Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norlite Nursing Center during CMS and state inspections, most recent first.
The facility failed to keep lift slings readily available for two dependent residents who required total-assist lift transfers and bathing. One resident with hemiparesis after a stroke and MS reported being kept in bed for entire weekends, missing showers, and losing socialization and activities because slings were unavailable, while staff confirmed repeated shortages and delays from outside laundry. Another resident with wheelchair dependence and incontinence said her back hurt when slings were unavailable, and her record showed a weight could not be obtained because no slings were available.
Insufficient nursing staffing led to delayed ADL care, late meal trays, and poor supervision of wandering residents. Residents and staff reported too few CNAs and nurses on the halls, especially on weekends and nights, with some residents waiting extended periods for washing, dressing, and other assistance. Surveyors also observed a resident with daily wandering behavior entering rooms and moving through common areas without staff redirection, while another resident reported an unwanted room entry and physical contact by a wandering resident.
A facility failed to provide a dignified dining experience for multiple residents during meal assistance. Residents were observed being fed in rooms or hallways by staff wearing blue gloves, and two residents with dementia and dysphagia were served with small brightly colored utensils resembling baby spoons; staff were unsure why those utensils were being used, and one resident’s DPOA was unaware of the practice.
Failure to provide advance written notice for room changes. A resident with cognitive impairment had a room change confirmed by census records, but the DPOA reported no explanation or written notice, and the EMR had no documentation of notification. In a confidential group interview, three residents also reported being moved without prior consultation or notice. The SW said there was no signed consent form before room changes and the NHA was unaware written advance notice was required.
Resident room temperatures were not maintained within acceptable limits after a partial HVAC failure on the 300 wing. Two residents and two confidential residents reported prolonged loss of heat, weak space heaters, extra blankets, and cold rooms near exterior walls and windows; one resident said he was not offered relocation to a warmer room, and another refused a shower because she was too cold. The facility's temperature log showed several occupied rooms remained in the mid-60s, and the emergency preparedness plan stated rooms must be evacuated when temperatures stay below 72 F for 12 continuous hours.
Food was not consistently served at an appetizing temperature or at consistent times. In a resident group interview, most residents said meals were almost always cold and several said meal times were unpredictable. During a lunch meal with hallway trays, trays were observed being delivered over extended periods and placed in rooms even when residents were not present. The NHA acknowledged mealtime delays had been a known issue for months, and Resident Council minutes documented repeated complaints about late trays, cold food, incorrect orders, and meals interfering with activities.
Food service practices were not maintained in the kitchen and storage areas. Boxes of single-serve items and canned foods were observed stored on the floor, a plate warmer was found with a missing gasket seal while still being used for lunch service, a steam jacket soup kettle was cleaned with soap and water only, a utensil drawer contained dried food debris, and kitchen staff handled dirty equipment and then unloaded clean utensils without washing hands.
The facility failed to follow its Unusual Occurrence Report policy after a resident-to-resident altercation. Two residents with Alzheimer’s disease and documented cognitive impairment were involved when one resident grabbed the other’s head while they were preparing for dinner, an event charted in the EMR as aggression toward others. An LPN reported that the residents were immediately separated and that the DON was notified due to the aggressiveness of the resident involved, but the LPN did not complete a UOR and was unaware of anyone else doing so. The NHA later acknowledged awareness of the incident but confirmed there was no completed UOR, despite facility policy requiring UOR completion and investigation for resident-to-resident altercations.
A resident with severe cognitive impairment and a documented history of aggressive behaviors, including hitting, punching, spitting, and threatening staff and other residents, grabbed another cognitively impaired, blind, hard-of-hearing hospice resident’s head while both were in a common area. An LPN reported that the action was not gentle, immediately separated the residents, and notified the DON, and behavior charting noted the aggressor resident placing hands over the other resident’s hair/eyes. However, the administrator later acknowledged awareness of the incident but did not complete an Unusual Occurrence Report or a Facility Reported Incident, and there was no documentation of the event in the affected resident’s EMR, despite facility policy requiring immediate reporting, documentation, and investigation of all abuse allegations, including resident-to-resident incidents.
The facility failed to follow its abuse investigation and reporting policy after an incident in which one cognitively impaired resident with Alzheimer’s disease and a history of aggressive behaviors grabbed another cognitively impaired, blind, hard-of-hearing hospice resident’s head during dinner. An LPN documented aggression toward others and reported that the resident’s action was not gentle, that the residents were separated, and that the DON was called due to the resident’s known violent behaviors. However, the administrator, though aware of the incident, did not complete an Unusual Occurrence Report or a Facility Reported Incident, and there was no documentation of the event in the affected resident’s EMR, contrary to the facility’s written abuse policy requiring immediate reporting, documentation, and thorough investigation of all alleged or suspected abuse.
