Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Portage during CMS and state inspections, most recent first.
Failure to manage pressure ulcers and prevent new skin breakdown: A resident with multiple severe wounds and a wound vac had repeated seal failures, inconsistent dressing coverage, and no documented communication with the wound clinic about alternate treatment, and arrived at the wound clinic with no dressings or wound vac supplies, fever, necrotic tissue, and purulent drainage. Another resident at risk for skin breakdown developed new heel and calf pressure injuries while ordered offloading and repositioning measures were not consistently observed, and the chart lacked refusals for those interventions.
Delayed call light response and unmet resident needs. Surveyors found that multiple residents reported long waits for call lights to be answered, including waits of 20 minutes to over 2 hours for incontinence care and other assistance. Residents described being soaked, urinating on themselves, and feeling frustrated, embarrassed, and not worth anything. Family also reported a resident’s call light being turned off before needs were met and staff not returning to complete care.
A resident with dementia and a history of falls had repeated falls tied to self-transfers and toileting needs, yet staff continued to transport him in a wheelchair with unsecured or missing foot pedals and without the level of supervision documented in the record. Another resident was transferred between bed and bedside commode without a gait belt, despite staff stating gait belts were required and the resident needing added support. A third resident with neurocognitive disorder and dementia was pushed in a wheelchair without footrests while the DON walked beside the chair and told the resident to keep his feet up.
Unsafe and Unsanitary Facility Environment: Slings in storage and the spa room were hung so they dragged on the floor, and dining room furniture had debris, trash, and an Albuterol vial mixed in with resident paperwork. Multiple resident rooms and hallways also had dirt, black streaks, scrapes, missing paint, cracked or missing tile, a dirty fall mat, and bathroom areas with possible mold/mildew and dried liquid buildup. Exterior drainage pipes were broken, allowing rainwater to run down the brick outer wall.
Failure to provide individualized activities for a resident with stroke and TBI. The resident was nonverbal, dependent for ADLs, and had preferences for family visits, gardening/outdoor activities, TV, and music, but the care plan was not updated to include all preferred activities and did not reflect the music machine the AD stated was obtained. Observations showed the resident lying in bed staring at the ceiling or curtain with no visible music machine, while staff reported he could not communicate needs or refuse activities and was not routinely assisted to activities unless asked.
A resident with an indwelling Foley catheter related to urine retention and recent stroke was observed multiple times self-propelling in a wheelchair with the catheter bag hanging under the chair and dragging on the floor. The care plan directed catheter and drainage system care, including keeping the drainage bag below bladder level, and an LPN and the UM/DON stated the bag should not be on the floor because it was an infection control concern.
A resident with chronic respiratory failure, CHF, and continuous O2 orders was observed receiving oxygen above the prescribed 2.5 L/min rate, with the concentrator found at 3.5 L/min and later 4 L/min. An LPN noted she had not been informed of any change in the O2 setting, and administration stated that oxygen is a medication order.
A resident with multiple chronic conditions had topical products left in the room without labels or dates, including zinc oxide, antifungal powder, and Bio Freeze gel, while the chart showed no order for the antifungal powder and no care plan focus for it. Staff said the resident did not self-administer these products. Surveyors also found the A hall med room refrigerator unlocked even though staff confirmed it stored meds, including narcotics, and facility policy required controlled substances to be under double lock and key.
Inaccurate documentation of fluid restriction status: A resident with SIADH and hyponatremia had a 1000 mL/24 hr fluid restriction reflected in the MAR and care plan, but observation showed multiple drinks and cups in the room, and the resident stated she was not on a fluid restriction and could drink what she wanted. Staff said the MAR entries only showed acknowledgment of the restriction, not actual compliance, while the RD and NP confirmed the restriction order and noted that noncompliance needed to be documented.
A resident with a history of stroke, left-sided hemiplegia, and intact cognition was documented as needing one-person assistance with eating and was identified on admission as being at risk for hot liquid spills due to upper extremity weakness. Despite this, the care plan and Kardex did not include specific hot-liquid precautions or assistive devices, and staff left the resident alone with hot coffee on two separate occasions. In the first incident, a CNA, after confirming with an RN, placed a lidded cup of hot coffee at the bedside and left; the resident spilled it and sustained a painful burn with open skin on the left forearm, which was treated with triple antibiotic ointment rather than immediate cooling as described in external burn-care guidance cited in the report. In the second incident, another CNA, unaware of the prior burn and without any hot-liquid precautions documented, provided coffee at the resident’s request and left; the resident again spilled the coffee and food, resulting in a burn to the left hand. Interviews showed that multiple staff knew the resident required assistance with meals and had a shaky right hand, yet the facility’s hot liquids and assistive device policies were not effectively implemented or communicated, leading to inadequate supervision and two burn injuries.
