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 Oakland Manor Nursing And Rehabilitation Center Ll during CMS and state inspections, most recent first.
Failure to Inventory and Secure Resident Valuables: A cognitively intact resident reported that an Activities Director removed his gold chain with a cross during a card game and did not return it. Surveyors found no admission inventory sheet for the resident’s valuables, and a later inventory omitted the necklace and pendant. Video showed the staff member taking the necklace, while the staff member denied the event and acknowledged she did not inventory the item or know the process for securing valuables.
Misappropriation of Resident Jewelry by Activities Staff: A cognitively intact resident with a hx of stroke and seizures reported that an activities staff member removed his gold necklace with a cross and rings during a card game and did not return it. Nursing staff documented the resident’s consistent account, and video footage showed the staff member taking the necklace and leaving with it. The staff member denied the allegation, but the footage and interviews supported the resident’s report, and the incident was not reported to the State Agency until several days later.
Delayed Reporting of Alleged Misappropriation: A cognitively intact resident reported that an activities director removed his necklace during a card game and the item was missing. Staff, including the DON and NHA, were informed the same day and searches were done, but the allegation was not reported to the State Agency until several days later, after video footage showed the activities director unfastening the necklace and leaving with it.
Incomplete wound documentation and missed TAR entries: The facility failed to maintain clear skin and wound records for a resident with dependent care needs and multiple medical diagnoses. Wound tx orders for the sacrum and left gluteal area lacked wound descriptions and reasons, several TAR entries were blank, and nursing and physician notes did not explain the treatments or omissions. Records also conflicted on whether the resident had MASD, an abrasion, or open areas, and the DON confirmed the chart lacked wound assessments and descriptions.
Unlocked Treatment Cart: Medication and treatment supplies were left unsecured in the patient care area when a treatment cart was observed unlocked and unattended multiple times across from the nurse's station. An LPN acknowledged the cart should be locked and secured it, and the DON later stated treatment carts should be locked when unattended.
No Ongoing Resident-Centered Activities Program: The facility had no Activity Director or activity staff, no activity calendar, no resident council meetings, and no documented group or individualized activities. Several residents with varying diagnoses and cognitive/physical needs stated they were bored or had nothing to do, while staff reported CNAs were not providing activities and residents were mostly left watching TV, sitting in hallways, or staying in bed. Records showed no activity assessments, logs, participation documentation, or activity care plans for the residents reviewed.
A facility failed to have a qualified activity professional directing an ongoing activities program. The NHA/DON and HR Manager stated there was no Activity Director, no activity staff, and no CNA assigned to that role after the prior director left, and residents reported boredom and a lack of things to do. Surveyors observed no activity calendars, no group or individualized activities, and no activity documentation or care planning for the residents reviewed.
Failure to provide appropriate geri-chairs for two residents. One resident with metabolic encephalopathy, muscle weakness, and impaired cognition had not been up in a long time and later was finally observed in a tan geri-chair. Another resident with T7-T8 fracture, paraplegia, and GAD was found eating in bed while a narrow blue geri-chair in the room was too small and damaged; staff said only one resident could get up at a time and that the facility had only two geri-chairs, one of which was very small.
A resident admitted for therapy on a skilled level of care was discharged AMA, but the facility did not complete the required MDS discharge assessment. Review of the MDS record showed no discharge assessment was present, and the MDS RN stated the assessment was missed and should have been completed around the time of discharge.
A resident with cognitive impairment and incontinence had a wound to the left gluteal fold/buttock area that was documented inconsistently as a stage 2 pressure ulcer, a quarter-sized bed sore, MASD, or a skin tear. Nursing notes and skin assessments lacked ongoing wound descriptions and measurements after the initial entry, the EMR had no clear wound consult or measurement record, and staff acknowledged the wound should have been measured and documented when first identified.
Missed and incomplete wound care treatments were identified for a resident with metabolic encephalopathy, an unstageable sacral pressure ulcer, and muscle weakness. Wound care documented new wounds on the mid lower back and a new R heel stage 2, with silver nitrate used on hypergranulating heels and offloading ordered. However, the ordered wound treatments were not carried out in the medical record, and the DON stated floor nurses were responsible for implementing new or changed wound orders.
