Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Howell during CMS and state inspections, most recent first.
A resident with common variable immunodeficiencies and Crohn’s disease had a standing weekly order for Hizentra, an immune globulin therapy, but the MAR over several months showed repeated entries of the drug as not available or not given, with only sporadic administrations. The resident, who was cognitively intact, reported not receiving the medication for months despite expecting weekly doses. The DON stated the drug was supplied by a specialty pharmacy, and a pharmacy employee confirmed that the last monthly shipment was delivered in early September and that no further contact from the facility occurred afterward. This pattern shows the facility did not ensure the physician-ordered Hizentra was consistently obtained and administered in accordance with its own medication administration policy.
Two residents experienced medication administration failures when staff did not follow professional standards for reconciling and giving ordered drugs. A resident with immune deficiency and Crohn’s disease had a weekly Hizentra order, but the MAR showed repeated "not available" entries and sporadic documented administrations despite the specialty pharmacy confirming no shipments after an earlier month and the facility keeping no delivery records, leaving the accuracy of MAR entries in question. Another resident with cardiac and kidney disease returning from a hospital stay for severe sepsis and cellulitis had an order for Amoxicillin TID, but an LPN entered the order with an incorrect future start date, and subsequent nursing reconciliations did not detect the error, resulting in several days without the antibiotic until an NP and RN identified and corrected the omission.
Failure to implement fall interventions for multiple residents led to repeated falls and injuries. One resident with intact cognition had several unwitnessed falls after a room move, with bruising, swelling, head injury, and a hospital transfer, while the documented interventions were already in the care plan before the incidents. Another resident with dementia and prior independence fell when a RW moved, resulting in a head bump and decline in ADLs, and the RW was found to have faulty locks. A third resident with dementia and repeated falls was observed with facial bruising while the wheelchair lacked Dycem, an anti-rollback bar, proper lighting, and footwear, despite these interventions being listed in the care plan.
Improper medication and biological storage was observed in multiple med carts, including loose unpackaged pills and capsules without resident identifiers, spilled residue in drawers where liquid stock meds were kept, and non-medication items such as candy, cereal, batteries, sunglasses, and a lighter stored with meds and supplies. A single-use vial of Cyclosporine and other items were also found in unsecured areas, and lancets, glucometer strips, and a clear liquid substance were left on top of a med cart while residents and staff passed by.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: Surveyors found multiple resident-to-resident physical abuse incidents involving a resident with dementia and another resident with paranoid schizophrenia, as well as a separate altercation between two residents over TV volume. Injuries included a bruised forearm, skin tear, scratches, a bruise, a bump, and an abrasion, and one resident later admitted to hitting the other. The facility did not consistently document the incidents in the clinical record and concluded one event was not abuse based on lack of intent.
A facility failed to administer scheduled IV antibiotics as ordered for two residents, including one with endocarditis whose IV Vancomycin was not given for two days after a cardiology recommendation to continue treatment, and another resident who reported missed doses and frustration about delayed treatment. The facility also failed to complete a current skin assessment for a resident with bilateral lower leg sores, itching, and open scabbed lesions, despite prior wound concerns and an overdue skin assessment noted by the DON.
Infection Control and Laundry Handling Deficiencies: A resident on contact isolation had a phlebotomist enter the room without an isolation gown, place a blood draw kit on the floor, and leave without sanitizing the kit. In the laundry area, clean clothing was stored uncovered near the washer, soiled linen was handled from the dirty room to the machine, and a washer was leaking with standing water behind it.
Incomplete Inventory of Resident Personal Belongings: A resident with intact cognition reported missing hearing aids and ice packs brought from home, and said staff dismissed the concern because the items were not listed on the inventory sheet. The resident’s belongings form documented only one item and was signed by staff but not the resident, despite the form including sections for electronics and assistive devices such as hearing aids. The DON stated the form should have been fully completed and signed by the resident.
Call Light Left Out of Reach for A Resident A resident was observed sitting in a recliner with the call light clipped to the bed about five feet away and out of reach. The resident said they were in pain, could not reach the call light, and could not ambulate to get it, and appeared frustrated. An RN acknowledged the call light should have been within reach. The resident had a recent readmission with diagnoses including humerus fracture, syncope and collapse, bone cancer, breast cancer, brain cancer, pain, and muscle weakness, and was cognitively intact.
A resident receiving IV antibiotics for MSSA bacteremia voiced repeated complaints that scheduled doses were being missed and became upset after not receiving a 6 AM dose. The nurse confirmed the dose was not given because the medication was not available, and the RN/unit manager documented the resident as verbally aggressive rather than assisting with a grievance form. The DON stated the resident should have been offered help filing a grievance so the concern could be investigated and explained.
Failure to report alleged abuse: A resident with intact cognition and diagnoses including DM2, difficulty walking, and acute respiratory failure reported that staff were rude, disrespectful, and at times not physically careful. The record included a note that the resident said staff pushed her into a wall during toileting, but no IA report was provided and the DON/Abuse Coordinator stated they were not aware of the allegation. Facility policy required alleged abuse to be reported to the Administrator immediately, and no later than 2 hours when abuse was involved.
A resident with intact cognition, spinal fusion, and a history of constipation reported not having a BM for a week, with stomach pain, discomfort, and anxiety. Although the resident had a PRN bisacodyl suppository order after two days without a BM, the MAR showed no administration until later, when the resident finally had a large BM and expressed relief. The DON stated the facility should have followed the bowel protocol and MD orders, and the Administrator said there was no bowel protocol policy.
Delayed PICC Dressing Change: A resident receiving IV abx via a PICC had a dressing observed with an outdated date, and the dressing remained unchanged on a later observation. The resident stated the dressing had not been changed since admission, even though the MAR/TAR showed the dressing change as completed. The resident had MSSA infection and was admitted for rehab and IV abx therapy.
Failure to document and monitor bedside suctioning for a resident with impaired respiratory status. A resident with interstitial emphysema, acute hypoxic respiratory failure history, and severely impaired cognition had a bedside suction setup with dried mucus in the tubing and a canister 3/4 full of dried green mucus, with no dates showing when equipment was last changed or emptied. Nursing staff could not state when suctioning was last done or how often the canister should be emptied, and the MAR had no documentation of self-suctioning.
Incomplete and Inaccurate Medical Records After Resident-to-Resident Incident: The facility failed to keep complete and accurate clinical records for two residents after a resident-to-resident altercation in a common area. The injured resident’s chart did not include the incident details, the abrasion documented on the incident report was missing from the EMR, and progress notes, NP documentation, and psych notes did not reflect the event or the follow-up care despite nursing documentation of a bruise, skin treatment orders, and treatment provided.
A resident with severe wounds and a complex pain regimen did not receive ordered Oxycodone for pain management despite repeated requests and nursing assurances. Documentation confirmed that the medication was not administered as ordered, resulting in a significant delay before the resident received the first dose.
A nurse mistakenly administered a resident the full dose of his roommate's medications, which included multiple anticonvulsants, a benzodiazepine, an antipsychotic, and a diabetic medication. The resident, who had complex cardiac and metabolic conditions, became increasingly lethargic and unresponsive over several hours, prompting transfer to the hospital. The error was recognized immediately, but there were delays in provider response and follow-up as the resident's condition worsened.
A deficiency was identified when the facility did not provide enough nursing staff with the required competencies to meet the medical and supervision needs of multiple residents, as determined by their assessments and care plans.
The facility did not report allegations of abuse and mistreatment involving two residents to the State Agency as required. One resident, with a documented history of behavioral and substance abuse issues, was alleged to have inappropriately touched another resident and exhibited ongoing aggressive behavior. Staff were aware of the incidents but failed to follow mandated reporting procedures.
A resident with symptoms of a UTI experienced a delay in assessment, lab processing, and initiation of antibiotics, despite ongoing decline and documented signs of infection. Another resident with quadriplegia and a stage 4 pressure ulcer faced a prolonged delay in obtaining a medically necessary power tilt recline wheelchair due to the facility's failure to submit required documentation, resulting in distress and frustration for the resident.
A resident exhibiting symptoms of a UTI had a urine specimen collected, but the lab did not pick up the specimen for processing until two days later, resulting in a delay in diagnosis and treatment. The DON confirmed that specimens are supposed to be picked up daily, and the facility's policy lacked clear timeframes for lab collection and transport.
Two residents with cognitive impairment and alcohol dependence were found intoxicated together, resulting in an abuse allegation that was not promptly reported to the administrator as required by facility policy. During the same shift, the facility was understaffed, leading to delayed medication administration and inadequate supervision for multiple residents, including those with behavioral issues.