A resident with a history of intracerebral hemorrhage and left-sided hemiplegia, who was left-handed and required assistance with ADLs, experienced two separate hot coffee burns to the left arm/hand after being given coffee without adequate assistance despite being assessed as at risk for hot liquid spills. The care plan and Kardex only reflected a one-person assist for eating and did not include specific interventions for hot liquid safety or special equipment, even though CNAs and an RN recognized the resident needed help with drinks and that lids and straws were used due to frequent spills. After the first burn, no additional interventions or communication of hot liquid risk were incorporated into the care plan or Kardex, and the incident was not reported as neglect, contrary to the facility’s abuse/neglect policy that defines neglect as failure to provide necessary care to avoid physical harm and discomfort.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards.
Surveyors found that appropriate care was not consistently provided for residents with bowel or bladder continence or incontinence, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
The facility was cited for failing to meet food service safety standards, including an inaccessible handwashing sink due to blocked access, and dietary staff not following hand hygiene protocols. Staff were observed wearing artificial fingernails and jewelry, handling food without gloves, and not washing hands after leaving and re-entering the kitchen or using personal items, all in violation of FDA Food Code requirements.
Residents repeatedly reported delayed call light response, staff turning off call lights before needs were met, and inconsistent water pass during RC meetings. Despite these ongoing concerns, documentation of actions taken was often incomplete or absent, and residents felt their grievances were not taken seriously by facility leadership, leading some to stop reporting issues.
Multiple residents reported that hot foods were consistently served cold, with group interviews confirming widespread dissatisfaction regarding food temperature, quality, and missing items. Observations during meal service showed that while food started at safe temperatures, it cooled significantly before reaching residents, and there was no ongoing temperature monitoring during tray delivery.
A resident with moderate cognitive impairment and diabetes was not provided with facial hair grooming despite expressing her desire for it and facility policy requiring such care on shower days. Staff interviews confirmed the expectation to offer grooming, but documentation and follow-through were lacking, resulting in the resident's needs not being met.
A resident with reduced mobility and decreased strength did not receive the ordered restorative range of motion (ROM) program, as confirmed by interviews and a lack of documentation for the past month. Staff cited inconsistent scheduling and poor oversight as reasons for the missed services, and the resident expressed a desire to participate in the program. The facility's policy requiring daily review and documentation of restorative care was not followed.
A resident's care plan was not updated to reflect changes in adaptive equipment needs, despite communication from the occupational therapist. The resident, with severe cognitive impairment and other health issues, continued to receive outdated equipment, as the nursing and dietary departments did not implement the communicated changes.
A resident was supposed to receive Norco for pain management, but the order was incorrectly entered as Percocet in the EHR. The error was identified when the resident's family member reported the discrepancy. Staff confirmed the clerical error, and the resident was actually given Norco, which was available in the medication cart.
A resident with a cervical vertebra fracture was not properly managed during a transfer, as a CNA removed the Aspen collar before the transfer, contrary to care plan instructions. The CNA was unaware of the requirement to keep the collar on during transfers, as it was not specified in the Kardex. This deficiency was confirmed by an RN and UM/LPN, who stated the collar should remain on to prevent further injury.
A resident's medical records inaccurately documented an order for Percocet instead of Norco due to a clerical error by a nurse. The resident, who was cognitively intact, had diagnoses including pain and muscle weakness. The error was confirmed by facility staff and had the potential to affect the resident's medical outcome.
During a COVID outbreak, staff at the facility failed to wear face masks correctly, with multiple instances of masks worn below the nose or chin. Despite signage and re-education efforts by the Infection Preventionist, non-compliance was observed among various staff members, including dietary aides, RNs, CNAs, and housekeepers, posing a potential risk for infection spread.