A resident with cognitive impairment, dementia, and a history of falls had a care plan calling for the bed to be kept low and the call light kept within reach, but surveyors found the bed at mid-height and the call light out of reach. The resident had repeated falls out of bed, including one with a skin tear, and the fall care plan was not reviewed or updated after the bed falls until later. A CNA reported the call light had been removed and not returned, was unaware the bed should be in the lowest position, and said they did not have access to care plans.
Missing Physician Orders for PICC Line Care and Monitoring: A resident receiving IV antibiotics through a PICC line was observed with a taped dressing on the right upper arm, and the resident was unsure when the dressing had last been changed. Record review found no MD order for PICC dressing changes or for monitoring the site for signs and symptoms of infection. The DON stated PICC dressings are changed weekly or if soiled, but could not explain how staff would know when to change or document the dressing change.
A resident with stroke, HF, and DM had documentation showing acceptance of the flu vaccine, but the vaccine was not administered and no flu vaccine record was present. The resident said she had signed up for it but had not received it yet, despite the facility policy requiring annual influenza vaccinations to be offered and consent obtained before administration.
The facility failed to maintain a pest-free environment, with standing water and cobwebs found under the steam table in the kitchen, and gnats observed in both the kitchen and hallway near resident rooms. The Dietary Manager could not explain the presence of gnats, which violates the 2017 FDA Food Code requiring premises to be free of pests.
The facility failed to notify the State Long Term Care Ombudsman of the discharges of two residents. One resident was discharged in July and another in September, but neither was included in the monthly discharge reports sent to the Ombudsman. The facility's policy requires such notifications, and the omission was acknowledged as an oversight by the Nursing Home Administrator.
The facility failed to provide a resident or their representative with written notification of the bed hold policy prior to a hospital transfer. The social worker admitted that the policy was not given, and there was no documentation in the resident's file. The facility's policy requires such a notice at the time of transfer, but it was missed in this case.
A facility failed to complete a discharge summary for a resident upon their discharge, as required by their policy. The resident's electronic medical record lacked the necessary documentation, which is essential for ensuring coordinated care and a safe transition. Both the RN/MDS responsible and the Nursing Home Administrator acknowledged the oversight.
A resident requiring substantial assistance for bathing received only one shower since admission, despite being scheduled for showers twice a week. The facility's policy requires assisting residents with bathing, but the lack of documentation and adherence to the schedule resulted in unmet care needs.
A resident with diagnoses of diabetes, malnutrition, anxiety, and depression did not have weekly weights recorded as ordered, following their admission to the facility. Despite the resident's report of weight loss and insufficient food, staff did not acknowledge the issue. The facility's policy required weekly weight monitoring for newly admitted residents, which was not adhered to.
The facility did not post the required nurse staffing information, preventing residents from knowing the staff available for care. Observations showed the staffing sheet was either inaccessible or missing, and staff confirmed residents could not view it. The NHA acknowledged the deficiency.
Failure to Inventory and Secure Resident Valuables
Penalty
Summary
The facility failed to protect a cognitively intact resident’s right to a safe, homelike environment by not properly inventorying and securing the resident’s valuables. The resident, who had a BIMS score of 15/15 and was his own responsible party, reported that his gold chain with a cross and two rings were missing after an interaction with the Activities Director. The resident stated that the staff member removed his chain while they were playing cards and did not return it when asked. The facility’s investigation showed that the resident had admitted with jewelry and cash, but no admission inventory sheet was available when requested by surveyors. A later inventory sheet dated after the incident listed only three gold rings, one silver ring, and $100 cash, and did not include the gold necklace and cross pendant. The resident told surveyors that the chain and religious medal had been taken from him by the staff member, and the staff member later denied both playing cards with the resident and having the necklace. Video footage reviewed by the facility showed the Activities Director playing cards with the resident and taking the resident’s necklace, with no observation of it being returned. The facility also reported that the necklace was not found during a room search and that the incident was not reported to police or the State Agency until several days after it occurred. The report also states that the staff member acknowledged she did not inventory the necklace when she took it and said she did not know the process for securing valuables.
