Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with a central venous port and dependence on renal dialysis was placed on enhanced barrier precautions (EBP) per physician order and care plan, requiring PPE use during high-contact care such as hygiene and repositioning. During care, a CNA scratched the resident’s bare back and repositioned her in bed without wearing gloves or a gown, despite acknowledging awareness of the EBP requirement, and the ICP confirmed PPE should have been used. Separately, the Maintenance Director reported the water management plan was still in progress, with no active disinfection sampling and only intermittent flushing of some fixtures. Surveyors observed unflushed fixtures, including a hopper, hose sprayer, and over-hopper sink that produced brown, discolored water when turned on, as well as capped water lines in a shower room that had not been flushed or removed, despite facility policies calling for defined control measures, testing protocols, and monthly disinfectant residual testing.
A resident with stroke, DM, dementia, and AFib had severe cognitive impairment and active orders for Eliquis, Lantus, and NovoLOG. Nursing notes documented repeated blood sugar swings, including hyperglycemia and multiple hypoglycemic episodes requiring treatment and rechecks. The current care plan had no specific diabetes focus, no interventions for hypo/hyperglycemia monitoring, and no AFib focus or bleeding/bruising monitoring despite anticoagulant use.
Inconsistent therapeutic diet textures and food preparation. A resident with dysphagia on a minced and moist diet was repeatedly served pureed foods instead of the ordered texture, and the resident reported poor taste and low intake with weight loss. Another resident with TD on a soft and bite-sized diet was served a whole sandwich despite an order for quarter-size pieces, and a CI reported receiving the wrong food texture at times.
A resident with CKD stage 4 and acute kidney failure was receiving dialysis, but the chart lacked a physician order for dialysis care and treatment. The DON confirmed no dialysis order was in place, and nursing staff reported they checked the access site after dialysis but had no place to document routine post-dialysis assessments or monitoring for signs of infection or complications.
A resident experienced mental anguish and fear due to another resident's aggressive and inappropriate behavior, which the facility failed to adequately address. Despite staff observations and reports, the administration did not conduct a thorough investigation or implement sufficient protective measures, resulting in a deficiency in ensuring a safe environment.
A resident with a history of falls and severe cognitive impairment fell and sustained injuries due to inadequate supervision in an LTC facility. The resident required maximal assistance and was placed in a room far from the nurses' station, limiting staff's ability to monitor him closely. Despite known risks and family warnings, the facility did not provide sufficient supervision, resulting in the resident's fall and injury.
A facility failed to notify a resident's family member and DPOA of changes in the resident's condition, including an open area on the ankle and localized edema. The family member only learned of these issues by asking the nurse during a visit, despite the facility's policy to inform the DPOA of acute health changes.
The facility failed to follow its abuse policy for three residents, leading to unreported and uninvestigated incidents of resident-to-resident abuse. A resident with a history of aggressive behavior approached another resident aggressively, causing fear and distress. Staff intervened but did not report the incidents immediately, and the NHA did not conduct an investigation. Additionally, concerns about potential sexual abuse involving another resident were not investigated or reported to the state agency.
The facility failed to report allegations of abuse involving three residents to the State Agency in a timely manner. A resident with a history of aggressive behavior approached another resident aggressively, causing fear and distress, but the incidents were not reported as required. Additionally, an allegation of potential sexual abuse involving a severely cognitively impaired resident was not reported or investigated. The facility's staff, including the NHA and DON, did not follow the policy for reporting and investigating abuse allegations.
The facility failed to investigate allegations of abuse involving three residents, including aggressive behavior by a resident with dementia and potential sexual abuse concerns. Despite staff intervention and reports, the incidents were not thoroughly investigated, and the state agency was not notified, violating the facility's policy on abuse, neglect, and exploitation.
A facility failed to refer a resident for a Level II PASARR evaluation despite the resident exhibiting significant mental health issues, including verbal and sexual behaviors, and receiving antipsychotic medication. The resident's care plan addressed these behaviors, but no referral was made to the state mental health authority, as confirmed by interviews with the LMSW and DON.
A resident's aggressive behavior towards another resident was not documented by an LPN, despite being witnessed during two separate incidents. The LPN reported the incident to the NHA, who advised against documentation due to concerns about transfer referrals. This lack of documentation left the PA unaware of the incidents, hindering the evaluation and management of the resident's behavior.
A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite interventions in place, inadequate staffing levels during meals allowed the incident to occur without immediate intervention, resulting in the resident being unable to protect herself.
The facility failed to maintain a safe and sanitary environment, with issues such as raw wood shelving for clean supplies, deteriorating storage areas, and stained privacy curtains. A resident with COPD had a dusty fan, soiled curtain, and dusty windowsill, despite cleaning protocols. Housekeepers acknowledged the oversight, but deficiencies persisted.
