Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mission Point Nsg Phy Rehab Ctr Of Madison Heights during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including a history of falls, experienced a fall due to inadequate supervision and incorrect care plan documentation. The facility failed to update the care plan and CNA Kardex to reflect the need for a two-person assist for bed mobility, despite a decision made by the interdisciplinary team. This discrepancy led to a potential risk for additional falls.
The facility's ice machines in the main kitchen and on the first floor were found to lack backflow protection, as their drain lines extended into the floor drains without an air gap. This deficiency was observed and confirmed through interviews, with the Dietary Manager unaware of the requirement. The lack of backflow prevention posed a potential risk to all residents.
The facility failed to maintain light cords at an appropriate length within reach for five residents on the 2 East unit. Observations showed that the light pull strings were too short, making them inaccessible. Staff were unaware of the issue, and no documentation of repairs was provided.
The facility failed to maintain a safe, clean, and homelike environment, affecting multiple residents. Observations revealed foul odors, mold, and maintenance issues in shower rooms, as well as debris and cleanliness problems in residents' rooms. Staff confirmed these issues, and documentation for maintenance was lacking. Facility policies on cleaning and resident rights were not followed, leading to these deficiencies.
The facility failed to properly store and label medications in two medication carts. An insulin pen was found without a label, and another was mislabeled with a future date. Additionally, an antidepressant was stored in the wrong cart and left unsecured. The DON confirmed the protocol for labeling and storing medications.
An LPN failed to follow infection control protocols during medication administration by not cleaning equipment and neglecting hand hygiene between residents. Additionally, a CNA improperly placed a meal tray on their lap while assisting a resident, contrary to hygienic dining practices. These actions were against the facility's policies.
The facility failed to maintain adequate ventilation in the 2 East Shower Room, resulting in stale and malodorous air affecting all residents using the room. Observations confirmed non-functioning ventilation, and the Plant Operations Manager acknowledged the issue without providing an explanation for the lack of monitoring. Maintenance logs showed no documented concerns, and the facility did not provide a policy on bathroom ventilation or relevant repair invoices.
The facility failed to maintain residents' rights to receive unopened and private mail. Two residents reported issues: one received opened Christmas cards, and another experienced delays and was told to open packages in front of staff, violating their privacy. The Administrator was unaware of these practices, which contradicted facility policies on mail privacy.
The facility failed to educate and offer a resident the opportunity to formulate an advance directive, as required by policy. The resident, admitted with bipolar disorder and depression, had no documentation of being offered this option. Interviews revealed confusion about departmental responsibilities, with the Social Services Manager stating they only handled code status, not advance directives. The Acting Administrator later confirmed the social services department's responsibility, but no further documentation was provided.
A resident with severe cognitive impairment was found with a bruise around their eye, initially attributed to lying on a bed remote. Despite worsening bruising and swelling, the facility did not report the injury as unknown in origin to the state agency, believing they knew the cause. Staff interviews revealed the resident's condition was assessed, but the facility assumed the injury's origin and did not report it.
A resident with mental health diagnoses did not receive a required PASARR Level II Evaluation by the specified deadline. The facility's Social Services Manager confirmed the evaluation was neither completed nor submitted, despite policy requirements for tracking PASARR screening status.
An LPN failed to ensure proper medication administration for two residents. The LPN did not observe one resident consuming their medications and left another resident's pills unattended. The facility's policy requires observation to ensure ingestion, which was not followed. The DON confirmed the LPN's actions were inconsistent with protocol.
A facility failed to accurately account for a resident's controlled medication, Hydrocodone-Acetaminophen, due to improper documentation and protocol adherence. An LPN reported administering one pill and discarding another without documenting the wastage on the proof-of-use form. Although a second LPN witnessed the wastage, neither signed the form as required by facility protocol. The Director of Nursing confirmed the protocol, but a policy was not provided during the survey.
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. A resident with a history of violent behavior punched another resident over a disagreement, and another resident with severely impaired cognition assaulted two different residents on separate occasions. Despite these incidents being witnessed and reported, the facility delayed implementing appropriate care plans to prevent further harm.
The facility failed to thoroughly investigate multiple incidents of resident-to-resident abuse, involving residents with impaired cognition and aggressive behavior. Key witnesses and involved parties were not interviewed, and documentation was insufficient, leading to a lack of understanding of the root causes and potential for further abuse.
A resident with severely impaired cognition and a history of elopement risk exited a facility unnoticed and walked to a police station. Despite being identified as an elopement risk, the facility failed to implement effective interventions or provide adequate supervision. Staff interviews revealed a lack of communication and awareness regarding the resident's elopement risk and necessary interventions.
A resident experienced a 13.5% weight loss over several months due to the facility's failure to monitor and address nutritional needs. Despite being dependent on staff and having severe cognitive impairment, the resident's weight was not documented in March, and significant weight loss was not addressed until May. The registered dietician was unaware of the weight loss due to missed alerts, and the facility's weight monitoring policy was not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions such as pressure ulcers and indwelling devices, as required. Observations showed a lack of EBP signage and PPE availability in residents' rooms. Staff interviews revealed insufficient training and awareness of EBP protocols, contributing to the deficiency. During a dressing change for a resident with a pressure ulcer, an LPN did not use the required PPE, further highlighting the facility's failure in infection control measures.
The facility failed to ensure a safe environment by leaving emergency carts unlocked with sharp objects accessible, including razors and suture kits. A resident was observed accessing one of these carts and removing emergency equipment, highlighting inadequate supervision and increased accident risk. The DON and an LPN acknowledged the issue.
The facility failed to maintain an effective antibiotic stewardship program in May 2024, with incomplete documentation and lack of infection control measures. The DON, who started at the end of May, found the program disorganized and began revamping it. The Administrator confirmed the issue, noting a past non-compliance finding.
The facility failed to respect the dignity and preferences of two residents. One resident, who is cognitively intact, felt forced to take a shower despite preferring bed baths, and had to use an unsuitable wheelchair due to the lack of an appropriate shower chair. Another resident, who is blind, reported that some CNAs argued or refused to provide showers, and they could not identify the CNAs due to their blindness and lack of name disclosure. The facility's policy on maintaining resident dignity was not followed.
A facility failed to report an abuse allegation when a resident threatened another with a fork. The incident was reported to staff, including a Social Worker, but not documented or reported to the Abuse Coordinator and State Agency. The resident who reported the threat was cognitively intact, while the resident who made the threat had schizophrenia and was later sent for psychiatric evaluation. Despite awareness by the Social Worker, the Administrator was not informed, violating the facility's abuse reporting policy.