The facility failed to follow its abuse reporting and investigation policy after an aggressive resident-to-resident incident. A cognitively impaired resident with Alzheimer’s disease and a history of aggressive behaviors grabbed another cognitively impaired, blind, hard-of-hearing hospice resident’s head, leading staff to immediately separate them and notify the DON. Behavior charting documented aggression by the first resident, but the second resident’s record contained no note of the incident. The NHA acknowledged knowing about the event, chose not to report or investigate it, and stated that video footage was no longer available, resulting in a failure to report a reasonable suspicion of a crime and to complete required internal investigation steps.
Failure to supervise wandering residents allowed them to enter other residents’ rooms and common areas without staff intervention. Several residents reported that wanderers frequently came into their rooms, forcing them to keep doors shut or redirect the wanderers themselves. Observations showed one resident shouting at another at a room entrance and another resident wandering through halls, into rooms, and near an emergency exit, while an LPN said the facility had many wanderers and could not sustain the one-on-one supervision they required.
A resident was placed on droplet precautions after a change in condition, and a precaution sign was posted at the room entrance. A hospitality aide entered the room to deliver a lunch tray without PPE, then acknowledged PPE should have been worn; the IP confirmed this was required under the facility’s transmission-based precautions policy.
The facility failed to maintain food safety standards, with pureed food held at improper temperatures and inadequate dishwashing practices. Additionally, the kitchen's ventilation system was insufficient, allowing steam to condense on the ceiling, potentially contaminating food. These issues were confirmed by staff and pose a risk of foodborne illness to residents.
The facility failed to provide a dignified dining experience by serving residents at the same table at different times, causing some to wait while others ate. Staff were also observed standing over residents while feeding, contrary to expected practices. The DON and CDM acknowledged these practices were not in line with facility standards, but no policies addressing these issues were found.
The facility failed to keep a medication cart locked when unattended, risking medication misappropriation for nine residents. Additionally, two expired glucose meter control solutions were not discarded, potentially affecting blood glucose readings for six residents. The DON confirmed these practices were against facility policies.
A resident experienced significant weight loss, losing 11 pounds in one month, without adequate nutritional assessment or intervention from the facility. Despite the resident's cognitive awareness and communication with the CDM about food preferences, the care plan was not updated, and the RD was not informed of the weight loss until contacted by a state surveyor. The facility's process for notifying the RD of significant weight loss was not followed, contributing to the deficiency.
A resident with a history of acute kidney failure and urine retention showed symptoms of a DVT, including pitting edema, warmth, and redness in the left leg. Despite these symptoms being documented by an LPN and communicated to the charge nurse, the physician was not notified in a timely manner, and no physician assessment was conducted. The resident was later diagnosed with a left leg DVT after being transferred to the emergency room for an unrelated issue.
Two residents in the facility were not provided with the correct therapeutic diets and fluid restrictions as prescribed. One resident, with dementia and diabetes, received incorrect meal portions and items, including pepper packets against instructions. Another resident, with congestive heart failure, exceeded fluid restrictions due to staff unawareness and inaccurate recording of fluid intake. These deficiencies highlight a lack of compliance with dietary orders and monitoring systems.
A resident experienced a 12.9% weight loss within three weeks of admission, but the facility failed to assess or prevent this loss. Despite the resident's medical conditions, there was no re-weighing or dietary progress notes. Staff interviews revealed a lack of communication and responsibility regarding dietary assessments, and the DON confirmed the absence of documentation in the EMR. The facility's Weight Management policy was not followed, leading to this deficiency.
A resident with multiple diagnoses experienced severe pain due to the facility's failure to administer pain medication on time and as prescribed. Despite a care plan and policies in place, medications like Gabapentin and Hydrocodone-acetaminophen were often given late or not at all, leading to unmanaged pain. The facility was aware of the issue but did not take sufficient action to address it.
Failure to Keep Lift Slings Available for Dependent Residents
Penalty
Summary
The facility failed to ensure that necessary transfer equipment was readily available for two dependent residents who required a total lift for transfers and bathing. Resident 62 was admitted with hemiparesis following a stroke, multiple sclerosis, muscle weakness, and need for assistance with personal care, and her care plan directed total assistance with a brand-name lift for transfers and toileting. Resident 46 was admitted with disorders of psychological development, low back pain, mixed incontinence, morbid obesity, and wheelchair dependence, and her care plan directed total assist of 2 with a brand-name lift for transfers and toileting. Resident 62 stated she had repeatedly been unable to get out of bed for entire weekends because the facility had run out of slings, and she reported missing showers on several occasions for the same reason. She was observed lying in bed with greasy, unkempt hair, and she stated the sling shortage had been going on for months, causing her to miss socialization and activities such as bingo. Staff interviews confirmed repeated shortages of slings, with staff stating the facility ran out of slings all the time, that clean slings were not returned timely from an outside laundry, and that residents had been unable to get out of bed or showered when slings or the correct size sling were unavailable. A sign posted in the hallway stated there was a shortage of slings because they were not put into laundry every night. Resident 46 confirmed the facility ran out of slings at times and stated her back hurt when no slings were available. Her record also documented that a weight was carried over from the prior week because she could not be lifted for weighing due to no slings being available. The nursing home administrator acknowledged the sling shortage and stated he believed slings were being left and used at the laundry facility. The facility assessment listed lifts and lift slings as physical equipment.