Misappropriation of Resident Jewelry by Activities Staff
Penalty
Summary
The facility failed to protect a cognitively intact resident from the wrongful use of his belongings when an activities staff member was found on video removing the resident’s gold necklace with a cross and rings during a card game. The resident, who had a history of stroke, seizures, and adjustment disorder with anxiety, repeatedly reported that the staff member took the necklace off his neck and did not return it. His BIMS score was 15/15, and the MDS described him as cognitively intact and his own responsible party. The resident’s account remained consistent across interviews with the DON, unit staff, and the surveyor. He stated that the staff member removed the chain while they were playing cards, said she needed to use the bathroom, and then returned without giving it back. CNA and nursing staff also reported that the resident was upset and clearly stated that the staff member had taken his necklace. The DON, LPN, CNA, and unit manager all documented that the resident reported the necklace was missing and that he identified the activities staff member as the person who had taken it. Video footage reviewed by the surveyor showed the resident and the activities staff member playing cards, the staff member leaning over and removing the necklace, placing it on the table, picking it up, and leaving the area with it. The staff member later denied taking the necklace and denied playing cards with the resident, which conflicted with the video and with the resident’s statements. The facility’s investigation also showed that the incident occurred on 4/24/26 but was not reported to the State Agency until 4/29/26, five days later. The report and policy review identified this as misappropriation of resident property.
Delayed Reporting of Alleged Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation timely after a cognitively intact resident reported that his gold chain with a cross and rings were missing and stated that an activities director had removed the necklace while they were playing cards. The resident had a BIMS score of 15/15 and was described by staff as alert, oriented, and a reliable reporter. Staff interviews consistently reflected that the resident reported the necklace missing on the day of the incident and identified the activities director as the person who took it. Multiple staff members confirmed that the resident reported the missing necklace to nursing staff at the nurse’s station, that the DON was present, and that searches of the resident’s room and the surrounding area did not locate the necklace. The DON stated the resident reported that the activities director took the necklace off during the card game and that the matter was considered misappropriation. The NHA also acknowledged being informed of the allegation by the DON on the day it occurred. Video footage later reviewed by the facility showed the resident and the activities director playing cards, the activities director reaching for and unfastening the necklace, and then leaving with the necklace not seen being returned. Despite the allegation being reported internally on the day of the incident, the facility did not report it to the State Agency until five days later, after reviewing the video. The facility policy required allegations of abuse, neglect, exploitation, and misappropriation of resident property to be reported immediately to the Administrator and to appropriate agencies within prescribed timeframes.
Incomplete wound documentation and missed TAR entries
Penalty
Summary
The facility failed to ensure appropriate documentation for skin and wound treatment for one resident who was admitted with diagnoses including lung disease, pneumonia, heart failure, and morbid obesity, and who was dependent for toileting, bed mobility, and transfers. The resident’s skin assessment on admission showed no pressure ulcers and MASD, but the record later contained wound treatment orders for the sacrum and left gluteal area without wound descriptions or clear reasons for treatment. The orders included cleansing, topical products, and dressings, yet the documentation did not identify the wound type, wound stage, or the basis for the treatments. The Treatment Administration Record for February 2026 contained multiple blank entries for both the sacral and buttocks wound treatments, and the EMR progress notes did not document reasons for the omissions. Nursing and physician notes reviewed during the survey also did not describe the wounds or explain why the treatments were being provided. Several advanced skilled evaluations stated that no skin issues were identified even though wound care treatments were active on those dates, while one nursing note referenced an open area to the left gluteal region receiving treatment without further description. Additional records created confusion about the resident’s skin condition. A transfer form to the hospital documented red, moist groin skin and open areas on both buttocks, while a hospital handoff form referenced friction and shear on the right buttock and a non-stageable area on the left buttock with Triad and foam. A wound care provider note described a left gluteal skin concern and an abrasion on the left lower leg, but these details were not consistently reflected in the facility’s EMR, care plan, or physician documentation. The DON confirmed there were no wound assessments, descriptions, or skin assessments found in the record and had no explanation for the missing TAR entries.
Unlocked Treatment Cart
Penalty
Summary
Medication and treatment supplies were not secured to prevent unauthorized access, as an unlocked treatment cart was observed in the patient care area. On 1/26/26 at 8:44 AM, the medication treatment cart was observed unlocked and unsecured across from the nurse's station, and it was again observed unlocked at 9:18 AM. Nurse E was asked whether the treatment cart should be locked and stated yes, then locked the cart. The cart was later observed unlocked and unsecured again on 1/26/26 at 1:32 PM and on 1/27/26 at 8:21 AM across from the nurse's station. On 1/27/26 at 12:03 PM, the DON was interviewed and stated that treatment carts should be locked when unattended.