A resident with a history of falls was not provided with a concave mattress or floor mats as indicated in their care plan. Despite a physician's order, these interventions were absent during observations. The resident, with severe cognitive impairment and dependent on staff, had a care plan that was not updated to reflect changes in their fall risk status, leading to a deficiency.
A resident with multiple diagnoses, including diabetes and atrial fibrillation, refused medications during an observed administration. However, an LPN erroneously documented the medications as given in the MAR. The LPN later confirmed the error, attributing it to nervousness during the observation. The DON was informed of the documentation mistake.
The facility failed to ensure shaving per personal preference for two residents who required assistance with ADLs. One resident, who is blind, reported CNAs refused to shave him, while another resident with impaired cognition was observed with a full beard despite preferring to be clean-shaven. Both residents were later observed clean-shaven after receiving assistance. Interviews revealed residents are usually shaved during showers or upon request, as per facility policy.
A facility failed to monitor blood glucose levels for a diabetic resident after readmission, despite previous unstable levels and sliding scale insulin use. The resident, with multiple health issues, was not monitored for 12 days, leading to a cardiac arrest and death. Interviews revealed a lack of clarity and documentation regarding monitoring decisions.
A resident developed an avoidable unstageable pressure ulcer due to the facility's failure to provide an appropriate support surface bed. Despite the resident's repeated complaints about the bed's inadequacy, no corrective action was taken. The resident's pressure ulcer was not present upon admission and was observed to be a Stage III ulcer with moderate drainage. Dressing change orders were inconsistently followed, and the facility's maintenance records did not document any requests regarding the bed issue. The facility's policy on pressure injury prevention was not effectively implemented.
A resident with significant cognitive impairment and multiple diagnoses, including stroke and muscle weakness, was observed without prescribed braces or palm protectors to maintain range of motion. Despite care plan orders, staff failed to apply these interventions consistently, as confirmed by multiple observations and staff interviews. The facility's policy required systematic assessment and care planning, which was not effectively executed, leading to potential further decline in the resident's condition.
A resident with PTSD, stroke-induced paralysis, and schizophrenia did not receive a trauma-informed care assessment or care plan upon admission to the facility. Despite the facility's policy requiring such assessments, the Social Work Director confirmed that the assessment was not completed, resulting in a lack of interventions to address potential PTSD triggers.
A facility failed to document a physician's response to pharmacy recommendations for a resident with dementia, breast cancer, and anorexia. The resident's MRR dated February 2024 lacked a report or response in the electronic record. The new DON could not locate the report or identify the concern, and the facility did not provide an MRR policy by the survey's end.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.9%. An LPN documented administering Eliquis and Ferrous Sulfate to a resident who refused the medications, leading to a discrepancy in the MAR. The DON was informed of the error, which violated the facility's medication administration policy.
The facility failed to provide timely laboratory services for two residents receiving Depakote, as ordered by their physicians. One resident required valproic acid level monitoring, but no results were found in their clinical record despite a pharmacy recommendation and physician's order. Another resident's lab tests were delayed by a month, with results showing low valproic acid levels. The facility's policy requires timely provision of laboratory services, which was not met in these instances.
The facility failed to maintain a clean, comfortable, and homelike environment, with offensive odors, overflowing garbage, soiled floors, and broken equipment. Housekeepers reported being short-staffed, leading to significant cleanliness issues. The facility lacked documentation for work orders, cleaning schedules, and policies for storage and cleaning.
The facility failed to provide necessary monitoring, supervision, and interventions for a resident with a known alcohol addiction. Despite multiple instances of the resident leaving and returning intoxicated, no care plans or interventions were implemented. Staff acknowledged the lack of formal care plans and interventions, leading to the cited deficiency.
The facility failed to protect two residents from physical abuse by another resident and did not adequately address a staff member's misappropriation of funds from a resident. The incidents were substantiated as abuse after investigations, revealing significant deficiencies in ensuring a safe environment.
The facility failed to report a suspected abuse incident involving two residents within the required 24-hour window. The incident, which involved verbal sexual requests, occurred in January but was not reported until February. Both residents were interviewed, and the delay in reporting was confirmed by the RN Regional Clinical Director.
The facility failed to thoroughly investigate allegations of stolen money from one resident and verbal abuse by a staff member towards another resident. The DON was unaware of the incidents until days later and did not conduct a thorough investigation. Additionally, the facility did not address the theft of $75 from another resident, and staff were unclear about where to store personal items, leading to potential security issues.
The facility failed to follow its policies for Leave Of Absence (LOA) and Against Medical Advice (AMA) discharge for a resident. The resident left the facility without a physician's order or proper documentation, and the DON and SSM did not follow procedures for educating the resident or notifying the physician. This resulted in inadequate documentation and communication regarding the resident's status.
The facility failed to revise the care plan for a resident who exhibited aggressive behavior towards another resident. Despite the incident being documented and witnessed by a CNA, no interventions were added to the care plan to prevent further mistreatment, and there was no documentation of the interdisciplinary team meeting to discuss the behavior.
The facility failed to provide necessary behavioral health care for a resident with alcohol dependence, allowing the resident to leave unsupervised and return intoxicated multiple times. Interviews revealed a lack of internal planning and coordinated efforts to manage the resident's condition, resulting in ongoing substance abuse issues.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement appropriate interventions and update the care guides for a resident, R602, after a fall, which resulted in the potential for additional falls. R602 was observed in bed with a fall mat on the right side, and their clinical record indicated multiple diagnoses, including cerebrovascular disease, flaccid hemiplegia, and a history of falls. On a specific date, a nurse noted that an aide had lowered R602 to the floor after being unable to hold them during a brief change. The aide was alone and believed R602 required only a one-person assist for bed mobility, as indicated in the CNA Kardex. Interviews with staff revealed inconsistencies in the care plan and CNA Kardex regarding the level of assistance required for R602's bed mobility. While the interdisciplinary team had decided to change R602's status to a two-person assist for all activities of daily living (ADLs) after the fall, the care plan and CNA Kardex still documented a one-person assist for bed mobility. The Assistant Director of Nursing acknowledged the discrepancy and agreed that the documentation should have been updated to reflect the change. The facility's Fall Reduction Policy requires that care plans be reviewed and updated after a fall, which was not adequately done in this case.
