanned into the electronic record. The DON reported that after discovering the missing consents during the admission audit, she had an LPN meet with the resident to complete the consents, including the DNR form. The resident, who was her own responsible party, signed the facility DNR form in the presence of the DON and the LPN, and the form was later signed by the physician. The DON emailed the DNR form to the medical director for signature and received the signed DNR back in her individual email inbox at 3:37 PM on the day of the code event. However, the DON was not working that day, did not check her email, and no one else had access to that inbox. As a result, the signed DNR form was not retrieved, the resident’s code status in the electronic medical record was not updated from “Full Code” to “Do Not Resuscitate,” and the DNR form was not placed or scanned into the resident’s record prior to the code event. Later that evening, the resident was found unresponsive on the bathroom floor by an LPN, who checked the code status in the physician’s orders and saw it listed as “Full Code.” Based on that information, staff initiated CPR, brought the crash cart and AED, and called EMS. The facility’s Code Blue documentation and EMS records show that CPR, AED use, airway management, administration of epinephrine, IV fluids, and intraosseous access to the tibia were performed in an attempt to resuscitate the resident, and the resident was later pronounced deceased. The resident’s family member reported that the resident had completed DNR paperwork with the admission nurse on the first day of admission and that hospice had sent preadmission screening documents indicating the resident’s wish to be DNR. The family member expressed concern that the resident’s advance directives and end-of-life care were not honored and that the resident underwent a code despite her stated wishes.
Failure to Implement Treatment for Change in Condition
Penalty
Summary
The facility failed to implement appropriate treatment measures when a change in condition was identified for a resident, resulting in an Immediate Jeopardy situation. The resident, who had a history of cerebral infarction due to occlusion, epilepsy, spastic diplegic cerebral palsy, and hydrocephalus, exhibited signs and symptoms of a stroke. Despite these symptoms, the facility staff did not recognize the condition as a stroke, leading to a delay in treatment and a subsequent 27-day hospitalization for the resident. On the day of the incident, the resident was noted to have a decreased level of consciousness, was unresponsive, and unable to swallow medications. The nursing staff, including an RN and an ADON, were aware of the change in condition but did not take appropriate action to transfer the resident to the emergency room immediately. The RN did not complete the necessary documentation or notify the family, and the ADON did not document any assessment of the resident's condition. The resident was only sent to the emergency room the following day after the family insisted on it. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's change in condition. The DON and MD were aware of the situation but did not provide specific instructions for monitoring or treatment. The facility's policy on notification of changes was not followed, as the family was not informed of the resident's condition until they visited the facility. The lack of timely intervention and failure to follow established protocols contributed to the resident's prolonged hospitalization and diagnosis of a cerebral infarction.
Removal Plan
- The facility identified that the resident had a change in condition. The resident was transferred to the emergency room for evaluation.
- The facility identified treatment was not implemented for a change in condition for Resident #100.
- The Director of Nursing and/or designee began education of the facility staff on signs and symptoms of a stroke, to include specifically decreased oral intake, unresponsiveness, inability to take medications and decreased level of consciousness. How to seek medical direction and treatment for urgent levels of care. Notification of family of change in condition. Physician/provider notification of change in condition. Documentation of notifications and assessments. How to identify acute changes in condition. No staff will not be permitted to work prior to receiving the education.
- The DON and/or designee completed a chart audit of all residents to determine if any other residents had sustained an acute change of condition. No others were found.
- The QAPI committee had reviewed the change in condition policy and deemed it appropriate.
- The facility had an Ad Hoc QAPI Meeting, including the Medical Director, and deemed this removal plan appropriate.
Inadequate Supervision Leads to Repeated Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for Resident #102, who was moderately cognitively impaired and had a history of falls. The resident required moderate assistance for transfers and ambulation and had a care plan in place to reduce the risk of injury. Despite this, the resident experienced multiple falls, including one that resulted in a head laceration requiring stitches and a hematoma. The care plan interventions included educating the resident on safety, encouraging the use of a call light, and keeping needed items within reach. However, these measures were insufficient to prevent the resident from attempting to stand and transfer independently, leading to repeated falls. Interviews with staff and family members revealed that the facility was understaffed and unable to provide the level of supervision needed for Resident #102. The resident was known to be impulsive and required constant reminders and monitoring, yet the facility did not have enough staff to provide 1:1 supervision consistently. Staff members reported that the resident often attempted to stand up and fell when left unsupervised, and the facility's staffing levels were inadequate to meet the resident's needs. The Director of Nursing acknowledged the need for frequent checks and supervision but admitted that the facility struggled to provide the necessary level of care. The facility's fall prevention policy stated that each resident should receive care and services according to their level of risk to minimize falls. However, the nursing schedules reviewed for the days when Resident #102 fell showed that the facility was operating with less staff than required for the resident's unit. This lack of adequate staffing and supervision directly contributed to the resident's repeated falls and injuries, highlighting a deficiency in the facility's ability to ensure a safe environment for residents at risk of falls.
