Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Optalis Health And Rehabilitation Of Grand Rapids during CMS and state inspections, most recent first.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
Two residents experienced worsening pressure injuries and infection due to the facility’s failure to transcribe, implement, and consistently provide ordered wound care. For one resident with cognitive impairment and incontinence, hospital discharge instructions for existing skin wounds and pressure prevention were not entered into facility orders or care plans, the sacral pressure ulcer was not promptly assessed or care-planned, wound provider orders for daily Manuka dressings and pressure-relief devices were entered incorrectly as every other day, and dressing changes were missed or left soiled for extended periods despite no documented refusals. The resident’s sacral ulcer progressed to a large, foul-smelling unstageable wound associated with sepsis. For another resident with a right heel pressure injury, wound provider notes over several months documented soiled, outdated, and incorrect dressings, deterioration of the unstageable heel ulcer, and concerns for cellulitis and infection, while treatment records showed multiple missed and undocumented dressing changes and incomplete antibiotic and topical treatment implementation. Staff interviews revealed lack of awareness of wound orders, reliance on night shift and agency nurses for dressings, and poor documentation of refusals, contributing to the cited deficiency in pressure ulcer care.
A resident with depression, generalized muscle weakness, impaired walking, and cognitive communication deficit, who was care planned as at risk for falls, was repeatedly observed in bed with the call light not visible and hanging behind the head of the bed near the floor, out of reach. Over multiple observations on consecutive days, staff did not ensure the call light was placed on or near the resident’s body as required. In interviews, CNAs and the ADON confirmed that call lights were supposed to be within residents’ physical reach and acknowledged that the observed placement behind the bed frame near the floor was not acceptable.
A resident with a right heel pressure injury had physician orders for specific wound care regimens and weekly skin evaluations, but records showed multiple missed and refused treatments without corresponding progress notes or PRN documentation, and several weekly skin checks were not completed. A NP twice found the heel dressing grossly soiled, unchanged for several days beyond ordered frequency, and once inconsistent with the ordered dressing type, and also noted that a prescribed topical antibiotic was not available. MARs showed the resident did not receive all ordered doses of oral antibiotics on two separate treatment courses. A TAR entry indicated an LPN had checked the heel dressing, but in interview the LPN stated she was unaware of any dressing despite having documented the check that morning. The ADON acknowledged finding unchanged dressings, missing or inconsistent documentation, and prior concerns from the wound care provider about dressings not being changed as ordered.
A resident with a full code status was found unresponsive and did not receive CPR from the assigned agency RN, who assumed hospice status meant DNR and did not verify the resident's documented wishes. Other staff were aware of the full code status, but no resuscitative efforts or emergency calls were made, resulting in the resident's death without basic life support.
Multiple residents were not protected from physical abuse, including one resident with dementia who was struck by another resident with a history of aggression, and another resident who was hit in the face by an agency LPN during an argument. The facility did not implement a behavior care plan for the aggressive resident prior to the incident and failed to thoroughly investigate the staff-to-resident abuse, collecting only one witness statement despite multiple available witnesses.
Two residents' narcotic medications were misappropriated due to failures in medication tracking, incomplete shift-to-shift controlled substance counts, and lack of proper documentation by nursing staff. Pharmacy and administration records did not account for all received doses, and required signatures and explanations for missing medications were absent, resulting in unaccounted controlled substances.
A resident reported being struck by an agency LPN during an argument related to insulin administration. Multiple witnesses, including a CNA and a family member, observed or heard the altercation, and a police report documented the incident. However, the facility's investigation was incomplete, as not all witnesses were interviewed and documentation was lacking, contrary to the facility's abuse policy.
A resident with complex cardiovascular conditions did not receive medications according to physician orders when an LPN administered Metoprolol and Midodrine together and outside the prescribed time frames. The medications, which have opposing effects on blood pressure and heart rate, were not to be given simultaneously, and one was administered late and not with a meal as ordered. This failure was confirmed by both the LPN and the unit manager.
A resident with chronic lymphedema, heart failure, and constipation did not receive consistent assessment, monitoring, or treatment as ordered. Nursing staff failed to provide timely bowel interventions, resulting in hospitalization for fecal impaction and hyperkalemia. Wound care was not performed per orders, with staff using briefs instead of prescribed dressings when supplies ran out, and there were missed applications of compression stockings and lymphedema boots without proper documentation. Medication administration records showed multiple missed treatments and lack of documentation for refusals.
A resident with multiple urinary and bladder conditions did not receive appropriate care for her Pure Wick external catheter, as staff failed to respond promptly to care requests, left the canister unemptied and uncleaned for extended periods, and lacked clear protocols or education on proper device maintenance. This resulted in inconsistent catheter replacement, inadequate cleaning, and insufficient monitoring, contrary to facility policy and manufacturer guidelines.
Surveyors found that current daily nurse staffing hours were not consistently posted in a prominent and accessible location. Outdated staffing information remained displayed for several days, and staff acknowledged that postings were not updated regularly as required.
A resident with multiple medical conditions on a vegetarian diet did not consistently receive her selected menu items, including missing meals and lack of suitable condiments, due to staff errors in ordering and meal preparation. Dietary staff acknowledged forgetting to order specific items and failing to provide planned meals, leading to resident dissatisfaction and concerns about limited vegetarian options.
A resident with OSA, chronic respiratory failure with hypoxia, and obesity hypoventilation syndrome was found on BiPAP without O2 connected, and staff could not obtain stable vital signs. Interviews and observations showed repeated confusion among nursing staff about how to operate the BiPAP, verify whether it was actually running, and ensure oxygen was bled into the device. The resident’s family also reported multiple prior concerns that the BiPAP was not functioning correctly, and the DON and UM were unable to explain the machine or its settings.
A resident with moderate cognitive impairment received another resident’s medications during a med pass when an agency LPN and nursing students mixed up medications for two residents with very similar names. The resident was later found lethargic and sent to the hospital, where records documented acute metabolic encephalopathy and iatrogenic polypharmacy after receiving multiple meds not ordered for her.
Failure to complete CNA annual performance reviews. During record review, the facility could not provide yearly performance reviews for five sampled CNA files, and the NHA stated that annual performance reviews had not been completed for CNA staff.
An LPN supervising two nursing students allowed them to prepare and administer meds, and a resident received another resident’s medications after the LPN failed to verify identity using birthdate, room number, or MAR photo. The resident, who was moderately cognitively impaired, later required hospitalization with acute metabolic encephalopathy and iatrogenic polypharmacy. Facility leadership could not provide a current nursing school contract or policies for student nurse roles, and staff confirmed the school had continued clinical rotations without a contract in place.
Facility assessment was not reviewed and updated after changes requiring substantial modification. The assessment omitted key participants, did not include needed staff competencies, services such as PT, pharmacy, behavioral health, or rehab therapies, and did not account for all personnel, contract staff, volunteers, or third-party agreements for normal operations and emergencies. Surveyors also found CNA annual performance reviews and required 12-hour in-services were not completed, and a nursing school was using clinical rotations without an active contract or review of student training and competencies.
Failure to Maintain CNA Annual In-Service Training: The facility did not develop, implement, or permanently maintain an in-service training program for CNAs based on yearly performance reviews, and it could not verify that sampled CNAs had completed the required 12 hours of annual education. The NHA stated that annual CNA reviews had not been completed and that the facility was not ensuring the required in-service education was provided.
A resident with severe dementia, poor safety awareness, and a history of falls was left unsupervised on a bedside commode despite requiring two-person assistance for all ADLs. Staff were not within arm's reach, and the resident fell, sustaining a fractured patella and head injury. Facility records and staff interviews confirmed the resident's need for direct supervision during toileting, which was not provided.