A resident admitted with severe injuries requiring enteral feeding experienced a 15-hour delay in receiving nutrition due to a lack of a feeding pump. Despite the availability of supplies, the facility was replacing pumps, causing the delay. The nursing staff failed to document the feeding administration timely, and the facility's policy on feeding tubes was not followed.
A facility failed to prevent falls and ensure timely investigation for two residents, leading to one sustaining a femoral neck fracture. A resident with severe cognitive impairment was found on the floor by a CNA, who did not immediately assist or notify the nurse. The resident was improperly assisted back to bed without injury assessment, and later complained of pain. Another resident with a history of falls experienced multiple falls due to inadequate supervision and failure to implement recommended interventions.
The facility's call system failed to effectively alert caregivers, relying solely on a hallway monitor that staff had to check periodically. Interviews with staff and residents revealed that there were no audible or visual alerts, and pagers were not in use. Residents reported long wait times for assistance, and the facility's leadership acknowledged the issue but had not implemented a solution.
The facility failed to adhere to professional standards for medication administration and disposal. A resident had a prescription left unsecured in their room without an order, and another resident was left with medications to self-administer without supervision or an order. Additionally, a nurse improperly disposed of liquid medication by pouring it down the drain, against facility policy.
A resident with mixed incontinence and other conditions did not receive scheduled showers, as only four were documented over a 30-day period. The resident reported staff postponing her requests, and observations confirmed inadequate hygiene care, including a soiled brief and skin issues. The DON confirmed the lack of documentation for the required showers.
The facility failed to follow infection control protocols, as staff were observed exiting a resident's room with PPE still on, contrary to CDC guidelines. Additionally, a resident's catheter bag was found touching the floor, and there was a delay in implementing Enhanced Barrier Precautions due to an outbreak, despite physician orders being in place.
The facility failed to provide necessary social services for two residents. One resident with severe cognitive impairment lacked a legal decision maker, and no initial social service assessment was completed. Another resident with a history of suicidal behavior was not properly followed up after a hospital visit for suicidal ideations, with no documentation of evaluation or safety checks. The facility did not adhere to its social services responsibilities, failing to perform assessments and update care plans.
The facility failed to accurately reconcile controlled medications for two residents. A nurse forgot to administer a Hydrocodone/Acetaminophen tablet to a resident after being distracted, leading to a discrepancy in the narcotic binder. Another nurse administered a Tramadol tablet but did not update the binder, resulting in a mismatch between the recorded and actual tablet count. The DON was informed of these issues.
A facility failed to complete physician-ordered lab diagnostics for a resident with respiratory issues. Despite a Nurse Practitioner ordering a STAT CO2 level and CMP due to shortness of breath, the tests were not conducted, and no results were available. The DON confirmed the oversight, and the Administrator acknowledged an issue with lab diagnostics.
A resident with hand contractures and other conditions did not receive necessary rehabilitative services, including periodic screenings and maintenance programs, leading to a lack of intervention for their condition. Observations showed the resident's hands in a clenched position without the use of prescribed palm protectors. Staff interviews confirmed the absence of a maintenance program since 2023, and the facility lacked a process for routine screening or assessment of range of motion for residents with contractures.
A resident with multiple medical diagnoses, including heart failure and dementia, consented to receive a pneumonia vaccine. Despite this consent, the vaccine was not administered, as confirmed by the Infection Preventionist and Corporate Clinical Services. The Electronic Medical Record incorrectly documented the vaccine as refused.
The facility failed to offer and administer the COVID-19 vaccine in a timely manner to two residents, one with moderate cognitive impairment and multiple medical conditions, and another with severe cognitive impairment. Delays were due to oversight and insurance authorization issues, leading to a deficiency in the immunization process.
A resident with multiple health issues reported missing personal items and other concerns to the facility, which failed to document and promptly resolve these grievances. The facility's grievance process was found lacking, with no documentation or follow-up on issues related to medication, care, and appointments. Interviews revealed inconsistencies in the grievance process, and the facility's policy lacked specifics on resolving grievances.
A resident with diabetes and foot issues did not receive timely podiatry care despite a physician's order. The resident experienced foot pain and swelling, and had ingrown toenails, but the facility failed to ensure a podiatry consult was completed. Staff interviews revealed a lack of awareness and issues with the electronic medical record system, leading to a delay of over 40 days in obtaining necessary care.
The facility failed to provide proper respiratory care for two residents. One resident did not receive continued oxygen therapy as per the NP's evaluation, while another was given an ill-fitting nasal cannula, making it difficult to breathe. The facility did not adhere to its policy of changing oxygen equipment weekly, and there was a lack of documentation and orders for necessary respiratory care.
A resident did not receive a scheduled dose of Haldol Decanoate due to the facility's failure to coordinate with the CMH agency. The medication was due every two weeks, but the dose on 6/28/24 was missed, leading to increased mental health symptoms. The facility did not document efforts to obtain the medication or address the issue before the resident's discharge.
A resident with a history of falls and under hospice care experienced multiple falls due to the facility's failure to provide the required two-person assistance for bed mobility. The resident rolled out of bed while a single aide was changing their brief and linens, despite the care plan indicating the need for two-person assistance. The facility staff lacked proper documentation and training on the resident's care needs, leading to repeated falls and injuries.
A resident with major depression, chronic respiratory failure, and diabetes did not receive a physician-ordered skin scraping test to rule out scabies. Despite multiple inquiries and a review of the clinical record, the facility could not provide the test results. Interviews revealed that the facility's process for ensuring laboratory orders are executed was not followed, and no explanation was given for the oversight.
Failure to Obtain and Administer Ordered Hizentra Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer a physician-ordered immune globulin medication, Hizentra, for a resident with common variable immunodeficiencies and Crohn’s disease. The resident, who was cognitively intact and had diagnoses including respiratory failure and common variable immunodeficiencies, had an order dated 2/28/25 for Hizentra 10 g/50 mL to be given subcutaneously once weekly. Although this order was discontinued on 10/22/25, a similar weekly Hizentra order was started on 10/27/25 and continued, with a later change to a Wednesday schedule beginning 3/11/26. Review of the Medication Administration Records from October 2025 through March 2026 showed multiple weeks where the medication was documented as “not available” or “not given,” with only sporadic administrations noted by nursing staff. The resident reported on 3/23/26 that they had not received Hizentra in months despite being supposed to receive it weekly and stated they had an immune-compromised disease. The DON stated the medication was supplied by a specialty pharmacy and provided a letter from the infusion pharmacy dated 3/13/26 indicating the pharmacy had been unable to reach the resident and would close the case pending a return call. In a phone interview, a pharmacy employee reported that the last monthly supply of Hizentra (four doses) was shipped to the facility on 9/2/25 for delivery on 9/3/25 and that the pharmacy had not received any calls from the facility after that shipment. The facility’s own medication administration policy required medications to be administered by licensed staff as ordered by the physician and in accordance with professional standards of practice, but the facility did not ensure ongoing availability and administration of the ordered Hizentra for this resident.
Failure to Accurately Reconcile and Administer Hizentra and Amoxicillin
Penalty
Summary
The deficiency involves the facility’s failure to reconcile and administer prescribed medications according to professional standards for two residents. One resident with respiratory failure, common variable immunodeficiencies, and Crohn’s disease had a standing order for weekly subcutaneous Hizentra, supplied by a specialty pharmacy and stored in the medication room refrigerator. The MAR from October through March showed multiple weeks where Hizentra was documented as “not available,” interspersed with a few entries indicating administration by nursing staff. The resident reported not receiving Hizentra for months after a hospital stay in November, and the specialty pharmacy confirmed the last shipment of a one‑month supply was delivered in early September, with no subsequent orders or contacts from the facility. The Administrator acknowledged the facility did not keep records of specialty pharmacy deliveries and could not confirm that doses documented as given on the MAR were actually administered. For this same resident, nursing staff interviews revealed inconsistencies between staff recollections and pharmacy records. One nurse stated they administered Hizentra on a December date as documented on the MAR and recalled sometimes the medication was not available, while another nurse could not recall one of the documented administration dates but reported obtaining the medication from the storage room refrigerator on a later date. Despite these MAR entries, the specialty pharmacy reported no shipments after September and no calls from the facility requesting additional medication. The facility lacked a tracking system for specialty pharmacy deliveries, and there was no documentation to reconcile the discrepancy between the MAR entries, staff statements, and the pharmacy’s delivery history. A second resident, a long‑term resident with cardiac and kidney disease and moderately impaired cognition, experienced a failure in timely initiation of a prescribed antibiotic. After hospitalization for severe sepsis related to cellulitis of the left lower extremity, the infectious disease consultant and the hospital AVS directed that Amoxicillin 1 g orally three times daily be started and continued for four weeks. The resident returned to the facility, and the admitting LPN described a process in which hospital discharge orders are entered and then reviewed by a unit manager and a nursing leader. However, the MAR showed that Amoxicillin was not administered by the facility until several days after readmission. Review of the electronic orders revealed that the LPN had entered the Amoxicillin with an incorrect future start date, and the order was not corrected until identified by the NP and entered by an RN several days later. The DON and ADON confirmed that the medication was not ordered correctly and that the multiple reconciliation steps in the admission process were not performed accurately.