Inadequate PPE Use and Equipment Cleaning in LTC Facility
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and proper cleaning of shared equipment, leading to potential infection risks. Resident #100, who had diagnoses including cerebral infarction and epilepsy, was supposed to be under enhanced barrier precautions due to a feeding tube. However, staff, including the Director of Nursing (DON) and Certified Nurse Assistants (CNAs), were observed not wearing gowns as required when providing care or repositioning the resident. Additionally, there was no PPE available in the shower room for Resident #100, and staff were not consistently aware of the need for enhanced precautions. Resident #103, diagnosed with cerebral palsy and muscle contractures, was also under enhanced barrier precautions. Despite this, the DON and a CNA were observed transferring the resident without wearing the required PPE. The CNA admitted to not being fully educated on the precautions, and the DON initially stated PPE was not needed for transfers but later acknowledged it was required. Furthermore, shared equipment like the hoyer lift was not cleaned after use, and other equipment in the facility was found to be heavily soiled, indicating a lack of proper cleaning protocols. Interviews with staff revealed a lack of consistent understanding and implementation of infection control measures. The Staff Development/Infection Control (SD/IC) personnel, who was still in training, confirmed the absence of PPE in certain areas and the need for staff education. The facility provided a certificate for the DON's completion of an infection preventionist training course, but the report highlights ongoing issues with adherence to infection control protocols.
Inadequate Staffing Leads to Falls and Unmet Care Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to provide adequate care for residents, resulting in multiple incidents of falls and unmet care needs. Resident #102, who was moderately cognitively impaired and at risk for falls, experienced several unwitnessed falls due to inadequate supervision. Despite the care plan indicating the need for constant reminders and monitoring, the facility was understaffed, with only two nurses and three CNAs for 54 residents, which was below the necessary staffing levels. This lack of supervision led to Resident #102 suffering head injuries and requiring emergency room visits. Interviews with staff and family members highlighted the inadequate staffing levels and their impact on resident care. Staff reported being unable to provide the necessary supervision for Resident #102, who was impulsive and prone to falls. Family members expressed concerns about the resident's safety and the increased frequency of falls compared to when the resident was at home. The Director of Nursing acknowledged the staffing shortages and the challenges in providing the required level of supervision for Resident #102. Resident #100 also experienced inadequate care due to staffing shortages. The resident, who required assistance with activities of daily living, was not able to get out of bed and into a wheelchair on days when staffing was short. The care plan indicated the need for daily grooming, but the resident was observed with significant facial hair and was not out of bed during the survey period. Staff interviews confirmed that showers and other care tasks were delayed or not completed due to insufficient staffing, leading to longer wait times for assistance and unmet care needs.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to preserve resident dignity during care for two residents. Resident #100, who had diagnoses including cerebral infarction, epilepsy, spastic diplegic cerebral palsy, and hydrocephalus, was observed with significant facial hair despite a care plan intervention stating she preferred to be shaved daily. Observations and interviews revealed that shaving was only performed on shower days, which was confirmed by the Director of Nursing and Certified Nurse Assistants. A family member expressed concern that Resident #100 would be embarrassed by her unshaven appearance, and often had to shave her himself. Resident #103, diagnosed with cerebral palsy and muscle contractures, was transferred via a mechanical lift with her room door open, allowing anyone in the hallway to observe the process. The Certified Nurse Assistant involved acknowledged that the door and curtain should have been closed to maintain privacy. The facility's policy on promoting and maintaining resident dignity, which includes grooming residents according to their preferences and maintaining privacy, was not adhered to in these instances.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's responsible party regarding a change in condition, which resulted in a delay in transferring the resident to the emergency room for evaluation and treatment. The resident, who had a history of cerebral infarction, epilepsy, spastic diplegic cerebral palsy, and hydrocephalus, was observed by a registered nurse to have a decreased level of consciousness and was not responding to stimuli as usual. Despite these observations, the resident's family was not informed of the change in condition, which is a requirement according to the facility's policy. Multiple staff members, including registered nurses, the assistant director of nursing, and the medical doctor, confirmed that they did not contact the family when the change in condition was noted. The family only became aware of the situation when they visited the resident and noticed the change themselves. The facility's policy mandates that the family should be notified of significant changes in a resident's condition, but this was not adhered to, leading to a delay in the resident receiving necessary medical attention.
Lack of Physician Orders for Wound Care and Compression Stockings
Penalty
Summary
The facility failed to ensure that wound care and compression stocking physician orders were in place for a resident, leading to care being provided without the direction of a physician. The resident, who was admitted with diagnoses including varicose veins, chronic kidney disease, right bundle branch block, and Waldenstrom macroglobulinemia, did not have any skin issues noted in a recent assessment. However, a care plan indicated a risk for impaired skin integrity, and interventions included administering medications as ordered and notifying a physician of any new skin impairments. Despite this, there were no physician orders for wound care or compression stockings for the resident. A nurse's note documented an incident where the resident cut their hand on a gait belt, but there was no record of physician notification. Observations revealed that a CNA applied compression stockings, and the DON performed a dressing change on the resident's hand without physician orders. Interviews with the DON and an RN confirmed the absence of necessary physician orders, with the DON noting that the resident's spouse requested the compression stockings, although there was no swelling to justify their use.