Failure to Manage Pressure Ulcers and Prevent New Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for two residents. One resident was admitted with multiple severe wounds, including a stage 4 sacral pressure ulcer, paraplegia, and sepsis, and had orders for wound vac therapy with dressing changes twice weekly. Facility staff reported that the wound vac was difficult to maintain because of heavy drainage and that wet-to-dry dressings were used when the vac would not seal. The resident’s wounds were documented as multiple stage 3 and unstageable ulcers involving both trochanters and gluteal areas, with moderate to heavy serosanguineous drainage and repeated problems maintaining the wound vac seal. The record showed that the wound vac repeatedly malfunctioned and was eventually replaced with wet-to-dry dressings, but the facility did not document communication with the wound clinic about the ongoing wound vac problems or alternate treatment options. When the resident arrived at the wound clinic, he had no dressings on his wounds and no wound vac supplies. The wound clinic documented a fever, necrotic tissue, copious purulent drainage, and probing to bone, and sent the resident to the emergency room for treatment. Interviews confirmed that facility staff had not contacted the wound clinic regarding the wound vac malfunctioning or the resident’s wound care needs, and the resident’s wound vac order was documented as discontinued on 2/23/26. A second resident was identified as being at risk for impaired skin integrity and had care plan interventions for an alternating pressure mattress, barrier cream, turning and repositioning every 2 to 3 hours, and elevating heels off the mattress. The resident developed a new deep tissue pressure ulcer on the left heel and a new facility-acquired wound on the left lateral calf. Observations showed the resident lying in bed without heel offloading boots and without a pillow or bolster under the feet, with the head of the bed elevated. The medical record contained no refusals for repositioning or for wearing pressure redistribution boots, despite staff statements that refusals should be documented if they occurred.
Delayed Call Light Response and Incontinence Care
Penalty
Summary
The facility failed to ensure timely response to call lights to meet resident needs for dignity and self-determination. Surveyors found that 4 of 5 residents reviewed for dignity—Residents #8, #14, #58, and #119—reported long waits for staff to answer call lights, and 6 of 13 residents in a confidential group interview reported similar concerns, including staff turning off call lights before needs were met and not returning to complete requested care. Resident #8 was cognitively intact with diagnoses including heart failure, obstructive lung disease, morbid obesity, diabetes, high blood pressure, depression, and anxiety, and was always incontinent of bowel and bladder. She reported call light response times of 20 to 30 minutes on first shift, sometimes up to an hour, and about 45 minutes on second shift for incontinence care and brief changes. She stated that waiting so long for care made her feel like she was not worth anything and did not mean anything. Resident #14 was cognitively intact and always incontinent of bowel and bladder, with diagnoses including heart failure, heart disease, obstructive lung disease, morbid obesity, chronic pain, anxiety, high blood pressure, muscle weakness, reduced mobility, diabetes, and a history of falls. She reported waiting about two hours for incontinence care during the morning shift and said she was soaked and burning. Resident #58 reported third shift staff took over an hour to answer his call light, and he urinated on himself while waiting. Resident #119, who had stage 4 sacral pressure ulcer, sepsis, paraplegia, and required extensive assistance including Hoyer lift transfers, was reported by family to have call lights left on for over 20 minutes, with staff turning them off, asking what he needed, and not returning; family also reported repeated calls to the facility to get staff attention.
Falls, Unsafe Transfers, and Wheelchair Transport Without Footrests
Penalty
Summary
The facility failed to ensure resident safety to prevent falls, failed to provide adequate supervision and assistance to prevent falls, and failed to use wheelchair footrests during transport for three residents. Resident #40 had diagnoses including Alzheimer’s disease, dementia, insomnia, kidney disease stage 3, and a history of falling. The record showed 22 falls over a two-month period, with many incidents tied to self-transferring and toileting needs. During observations, Resident #40 was seen with bruising under the left eye and was later observed being pushed in a wheelchair with foot pedals that were not secured, including one pedal falling off and the other dragging under the wheelchair while staff continued transporting him. Resident #40’s fall record showed repeated incidents in which he was found on the floor, in the bathroom, in the hallway, or attempting to stand or walk without assistance. Several entries identified the root cause as attempts to self-transfer, self-transfer to the toilet, or ambulating unassisted. The care plan included multiple interventions over time, such as toileting before meals, assisting him to bed when sleepy, and other environmental measures, but the record review stated the facility did not add supervision interventions after each fall. Interviews with the UM, NHA, and LPN confirmed that Resident #40 required a hoyer lift with two staff for transfers and that a resident should not be transported in a wheelchair without foot pedals. Resident #26 was observed being transferred from bed to bedside commode and back without a gait belt. The CNA held the resident under both arms during the transfer and lifted the resident without using the gait belt that staff later confirmed was required for transfers. Resident #26 reported staff did not use a gait belt for the transfer, and the LPN stated the resident had been reevaluated after a difficult transfer and needed additional support because strength varied. Resident #95, who had neurocognitive disorder with Lewy bodies and dementia, was observed being pushed in a wheelchair without footrests while the DON walked behind and slightly to the side, carrying a laptop and telling the resident to pick up his feet. The DON stated the resident could be pushed without footrests if staff were beside the wheelchair and watching the feet, and acknowledged the resident could flip out of the wheelchair if the feet were put down while being pushed.
