Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Livingston during CMS and state inspections, most recent first.
Unsanitary kitchen and pantry food storage conditions were observed when the ice machine had thick dust on the external vents, freezer areas contained brown debris, and multiple refrigerated items were uncovered, unlabeled, undated, or expired. Staff identified that the ice machine vents were not included in routine cleaning, and the Administrator stated there was no specific vent cleaning policy for the ice machine. Food storage practices did not match facility policy requiring clean storage areas and covered, labeled, and dated food items.
Improper hand hygiene occurred during medication administration for two residents. An LPN donned gloves without washing hands, handled the privacy curtain, administered insulin, then prepared Miralax after using hand sanitizer but without cleaning hands. The same LPN later gave medication and a health shake to another resident without hand hygiene. In addition, two loose pills were found in the narcotic drawer, and an LPN used a knife after removing chewing gum from their mouth to retrieve the pills while a Unit Manager observed.
Failure to Respect Resident Property and Dignity: A resident who was oriented and receiving dialysis reported that staff entered the room and confiscated cigarettes, a lighter, an unopened shot of whiskey, and a Trelegy inhaler while he was outside smoking. The resident was upset and said the NHA demanded reimbursement or return of the items; an LPN confirmed loud commotion and that items were taken while the resident was not present, and the NHA later acknowledged corporate staff had checked rooms and removed the belongings without the resident’s knowledge or presence.
Failure to resolve a resident grievance about personal food being discarded: a cognitively intact resident who was legally blind and on in-house HD reported that staff threw away purchased pizza leftovers because the food was not dated. Interviews confirmed staff were responsible for dating the food, but it was not done. The resident said promised reimbursement and extra pizza never occurred, and the NHA acknowledged the grievance had never been reconciled.
Medication administration did not meet professional standards for two residents. An LPN was observed reading MAR orders aloud while another LPN pulled medications at a separate cart, and a MAR review showed medications documented under another nurse’s credentials. The DON acknowledged that one nurse reading medications while another pulls them was unsafe and that staff must use their own computer logins.
A resident who was oriented and had resumed smoking was observed and interviewed as an active smoker who went outside several times daily, kept cigarettes in personal belongings, and was known to staff. Staff and the NHA confirmed the resident smoked and signed out to smoke, but the facility had no smoking policy and the Safe Smoking Assessment was not completed until after the State survey began.
A resident receiving Ativan had incomplete controlled substance documentation when the nurse who last administered the medication did not record the date or time in the binder. Another LPN filled in the blank areas, and an LPN later told the NHA that the narcotic book had not been signed out. The DON acknowledged that nursing must document controlled substances in the binder and that a two-nurse reconciliation is performed each shift.
Survey results were not readily accessible to residents, family members, or legal representatives, and no notice was posted showing that survey reports from the past 3 years were available. Seven residents said they did not know where to find the survey results. A former DON said the survey binder was in the front lobby, but surveyors found the binders piled behind the front desk, and the Administrator said people could ask him for them. No visible posting was observed in the facility.
A resident with opioid dependence, depression, and homelessness did not receive recommended psychotherapy or addiction specialist follow-up, despite psychiatric evaluations and care plans indicating these services were needed. Facility staff were unaware of the recommendations, and documentation showed no evidence of ongoing behavioral health interventions beyond initial assessments.
A resident with intact cognition and significant medical conditions did not consistently receive scheduled showers as outlined in their care plan, with multiple missed showers and inadequate documentation of refusals or preferences. The resident reported irregular showering and had submitted a grievance regarding this issue, which had not yet been resolved.
A resident with complex respiratory needs did not receive timely respiratory assessments upon admission and before and after breathing treatments. Staff documented outdated vital signs instead of current measurements, and progress notes contained inaccuracies regarding ventilator settings. The respiratory director confirmed that assessments should have been performed at the time of treatment, but staff used previous vital signs due to staffing shortages.
A resident with a history of atrial fibrillation and diabetes fell from a mechanical lift due to a worn-out sling, resulting in fractures and surgery. The sling appeared old and worn, and staff were unclear about who was responsible for checking its integrity. The facility's policy required routine checks, but there was a lack of clarity and enforcement regarding final inspections.