Ice Machines Lack Backflow Protection
Penalty
Summary
The facility failed to ensure that the ice machines in the main kitchen and on the first floor were backflow protected, which is a requirement to prevent contamination. During an observation on January 7, 2025, it was noted that the drain lines of both ice machines extended approximately 2 inches into the floor drains, lacking the necessary air gap to prevent backflow. This deficiency was confirmed through interviews and record reviews, with the Dietary Manager acknowledging the issue but being unsure about the air gap requirement. The lack of backflow prevention was identified as a potential risk to all residents in the facility, as it could lead to contamination of the ice used by residents.
Inaccessible Light Cords for Residents
Penalty
Summary
The facility failed to ensure that light cords were maintained at an appropriate length and within reach for five residents on the 2 East unit. Observations conducted over two days revealed that the rooms occupied by these residents had lights above their beds with metal pull strings that were only a few inches long, making them inaccessible for use. During a walkthrough with the Plant Operations Manager/Maintenance Director and the Housekeeping/Laundry Supervisor, it was noted that the issue had not been identified in any audits or maintenance logs. Staff reported that many residents on the unit had behaviors of pulling things off the walls, including light cords, but there was no specific awareness of the issue in these rooms. The facility was unable to provide any documentation of furniture, room, or equipment repairs related to this issue by the end of the survey.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, affecting multiple residents throughout the facility. Observations on the 2 East unit revealed stagnant, strong foul odors in the shower room, a build-up of dark brownish substance along the shower walls and flooring, chipped and missing tiles, and a sharp metal area on the handrail. The 1 East shower room had heavy mold/mildew accumulation, a dust-coated ceiling vent cover, and water-stained ceiling tiles. A brown soiled towel was left on the floor in a resident's bathroom, and an overbed tray table used by multiple residents was caked with debris and had a damaged surface. Several residents' rooms were observed with various cleanliness and maintenance issues. One room had a wall with missing paint, a broken soap dispenser, and no available soap. Another resident's overbed tray table was heavily soiled, and the room's flooring was scattered with debris. Privacy curtains were soiled, and bedside dressers were heavily worn and broken. Debris was scattered in another resident's room, and the resident reported that housekeeping had not cleaned the room for several days. A shared room had trash and debris throughout, used gloves scattered around beds, and a trash can without a bag. The facility's staff, including the Plant Operations Manager and Housekeeping/Laundry Supervisor, confirmed many of these observations. They acknowledged that the showers should be cleaned daily and that the sharp metal handrail should have been reported. The maintenance binder lacked documentation of issues with overbed tray tables, and there was no further documentation provided for furniture or equipment repairs. The facility's policies on cleaning and resident rights emphasize the importance of maintaining a safe and clean environment, but these were not adhered to, leading to the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications in two of the three medication carts reviewed. During an observation of the 1 Central Unit medication cart, a Novolog insulin pen was found without a label indicating the resident's name or the date it was opened. LPN 'B' acknowledged the oversight, stating that the pen should have been labeled with both the resident's name and the date it was opened. Additionally, a Lantus insulin pen was incorrectly labeled with a future date, and LPN 'B' was uncertain about the actual date it was opened. In another instance, an antidepressant medication was found in the wrong medication cart on the 1 [NAME] Unit. LPN 'C' identified that the medication belonged to a resident on a different hallway and removed it from the cart, placing it on top. However, LPN 'C' left the unit shortly after, leaving the medication unsecured on top of the cart. The Director of Nursing confirmed that the facility's protocol required insulin pens to be labeled with the date they were opened and the resident's name, and that medications should be accessible only to authorized personnel.
Infection Control and Dining Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for three residents. An LPN was observed not cleaning the blood pressure cuff and pulse oximetry device after use on one resident before using them on another. The LPN also failed to clean the glucometer after use and did not perform hand hygiene between resident care. Additionally, the LPN administered insulin injections and eye drops to a resident without changing gloves or washing hands between procedures. These actions were contrary to the facility's policies on cleaning and disinfection of resident-care equipment, hand hygiene, and medication administration. During a meal observation, a CNA placed a resident's breakfast tray on their lap while assisting the resident with their meal, as the overbed tray table was soiled and on the roommate's side of the room. The CNA did not express any concerns about this practice, which was against the facility's dining services policy that emphasizes hygienic practices to prevent food from coming into contact with staff clothing. The Administrator confirmed that this practice should not have occurred.
Inadequate Ventilation in Shower Room
Penalty
Summary
The facility failed to maintain adequate ventilation in the 2 East Shower Room, resulting in stale and malodorous air affecting all residents utilizing the room. On January 7, 2025, an observation revealed that the air was stagnant, and a test with tissue paper showed no suction at the ceiling vent, indicating non-functioning ventilation. Further observations on January 8, 2025, with the Plant Operations Manager and Housekeeping/Laundry Supervisor confirmed the lack of ventilation, as the toilet paper did not suction to the vent. The Plant Operations Manager acknowledged the issue but could not provide an explanation for the lack of monitoring. Maintenance logs reviewed showed no documented concerns about the ventilation, and the facility failed to provide a policy on bathroom ventilation or any relevant repair invoices by the end of the survey.
Violation of Resident Mail Privacy
Penalty
Summary
The facility failed to ensure the residents' right to receive unopened and private mail delivery was maintained for two of the eight residents who participated in a confidential resident group interview. One resident reported receiving several Christmas cards from family members that were opened upon delivery. Another resident expressed frustration over having to request their mail and experiencing delays in receiving packages, which were sometimes mixed up with staff items. This resident also reported being told that staff needed to watch them open packages to verify contents, which they felt violated their rights and privacy. The facility's Administrator was unaware of these practices and stated that mail was coordinated by the activity staff, who delivered it directly to residents. The Activity Director confirmed that packages were previously opened with residents due to concerns about medications and vapes being ordered, but acknowledged that this practice was not in line with resident rights. The facility's policies on resident rights and mail delivery emphasize the right to receive unopened mail and maintain privacy, which were not adhered to in these instances.