Unsafe and Unsanitary Facility Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment. During observation, resident slings in the D hall closet and B hall spa room were hung by one side only, allowing the bottoms of the slings to drag on the floor. In the dining room, a love seat and chair had an accumulation of debris, sand, wrappers, paper trash, and a yellow push pin, and the chair also contained a sheet of paper with resident names and room numbers for D hall and an intact plastic vial of Albuterol Sulfate. The Housekeeping Manager stated the dining room furniture is cleaned daily and that the area gets a lot of use from residents. Additional observations showed environmental and maintenance issues throughout the facility, including broken discharge pipes on the exterior that allowed rainwater to run down the brick outer layer, and multiple areas with dirt, debris, black streaks, scrapes, missing paint, cracked or missing tile, and damaged thresholds, doorframes, and walls in resident rooms and hallways. Room A-05 had a dirty bathroom floor, black coating on the toilet caulking that appeared to be mold/mildew, black marks on the walls and doorframes, dried liquid behind the bathroom door, and a shared floor space that needed sweeping and mopping. Other observations included a dirty fall mat in Room D-01, damaged and dirty surfaces in Rooms C3, C5, and C8, a missing metal door stopper in Room C2 that left a divot and exposed metal, and missing or cracked hallway tile near the Activity Supplies room and Personal Linens room doors.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities designed to support the psychosocial well-being of one resident, who was reviewed for activities and was unable to complete the BIMS, absent of spoken words, and rarely or never understood. The resident had diagnoses including stroke and traumatic brain injury, was dependent on staff for ADLs, positioning, and sensory stimulation, and the care plan identified altered activity patterns related to cerebral infarction. The care plan included visiting with his son, listening to R&B music, and short room visits, but the intervention had not been revised since 12/17/2023 and did not include other activities listed in the resident’s activity evaluation, such as gardening and being outdoors. The resident’s activity evaluation stated he enjoyed family and friend visits, gardening/outdoor activities, movies/TV, and music/talk radio, and noted a television and radio were needed in his room. The quarterly progress note stated he needed assistance for most activities and transport and that he enjoyed music, watching sports, and spending time with family. The 1:1 program documentation from 4/16/26 through 5/13/26 showed the resident listened or participated in music 7 times, refused once, and 12 times activities were marked not applicable, with no outdoor activity provided during that period despite the resident’s stated preference for outdoor activities. Observations showed the resident lying supine in bed staring at the curtain or blank ceiling while the television was on, with no music machine visible in the room and family photographs placed out of his sight. The activity director stated he had bought a music machine for the resident, did not know whether staff turned it on, and said he had not been following CNA charting and did not know the resident was not up and listening to the music program. Staff stated the resident could not communicate needs or refuse activities, did not have a music machine they were aware of, and was not routinely assisted to get up for activities unless activities asked them to. The resident’s guardian was called but did not return the call by the end of the survey.
Catheter Bag Dragging on Floor
Penalty
Summary
The facility failed to ensure a urinary catheter was maintained in a sanitary manner for Resident #122, who had an indwelling Foley catheter related to urine retention. The resident’s care plan directed staff to change the catheter and drainage system as clinically indicated per orders, observe for signs and symptoms of obstruction or infection, irrigate the Foley catheter as indicated, maintain the drainage bag below bladder level, and use a privacy cover for the drainage bag. The resident’s nursing evaluation summary also noted a recent stroke, left-sided weakness in the upper extremity, and that he had previously straight catheterized himself at home before the stroke. During observations on 05/12/2026 and 05/13/2026, Resident #122 was seen in his wheelchair in the hallway and doorway with the catheter bag hanging under the wheelchair and partially lying on the floor, with the bottom of the bag dragging on the floor as he self-propelled and moved back and forth. An LPN told the resident she had another attachment for him and then had him go into his room and shut the door, and later reported she replaced the catheter tubing securement device. The Unit Manager and DON both stated the catheter bag should not be on the floor because it was an infection control concern.
Oxygen Flow Set Above Ordered Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with chronic respiratory failure with hypoxia or hypercapnia, heart failure, and debility due to cardiorespiratory conditions. The resident’s MDS showed cognitive impairment with a BIMS score of 8/15, dependence on staff for transferring and mobility, and continuous oxygen use in the facility. The order summary and MAR documented oxygen at 2.5 L/min via nasal cannula continuously, and the care plan identified altered respiratory status with continuous O2 use as ordered. During observations, the resident’s oxygen was found running above the ordered rate, at 3.5 L/min on two occasions and later at 4 L/min. An LPN reviewed the physician order and observed the concentrator set at 4 L/min, stating she had not known it was set that way and that if the night nurse had changed the flow with a new order, she should have been told on shift report. Administration stated that oxygen is a medication order.