Insufficient Nursing Staffing and Unsupervised Wandering Residents
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of the resident population and to have a licensed nurse in charge on each shift. Observation, interview, and record review showed residents and staff repeatedly reported too few CNAs and nurses on the halls, delayed assistance with care needs, and late meal tray delivery. Resident Council minutes from multiple meetings documented ongoing complaints about late or cold trays, only one or two CNA members assigned to a hall, and one nurse covering two halls. A confidential group interview also found several residents concerned about timely assistance and meal service, and one resident stated the facility was understaffed and CNAs were often assigned to cover more than one hallway. The staffing concerns were reflected in resident care experiences. One resident with hemiparesis, multiple sclerosis, muscle weakness, and a need for assistance with personal care reported frequent delays with washing up, getting dressed, and receiving a shirt, especially on weekends, when staffing was described as worse. The resident’s family member also reported the resident was not getting requested PT appointments because of lack of staffing. Another resident with intact cognition submitted a concern stating a man entered the room wearing a gown, said the bed was his, placed his gown over the resident’s legs, handled the resident’s legs, and moved items in the room. Several residents reported wandering residents entering their rooms and said they often had to redirect them themselves because staff were not available or did not respond promptly. Survey observations confirmed wandering residents were not consistently redirected by staff. One resident was observed shouting at another resident in the hallway with no staff intervention observed. Another resident was observed wandering into other residents’ rooms on one hallway, later wandering on another hallway and in the dining room, including near an emergency exit door, with no staff observed redirecting her. The resident’s MDS indicated wandering occurred daily. Staff interviews also described the staffing as inadequate, with one LPN stating the facility had so many wanderers that a dementia ward was needed and that one-on-one supervision was not sustainable with current staffing. Review of the scheduling lookback showed that during the review period, only four CNAs were scheduled for at least a four-hour block on most night shifts, and only three CNAs were scheduled on two of the nights, while the census ranged from 82 to 86 residents.
Dignity Concerns During Meal Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for five residents during meal assistance, resulting in a deficiency related to resident dignity. During dining observations, residents were seen receiving meals in their rooms or in the hallway while staff assisted them using blue medical gloves and, in multiple cases, small brightly colored utensils that resembled baby spoons. Resident #35 had diagnoses including dementia, age-related physical debility, and dysphagia, and was assessed as severely impaired in daily decision-making; this resident was observed being fed in the hallway with a small spoon holding about one teaspoon of food, and similar utensils were also seen on the tray. The speech language pathologist stated plastic spoons were recommended because the resident had been biting metallic utensils, but she did not specifically recommend utensils resembling baby spoons. Resident #30, who had diagnoses including Alzheimer’s disease and dysphagia and was also assessed as severely impaired in daily decision-making, was observed receiving feeding assistance with a small brightly colored spoon resembling a baby spoon, and staff were unsure why those spoons were being used. Resident #10, Resident #37, and Resident #56 were also observed receiving meal assistance while staff wore blue gloves. Review of Resident #35’s EMR and plan of care revealed no orders or interventions regarding adaptive dining utensils, and the DPOA stated he was unaware the facility would be using the small spoons during mealtimes. The facility policy on resident rights stated residents are to receive humane care and treatment with consideration consistent with recognition of dignity, and the Michigan rights document stated residents have the right to be treated with respect and dignity.
Failure to Provide Advance Written Notice for Room Changes
Penalty
Summary
The facility failed to provide advance written notification before changing residents’ rooms, including one resident with Alzheimer’s disease, panic disorder, generalized anxiety disorder, and obsessive compulsive disorder whose most recent MDS showed moderately impaired cognitive skills for daily decision making and cues/supervision required. The resident’s DPOA stated the room was changed without explanation or written notice and without permission, and the EMR contained no written notification of the room change. A census report confirmed the room change, and the Social Worker stated there was no consent form signed by the resident or representative before a room change and that the reason for transfer was not usually documented, although it should be documented. During a confidential resident group interview, three residents reported room changes without prior consultation or notification. One resident described being moved into another resident’s room without being told, another said staff do not consult residents about room changes, and a third reported at least one room change in the prior year without proper notification. Census records confirmed room changes for those residents, and their EMRs contained no documentation of the reason for the room changes or written notification. The Nursing Home Administrator stated he was unaware that residents or representatives had to receive advance written notification of a room change and said room changes were often indicated because of resident behaviors.