Failure to Educate and Offer Advance Directive to Resident
Penalty
Summary
The facility failed to educate and offer the formulation of an advance directive to a resident, identified as R28, who was admitted with diagnoses including bipolar disorder and depression. During the survey, it was observed that R28 was in their room listening to music and refused an interview. A review of R28's medical record showed no documentation that the facility had educated or offered R28 the opportunity to formulate an advance directive, as required by the facility's policy. Interviews conducted with the Social Services Manager (SSM) and the Acting Administrator (AA) revealed a lack of clarity and responsibility regarding the process of educating and offering advance directives to residents. The SSM stated that their department was only responsible for obtaining code status and not for advance directive education. The AA initially stated they would investigate the process and later confirmed that the social services department was responsible for this task, indicating that SSM H had been educated on the matter. No further explanation or documentation was provided by the end of the survey.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Agency for a resident with severe impaired cognition. The resident, who had a diagnosis of dementia, mood disorder, and delusional disorders, was observed with a dark purple/bluish bruise around their right eye and discoloration on the surrounding skin. The resident's guardian was informed by the facility that the resident had a red area on their face from sleeping on a remote, but later, the resident was sent to the hospital to rule out a facial fracture due to swelling and pain. Interviews with staff revealed that a CNA noticed the resident's face was red and imprinted from a bed remote on the morning of the incident. The unit manager assessed the resident and informed the medical doctor, DON, and the guardian. However, the condition of the resident's face worsened, showing more bruising the following day. Despite this, the facility did not report the incident as an injury of unknown origin, as they believed the injury was caused by the bed remote. The facility's administrator stated that they did not report the incident to the state agency because they assumed the injury was from the initial contact with the remote. The administrator acknowledged that the midnight nurse reported the bruising, but they did not consider it necessary to report to the state agency since they believed they knew the cause of the injury. The facility's investigation report noted the resident's tendency to bruise easily and skin integrity issues, but no further action was taken to report the injury as unknown in origin.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to adhere to the recommendation of a Level II Evaluation for a resident who was reviewed for PASARR. The resident, who was admitted with diagnoses including bipolar disorder, depression, anxiety, and schizoaffective disorder, was observed in their room but refused an interview. A letter from the Neighborhood Services Organization indicated that a Level II Evaluation was required by November 6, 2024, but a review of the medical record showed no documentation of the evaluation being completed or requested. The Social Services Manager was interviewed and acknowledged that the follow-up Level II evaluation for the resident was neither completed nor submitted. The facility's policy on Resident Assessment-Coordination with PASARR Program, revised in December 2023, mandates that all applicants be screened for serious mental disorders or intellectual disabilities, with the Social Services Director responsible for tracking each resident's PASARR screening status. Despite this policy, no further explanation or documentation was provided by the end of the survey.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that nursing services consistently met professional standards during medication administration for two residents. On the morning of January 8, 2025, an LPN was observed preparing and administering morning medications to a resident (R15) without ensuring the resident consumed them. The LPN left the room to obtain a blood pressure cuff, leaving the resident unattended and unobserved. Upon returning, the LPN proceeded to attend to the resident's roommate (R45) without verifying if R15 had ingested their medications. Additionally, the LPN administered insulin and eye drops to R45 and left a cup of pills at the bedside without confirming their consumption. The medical records for both residents revealed no documentation of a self-administration of medication assessment. The facility's policy on medication administration, dated June 2019, requires that residents be observed to ensure medication ingestion. The Director of Nursing confirmed that the LPN should have observed the residents taking their medications and should have obtained the blood sugar level before R45's meal for an accurate reading. No further explanation or documentation was provided by the end of the survey.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to ensure accurate accounting for a resident's controlled medication, specifically Hydrocodone-Acetaminophen, during a review of one of the medication carts. During an observation, it was noted that the Controlled Substance Proof-Of-Use form indicated there were 103 pills remaining, but only 101 were found in the blister pack. The LPN involved reported administering one pill to the resident and dropping another, which was then discarded in the sharps container. However, this action was not documented on the proof-of-use sheet at the time of the incident. The facility's protocol requires that when a controlled medication is wasted, a second nurse must witness the disposal and both nurses must sign off on the proof-of-use form. In this case, although the second LPN confirmed witnessing the wastage, neither nurse signed the form as required. The Director of Nursing confirmed the protocol but a policy regarding the administration of controlled substances was not provided during the survey.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident R401, who had a history of violent behavior and diagnoses including paranoid schizophrenia and bipolar disorder, punched resident R402 in the face after a disagreement over a joke. Despite R401's documented aggressive behaviors, including hitting staff and throwing objects, the facility did not take immediate action to prevent further incidents, resulting in R401 eventually being removed from the facility. Another incident involved resident R404, who had severely impaired cognition and diagnoses including major depressive disorder and delusional disorders. R404 physically assaulted resident R407, who had moderately impaired cognition, during a room transfer. Despite the altercation being witnessed by staff and reported to the police, the facility did not implement a physical behavior care plan or interventions for R404 until after a third altercation occurred. Resident R404 was also involved in two separate incidents with resident R405, who had moderately impaired cognition and diagnoses including Alzheimer's disease. R404 pushed R405 back into his wheelchair during an argument and later kicked R405 in the face. These incidents were witnessed by another resident, R409, and reported to the police. Despite these repeated incidents, the facility delayed implementing a care plan for R404's physical behaviors, failing to protect residents from further harm.
Inadequate Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of resident-to-resident abuse involving several residents, including one resident who was involved in three separate incidents. The facility's policy on abuse, neglect, and exploitation requires comprehensive investigations, including interviewing all involved parties and documenting the findings. However, the investigations into these incidents were incomplete, lacking interviews with key witnesses and other residents who might have had relevant information. In one incident, a resident with severely impaired cognition was reported to have struck another resident in the face. Despite a staff member witnessing the event, the facility's investigation did not include interviews with the staff or other residents. Similarly, in another incident involving the same resident, the facility failed to interview the involved parties and witnesses, including a resident who had observed the altercations. The facility's documentation was insufficient, and the administrator admitted to not having conducted thorough interviews. Another incident involved a different resident with a history of aggressive behavior, who punched a fellow resident. The investigation into this incident was also lacking, as it did not include interviews with staff or other residents who witnessed the event. The facility's administrator confirmed the aggressive behavior but did not know the details of the incident, such as the content of a joke that allegedly provoked the altercation. Overall, the facility's failure to conduct comprehensive investigations into these incidents resulted in a lack of understanding of the root causes and potential for further abuse.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement effective interventions to prevent the elopement of a resident, identified as R406, who was at risk for elopement and had severely impaired cognition. On 9/19/24, R406 exited the facility without staff knowledge and walked approximately one and a half miles to a local police station. The resident was able to leave the facility by placing his foot in the door as a visitor exited, which allowed him to leave unnoticed. Despite being identified as an elopement risk since 5/16/24, the facility did not have adequate measures in place to prevent this incident. R406 had a history of acute necrotizing hemorrhagic encephalopathy, auditory and visual hallucinations, early onset Alzheimer's Disease, and paranoid schizophrenia. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition and delusions. Prior to the elopement, R406 had been sent to the hospital on 9/17/24 due to distressing delusional and paranoid thinking, as well as aggressive behavior. Upon returning to the facility on 9/19/24, no new orders were implemented, and the resident was not provided with the necessary supervision to prevent elopement. Interviews with staff revealed a lack of communication and awareness regarding R406's elopement risk and the interventions required. LPN 'N', who was on duty during the elopement, was not informed of any additional monitoring or interventions for R406. The facility's policy on elopements and wandering residents emphasized the need for a systemic approach to monitoring and managing residents at risk for elopement, but this was not effectively executed in R406's case. The facility's failure to provide adequate supervision and implement effective interventions directly contributed to the resident's elopement.