The facility failed to provide palatable and appropriately heated food to several residents, leading to dissatisfaction and potential nutritional decline. Residents reported cold meals, unappetizing food, and inadequate seasoning, with meal trays transported in non-insulated carts. This issue affected residents with various health conditions, including stroke, diabetes, and dysphagia, highlighting a significant deficiency in meal service.
The facility did not ensure an effective training program for abuse prevention, leading to potential resident safety risks. The DON reported the absence of a staff development role and that she monitored online training completion. The facility lacked an on-site HR employee, with records kept at the corporate level. A former administrator noted annual online abuse education, last completed in the summer. A review showed 11 out of 66 employees had not started the required module, and the DON and a Unit Manager were still in progress. The facility failed to provide documentation of completed abuse training for all employees.
The facility failed to ensure timely meal service and call light response, affecting residents' dignity and care. Observations showed inconsistent meal service, with some residents waiting longer than others, contrary to the expected practice of serving one table at a time. A resident with Alzheimer's and another cognitively intact resident expressed dissatisfaction with the meal service order. Additionally, a resident reported long call light wait times, sometimes up to an hour, despite the facility's standard of a 3-minute response time.
A facility failed to update a care plan for a resident after a new diagnosis of dementia. The resident, who was cognitively intact, was diagnosed with dementia, but the care plan did not reflect this change. The Unit Manager confirmed the oversight during an interview.
A facility failed to consistently apply a brace for a resident with limited ROM, potentially leading to decreased ROM and contractures. The resident, with a history of stroke and paralysis, had a care plan requiring PROM exercises and a brace application, but observations showed the brace was often not used or improperly applied. The Rehab Director had to intervene to adjust the brace and perform ROM exercises, highlighting a lapse in following the facility's restorative nursing policy.
The facility failed to ensure proper PPE usage during a COVID-19 outbreak, with staff observed not wearing required masks and eye protection. A resident with COVID-19 was under droplet/contact precautions, but staff did not adhere to PPE requirements. Another resident on Enhanced Barrier Precautions due to a pressure ulcer received care without staff donning gowns, indicating a lack of awareness of EBP protocols.
A resident with multiple health conditions experienced issues with the call light system, which was not within reach and malfunctioned, leading to delayed staff response. The facility provided a doorbell pendant as an alternative, but it was ineffective due to its single ding and potential confusion with the front doorbell. Staff interviews and observations confirmed ongoing issues with the call light system, attributed to electrical problems within the wall.
The facility failed to protect residents from sexual abuse, involving three residents with cognitive impairments. A resident was found with another resident's hand up her shorts, and two other residents engaged in inappropriate sexual interactions despite guardians' consent for limited contact. Staff were unclear about boundaries, leading to multiple incidents of inappropriate contact. The facility's policies failed to prevent these incidents, resulting in a deficiency.
A cognitively impaired resident was allegedly abused by another resident in a LTC facility. The incident was witnessed by a CNA, who intervened and reported it. The facility's response included 15-minute checks and moving the victim, but staff reported these measures were insufficient, especially during short staffing. The facility did not conduct a thorough investigation or implement adequate interventions, leading to further abuse allegations.
The facility failed to maintain accurate medical records for two residents with cognitive impairments, leading to incomplete documentation of observed sexual interactions. Staff, including CNAs and an RN-UM, witnessed these interactions but did not document them in the EHR, believing existing care plans sufficed. A Social Services Manager also failed to document a conversation with a guardian about consent boundaries. This lack of documentation could impact the facility's ability to provide appropriate care.
Failure to Implement Enhanced Barrier Precautions and Maintain Water Management Controls
Penalty
Summary
The deficiency involves failure to properly implement enhanced barrier precautions (EBP) for a resident and failure to maintain an active, ongoing water management program to reduce the risk of Legionella and other opportunistic premise plumbing pathogens. A female resident with dependence on renal dialysis and a central venous port was under physician orders and care plan directives for EBP during high-contact care activities, including dressing, bathing, transferring, hygiene, linen changes, toileting/brief changes, and device or wound care. During observation, a CNA was seen scratching and rubbing the resident’s bare back and then repositioning her in bed without wearing gloves or a gown, despite acknowledging that the resident was on EBP and that PPE should have been used for this type of care. The Infection Control Preventionist confirmed that the resident was on EBP due to the central line and that PPE was required during such high-contact care activities. The deficiency also includes lack of a fully implemented water management program consistent with the facility’s own policy. The Maintenance Director reported that the water management plan was still a work in progress and that there were no established control measures and control limits in active use to reduce the risk of Legionella or OPPP, including no current sampling for disinfection levels. He stated that he maintained ice machines, cleaned the fountain in the summer, and flushed some taps every few days, but had not been flushing certain fixtures. Observation of a soiled utility room revealed a hopper with an attached hose sprayer and an over-hopper sink that had not been fully flushed; when the water was turned on, brown and discolored water came from both hot and cold lines and the sprayer. In a shower room, capped water lines extended several feet from the main water line and had not been flushed or removed. Review of the facility’s written Water Management Program and related documents showed that control measures, testing protocols, and control limits, including monthly disinfectant residual testing of hand sinks, showers, and whirlpool baths, were required but not being carried out as described.