Resident Room Temperatures Not Maintained During HVAC Failure
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing resident room temperatures to remain below acceptable levels during a heating system failure on the 300 wing. The incident involved a partial HVAC motor and heat exchanger failure after a severe blizzard, and room temperatures on the affected wing gradually dropped to 62 F near exterior walls and windows. The facility increased hallway thermostats, used hallway fans to direct warmer air, provided extra blankets, and placed portable space heaters in resident rooms, but room temperatures in several occupied rooms remained in the mid-60s during the period documented in the temperature log. Resident #62 was admitted with diagnoses including hemiparesis following cerebral infarction, multiple sclerosis, muscle weakness, and need for assistance with personal care. Her most recent BIMS score was 15, indicating intact cognition. She reported that the hallway unit had no heat for approximately six days around the Christmas holiday, that she was told a furnace belt broke and the unit smelled strongly of burning rubber, and that she had to wear a mask in her room because of the odor. She stated the space heater did a poor job keeping her warm because her bed was on an exterior wall near a window, she used extra blankets and several sweaters, and the room remained cold; a progress note also documented that she refused her weekly shower because she was too cold. Resident #39 was admitted with diagnoses including intracerebral hemorrhage, generalized anxiety disorder, morbid obesity, and low back pain, and had a BIMS score of 14. He stated the facility was without heat for an extended period during the holiday and that the electric space heater did not do much to keep him warm. He also stated the facility did not offer to temporarily relocate him to a warmer room. In a confidential group interview, two residents reported the heat was out for six days, that they were repeatedly told it would be fixed, that the small heaters and extra blankets did not help much, and that they had to go to the nurse's station to warm up. The facility's emergency preparedness plan stated that for cold weather, when temperature is below 72 degrees for 12 continuous hours, the facility must evacuate the room(s).
Food Served Cold and Meal Delivery Delayed
Penalty
Summary
The facility failed to ensure food was served at an appropriate temperature and in a palatable manner for 9 of 14 residents reviewed for food satisfaction. During a confidential group interview, 9 of 14 residents stated their food was almost always cold, and one resident said food temperature was a problem while another said last night's dinner was inedible because it was so cold. Six of 14 residents also reported meals were served at inconsistent times, with one resident stating, "You have to guess [what time meals will be served]." During the lunch meal, which was limited to hallway trays because of an infectious outbreak, meal trays were observed being passed out on the 500, 300, 400, and 200 halls over extended time periods, with trays delivered to resident rooms even when residents were not in their rooms or in the hallway. The Nursing Home Administrator stated during the QAPI task that mealtimes had been a known issue since the summer of 2025, including weekends and supper times. CNA E stated meal carts had a 15-minute timer and any trays left after the timer went off were sent back to the kitchen for a new meal. Resident Council minutes from July through November 2025 documented repeated complaints that meal trays were taking too long, meals were late, food was cold, some orders were incorrect, and late meals interfered with activities.
Food Storage, Equipment, and Hand Hygiene Deficiencies
Penalty
Summary
Food service practices were not maintained in accordance with professional standards in the kitchen and storage areas. On 1/27/2026 at 3:30 PM, three boxes of single-serve items, including cups and lids, were observed sitting on the storage room floor, with the boxes opened and some contents already used. The Dietary Manager stated the last delivery had come in the day before. At 4:25 PM, boxes of canned soup, canned beans, and other canned food items were also observed sitting on the floor in the dry storage room. Additional food service deficiencies were observed during meal service and equipment cleaning. At 3:45 PM, the Roundup plate warmer, model HPD-2, was observed with the lid open and the gasket seal missing, with degraded gasket parts and adhesive still in the lid groove; the unit had been unplugged, but plates were still warm and had been used for lunch service. At 4:10 PM, a large steam jacket soup kettle was being cleaned with soapy water and a brush, and the Dietary Manager stated it was washed with hot soapy water and rinsed with clean hot water, with no other cleaning method known to staff. At 4:15 PM, a utensil drawer tray was observed with dried syrup and food debris stuck to the bottom. At 4:30 PM, kitchen staff ran dirty utensils through the dish machine, handled a lid from the chemical dispensing trough, placed the dirty lid back on the dirty side of the dish machine table, and then unloaded clean utensils with unwashed hands.
Failure to Complete Unusual Occurrence Report After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Unusual Occurrence Report (UOR) policy after a resident-to-resident incident involving two residents with Alzheimer’s disease. An anonymous complaint to the State Agency alleged that one resident (R82) grabbed another resident’s (R90’s) head aggressively, that staff intervened, and that the Nursing Home Administrator later stated he had watched video and characterized the action as “petting” rather than an aggressive act. The complaint further alleged that this resident-to-resident incident was not reported by the facility as required. Record review showed that R82 had a diagnosis of Alzheimer’s disease and a Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 99/15, indicating severe cognitive impairment. R90 also had Alzheimer’s disease and an MDS BIMS score of 00/15, indicating cognitive impairment. Behavior charting in R82’s electronic medical record documented that on 12/06/2025 at 5:00 p.m., R82 exhibited aggression toward others, with additional information stating that the resident, while getting ready to eat dinner and standing next to R90, put his hands over her hair/eyes. This behavior entry was documented by LPN S. In an interview, the Nursing Home Administrator reported awareness of a situation between R82 and R90 about a month prior but stated he did not have a completed UOR for the event. In a separate interview, LPN S reported that on the date of the incident, R82 grabbed onto R90’s head and the two residents were immediately separated. LPN S stated that a phone call was made to the DON to report the incident because R82 was known to have extremely aggressive behaviors, especially toward staff, but she was unsure whether the DON or any other staff member completed a UOR and confirmed that she did not complete one herself. Review of the facility’s UOR policy showed that resident-to-resident altercations are defined as unusual occurrences requiring completion and investigation of an Unusual Occurrence Report, including assessment, documentation, and follow-up, which was not done for this incident.