Failure to Monitor and Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in a resident, identified as R10, who experienced a 13.5% weight loss over a period from February 12, 2024, to May 1, 2024. R10, who was dependent on staff for most activities of daily living and had severe cognitive impairment, was observed with enteral feeding and reported weight loss. The resident's medical history included diagnoses of protein-calorie malnutrition, anorexia, COPD, depression, dysphagia, obesity, tube feeding, CHF, and hypertension. Despite these conditions, the facility's comprehensive care plan, which included monitoring weight and reporting significant changes, was not effectively implemented. The facility's records revealed that R10's weight was not documented in March 2024, and no assessments or notes were completed after a significant weight loss was recorded on April 12, 2024. The registered dietician (RD) was unaware of the weight loss until May 3, 2024, when a dietary note indicated a further weight loss and recommended adjustments to the tube feeding. The RD acknowledged issues with obtaining weights and missed alerts in the electronic medical record system, which contributed to the oversight. The facility's administrator confirmed that a problem with weight monitoring was identified in June 2024. The facility's weight monitoring policy required weights to be obtained upon admission, readmission, weekly for the first four weeks, and at least monthly thereafter. However, these procedures were not followed, leading to the failure to identify and address R10's significant weight loss in a timely manner.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for nine residents who required such measures due to their medical conditions. These residents had conditions such as pressure ulcers, urinary catheters, feeding tubes, and other indwelling medical devices, which necessitated the use of EBP to prevent the spread of infections. Observations revealed that there were no EBP signs posted, and no personal protective equipment (PPE) was available in or near the rooms of these residents. Interviews with staff members, including a Certified Nursing Assistant (CNA) and a housekeeper, indicated a lack of recent training and awareness regarding EBP. The CNA mentioned that they had been trained on EBP a long time ago, but this was the first time they had seen the signs posted. Similarly, the housekeeper stated that they had been trained on EBP quite a while ago, suggesting a gap in ongoing education and reinforcement of infection control protocols. The deficiency was further highlighted during a dressing change observation for a resident with a pressure ulcer, where the Licensed Practical Nurse (LPN) failed to don the required PPE. The LPN was unaware that EBP was required for the resident, despite the presence of a Stage III pressure ulcer with drainage. This lack of adherence to EBP protocols and insufficient staff training contributed to the facility's failure to ensure proper infection prevention and control measures were in place for residents with high-risk conditions.
Unsafe Storage of Sharp Objects in Emergency Carts
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding the storage of sharp objects in emergency carts. During observations, it was noted that four emergency carts were left unlocked, with sharp objects such as disposable razors, suture removal kits containing sterile scissors and suture forceps, and used syringes in sharps containers accessible. These carts were located in various hallways and units, including the 100 Hallway, in front of specific rooms, and the 229 Hallway. The presence of these sharp objects in unlocked carts posed an increased risk of avoidable accidents for all residents. A specific incident was observed where a resident, who was walking down the hall, approached an unlocked emergency cart, opened the top drawer multiple times, and then took a black bag containing emergency suction equipment from the top of the cart and carried it down the hall. This incident highlights the lack of adequate supervision and the potential for residents to access hazardous materials, which could lead to accidents. The Director of Nursing and an LPN Unit Manager were informed of these observations and acknowledged the issue.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for the month of May 2024, as evidenced by incomplete documentation and lack of infection control measures. The facility's policy on antibiotic stewardship, revised in January 2024, aimed to optimize infection treatment and reduce adverse events associated with antibiotic use. However, during a review on July 10, 2024, it was found that the Monthly Infection Control Log for May 2024 was incomplete, with only one resident's information fully documented. Additionally, there was no infection mapping or employee health illness log available for that month. The Director of Nursing (DON), who also served as the Infection Control Nurse, acknowledged the absence of antibiotic stewardship activities in May 2024, attributing it to the previous DON's oversight. The current DON, who started at the facility at the end of May 2024, had begun revamping the program due to its disorganized state. The facility's Administrator confirmed the issue, noting that a problem with the antibiotic stewardship program had been identified in May 2024, leading to a past non-compliance finding with a compliance date of June 1, 2024.
Failure to Respect Resident Dignity and Preferences
Penalty
Summary
The facility failed to treat two residents, R42 and R94, in a dignified manner. R42, who is cognitively intact and requires extensive assistance for most activities of daily living, reported feeling forced to take a shower despite their preference for bed baths. The facility did not have a shower chair that could accommodate R42's size, resulting in the resident having to use their regular wheelchair, which made them feel uncomfortable and unsafe. The facility's records showed inconsistencies regarding the type of bath provided, and staff interviews confirmed that R42's preferences were not respected. The facility's maintenance supervisor could not provide evidence of ordering an appropriate shower chair, and the administrator acknowledged the resident's feelings of being forced to shower. R94, who is blind, reported that some CNAs would argue with them about taking a shower or refuse to provide one. R94 could not identify the CNAs involved due to their inability to see and the CNAs not providing their names. The facility's policy on promoting and maintaining resident dignity emphasizes respecting resident preferences and ensuring staff report and document such preferences. However, the facility failed to adhere to this policy, resulting in a lack of respect for R94's dignity and preferences.
Failure to Report Alleged Abuse Threat
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, where one resident threatened another with a fork. The incident was reported by the threatened resident to multiple staff members, including the Social Worker, but was not documented in the resident's clinical record or reported to the Abuse Coordinator and the State Agency. The resident who made the threat was later sent out for psychiatric evaluation due to an acute behavior change, but the initial threat was not properly addressed or investigated by the facility. The resident who reported the threat was cognitively intact, as indicated by a BIMS score of 15/15, and had a medical history including type II diabetes, heart failure, and bipolar disorder. The resident who made the threat also had a relatively intact cognition with a BIMS score of 13/15 and was diagnosed with schizophrenia, anxiety, and delusional disorders. Despite the Social Worker being aware of the threat and informing the Administrator, the facility's policy on abuse reporting was not followed, as the Administrator claimed they were not informed of the incident.