A resident with chronic pain and vascular dementia, who was fully dependent for care, sustained a nondisplaced distal radius fracture of unknown origin. Despite hospital records confirming the injury and facility policy requiring immediate reporting of such incidents, the facility did not report the injury to the state agency or address it in their internal investigation. Interviews revealed that key staff did not review or recognize the x-ray findings, resulting in a failure to follow required abuse and injury reporting procedures.
A resident who was bed bound and dependent on staff for all care was found to have a nondisplaced distal radius fracture during a hospital visit. Despite documentation of the injury in hospital records and the facility's policy requiring investigation of injuries of unknown source, the facility did not identify, investigate, or report the injury, and key staff were unaware of the documented fracture.
A resident at high risk for skin breakdown was not properly assessed or treated for a coccyx wound, despite staff observations and a care plan indicating the need for interventions. No treatment orders were obtained, and the wound worsened, as confirmed during a hospital visit. Facility leadership acknowledged that required wound care protocols were not followed.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific actions or events involved.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident's legal guardian was not properly informed or accommodated to participate in the care planning process following the resident's readmission from a psychiatric facility. Despite policy requiring advance notice and participation, the guardian was unable to attend the care conference due to poor communication from facility staff, and the conference was inaccurately documented as attended.
A resident with significant mobility and coordination issues was unable to access their call light, which was found under the bed and out of reach. The resident, who depended on staff for assistance and was identified as a high fall risk, was observed attempting to stand unassisted and repeatedly calling for help. Facility policy requires call lights to be within reach, but this was not followed, resulting in the resident's inability to request staff assistance.
The facility did not ensure that a resident was protected from being separated from others, their room, or being confined to their room, resulting in a deficiency related to resident rights.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Staff did not consistently follow Enhanced Barrier Precautions for residents with wounds or indwelling devices, with multiple instances of care being provided without required gowns and gaps in staff knowledge of EBP policy. Additionally, the facility lacked an active water management plan, with stagnant water lines, infrequent flushing, and no routine testing for disinfectant levels, contrary to facility policy.
Surveyors found that medications, including insulin pens and eye drops, were not properly labeled with resident names or open dates, and expired medications were not removed from medication carts. Additionally, a medication cart containing narcotics was left unlocked and unattended in a hallway, contrary to facility policy requiring all medications to be securely stored.
Three residents with chronic medical conditions were not offered or did not have documentation of being offered COVID-19 vaccinations after 2022, despite facility policy requiring annual offers and documentation. The facility could not provide evidence that these eligible residents received education or offers for the updated vaccine.
The facility did not maintain a fully operational call light system, resulting in several residents experiencing malfunctioning call lights, long response times, and in some cases, call lights being out of reach. Staff and family interviews, as well as direct observations, confirmed ongoing issues with the system, including hallway indicators not activating and repeated maintenance requests that did not resolve the problems.
The facility did not ensure that agency staff received or completed mandatory training on infection prevention and Enhanced Barrier Precautions (EBP). Several agency nurses and a CNA reported not receiving EBP education or being asked to review relevant materials before starting work. One agency RN, unfamiliar with EBP, was preparing to perform wound care without proper protective equipment, highlighting the lack of effective training and verification processes.
A CNA publicly referred to three cognitively impaired residents as "lay backs" while they were seated in geri chairs near the nurses' station, in violation of the facility's dignity policy. The DON confirmed that such language is inappropriate and does not align with expectations for respectful communication with residents.
A resident with severe cognitive impairment and multiple diagnoses was administered several psychotropic medications without documented consent, as required by facility policy. Staff confirmed that no consents were on file prior to administration, and the care plan's intervention to provide education on medication risks and benefits was not documented as completed.
A resident with a history of muscle weakness and hemiplegia was found on the floor with injuries and was sent to the hospital after an unwitnessed fall. The LPN on duty contacted the physician and arranged the transfer but did not notify the resident's DPOA or emergency contact, as confirmed by interviews and documentation review. The facility's policy requires such notification, but it was not completed or documented.
A resident who chose to end skilled therapy services and transition to private pay was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to inform her of potential financial liability for non-covered services. Although the resident was told her payer source would change, there was no documentation that she was notified of the private pay costs, as confirmed by the Business Office Manager.
The facility did not send required discharge notifications to the LTC Ombudsman for a resident transferred to a psychiatric hospital and failed to provide a bed-hold policy notice to the DPOA of another resident with hemiplegia after hospital transfer. Documentation supporting these notifications was not available, and the omissions were confirmed by the NHA.
A resident with multiple fall risk factors did not consistently have prescribed fall prevention interventions, such as a fall mat and accessible call light, implemented as outlined in the care plan. Observations showed the fall mat was often missing or improperly placed, and the call light was out of reach. Staff confirmed the fall mat was not always returned after meals, resulting in a potential for unmet care needs.
A resident with a history of pressure ulcers developed new and worsening wounds on both heels and toes due to inadequate offloading, insufficient wound care, and lack of cleanliness. Staff were not consistently aware of all wounds, and interventions such as pressure-relieving boots and bed adjustments were not effectively implemented, resulting in preventable skin breakdown.
A resident with a history of muscle weakness and repeated falls was injured after an agency CNA provided bed mobility assistance alone, despite the care plan requiring a two-person assist. The CNA did not review the care plan or consult with staff, leading to the resident falling from the bed and sustaining multiple abrasions.
A resident with end stage renal disease did not receive required post-dialysis assessment and monitoring, as the assigned nurse failed to retrieve and review the dialysis communication form, did not record vital signs, and did not document a progress note after the resident's return from dialysis. The facility's policy for immediate post-dialysis assessment and documentation was not followed.
The facility did not ensure timely follow-up on pharmacist medication regimen review recommendations for three residents, including those with severe cognitive impairment and complex medication regimens. Recommendations to evaluate or discontinue certain medications were not promptly addressed or documented, and required assessments and consents were missing. Staff interviews confirmed lapses in the process for reviewing and implementing pharmacy recommendations, contrary to facility policy.