The facility did not consistently implement physician-approved pharmacist recommendations for residents' medication regimens. For example, a resident's digoxin administration lacked required pulse monitoring, and another resident's medication diagnosis was not updated as recommended. Additionally, multiple requests for blood tests were delayed, and results were not shared with the pharmacist. These actions violated the facility's policy on addressing medication regimen review irregularities.
The facility failed to ensure proper medication storage and labeling in two medication carts. Observations revealed loose medications not contained in bottles or blister packs, and an open albuterol inhaler without a date. Another cart had an opened nitroglycerin bottle without resident identifiers and loose medications, including Xanax. The DON and ADON confirmed the facility's procedure required dating inhalers and acknowledged the inappropriate storage and labeling.
A facility failed to maintain professional standards in medication administration when an LPN did not document the administration of Oxycodone to a resident in the narcotic log, resulting in a discrepancy between the documented and actual count of tablets. The LPN acknowledged the oversight, which violated the facility's medication administration policy.
A resident with a history of falling, TBI, and dementia experienced multiple falls due to inadequate supervision and ineffective interventions. Despite being at high risk, the facility failed to consistently implement measures like visual checks and supervision during meals. The DON acknowledged the lack of documentation and the need for more effective strategies.
A resident with severe cognitive impairment and chronic conditions was observed receiving the wrong enteral nutrition formula and infusion rate, contrary to the physician's order. The resident was supposed to receive Osmolite 1.5 at 70ml/hour for 18 hours a day, but was instead given Jevity 1.5 at 60ml/hour. This discrepancy was confirmed by the ADON upon reviewing the EMR, highlighting a failure to adhere to the facility's policy on feeding tubes.
The facility experienced inadequate staffing levels, particularly during weekends and night shifts over the summer, leading to unmet care needs for residents. Residents and CNAs reported delayed responses to call lights and insufficient supervision for fall-risk residents. A resident noted that staffing was typically low, with only one CNA for 31 patients, but observed increased staff presence during the survey visit.
A resident with a history of falling, traumatic brain injury, and dementia was administered PRN Ativan for anxiety multiple times without documented non-pharmacological interventions being attempted first. The facility's policy requires such interventions to be attempted and documented, but this was not done, leading to a deficiency.
Unsanitary kitchen and pantry food storage conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and pantry during observations of food storage areas and the ice machine. In the main kitchen, the ice machine near the meal prep area had black vents on both sides that were visibly soiled with a thick layer of dust. The Certified Dietary Manager stated that maintenance was responsible for the ice machine, and the Maintenance Director later reported that external vents were not part of the monthly routine internal cleaning process for the ice machines. Food storage problems were also observed in the kitchen freezer and pantry refrigerators. A reach-in freezer contained an opened clear plastic bag of frozen beef patties inside an opened cardboard box, and the bag was not sealed. In the pantry, several refrigerators with top freezers contained food items that were not properly labeled or dated, including smoked pork hocks with a use-by date of 11/21/25 for a resident who was no longer current, a bag of small ice cubes with no name or date that was not provided by the facility, greek yogurt containers with no resident name and a manufacturer expiration date of 12/14/15, and a blue and white striped lunch box with unidentifiable food items and no resident name or date. Multiple refrigerators also had brownish debris throughout the bottom of the freezer areas, with other food items stored on top of the debris. Additional observations in the pantry showed vents in the storage room where disposable cups, lids, and straws were kept covered in thick dust, with dust debris blown around the vent and onto the surrounding wall. The Administrator reported there was no specific vent cleaning policy for the ice machine and that the facility relied on the manufacturer's recommendation. The facility policy required food storage areas to be kept clean, foods in refrigerators and freezers to be covered, labeled, and dated, and ice machines and ice storage/distribution containers to be maintained to assure a safe and sanitary supply of ice.
Improper Hand Hygiene During Medication Administration and Unsafe Medication Retrieval
Penalty
Summary
The facility failed to provide proper hand hygiene during medication administration for two residents reviewed for medication administration. During an observation, an LPN donned clear gloves in the bathroom without washing hands first, then used the gloved hand to pull the privacy curtain before injecting insulin into a resident's left lower abdomen. The same LPN later used hand sanitizer, opened a blue zipper shoulder bag, retrieved a marker to date a bottle, rezipped the bag, moved items on the cart, and opened a new bottle to prepare Miralax without cleaning hands. The LPN was also observed giving medication and a health shake to another resident without hand hygiene. In a separate medication storage observation, two loose pills were seen in the locked narcotic drawer, and an LPN used a red plastic knife after removing chewing gum from their mouth to poke into the drawer and retrieve the pills while a Unit Manager commented, "I know this is gross." The DON acknowledged hand hygiene should be consistent and stated the gum and pill retrieval was not sanitary.