Unlabeled topical medications and unsecured narcotic storage
Penalty
Summary
Medications and topical treatments were not consistently labeled, dated, or stored as required for one resident who was cognitively intact with multiple diagnoses including heart failure, arthritis, non-Alzheimer’s dementia, and bipolar disorder. During observation, a tube of zinc oxide was found on the resident’s dresser with the cap off and debris on the ointment opening, while antifungal powder and Bio Freeze gel were also observed in the room without labeling or dating. The resident stated staff had used the zinc ointment earlier that day and left it on the dresser, and reported the powder was used under the breasts and belly and the gel was used on the knees. Record review showed orders for Bio Freeze gel to the bilateral knees and zinc oxide to the bilateral buttocks, but no order for antifungal powder. The MAR/TAR documented administration of Bio Freeze and zinc oxide as ordered, but there was no documentation that antifungal powder had been applied. The care plan addressed impaired skin integrity and barrier cream use, but did not include a focus, goal, or interventions for antifungal cream or Bio Freeze gel. Staff interviews indicated the resident did not self-administer these products, and CNAs reported powders, ointments, and lotions should not be kept in resident rooms. The facility also failed to store medications securely in the A hall medication room. Surveyors observed the refrigerator in the medication room unlocked, and staff confirmed it was used to store medications, including narcotics. RN staff and the DON stated the refrigerators should be locked at all times, and one RN removed a sealed plastic container from the refrigerator that was labeled as containing a narcotic. Facility policy stated narcotics and controlled substances are to be stored under double lock and key.
Inaccurate documentation of fluid restriction status
Penalty
Summary
The facility failed to ensure accurate medical records for one resident, resulting in an inaccurate representation of the resident’s current care needs. Resident #77 had a diagnosis of SIADH and a care plan and MAR that reflected a fluid restriction of 1000 mL/24 hours, with 540 mL from dietary and 460 mL from nursing for hyponatremia. During observation, the resident’s breakfast tray included fluid restriction instructions, but the tray and room contained multiple beverages, including water, coffee, soda, and several partially consumed cups of water. The resident was observed drinking coffee and later stated that her sodium was fine and she was not on a fluid restriction now, although staff identified that she was on one. Record review showed the MAR contained documented entries for the fluid restriction, but staff explained those entries reflected acknowledgment of the restriction rather than the resident’s actual compliance with it. A CNA stated it was the responsibility of all staff to monitor compliance, and another CNA said the resident did not appear compliant based on the number of cups removed from the room. The RD confirmed the fluid restriction order, and the NP stated the resident should be on a fluid restriction and that if she was not compliant, nursing staff needed to document that; the NP also stated the resident would not follow the restriction.
Failure to Supervise Resident With Hot Liquids Resulting in Repeated Burns
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards related to hot liquids for a resident with significant functional limitations, resulting in two burn injuries. The resident had a history of nontraumatic intracerebral hemorrhage with flaccid hemiplegia affecting the left dominant side, chronic pain, and depression. On admission, the nursing evaluation documented that the resident was at risk of hot liquid spills due to weakness/paresis and reduced mobility in the upper extremities, and the care plan and Kardex both indicated the resident required one-person assistance with eating. The MDS also reflected that the resident needed partial/moderate assistance with eating. Despite this, there was no documentation in the care plan or Kardex that the resident was at risk for hot liquid spills or required special equipment to reduce that risk. On the first incident date, staff provided the resident with hot coffee in her room. A CNA reported that the resident had previously spilled soda on herself and the bed and asked an RN if the resident could have coffee; the RN allowed it. The CNA placed a lidded cup of coffee on the bedside table and left the resident alone. Later, staff found that the resident had spilled the coffee and sustained a burn on her left lower forearm. The resident’s family member stated that the resident had a stroke, had left-sided paralysis, used only her right (non-dominant) hand, and needed assistance with meals and drinks, and that she had informed staff of this. The resident herself reported that the coffee lid was on the cup but fell off when she took a drink, and that she needed help with meals and drinks. Clinical documentation and photographs showed an in-house–acquired burn on the left inner forearm with open skin, redness, pain, and later blistering consistent with a second-degree burn. The nurse who first treated the burn did not apply cool water and instead used triple antibiotic ointment and a non-adherent dressing, contrary to external burn first-aid guidance cited in the report and to the expectations later described by facility clinical leadership. A second burn incident occurred a few days later, again involving hot coffee. On that day, a CNA brought the resident a cup of coffee at her request, not knowing about the prior burn. The Kardex indicated the resident was a one-person assist for meals, but there were still no specific interventions regarding hot liquids or assistive devices documented or communicated to staff. The resident was again left alone with hot coffee and subsequently spilled her lunch plate and coffee on herself and the floor. When another CNA responded to the call light, the resident’s left hand was noted to be red, and cool water was poured over the