Failure to Implement Fall Interventions for Residents with Repeated Falls
Penalty
Summary
The facility failed to implement fall interventions for three residents reviewed for falls and accidents. For one resident with CHF and type II DM and intact cognition, multiple falls occurred after a room move and bed move. The resident reported pushing the call light, waiting a long time, then trying to get up alone and falling. The record showed repeated unwitnessed falls with injuries including bruising and swelling to the hand, bruising to both knees, head injury, and a hospital transfer after one fall. The fall assessments and incident reports documented interventions such as call light use education, Dycem, and assist bars, but those interventions were already listed in the care plan before the incidents, and the DON confirmed no additional information had been identified during review. A second resident with weakness, chronic pain, cardiovascular disease, and dementia sustained a fall when reaching for a rolling walker that moved, causing the resident to land on the buttocks and hit the head. After the fall, the resident had a newly bruised bump on the mid back of the head, pain and discomfort, and a decline from prior independence in dressing, toileting, feeding, transfers, and ambulation. The record review showed the walker locks were not locking, and a work order was submitted for repair. The Director of Maintenance confirmed responsibility for repairing resident adaptive equipment and stated there was no preventative maintenance schedule for resident equipment. A third resident with dementia, repeated falls, and restless/agitation was observed with facial bruising and a bloodshot eye, and could not say what happened. Observation and record review showed the resident’s wheelchair lacked a cushion or Dycem, was unlocked, had one missing anti-rollback bar, and the resident had no shoes on. The care plan already required an overhead light on at night, nonskid socks, frequent monitoring, Dycem to the wheelchair, and ensuring the room was free from accident hazards. The Nurse Manager confirmed these interventions should have been in place, including Dycem on the wheelchair, the overhead light on while sleeping, the wheelchair locked at the bedside, and replacement of the anti-rollback bar.
Improper Medication and Biological Storage in Multiple Medication Carts
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals in four of four medication carts reviewed. During observation of the Mum Front Medication Cart, loose unpackaged tablets were found in the second drawer without patient identifiers, and the third drawer base had moderate amounts of red and brown dried spilled matter where liquid stock medications were stored. A liquid-stained envelope with a resident’s name contained four size 13 Kirkland Brand hearing aid batteries, and the LPN stated the resident was no longer at the facility. At the Lilly Back Medication Cart, loose unpackaged medications without patient identifiers were observed in the second drawer, including multiple tablets and capsules of various shapes and colors. The third drawer base contained chalklike crushed debris and red and brown dried spilled matter where liquid stock medications were stored. The fourth drawer contained an open pack of strawberry flavored hard candies, and the RN acknowledged food should not be stored in the medication cart. At another medication cart, four individual packaged Risperidone doses had no resident identifiers, loose unpackaged medications were present in the second drawer, and a single-use vial of Cyclosporine eye drops had no resident identifier. The top drawer on the right side of the cart, where insulin, syringes, and glucometer supplies were stored, also contained a single-use vial of Cyclosporine, a yellow lighter, and a pair of sunglasses. In addition, a medication storage unit contained an opened package of Froot Loop cereal among medical storage supplies. On the Unit 3 medication cart, two lancets and two glucometer test strips were stored in cups on top of the cart, along with a clear thicker liquid substance later thought to be icy hot; multiple residents and staff passed by the cart while these items were observed. The DON acknowledged the loose unidentified medications and lack of resident identifiers were not safe or proper storage, and the facility policy required all drugs and biologicals to be stored in locked compartments.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse in multiple incidents reviewed by surveyors. One incident involved a resident with diagnoses including staphylococcus infection, mild neurocognitive disorder, and dementia with mood disturbance who reported that a roommate hit them after a disagreement about room temperature. The resident had a large bruise on the left forearm, bloody scabs, scratches, and a 3 cm skin tear that was actively bleeding. The resident’s legal guardian confirmed awareness of the allegation, and the roommate later acknowledged that he did hit the resident during the altercation. The roommate also had a history of prior altercations with other residents and was documented as having paranoid schizophrenia and a BIMS score of 14/15. Another incident involved two residents during a disagreement in a common area over television volume. One resident, who had diagnoses including vascular dementia with psychotic disturbance, type 2 diabetes, adjustment disorder, adjustment insomnia, and unspecified psychosis, was independent with walking using a cane and had a BIMS score of 15/15. The other resident had diagnoses including alcohol-induced persisting dementia, degeneration of the nervous system due to alcohol, generalized anxiety disorder, major depressive disorder, and cognitive communication deficit, with a BIMS score of 7/15 indicating severe cognitive impairment. During the altercation, the resident with the cane made contact with the other resident’s left lower extremity, resulting in a bruise and a small bump, and the facility’s documentation also identified an abrasion and skin treatment order for the injury. Survey review found that the facility did not consistently document or recognize the resident-to-resident incident in the clinical records for both residents involved in the television-volume altercation. The documentation provided to the State Agency did not include the abrasion and new skin treatment orders noted in the original incident report, and the related information was not available in the electronic clinical record during the survey. The facility’s abuse policy defined abuse to include willful infliction of injury and noted that physical marks such as bruises may be indicators of abuse, but the facility concluded the incident was not abuse because it believed there was no intent to harm and no emotional harm was identified.
Missed IV Antibiotics and Incomplete Skin Assessment
Penalty
Summary
The facility failed to ensure scheduled IV antibiotics were administered per physician orders for two residents. One resident reported that IV antibiotics ordered three times daily were not being given as scheduled and stated they missed a 6 AM dose, which left them upset and frustrated about the missed treatment and how it could affect recovery. The Director of Nursing acknowledged the resident’s concern about an extra day in the facility related to the missed medication doses. For the second resident, who had a history of a prosthetic heart valve and infective endocarditis, a cardiology consult recommended continuing IV Vancomycin until follow-up with Infectious Disease. The progress note documented that the medication had been completed and then re-ordered to restart the next day, but the MAR showed the resident did not receive IV Vancomycin on two consecutive days. During interviews, the NP stated they collaborated with Infectious Disease nursing about reordering, but the Infectious Disease RN stated they had no knowledge that the antibiotic was to continue and had not collaborated with the NP about reordering it. The verbal order for Vancomycin was not obtained until later, and the medication was not administered until the following day. The facility also failed to provide a comprehensive skin assessment and initiate treatment considerations for a resident with bilateral lower leg sores. The resident, who had no cognitive impairment, reported concern about a skin sore on both lower legs and was observed with numerous round, partially scabbed and open sores with inflamed red borders and itching. A wound consult had previously described scratches and picking marks and noted the issue appeared psychiatric in nature. The resident’s care plan addressed skin picking, but the record showed no documented skin assessment since 10/25/25, and the DON confirmed the skin assessment was overdue.
Infection Control and Laundry Handling Deficiencies
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not follow appropriate infection control practices related to transmission-based precautions and laundry handling. R185 had a sign on the room door indicating contact isolation precautions, and personal protective equipment, including isolation gowns, gloves, masks, and face shields, was available in the hallway outside the room. On 12/11/25 at 9:20 AM, Phlebotomist W entered R185's room with a phlebotomy kit, did not don an isolation gown, placed the kit on the floor, obtained a lab specimen, and then exited without sanitizing the kit after it had been placed on the floor in the contact isolation room. During interview, the phlebotomist stated they did not know R185 was on contact isolation precautions and did not respond when asked about the sign on the door. The DON stated the phlebotomist should have worn the appropriate PPE before entering the room. Laundry practices were also observed to be inconsistent with infection control. In the laundry room, three bins of clean personal clothing were left uncovered in close proximity to the washing machine, and the laundry aide stated there was a room for clean clothing after washing but it was not being used for clean storage at that time. The aide described taking soiled linen and clothing from the dirty room to the washing machine and placing it in the machine. The aide acknowledged the risk of contamination from the soiled clothing and stated they did not think it was being done correctly. The middle washing machine was also observed leaking water with a standing puddle of water behind it, and the laundry aide stated maintenance would need to be notified about the water.