Incomplete care plan for diabetes and atrial fibrillation
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a male resident with stroke, diabetes with diabetic neuropathy, dementia, depression, anxiety, hypertension, and atrial fibrillation. The resident had severe cognitive impairment with a BIMS score of 7 and active orders for Eliquis for clot prevention, Lantus 30 units twice daily, and NovoLOG 15 units with meals for type 2 diabetes. A physician assistant note documented persistent blood sugar fluctuation and recent hypoglycemic episodes, with parameters added to long-acting insulin and existing parameters for short-acting insulin. Nursing documentation showed multiple blood sugar events, including a blood sugar of 568 with provider notification and an order for extra NovoLOG, followed by a recheck of 503, as well as several hypoglycemic episodes with blood sugars of 58, 66, 48, and 56. These episodes required treatment with simple carbohydrates such as orange juice, fig snack bar, cookie, and nutritional supplement, with repeat checks showing improvement. A physician assistant note later documented significant fluctuation, recent hyperglycemia, and multiple hypoglycemic episodes, and the insulin regimen was adjusted to split long-acting insulin and reduce short-acting insulin. Review of the current care plan showed no specific focus for diabetes and no interventions to monitor for hypoglycemia or hyperglycemia. The care plan also lacked a specific focus for atrial fibrillation and did not include interventions related to monitoring for bruising or bleeding despite the resident's anticoagulant use. During interviews, staff stated that diabetes and cardiac issues, including anticoagulant monitoring, should be included in the comprehensive care plan, and that the resident should have had care plan focus areas for both diabetes and atrial fibrillation.
Inconsistent Therapeutic Diet Textures and Food Preparation
Penalty
Summary
The facility failed to consistently provide therapeutic diet food textures in the form ordered for residents on modified diets. For a resident with oropharyngeal dysphagia and moderately impaired cognition, the resident reported being on a minced and moist diet since admission but stated the food usually tasted bad because it was almost always pureed. During meal observations, the resident was served foods that appeared pureed, including green beans, meat, bread, and carrots, even though the tray ticket identified the diet as minced and moist. The speech therapist confirmed that minced and moist level 5 foods should contain pieces no larger than 4 millimeters and that some foods, such as green beans, did not need to be pureed to meet that texture. Record review and kitchen observation showed that the facility had separate recipes for regular, minced and moist, and pureed carrots, but only regular cooked carrots and pureed carrots were prepared and served for lunch. The corporate registered dietitian confirmed that a third carrot texture should have been made for residents on the minced and moist diet and that the minced and moist carrots should have been different from the pureed carrots. The resident had poor oral intake and weight loss, and documentation noted low meal intake, dissatisfaction with the food, and significant weight loss during the admission. A second resident with bipolar disorder and tardive dyskinesia was ordered a level 6 soft and bite-sized diet with bread cut into quarter-size pieces. During lunch observation, the resident’s peanut butter sandwich was served whole and not cut up, and the resident stated staff had not cut it up despite needing it to reduce choking risk related to tongue movements. Staff did not cut the sandwich or supervise the resident eating it while passing trays to other residents. A confidential informant also reported receiving the wrong textured food at times and stated that the correct texture was usually provided only after staff were notified.
Missing Dialysis Orders and Post-Dialysis Documentation
Penalty
Summary
The facility failed to ensure that a physician order was in place for dialysis treatments and failed to document post-dialysis assessment and monitoring for Resident #11. Resident #11 was a male with diagnoses including chronic kidney disease stage 4 and acute kidney failure. During survey review, the resident was observed to be at dialysis, but the Order Summary contained no physician order for dialysis care and treatment. During interviews, the DON confirmed there was no order in place for dialysis care and treatment and stated there should be an order from the physician. The DON also stated the MAR should reflect an order to monitor the dialysis site after dialysis, but no such order was present. The RDCO confirmed the facility should have orders in place and should monitor the access site for signs and symptoms of infection or complications. Nursing staff reported they checked the access site and dressing when the resident returned from dialysis, but there was nowhere to document those observations, and the facility did not have regular documentation for post-dialysis assessments.