A resident with Alzheimer's disease, dementia, and hypertension was not properly screened for pneumococcal vaccine eligibility, and there was no documentation that the appropriate vaccine was offered or administered according to CDC guidelines. The resident received two doses of PPSV23, but the facility did not assess or document the need for additional vaccination with PCV20 as required.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Transcribe, Implement, and Consistently Provide Ordered Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer care and to prevent worsening of existing pressure injuries for two residents. For one resident with metabolic encephalopathy, hospital discharge paperwork and a handwritten note from hospital staff documented existing skin issues, including a right hip wound and incontinence-associated dermatitis, with specific wound care instructions such as cleansing, Xeroform and foam dressings on a set schedule, frequent turning and repositioning, heel offloading, and use of barrier creams. These instructions were not transcribed into the facility’s physician orders, treatment records, or care plans upon admission. The admission skin assessment documented only a right hip surgical site and did not record any open wounds or refusals for skin assessment, and there were no sacral wound orders or treatments documented for several days after admission. The pressure ulcer care plan for the sacrum was not developed until two weeks after admission, and the incontinence and skin care plans did not reflect the resident’s need for frequent incontinence care or any refusals of care. Subsequent assessments and documentation for this resident showed inconsistent and delayed recognition and treatment of a sacral pressure injury. A new sacral pressure ulcer was first documented days after admission as a Stage 3 pressure ulcer, with measurements and moderate drainage, and wound care orders were initiated the following day. A wound provider later assessed the sacral wound as an unstageable pressure ulcer, noted heavy drainage, and ordered daily dressing changes with Manuka dressing, an APM bed, heel protectors, offloading, and frequent incontinence changes. However, the provider’s daily dressing order was incorrectly entered as every other day, and the TAR showed missed or undocumented treatments, including no documented dressing change on a scheduled day and no PRN wound care orders. Staff interviews revealed that the resident was very hard to reposition, required two-person assistance, was incontinent, and did not refuse care, and CNA documentation showed no refusals of incontinence care. A CNA reported finding a large sacral dressing that was foul-smelling and urine-soaked, notifying an LPN twice, and observing that the dressing remained unchanged for many hours; another LPN later changed the dressing without cleansing the wound. The resident’s change in mental status and suspected sepsis from the coccyx wound were documented only shortly before transfer to the hospital, where the sacral ulcer was described as a large, foul-smelling, unstageable pressure sore with black eschar and sepsis secondary to the sacral decubitus ulcer. For a second resident with a right heel pressure injury, the facility failed to provide consistent wound care as ordered, resulting in deterioration and infection of the heel wound. The pressure ulcer care plan identified a right heel pressure injury and called for wound care per physician orders and weekly skin evaluations, but wound provider notes over several months documented that dressings were grossly soiled, left in place far beyond the ordered change frequency, and not consistent with the prescribed products. The wound provider repeatedly noted missed dressing changes, wrong dressings, deterioration of the wound, strong odor, and concerns for cellulitis and infection, and ordered systemic and topical antibiotics and more frequent dressing changes. Review of physician orders and treatment records showed multiple missed and refused treatments across three months, with no corresponding progress notes or documentation of PRN wound care or re-attempts after refusals. Staff interviews indicated that some nurses, including agency staff, were unaware of the resident’s wound or dressing orders, that dressing changes were typically assigned to night shift, and that the resident did not usually refuse care, despite multiple refusals being recorded without supporting narrative documentation. These actions and omissions led to worsening of the resident’s unstageable right heel pressure injury and required antibiotic interventions for infection. The facility’s internal nursing leadership acknowledged awareness of ongoing issues with wound care not being completed as ordered for multiple residents, including missed dressing changes, incomplete documentation, and lack of availability of ordered wound care products. The ADON, who managed wounds, reported not reviewing the first resident’s hospital discharge paperwork until after the wound had already worsened and acknowledged that wound orders from the hospital should have been entered on admission. She also reported discovering months earlier that other residents were not receiving ordered wound care and that she and the unit manager had been monitoring for missed treatments. The DON confirmed that there were no documented refusals of incontinence or wound care for the first resident and that she was aware of prior problems with wound care not being completed. The administrator reported that wound-related QAPI discussions had focused only on the number of wounds, not on missed or incomplete wound care, indicating that the documented failures in assessment, order transcription, treatment implementation, and monitoring directly contributed to the cited deficiencies in pressure ulcer care for both residents.
Failure to Keep Call Light Within Reach of a Bedbound Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by the resident’s care plan and facility expectations. The resident was a female with diagnoses including other recurrent depressive disorders, generalized muscle weakness, difficulty in walking, and cognitive communication deficit, and had a care plan focus of being at risk for falls due to a history of falls. The care plan, revised on 11/9/25, included an intervention to orient the resident to her surroundings and the use of the call light, initiated on 4/24/25. On multiple observations over two consecutive days, the resident was seen in bed with her call light not visible and hanging on the bottom of the bed frame behind the head of the bed near the floor, out of her reach. This positioning of the call light was documented at 9:27 AM, 11:07 AM, and 2:54 PM on 3/4/26, and again at 8:49 AM on 3/5/26. In interviews, CNAs and the ADON consistently reported that call lights were supposed to be within physical reach of residents, placed on or near their body so they could touch and activate them, and confirmed that it was not acceptable for the call light to be behind the resident on the bed frame near the floor. One CNA reported she had just found the resident’s call light in that inaccessible location and confirmed the resident did use her call light sometimes.
Incomplete and Inaccurate Wound Care Documentation for Heel Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and treatment documentation for a resident with a right heel pressure injury. The resident was admitted with weakness and falls and had an active care plan for a right heel pressure injury requiring wound care per physician orders and weekly skin evaluations. Review of physician orders and treatment records from December through February showed multiple missed and refused wound care treatments without corresponding progress notes or documentation of PRN wound care, despite orders specifying every other day, then daily wound care, and checks of dressing placement. The care plan also called for weekly full skin checks, but several of these were not completed on specified dates. The Unit Manager stated she was aware of issues in December and January with wound dressings not being changed and incomplete documentation, and confirmed that refusals of wound care in February were not supported by progress notes or documentation of re-attempts. The Nurse Practitioner reported that on two separate visits, the resident’s right heel dressing was grossly soiled, had not been changed for several days beyond the ordered frequency, and did not match the ordered dressing type on one occasion. The NP documented concern for cellulitis, ordered oral antibiotics, and later added a topical antibiotic and daily dressing changes when the wound deteriorated, but on a subsequent visit again found a soiled dressing that had not been changed as ordered and noted the topical antibiotic was not available. Medication records showed the resident did not receive all ordered doses of oral antibiotics in both December and January. Additionally, a Treatment Administration Record entry showed that an LPN documented checking the placement of the right heel dressing, but in interview that LPN stated she was not aware of a wound dressing on the resident, despite having documented the check that same morning. The ADON acknowledged finding the resident’s dressing not changed, missing documentation, and documentation indicating dressings had been changed more than once in the past, and was aware that the wound care provider had previously been upset about dressings not being changed as ordered.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident having a documented full code status. The assigned agency RN did not perform CPR upon discovering the resident unresponsive and without vital signs, and instead pronounced the resident deceased. The nurse stated she was informed the resident was on hospice and did not recall the code status, leading to no resuscitative efforts being made. Other staff, including CNAs, were aware of the resident's full code status and expected that CPR should have been started, but no action was taken to initiate a code or call emergency services. The resident involved had a history of hereditary ataxias, dysphagia following cerebral infarction, and Parkinson's disease, and was admitted to hospice services with a clear advance directive indicating full cardiopulmonary resuscitation. Despite this, the care plan did not document the code status or advance directives, and the nurse relied on verbal information about hospice status rather than verifying the resident's documented wishes. The nurse did not check the medical record or care plan for code status before deciding not to initiate CPR. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, with some staff assuming hospice status equated to a do-not-resuscitate (DNR) order. The facility's policies required CPR to be initiated for full code residents unless a DNR order was present and documented. The failure to follow these policies and verify the resident's code status resulted in the resident not receiving basic life support prior to death.
Removal Plan
- All resident charts were audited to confirm code status based on Resident/POA wishes.
- Facility licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- Agency licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.
- The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.
- The medical director was notified.
- The Director of Nursing held mock CPR drills with nursing staff on each shift.
- Director of Nursing will conduct mock CPR drills monthly on each shift.
- Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.
- An Ad-Hoc QAPI meeting was held to review findings and action plan.
Failure to Protect Residents from Abuse and Inadequate Investigation of Incidents
Penalty
Summary
The facility failed to protect residents from both resident-to-resident and staff-to-resident physical abuse, as evidenced by multiple incidents involving three residents. One incident involved a resident with Alzheimer's disease and dementia who was struck in the mouth by another resident with a known history of aggression and behavioral disturbances. Documentation and interviews revealed that the aggressive resident had exhibited repeated episodes of anger, verbal and physical aggression, and difficulty with redirection in the weeks leading up to the incident. Despite these documented behaviors, there was no behavior care plan implemented prior to the altercation, and staff supervision was reported as insufficient, particularly when staffing levels were low or when unfamiliar staff were present on the unit. Another incident involved a cognitively intact resident who reported being struck in the face by an agency LPN during an argument about the administration of an insulin injection. Multiple interviews with staff and witnesses confirmed that a physical altercation occurred, with the resident sustaining a bloody lip and both parties engaging in yelling and physical contact. The LPN admitted to pushing the resident's hands away after being poked in the chest, and a police report classified the event as a simple assault. The facility's investigation into this incident was incomplete, as only one written witness statement was collected and not all available witnesses were interviewed. The facility's abuse prevention policy requires ongoing assessment, care planning, and monitoring of residents with behavioral issues, as well as immediate reporting and investigation of abuse allegations. However, the facility did not implement appropriate interventions or supervision for residents with known aggressive behaviors, nor did it conduct a thorough investigation into the staff-to-resident abuse incident. These failures resulted in residents being exposed to physical harm and not being protected from abuse as required by facility policy and regulatory standards.