No Ongoing Resident-Centered Activities Program
Penalty
Summary
The facility failed to maintain an ongoing resident-centered activities program to provide meaningful activities based on resident preferences and needs for five residents reviewed for activities. The census was 21 residents, and the NHA/DON stated there was no Activity Director or activity staff, with CNAs reportedly completing activities. The facility was described as a 29-bed SNF/NF, yet there was no resident council meetings, no resident council president, and no activity calendar on the unit when surveyed. Nursing staff confirmed there had not been an activity calendar for at least a few months, and observations throughout the survey found no group or individualized activities in common areas, the dining room, resident rooms, or on the unit. R6 was observed in the room with only crayons on the bedside table and no other activities present. R6 stated the daughter brought the crayons and said they wanted word searches, puzzle books, coloring pages, BINGO, and parties, and reported that therapy was their only activity and staff were not doing any activities with them. The EMR showed no activity assessment, activity logging, activity participation, or activity care planning for R6. R9, who had diagnoses including sepsis, pulmonary embolism, and schizophrenia and had a guardian, said there was nothing to do and wanted more to do; staff stated the aides were not providing activities and that residents were mostly sitting with TVs on. R10, admitted with compression fractures, sepsis, and metabolic encephalopathy, said they would participate in music, bowling, BINGO, or cards if offered and later stated, “I am bored.” Their record also showed no activity assessment, logging, participation, or care planning. R15, who had cognitive impairment and diagnoses including metabolic encephalopathy, dementia, heart disease, kidney disease, a fractured clavicle, and prior hip replacements, was repeatedly observed sitting in a wheelchair across from the nurse’s station or in bed with no activities, magazines, puzzle books, or coloring pages. R15 stated they wanted to talk to their wife, wished they could go fishing and be with family, liked music activities, magazines about fishing and travel, church, games, and cards, and said, “It is boring (here)” and later that they had nothing to do. Their care plan had no activity problems, goals, or interventions, despite agitation and care refusals being documented. R30, admitted with a thoracic vertebra fracture, paraplegia, and generalized anxiety disorder, was observed lying in bed and stated there was nothing else to do and that they stayed in bed all the time, but would attend activities and liked meeting new people. The regional social worker and CNA described only limited informal options such as watching TV, talking, or playing cards if someone else was available. The records for R6, R9, R10, R15, and R30 showed no activity assessment, activity logging, activity participation, or activity care planning with goals, interests, preferences, or abilities.
No Qualified Activity Director and No Ongoing Activities Program
Penalty
Summary
The facility failed to ensure that a qualified activity professional directed and oversaw an ongoing activities program for residents. On survey entry, the census was 21 residents in a 29-bed facility, and the NHA/DON stated there was no activity director, no activity staff, and no resident council meetings. The NHA/DON also clarified that CNAs were completing activities with residents, but later the Human Resources Manager stated there was nobody in the activity position, no activity aide or other activity staff, and no CNA known to be fulfilling that role. The former Activity Director had left on 8/04/25, and staff confirmed there had been no Activity Director, activity staff, or activity aide since that time. Resident interviews showed a lack of activities being provided and residents expressing boredom. One resident said they wished there were facility activities such as BINGO, parties, word searches, coloring pages, and arts and crafts. Another resident said they wished they could go fishing and be with family, liked to keep busy, and said they wished they had something to do; later the same resident said it was boring there. A third resident said there was nothing to do and that this bothered them, and another resident said they were bored and would participate in activities if offered, including music, bowling, BINGO, or cards. A nurse also stated aides were not providing activities, residents were sitting bored with TVs on, and there were no activities going on in the facility aside from therapy getting residents moving. Record review showed no activity assessment, activity logging, activity participation, or activity care planning for the residents reviewed, including no activity goals, interests, preferences, or abilities documented in the EMR. Observations throughout the survey found no activity calendars in resident areas, no group or individualized activities, and no activity materials at the bedsides of the residents reviewed. The NHA B stated there was no documentation of checking in with residents and acknowledged there had been no formal activities since August 2025 when the former Activity Director left. The facility’s job description for the Activity Director described responsibility for directing the activities program, resident council, calendars, assessments, care plan input, and daily scheduled activities.