Failure to Protect Resident from Mental and Psychosocial Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and psychosocial abuse, specifically involving resident-to-resident interactions. Resident #106, who was cognitively intact with a BIMS score of 15/15, experienced mental anguish and fear due to the behavior of Resident #105. Resident #105, who also had a BIMS score of 15/15, exhibited behaviors such as staring, aggressive verbal interactions, and inappropriate sexual conduct, which were not adequately addressed by the facility. Staff members, including a registered nurse, a certified nursing assistant, and a licensed practical nurse, observed and reported Resident #105's behavior towards Resident #106. Despite these observations and reports, the facility's administration, including the Nursing Home Administrator, did not conduct a thorough investigation or implement sufficient measures to protect Resident #106. The facility's inaction led to Resident #106 feeling unsafe and fearful, impacting her ability to move freely within the facility. The facility's policies on abuse prevention and response were not effectively implemented, as evidenced by the lack of immediate action following the incidents. The Interdisciplinary Team discussed potential interventions, such as increased supervision and door alarms, but these were not promptly executed. The failure to address Resident #105's behavior and protect Resident #106 from mental and psychosocial abuse constitutes a deficiency in the facility's duty to ensure a safe environment for all residents.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with a history of multiple falls. The resident, who was severely cognitively impaired and required maximal assistance to stand and transfer, was admitted with diagnoses including unsteadiness on feet and repeated falls. Despite these known risks, the resident was placed in a room far from the common areas and nurses' station, limiting the ability of staff to provide close supervision. On the night of the incident, the staffing on the resident's hall was limited to one nurse and one CNA for 21 residents, which was insufficient to meet the resident's needs for close supervision. The resident was found on the floor after an unwitnessed fall, having sustained a fracture to the right humerus and thoracic vertebrae. Prior to the fall, the resident exhibited increased agitation, poor safety awareness, and attempted to transfer without assistance, indicating a need for more frequent monitoring than was provided. Interviews with staff and family members revealed that the resident was known to be confused and restless, particularly at night, and required immediate response to his needs. Despite this, the facility did not implement additional measures to ensure the resident's safety, such as increased supervision or frequent checks, leading to the fall and subsequent injury.
Plan Of Correction
Element 1: Resident #100 no longer resides at the facility. Element 2: All residents have the potential to be affected by this deficient practice. A 100% audit of current residents with falls in the last 30 days was completed on 3/24/25 to ensure residents' current needs, have appropriate notification and care plans were updated as needed. Element 3: NHA and DON reviewed the Fall prevention policy on 3/17/25 and deemed it appropriate. The DON/designee will re-educate all licensed nurses on fall prevention policy prior to 3/24/2025. Any licensed nurses not re-educated by 3/24/25 will not work until re-education is completed. An Ad-Hoc QAPI meeting will be held on 3/20/25 to review fall reduction policies and the plan of correction. Medical Director reviewed. Element 4: DON/Designee will review newly admitted residents and residents with falls weekly during clinical meetings for three (3) months to ensure interventions were implemented and appropriate, and notifications completed. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. DON is responsible for achieving and sustaining compliance.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in care or condition for one of the residents reviewed for notification of change. This deficiency involved a resident with a history of Huntington's disease, dementia, and adult failure to thrive, who was found to have an open area on the right ankle and was diagnosed with localized edema. Despite these changes in the resident's condition, the family member and Durable Power of Attorney (DPOA) reported not being informed by the facility since the resident's admission. The family member expressed frustration over the lack of communication, stating that she only became aware of the resident's new health issues when she inquired with the resident's nurse during a visit to the facility. The Director of Nursing confirmed that it is the facility's policy to inform a resident's DPOA of any acute changes in health, which was not adhered to in this case.
Plan Of Correction
Element 1: Resident #102 resides in the facility and has a FM / DPOA who was notified of resident's condition on 3/17/2025. Element 2: All residents reviewed in Clinical stand-up meeting on 3/19/25 to identify any change of condition in real time. DPOA notified of any changes identified. Element 3: All Nursing staff will be re-educated by the QAPI Development Coordinator on the Change in Condition policy by 3/24/2025. Any staff member that has not been re-educated by 3/24/2025 will be removed from the schedule until re-education is completed. Element 4: DON / designee will review the clinical dashboard daily, Monday-Friday to identify changes of condition and ensure notifications are completed appropriately. The Director of Nursing is responsible for achieving and maintaining compliance.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for three residents, resulting in staff not reporting resident-to-resident observations of abuse to the Nursing Home Administrator (NHA) immediately, the facility not initiating a thorough investigation, and the facility not reporting allegations of abuse to the state agency. This deficiency involved Resident #105, who had a history of inappropriate physical touching and aggressive verbal behaviors, and Resident #106, who was the target of Resident #105's aggressive actions. Despite staff interventions during incidents where Resident #105 approached Resident #106 aggressively, the incidents were not reported immediately, and no investigation was initiated. Resident #105, who was cognitively intact, exhibited aggressive verbal behaviors towards Resident #106, causing fear and distress. Staff members, including an LPN and a Physical Therapy Assistant, witnessed these incidents and intervened to redirect Resident #105. However, the incidents were not documented or reported to the NHA immediately. The NHA did not conduct an abuse investigation, believing the staff's reactions were overly reactive and that Resident #106 was not significantly affected. This inaction led to a failure in addressing the potential abuse and ensuring the safety of Resident #106. Additionally, concerns were raised about potential sexual abuse involving Resident #107, who was severely cognitively impaired. A family member reported these concerns to a Unit Manager, but the facility did not investigate further or report the allegations to the state agency. The Director of Nursing confirmed that the facility's abuse policy was not followed, as there were no obvious signs of injury, and the resident stated they felt safe. This lack of action and failure to follow the facility's abuse policy resulted in the deficiency noted in the report.