area. The unit manager observed spilled coffee on the bed and floor and redness of the left hand. Staff interviews confirmed that the resident was known to need assistance with meals due to left-sided weakness and a shaky right hand, and that she was considered a one-to-one assist at meals. However, the hot liquid safety assessment process described in facility policy was not effectively implemented: although the admission assessment identified the resident as at risk for hot liquid spills, this risk was not translated into specific, documented interventions on the care plan or Kardex, and there was no systematic communication to direct care staff about hot liquid precautions prior to the second burn. The facility’s own Hot Liquids/Food Assessment Policy required that when a resident is identified as having concerns with handling hot liquids, a hot liquids safety evaluation should be completed and immediate interventions such as cooling liquids, use of lids, avoidance of hot liquids until evaluation, therapy evaluation, IDT review, and an immediate plan of care should be implemented and added to the care plan and Kardex. The Use of Assistive Devices Policy required IDT collaboration to provide and support assistive devices and staff training. Despite these policies, the unit manager stated that the facility did not do anything different for residents at risk for hot liquid spills because all residents received plastic lids, and that such risk would not be specifically communicated. The administrator acknowledged that no interventions were put in place after the first burn and that no full staff education occurred. Dietary staff monitored coffee temperatures but not all hot liquids, and there was no separate documentation line for hot water temperatures. Therapy only formally evaluated the resident for assistive devices and dining-room supervision after the second burn. Collectively, these actions and inactions led to the resident twice being left unsupervised with hot coffee despite known physical limitations and documented assistance needs, resulting in two burn injuries and the resident’s expressed fear of being burned again.
Failure to Report and Care Plan for Resident at Risk for Hot Liquid Burns
Penalty
Summary
The deficiency involves the facility’s failure to report an incident of neglect related to hot liquid burns and to implement appropriate interventions after an initial burn, resulting in a second burn to the same resident. The resident had a history of nontraumatic intracerebral hemorrhage with flaccid hemiplegia affecting the left dominant side and was assessed on admission as being at risk for hot liquid spills due to upper extremity weakness and reduced mobility. The resident’s MDS showed intact cognition, and the care plan and Kardex identified a one-person assist for eating but did not include any interventions or information regarding risk for hot liquid spills or special equipment to reduce that risk. On one occasion, the resident’s family member found the resident covered in dried coffee with a burn on the left forearm that was red, swollen, with peeled skin, and the resident complained of pain. An incident report documented that staff notified an LPN that the resident had spilled coffee and burned herself, and the daughter stated the resident was not supposed to be left alone with hot drinks. CNAs reported that the resident was a one-to-one assist with meals because her right (non-dominant) hand was shaky and that the Kardex should indicate if assistance with hot beverages was needed. The resident herself reported having two burns on her left arm/hand, described the first burn as severe with blisters, and stated that although the coffee lid was on the cup both times, it fell off when she took a drink; she also stated she was left-handed, had to use her right hand due to left-sided neglect, and needed help with meals and drinks. A second incident report documented another hot coffee spill in which a CNA responded to the resident’s call light and found coffee spilled on the bed and floor, with the resident’s left hand noted to be red and blanching. The Unit Manager confirmed that a hot liquid safety assessment completed on admission identified the resident as at risk for hot liquid spills, but stated that the facility did not do anything specific with these assessments for high-risk residents beyond providing lids on cups, and that this risk was not otherwise communicated. The Nursing Home Administrator stated the first burn was not reported because it was not considered an injury of unknown origin, despite the facility’s abuse/neglect policy defining neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and listing failure to provide care needs such as comfort and safety as a possible indicator of abuse or neglect.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the cited deficiency.
Food Service Safety Deficiencies Due to Inaccessible Handwashing Sink and Staff Noncompliance
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations during kitchen operations. The only handwashing sink in the kitchen was blocked by a large dietary cart full of dirty dishes, making it inaccessible to staff. Interviews with facility staff revealed ongoing concerns about the lack of a conveniently located handwashing sink, with discussions about adding another sink but no resolution due to space and plumbing constraints. The placement of dietary carts further contributed to the inaccessibility of the handwashing sink, impeding regular hand hygiene practices. During lunch service, dietary staff were observed violating food safety protocols, including wearing artificial fingernails and jewelry while handling food without gloves, and failing to wash hands after activities that could contaminate them, such as leaving and re-entering the kitchen or handling personal items like cell phones. The Certified Dietary Manager was also observed assisting with food items without washing hands after entering the kitchen. These actions were not in compliance with the 2022 FDA Food Code requirements for hand hygiene, fingernail maintenance, and jewelry restrictions for food employees.