Resident Chokes Due to Incorrect Meal Tray and Lack of Supervision
Penalty
Summary
The facility failed to ensure that a resident received the correct food tray and necessary assistance during mealtime, leading to a tragic incident. A resident with a history of dysphagia, paralysis, and cognitive communication deficits was mistakenly given a regular diet tray instead of their prescribed pureed diet with honey-thick liquids. This error occurred because a new Certified Nursing Assistant (CNA) in orientation, who was unfamiliar with the residents, delivered the wrong tray without proper supervision or verification. The resident, who required one-person assistance during meals due to their condition, began choking on a piece of cauliflower from the incorrect tray. Despite immediate attempts by the Registered Nurse (RN) to perform the Heimlich maneuver and subsequent CPR, the resident was unable to be resuscitated and later died at the hospital. The incident was exacerbated by the fact that the facility was short-staffed, with only two nurses on shift, and the CNA responsible for the error did not have access to the charting system to verify the resident's diet. Interviews with staff and family members revealed that the wrong trays were frequently given to residents, indicating a systemic issue with meal service procedures. The CNA involved in the incident admitted to not verifying the meal tray due to being directed to assist another resident, highlighting a lack of proper training and oversight during the orientation process. The facility's failure to ensure accurate meal service and adequate supervision directly contributed to the resident's choking and subsequent death.
Removal Plan
- The facility identified that a resident was given a regular diet instead of his ordered puree honey thick liquid diet. The resident began choking and ultimately requiring CPR. The facility identified that the CENA in orientation did not have her preceptor with her and did not know how to identify residents.
- The Director of Nursing and/or designee began education of facility staff on providing accurate diet, not providing care without preceptor/Nurse in attendance until relieved from Orientation, and that preceptors will not leave or allow new employees to provide care until they are deemed competent to provide care without preceptor. Staff were also educated on utilizing the kiosk when needing to identify residents.
- NHA and DON were educated on orientation process and preceptor expectations as well as the policy for orientation.
- The facility implemented resident diet info binders to include diet terminology conversion, pictures of diets and allowable foods for texture, resident pictures who have altered diets.
- The facility implemented re-education upon identification that staff were unable to verbalize use of resident diet info binders.
- The facility has 15 Licensed Nurses and 27 C.E.N.A.'s. The facility had educated 6 of the 15 Licensed Nurses and 14 of the 27 C.E.N.A/s.
- Any staff not educated at the time would not be permitted to work a shift until education had been completed.
- The facility Medical Director was notified.
- The Director of Nursing and/or designee completed an audit on all residents with an altered diets to ensure orders are entered correctly and match the binders. This audit for accuracy was completed and no concerns noted.
- The QAPI committee has reviewed the Orientation policy, therapeutic diet orders and ADLs and has deemed them appropriate.
- The facility had an Ad hoc QAPI meeting including the Medical Director (via phone) and deemed this removal plan appropriate.
- The Administrator and Director of Nursing are responsible for continued compliance.
Failure to Report Resident Choking Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who choked and subsequently died after receiving the wrong meal tray. The resident, who had a history of paralysis, aphasia, cognitive communication deficit, dysphagia, and other conditions, was on a National Dysphagia Diet Level 1 diet with pureed texture and honey-thick liquids. Despite these dietary restrictions, a new Certified Nursing Assistant (CENA) in orientation mistakenly served the resident a regular meal tray, which led to the choking incident. During the incident, the resident was sitting in the dining room when they began choking after being served the incorrect meal. A Registered Nurse (RN) attempted the Heimlich maneuver multiple times without success, and the resident turned blue and showed no air exchange. The resident was then placed on the floor, and CPR was initiated. Emergency Medical Services (EMS) arrived, continued resuscitation efforts, and transported the resident to a local hospital, but the resident did not regain a spontaneous pulse. The incident was not reported to the State Agency as required by facility policy. The facility's administrator stated that they were advised by corporate not to report the incident, believing it was the hospital's responsibility to do so. As a result, the incident went unreported, which is a violation of the facility's policy and procedure for reporting suspected neglect or abuse to the appropriate authorities.