Failure to Protect Resident From Peer Abuse and to Report/Investigate Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to follow its own abuse reporting and investigation policies. An anonymous complaint to the State Agency alleged that one resident aggressively grabbed another resident’s head, and that staff intervened between the two. The complaint further alleged that two nurses reported the incident to the DON, and that the NHA later stated he had watched video and characterized the action as the aggressor resident “petting” the other resident’s head, and that the incident was not reported by the facility as a resident-to-resident event. The NHA later reported to the surveyor that he was aware of the situation between the two residents about a month prior but did not complete an Unusual Occurrence Report or a Facility Reported Incident to the State Agency. Resident #82 was admitted with Alzheimer’s disease and had a BIMS score indicating severe cognitive impairment. Behavior charting and EMR notes documented a pattern of aggressive behaviors by this resident around the time of the incident, including aggression toward others, raising fists in a threatening manner at an activity aide, following a female resident and placing a hand on her back in a way that upset her, being aggressive and combative with staff during care, backhanding a CNA across the face and grabbing an arm leaving red marks, and multiple instances of hitting, punching, spitting, and pushing staff, with some incidents causing staff injury. A hospice RN documented that this resident had experienced agitation involving violence toward other residents, and facility documentation noted increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions toward care staff, as well as difficulty redirecting the resident and identifying techniques to keep staff safe. Resident #90 was also admitted with Alzheimer’s disease and had a BIMS score indicating cognitive impairment. The resident was described as elderly, blind, hard of hearing, and on hospice care. A hospice social worker note shortly before the incident described this resident as asleep in a wheelchair in the dining room, appearing comfortable and peaceful, and not arousing to verbal or gentle touch. On the date of the alleged head-grabbing incident, behavior charting for Resident #82 documented that he was standing next to Resident #90 and put his hands over her hair/eyes. LPN S, who authored this behavior note, later reported that Resident #82 grabbed onto Resident #90’s head, that the two residents were immediately separated, and that a phone call was made to the DON to report the incident because Resident #82 was known to have extremely aggressive behaviors. LPN S stated that when Resident #82 grabbed Resident #90’s head, it was not gentle. However, review of Resident #90’s EMR progress notes over the relevant period showed no documentation of any aggressive physical or verbal interaction with other residents and no documentation of Resident #82 touching or grabbing her head on the date in question. The facility’s written policy on abuse investigation and reporting required that all alleged violations involving mistreatment, neglect, or abuse, including resident-to-resident incidents, be immediately addressed, that an Unusual Occurrence Report be completed by the charge nurse for all allegations or suspicions of abuse, and that allegations of abuse of any nature be reported to the State Agency within 24 hours of the incident. The policy also outlined steps for investigation, including interviews, record review, and documentation of the event. In this case, despite staff reporting that Resident #82 grabbed Resident #90’s head and the facility’s knowledge of Resident #82’s ongoing aggressive behaviors toward others, the NHA acknowledged that no Unusual Occurrence Report or Facility Reported Incident was completed, and there was no documentation of the incident in Resident #90’s record. Based on the reasonable person concept, the surveyors determined that Resident #82’s action of grabbing Resident #90’s head would cause feelings of pain, fear, and intimidation, and that the facility failed to protect Resident #90’s right to be free from physical abuse by another resident and failed to follow its own abuse reporting and investigation procedures.