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for additional allegations to go unreported and delayed investigation. Resident #105, who has a history of inappropriate physical behavior and aggressive tendencies, was involved in two incidents with Resident #106. During these incidents, Resident #105 approached Resident #106 aggressively, causing fear and distress. Despite staff intervention, the incidents were not reported immediately as required by the facility's policy. Resident #106, who was the victim of Resident #105's aggressive behavior, reported feeling scared and harassed. The facility's Unit Manager and Nursing Home Administrator were aware of the incidents but did not conduct an abuse investigation or report the incidents to the state agency. The Nursing Home Administrator believed that staff were overreacting to Resident #105's behavior and did not consider the incidents as abuse. Additionally, there was an allegation of potential sexual abuse involving Resident #107, who is severely cognitively impaired. A family member reported concerns about a male staff member to the Unit Manager, but the facility did not report the allegation to the state agency or conduct a further investigation. The Director of Nursing confirmed that the facility did not report the allegation, which was a violation of the facility's policy to protect residents and report all alleged violations immediately.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving three residents, leading to a potential risk of further abuse. Resident #105, who had diagnoses including depression, paraphilia, unspecified dementia with psychotic disturbance, and anxiety, was involved in an incident with Resident #106. Resident #106 reported feeling harassed and fearful after Resident #105 approached her aggressively on two occasions, despite staff intervention. LPN H, who witnessed the incidents, did not report them immediately but later informed the Nursing Home Administrator (NHA) A, who decided against documenting the incident to avoid affecting admission referrals for Resident #105. Additionally, a family member of Resident #107's roommate reported concerns of potential sexual abuse by a male staff member. Unit Manager (UM) E was informed of these concerns but did not conduct a full investigation, as it was determined there was no immediate concern due to limited male staff presence. The Director of Nursing (DON) B confirmed that a full investigation was not completed for the sexual abuse concerns involving Resident #107. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of all alleged violations to the facility administrator and state agency. However, in these cases, the facility did not adhere to its policy, as the allegations were not thoroughly investigated, and the state agency was not notified. This failure to act according to policy resulted in a deficiency citation for the facility.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/25 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a referral was made for a Level II PASARR evaluation for a resident who exhibited significant mental health issues. The resident, who was admitted with diagnoses of depression and anxiety, was cognitively intact but displayed verbal behaviors such as threatening, screaming, and cursing at others. The resident was also receiving antipsychotic medication. Despite these behaviors and the initiation of antipsychotic medication, the facility did not refer the resident for a Level II PASARR evaluation, which is required when a resident exhibits a newly evident or possible serious mental disorder. The resident's care plan included interventions for inappropriate physical and verbal behaviors, and the resident was diagnosed with paraphilia. A behavioral health provider noted episodes of sexual behaviors, auditory hallucinations, and delusional thinking. Despite these significant changes, the facility did not report them to the state mental health authority for a Level II PASARR assessment. Interviews with the Licensed Medical Social Worker and the Director of Nursing confirmed that no referral had been made, indicating a failure to address the resident's psychosocial needs adequately.
Plan Of Correction
Element 1: Resident #105's change in condition was submitted to OBRA on 3/17/25. Element 2: A facility-wide audit was completed by the regional social worker on 3/13/25 to ensure that no significant diagnosis or medications have been changed. Any changes identified were corrected. Element 3: The resident assessment/coordination with PASARR program policy was reviewed by the NHA and deemed appropriate on 3/17/25. The social services director/designee was re-educated regarding the resident assessment/coordination with PASARR program policy on 3/17/25. Element 4: All residents reviewed in daily clinical meeting for any new significant mental illness diagnosis or medications weekly x4 weeks and monthly 3 months. Any diagnosis or medications requiring a Level II assessment will be submitted to OBRA by social services director/designee. The NHA is responsible for achieving and sustaining compliance.
Failure to Document Resident Altercations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the residents reviewed, specifically regarding the documentation of abusive behaviors. On February 26, 2025, Resident #105 was involved in two separate incidents where they aggressively confronted another resident, Resident #106, in the hallway and later in the therapy gym. Despite witnessing these altercations, LPN H did not document the incidents in Resident #105's medical records. LPN H reported the incident to the Nursing Home Administrator (NHA) the following day but was instructed not to document it due to concerns about the impact on Resident #105's transfer referrals. The lack of documentation meant that the Physician's Assistant (PA) responsible for managing Resident #105's behaviors was unaware of the incidents and could not evaluate or adjust interventions accordingly. The Director of Nursing (DON) confirmed that staff are expected to report and document any potential abuse immediately, but this protocol was not followed. The failure to document these incidents resulted in a lack of proper evaluation and monitoring of Resident #105's behaviors, potentially compromising the safety and well-being of other residents.