Sanitary Conditions and Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, a container of breakfast sausage was found in the walk-in cooler, tightly covered with saran wrap and warm to the touch, with a temperature of 109°F. It was revealed that the sausage links had been pulled from the breakfast line about an hour prior and placed in the cooler. The cooling temperature log showed previous instances where cooling for sausage was logged above 70°F after two hours, indicating improper cooling practices. Further observations during the tour revealed additional sanitary issues. A box of raw hamburgers was found open and exposed in the walk-in freezer, violating food protection standards. Several saucepans were heavily encrusted with black carbon accumulation, and the dish machine area had a loose drain leaking water on the floor. The dish machine's wash temperature was consistently logged below the required minimum of 160°F, as per the machine's data plate, indicating non-compliance with mechanical warewashing equipment standards. Additional deficiencies were noted in the storage and labeling of food items. Open containers of thickened juices and nutritional shakes were found without proper date labeling, exceeding the recommended time for safe consumption. These observations highlight a lack of adherence to food safety protocols, including proper cooling, storage, and equipment maintenance, which are essential to prevent cross-contamination and ensure the safety of food served to residents.
Resident Privacy and Dignity Concerns
Penalty
Summary
The facility failed to ensure resident dignity and rights to privacy were honored, as reported by eight of nine residents during a confidential Resident Council meeting. Residents expressed feelings of frustration and disrespect due to ongoing privacy issues. One resident reported that a sign on her door, intended to ensure staff knocked before entering, was removed and not replaced. Another resident mentioned that staff entered his room without knocking. Additionally, five residents noted that during the third shift, staff were often distracted by their phones or tablets, wearing earbuds, and sometimes engaged in phone conversations while in resident rooms. The Resident Council minutes from a previous meeting indicated that residents had previously raised concerns about staff entering rooms without introducing themselves or greeting the residents. During interviews, the Activities Director was unaware of recent privacy concerns, believing previous issues had been resolved. The Nursing Home Administrator also believed there had been improvements in privacy concerns based on completed audits.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve concerns and grievances reported during Resident Council Meetings, as evidenced by interviews and record reviews. Seven out of nine residents expressed that their concerns were not being resolved, despite being brought up in meetings and to various staff members. Specific issues included long wait times for showers, cold food, and extended call light response times. Residents reported having to repeatedly ask for assistance, with some waiting weeks for showers or experiencing cold meals frequently. The Resident Council minutes from January to June 2024 documented ongoing complaints about these issues, indicating a lack of resolution over several months. The Activities Director (AD) acknowledged awareness of these concerns and stated that they were communicated to the appropriate department heads. However, the AD did not fill out grievances from Resident Council meetings unless they pertained to missing laundry items. The facility's policy requires the use of a Resident Council Minutes and Quality Assistance Form to track issues and their resolution, with the Administrator responsible for ensuring all group concerns are investigated and responses provided. Despite this policy, the facility did not effectively address or resolve the residents' grievances, leading to unmet needs and dissatisfaction among the residents.
Facility Fails to Maintain Adequate Linen Supplies and Sanitary Conditions
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment by not maintaining adequate supplies of bath linens and incontinence products, leading to unsanitary conditions and frustration among residents. Resident #13, who has multiple sclerosis and requires assistance with personal care, reported that the facility frequently ran out of washcloths and the preferred type of incontinence briefs. Staff interviews confirmed these shortages, with reports of staff resorting to cutting towels to make washcloths and taping smaller briefs together to accommodate residents' needs. Observations revealed a lack of washcloths in the clean utility room, and staff confirmed that the facility often ran out of necessary supplies. Resident #18, who is cognitively intact and has heart failure, also reported frequent shortages of washcloths and other supplies, which had been communicated to management without resolution. During a confidential resident council meeting, several residents expressed concerns about the lack of towels, washcloths, and linens, indicating that these issues had been ongoing and previously reported to staff. The facility's decision to stop using disposable wipes and increase the use of washcloths further exacerbated the shortage, as the ordered washcloths had not yet arrived. Additionally, the facility failed to maintain sanitary conditions in common areas, as evidenced by the thick buildup of dust and debris on artificial trees in the resident common area. Despite housekeeping efforts, the dust remained, contributing to an unsanitary environment. The laundry area also showed signs of neglect, with trash and debris accumulating under equipment, and a lack of clean washcloths in stock. Interviews with laundry staff and management revealed that the facility lacked a par count system to ensure adequate linen supplies, further contributing to the deficiency.