Incomplete Inventory of Resident Personal Belongings
Penalty
Summary
The facility failed to thoroughly inventory and document a resident’s personal belongings upon admission, affecting one resident who had intact cognition and diagnoses including spinal fusions, spinal instabilities, falls, traumatic subarachnoid hemorrhage, diabetes, and heart disease. The resident was observed in bed and reported that the facility lost their hearing aids and ice packs brought from home. The resident also had other personal items in the room, including a cell phone, electric razor, and tablet, and stated they had alerted someone about the missing items but did not know who. They further reported that the staff member they told dismissed the concern because the items were not listed on the inventory sheet, and they said staff did not assist them with a grievance form. Review of the resident’s INVENTORY OF PERSONAL EFFECTS form showed only one item documented, “wheelchair catalyst,” with no completed entries for electronics or personal assistive devices such as hearing aids. The form was signed by a staff member but not by the resident. Staff interview indicated that inventory forms are usually completed by CNAs or sometimes a nurse, and the DON stated the form should have been fully completed by staff and signed by the resident. The facility policy required all resident possessions to be inventoried at admission and documented in the record.
Call Light Left Out of Reach for Resident in Recliner
Penalty
Summary
The facility failed to ensure a resident's call light was within reach while the resident was seated in a recliner. On 12/9/25 at 11:49 AM, the resident was observed in their room sitting in a recliner with their legs elevated, with the recliner positioned about five feet from the right side of the bed. During interview, the resident said they were experiencing pain and stated they could not reach the call light because it was clipped to the bed and was "way over there." The resident also said they could not ambulate from the recliner to the bed to retrieve it and appeared frustrated, stating, "It's such a simple thing," about having the call light left within reach after being assisted to the recliner. At 11:56 AM, Nurse S acknowledged that the call light should have been within reach. Review of the resident's record showed a recent readmission with diagnoses including humerus fracture, syncope and collapse, bone cancer, breast cancer, brain cancer, pain, and muscle weakness. The resident's most recent MDS assessment indicated they were cognitively intact. The facility policy titled, "Call Lights: Accessibility and Timely Response," stated staff are educated in the proper use of the resident call system, including ensuring resident access to the call light.
Failure to Address Resident Grievance About Missed IV Antibiotic Dose
Penalty
Summary
The facility failed to implement its grievance process for one resident who voiced complaints about not receiving scheduled IV antibiotics. The resident was observed in their room with an IV pump and pole and stated they were supposed to receive IV antibiotics three times a day but believed doses had been missed. On a later interview, the resident said they did not receive their 6 AM IV antibiotic dose and appeared upset, frustrated, and worried about how the missed doses would affect recovery. The resident’s nurse confirmed the 6 AM dose was not given and stated the medication was not available because the pharmacy had not delivered it overnight. The clinical record showed the resident was admitted for surgical aftercare and MSSA bacteremia, had intact cognition, and was receiving IV antibiotic therapy. The MAR documented the missed 6 AM dose, and a behavior note entered by the RN/unit manager described the resident as making accusations that staff were not providing care or medications and being verbally aggressive. The RN/unit manager stated they did not assist the resident with a grievance form because they were the unit manager and handled it, while the DON stated the resident should have been offered or assisted to file a grievance so the concern could be investigated and explained.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the Administrator/Abuse Coordinator and to the State Agency for one resident. The resident was observed sitting in a wheelchair in their room, alert and able to answer questions, and stated that some staff are often rude, disrespectful, and at times not physically careful. The resident’s record showed diagnoses including type II diabetes, difficulty walking, and acute respiratory failure, and the MDS indicated a BIMS score of 15/15 with the resident as their own responsible party. Record review showed a charted behavior note stating the resident was screaming at staff and said staff pushed her into a wall during toileting, with two persons present during care due to allegations. No Incident and Accident reports related to the physical abuse allegation were provided. The Administrator/Abuse Coordinator stated they were not made aware of the allegation and confirmed that all allegations of physical abuse should be reported to them. The facility policy required alleged violations to be reported to the Administrator immediately, and no later than 2 hours if the events involved abuse.
Failure to Follow Bowel Protocol and PRN Suppository Order
Penalty
Summary
The facility failed to initiate its bowel protocol for one resident with bowel and bladder needs, resulting in constipation and complaints of pain and discomfort. The resident was observed in bed and reported not having had a bowel movement in a week, along with anxiousness, stomach pain, and discomfort. The resident stated staff were aware of the situation and that they had been told a suppository would be given later in the day. The resident also reported a history of spinal fusion, a strict bowel regimen at home, prior hospitalization for constipation, and fear of being hospitalized again. The resident’s record showed diagnoses including falls, spinal fusion, traumatic subarachnoid hemorrhage, heart disease, and diabetes, and the MDS assessment indicated intact cognition. Record review showed the last documented bowel movement was several days earlier, and a nursing note documented the resident’s request for a daily suppository and report of pain shooting down the legs when unable to go. The resident had a physician’s order for bisacodyl rectal suppository every 24 hours as needed if no bowel movement occurred in two days, but the December MAR did not show any administration of the PRN suppository. The resident later reported they finally received the suppository and had a large bowel movement, describing significant relief and questioning why they had to wait so long. The DON stated the facility should have followed its bowel protocol and the physician’s orders, and the Administrator reported the facility did not have a bowel protocol policy.
Delayed PICC Dressing Change
Penalty
Summary
The facility failed to ensure timely dressing changes for a resident’s PICC line used for IV antibiotic therapy. On 12/9/25, the resident was observed in their room seated in a wheelchair and stated they had a PICC line in the right arm for IV medications. During observation, the PICC dressing was noted to be dated 12/2/25. A second observation on 12/10/25 showed the dressing still dated 12/2/25, and the resident stated the dressing had not been changed since admission. Record review showed the resident was admitted with diagnoses including surgical aftercare and MSSA bacterial infection, with intact cognition and admission for physical rehabilitation and IV antibiotic therapy. The physician orders, MAR, and TAR included a PICC dressing change scheduled for 12/7/25 and signed out as completed, despite the dressing remaining dated 12/2/25. The RN/Unit Manager was informed of the discrepancy and stated the dressing should have been changed per schedule. The facility policy reviewed did not define PICC dressing change frequency, while the cited reference stated PICC dressings should be changed at least once weekly.
Failure to Document and Monitor Bedside Suctioning
Penalty
Summary
The facility failed to ensure adequate documentation and monitoring of bedside suctioning for a resident with impaired pulmonary/respiratory status. R46 was admitted with diagnoses including interstitial emphysema, had a BIMS score of 7 indicating severely impaired cognition, and required assistance with most activities of daily living. The care plan identified a history of acute hypoxic respiratory failure, use of bedside suction, and emphysema, with an intervention to ensure tubing and apparatus were cleaned and dated. The physician’s order stated that bedside suction was to be used as needed and that the resident suctioned self as needed. During multiple observations, R46’s suction machine was next to the bed with multiple tubes containing dried mucus, and the suction container was observed to be 3/4 full of dried green mucus. No dating was observed on the tubing or container to show when they had last been changed or emptied. Nursing staff were unable to state when the tubing or container had last been changed, how often the container should be emptied or replaced, or when the resident last suctioned self. The December 2025 MAR contained no documentation of bedside suctioning being completed, and the respiratory therapist stated there was no current way to track self-suctioning and that nurses would need to ask the resident each day or shift and document it in the record.
Incomplete and Inaccurate Medical Records After Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate electronic medical records for two residents reviewed for medical records. The deficiency involved a resident-to-resident physical altercation between one resident with diagnoses including vascular dementia, diabetes, adjustment disorder, insomnia, and psychosis, and another resident with diagnoses including alcohol-induced persisting dementia, nervous system degeneration due to alcohol, breast cancer, anxiety, depression, and cognitive communication deficit. The incident was reported to have occurred in a common area during a disagreement over television volume, and the facility’s investigation described contact made by one resident’s quad-point cane to the other resident’s leg, with a small bump and later documentation of a bruise and abrasion. The resident record for the injured resident did not contain documentation of the incident, and the electronic clinical record did not include the abrasion that was documented on the incident report. The only mention of the abrasion was on the incident report completed by the former DON, but that report was not available in the resident’s electronic clinical record during survey. The skin assessment documented a one-inch bump with bruise and treatment initiated, but did not mention an abrasion. Physician orders showed a skin treatment order for cleansing the left lower extremity, applying A&D ointment, and covering with a dry dressing for seven days, yet the interdisciplinary progress notes for both residents contained no identification of the incident or details of follow-up evaluation. Provider documentation was also inconsistent with the nursing findings. The NP notes on subsequent visits documented no wounds, erythema, rash, or bruising, despite nursing documentation of a bruise and abrasion and treatment provided on multiple days. The psychiatry NP note did not identify whether they had been notified of the incident, and the facility administrator stated that incident report information was in the report rather than the medical record. The administrator also stated that the facility did not have a policy for complete and accurate medical records, and acknowledged that some incident-report information should have gone into the clinical record but did not.