Failure to Respect Resident Property and Dignity
Penalty
Summary
The facility failed to promote a resident’s right to be treated with dignity and respect when staff searched the resident’s personal possessions without giving the resident the opportunity to decline. The resident, who was admitted requiring dialysis for acute kidney failure due to rhabdomyolysis, was documented as oriented to person, place, date, and time on the Skilled Medical Assessment dated 12/25/25. On 1/5/26, the resident was observed upset and stated that after going outside to smoke and returning to the room, cigarettes, a lighter, an unopened shot of peanut butter whiskey saved for discharge, and a Trelegy inhaler were missing. The resident said the Nursing Home Administrator told him to return the items or reimburse him ten dollars and stated that staff knew he smoked and had come into the room and taken his belongings. An LPN later confirmed there had been loud commotion in the room and said someone took items from the room while the resident was not there. On 1/7/26, the NHA acknowledged that corporate staff had checked rooms, saw the items in the resident’s room, and confiscated them without the resident’s knowledge or presence, and admitted this was not appropriate.
Failure to Resolve Resident Grievance About Discarded Personal Food
Penalty
Summary
The facility failed to ensure prompt efforts to resolve a grievance involving a resident who was legally blind and cognitively intact, with an admission diagnosis of end stage kidney disease and requiring in-house hemodialysis. The resident reported that after ordering a delivery of JETS Pizza, the leftovers were thrown away by kitchen staff because the food was not dated. The resident stated they relied on staff to label the food because of blindness, and the grievance form documented that the food was thrown out because items were never dated according to staff. Interviews confirmed that staff were responsible for dating residents’ food items placed in the refrigerator, and that this resident’s pizza was not dated by staff before it was discarded. The resident reported that the Nursing Home Administrator said they would reimburse $40.00 for the meal and that the Certified Dietary Manager said the resident would receive extra pizza the next time it was served, but the resident stated neither had occurred. The Nursing Home Administrator reviewed the grievance and acknowledged the facility had never reconciled it with the resident.
Medication Administration Documentation and Credential Use Errors
Penalty
Summary
The facility failed to meet professional standards of quality for medication administration for two residents reviewed. During an observation on 1/6/26, an LPN was seen at one medication cart reading aloud MAR orders for a resident’s morning medications while another LPN, at a separate cart, pulled the medications as the orders were read. A later record review of another resident’s MAR showed the medications had been documented as signed off by the first LPN, and the second LPN acknowledged the error, stating they had not signed in under their own login and had charted on another nurse’s credentials. The DON acknowledged that having one nurse read off medications while another nurse pulls them was not safe and unacceptable, and confirmed that nurses must sign in and out of the computer using their own credentials. The facility’s medication administration policy stated that medications are administered by licensed nurses in accordance with professional standards of practice and that the MAR source should be compared to verify the resident name, medication name, form, dose, route, and time of administration.
Failure to Complete Safe Smoking Assessment for Resident Who Smoked
Penalty
Summary
The facility failed to conduct a Safe Smoking Assessment for one resident who was identified as a smoker. The resident was admitted requiring dialysis for acute kidney failure due to rhabdomyolysis, and a skilled medical assessment documented that the resident was oriented to person, place, date, and time. During the survey, the resident stated they had resumed smoking at the end of November, that cigarettes were brought in by a niece, and that they kept cigarettes in a nightstand drawer or coat pocket without needing them locked up or asking staff for them. The resident also stated they smoked outside approximately 4 to 5 times daily and that staff were aware of this. Facility staff confirmed the resident smoked and went outside to smoke beyond the parking lot, and the receptionist verified the resident signed in and out in December for smoking. The Nursing Home Administrator acknowledged the resident had previously been caught smoking and had been told the facility was non-smoking, and also confirmed there was no smoking policy for the facility. A blank acknowledgment form was provided, but it was not found in the resident’s medical record, and the Safe Smoking Assessment was not completed until after the State survey had already begun.