Failure to Provide Appropriate Geri-Chairs for Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not ensuring an appropriate geri-chair was available for each of them. One resident, admitted with diagnoses including metabolic encephalopathy, muscle weakness, and need for assistance with personal care, had moderately impaired cognition on MDS review. On observation, the resident was found lying in bed and stated she wanted to get out of bed but had not been up in a long time. She said staff would bring in a reclining chair for her, but it had been a long time since she had seen it. Later that day, she was observed sitting in a tan geri-chair in her room and said it was the first time she had been up in a long time and that she was happy. A second resident, admitted with diagnoses including fracture of T7-T8 thoracic vertebra, paraplegia, and generalized anxiety disorder, was observed lying in bed eating lunch while a narrow blue geri-chair with tape on both arm rests and a rip in the right arm rest was in the room. The resident stated he had previously sat in a wheelchair but kept sliding out, so staff had put him in a geri-chair, and he identified the chair he had used as tan. He also stated he wanted to get out of his room and meet people. Staff interviews revealed there were only two geri-chairs in the facility, one of which was very small, and that only one resident could get up at a time. The Administrator/DON stated she had not been informed that additional residents were requesting a geri-chair and acknowledged the small blue geri-chair should be removed and additional geri-chairs obtained.
Missed MDS Discharge Assessment After AMA Discharge
Penalty
Summary
The facility failed to complete the MDS discharge assessment for one resident who had been admitted on a skilled level of care and later discharged from the facility against medical advice. Review of the resident assessment documentation showed the resident’s MDS record was over [AGE] years old and had not been completed. The resident’s census record showed the resident was discharged on 9/16/25, and the nursing discharge summary, closed on 9/18/25 by the MDS nurse, documented the resident left the facility AMA after being admitted for therapy. During review of the MDS assessment page on 1/28/26, there was no discharge assessment present. When asked about the missing assessment, the RN who served as the MDS nurse stated the discharge MDS assessment was missed and should have been completed on or near the time of the AMA discharge. The RN stated the omission was accidental and not intentional. The NHA/DON and former NHA were informed of the missing discharge MDS assessment during the survey, and they had no comment at that time.
Inconsistent wound assessment and missing measurements
Penalty
Summary
The facility failed to provide an accurate, consistent description and assessment of a wound for one resident with dementia, cognitive impairment, bowel and bladder incontinence, and diagnoses including arteriosclerotic heart disease and kidney disease. The resident was identified as having a wound to the left inner gluteal fold/left buttock area, but the documentation in the record was inconsistent across nursing notes and skin assessments. The initial nursing note described an open area to the left buttock/intergluteal fold and treatment with Calmoseptine and a dry dressing, but later documentation varied between a stage 2 pressure ulcer, a quarter-sized bed sore, and an area that appeared to be moisture associated skin damage or a skin tear. The record review showed that after the initial wound description, subsequent skin assessments did not include wound descriptions or measurements, and there were no wound measurements documented after the first note. The wound was entered into the care plan as a stage 2 pressure ulcer, yet staff later acknowledged that the wound did not appear to be a pressure ulcer when observed. The wound care team was expected to round weekly, but the resident was not seen by wound care when expected, and the next planned wound care review was several days later. The EMR also lacked a wound consult and lacked clear wound documentation after the initial entry. During interviews, nursing staff and the MDS nurse acknowledged that the wound should have been measured and documented when first identified, and that the description should have been entered in the wound management section of the chart. The RN stated that measurements had been taken but were not placed in the chart, and also confirmed that no wound measurements were present in the EMR. The facility policy required documentation of wound characteristics including size, depth, tissue condition, peri-wound skin, and ongoing assessment of wound effectiveness, but the resident’s wound record did not contain consistent descriptions or measurements reflecting those requirements.
Missed and Incomplete Wound Care Treatments
Penalty
Summary
Failure to provide wound care per physician orders was identified for one resident with a history of metabolic encephalopathy, an unstageable sacral pressure ulcer, and muscle weakness. On 1/16/26, the resident was seen by wound care and the consult documented two new wounds on the mid lower back, including an unable-to-determine area, and a new right heel stage 2. The consult also noted both heels were hypergranulating, silver nitrate was used, and offloading was ordered. The wound care orders included treatment for the left lower back unstageable wound three times a week and as needed with normal saline or wound cleanser, calcium alginate, Medi honey, and border foam. On 1/28/26, the wound care orders from the 1/16/26 consult were not carried out in the medical record. During interview, the DON stated an outside company oversaw wound care and physician oversight, while floor nurses were responsible for carrying out new or changed orders. The DON also stated the resident was seen monthly and that it was up to the facility to ensure treatments and skin checks were completed accurately. The DON was asked about the wound care consult, the location of the orders, and documentation of the silver nitrate treatment, and reported that the facility would be overseeing coordination of care for wounds moving forward.