Failure to Provide Routine Showers
Penalty
Summary
The facility failed to provide routine showers for several residents, leading to feelings of frustration, disappointment, and embarrassment among the affected individuals. Resident #11, who has multiple sclerosis and is dependent on a wheelchair, reported not receiving showers twice a week as scheduled, missing 7 out of 25 opportunities. This resident expressed frustration about the lack of support in meeting her hygiene needs. Similarly, Resident #13, also with multiple sclerosis and requiring full assistance for showers, missed 10 out of 24 scheduled opportunities, leading to feelings of self-consciousness and a negative impact on her outlook and energy levels. Resident #22, with moderate cognitive impairment and a history of stroke, was observed with greasy hair and a strong smell of urine, indicating a lack of personal hygiene care. This resident missed 11 out of 24 scheduled shower opportunities and expressed concern about her appearance and odor. Resident #35, who is cognitively intact, reported missing showers frequently, including a period of 11 days without one. Despite raising concerns with facility management, the issue persisted, and the facility was unable to provide shower records for this resident. The deficiency was further highlighted during a confidential resident council meeting, where seven out of nine residents reported not receiving showers as scheduled. The facility's Director of Nursing acknowledged the issue, attributing it to staffing shortages, and the Nursing Home Administrator believed there had been improvements based on audits, although the problem remained unresolved. The facility's failure to provide necessary services to maintain personal hygiene was a clear violation of their policy and resulted in significant dissatisfaction among residents.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in long call light wait times, missed showers, and insufficient supervision. Several residents, including those with multiple sclerosis, anxiety disorders, and cognitive impairments, reported delays in receiving assistance for daily activities such as getting out of bed, dressing, and showering. These delays were attributed to the lack of sufficient staff, with reports indicating that often only one CNA was available per unit, making it difficult to provide necessary care, especially for residents requiring two-person assistance. Interviews with staff, including CNAs and RNs, confirmed the staffing shortages and the challenges they faced in providing timely care. Staff reported that open shifts frequently went unfilled, and management did not use contractual staff to cover these gaps. The facility's staffing levels were based on resident census rather than acuity, and there was no provision for additional staff based on the specific needs of residents. This led to situations where residents had to wait extended periods for assistance, affecting their personal hygiene and overall quality of life. The deficiency was further highlighted during a confidential resident council meeting, where residents expressed their dissatisfaction with the long wait times for assistance and the impact on their daily routines. The facility's nursing home administrator acknowledged the staffing issues but attributed them to the need for better teamwork among existing staff rather than an increase in staffing levels. Despite concerns raised by both residents and staff, the facility had not implemented measures to address the staffing shortages effectively.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable temperature to residents, as observed during a survey. During a lunch service tour, it was noted that hot food on the steam table should be around 165F to remain hot for residents. However, a test tray of the regular meal showed that the pasta/meat was at 122F and the peas were at 121F, indicating that the food was not served at the appropriate temperature. Similarly, during a breakfast service, the scrambled eggs were at 124F, sausage links at 103F, and oatmeal at 125F, all below the expected temperature. Residents consistently reported that their food and drinks, such as coffee, were cold, whether served in their rooms or the main dining room. Resident #15, who is cognitively intact, and Resident #27, who is moderately impaired, both reported that their food was almost always cold. The issue of cold food had been raised multiple times in Resident Council meetings, with records showing that residents had been experiencing this problem for several months. Despite these concerns being communicated to the appropriate department head, the problem persisted. The Regional Dietitian acknowledged that trays might sit if residents are not present when delivered, suggesting that another tray should be requested or delivery should be timed better.
Failure to Provide Nourishing Nighttime Snacks
Penalty
Summary
The facility failed to consistently provide a nourishing nighttime snack to eight of nine residents who attended a confidential Resident Council meeting. These residents reported not receiving snacks at bedtime, and when they did request them, they were often given only one choice. One resident noted the lack of healthy options, mentioning that the snacks were salty and not diabetic-friendly. Another resident expressed suspicion that staff might be consuming the snacks meant for residents. The review of the facility's mealtime schedule showed a potential gap of 13-14 hours between dinner and breakfast, which could lead to decreased oral intake and potential weight loss. The facility's policy on offering bedtime snacks requires nursing staff to offer snacks in accordance with residents' needs, preferences, and requests, and to document the intake in the medical record. However, during interviews, it was revealed that while the dietary staff stocked the nourishment room with a variety of snacks, the nursing staff was responsible for distributing them. Despite this, residents reported issues with the availability and variety of snacks, and there were allegations of staff consuming the snacks. The Resident Council minutes also documented a resident's observation of CNAs taking snacks for themselves, which was not addressed by the facility.