Controlled Substance Documentation Not Completed
Penalty
Summary
The facility failed to ensure accurate accounting for an administered controlled medication for one resident receiving Ativan 0.5 mg every 12 hours. During a medication administration observation on 1/6/26, the controlled substance binder for the resident showed that the nurse who last administered the medication, LPN C, did not document the date or time the medication was last given. LPN B then filled in the blank areas and stated that the nurse did not do it. Shortly afterward, LPN B told the NHA that they needed to call LPN C because the narcotic book had not been signed out. Later that day, the DON, in the presence of RN A, acknowledged that nursing must document controlled substances in the controlled substance binder and stated that nursing performs a two-nurse reconciliation of controlled substances every shift and that this should not have been missed.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent recertification survey were readily accessible to residents, their family members, and their legal representatives, and failed to post a notice that survey reports from the past three years were available for review. During a resident council interview, seven residents stated they did not know where to find the survey results. A former DON reported that a binder with the survey results was located in the front lobby and required a code to enter the lobby, but observation showed the binders were actually in a pile behind the front desk off to the side. The Administrator stated that anyone who wanted to see the results could ask him and he would provide the binders. Observation also found no visible postings in the facility indicating that survey results were available for review. A facility policy titled Facility Required Postings stated that required postings must be in an area accessible to all staff and residents and must include the most recent survey results of the facility.
Failure to Provide Behavioral Health Services for Resident with Depression and Substance Dependence
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate behavioral health services to a resident with a history of opioid dependence, depression, and homelessness. The resident was admitted for long-term care due to the need for 24-hour assistance with activities of daily living, skilled nursing care, and medication management. Upon admission and during subsequent evaluations, the resident reported ongoing moderate depression, anxiety, and insomnia, which were attributed to his life circumstances, including homelessness and health issues. Psychiatric evaluations recommended increasing antidepressant medication and specifically advised psychotherapy for ongoing depression, with the resident agreeing to the plan of care. Despite these recommendations, the facility did not arrange for the resident to receive psychotherapy or ensure follow-up with an addiction specialist as documented in the medical record. Interviews with the Social Work Assistant revealed that they were unaware of the recommendation for psychotherapy and had no documentation that such services were provided. Additionally, there was no evidence that the resident was seen by an addiction specialist, despite multiple notes indicating referrals were needed for addiction medicine and withdrawal management. Facility policy required that residents exhibiting behavioral health needs be reviewed by a Behavior Management team and that individualized plans of care, including non-pharmacological interventions, be implemented. However, the resident was only seen by behavioral health providers on two occasions, and no ongoing psychotherapy or addiction specialist services were documented. This lack of follow-through on recommended behavioral health interventions constituted the deficiency.
Failure to Provide Scheduled Showers for Resident Requiring ADL Assistance
Penalty
Summary
A deficiency was identified when a resident, who was alert and cognitively intact with a BIMS score of 14/15 and diagnoses including type II diabetes and acute respiratory failure, did not consistently receive scheduled showers as required by their care plan. The resident was observed in bed and reported that while they had received a shower the previous day, they were not regularly provided showers and often only received bed baths. Review of the resident's clinical and task records over a 30-day period showed multiple missed scheduled showers, with some days where neither a shower nor a bed bath was documented, and no notes indicating refusals or preferences for bed baths on those dates. Further investigation included interviews with the CNA assigned to the resident, who confirmed that showers are generally given twice per week and stated that they provide showers as preferred by residents. However, documentation did not support that the resident's preferences were honored or that refusals were recorded. Additionally, a grievance regarding missed showers was submitted by the resident, but it had not yet been fully addressed at the time of the survey.