Failure to Address and Resolve Resident Grievances Regarding Call Light Response and Water Pass
Penalty
Summary
The facility failed to ensure that grievances raised by residents during Resident Council (RC) meetings were promptly documented, investigated, and resolved. Over several months, RC meeting minutes consistently recorded concerns regarding delayed call light response times, particularly on the third shift, staff turning off call lights before addressing residents' needs, and inconsistent water pass. Despite these recurring issues being documented as both old and new business in multiple RC meetings, the 'Actions taken' sections were frequently left blank or marked as 'ongoing,' with no clear evidence of resolution or follow-up. During an RC meeting, all nine participants confirmed that assistance was not provided in a timely manner on the third shift, with one resident reporting a wait of several hours for help after activating the call light. Residents expressed frustration that their repeated complaints were not being taken seriously by facility leadership, with some stating they had stopped voicing concerns to the Nursing Home Administrator (NHA) or Director of Nursing (DON) due to a lack of meaningful response. Several residents described receiving generic assurances without observable improvement, and the issues would temporarily improve before recurring. The NHA acknowledged awareness of the concerns and described a staffing schedule change, but the report does not indicate that these actions effectively addressed the residents' grievances.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for multiple residents. Two residents with cognitive intactness, one with anemia, diabetes, depression, and anxiety, and another with a history of sepsis, reported that hot foods were often served cold, with one specifically mentioning a cold pork chop at dinner. Both residents had previously communicated their concerns to staff, including the registered dietitian, but continued to experience the same issues. Additionally, a group interview with nine residents revealed unanimous dissatisfaction, with all participants stating that food was always cold, vegetables were overcooked and mushy, and items were frequently missing from trays. The group also reported that their food preferences and requests were not honored, and that a food committee had not led to any improvements. Observations during meal service confirmed the deficiency. While hot food items on the steam table were initially at appropriate temperatures (over 175°F), the process of delivering trays to different halls resulted in significant temperature drops. A test tray placed on the last cart delivered to a hall was found to have mashed potatoes at 119°F, Salisbury steak at 109°F, and carrots at 118°F, well below the recommended serving temperatures. No additional food temperatures were recorded during the meal service, indicating a lack of ongoing monitoring to ensure food remained at a safe and appetizing temperature until served.
Failure to Provide Dignified Grooming for Resident
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and a history of type 2 diabetes and muscle weakness was observed to have long gray facial hairs on her chin. The resident reported that facial hair grooming was performed regularly at her previous group home, but since admission to the facility, this grooming had not occurred. Despite expressing her desire to have her facial hair shaved, the grooming was not provided. Multiple staff interviews confirmed that the facility's standard practice is to offer shaving or plucking of facial hair on shower days or upon resident request. However, the resident stated that even after a recent shower, her facial hair was not addressed as expected. Review of the resident's care records showed that her bathing schedule was documented, but the shower sheets only indicated whether skin checks were performed and did not include a section for grooming tasks. The facility's written expectations require staff to attend to facial hair for both men and women during each shower, and to inform the nurse if a resident refuses grooming. In this case, the lack of documentation and follow-through resulted in the resident's grooming needs not being met, impacting her dignity and personal preferences.
Failure to Implement and Document Ordered Restorative ROM Program
Penalty
Summary
The facility failed to implement and document an ordered restorative program for a resident with reduced mobility and decreased strength in both upper and lower extremities. The resident had a physician's order for a Level 2 restorative ADL/hygiene and range of motion (ROM) program, and the care plan specified the need for restorative ROM interventions. Despite this, there was no documentation of restorative services being provided for the last 30 days. Interviews with the resident, restorative aide, and the restorative director confirmed that the resident had not been consistently seen for restorative care, with staff citing the resident's preference for spending time outside and lack of set scheduling as reasons. The restorative director also admitted to not ensuring proper documentation or oversight of the program. The facility's own policy required daily review and documentation of restorative services, including time spent, resident tolerance, and reasons for missed sessions. However, these requirements were not met, as evidenced by the absence of documentation and staff acknowledgment of lapses in both service delivery and record-keeping. The resident expressed awareness of the missed services and a desire to participate in the restorative program, further confirming the deficiency in care.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to revise a person-centered care plan for a resident, resulting in an inaccurate reflection of the resident's current care needs. The resident, who had diagnoses including adult failure to thrive, restlessness and agitation, and severe protein calorie malnutrition, was assessed with a severe cognitive impairment. The care plan initially included the use of adaptive equipment such as a plate guard, built-up utensils, and a 2-handled cup with a straw. However, the occupational therapist had upgraded the resident to regular silverware and communicated these changes to the nursing and dietary departments, but the care plan was not updated to reflect these changes. Observations revealed that the resident was still being provided with built-up utensils and other adaptive equipment that were no longer necessary according to the occupational therapist's assessment. Despite the communication of changes in December, the care plan and meal tickets continued to list outdated equipment needs. The unit manager acknowledged that the updates had not been made in the nursing department, which also affected the dietary department's adherence to the resident's current needs.