Inaccurate Advanced Directive Information
Penalty
Summary
The facility failed to ensure accurate advanced directive information was in place for a resident, resulting in the potential for the resident's preferences for medical care to not be followed. The resident was admitted with a diagnosis of adult failure to thrive and had an advance directive signed by their guardian indicating a preference for no resuscitation in the event of cardiac or respiratory arrest. However, the electronic health record (EHR) listed the resident as full resuscitation, which was inconsistent with the advance directive. Interviews with facility staff revealed that they relied on the EHR to determine a resident's code status in emergencies. A Certified Nursing Assistant and a Registered Nurse both confirmed this practice. The daily report sheet for the resident did not indicate the code status, and the Social Worker acknowledged that the facility had missed the error in the EHR. The facility's policy stated that advance directives should be reviewed during quarterly care planning sessions or with significant changes in condition, but the Social Worker could not confirm the date of the resident's most recent care conference.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident, resulting in the potential for unmet mental health and psychiatric care needs. The resident was admitted with diagnoses including schizoaffective disorder, major depressive disorder, anxiety disorder, and suicidal ideations. The resident's Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening indicated the presence of mental illness, treatment for mental illness, recent use of antipsychotic or antidepressant medications, and evidence of mental illness or dementia. Despite these indicators, the resident's Electronic Health Record did not contain a Level II PASARR screening. The Regional Social Worker (RSW) responsible for completing PASARR screenings reported that she had completed the Level II screening and noted the resident as dementia exempt. However, the screening was still awaiting review and signature from the facility's medical doctor. The RSW stated she was not responsible for ensuring the completion of the PASARR process and was unaware that the screening was pending review. The Medical Doctor (MD) reported not reviewing the Level II screening because she was not informed of her responsibility to review PASARR screenings and did not have the necessary login credentials to access the forms.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, resulting in an incomplete reflection of their status and potential unmet care needs. Resident #12, a cognitively intact female with stiffness in her wrists and hands, reported that she had splints for her hands to wear at night but often forgot to do so without staff reminders. Therapy staff confirmed that Resident #12 required assistance to apply the splints and had a history of non-compliance with therapy recommendations. Despite these needs, the care plan for Resident #12 lacked any focus, goals, or interventions related to her non-compliance with therapy recommendations or the use of hand splints. Resident #27, who was cognitively impaired and had diagnoses including End Stage Renal Disease, Type 2 diabetes, and depression, attended dialysis three times a week. However, the facility did not have a nursing care plan in place for his dialysis status upon admission. Although the Registered Dietitian had put a nutrition care plan related to dialysis, the nursing dialysis care plan was not completed until later, under impaired genitourinary status. The facility's policy required the care plan to reflect coordination between the facility and the dialysis provider, including specific interventions, but this was not initially done. The lack of comprehensive care plans for both residents indicates a failure to adequately address their specific medical needs and conditions. This deficiency was identified through interviews and record reviews, highlighting the facility's oversight in ensuring that care plans were updated and reflective of the residents' current health status and treatment requirements.
Delay in Lab Processing Leads to Prolonged Resident Discomfort
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident who experienced dysuria for approximately two weeks. The resident, who was cognitively intact, reported pain with urination and increased frequency, prompting an order for a urinalysis with reflex to culture and sensitivity. However, the urine specimen collected on the initial date was sent to the wrong lab due to a recent switch in lab providers, and the nurses were unclear on the new process. This mishandling resulted in a significant delay in obtaining the necessary lab results and subsequent treatment. Interviews revealed that the nursing staff did not monitor the pending lab results, and the resident's continued reports of pain were not communicated to the provider in a timely manner. The Director of Nursing acknowledged the lack of training on the new lab process and the absence of documented assessments of the resident's symptoms in the electronic health record. The delay in obtaining a second urine sample and the lack of provider assessment contributed to the resident's prolonged discomfort and delayed treatment for vulvovaginitis.
Failure to Reassess Resident's Use of Therapy-Recommended Device
Penalty
Summary
The facility failed to reassess a resident's preference for using a therapy-recommended positioning device, specifically hand splints, which resulted in the potential for decreased range of motion and related complications. The resident, who was cognitively intact, had a history of stiffness in her wrists and hands, and an amputation of a right toe. She reported needing assistance to apply the splints and that staff did not remind her to wear them, leading to her belief that her hand condition was worsening. Observations and interviews revealed that the resident had a schedule to wear the splints on alternating hands each night, but staff did not consistently assist her in following this schedule. Therapy staff had posted a sign in the resident's room to alert staff of the need to apply the splints, but during an observation, no such sign was found. The therapy staff also reported that the resident had a known history of non-compliance with therapy recommendations, but there was no physician's order in place for the splints, nor was there documentation of the resident's refusal to wear them. The Senior Director of Nursing indicated that a physician's order was necessary for therapy recommendations and that these should be included in the care plan. However, a review of the resident's care plan showed no focus, goals, or interventions related to the resident's non-compliance with therapy recommendations or the use of hand splints. This lack of documentation and follow-through on therapy recommendations contributed to the deficiency identified by the surveyors.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate supra-pubic catheter care for a resident, leading to the potential for urinary tract infection and complications related to catheter tubing occlusion. The resident, who was admitted with diagnoses including tubulo-interstitial nephritis, obstructive uropathy, and unspecified hydronephrosis, had an indwelling urinary catheter as per their care plan. The care plan included interventions such as observing for signs of urinary tract infection and changing the catheter as clinically indicated. However, the resident's catheter had not been changed since May, despite observations of dark, orange-tinged urine with cloudy sediment and a strong smell of urine in July. During interviews, a registered nurse acknowledged that catheters should be changed when sediment is present but was unaware of the last catheter change for the resident or the facility's process for tracking catheter replacement frequency. The medical director also noted that the catheter had been in place too long, increasing the risk of infection. The facility's catheter care policy aimed to reduce infections, but the lack of adherence to this policy resulted in the deficiency.