Failure to Prevent Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for two residents, resulting in missing controlled substances and incomplete documentation. During the discharge process for one resident, discrepancies were identified in the narcotic card and sheet counts, with three cards missing and no documented explanation for their removal. The agency RN involved could not account for the missing medications or provide details on the disposition of the blister packs and count sheets. The controlled substance shift inventory sheets were not properly completed, with missing signatures and blank sections where explanations should have been provided. One resident was admitted for a respite stay under hospice care and had orders for hydrocodone-acetaminophen. Pharmacy records indicated a specific quantity of medication was received, but the medication administration record only documented the administration of three tablets during the stay. The controlled substance inventory showed a reduction of three cards without corresponding documentation or explanation. The former DON confirmed that the medications and count sheets were missing and could not be located after an internal investigation. A second resident, admitted with multiple injuries and prescribed oxycodone, also had missing narcotic medications. Pharmacy records and medication administration records did not account for all tablets received, and witness statements confirmed that medications for both residents were unaccounted for. Interviews with staff revealed that the required shift-to-shift controlled substance counts were not consistently signed by both incoming and outgoing nurses, contrary to facility policy. The facility's policy required immediate reporting and documentation of unresolved discrepancies, which was not followed in these instances.
Failure to Thoroughly Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving one resident. The resident reported that during an argument with an agency LPN, he was struck by the nurse after he pushed the LPN. The incident occurred after the resident requested an insulin injection in the dining area, which the LPN refused, leading to a confrontation in the resident's room. Multiple witnesses, including a CNA and a family member, reported hearing or observing the altercation, with one CNA noting the resident had a bloody lip and stating that both the resident and LPN admitted to physical contact. A police report also documented the incident, with the LPN admitting to slapping the resident's hand away after being poked in the chest. Despite these accounts, the facility's investigation was incomplete. The interim DON only collected a written statement from one CNA and did not interview all staff or witnesses present during the incident, including another CNA and a family member who directly observed or heard the altercation. The facility's abuse policy requires a thorough investigation, including interviewing all involved persons and witnesses, but this was not followed. As a result, the incident of staff-to-resident physical abuse was not fully identified or documented, and there was a potential for additional abuse to go unrecognized.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for a resident with multiple cardiovascular diagnoses, including paroxysmal atrial fibrillation, pulmonary embolism, popliteal vein thrombosis, hypertension, heart failure, and hypotension. The resident had physician orders for Midodrine to be given with meals for hypotension, to be held if systolic blood pressure was greater than 130, and for Metoprolol to be given once daily for cardiac arrhythmia, to be held if systolic blood pressure was less than 100, diastolic blood pressure less than 60, or heart rate less than 55. The orders also specified that Midodrine and Metoprolol should not be administered at the same time per the cardiologist. Observation and interviews revealed that an LPN administered both Metoprolol and Midodrine together at 9:39 AM, with the Midodrine being given late (scheduled for 8:00 AM) and not with a meal as ordered. The LPN acknowledged the error, stating that medication administration was difficult due to frequent interruptions. The unit manager confirmed that the medications were administered together, contrary to the physician's order, and explained that the medications have opposing effects on blood pressure and heart rate. The failure to follow the physician's orders and professional standards resulted in the resident not receiving medications as intended.
Failure to Provide Consistent Assessment, Monitoring, and Treatment for Resident with Complex Needs
Penalty
Summary
A resident with a complex medical history, including chronic lymphedema, morbid obesity, heart failure, chronic constipation, and hyperkalemia, experienced multiple failures in care delivery. The facility did not consistently assess, monitor, document, or provide treatment according to professional standards and physician orders. The resident reported significant pain from constipation and requested an enema, which was refused by nursing staff despite her history of fecal impaction. She was later hospitalized for fecal impaction and dangerously high potassium levels. Hospital records confirmed severe constipation, hyperkalemia, and the need for disimpaction and urgent medical intervention. The resident also reported that wound care was not being provided as ordered. She had open, weeping areas on her legs due to lymphedema, and facility staff used incontinence briefs instead of prescribed wound dressings when supplies ran out. The resident stated that she often had to clean her own wounds, and there were periods when the wound nurse did not assess her skin as scheduled. Documentation and interviews confirmed missed applications of compression stockings and lymphedema boots, with no progress notes indicating resident refusal. Supply orders for wound care were not consistently maintained, leading to lapses in appropriate wound management. Review of the Medication Administration Records (MAR) revealed multiple missed treatments, including compression stockings and lymphedema boots, without documentation of resident refusal. There were also inconsistencies in the administration and documentation of bowel management interventions, such as enemas and laxatives. Staff interviews indicated a lack of communication and follow-through regarding supply shortages and resident care needs. These failures resulted in the resident's hospitalization and ongoing issues with wound care, bowel management, and monitoring of critical lab values.
Failure to Provide Proper External Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a female resident using a Pure Wick external urinary catheter. The resident, who had diagnoses including acute cystitis with hematuria, overactive bladder, neuromuscular dysfunction of the bladder, and was a carrier of carbapenem-resistant enterobacterales (CRE), reported that staff did not respond promptly to her requests for assistance. She described being left in feces for extended periods, sometimes up to five hours, and noted that the Pure Wick device was not always functioning properly, leading to leakage and the need for additional pads. The resident also had to instruct CNAs on how to properly reattach tubing and clean the canister, indicating a lack of staff competency and adherence to proper procedures. Observations and interviews revealed that the Pure Wick canister was often left full or over halfway full, and staff did not consistently empty or clean it as required. The resident reported that the canister had not been cleaned for two or three days at times, and staff were not coming in to provide care until late in the evening. The Unit Manager acknowledged there were no specific orders or protocols in the resident's record regarding cleaning the Pure Wick canister, when to empty it, or when to replace the canister and tubing. Additionally, there was no documentation of staff education or resident monitoring related to the use and care of the Pure Wick system, despite the resident's history of multiple urinary tract infections and CRE. Review of facility policy and manufacturer guidelines confirmed that the Pure Wick external catheter should be replaced every 8 to 12 hours or immediately if soiled, and that canisters and tubing should be cleaned and disinfected at least daily and replaced every 60 days. However, the facility's practice did not align with these standards, as staff were not consistently following the required procedures for replacement, cleaning, and monitoring. The Director of Nursing was unable to confirm whether staff were ensuring timely replacement of the external catheter or proper documentation, and there was a lack of clear protocols and staff education regarding the care of the Pure Wick system.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current daily nurse staffing hours were posted in a prominent location readily accessible to residents, staff, and visitors. Observations on multiple dates revealed that outdated staffing information was displayed, with staffing hours from previous days remaining posted for extended periods. On several occasions, the most current staffing hours were not posted as required, and the information available was several days old. The postings were located in a glass-enclosed bulletin board behind the entryway and reception area, but due to a missing key, updated postings were taped to the outside of the enclosure rather than placed inside. Interviews with facility staff confirmed that the responsibility for posting staffing hours had recently transitioned from one staff member to another. The new scheduler acknowledged that the postings were not being updated regularly and admitted that the current day's staffing hours had not yet been posted at the time of the surveyor's inquiry. The Nursing Home Administrator also confirmed that staffing hours were supposed to be posted daily and recognized that the postings were not current during the surveyor's visit.