Plan Of Correction
Element 1: Resident #105 no longer resides at the facility. Resident #106 care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Element 2: All residents have the potential to be affected by this practice. IDT team reviewed 24-hour on 3/19/2025 to review all residents and ensure information was not missing from medical record. Element 3: Clinical staff have been re-educated by the DON/designee on Nursing documentation of healthcare data from Perry and Potter 10th edition pg 51- 53; Legal guidelines for documenting and reporting and recording. to include timely documentation of resident condition variances. Those not receiving the education prior to date of allegation of compliance 3/24/25 will complete the education prior to their next scheduled shift. Element 4: Facility IDT will review the electronic health record during facility daily clinical meeting Monday through Friday with a lookback review done on Monday for any weekend documentation. The DON/designee will follow up on any identified missing or incomplete documentation. Any incomplete documentation will be resolved upon identification. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. The Administrator is responsible for achieving and sustaining compliance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with severe cognitive impairment due to dementia and anxiety, who was unable to effectively communicate or understand situations. This resident was found outside the south cafe door when another male resident, who was cognitively intact, was seen with his hand in her pants. Despite attempts to roll away, the male resident grabbed her hair and pulled her back. Witnesses reported the female resident was crying and appeared helpless during the incident. The male resident had a documented history of inappropriate sexual behavior, including making sexual requests to staff and other residents, exposing himself, and masturbating in public areas. Despite these behaviors, the facility's care plan for him included interventions such as having two staff members present during personal care and informing him that his behavior was inappropriate. However, these measures were insufficient to prevent the incident with the female resident. Staffing levels during the incident were inadequate, with only one CNA and one nurse present on the unit, as the second CNA was assisting in the dining room. This lack of supervision contributed to the male resident's ability to engage in inappropriate behavior without immediate intervention. Interviews with staff and witnesses confirmed that the male resident's behavior was escalating, and the facility's response was insufficient to protect the female resident from harm.
Environmental and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During a tour of the central supply storage, raw wood shelving was used for storing clean and sanitary supplies, which were stained, chipped, and pitted. The outside storage barn had openings and rusted areas that could allow pest entry, and the outside storage shed had a deteriorating roof dropping debris onto stored equipment. In the main hall soiled utility room, brown water was discharged from old water lines, and privacy curtains in the west hall spa room were stained. The east hall spa room had a shower chair with crusty debris, and the south hall spa room had a shower chair with a smeared disposable wipe. Additionally, the microwave in the cafe had pitting and scuffing, and brown-tinged water was observed in the south hall soiled utility room. Resident #22, who was cognitively intact and had chronic obstructive pulmonary disease, was found to have a personal fan caked with dust and debris, a soiled privacy curtain, and a dusty windowsill in his room. Despite the facility's cleaning protocol, these issues persisted over multiple days. Housekeepers reported that resident rooms were cleaned daily, including wiping down surfaces and inspecting privacy curtains, but the deficiencies in Resident #22's room were not addressed. The facility's Room Clean / Deep Clean / Discharge Check Off Sheet indicated that staff should clean and dust various areas, but these tasks were not completed in Resident #22's room.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food products to five out of seven residents reviewed for food palatability, resulting in dissatisfaction with meals and the potential for nutritional decline. The Resident Council Minutes from late November and early December 2024 revealed ongoing concerns about cold food and lack of flavor. Interviews with residents confirmed these issues, with reports of cold meals, unappetizing food, and inadequate seasoning. Residents expressed dissatisfaction with the temperature and taste of the food, noting that the meal trays were transported in non-insulated carts, contributing to the problem. Resident #8, who is cognitively intact and has a history of stroke, protein-calorie malnutrition, and diabetes, reported that the food was often cold and unpalatable, with specific complaints about the coffee and certain meals being dry or hard. Resident #9, also cognitively intact, mentioned that the quality of food varied depending on the kitchen staff and that meals were sometimes cold when served in her room. Resident #4, with cognitive communication deficits and other health issues, expressed that her food was unappealing and cold, and the lack of seasoning did not improve the taste. Resident #12, with Parkinson's disease and dysphagia, had family members report that the food was cold and lacked options for softer foods, leading to her refusal to eat. Resident #22, who is cognitively intact and has Type 2 Diabetes Mellitus, reported that the food was not consistently served at a palatable temperature, with meat often being tough. These consistent reports from residents highlight a significant deficiency in the facility's ability to provide meals that meet the residents' expectations for temperature and taste, potentially impacting their nutritional intake.