Inadequate Care for Resident with Enteral Nutrition
Penalty
Summary
The facility failed to provide adequate care for a resident receiving enteral nutrition, specifically for Resident #21, who was admitted with diagnoses including adult failure to thrive and dysphagia following a stroke. The resident had orders for continuous tube feeding with Jevity at 50 ml/hr and required the head of the bed to be elevated between 30-45 degrees. However, during observations on two separate occasions, it was noted that the resident's bed was not elevated as required, and the Jevity bottle lacked essential labeling information such as the open date, start date and time, and the initials of the nursing staff member who initiated the tube feeding. Interviews with the RN and the Director of Nursing (DON) confirmed these deficiencies. The RN acknowledged the incorrect bed positioning and the missing labeling on the Jevity bottle. The DON stated that nurses were expected to ensure proper bed elevation during tube feeding and to label the feeding formula with the date and time it was started. The facility's Feeding Tube policy, last revised in June 2022, mandates that feeding tubes be maintained according to current clinical standards and physician orders, which were not adhered to in this case.
Failure to Obtain Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to obtain physician orders for the use of oxygen for a resident, resulting in the potential for improper use, inaccurate settings, irregular cleaning, and respiratory infection. The resident was admitted with a diagnosis of weakness, but there were no orders for oxygen administration in their records. Observations revealed the resident receiving oxygen via nasal cannula at varying flow rates, without a corresponding care plan focus area related to oxygen use. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed the absence of a physician's order for the oxygen. The medical doctor was unaware of the resident's oxygen use and had not approved any orders for it.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely completion of physician-ordered laboratory services for a resident, resulting in delayed treatment and increased discomfort. The resident had a urinalysis ordered on 7/12/24 due to experiencing pain with urination, but the facility did not receive the results. It was discovered on 7/19/24 that the results were never obtained, prompting a request for another urine sample. Interviews revealed that the urine sample was sent to the wrong lab due to a recent switch in lab providers, and there was confusion among the nursing staff regarding the new lab ordering process. The Director of Nursing confirmed that the facility had not yet provided education and training to all nursing staff responsible for lab orders. The facility's policy required tracking and monitoring of lab tests, but the Director of Nursing could not confirm if the resident's lab order was followed up on. The Medical Doctor and Registered Nurse both acknowledged the delay in treatment and care due to the miscommunication and lack of tracking of the lab order, which was not completed as required by the facility's guidelines.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices, leading to unsanitary conditions and the potential for the spread of infection among residents. Resident #103, who required enhanced barrier precautions (EBP) due to a urinary catheter, was found in a room with a strong smell of dried urine and visibly soiled surfaces. Certified Nurse Aide (CNA) U performed catheter care without donning the required personal protective equipment (PPE) and admitted to not receiving formal training on EBP guidelines. Additionally, the transmission-based precautions (TBP) cart in Resident #103's room was not noticed by the CNA until pointed out by the surveyor. Resident #104, diagnosed with psoriatic arthritis, was observed with blood-stained linens and visibly soiled skin. The resident's care plan required daily linen changes due to her skin condition, but this was not adhered to. Registered Nurse (RN) P confirmed that Resident #104's linens should be changed daily and admitted to not being informed or educated on EBP for residents with open skin areas. The resident's bedside table was also found to be visibly soiled, and the resident reported that staff did not change her bedding frequently. Resident #107, who had a pressure ulcer and required EBP, was assisted by CNA F without the use of proper PPE. The CNA admitted to knowing the requirements but failed to follow them. Additionally, shared equipment such as mechanical lifts and electric wheelchairs were found to be heavily soiled and not sanitized between uses. Staff reported that cleansing wipes were not always available, leading to inconsistent cleaning practices. The facility's infection prevention and control program policy was not effectively implemented, resulting in unsanitary conditions and the potential for cross-contamination and disease transmission.
Failure to Respect Resident Privacy
Penalty
Summary
The facility failed to respect residents' private space, resulting in feelings of embarrassment and potential negative psychosocial outcomes for three residents. Resident #103, who was mildly cognitively impaired, experienced an incident where a staff member entered the room without proper knocking while catheter care was being performed, exposing the resident's private parts. Resident #103 reported that staff rarely knock and often just walk in, and also mentioned that call lights are not answered promptly. The staff member involved admitted to not following the procedure for resident privacy. Resident #107, who was cognitively intact, was being assisted with toileting when another staff member knocked once and entered the room without waiting for a response, leaving the bathroom door open and exposing the resident. The staff member assisting Resident #107 acknowledged that they should have communicated to prevent the interruption. Resident #111, also cognitively intact, reported that staff rarely knock and often enter without respecting privacy. The facility's policy on resident rights did not include specific information on resident privacy rights.