Fall interventions not implemented after repeated bed falls
Penalty
Summary
The facility failed to ensure that a resident at risk for falls had fall interventions implemented after repeated falls out of bed. The resident had a BIMS score of 4/15 indicating cognitive impairment and diagnoses including metabolic encephalopathy, dementia, heart disease, kidney disease, a prior fall with fractured clavicle, and a history of bilateral hip replacements. The resident’s fall care plan identified mobility limits, cognitive limits, a history of falls, and impulsive attempts to self-transfer, and noted that the resident would not remember to use the call light for assistance. After the resident’s falls, the care plan interventions included keeping the bed in the lowest position and keeping the call light within reach at all times. However, observations showed the resident’s bed was at mid-height rather than in the low position, and the call light was placed on the nightstand out of reach. Staff observed and confirmed these conditions during the survey. One CNA stated the call light had been removed while cleaning and was forgotten, and also stated they were not aware the bed was supposed to be in the lowest position. The CNA further reported they had not been given access to residents’ care plans. The resident had three falls after admission, including one fall out of a chair, then two falls out of bed, with the second fall out of bed resulting in a skin tear to the left elbow. Review of the fall event reports showed the care plan was updated after the first fall, but was not marked as reviewed or updated after the two falls out of bed until two days after the second fall. The NHA/DON reviewed the care plan and acknowledged the concerns related to training and implementation/review of the interventions.
Missing Physician Orders for PICC Line Care and Monitoring
Penalty
Summary
The facility failed to obtain physician orders for the care and monitoring of a resident’s PICC line. The resident was admitted and readmitted with diagnoses including osteomyelitis of the vertebra, heart disease, and osteoporosis, and was cognitively intact per the MDS assessment. During observation, the resident was seen with an IV pole, IV bag, and tubing next to the bed and stated he was receiving antibiotics through his PICC line. He was unsure whether the PICC dressing had been changed. The dressing on the right upper arm PICC line was observed secured with tape at the top and bottom and faintly dated either 1/12/26 or 1/22/26. Review of the clinical record found no physician order for PICC dressing changes and no order for monitoring the PICC site for signs and symptoms of infection. The Administrator, who also served as the DON, stated that PICC dressings should be changed weekly or if soiled, and said the resident had gone to the hospital to have the PICC replaced on 1/22/26 and was not yet due for a dressing change. When asked how staff would know when to change the dressing or where it would be documented, the Administrator/DON had no answer. The facility policy stated that PICC, midline, or CVAD dressings are to be changed weekly or if soiled, and that physician orders will specify the type of dressing and frequency of changes.
Failure to Administer Accepted Influenza Vaccine
Penalty
Summary
The facility failed to provide administration of the Influenza vaccine for one resident reviewed for immunizations. The resident was admitted with diagnoses including stroke, heart failure, and diabetes. The resident's preventive health care record showed documentation of Pneumococcal, RSV, and COVID-19 vaccines received prior to admission, but there was no documentation of an Influenza vaccine. A Resident-Vaccine Consent form signed by the resident and dated 12/23/25 showed the FLU vaccine was accepted, yet when asked on 1/27/26, the Administrator/DON/Infection Preventionist could not provide documentation of the resident's consent or declination form for the Influenza vaccine. The resident stated that she had signed up for the vaccine but had not received it yet. The facility policy stated that Influenza vaccinations are to be routinely offered annually from October 1st through March 31st and that a signed consent form is required prior to administration.