Failure to Honor Resident Food Choices and Menu Consistency
Penalty
Summary
The facility failed to ensure that a resident's food choices were consistently obtained and honored, resulting in dissatisfaction with meal services and the potential for inadequate food or fluid intake. The resident, who had a complex medical history including iron deficiency, slow transit constipation, mixed irritable bowel syndrome, lymphedema, CHF, morbid obesity, recurrent UTI, hypertension, depression, and a history of pressure injuries, was on a regular vegetarian diet and was supposed to be offered food and beverage selections with substitutes as requested. Despite this, the resident reported not receiving planned menu items on multiple occasions, such as the Christmas lunch meal and lentil meatloaf, and expressed frustration over the lack of suitable vegetarian options and necessary condiments for her meals. Interviews with dietary staff and the registered dietician revealed that errors in ordering and meal preparation contributed to the resident not receiving her selected meals. The dietary manager admitted to forgetting to order specific items, and the registered dietician confirmed that some preferred items were not available from the supplier, requiring alternative discussions with the resident. The resident also reported feeling that she was expected to supply her own food due to the limited vegetarian options available, and staff acknowledged lapses in providing the correct menu items as ordered.
Failure to Provide Correct BiPAP and Oxygen Support
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with obstructive sleep apnea, chronic respiratory failure with hypoxia, and obesity hypoventilation syndrome. The resident’s orders required BiPAP use at night, during naps, and at all times except during meals and care, with oxygen bled into the machine and staff verification that the device was operating correctly. The care plan also directed staff to ensure the nasal cannula was in place when BiPAP was not on and that only a licensed nurse remove and replace the mask. On 1/21/26, the resident was found in bed with the BiPAP mask on but oxygen disconnected. The resident’s son reported that he found the resident on BiPAP without oxygen connected and that after oxygen was connected, pulse oximetry readings remained in the 70s and 80s. Staff were unable to obtain a manual blood pressure, and the nurse practitioner documented that EMS was contacted after the resident was found with BiPAP disconnected from oxygen for an unknown amount of time. The resident was alert and responsive but had significant cognitive impairment and could not converse appropriately. Multiple interviews showed staff uncertainty about how to operate the resident’s BiPAP machine. An LPN reported that many staff were having issues using the BiPAP and were unsure whether it had been repaired or whether education had been provided. The nurse practitioner confirmed staff were not aware of how to use the BiPAP properly. During observation, the machine displayed a green light while the posted instructions indicated green meant off, and the unit manager was unable to explain how the machine worked or how to verify it was running correctly. On 1/29/26, an LPN caring for the resident stated she had not done anything with the BiPAP that shift and did not know how to operate it. During another observation, the resident’s BiPAP was on, but the machine was completely out of water, and the DON was unable to explain how the BiPAP worked or confirm the new settings.
Wrong Resident Medications Administered During Medication Pass
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when a resident with moderate cognitive impairment received another resident’s medications during a medication pass. The resident had diagnoses including muscle weakness and essential hypertension and had a BIMS score of 10/15. On 10/9/25, an agency LPN was supervising two nursing students while medications were being prepared and administered. The resident was asked to confirm her name, stated her first and last name, and then received the medications that had been prepared for the other resident with a similar name. The medications given in error included multiple prescription drugs and supplements, among them bupropion, dronedarone, Eliquis, fluconazole, fludrocortisone, gabapentin, Norco, Synthroid, metoprolol, midodrine, pantoprazole, torsemide, Zoloft, Robaxin, and vitamins/supplements. The nurse later discovered that the other resident’s medications had been documented as administered even though that resident had not yet received them. The resident was found about an hour later to be lethargic, with low blood pressure and decreased responsiveness, and the NP ordered transfer to the hospital. Hospital records documented acute metabolic encephalopathy and iatrogenic polypharmacy after the resident had taken another resident’s medications. The NP reported concern about the large number and doses of medications received, including the potential for serotonin syndrome, cardiac complications, and harm from the gabapentin dose. The resident’s family reported that before the incident she was able to communicate well, was alert and oriented, and fed herself, but after the hospitalization she became much more confused and weak and was later enrolled in hospice services.
Failure to Complete CNA Annual Performance Reviews
Penalty
Summary
The facility failed to ensure annual performance reviews were completed for CNA staff. During record review on 10/23/25 at 12:48 PM, verification of yearly performance reviews was requested for five sampled CNA files, including CNA H, M, OO, PP, and QQ, but the facility was unable to provide the information. In an interview on 10/23/25 at 1:06 PM, the NHA stated that the facility had not completed annual performance reviews for the CNA staff.
Medication Error Involving Student Nurse Supervision and Missing Nursing School Contract
Penalty
Summary
The facility failed to administer itself in a manner that ensured the highest practicable physical well-being of each resident by not maintaining an active contract with the nursing school that had students in the building, not having policies or procedures for nurses working with nursing students, and not ensuring medication administration practices were based on acceptable clinical standards for resident verification. These failures were tied to an incident in which a nursing student, under the supervision of an agency LPN, administered another resident’s medications to a resident who was moderately cognitively impaired, with a BIMS score of 10/15. Resident #101’s hospital records showed that after receiving the wrong medications, she was admitted with acute metabolic encephalopathy and iatrogenic polypharmacy. The hospital documentation stated that she presented with somnolence after taking another resident’s medications and that she responded only to verbal stimuli, did not engage in conversation, and could follow only simple commands. The medications given in error included multiple high-risk medications such as bupropion, dronedarone, Eliquis, fluconazole, fludrocortisone, gabapentin, Norco, Synthroid, metoprolol, midodrine, pantoprazole, and torsemide. The facility incident report stated that an LPN, accompanied by two student nurses, prepared medications and that the students verified and pulled the medications while the nurse rechecked them before they were placed in the medication cup. The medications intended for another resident were then given to Resident #101. In interview, the LPN stated she was an agency nurse, had not worked on the unit before, allowed the students to prepare and dispense medications, and did not verify Resident #101 by birthdate, room number, or MAR photo. She also stated she had received no guidance from the facility about what nursing students were allowed to do. Facility leadership and other staff confirmed that they could not provide guidance documents or current policies for student nurse roles, that the facility did not have a current contract with the nursing school involved, and that the school had continued clinical rotations in the facility without a contract in place.
Facility Assessment Not Updated to Reflect Staffing, Competencies, and Service Needs
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that was reviewed and updated after changes requiring substantial modification. The assessment dated [DATE]-6/31/25 was documented as reviewed on 6/3/25, but it did not include a facility nursing assistant, resident, or resident representative as part of the review. Although staffing needs were reviewed, the assessment had not been updated or reviewed after 6/2025, and the facility had been cited for staffing in August 2025. The assessment also did not include the staff competencies and skill sets needed to provide the level and types of care required by the resident population, and it did not include services such as physical therapy, pharmacy, behavioral health, or specific rehabilitation therapies. It also did not include all personnel, including managers, nursing and other direct care staff, contract staff, and volunteers, along with their education, training, competencies, or contracts, memorandums of understanding, or other agreements with third parties for services or equipment during normal operations and emergencies. During survey, it was identified that CNA annual performance reviews had not been completed and that the required 12-hour in-service education was not being ensured based on those reviews. The surveyor also found that the facility had a nursing school conducting clinical rotations without an active contract and without determining what training or competencies related to resident care the students had completed before providing care. In interview, the NHA stated the facility was purchased in August 2024, that the first assessment was completed in June 2025 as a look-back from 7/2024-6/2025, and confirmed it had not been reviewed and updated after June 2025.