Failure to Accommodate Resident Choices and Preferences
Penalty
Summary
The facility failed to accommodate a resident's right to make choices consistent with their plan of care for three residents. Resident #107, who was cognitively intact and dependent on assistance for toileting hygiene, reported sitting in a heavily soiled brief since the previous night. Despite asking multiple staff members for help, she did not receive assistance until a surveyor intervened. The CNA who eventually assisted her failed to ensure proper hygiene and did not check the resident's wound dressing as requested by a nurse. Resident #104, who was mildly cognitively impaired and had chronic respiratory failure, reported not receiving any care on the day of the observation. She expressed a preference for daily bed baths, which were not being provided. Her linens, which were stained with blood due to her psoriasis, were not changed regularly, despite the nurse acknowledging that they should be. Resident #111, who was cognitively intact and had a history of stroke, reported that night staff were supposed to check on him and empty his urinals but often failed to do so. This led to his urinals being too full to use by morning, causing potential spills. The facility's Quality Assistance Forms and Resident Council Minutes revealed ongoing issues with staff responsiveness, cleanliness, and food quality, indicating a broader pattern of neglecting resident preferences and needs.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's narcotic medications, specifically Oxycodone IR 15 mg, for one resident. The incident was identified when a Licensed Practical Nurse (LPN) noticed that the narcotic count sheet had been altered, showing a change from 19 to 14 tablets with two nurses' signatures indicating that four tablets were wasted. The LPN admitted to removing the pills from a torn blister pack and placing them in a medication cup to destroy later but inadvertently threw them away. The facility could not substantiate that the LPN took the medications, but her employment was terminated for failing to follow the narcotic destruction policy and falsifying a signature. The facility requested replacement pills from the pharmacy and billed them to the facility. Despite the incident, residents, including the affected resident, reported receiving their medications without issues, and a review of all narcotics in the center revealed accurate counts and no other discrepancies. The affected resident, who was cognitively intact and diagnosed with multiple sclerosis, had a physician's order for Oxycodone HCl 15 mg to be taken four times a day for chronic pain. During the investigation, it was found that the narcotic count sheet for the resident's Oxycodone had been altered with white-out, which is against the protocol for controlled substances. The Director of Clinical Services (DCS) and other staff conducted a thorough audit of all medication carts and narcotic medications, finding no other concerns. The facility also implemented training and audits with all nurses to ensure compliance with protocols for handling controlled substances. Interviews with various staff members, including the DCS, Registered Nurse (RN), and other LPNs, confirmed that multiple training sessions and audits were conducted to reinforce the proper procedures for handling and documenting controlled substances. The facility also ensured that two nurses were always present when counting and destroying controlled substances, and that no white-out was used on any documentation. The facility reported the incident to the State Agency and conducted an internal investigation, which included ongoing audits and education to prevent future occurrences.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to provide palatable food for three residents, resulting in dissatisfaction with the quality, portion size, taste, and temperature of their meals. Observations revealed that many meal trays had 50%-75% of the food uneaten. Certified Nurse Aides reported frequent complaints from residents about the food being repetitive, cold, and unappetizing. Residents also reported issues such as food being served still frozen, lack of variety in the alternative menu, and insufficient water service. One resident mentioned that the facility had run out of milk for a day, and another reported receiving raw chicken. The Regional Registered Dietician acknowledged the issues, attributing them to staff turnover and the kitchen's focus on menus suitable for Assisted Living residents rather than those in Long Term Care. Resident #102, who is cognitively intact, reported that the facility often lacks menu items and that her water is not refreshed as required. She also mentioned receiving food that was still frozen inside. Resident #104, who is mildly cognitively impaired, echoed similar complaints about the food being cold, bland, and repetitive. Resident #111, also cognitively intact, described the food as disgusting, citing instances of raw chicken and small portion sizes. Observations and interviews with staff confirmed these issues, with one CNA noting that the alternative menu options are rarely available to Long Term Care residents. The Regional Registered Dietician confirmed that a significant amount of food is returned uneaten, highlighting the severity of the problem.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment by not properly cleaning resident rooms, common areas, and commonly touched items. This resulted in strong odors and an increased potential for infection. Resident Council Minutes from January to March revealed multiple complaints about dirty dining tables, uncleaned floors under beds, and overflowing trash cans. Observations confirmed these issues, with multiple cloth chairs in the TV area visibly soiled and emitting a strong smell of dried urine. Resident #102, who was cognitively intact, reported that her room was not cleaned daily, especially under her bed, and that stale urine odors were present due to improper cleaning of urine spills. Resident #104, who was mildly cognitively impaired, had a bedroom floor that was visibly soiled with food crumbs, dust, debris, and random wrappers. The floor was sticky, and a heavy accumulation of dust and debris was found under the bed. Housekeeping staff admitted that due to being short-staffed, sweeping and mopping were not always completed for every resident. The facility's policy required routine cleaning of environmental surfaces and non-critical resident care items, but this was not adhered to.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 332 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation At Leonard | 0.4 mi | ★★★★★ | 14 | 0 |
| Corewell Health Grand Rapids Hospitals Rehabilitat | 1 mi | ★★★★★ | 10 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 1 mi | ★★★★★ | 0 | 0 |
| Mary Free Bed Sub-acute Rehabilitation | 2.5 mi | ★★★★★ | 2 | 0 |
| Clark Retirement Community | 2.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.