Pest Control Deficiency in Kitchen and Hallway
Penalty
Summary
The facility failed to maintain a pest-free environment, as observed during a survey. During a tour of the kitchen serving area, standing water and cobwebs were found under the steam table, and several gnats were observed near the standing water and flying around the kitchen. The Dietary Manager explained that the water was from filling the wells of the steam table but did not provide an explanation for the presence of gnats. Additionally, several gnats were observed flying in the hallway near the resident rooms. According to the 2017 FDA Food Code section 6-501.111, the premises should be maintained free of insects, rodents, and other pests, and conditions that allow for pest harborage should be eliminated. This deficiency had the potential to affect all residents in the facility.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide written notification of discharge to the State Long Term Care Ombudsman for two residents, identified as R15 and R17, who were reviewed for discharge. Resident R15 was admitted to the facility and discharged on 7/31/24, but was not included in the facility's discharge report sent to the Ombudsman for July 2024. Similarly, Resident R17 was admitted and discharged on 9/2/24, yet was not listed in the September 2024 discharge report sent to the Ombudsman. During an interview, Social Worker C acknowledged that R17 should have been on the list for the Ombudsman. The facility's policy, implemented on 11/1/22, requires that the Social Services Director or designee provide copies of transfer/discharge notices to the Ombudsman, including a monthly list of residents. The Nursing Home Administrator admitted that the omission of the discharge list to the Ombudsman was an oversight.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident or their representative prior to a hospital transfer. This deficiency was identified for one resident, who was admitted to the facility and later discharged to the hospital. During an interview, the social worker admitted that the bed hold policy was not given to the resident or their representative upon discharge, and there was no documentation of such a notice in the resident's file. The facility's policy requires that a written notice specifying the duration of the bed hold policy be provided at the time of transfer, and a signed and dated copy should be kept in the resident's file. The Nursing Home Administrator acknowledged that the bed hold policy was supposed to be given upon discharge but was missed in this instance.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for one resident, identified as R17, upon their discharge. R17 was admitted to the facility and discharged on the same date, as noted in the MDS assessment dated 9/2/24. A review of R17's electronic medical record revealed the absence of a discharge summary or recapitulation of stay. The facility's policy, implemented on 11/1/22, mandates that a discharge summary be provided upon a resident's discharge, detailing the resident's course of treatment and plan of care after discharge. This summary is essential for ensuring coordinated care and a safe transition to another setting. During interviews, both the RN/MDS responsible for discharge summaries and the Nursing Home Administrator acknowledged that the discharge summary for R17 was not completed, indicating a lapse in following the facility's discharge policy.
Failure to Assist Resident with Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received assistance with showering, resulting in unmet care needs. The resident, who was admitted with diagnoses including diabetes mellitus, hypertension, and arthritis, required substantial assistance for bathing as indicated in the Minimum Data Set (MDS) assessment. Despite being scheduled for showers twice a week, the resident reported having only one shower since admission. This was corroborated by the Electronic Medical Record (EMR), which showed only one recorded shower. The facility's policy mandates assisting residents with bathing to maintain hygiene, but the lack of documentation and adherence to the shower schedule led to this deficiency.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure weekly weights were completed for a resident reviewed for nutritional needs, resulting in the potential for missed weight fluctuations. The resident, who had active diagnoses including diabetes mellitus, malnutrition, anxiety disorder, and depression, was admitted to the facility with a doctor's order for weekly weights. Despite this order, only an admission weight was recorded, and no subsequent weights were completed. The resident expressed concerns about not receiving enough food or snacks and reported losing weight, which was not acknowledged by the staff. The facility's policy required weekly weight monitoring for newly admitted residents for four weeks, which was not followed in this case.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information, which resulted in residents being unable to determine the number of staff available to provide care. This deficiency was observed during a survey when the daily nursing staffing sheet for a previous day was found near the entrance to a wing of the facility, where residents did not have direct access. On a subsequent day, the staffing sheet was not available for residents to review at all. Interviews with staff, including an RN/MDS and a CNA, confirmed that the staffing information was not accessible to residents, as they did not frequent the area where the sheet was posted. The Nursing Home Administrator acknowledged the absence of the required staffing information for resident viewing.
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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.
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Nursing homes near Pontiac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Waterford | 3.2 mi | ★★★★★ | 3 | 0 |
| Pomeroy Living Rochester Skilled Rehabilitation | 4 mi | ★★★★★ | 13 | 0 |
| Lourdes Rehabilitation And Healthcare Center | 4.4 mi | ★★★★★ | 1 | 0 |
| Woodward Hills Health And Rehabilitation Center | 5 mi | ★★★★★ | 19 | 0 |
| The Villa At Silverbell Estates | 5.3 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.