Failure to Investigate and Report Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its Abuse Program Policy and Procedure by not immediately identifying, documenting, and thoroughly investigating an incident of resident-to-resident abuse involving two residents. An anonymous complaint to the State Agency reported that one resident aggressively grabbed another resident’s head, that two nurses intervened, and that both nurses called the DON immediately after the incident. The complaint further alleged that the NHA later stated he had watched video footage and characterized the interaction as the resident ‘petting’ the other resident’s head, and that the incident was not reported by the facility as resident-to-resident abuse. Resident #82 was admitted with Alzheimer’s disease and had a MDS BIMS score indicating severe cognitive impairment. Behavior charting and EMR progress notes documented a pattern of aggressive behaviors by this resident around the time of the incident, including aggression toward others, raising fists in a threatening manner at an activity aide, following a female resident and placing a hand on her back in a way that upset her, aggressive behavior with staff during care, hitting staff, backhanding a CNA across the face and grabbing an arm leaving red marks, and multiple episodes of combative behavior causing staff injury. On 12/6/25 at 17:00, behavior charting documented that this resident, while getting ready to eat dinner and standing next to Resident #90, put his hands over her hair/eyes. LPN S, who wrote this note, later stated that the resident grabbed the other resident’s head, that it was not gentle, and that the two residents were immediately separated. LPN S also reported that a phone call was made to the DON to report the incident because the resident was known to have extremely aggressive behaviors. Resident #90 was also admitted with Alzheimer’s disease and had a MDS BIMS score of 0/15, indicating cognitive impairment. EMR progress notes for this resident from 10/1/25–12/12/25 contained no documentation of any aggressive physical or verbal interaction with other residents and no documentation that Resident #82 touched or grabbed her head on 12/6/25. The record also showed that Resident #90 was elderly, blind, hard of hearing, and receiving hospice care, and a hospice social worker note described her as asleep, peaceful, and not arousing to verbal or gentle touch during a visit shortly before the incident period. Despite the facility’s written Abuse; Investigative and Reporting policy requiring immediate (within two hours) reporting and investigation of all alleged or suspected abuse, completion of an Unusual Occurrence Report by the charge nurse, notification of the Administrator, and reporting allegations of abuse to the State Agency within 24 hours, the NHA acknowledged being aware of the situation between the two residents about a month prior and reported that he did not complete an Unusual Occurrence Report or a Facility Reported Incident. The investigation checklist and policy requirements for interviews, record review, and documentation were not shown to have been followed for this incident, and there was no corresponding documentation in Resident #90’s record, demonstrating the facility’s failure to fully implement its abuse investigation and reporting procedures.
Failure to Report and Investigate Resident-to-Resident Aggression as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation and reporting policy and to report a reasonable suspicion of a crime under Section 1150B of the Act after an aggressive resident-to-resident incident. An anonymous complaint to the State Agency alleged that one resident aggressively grabbed another resident’s head, that two nurses intervened and reported the incident to the DON, and that the NHA later stated he had watched video and believed the resident was only petting the other resident’s head. The complaint further alleged this resident-to-resident incident was not reported by the facility. The facility’s written policy required that all allegations or suspicions of abuse, including mistreatment and injuries of unknown source, be immediately addressed, that an Unusual Occurrence report be completed by the charge nurse, that the Administrator be notified, that an investigation be initiated within 24 hours, and that allegations of abuse of any nature be reported to the State Agency within 24 hours of the incident. Resident 82 was admitted with Alzheimer’s disease and had a BIMS score indicating severe cognitive impairment. Behavior charting for this resident documented aggression toward others, including an entry on 12/06/2025 at 17:00 stating that the resident, while getting ready to eat dinner and standing next to another resident, put his hands over her hair/eyes. LPN S, who documented this note, later reported that she was working at the time of the incident when the resident grabbed onto the other resident’s head, that the two residents were immediately separated, and that a phone call was made to the DON to report the incident because this resident was known to have extremely aggressive behaviors such as hitting, punching, spitting, swinging, kicking, and reaching out toward others. LPN S stated that when the resident grabbed the other resident’s head, it was not gentle. Additional behavior charting for this resident on subsequent dates documented further aggressive behaviors, including raising fists in a threatening manner and following a female resident, placing a hand on her back and reaching toward her again, which upset the other resident. Resident 90, the other resident involved, was also admitted with Alzheimer’s disease and had a BIMS score of 0/15, indicating cognitive impairment. Her EMR progress notes over a several‑month period showed no documentation of any aggressive physical or verbal interaction with other residents and no documentation that the aggressive resident touched or grabbed her head on the date of the incident. Her record also indicated that she was elderly, blind, hard of hearing, and receiving hospice care. The NHA acknowledged in an interview that he was aware of a situation between these two residents about a month prior, that he did not report or investigate the occurrence because he felt it did not rise to the level of being reportable or needing investigation, and that he no longer had video footage of the occurrence. This combination of staff reports, behavior charting, and the NHA’s decision not to report or investigate, despite the facility’s abuse policy requirements, formed the basis of the cited deficiency.
Failure to Supervise Wandering Residents
Penalty
Summary
The facility failed to provide adequate supervision to prevent wandering residents from entering private resident rooms and other resident areas. During a confidential group interview, five residents reported that wandering residents frequently entered their rooms, forcing them to keep their doors closed or redirect the wandering residents themselves because staff did not do so. One resident stated that a wandering resident followed her throughout the day and stared at her, while another said wandering residents were coming into rooms so often that she could not keep her door open. A third resident reported that she had to redirect a wandering resident because she did not want the resident near her, and another stated that wandering occurred all night long. Observation and record review showed multiple examples of wandering without staff intervention. One resident was observed in the 300 hallway shouting at another resident outside a room, with no staff response observed. That resident’s care plan identified a high risk for resident-to-resident altercations and directed consistent verbal redirection when attempting to enter other residents’ rooms. Another resident was observed wandering into and out of rooms on the 300 hallway, later wandering on the 500 hallway and in the dining room, including near an emergency exit door, with no staff intervention observed. The resident’s MDS documented daily wandering. A separate resident with a BIMS score of 15 wrote that he woke to a man in his room wearing a gown, saying the bed was his and handling his legs and items. An LPN stated the facility had many wanderers and that it was not sustainable to provide the one-on-one supervision they required given current staffing levels.