Failure to Update and Implement Resident's Care Plan for Fall Prevention
Penalty
Summary
The facility failed to ensure a comprehensive plan of care was revised and modified to reflect a resident-centered and individualized plan of care for a resident identified as R10. Observations over three consecutive days revealed that R10, who had a history of falls, was not provided with a concave mattress or floor mats as indicated in their care plan. Despite having a physician's order for a concave mattress dated several months prior, these interventions were not present in R10's room during the observations. R10 was admitted with diagnoses including Protein Calorie-Malnutrition and Anorexia and was dependent on staff for most activities of daily living, with a severely impaired cognition as indicated by a BIMS score of four. The care plan initially included interventions for fall prevention, such as a concave mattress and floor mats, but these were not implemented. The Nurse Manager acknowledged that the interventions were removed due to a change in R10's fall risk status, but the care plan was not updated to reflect this change, leading to the deficiency.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure nursing services met professional standards for medication administration documentation for a resident. The resident, who was cognitively intact with a BIMS score of 15/15, had diagnoses including diabetes, right below the knee leg amputation, morbid obesity, atrial fibrillation, and hypertension. During an observation of medication administration, an LPN presented the resident with ordered medications, Eliquis and Ferrous Sulfate, which the resident refused. However, a subsequent review of the Medication Administration Record (MAR) revealed that the LPN had documented these medications as administered. Upon interview, the LPN confirmed that the medications were not given and acknowledged the documentation error, attributing it to nervousness during the observation. The Director of Nursing was informed of the incident and confirmed the documentation error.
Failure to Provide Shaving Per Personal Preference
Penalty
Summary
The facility failed to provide shaving per personal preference for two residents, R94 and R54, who were reviewed for activities of daily living (ADLs). R94, who is blind and has severely impaired vision, expressed a desire to be clean-shaven but reported that some Certified Nursing Assistants (CNAs) refused to shave him and did not disclose their names. Observations on 7/8/24 showed R94 with stubble, but by 7/9/24, he was clean-shaven after receiving assistance the previous night. R94's clinical record indicated he was cognitively intact and required staff assistance for ADLs. Similarly, R54, who has moderately impaired cognition and is dependent on staff for ADLs, was observed with a full beard on 7/8/24, despite his preference to be clean-shaven. By 7/9/24, R54 was observed to be clean-shaven and expressed satisfaction with his appearance. Interviews with CNA I and the Director of Nursing (DON) revealed that residents are typically shaved during showers or upon request, aligning with the facility's policy on ADLs, which mandates necessary services for grooming and personal hygiene for residents unable to perform these activities themselves.
Failure to Monitor Blood Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to consistently monitor blood glucose levels for a resident with type 2 diabetes, leading to a potential risk of complications from abnormal blood sugar levels. The resident, who had a history of diabetes, anxiety disorder, depression, diabetic neuropathy, and chronic kidney disease, was readmitted to the facility after a recent hospitalization. Despite having unstable blood sugars prior to hospitalization and being on sliding scale insulin, there were no orders to monitor the resident's blood sugar after readmission. The resident's electronic medical record and physician progress notes indicated the need for blood glucose monitoring, yet no such monitoring was conducted for 12 days following readmission. The resident's blood sugar levels were previously monitored multiple times a day, and they were receiving sliding scale insulin. However, after readmission, the facility did not continue this monitoring, and the resident experienced a cardiac arrest and expired at the facility. Interviews with the Director of Nursing, Unit Manager, and Nurse Practitioner revealed a lack of clarity and communication regarding the resident's blood sugar monitoring. The Nurse Practitioner mentioned that the resident's hemoglobin A1c was within normal limits, leading to the discontinuation of insulin, but there was no documentation to support this decision. Additionally, the facility failed to provide a policy or protocol on blood sugar monitoring when requested by the surveyor.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide an appropriate support surface bed for a resident, resulting in the development of an avoidable unstageable pressure ulcer. The resident, who was admitted with medical conditions including opioid abuse, hypertension, anemia, chronic kidney disease, and rheumatoid arthritis, was independent with activities of daily living and had a BIMS score indicating cognitive intactness. Despite the resident's repeated verbal complaints about the inadequate support from the bed mattress and the pressure applied by the bed frame bar, no corrective action was taken by the facility staff. The resident developed a pressure ulcer on the left buttock, which was not present upon admission. The wound was observed to be a Stage III pressure ulcer with moderate seropurulent drainage and a pink, macerated wound bed. The dressing change orders were not consistently followed, as evidenced by the discrepancy between the documented dressing change schedule and the actual dressing change observed. The resident expressed dissatisfaction with the care provided, noting that the dressing was not changed daily as required. The facility's maintenance records did not document any requests regarding the bed issue, and the staff, including the maintenance manager and wound care provider, were not adequately informed or responsive to the resident's complaints. The Director of Nursing was made aware of the facility-acquired pressure ulcer, and the facility's policy on skin and pressure injury risk assessment and prevention was not effectively implemented, as it included providing appropriate pressure-redistributing support surfaces.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to maintain or prevent further decline in range of motion for a long-term resident, identified as R3, who was admitted with diagnoses including seizures, stroke, osteoarthritis, abnormal posture, and muscle weakness. Observations revealed that R3 had significant cognitive impairment and was often found in bed with a contracted right hand and elbow, without any braces or palm protectors as prescribed. The resident's care plan included orders for a soft carrot or palm protector and a hand splint to be applied daily, but these were not consistently implemented. During multiple observations over two days, R3 was repeatedly seen without the prescribed brace or palm protector, despite the care plan and physician orders indicating their necessity to maintain skin integrity and prevent further contracture. Interviews with staff, including a CNA and the DON, revealed a lack of adherence to the care plan, with the CNA unable to locate the brace and the DON acknowledging that nurses were supposed to ensure CNAs followed the orders. The facility's policy required systematic assessment and care planning to prevent decline in range of motion, but this was not effectively executed for R3. The facility's documentation indicated that staff were signing off on tasks related to the application of the palm protector, despite it not being applied during the surveyor's observations. The DON and unit manager were informed of the discrepancies, and both acknowledged the concern, indicating a failure in monitoring and ensuring compliance with the care plan interventions. This lack of implementation and oversight resulted in a potential for further decline in R3's range of motion or worsening of contracture.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), as evidenced by the lack of assessment and care planning for the condition. The resident, who also had a history of stroke with left side paralysis and schizophrenia, was observed with physical limitations and moderately impaired cognition. Despite these conditions, the facility did not conduct a trauma-informed care assessment upon the resident's admission or readmission, nor did they develop a care plan to address the PTSD diagnosis. Interviews with the Social Work Director and the Administrator revealed that the trauma-informed care assessment, which should have been completed by Social Work, was not conducted. Consequently, no care plan was implemented to identify and mitigate potential PTSD triggers for the resident. The facility's policy on trauma-informed care emphasized the importance of identifying a resident's history of trauma and cultural preferences, yet this was not adhered to in the case of the resident in question.