Deficiency in Staff Training for Abuse Prevention
Penalty
Summary
The facility failed to maintain and monitor an effective training program for abuse prevention for all staff, which resulted in the potential for decreased resident safety. During an interview, the Director of Nursing (DON) reported that the facility lacked a staff development role and that she was responsible for monitoring the completion of assigned online trainings. The facility also did not have an on-site human resources employee, with training records being maintained at the corporate level. A former Nursing Home Administrator indicated that abuse education was completed online annually, with the last session occurring in the summer. A review of the Course Completion History for the Abuse, Neglect, and Exploitation module revealed that it was due on July 31, 2024, and out of 66 employees, 11 had not started the module, while the DON and a Unit Manager were still in progress. The facility was unable to provide documentation confirming the completion of abuse training by all employees by the time of the survey exit.
Deficiency in Meal Service and Call Light Response Times
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity during meal times for three residents. Observations revealed that during lunch service in the main dining room, residents were not served in a consistent order, leading to some residents waiting longer for their meals. For instance, Resident #14, who has Alzheimer's disease and moderate cognitive impairment, was observed waiting longer than others at her table to be served. Resident #17, who is cognitively intact, expressed frustration about the lack of a specific pattern in meal service, noting that it was bothersome to see others served while she had to wait. The Unit Manager confirmed that staff are supposed to serve one table at a time, but this was not being followed. Additionally, Resident #60 reported long wait times for call light responses, sometimes up to an hour, which was corroborated by Resident Council Minutes and staff interviews. The expectation set by the facility was for call lights to be answered within 3 minutes or as soon as possible. The Director of Nursing confirmed this standard, but residents had complained about the delays, indicating a failure to meet the expected response times.
Failure to Update Care Plan Following Dementia Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident following a new diagnosis of dementia. The resident, who was cognitively intact with a BIMS score of 15/15, was diagnosed with dementia on 10/8/24. However, a review of the resident's care plan revealed no documentation of this diagnosis. During an interview, the Unit Manager confirmed the omission and acknowledged that the care plan should have been updated to reflect the resident's new diagnosis.
Inconsistent Application of Brace for Resident with Limited ROM
Penalty
Summary
The facility failed to consistently apply a positioning device, specifically a brace, for a resident with limited range of motion (ROM), which could potentially lead to decreased ROM, contractures, and pain. The resident, who was admitted with diagnoses including stroke, paralysis, and muscle weakness, had a care plan that required passive range of motion (PROM) exercises to the right hand and wrist before applying a right resting hand splint. Observations revealed that the resident was often without the brace or it was improperly applied, despite orders to monitor for skin breakdown and apply the brace every shift. During observations, the resident was seen without the brace or with it improperly applied, and the Rehab Director had to intervene to adjust the brace and perform ROM exercises. The Rehab Director noted that the brace was to be applied by CNAs each day, and there was no record of the resident refusing the brace. The facility's policy on restorative nursing emphasized maintaining or improving residents' abilities, including the use of assistive devices and ROM exercises, but these were not consistently implemented for the resident in question.
Inadequate PPE Usage During COVID-19 Outbreak and EBP Non-Compliance
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was utilized as required during a COVID-19 outbreak, leading to potential infection control deficiencies. During observations, multiple staff members were seen without surgical masks, despite the requirement due to the outbreak. Specifically, a CNA was observed entering a COVID-positive resident's room without proper eye protection, and a Registered Dietician entered the same room without any PPE, despite clear signage indicating droplet precautions were necessary. The Director of Nursing reported that staff were informed of PPE requirements through a messaging system, but compliance was not observed. Resident #40, who was COVID-positive, was under droplet/contact precautions, requiring staff to wear gowns, N95 masks, eye protection, and gloves. However, staff were observed not adhering to these requirements. For instance, a CNA was seen wearing an N95 mask over a surgical mask but did not use eye protection. Additionally, a Licensed Practical Nurse was observed with an N95 mask that did not cover her nose, and a Registered Dietician entered the resident's room without donning any PPE, despite the resident still being under isolation precautions. Resident #17 was on Enhanced Barrier Precautions (EBP) due to a stage two sacral pressure ulcer, requiring gowns and gloves for direct care. However, during an observation, an LPN and a CNA provided care without donning gowns, indicating a lack of awareness of the EBP requirements. Interviews with staff revealed confusion and lack of awareness regarding the current precautions for Resident #17, despite the presence of a sign on the door and a care plan indicating the need for EBP. The Unit Manager confirmed that EBP was initiated for the resident due to the new wound, but staff failed to comply with the necessary precautions.