Failure to Perform Timely Respiratory Assessments and Accurate Documentation
Penalty
Summary
The facility failed to perform appropriate respiratory assessments for a resident who was dependent on a mechanical ventilator and had multiple complex diagnoses, including chronic respiratory failure with hypoxia, COPD, a history of lung cancer, and end stage renal disease. Upon the resident's readmission, documentation errors were noted, including inaccurate progress notes regarding ventilator settings and the use of outdated vital signs from a previous hospitalization. The respiratory evaluation on the day of readmission recorded vital signs from a prior date, rather than current measurements. Additionally, during the administration of breathing treatments, the respiratory therapist documented pre- and post-treatment vital signs that were several hours old and not reflective of the resident's current status at the time of treatment. The facility's respiratory director confirmed that vital signs should be taken at the time of assessment and treatment, but acknowledged that staff sometimes used previous nursing vital signs due to staffing shortages. The care plan for the resident included monitoring for effectiveness of medications and reporting adverse effects, but the required assessments were not performed as ordered.
Failure to Assess Sling Integrity Leads to Resident Fall
Penalty
Summary
The facility failed to assess the integrity of a mechanical transfer sling, resulting in an avoidable fall for a resident who required emergent transfer to a higher level of care and surgery for fractures. The resident, who was cognitively intact and had a medical history including atrial fibrillation, chronic osteomyelitis, and diabetes, required assistance with activities of daily living due to muscle weakness, reduced mobility, and morbid obesity. The incident occurred when the resident was being transferred using a mechanical lift, and the sling ripped, causing the resident to fall and sustain injuries. Interviews and record reviews revealed that the sling used during the transfer appeared worn out, and the fabric sewn to the strap looked old and worn. The CNAs involved in the transfer noted the sling's compromised condition and intended to discard it after the transfer. However, the sling failed during the transfer, leading to the resident's fall. The CNAs and other staff members were unable to confirm who was responsible for checking the integrity of the slings before use. The facility's policy required routine checks and maintenance of mechanical lift equipment by nursing and maintenance staff to ensure equipment remained in good working order. However, there was a lack of clarity among staff regarding who was responsible for the final inspection of the slings. The Director of Nursing confirmed that the responsibility lay with the staff placing residents into the sling, but this was not effectively communicated or enforced, contributing to the incident.
Failure to Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physician-approved recommendations from the pharmacist were consistently implemented for several residents. For one resident, the pharmacist recommended daily apical pulse readings before administering digoxin, with specific parameters to hold the medication if the pulse was below 60. Although the physician agreed with this recommendation, it was not reflected in the resident's medication order or administration record. Another resident's medication regimen review showed a recommendation from the pharmacist that lacked a documented physician response, and the Director of Nursing (DON) was unable to provide this documentation before the survey exit. Additionally, a resident with multiple health conditions, including end-stage renal disease and major depressive disorder, had a pharmacist's recommendation to update the diagnosis associated with an antipsychotic medication, which was not implemented. The pharmacist also made multiple requests for specific blood tests over several months, which were not conducted until much later, and the results were not uploaded for the pharmacist's review. The facility's policy requires that irregularities reported by the pharmacist be documented and acted upon, but this was not consistently followed, leading to deficiencies in medication management.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling in two of the three medication carts reviewed. During an observation of Medication Cart C Hall #2, it was found that loose medications were not contained in bottles or blister packs. The loose medications included a white round pill, an orange oval pill, a tan oval pill, and half a tablet of a purple pill, which was identified by the LPN as midodrine. Additionally, an open albuterol inhaler was found without a date, which the LPN acknowledged should have been dated per protocol. In another observation of Medication Cart E 500 Hall, a bottle of opened nitroglycerin was found without any resident identifiers, and the LPN was unable to specify which resident it belonged to. The cart also contained loose medications, including a round white pill, a quarter white pill, and half a tan pill. The narcotic box contained half a tab of a peach-colored pill, identified by the LPN as Xanax. Furthermore, three open boxes of albuterol inhalers were not dated, and the LPN was unclear about the facility's policy on dating inhalers. The DON and ADON confirmed that the facility's procedure required dating inhalers and acknowledged the inappropriate storage and labeling of medications.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure that nursing staff maintained professional standards and practices in medication administration for a resident. During an observation, an LPN was seen preparing Oxycodone, a narcotic for pain, for a resident. Upon reviewing the narcotic log, it was found that there was a discrepancy between the documented number of Oxycodone tablets and the actual count in the blister pack. The LPN admitted that the medication had been administered earlier but was not documented in the narcotic log, which is a requirement according to the facility's medication administration policy.