Failure to Timely Administer Ordered Pain Medication
Penalty
Summary
A resident with a history of trauma resulting in necrotizing fasciitis of the left upper and lower extremities was admitted for skilled nursing care and rehabilitation. The resident underwent multiple surgical procedures, including debridement, fasciotomy, and a muscle flap graft, and required a Wound VAC. The resident's pain management regimen included Oxycodone 10 mg every four hours as needed, with the last dose documented prior to admission. Upon admission, the resident requested Oxycodone, and the admitting nurse confirmed the medication was ordered and could be accessed from a backup supply until the pharmacy order was filled. Despite repeated requests by the resident and assurances from nursing staff that the medication would be provided, the resident did not receive the ordered Oxycodone as scheduled. Record review showed that the Medication Administration Record (MAR) had an active order for Oxycodone 10 mg every four hours as needed for pain, starting on the day of admission. However, there was no documentation of administration on that day, and the controlled substance record confirmed that the resident did not receive the medication as ordered. The Director of Nursing acknowledged that the Oxycodone was not provided according to the physician's order, and the resident did not receive the first dose until the following evening, resulting in a significant delay in pain management.
Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a nurse administered a resident the medications intended for his roommate. The incident took place during the midnight shift, when the nurse, while managing two residents in the same room, set down a cup containing the roommate's medications on the wrong resident's tray table. After assisting both residents back into bed, the nurse inadvertently gave the medications to the wrong resident. The nurse realized the error immediately after administration and attempted to notify the physician and the Director of Nursing, but did not receive an immediate response. The affected resident had multiple complex medical diagnoses, including ischemic cardiomyopathy, atrial fibrillation, congestive heart failure, diabetes, acute kidney failure, and a recent femur fracture. Following the medication error, the resident initially showed no adverse reaction, but over the next several hours became increasingly lethargic, with fluctuating vital signs and eventually became unresponsive with increased secretions. Nursing staff documented these changes and communicated with the on-call provider, who advised monitoring and did not provide new orders despite the resident's declining condition. The resident's condition continued to deteriorate, and he was ultimately transferred to the hospital for further evaluation. Documentation shows that the medications administered in error included several anticonvulsants, a benzodiazepine, an antipsychotic, and a diabetic medication, none of which were prescribed for the affected resident. The facility's records indicate that the error was recognized and reported, but there were delays and gaps in provider response and follow-up documentation regarding the resident's significant change in condition.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to ensure that sufficient nursing staff with appropriate competencies and skill sets were available to meet the medical and supervision needs of 15 residents. This deficiency was identified through interviews and record reviews, which revealed that the number and qualifications of nursing personnel were inadequate to provide necessary nursing and related services as required by resident assessments and care plans. The lack of sufficient staff included both licensed nurses and other nursing personnel, such as nurse aides, and resulted in unmet resident needs for medical care and supervision during the period reviewed.
Plan Of Correction
Element 1: Resident R907 has been reviewed for any negative outcomes related to the alleged violation by Social Services / Designee. Care plan has been reviewed and updated as needed by Social Services. Completed by 5/8/2025. Resident R901 no longer resides in the facility. Nurse staffing patterns were reviewed by the Administrator to ensure that nurse staffing was sufficient to meet all current resident needs on 5/9/2025. Element 2: Nurse staffing was reviewed for the last 14 days to ensure that staffing was sufficient to meet all current residents needs. This was completed by the Administrator / Designee on 5/9/2025. Element 3: The Nursing Services and Sufficient Staff policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The facility Administrator and Director of Nursing were re-educated on the Nursing Services and Sufficient Staff policy by the Regional Director of Operations on 5/7/2025. Staffing will be reviewed daily, Monday through Friday, in morning stand-up meetings. Any concerns will be addressed.
Failure to Report Alleged Abuse and Mistreatment to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and mistreatment to the State Agency as required, involving two residents. Specifically, an incident occurred in which one resident was alleged to have touched another resident inappropriately during the midnight shift, and there were additional concerns that the same resident was seeking out other women in the facility for sexual activity. Despite these serious allegations, the facility did not report the incidents to the State Agency in accordance with federal requirements. The medical record review and interviews confirmed that staff were aware of the events, including a commotion in the room, visible intoxication, and the presence of alcohol, but failed to follow established reporting procedures. The resident involved had a history of behavioral issues, including agitation, verbal and physical threats, and substance abuse, as documented in multiple progress notes. These notes detailed repeated incidents of aggression toward other residents and staff, including attempts to physically confront or threaten others, use of profanities, and disruptive behavior. Despite this documented pattern and the specific incident of alleged abuse, the facility did not ensure timely reporting to the appropriate authorities as required by regulation.
Plan Of Correction
Element 1: Resident R907's allegation of abuse has been reported to the State of Michigan. Completed by the Abuse Coordinator on 5/1/2025. Resident R907 has been reviewed for any negative outcomes related to the alleged violation by Social Services / Designee. Care plan has been reviewed and updated as needed by Social Services. Completed by 5/8/2025. Resident R901 no longer resides in the facility. Element 2: All current residents in the facility have the potential to be affected. The facility Administrator / Designee has reviewed all grievance forms for the last 30 days for any reportable incidents. Any reportable incidents were reported. This was completed by the administrator on 5/6/2025. Root Cause Analysis: Facility failed to follow the abuse, neglect, and exploitation policy to report an allegation of abuse within 2 hours of notification. Element 3: The Abuse, Neglect, and Exploitation policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The facility administrator was re-educated on the reporting guidelines of abuse by the Regional Director of Operations on 5/7/2025. The Director of Nursing / Designee has re-educated all current employees on the Abuse, Neglect, and Exploitation policy by 5/19/2025. Any current employee who is not re-educated by 5/19/2025 will be re-educated prior to their next scheduled shift. All allegations of abuse and grievance forms are to be reviewed daily, Monday through Friday, in morning meetings and are to be reported by the facility. Element 4: The Administrator will audit up to 5 grievance forms weekly to ensure there are no reportable incidents. Audits will be weekly x4 weeks then monthly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.
Delayed Response to Change of Condition and Failure to Provide Medically Necessary Equipment
Penalty
Summary
The facility failed to timely address a change in condition for one resident who exhibited symptoms consistent with a urinary tract infection (UTI), including confusion, general weakness, increased urinary frequency, abdominal cramping, and pain during urination. Despite these symptoms being documented by nursing staff, there was a delay in collecting and processing the urine specimen, and antibiotics were not started until four days after symptom onset. The nurse practitioner did not initiate antibiotic treatment based on the resident's symptoms and chose to wait for culture results, even though the resident's condition continued to decline, with documented altered mental status, rapid heart rate, low oxygen saturation, and eventual transfer to the hospital for further evaluation. The Director of Nursing acknowledged that antibiotics could have been started earlier and that the delay should not have occurred. Additionally, the facility failed to ensure timely submission of medically necessary documentation for a power tilt recline wheelchair for another resident with quadriplegia, a traumatic brain injury, and a stage 4 pressure ulcer. The resident was dependent on a power wheelchair for mobility and pressure relief, but the process to obtain a customized wheelchair was delayed for nearly three months due to the facility's lack of follow-up on documentation requests from the equipment vendor. Multiple emails and voicemails from the vendor went unanswered, and the interim rehabilitation director did not submit the required paperwork while covering the department. The resident, who was cognitively intact, became distressed and frustrated by having to coordinate their own care and repeatedly advocate for the necessary equipment. The facility did not have a policy addressing timely assessment, monitoring, and treatment for a change of condition, and failed to provide a requested policy for rehabilitation services. The deficiencies resulted from lapses in communication, lack of timely clinical intervention, and inadequate follow-up on essential documentation, directly impacting the care and well-being of the residents involved.
Plan Of Correction
Element 1: Resident R904 no longer resides in the facility. Resident R905 appeal paperwork and supporting documentation for resident’s specialized wheelchair request has been sent to the vendor by the Director of Rehab on 5/1/2025. Element 2: Director of Nursing / designee reviewed last 7 days of Progress Notes for changes in condition being documented appropriately and timely and with proper notification. Any concerns identified were immediately addressed. Completed on 5/9/2025. Facility has reviewed all current residents that have been evaluated for a specialized wheelchair in the last 60 days to ensure all documentation has been completed timely and if appropriate wheelchair has been provided and care planned. Root Cause: Facility staff did not timely address a resident’s change in condition. Facility failed to submit additional necessary medical documentation timely to order a power wheelchair. Element 3: The Notification of Change policy and the Provision of Quality of Care policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The DON/Designee has re-educated all current nursing staff on Notification of Change policy by 5/14/2025. Any current nursing staff member not re-educated by 5/14/2025 will be re-educated prior to their next scheduled shift. The DON/Designee has re-educated the IDT team and the Rehab team on the Provision of Quality of Care policy by 5/19/2025. Any IDT team member or rehab staff member not re-educated prior to 5/19/2025, will be re-educated prior to their next working shift. The Medical Director has re-educated the Nurse Practitioner on Antibiotic monitoring and timeliness of follow-up. Completed by 5/19/2025. Element 4: The DON/Designee will audit all changes in condition daily, Monday - Friday, to ensure appropriate interventions are placed timely. Audits will continue daily for 4 weeks then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The DON/Designee will audit all specialized wheelchair requests weekly to ensure appropriate documentation is completed and submitted timely. Audits will continue weekly for 4 weeks then monthly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Administrator is responsible to maintain compliance.