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to maintain a functioning call light system for a resident, which could potentially result in delayed response and negative outcomes. The resident, who had a history of fracture, unsteadiness, chronic pain, muscle weakness, osteoporosis, hearing difficulties, and other conditions, was observed with a call light system that was not within reach. The resident expressed concerns about staff not responding promptly to her call light, and it was noted that the call light system only emitted a single ding, which could be confused with the front doorbell, and did not illuminate the light above the door. Interviews with staff revealed that the call light system had been malfunctioning, with reports of a short in the system and issues with the electrical wiring within the wall. The facility had provided the resident with a doorbell pendant as an alternative alert system, but this was not effective as it only dinged once and could be easily missed. Observations confirmed that the call light was not consistently working, and staff had to repeatedly plug and unplug the system to get it to function. A work order had been submitted to address the issue, but it had not been resolved by the due date.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, involving three residents with varying degrees of cognitive impairment. Resident #101, who was severely cognitively impaired, was found in a situation where another resident, Resident #102, who was cognitively intact, had his hand up her shorts. This incident was witnessed by a CNA who immediately intervened and reported it to the Director of Nursing. Resident #101 appeared confused and unaware of the situation, and the facility's response was to separate the residents and instruct Resident #102 to stay away from Resident #101. Additionally, the facility did not adequately manage the interactions between Resident #103 and Resident #104, both of whom had cognitive impairments and guardianship. Despite the guardians' consent for limited physical contact, the facility allowed these residents to engage in sexual interactions, including fondling and being found in compromising situations. Staff members were unclear about the boundaries set by the guardians and often allowed the residents to be alone in private rooms, believing they were permitted to have sexual interactions. This lack of clear communication and documentation regarding the guardians' consent led to multiple incidents of inappropriate contact between the residents. The facility's policies and procedures failed to prevent these incidents, as there was no clear documentation or communication regarding the boundaries of the residents' interactions. Staff members were not adequately informed or trained on how to handle the situation, leading to confusion and inappropriate actions. The facility's abuse policy, which was supposed to prevent non-consensual sexual contact, was not effectively implemented, resulting in the failure to protect the residents' rights to be free from abuse.
Inadequate Investigation and Prevention of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse and prevent further potential abuse. The incident involved a cognitively impaired resident who was allegedly abused by another resident who was cognitively intact. The incident was witnessed by a CNA who immediately intervened and reported it to the Director of Nursing (DON). Initial interventions included separating the residents, placing them on 15-minute checks, and moving the victim to another room. However, the facility did not conduct a comprehensive investigation or implement sufficient measures to prevent further incidents. Interviews with staff revealed that the only intervention consistently reported was the 15-minute checks on the alleged perpetrator. Staff expressed concerns about the effectiveness of these checks, especially during times of short staffing. The facility did not assess the alleged perpetrator for underlying behaviors or triggers, nor did they update the care plan to address the potential for further incidents. The Social Services Manager and other staff confirmed that no additional interventions were considered to prevent the alleged perpetrator from targeting other residents. The facility's investigation was deemed inadequate as it did not substantiate the abuse, and no further assessments or interventions were conducted. The DON and former Nursing Home Administrator (NHA) acknowledged the lack of documentation and assessment of the alleged perpetrator's behaviors. The facility's failure to implement comprehensive interventions and conduct a thorough investigation resulted in additional allegations of abuse by the same resident, highlighting a significant deficiency in the facility's response to the initial incident.
Failure to Document Resident Interactions and Update Care Plans
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in the potential for staff and providers not having all pertinent information to care for them. Resident #103, diagnosed with Alzheimer's disease, and Resident #104, diagnosed with cognitive communication deficit and Wernicke's encephalopathy, both had care plans indicating a potential for behaviors that sound or appear sexual in nature. Despite these care plans, multiple incidents of sexual interactions between the two residents were observed by staff but not documented in their electronic health records (EHR). Certified Nursing Assistants (CNAs) and a Registered Nurse Unit Manager (RN-UM) reported witnessing sexual interactions between the two residents in the facility's courtyard. These incidents were reported verbally to supervisors but were not documented in the residents' EHRs. The RN-UM believed documentation was unnecessary due to the existing care plans that required redirection of such behaviors. Additionally, a Social Services Manager discussed consent boundaries with Resident #104's guardian but failed to document the conversation or update the care plans accordingly. The Nursing Home Administrator (NHA) became aware of an alert in the EHR regarding an incident involving the two residents, but upon investigation, found the documentation to be inaccurate. The lack of documentation and communication among staff members led to incomplete medical records, which could hinder the facility's ability to provide appropriate care and interventions for the residents involved.
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 245 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Cedar Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Belmont | 11.2 mi | ★★★★★ | 4 | 0 |
| Corewell Health Greenville Hospital Rehabilitation | 14.1 mi | ★★★★★ | 0 | 0 |
| Michigan Veteran Homes At Grand Rapids | 15.2 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 15.5 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Grand Rapids | 16.6 mi | ★★★★★ | 2 | 1 |
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.