Failure to Document Physician's Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure a record of the attending physician's response to pharmacy recommendations for a resident reviewed for monthly medication regimen reviews. The resident, who was admitted with diagnoses including dementia, breast cancer, and anorexia, had a moderate impaired cognition with a BIMS score of 9/15. A monthly Medication Regimen Review dated February 15, 2024, was noted in the resident's electronic record, but no report or response was found. The Director of Nursing, who was new to the facility, was unable to locate the report or identify the concern related to the MRR. Additionally, the facility did not provide a policy pertaining to MRRs by the end of the survey.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a medication error rate of 6.9%. This deficiency was identified during an observation of medication administration for a resident, where two medication errors were noted out of 29 opportunities. On the specified date, an LPN was observed administering medications Eliquis and Ferrous Sulfate to the resident, who refused them. However, the Medication Administration Record (MAR) indicated that these medications were documented as administered at an earlier time, despite the resident's refusal. The LPN later confirmed that the medications were not given, yet they were signed off as administered. The Director of Nursing was informed of this discrepancy, which was a violation of the facility's medication administration policy that requires documentation and explanatory notes for doses not administered.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, R63 and R65, as ordered by their physicians. Resident R63, who was admitted with diagnoses including dementia and breast cancer, was receiving Depakote and required monitoring of valproic acid levels. Despite a pharmacy recommendation on 4/7/24 and a subsequent physician's order on 4/8/24, no laboratory results for valproic acid levels were found in the resident's clinical record. The Director of Nursing (DON) confirmed the absence of these results during an interview on 7/9/24 and was unable to obtain them by 7/10/24. Similarly, Resident R65, diagnosed with paraplegia and muscle weakness, also required valproic acid level monitoring. A pharmacy recommendation on 3/7/24 led to a physician's order on 3/27/24 for various lab tests, including valproic acid levels. However, no results were available until after a repeat order on 4/19/24, with results finally obtained on 4/26/24 showing low valproic acid levels. The DON was unable to explain the month-long delay in obtaining these laboratory diagnostics. The facility's policy mandates timely provision of laboratory services, which was not adhered to in these cases.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by offensive odors, overflow of garbage, soiled floors, and broken equipment. Upon entering the facility, a strong foul odor of urine and feces was noted, and the common area floors were sticky and visibly soiled. Medical exam gloves and condiment wrappers were observed on the floor. In resident rooms, such as those of R902 and R903, there were odors of spoiled milk, dried food matter, overflowing trash receptacles, and scattered clothing and food crumbs on the floor. The [NAME] Unit shower room had soiled utility towels, an overflowing sharps container, and unsanitary conditions in the toileting area, including dried urine and a broken hand soap wall mount. The Central Unit Shower was cluttered with equipment and had dried brown matter on the walls and floor, along with broken hand soap dispensers and no paper towels available. Housekeepers reported being short-staffed, with only one housekeeper for the entire second floor and no housekeeping staff over the weekend. This led to significant cleanliness issues, including soiled briefs left in the shower and overflowing trash receptacles. Housekeeper C mentioned that she was originally hired as a laundry aide but was working as a housekeeper due to staffing shortages. Housekeeper B indicated that the strong urine odor in the locked unit was due to residents with dementia urinating in inappropriate places. The facility lacked documentation for work orders, cleaning schedules, and policies for storage and cleaning, as confirmed by the Nursing Home Administrator. The facility activity room had a rotten food odor from an overflowing trash receptacle filled with empty soda cans, chips, candy wrappers, and uneaten food, attracting small flies. A surveyor slipped on a piece of bread surrounded by a red substance near the [NAME] shower room. The second floor had a strong urine odor in common areas and near residents eating breakfast, with sticky, visibly soiled floors and overflowing trash receptacles. The facility environment manager was unavailable for an interview, and the Nursing Home Administrator confirmed the lack of specific cleaning policies and tracking sheets for the shower rooms.
Failure to Monitor and Supervise Resident with Alcohol Addiction
Penalty
Summary
The facility failed to provide necessary monitoring, supervision, and interventions for a resident with a known alcohol addiction. The resident, who had diagnoses including dementia, dysphagia, and alcohol abuse, was admitted with a history of alcohol withdrawal. Despite having intact cognition and requiring staff assistance for all Activities of Daily Living (ADLs), the resident frequently left the facility on Leave of Absence (LOA) and returned intoxicated. Staff documented multiple instances of the resident leaving and returning intoxicated, including an episode where the resident was agitated and throwing objects, necessitating a visit to the emergency room for safety concerns. However, no care plans or interventions were implemented to address the resident's alcohol addiction or to monitor and supervise their LOA returns. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that although the issue was discussed in morning meetings, no formal care plans or interventions were put in place. The DON and Social Service Manager acknowledged the lack of implemented care plans and interventions for the resident's alcohol addiction and LOA returns. The facility's failure to provide adequate supervision and monitoring for the resident's known alcohol addiction led to the deficiency cited in the report.