Delay in Laboratory Specimen Pickup Resulting in Untimely UTI Diagnosis
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who was experiencing symptoms suggestive of a urinary tract infection (UTI). The resident, who had a history of confusion, increased urinary frequency, abdominal cramping, and pain during urination, had a urine specimen collected for urinalysis and culture as ordered by a nurse practitioner. Despite the specimen being collected promptly, there was a delay in its pickup, as the laboratory did not retrieve the specimen for processing until two days after collection. Interviews with the Director of Nursing confirmed that the facility's standard procedure was for lab specimens to be picked up daily on weekdays, with the option for a stat pickup on weekends if needed. The Director acknowledged that there should not have been a delay between specimen collection and delivery to the lab. Additionally, the facility's policy on laboratory and diagnostic guidelines did not specify timeframes for collection, transportation, or reporting of lab results, contributing to the lack of timely laboratory services.
Plan Of Correction
Element 1: Resident R904 no longer resides in the facility. Element 2: All current residents identified with labs and diagnostic tests ordered over the last 14 days were verified as completed. Any concerns were immediately addressed. Completed by the Director of Nursing / designee on 5/7/2025. Root Cause: Facility failed to ensure timely follow up for lab services. Element 3: The Laboratory and Diagnostic Guidelines Policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The Director of Nursing / Designee has re-educated all current licensed nurses on the Laboratory and Diagnostic Guidelines Policy by 5/19/2025. Any current licensed nurse not re-educated by 5/19/2025 will be re-educated prior to their next scheduled shift. Nurse managers will review the order listing report daily, Monday through Friday, in morning clinical meeting to ensure labs and diagnostics are completed as ordered. Element 4: The Director of Nursing / Designee will audit the order listing report daily, Monday through Friday, to ensure labs are completed as ordered. Audits will continue for 5 days per week x4 weeks and then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Administrator is responsible to maintain compliance.
Failure to Report Abuse Allegation and Maintain Sufficient Staffing
Penalty
Summary
On the night in question, two residents with histories of alcohol dependence and cognitive impairment were found intoxicated together in one resident's room. One resident, who had severely impaired cognition and a BIMS score of six, reported being prevented from leaving the room and being inappropriately touched by the other resident. Staff responded to the resident's calls for help and found both individuals in the same bed, with evidence of alcohol consumption present. The incident was reported by a CNA to a nurse, and a quality assurance form was completed, but the administrator was not informed until days later, contrary to facility policy requiring immediate reporting of abuse allegations. The facility was experiencing a staffing shortage during the shift when the incident occurred, with only four nurses present instead of the required six. Staff reported being unable to provide adequate supervision for residents, particularly those with behavioral issues and high fall risks. As a result, multiple residents received their medications late, and supervision was insufficient to prevent or promptly address incidents such as the one involving the two intoxicated residents. Staff also indicated that the resident accused of inappropriate touching had a history of problematic behavior, including drinking and inappropriate interactions with other residents. Facility policies reviewed during the investigation required immediate reporting of abuse allegations and sufficient staffing to ensure resident safety and well-being. However, the failure to promptly notify the administrator of the abuse allegation and the inability to maintain required staffing levels led to delayed medication administration and inadequate supervision. These actions and inactions directly contributed to the deficiencies identified in the report.
Plan Of Correction
Weekend staffing will be reviewed on Friday in morning stand-up meeting. Any concerns will be addressed. Element 4: The Administrator will conduct a daily staffing meeting, Monday through Friday, to ensure that nurse staffing is sufficient to meet the residents' needs. Staffing meetings will be held daily, Monday through Friday, for four weeks, then weekly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.
Delay in Enteral Feeding Administration
Penalty
Summary
The facility failed to administer enteral tube feeding in accordance with a physician's order for a resident, resulting in a delay in receiving necessary nutrition and hydration. The resident, who was admitted following a severe accident that resulted in multiple bone fractures and a diffuse brain injury, required enteral feeding due to an altered nutritional state. Upon admission, orders were in place to administer Jevity 1.5 at a continuous rate of 60 ml per hour with a 25 ml water flush every hour. However, due to a delay in obtaining the necessary feeding pump, the resident did not receive the prescribed nutrition until 15 hours after admission. The Director of Nursing and the Registered Dietician reviewed the situation and confirmed that the supplies and formula were available as floor stock, but the facility was in the process of replacing their Kangaroo Pumps, which caused the delay. Despite the availability of the pump on the morning following admission, the nursing staff failed to document the administration of the feeding on the Medication Administration Record until two days later. The facility's policy on feeding tubes, which includes maintaining feeding tubes in accordance with clinical standards and using gravity flow if necessary, was not adhered to, leading to the deficiency.
Plan Of Correction
Element 1: Resident 906 no longer resides in the facility. Element 2: All current residents who are on tube feed have been audited to ensure tube feed is being administered appropriately as ordered. This was completed by the Director of Nursing / designee by 2/27/2025. Root Cause: Facility failed to ensure that tube feed orders were followed. Element 3: The Tube Feed policy was reviewed by the QAPI committee and deemed appropriate on 2/27/2025. The Director of Nursing / designee has re-educated all current licensed nurses on the Tube Feed policy by 3/6/2025. Any current licensed nurse not re-educated by 3/6/2025 will be re-educated prior to their next scheduled shift. Residents who admit to the facility with tube feed will be reviewed and assessed by the nurse at admission to ensure tube feed, pump, and other supplies are readily available. If not available at admission, DON and Medical Provider are to be notified for timely interventions to address resident's nutrition needs. Residents who admit to the facility with tube feed will be reviewed by the IDT team in clinical morning meeting daily, Monday through Friday, to ensure tube feed is administered timely and as ordered. Element 4: The Director of Nursing / designee will audit all admissions daily, Monday through Friday, to ensure that tube feed is being administered appropriately, orders are in place, care plan is updated, and tube feed administration is documented appropriately in the resident's record. Audits will be daily for 4 weeks then monthly thereafter until substantial compliance is achieved. The Director of Nursing / designee will audit all current residents receiving tube feed to ensure that tube feed is being administered appropriately, orders are in place, care plan is updated, and tube feed administration is documented appropriately in the resident’s records weekly. Audits will be weekly for 4 weeks then monthly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.
Failure to Prevent Falls and Ensure Timely Investigation
Penalty
Summary
The facility failed to ensure a timely investigation of a fall and provide appropriate supervision and interventions to prevent falls for two residents, resulting in one resident sustaining an acute subcapital left femoral neck fracture. The incident involved a resident with severe cognitive impairment who was found on the floor by a CNA during the night shift. The CNA, instead of immediately assisting the resident or notifying the nurse, texted a colleague who was on break. The resident was then improperly assisted back to bed without a proper assessment for injuries, and later complained of pain, which was not immediately addressed. The resident's medical record indicated a history of cognitive deficits, difficulty walking, and a need for assistance with daily activities. Despite these needs, the resident was not adequately supervised, and the facility staff failed to follow the care plan, which required a two-person assist for transfers. The staff involved did not document the fall or the resident's change in condition, and the nurse on duty was not informed of the incident, leading to a delay in assessing and addressing the resident's injuries. Another resident with a history of falls and cognitive impairment experienced multiple falls due to inadequate supervision and failure to implement recommended interventions. The resident's care plan was not updated to include necessary measures such as a 1:1 sitter, despite recommendations from a nurse practitioner. The facility's failure to provide adequate supervision and timely interventions contributed to the resident's repeated falls and injuries.