Failure to Use PPE for Resident on Droplet Precautions
Penalty
Summary
The facility failed to maintain appropriate infection control practices to prevent the spread of pneumonia for one resident, R36, who was placed on droplet precautions after a change in condition was noted by nursing staff. The resident’s progress notes documented that droplet precautions were initiated and that the RN supervisor was notified. A sign indicating that R36 was on precautions was observed posted to the right of the resident’s door. At approximately 1:30 p.m., a Hospitality Aide/Staff Y was observed assisting hallway meal trays and then entering R36’s room without PPE to drop off the resident’s lunch tray. When exiting the room, Staff Y stated that she should have worn PPE into the room. During interview, the Infection Preventionist confirmed that Staff Y should have worn PPE. The facility’s Transmission Based Precautions policy stated that droplet precautions require PPE, including gloves, gowns, and masks.
Deficiencies in Food Safety and Kitchen Ventilation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a morning meal service. A stainless steel pan containing pureed eggs, sausage, and hashbrown potatoes was found on the steam table at a temperature of 115°F, which is below the required 135°F for hot holding. The food service worker, identified as [NAME] B, was unaware of the correct reheating temperature of 165°F and had not measured the temperature after the pureeing process. This oversight has the potential to result in foodborne illness among the facility's 76 residents. Additionally, the facility's dishwashing practices were found to be inadequate. A food service worker, identified as FSW C, was observed washing and rinsing food preparation equipment and then immersing them in a sanitizing solution for only two seconds, contrary to the required 60 seconds for proper sanitization. The worker was unaware of the correct immersion time, which is necessary to ensure the equipment is properly sanitized and safe for use. The facility also exhibited deficiencies in its kitchen ventilation system. The exhaust hood was unable to capture the steam released from the steamer equipment, resulting in condensation on the kitchen ceiling and potential contamination of food. The exhaust system was found to have a weak pull and was not properly engineered to handle the volume of steam and smoke produced, nor did it provide adequate make-up air to balance the exhaust volume. This ongoing issue was confirmed by the kitchen manager, indicating a long-standing problem with the facility's ventilation system.
Deficient Dining Experience and Feeding Practices
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the dining room, as observed during meal services. During lunch, several tables with multiple residents were partially served, resulting in some residents eating while others at the same table waited for their meals. This led to situations where residents were left waiting for extended periods, with one resident waiting from before 12:30 PM until 1:05 PM to be served. Similar issues were observed during breakfast, where residents at the same table were served at different times, causing some to wait while others ate. Staff members were observed serving meals in no particular order, contributing to the delays. Additionally, staff members were observed standing over residents while assisting with feeding, which was acknowledged by both a Registered Nurse and a staff member as not being the appropriate practice. The Director of Nursing confirmed that the expectation was for staff to be seated while feeding residents. The Certified Dietary Manager stated that the standard practice should be to serve the same table at the same time, but this was not reflected in the facility's training program or policies. No further policies addressing these issues were provided before the survey concluded.
Medication Cart Security and Expired Glucose Solutions
Penalty
Summary
The facility failed to ensure that a medication cart on the 500 unit remained locked when unattended, as observed on two separate occasions. This oversight was confirmed during an interview with the Director of Nursing (DON), who stated that the expectation is for medication carts to be locked when not in use. The unlocked cart posed a potential risk for the misappropriation of medications for the nine residents on the unit. Additionally, the facility did not discard two expired glucose meter control solutions, which were found on the countertop in the medication storage room. The control solutions had been opened beyond the recommended three-month period, as indicated by the dates written on the bottles. The Licensed Practical Nurse (LPN) present during the inspection was unaware of other available control solutions, although unopened boxes were found in a cupboard. The DON confirmed that the expired solutions should have been discarded within 90 days of opening, as per the facility's policy and the manufacturer's instructions. This failure could lead to inaccurate blood glucose readings for six residents receiving blood glucose testing.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutritional assessment and interventions for a resident who experienced significant weight loss. The resident, who was cognitively intact, reported losing weight and expressed dissatisfaction with the food, noting that scrambled eggs were often served cold. Despite discussing food preferences with the Certified Dietary Manager (CDM), the resident did not see any changes. The resident's electronic medical record indicated an 11-pound weight loss over one month, which was not promptly addressed by the facility. The care plan was not updated to reflect necessary nutritional interventions following a diet order change. The Registered Dietician (RD) was not informed of the resident's significant weight loss until contacted by a state surveyor. The RD stated that the facility's process for referral was not followed, as she was not notified via the referral list or phone call. The Director of Nursing (DON) confirmed that the RD should have been notified of any significant weight loss, defined as a 5% or greater loss in a month. Despite the facility's policy requiring notification of dietary concerns, the RD was unaware of the resident's condition until after the surveyor's involvement. The facility's failure to reweigh the resident or notify the RD in a timely manner contributed to the deficiency.