Failure to Maintain CNA Annual In-Service Training
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nursing Assistants (CNAs) based on yearly performance reviews, and failed to ensure CNAs completed 12 hours of yearly education. During record review on 10/23/25, verification of annual in-service education was requested for five sampled CNA files (CNA H, M, OO, PP, and QQ), but the facility was unable to provide the information. In an interview the same day, the Nursing Home Administrator stated that annual reviews for CNA staff had not been completed and that the facility was not ensuring CNAs had completed the required 12 hours of in-service education based on annual performance reviews.
Failure to Provide Supervision During Toileting Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, abnormal gait, chronic pain, and a history of falls was left unsupervised on a bedside commode. The resident was dependent on two staff members for all activities of daily living and was unable to make her needs known or use a call light. Despite these needs, the resident was left alone on the commode after a shift change, with staff only nearby outside the room and not within arm's reach. The incident was discovered when a registered nurse heard a loud noise and found the resident lying on the floor in front of the commode. The resident sustained a closed comminuted fracture of the left patella and a closed head injury, as confirmed by hospital records. Interviews with staff and the resident's guardian confirmed that the resident should not have been left unattended due to her cognitive and physical limitations, and that her care plan required staff to anticipate her needs and provide safety and comfort. Facility documentation, including the fall risk assessment and care plan, indicated the resident was at high risk for falls, had poor safety awareness, and required staff assistance for toileting. The facility's ADL policy also required appropriate support for residents unable to carry out activities independently. The failure to provide direct supervision during toileting led to the resident's unwitnessed fall and subsequent injuries.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an injury of unknown origin sustained by a resident. The resident, who had chronic pain, vascular dementia, and was dependent for all activities of daily living, was found to have a nondisplaced distal radius fracture after being transferred to the hospital. The hospital records indicated swelling, tenderness, and pain in the resident's left arm, with imaging confirming a concerning lucency in the distal radius. Despite these findings, the facility did not report the injury of unknown origin to the state agency as required by their abuse policy and federal regulations. The facility's internal investigation into the incident did not address the injury of unknown origin, even though the hospital records noting the fracture were present in the facility's incident folder. Interviews revealed that the administrator and medical director did not review or recognize the x-ray findings indicating a possible fracture. The administrator confirmed that such an injury should have been reported to the state agency but was unable to explain why this was not done. The family member of the resident also reported concerns about the injury, noting the resident's inability to self-inflict such harm due to being bedbound and dependent on staff for care. The facility's abuse policy required immediate reporting of any allegations or reasonable suspicions of abuse, neglect, or injuries of unknown source to the state agency and other authorities. However, the injury was not reported as required, and the investigation did not address the injury of unknown origin. This failure to report and investigate the injury in accordance with policy and regulatory requirements constituted the deficiency identified by surveyors.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and thoroughly investigate an injury of unknown origin for a resident who was dependent on staff for all activities of daily living due to chronic pain, vascular dementia, and multiple amputations. The resident was re-admitted to the facility following a lengthy hospitalization and was noted to be bed bound, requiring total assistance from staff. During a subsequent hospital visit, the resident was found to have a nondisplaced distal radius fracture, as confirmed by x-ray findings in the hospital records. Family members and staff interviews indicated that the resident had been in pain and exhibited swelling in the affected arm, but the source of the injury was not clear, and the resident was unable to communicate the cause due to cognitive and language barriers. Despite the presence of hospital records in the facility's incident investigation folder that documented the injury, the facility did not address or investigate the injury of unknown origin in its report to the State Agency or as part of its internal investigation. The Director of Nursing and the Nursing Home Administrator both confirmed that they were unaware of the fracture documented in the hospital records, and the hospital x-ray findings were not fully reviewed by the facility's medical director or administration. The facility's investigation focused on allegations of neglect and abuse but did not include a review or investigation of the resident's wrist injury, even though the resident was entirely dependent on staff for care and unable to self-inflict such an injury. The facility's abuse policy required a timely, thorough, and objective investigation of all alleged violations, including injuries of unknown source, and mandated reporting to the State Agency. However, the investigation did not identify or address the injury, did not include a review of all relevant medical records, and did not determine the cause or extent of the injury. As a result, the injury of unknown origin was not investigated as required by facility policy and regulatory standards.
Failure to Assess, Monitor, and Treat Pressure Ulcer Results in Worsening Wound
Penalty
Summary
A resident with reduced mobility and type 2 diabetes was identified as being at high risk for skin breakdown, as indicated by a Braden score of 11. The resident's care plan included multiple interventions for skin integrity, such as the use of an alternating pressure mattress, barrier cream, regular turning and repositioning, and daily skin monitoring. Despite these interventions being listed, the care plan was not updated upon the resident's re-admission, and there was a lack of follow-through in implementing and documenting appropriate wound care interventions. On assessment, the resident was found to have a wound on the coccyx, initially documented as moisture-associated skin damage (MASD) with incontinence-associated dermatitis (IAD). The wound was present on admission, but no treatment orders were obtained or implemented for this wound. Staff interviews revealed that both nursing assistants and nurses observed an open area on the coccyx, described as red and larger than a quarter, but the nurse who assessed the wound did not notify the provider or obtain specific treatment orders. Instead, a barrier cream and gauze were applied without clear documentation of the type of cream used, and the provider was not informed to establish a formal treatment plan. Further review showed that the wound worsened, as documented during a subsequent hospital visit, where multiple chronic shallow pressure ulcers were noted, and the coccyx wound was described as much worse than previously observed. The wound care provider confirmed not having assessed the resident, and the facility's own guidelines required provider-ordered treatments for wounds, which were not followed. The Director of Nursing and Assistant Director of Nursing acknowledged that treatment orders were missed and that the wound care team had not seen the resident as expected.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or events involved. No further information about the circumstances, individuals affected, or observations made by surveyors is included in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information or ensuring proper documentation of resident records were not followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Involve Responsible Party in Care Planning
Penalty
Summary
The facility failed to inform and accommodate a resident's responsible party (RP), who is also the legal guardian, in the development and implementation of the resident's person-centered care plan. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and schizoaffective disorder, was readmitted to the facility from a psychiatric hospital. The care plan indicated that the RP should be kept informed of changes in health and medical status to assist with ongoing care planning and decision-making. However, the RP reported that communication from the facility had declined since a change in ownership, and she was not being given the opportunity to participate in care planning as required. The RP had arranged to attend a scheduled care conference in person, but was told by the facility's social worker to cancel, with the promise of a phone call at the scheduled time. The social worker called earlier than scheduled, and when the RP missed the call and attempted to return it, she received no response. The care conference was documented as attended by the RP, but the RP stated she did not participate and was not contacted afterward despite leaving messages. The facility's policy requires advance notice and participation of the resident or RP in care planning, which was not followed in this instance.
Call Light Not Accessible to High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by facility policy. The resident, who had diagnoses including lack of coordination, epilepsy, muscle weakness, and difficulty walking, was dependent on staff for toileting, personal hygiene, and required substantial assistance with dressing. During an observation, the resident was found sitting at the edge of his bed, appearing weak and shaky while attempting to stand up unassisted. The resident repeatedly stated he needed help but was unable to use his call light because he did not know where it was. It was observed that the call light was under the bed and out of the resident's reach. In an interview, a registered nurse confirmed that the resident was a high fall risk and had recently experienced unwitnessed falls in the facility. The nurse also stated that the resident typically used his call light for assistance. Review of the facility's call light policy indicated that staff are responsible for ensuring call lights are plugged in, functioning, and within reach of residents. The failure to provide the resident with access to the call light resulted in the resident's inability to call for staff assistance.