Deficient Call System in LTC Facility
Penalty
Summary
The facility failed to maintain an effective resident call system, which was supposed to alert caregivers directly. Observations and interviews revealed that the system relied on a monitor in the hallway, which staff had to check periodically to see if any call lights were on. There were no audible or visual alerts in the nursing work areas or outside resident rooms, and staff confirmed that they had no way of knowing if a resident needed assistance unless they checked the monitor. This system was used throughout the facility, affecting all 142 residents. Interviews with various staff members, including LPNs, RNs, and CNAs, confirmed the reliance on the hallway monitor to identify resident needs. Staff reported that they had to physically check the monitor to know if a resident required assistance, as there were no other alert systems in place. Some staff mentioned that pagers were previously used but were no longer available or functional, leaving the monitor as the sole method of notification. Residents expressed concerns about the call light response time during a resident council meeting, with reports of waiting over two hours for assistance. The facility's Administrator and Director of Nursing acknowledged the issues with the call light system, noting that staff had to check a central monitor to be aware of resident needs. Despite repeated concerns raised in resident council meetings, the facility had not implemented an effective alert system to ensure timely responses to resident needs.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure nursing staff adhered to professional standards of medication administration for three residents. For one resident, a prescription for Ciclopirox was found on their tray table, and the resident reported that staff usually administers the medication. However, there was no order for this medication in the resident's clinical record, and the Director of Nursing (DON) confirmed that medication should not be left in the resident's room without an assessment and proper storage. Another resident was observed with a medicine cup containing multiple pills on their bedside table, and the assigned LPN admitted to leaving medications for the resident to take without supervision, despite the resident not having an order to self-administer. Additionally, a nurse was observed improperly disposing of a liquid medication by pouring it down the drain, contrary to the facility's policy, which requires medications to be disposed of in a designated container in the medication room. The DON confirmed that medications should not be disposed of down the drain and should follow the proper disposal protocol. These observations indicate a failure to adhere to professional standards and facility policies regarding medication administration and disposal.
Failure to Provide Regular Showers and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in ensuring regular showers for a resident identified as R27. Observations and interviews revealed that R27, who was admitted with conditions including mixed incontinence, functional diarrhea, muscle weakness, and anxiety disorder, did not receive showers as scheduled. The resident reported that staff frequently postponed her requests for showers, leaving her hair saturated with sweat. A review of the Treatment Administration Record (TAR) indicated that R27 was supposed to receive a bath or shower twice weekly, but only four instances were documented over a 30-day period, with no refusals noted. Further observations on a subsequent day found R27 in bed with a soiled brief, indicating inadequate toileting hygiene. The resident had redness and a small open area in the groin folds and buttocks, which was noted by the wound team. The Director of Nursing (DON) confirmed the lack of documentation for the required showers and acknowledged the deficiency in care. The DON was unable to find additional records of showers or baths beyond those already noted, confirming the resident's allegations of not receiving regular showers.
Infection Control Deficiencies in PPE Use and EBP Implementation
Penalty
Summary
The facility failed to consistently adhere to infection control standards and protocols, as observed during a survey. Registered Nurse B and Certified Nursing Assistant C were seen exiting a resident's room with their PPE still on, contrary to CDC guidelines which require the removal of gloves and gowns before exiting and the removal of respirators after exiting. The Assistant Director of Nursing confirmed this was not the facility's protocol. Additionally, several rooms with residents on Droplet/Contact/Airborne precautions had their doors open, and RN B was observed using the same N95 mask and shield for multiple residents, which was against the stated protocol of changing N95s for each resident and sanitizing shields between uses. Another deficiency was noted with a resident who had a catheter drainage bag touching the floor, and there was a delay in implementing Enhanced Barrier Precautions (EBP) for this resident. The Infection Preventionist acknowledged the delay, citing a scabies and COVID-19 outbreak as the reason for not being able to address all residents requiring EBP promptly. The resident had been admitted with several diagnoses, including severe cognitive impairment, and required assistance with most activities of daily living. The EBP was not implemented until five days after the resident's admission, despite physician orders being in place.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for two residents, R16 and R124, as required. For R124, the facility did not complete an initial social service assessment within the first seven days of admission, leaving all text fields blank. R124, who has severe cognitive impairment due to dementia, did not have an appointed legal decision maker, and there was no documentation of any legal guardianship or power of attorney process being initiated. The Social Service Worker acknowledged the oversight and indicated that they were waiting for documentation from the family to establish power of attorney. For R16, who has a history of anxiety, depression, and suicidal behavior, the facility failed to ensure proper follow-up and documentation after a recent hospital visit for suicidal ideations. R16 was sent to the hospital after expressing a plan to leave the facility, which was interpreted as a suicide plan. Upon readmission, there was no documentation of a psychological evaluation, medication changes, or follow-up appointments. The Director of Social Work was unaware of any updates or interventions, and there was no evidence of 15-minute safety checks being implemented, despite R16's history and recent ideations. The facility's Social Services department did not adhere to its essential functions, which include performing resident assessments upon admission and condition changes, and updating care plans and progress notes. The lack of documentation and follow-up for both residents highlights a failure to provide necessary psychosocial support and intervention, as outlined in the facility's job description for social workers.
Medication Reconciliation Failure for Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation for controlled medications for two residents. On September 18, 2024, during an observation of the North Tulip medication cart with RN CC, it was found that a tablet of Hydrocodone/Acetaminophen was not administered to a resident as recorded. The narcotic binder indicated that one tablet was given at 2:26 PM, leaving five tablets remaining, but the blister pack showed only four tablets. RN CC admitted to being distracted by assisting another resident in an isolation room and forgetting to administer the medication. Additionally, on the same day, a review of the Back Mum medication cart with RN Y revealed a discrepancy in the narcotic binder for another resident. The binder showed that a tablet of Tramadol was last given on September 16, 2024, with 13 tablets remaining, but the blister pack contained only 12 tablets. RN Y acknowledged administering the tablet before dinner but failed to reconcile the medication in the binder. The Director of Nursing was informed of these discrepancies and acknowledged the facility's failure to ensure accurate reconciliation.
Failure to Complete Physician-Ordered Lab Diagnostics
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory diagnostic was completed for a resident, identified as R149, who was admitted with diagnoses including respiratory failure, hypoxemia, pulmonary emphysema, and pulmonary edema. On 7/11/24, a Nurse Practitioner evaluated R149 due to a chief complaint of shortness of breath and ordered a STAT CO2 level, CBC, and CMP. Despite these orders, a review of R149's medical record revealed no documentation that the CO2 level or CMP lab tests were drawn or that results were reported to the medical provider. On 9/17/24, the Director of Nursing (DON) was queried about the missing lab results and indicated they would investigate the issue. The following day, the DON confirmed that the orders for the CO2 level and CMP, which were ordered STAT on 7/11/24, were never completed, and no results were available. During the exit conference, the Administrator acknowledged an issue with laboratory diagnostics and mentioned that a past non-compliance (PNC) was completed, including facility audits and education. However, the report focuses on the initial failure to complete the ordered laboratory diagnostics for R149.
Failure to Provide Rehabilitative Services for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary rehabilitative services for a long-term resident, identified as R108, who was admitted with multiple diagnoses including contractures of both hands, dementia, and anxiety disorder. Despite being confined to bed and requiring extensive assistance with Activities of Daily Living (ADL), the resident did not receive periodic rehabilitation screening or evaluation. Observations revealed that R108's hands were consistently in a clenched position, and a palm protector carrot intended to prevent worsening of hand contractures was not being used by staff, as reported by the resident. The resident's Electronic Medical Record (EMR) indicated orders for evaluations by Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP), but there was no evidence of completed therapy screens or evaluations addressing the resident's needs. The Certified Nursing Assistant (CNA) daily task list did not include any maintenance program for range of motion or splinting, and there was no follow-up or education provided by occupational therapy. Interviews with staff, including a CNA and the Restorative Nurse, confirmed that R108 was not on a maintenance program since 2023, and no referral from OT had been received to initiate such a program. Further interviews with the Therapy Manager (TM) revealed that there was no process in place for routine screening or assessment of range of motion for residents with contractures. The TM acknowledged that R108 had been receiving OT services until August 2023, which were discontinued when the resident was signed up for hospice, although hospice services were later discontinued. The Director of Nursing (DON) was aware of the issue and had discussed it with the therapy manager, but the facility's rehabilitation therapy and services document only addressed Medicare residents and did not include all residents of the facility.
Failure to Administer Pneumonia Vaccine After Consent
Penalty
Summary
The facility failed to ensure the administration of the pneumonia vaccine to a resident who had consented to receive it. The resident, who was admitted with medical diagnoses including heart failure, hypertension, diabetes, high cholesterol, and dementia, was cognitively intact with a BIMS score of 14/15. The resident signed a consent for the pneumonia vaccine, but the Electronic Medical Record indicated that the vaccine was refused. An interview with the Infection Preventionist confirmed the documentation of refusal despite the consent, and the vaccine had not been administered. Corporate Clinical Services acknowledged the failure to administer the vaccine after consent was given.