Inaccurate Physician Orders Lead to Potential Medication Error
Penalty
Summary
The facility failed to maintain professional standards of nursing practice related to physician orders for a resident, resulting in inaccurate physician orders and the potential for medication error. The resident, who was cognitively intact, was supposed to receive Norco for pain management as per the physician's verbal order. However, the order was incorrectly entered into the Electronic Health Record (EHR) as Percocet. This clerical error led to a discrepancy between the medication order and the medication administered. The error was identified when the resident's family member reported that the facility dispensed Percocet instead of Norco, which was not ordered by the physician. Interviews with the Director of Nursing, Nursing Home Administrator, and other staff confirmed that the order for Percocet was entered inaccurately and that the resident was actually given Norco, which was available in the medication cart. The incident was documented as a near miss, as the wrong medication was not administered to the resident.
Improper Aspen Collar Use During Resident Transfer
Penalty
Summary
The facility failed to ensure the proper placement of an Aspen collar during a transfer for a resident with a fracture of the second cervical vertebra. The resident, who was severely cognitively impaired, had specific orders to wear the Aspen collar when up in a wheelchair and during transfers. However, during an observation, a CNA removed the resident's Aspen collar before assisting with a transfer from a wheelchair to a bed, contrary to the care plan instructions. The CNA was unaware of the importance of keeping the collar on during transfers, as this information was not specified in the Kardex, which she relied on for resident care instructions. The RN and UM/LPN confirmed that the collar should remain on during transfers to prevent further injury. The deficiency was identified through observation, interviews, and record reviews, highlighting a gap in communication and adherence to the resident's care plan.
Inaccurate Medication Order Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to an incorrect documentation of medication orders. The resident, who was cognitively intact with a BIMS score of 15/15, had pertinent diagnoses including pain, muscle spasm, contracture of the left foot, and muscle weakness. A discrepancy was found in the medication orders where the resident's record inaccurately documented an order for Percocet instead of Norco. This error was identified during a review of the resident's medical records and confirmed through interviews with the resident's family member and facility staff. The error originated from a verbal order given by the resident's primary care physician, which was incorrectly transcribed by a registered nurse. The nurse mistakenly entered the order for Percocet into the electronic health record (EHR) instead of the correct medication, Norco. This clerical error was acknowledged by the Director of Nursing and the Education Training Director, who confirmed that there was no written prescription or verbal order for Percocet. The inaccurate documentation of the medication order had the potential to impact the resident's medical outcome.
Improper PPE Usage During COVID Outbreak
Penalty
Summary
The facility failed to ensure that personal protective equipment, specifically face masks, was worn correctly by staff during a COVID outbreak. Observations revealed multiple instances where staff members, including a dietary aide, registered nurse, certified nurse assistants, housekeepers, and a floor tech, were not wearing their face masks properly, with masks positioned below their noses or chins. This occurred despite signage indicating a COVID outbreak and the requirement for face masks to be worn throughout the building. Interviews with staff confirmed that they were aware of the requirement to wear masks covering both the nose and mouth, yet non-compliance was observed. The Infection Preventionist confirmed that during a COVID outbreak, all staff were required to wear face masks correctly, covering the nose and mouth. Despite having a laminated picture illustrating the proper way to wear a face mask and re-educating staff, the issue persisted. The report highlights that the facility's failure to enforce proper mask-wearing practices among staff during a COVID outbreak posed a potential risk for the spread of infection and disease transmission among residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 333 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harold And Grace Upjohn Community Care Center | 4.5 mi | ★★★★★ | 34 | 0 |
| Medilodge Of Kalamazoo | 6.1 mi | ★★★★★ | 4 | 0 |
| Friendship Village | 7.7 mi | ★★★★★ | 15 | 0 |
| Villa At Borgess Place | 8.1 mi | ★★★★★ | 13 | 0 |
| Medilodge Of Westwood | 8.5 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.