Failure to Prevent Recurring Falls for High-Risk Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent recurring falls for a resident identified as R22, who was at high risk for falls due to a history of falling, traumatic brain injury, and dementia. Observations and interviews revealed that the facility had insufficient staffing levels to adequately supervise residents at risk of falling, as noted by a nurse who expressed the need for more CNAs to ensure proper supervision. Despite the installation of anti-tippers on R22's wheelchair, the resident experienced multiple falls, indicating that the interventions in place were not sufficient. R22's medical records showed several falls occurring shortly after their admission, with incidents documented on multiple dates. The falls were often associated with activities such as eating or moving around the facility, and the resident was noted to have poor self-awareness and safety awareness. Despite these incidents, the facility's interventions, such as visual checks every 15 minutes and supervision while eating, were either not consistently implemented or not effective in preventing further falls. Additionally, a medication review was noted as an intervention, but no changes were made to the resident's medications. The Director of Nursing acknowledged the lack of documentation for the visual checks and the failure to continue certain interventions after reviewing the falls. The DON also recognized that the intervention of supervision while eating was not followed during a fall that occurred while the resident was eating in their room. The facility's policy stated that each resident would be assessed for fall risks and receive care accordingly, but the repeated falls of R22 highlighted a deficiency in the implementation of this policy.
Failure to Follow Physician's Order for Enteral Nutrition
Penalty
Summary
The facility failed to adhere to the physician's order for enteral nutrition for a resident who was observed receiving the incorrect formula and infusion rate. The resident, who had been admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed on multiple occasions receiving Jevity 1.5 at 60ml per hour with 55ml per hour autoflush, instead of the prescribed Osmolite 1.5 at 70ml per hour for 18 hours a day. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) upon reviewing the electronic medical record (EMR). The resident's medical record indicated a comprehensive care plan that included the administration of enteral nutrition per physician orders, initiated due to risks related to altered nutritional status, aspiration, and swallowing problems. Despite these documented needs, the facility did not follow the prescribed enteral nutrition orders, as evidenced by the incorrect formula and rate being administered. The facility's policy on feeding tubes emphasized the necessity of using them according to physician orders, which was not followed in this instance.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. During the fiscal quarter three, the facility had excessively low weekend staffing numbers, resulting in a one-star staffing rating. Residents reported that staffing during the night over the summer months was inadequate, leading to delayed responses to call lights and uncollected meal trays. The resident council minutes from April to June 2024 also documented complaints about untimely bed-making, uncollected trays, and grumpy aides on weekends. Certified Nursing Assistants (CNAs) confirmed that staffing levels were insufficient, particularly during the summer months, with only two aides assigned to a unit where three were needed to supervise fall-risk residents adequately. Resident 10, who is cognitively intact with a BIMS score of 15/15, expressed concerns about the lack of staff, noting that typically there is only one CNA for 31 patients. On the day of the survey, R10 observed an unusual increase in staff presence, which they attributed to the surveyors' visit. R10 felt that the usual staffing levels were inadequate and unfair to residents, describing the situation as an insult. The staffing coordinator acknowledged the staffing issues, citing the simultaneous resignation of several full-time CNAs as a contributing factor to the short-staffing during that period.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted prior to the administration of PRN psychotropic medication for a resident with a history of falling, traumatic brain injury, and dementia. The resident, who required assistance with most activities of daily living and had memory impairments, was prescribed Ativan as needed for anxiety. The medication was administered multiple times over a period of days without documented attempts of non-pharmacological interventions beforehand. The Director of Nursing acknowledged that nurses should attempt and document non-pharmacological interventions before administering PRN Ativan, but there was no documentation of such interventions in the resident's progress notes. The facility's policy requires that psychotropic drugs are only given when necessary and beneficial, with non-pharmacological approaches attempted and documented prior to administration. However, this policy was not followed in the case of the resident, leading to the deficiency.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 209 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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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 | 1.5 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Howell | 3 mi | ★★★★★ | 19 | 0 |
| Wellbridge Of Brighton | 7.8 mi | ★★★★★ | 7 | 0 |
| Wellbridge Of Pinckney | 11.7 mi | ★★★★★ | 1 | 0 |
| Caretel Inns Of Brighton | 12.1 mi | ★★★★★ | 6 | 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.