Deficiency in Timely COVID-19 Vaccine Administration
Penalty
Summary
The facility failed to ensure the COVID-19 vaccine was offered and administered in a timely manner to two residents, leading to a deficiency in their immunization process. One resident, identified as R136, was admitted with multiple medical diagnoses including cancer and renal failure, and had a moderate cognitive impairment. The COVID-19 vaccine was not offered to this resident until a random sample review by the Infection Preventionist, who admitted that the resident had 'slipped through the cracks.' The facility policy required the vaccine to be offered within 72 hours of admission, which was not adhered to in this case. Another resident, R29, who had severe cognitive impairment and medical conditions such as hypertension and diabetes, consented to receive the COVID-19 vaccine but experienced a significant delay in administration. The vaccine was offered and consented to on one date, but not administered until nearly a month later. The delay was attributed to the need for insurance authorization, which typically does not exceed a week, indicating a lapse in follow-up. The Infection Preventionist acknowledged the oversight, and Corporate Clinical Services confirmed the failure to ensure timely vaccine administration after consent.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances reported by a resident, identified as R79, who was admitted with diagnoses including heart failure, diabetes, muscle weakness, mild cognitive impairment, and legal blindness. The resident had a BIMS score of 14/15, indicating mild cognitive impairment, and required assistance with activities of daily living. A complaint was received by the State Agency indicating that concerns brought to the facility's attention were not resolved in a timely manner. Specifically, the resident and their family reported missing personal items, including a sweater, neck pillow, and pillowcase, on 7/21/24. However, the facility did not address these concerns until an interdisciplinary team meeting on 8/16/24, 26 days later, and only the missing sweater was addressed. The facility's grievance process was found lacking as it did not document or follow up on other concerns related to medication administration, care, and ancillary service appointments that were communicated during the meeting. The facility's documentation did not reflect any investigation or follow-up on these issues, and the resident's electronic medical record did not contain any further documentation related to these concerns. An interview with the resident's family member revealed that they had attempted to follow up on these issues but only managed to speak with the social worker, not the administration, and did not receive any callbacks. They also reported that they had to take time off work to attend a meeting they were informed the administrator would attend, but the administrator was absent. Interviews with facility staff, including the Director of Social Work and the facility administrator, revealed inconsistencies in the grievance process. The Director of Social Work confirmed that the resident's concerns were discussed but not documented, and the administrator acknowledged the delay in addressing the grievances. The facility's grievance policy, revised on 1/1/22, lacked specifics on the process and timeframe for resolving grievances, stating only that complaints would be documented but no response was required. This lack of documentation and timely follow-up on grievances led to the deficiency identified in the report.
Failure to Obtain Timely Podiatry Care for Resident
Penalty
Summary
The facility failed to obtain a podiatry appointment for a resident, identified as R79, who was experiencing foot pain and swelling, and had ingrown toenails. R79, who had a history of diabetes, heart failure, and mild cognitive impairment, was admitted to the facility with a physician's order for a podiatry consult dated 8/6/24. Despite this order, there was no evidence in the clinical records that the consult was completed. The resident continued to experience foot issues, and a subsequent order for a podiatry consult was made on 9/17/24, indicating a delay of over 40 days since the initial order. Interviews with facility staff revealed that the appointments/transport coordinator was unaware of the initial order and had only received the order on 9/17/24. The coordinator mentioned that sometimes orders fall off the electronic medical record system. The Director of Nursing was also unsure why the initial order showed as completed without the resident having been seen by a podiatrist. The facility's failure to ensure timely podiatry care for R79, despite the resident's diabetic condition and ongoing foot issues, led to the deficiency noted in the report.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R149 and R112, as observed during a survey. For R149, the deficiency involved the lack of continued oxygen therapy administration as per the Nurse Practitioner's evaluation. R149 was admitted with diagnoses including respiratory failure and hypoxemia, and was initially placed on 2L oxygen via nasal cannula on 7/11/24. However, there was no documentation of continued oxygen therapy after this date, despite the NP's evaluation on 7/12/24 indicating the need for ongoing oxygen support. The Director of Nursing acknowledged the oversight and confirmed that an additional order for oxygen administration was missed. For R112, the deficiency was related to the provision of an inappropriate nasal cannula that did not fit properly, making it difficult for the resident to breathe. R112, who was admitted with chronic respiratory conditions and dependence on supplemental oxygen, reported the issue to the facility upon admission. Despite notifying the Director of Social Work and Central Supply staff, the facility failed to provide a suitable nasal cannula, forcing R112 to use their own supply. The Central Supply staff member considered the request a personal preference and delayed action, while the Director of Nursing was unaware of the need for regular nasal cannula changes due to the absence of an order. The facility's policy on oxygen administration requires changing oxygen tubing and cannulas weekly, but this was not adhered to for R112. The lack of an active order for changing the nasal cannula contributed to the oversight. Both cases highlight the facility's failure to follow physician orders and ensure appropriate respiratory care, leading to deficiencies in the care provided to residents R149 and R112.
Failure to Administer Scheduled Antipsychotic Medication
Penalty
Summary
The facility failed to administer a scheduled long-acting antipsychotic medication, Haldol Decanoate, to a resident, identified as R601, as per the prescribed schedule. The resident was supposed to receive the medication every two weeks, but the facility did not administer the dose due on 6/28/24. This lapse was discovered following a complaint that the missed injection led to an increase in the resident's mental health symptoms, deviating from her mental health baseline. The resident's Community Mental Health Case Manager (CMH CSM 'D') had delivered the first dose to the facility on 6/13/24, which was administered on 6/14/24. However, there was no documentation or evidence of efforts made by the facility to obtain the subsequent dose due on 6/28/24. The facility's Director of Nursing (DON) and RN 'C' acknowledged that there was no further communication or coordination with the CMH agency or pharmacy to secure the medication after the initial dose was administered. The resident was discharged on 6/29/24 without receiving the scheduled Haldol injection. The discharge summary and home care referral did not document the missed dose, and there was no indication that the facility attempted to address the issue before the resident's discharge. The facility's inaction and lack of coordination with the CMH agency contributed to the failure to administer the medication as prescribed.
Failure to Provide Required Assistance for Bed Mobility
Penalty
Summary
The facility failed to ensure the required assistance level for bed mobility was provided to a resident, leading to multiple falls. The resident, who was under hospice care and had a history of falls, was observed without assist rails or bars in place. The resident reported that they rolled out of bed while a single aide was changing their brief and linens, despite the care plan indicating that two-person assistance was required for bed mobility and toileting. The resident had moderately impaired cognition and required substantial assistance with daily activities, including bed mobility. The clinical record revealed that the resident had been hospitalized and returned to the facility following a fall incident that resulted in a closed head injury. The resident's care plan included interventions such as a body pillow for bed boundary awareness and frequent rounding to ensure proper positioning. However, the facility did not identify that the aide was providing care alone when two-person assistance was required. The aide involved in the incident reported not being aware of the two-person assistance requirement and had not received adequate training on checking residents' care needs. Interviews with facility staff, including the Director of Nursing (DON), Administrator, and Regional Director of Operations, revealed a lack of proper documentation and follow-up on the incident. The DON, who was new to the role, was unaware of the specific care requirements and interventions needed to prevent falls. The facility's policy on accidents and supervision emphasized the need for individualized care plans, but this was not effectively implemented in the resident's case, leading to repeated falls and injuries.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident with diagnoses including major depression, chronic respiratory failure, and diabetes. Specifically, a skin scraping order from January 30, 2024, to rule out scabies was not completed. Despite multiple inquiries and a review of the resident's clinical record, the facility was unable to provide the results of the skin scraping test. Interviews with the infection preventionist and the Director of Nursing revealed that the facility's process for ensuring laboratory orders are executed involves discussing diagnostic testing orders in morning meetings and having the ordering provider follow up during their rounds. However, no explanation was provided for why the specific order from January 30, 2024, was not completed. The Nursing Home Administrator also confirmed that they were unsuccessful in locating the results for the skin scraping order. The facility's Laboratory and Diagnostic Guidelines policy mentions various methods for tracking laboratory and diagnostic tests, including tracking logs, electronic portals, and calendars. Despite these guidelines, the facility did not complete the skin scraping order, and no results were provided by the conclusion of the survey.
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What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — 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.
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Nursing homes near Howell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Howell | 1.9 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Livingston | 3 mi | ★★★★★ | 12 | 0 |
| Wellbridge Of Brighton | 4.8 mi | ★★★★★ | 7 | 0 |
| Caretel Inns Of Brighton | 9.2 mi | ★★★★★ | 6 | 0 |
| Wellbridge Of Pinckney | 10.6 mi | ★★★★★ | 1 | 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.