Failure to Protect Residents from Abuse and Misappropriation of Funds
Penalty
Summary
The facility failed to protect two residents, R902 and R906, from physical abuse by another resident, R911. The incidents were reported to the state agency, and an onsite investigation was conducted. During interviews, R911 admitted to provoking R906, which led to a physical altercation. The Director of Nursing (DON) and a Registered Nurse (RRN) acknowledged that despite their efforts, they could not prevent the residents from interacting and that the incidents were substantiated as abuse after their investigation. R906 initially denied any incident but later confirmed that R911 attempted to hit her, and staff intervened to separate them. The facility also failed to protect R906 from misappropriation of funds by a staff member, CNA J. During an interview, CNA J described how he discovered his missing backpack and other items in R906's room, including $105 in a tin cookie can. R906 claimed that $40 was missing, which the facility took seriously. The DON and RRN confirmed that the allegations were substantiated as abuse, although they acknowledged that R906 had a history of stealing and lying. The facility's response to CNA J's initial report of the missing items was inadequate, as the DON did not provide immediate guidance, and CNA J had to wait for further instructions. The facility's failure to protect residents from abuse and misappropriation of funds highlights significant deficiencies in their ability to ensure a safe environment. The DON and RRN admitted that their efforts to manage the residents' interactions were insufficient, and the facility's response to the staff member's report of missing items was delayed and ineffective. These deficiencies were substantiated by the facility's own investigations and the observations made during the onsite survey.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This deficiency was identified in an incident involving two residents, where one resident made verbal sexual requests to another. The incident occurred on January 11, 2024, but was not reported to the State Agency until February 20, 2024, well beyond the required 24-hour reporting window. The facility's own policy mandates that all alleged violations be reported to the State Agency within 24 hours if the events do not involve abuse and do not result in serious bodily injury. Resident R903, who was cognitively intact with a BIMS score of 14, expressed frustration when interviewed about the incident and confirmed feeling safe around the other resident involved, R902. Resident R902, who has moderate cognitive impairment with a BIMS score of 8, was also interviewed and stated that he respects the female residents. The delay in reporting was confirmed by the RN Regional Clinical Director, who acknowledged that the facility had outstanding Facility Reported Incidents (FRIs) from January 2024 that were not completed in a timely manner. This failure to report in accordance with guidelines resulted in the potential for unidentified or continued abuse.
Failure to Investigate Allegations of Theft and Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of stolen money from one resident and verbal abuse by a staff member towards another resident. Resident R907 reported that CNA J entered his room and accused him of stealing items that were later found in another resident's room. Although R907 did not feel threatened, his mother insisted on reporting the incident. CNA J admitted to asking R907 about the missing items but denied using profane language, a claim supported by Nurse K, who was present during the interaction. The Director of Nursing (DON) was not aware of the incident until two days later and did not conduct a thorough investigation, relying instead on written statements from staff members involved. The corporate administrator was notified but did not follow up adequately, leading to a lack of proper documentation and resolution of the incident. Additionally, the facility failed to address the theft of $75 from Resident R905 by Resident R906. The DON acknowledged that R906 had a history of taking items but did not take appropriate action to investigate or resolve the issue. The administrator later stated that R905 would be reimbursed, but this decision came after the surveyors' exit and was not part of the initial response to the incident. The lack of a timely and thorough investigation into both incidents highlights deficiencies in the facility's handling of resident complaints and staff conduct. The report also revealed that staff members were unclear about where to store their personal items, leading to confusion and potential security issues. CNA J's belongings were initially placed in a common area, which may have contributed to the theft. The facility's failure to provide clear guidelines and secure storage options for staff personal items further exacerbated the situation. Overall, the facility's inaction and inadequate response to the reported incidents demonstrate significant lapses in their investigative and administrative processes.
Failure to Follow AMA and LOA Policies
Penalty
Summary
The facility failed to follow its policies for Leave Of Absence (LOA) and Against Medical Advice (AMA) discharge for a resident identified as R913. On 3/7/24, the resident was noted to be out on LOA but had not returned by the end of the evening shift. The Licensed Practical Nurse (LPN) on duty reported the absence to the Director of Nursing (DON), who instructed the LPN to document the resident's absence if they had not returned by the end of the shift. However, there was no physician's order for the LOA, and the required Release of Responsibility for Leave of Absence form was not signed by the resident or the supervising person. Additionally, the DON and the Social Service Manager (SSM) failed to document the resident's irate behavior and the AMA discharge properly. The AMA form was incomplete, lacking the resident's initials on critical sections, and the physician was not notified before the resident left the facility. The DON and SSM admitted to not following the facility's policies regarding AMA discharges. The SSM did not educate the resident on the risks of leaving AMA or notify the physician, and the DON forgot about the AMA form provided by the SSM. The nursing staff were under the impression that the resident was on LOA, and the DON gave directives based on this incorrect assumption. The DON's documentation on 3/8/24 initially stated the resident was on LOA but later mentioned the AMA discharge, indicating confusion and lack of proper communication. The facility's failure to adhere to its AMA and LOA policies resulted in inadequate documentation and communication regarding the resident's status. The resident's medical record lacked proper documentation of the AMA discharge, and the required procedures for informing and educating the resident and notifying the physician were not followed. This deficiency highlights significant lapses in the facility's adherence to its policies and procedures, leading to potential risks for the resident's safety and well-being.
Failure to Revise Care Plan After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to revise the care plan for a resident (R908) who exhibited aggressive behavior towards another resident (R909). The incident involved R908 pulling the hair of R909 without any prior verbal exchange or provocation. Despite the incident being witnessed by a Certified Nursing Assistant (CNA I) and documented in a Facility Reported Incident (FRI), the facility did not update R908's care plan to include interventions to prevent further resident-to-resident mistreatment. Additionally, there was no documentation indicating that the interdisciplinary team met to discuss R908's behavior and modify or implement care plan interventions to ensure the safety of other residents. R908 was admitted to the facility with diagnoses including dementia, hallucinations, and schizoaffective disorder. The existing care plans for R908 included potential for physical behaviors and extremely aggressive behavior towards staff, but no interventions were added following the incident with R909. The Regional Clinical Director (RCD A) acknowledged the concern when interviewed but provided no further explanation or documentation by the end of the survey.
Failure to Provide Behavioral Health Services for Resident with Alcohol Dependence
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of alcohol dependence and abuse. The resident was observed returning to the facility intoxicated on multiple occasions, and the facility did not have a plan in place to address the resident's substance use disorder. The social worker admitted that no internal planning was done for residents with substance abuse issues, and the only measures offered were external treatments and classes, which the resident did not participate in. Despite the resident's known diagnosis and repeated intoxication, the facility allowed the resident to leave the premises unsupervised, leading to further alcohol consumption. Interviews with the social worker and the Director of Nursing revealed a lack of coordinated efforts to manage the resident's condition. The social worker initially claimed that the resident's leave of absence (LOA) privileges had been restricted but later retracted this statement, confirming that the resident was still allowed to leave the facility. The Director of Nursing deferred responsibility to the social worker, who had not implemented any specific interventions for the resident's alcohol abuse. The facility's failure to provide adequate behavioral health services and to restrict the resident's access to alcohol resulted in ongoing substance abuse issues within the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,177 citations issued within 25 miles in the last 12 months — including the 6 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 Madison Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Anthony Healthcare Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Pomeroy Living Sterling Skilled Rehabilitation | 1.6 mi | ★★★★★ | 1 | 0 |
| Windemere Park Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 2 | 0 |
| Harmony Village Of Clawson | 3.2 mi | ★★★★★ | 3 | 1 |
| Harmony Village Of Warren | 3.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.