Failure to Protect Residents from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from separation, including separation from other residents, their own rooms, or confinement to their rooms. The report notes that the facility failed to ensure that each resident was protected from such separation or confinement, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or their medical conditions at the time of the event.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Enhanced Barrier Precautions and Water Management Protocols
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) according to facility policy and CDC guidance for three out of four residents reviewed. In one instance, a nurse performed nephrostomy care and flushed nephrostomy tubes for a cognitively intact female resident with multiple comorbidities, including obstructive uropathy and wounds, without donning a gown as required. The resident reported that staff inconsistently wore gowns during her care. The nurse stated she did not believe a gown was necessary unless there was splashing, despite facility policy requiring gown and glove use for high-contact care. Another resident with chronic kidney disease and a hemodialysis catheter was repositioned and checked for wounds by a CNA who wore gloves but not a gown, under the mistaken belief that the resident was no longer on precautions, despite active EBP orders. A third resident with a stage 3 pressure ulcer received wound care from a nurse who wore gloves but not a gown and was unaware of EBP requirements, having not received facility education on the policy. Additionally, the facility did not maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in premise plumbing. Multiple janitors' sinks and spa tubs throughout the facility were observed with issues such as brown or discolored water, stagnant water lines, and lack of flushing schedules. Some sinks did not dispense water from certain handles, indicating stagnant lines, and some tubs and sinks were not regularly used or flushed. The Director of Facilities confirmed that not all areas were on a flushing schedule and that the facility did not routinely test for residual disinfectants in the water supply, despite having a test kit available. Review of facility policies confirmed that EBP requires gown and glove use for high-contact activities for residents with wounds or indwelling devices, and that the water management program requires control measures, testing protocols, and documentation for water safety. However, staff interviews and observations revealed gaps in knowledge, inconsistent implementation of precautions, and lack of adherence to water management protocols.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not properly labeled, dated, or stored in accordance with facility policy and professional standards. On the 400 hall medication cart, a bottle of nitroglycerin was found with an expired discard date, and two opened insulin pens (Lantus and Humalog) lacked open dates. Additionally, an opened lidocaine cream was missing both a resident name and an open date. Nursing staff confirmed that all medications should be labeled with the resident's name and the date opened, and that expired medications should be removed from the cart. On the 300 hall cart, two opened bottles of Genteal tears eye drops were found without resident names or open dates, and an opened insulin pen was missing an open date, making it unclear if it was safe to use. Staff interviews confirmed these labeling and dating requirements were not met. Further, an unlocked medication cart was observed in the hallway near the 300 Hall, with the narcotic drawer pulled open and no staff present to supervise. The cart was later secured by a nurse, who confirmed that medication carts should be locked when not in use. Review of the facility's policy indicated that all medications and biologicals are to be stored in locked compartments to ensure safety and security, which was not adhered to during the observations.
Failure to Offer and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered to eligible residents, as required by their policy and CDC/FDA guidelines. Specifically, three residents with significant medical histories, including conditions such as stroke, Alzheimer's disease, anemia, diabetes, and high blood pressure, did not have documentation in their medical records indicating that they were offered or administered COVID-19 vaccinations beyond 2022. For two residents, the last recorded COVID-19 vaccinations were in October 2022 and March 2022, respectively, with no further information about subsequent offers or administration. For the third resident, there was no documentation of any COVID-19 vaccination being offered or administered at all. Interviews with the Infection Preventionist confirmed that COVID-19 vaccinations are supposed to be offered upon admission and annually as the vaccine changes, but no additional documentation could be provided to show that these three residents were offered the vaccine after 2022. At the time of the survey, all three residents were eligible to receive the COVID-19 vaccination, but the facility lacked evidence that the required education and offer of vaccination had occurred as per policy.
Failure to Maintain Functional Call Light System for Residents
Penalty
Summary
The facility failed to ensure a fully functioning call light system was available and operational for all residents, specifically affecting four residents out of eighteen reviewed. Multiple residents reported that their call lights were either not working properly or not being answered in a timely manner. Observations confirmed that in several cases, the call light would activate inside the resident's room but would not trigger the hallway indicator to alert staff, and in some instances, the call light remained on even after staff attempted to turn it off. Additionally, some residents reported that their call lights were placed out of reach, preventing them from calling for assistance when needed. Interviews with residents revealed ongoing issues with the call light system, including long wait times for staff response and instances where no one responded at all. One resident reported waiting approximately two hours for assistance, while another stated that the call light system in her room frequently did not work and was often out of reach. Family members and roommates corroborated these accounts, noting repeated problems with the call light system and the need for residents to call out for help when the system failed. Facility staff, including the Director of Facilities and the DON, acknowledged awareness of the call light system's deficiencies. The facility had previously attempted to use cell phones as part of the system, but these were not functioning properly and were discontinued. The monitoring screen for call lights had also been placed in a location not visible to staff at the nurse's station until recently. Work orders confirmed repeated maintenance requests for the malfunctioning call light system in affected rooms, but issues persisted, resulting in residents' needs potentially going unmet.
Failure to Provide Mandatory Infection Control and EBP Training to Agency Staff
Penalty
Summary
The facility failed to implement an effective infection prevention and control training program, specifically regarding Enhanced Barrier Precautions (EBP), for agency staff. Record review and interviews revealed that four out of five staff members reviewed did not receive or complete required education on EBP prior to working shifts. The Infection Preventionist stated that agency staff were expected to review a binder containing EBP policies at the facility entrance, but there was no process in place to verify or document that this education was completed. Agency staff reported either not being informed about the binder, not receiving any EBP education, or only being asked to review unrelated materials such as the narcotic binder. Additionally, an agency RN preparing to perform wound care was unaware of the need to wear a gown and was not familiar with EBP, stating that she had not received any relevant education from the facility. This lack of training and verification created the potential for cross-contamination and the spread of infection among a vulnerable population, as staff were not adequately prepared to follow infection control protocols.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as required by policy. During an observation, a CNA referred to residents with the label "lay backs" in a public hallway while pointing to three residents who were seated in geri chairs near the nurses' station. This comment was made in the presence of other staff and residents, and the Director of Nursing later confirmed that such language is not appropriate and does not align with facility policy, which mandates respectful communication and addressing residents by their preferred names. The residents involved had significant cognitive impairments, including diagnoses of major depressive disorder, anxiety disorder, Alzheimer's disease, and dementia. Two of the residents were moderately cognitively impaired, while one had severely impaired cognitive skills and was unable to participate in a mental status interview. The incident was observed and documented by surveyors, and attempts to interview the CNA involved were unsuccessful prior to the survey exit. The facility's own dignity policy emphasizes the importance of promoting residents' well-being and self-worth, which was not upheld in this instance.
Failure to Obtain Psychotropic Medication Consent Prior to Administration
Penalty
Summary
The facility failed to obtain consent for psychotropic medications prior to administration for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia, depression, and anxiety, was unable to clearly verbalize needs and frequently refused care. Despite being prescribed multiple psychotropic medications such as Lexapro, Risperidone, Trazodone, and Ativan, there was no documentation of signed or verbally discussed consents for these medications prior to their administration. Record review confirmed the absence of psychotropic medication consents, and staff interviews verified that no consents were on file before a specified date. The resident's care plan included interventions to provide education on the risks and benefits of these medications, but there was no evidence that this was carried out as required by facility policy. This resulted in the resident and/or their representative not being fully informed about the medications being administered.