Failure to Monitor Change in Condition
Penalty
Summary
The facility failed to ensure that a change in condition for a resident was assessed and monitored by the attending physician. The resident, who had a history of acute kidney failure and urine retention, exhibited symptoms indicative of a deep vein thrombosis (DVT), including moderate pitting edema, warmth, and redness in the left lower leg. Despite these symptoms being documented by an LPN and communicated to the charge nurse, the physician was not notified in a timely manner, and no physician assessment was conducted following the initial identification of these symptoms. The resident was later transferred to the emergency room for an unrelated concern, where a diagnosis of left leg DVT was confirmed. The facility's policy required documentation of observations and physician notification, but no Change in Condition form was found for the resident. Interviews with the DON and a clinical consultant confirmed that the resident was not evaluated by a physician after the symptoms were identified, and the diagnosis of DVT was considered untimely.
Failure to Adhere to Therapeutic Diets and Fluid Restrictions
Penalty
Summary
The facility failed to ensure that a correct therapeutic diet was prescribed and served to two residents, leading to potential unmet nutritional needs and health complications. Resident #25, who was admitted with diagnoses including dementia, dysphagia, and diabetes mellitus, was observed receiving incorrect meal portions and items not aligned with the prescribed diet. The resident was supposed to receive a carbohydrate-controlled diet with no added salt and pureed food, but was served mixed items and incorrect portion sizes. Additionally, the resident received pepper packets despite instructions to exclude them, potentially due to a risk of consuming the packets themselves. Resident #41, diagnosed with chronic congestive heart failure, high blood pressure, and diabetes mellitus, was on a physician-ordered fluid restriction. However, the resident was observed consuming fluids exceeding the prescribed limits during meals and other times, such as activities. The staff, including an LPN, appeared unaware of the fluid restriction, leading to the resident consuming more fluids than allowed. The fluid intake was inaccurately recorded, and the resident was served additional fluids despite the restriction. The facility's failure to adhere to prescribed dietary and fluid restrictions for these residents indicates a lack of compliance with dietary orders and monitoring systems. The dietary manager and staff interviews revealed a lack of understanding and adherence to the therapeutic menus and fluid restriction plans, contributing to the deficiencies observed during the survey.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to assess and prevent a significant weight loss for a resident, identified as R2, who experienced a 12.9% weight loss within three weeks of admission. R2 was admitted with multiple diagnoses, including a fracture, cellulitis, and a Stage II pressure ulcer. Despite these conditions, there was no evidence of re-weighing to verify the significant weight loss, nor were there any dietary progress notes completed by the Certified Dietary Manager (CDM) or the Consultant Registered Dietitian (RD). Interviews revealed a lack of communication and responsibility among staff regarding dietary assessments. The Assistant Dietary Manager was unaware of the dietitian's visits, and the CDM did not document the weight loss due to a policy requiring a referral to the dietitian. The CDM mentioned that nursing was responsible for adding new admissions to a dietary referral sheet, but R2's significant weight loss was not addressed. The Consultant RD was also unaware of R2's condition, indicating a breakdown in the referral process. The Director of Nursing (DON) confirmed the absence of progress notes in the Electronic Medical Record (EMR) for R2's weight loss. A list of dietitian referrals showed R2 as a new admission, but the RD had not completed an assessment. The facility's Weight Management policy required re-weighing and dietary notification for weight discrepancies, but these procedures were not followed, leading to the deficiency in care for R2.
Failure in Timely Pain Management for a Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R2, who was admitted with multiple diagnoses including a fracture, cellulitis, and a pressure ulcer. Despite having a pain management plan in place, the facility consistently administered pain medication late and failed to administer PRN medications as needed. R2's pain was documented as severe, often reaching a 10 on the pain scale, yet the facility did not adhere to the prescribed medication schedule. R2's medical records indicated that pain medications such as Gabapentin and Hydrocodone-acetaminophen were either not administered or given late on multiple occasions. The resident's pain care plan, which aimed to maintain pain levels at a manageable level, was not effectively implemented. The facility's policy required pain assessments and timely medication administration, but these were not consistently followed, leading to prolonged periods of unmanaged pain for R2. Interviews with the complainant and the Director of Nursing revealed awareness of the issues, with complaints about the late administration of pain medication being raised multiple times. Despite these concerns, the facility did not take adequate steps to ensure timely pain relief for R2, resulting in the resident experiencing significant discomfort and distress during their stay.
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 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Marquette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dj Jacobetti Home For Veterans | 0.2 mi | ★★★★★ | 7 | 0 |
| Eastwood Nursing Center | 9.4 mi | ★★★★★ | 0 | 0 |
| Marquette County Medical Care Facility | 13.9 mi | ★★★★★ | 0 | 0 |
| Mission Point Nsg & Phy Rehab Ctr Of Ishpeming | 15.4 mi | — | 0 | 0 |
| Medilodge Of Munising | 36.7 mi | ★★★★★ | 25 | 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.