Failure to Notify DPOA of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's durable power of attorney (DPOA) or emergency contact after the resident experienced a fall and was transferred to the hospital. The resident, who had a history of muscle weakness and hemiplegia following a cerebral infarction, was found on the floor next to her bed with a large bruise on her right knee and a bump and bruise on the left side of her forehead. The LPN on duty initiated neurological assessments, contacted the on-call provider, and arranged for the resident to be transported to the hospital due to concerns about a possible head injury. However, there was no documentation that the resident's DPOA was notified of the incident or the hospital transfer. Interviews with the family member, LPN, DON, and regional nurse consultant confirmed that the DPOA was not contacted regarding the fall and subsequent hospital transfer. The facility's own policy requires notification of the resident's designated representative in the event of an accident or incident resulting in injury and requiring physician intervention or transfer. Review of the incident report and progress notes did not show evidence of such notification, and the family member only learned of the incident after being contacted by the hospital.
Failure to Issue SNF ABN for Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who transitioned from Medicare-covered skilled care to private pay after choosing to discontinue therapy services. Documentation showed that the resident was informed on her last covered day that her payer source would change to private pay, but there was no record of an SNF ABN being issued to notify her of potential financial liability for non-covered services. The Business Office Manager confirmed that the resident should have received an ABN but did not, and there was no documentation indicating the resident was informed of the private pay costs.
Failure to Provide Required Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required discharge notifications and bed-hold policy information for two residents during the discharge process. For one resident with a history of anxiety and depression, the State Long-Term Care (LTC) Ombudsman did not receive notification of the resident's discharge to a psychiatric hospital. The Nursing Home Administrator (NHA) was unable to provide documentation that notifications were sent to the ombudsman's office, and the resident was not listed on the facility's discharge log for the relevant month. Interviews and record reviews confirmed that the required notification was not completed. For another resident with muscle weakness and hemiplegia following a cerebral infarction, the facility did not provide the resident's Durable Power of Attorney (DPOA) with written notice of the bed-hold policy when the resident was transferred to the hospital. The NHA confirmed that the bed-hold notice was not provided. These failures were identified through interviews, record reviews, and correspondence with the LTC Ombudsman.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as being at risk for falls due to multiple factors, including medication side effects, debility, poor oral intake, ataxia, impaired safety awareness, visual impairment, and osteoporosis. The resident's care plan included specific interventions such as keeping the call light within reach and ensuring a fall mat was placed next to the bed. However, during multiple observations, the fall mat was either missing, improperly positioned, or folded against the wall, and the call light was found out of the resident's reach. Staff interviews confirmed that the fall mat was often moved to accommodate the bedside table during meals and was not consistently returned to its proper position afterward. A CNA acknowledged that staff frequently forgot to replace the fall mat after the resident finished eating, resulting in the resident being left without the prescribed fall prevention intervention. These lapses in following the care plan created a potential for unmet care needs for the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of unstageable pressure ulcers to the heels was not provided with adequate care and services to prevent the development and worsening of pressure injuries. The resident was observed multiple times with his feet pressed against the footboard of a bed that was too short, resulting in wounds on both heels and toes. The resident reported pain and that his feet were not being cleaned as needed, and observations confirmed the presence of open, bleeding, and scabbed wounds on his heels and toes, as well as soiled pressure-relieving boots and bedding. Nursing and agency staff were not consistently aware of all the resident's wounds, with some staff unaware of wounds on the toes and wound care orders not covering all affected areas. Wound assessments and documentation showed a lack of timely identification and treatment of new or worsening wounds, including a newly developed unstageable pressure injury to the right heel and scabbed, bleeding toes. The resident's care plan included the use of foam heel suspension boots and offloading, but these interventions were not consistently or effectively implemented, as evidenced by the resident's ongoing contact with the footboard and the condition of his feet. Record review indicated that the resident had a history of pressure injuries to both heels and toes, with recommendations for offloading and repositioning. Despite these recommendations, the resident continued to experience preventable skin breakdown due to inadequate offloading, insufficient wound care, and lack of cleanliness. The failure to provide necessary care and services consistent with professional standards resulted in the development of new pressure injuries and the potential for further harm.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of muscle weakness and repeated falls was not provided the care as outlined in his care plan. The resident required assistance from two staff members for bed mobility, as documented in his care plan and Kardex. However, on the date of the incident, an agency CNA provided care alone and attempted to move the resident in bed without the required second staff member present. During this process, the resident fell from the bed, resulting in abrasions to his face, knees, and a bleeding wound on his toe. The incident report and interviews confirmed that the CNA did not review the care plan or Kardex prior to providing care and did not consult with nursing staff or other personnel before proceeding. The resident was found on the floor, partially under the bed, after the fall. The DON confirmed that the CNA was alone in the room at the time of the incident, which was not in accordance with the resident's care plan requirements for a two-person assist during bed mobility.
Failure to Monitor and Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure appropriate post-dialysis assessment and monitoring for a resident with end stage renal disease who required hemodialysis. The resident's care plan included interventions such as monitoring for signs and symptoms of infection, renal insufficiency, bleeding, and other complications, as well as specific instructions not to draw blood or take blood pressure in the arm with a graft. Despite these interventions, there was no evidence that the resident was assessed or monitored upon return from dialysis on multiple occasions. The dialysis communication form was not immediately retrieved or reviewed by the assigned nurse, and vital signs were not recorded regularly, with the most recent entry being a month prior to the incident. Progress notes for the days the resident returned from dialysis were also missing. Interviews with staff revealed that the nurse assigned to the resident was unfamiliar with the resident and did not receive or review the dialysis communication form. The Director of Nursing confirmed that the form was later found in the resident's wheelchair pocket and acknowledged that the nurse did not monitor the resident or document a progress note after dialysis. The facility's policy required immediate retrieval of the dialysis communication form, assessment of the resident's stability, and documentation in the medical record, none of which were followed in this instance.
Failure to Address Pharmacist Medication Review Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure a prompt response to the registered pharmacist's monthly medication regimen review (MRR) recommendations for several residents, resulting in recommendations not being addressed in a timely manner. For one resident with severe cognitive impairment and diagnoses including dysphagia and dementia, the pharmacist repeatedly recommended evaluation and possible discontinuation of Nystatin-Triamcinolone cream and Acidophilus, as their continued use was not supported. Although the provider agreed with the recommendations, there was no documentation of timely follow-up or physician review, and the medications were not discontinued until much later than when the recommendations were signed. Another resident with severe cognitive impairment and multiple psychotropic medications did not have required Abnormal Involuntary Movement Scale (AIMS) assessments documented, and the facility was unable to produce MRR irregularity reports for review. Interviews revealed that the process for reviewing and implementing pharmacy recommendations had not been followed for at least two months, with reports not being reviewed or acted upon in a timely fashion. Additionally, medication consents were not on file for this resident prior to a certain date. A third resident with Alzheimer's disease and major depressive disorder had a pharmacist recommendation to evaluate the continued need for Vitamin B-12 and Lipitor due to terminal status, but there was no evidence that the physician or provider reviewed or responded to this recommendation. Interviews with facility staff confirmed a lack of awareness and follow-up regarding these recommendations. The facility's policy required that physicians document review and action on any pharmacist-identified irregularities by their next mandatory visit, but this process was not followed for the residents in question.
Failure to Screen and Document Pneumococcal Vaccination Eligibility
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive pneumococcal vaccinations and to document the administration or offer of the vaccine in accordance with facility policy and CDC guidelines. Review of the resident's medical record showed no documentation of screening for pneumococcal vaccination eligibility, and no record that the resident was offered the vaccine as recommended. Although a consent for vaccination was signed in 2022, there was no clear documentation of follow-up screening or administration of the appropriate pneumococcal vaccine. Further review revealed that the resident received two doses of the same pneumococcal polysaccharide vaccine (PPSV23) on separate occasions, but there was no evidence that the facility assessed the need for additional or different pneumococcal vaccines as per current recommendations. The lack of documentation and screening resulted in the resident not being offered the Prevnar 20 (PCV20) vaccine in a timely manner, as required by CDC guidelines for adults of her age and vaccination history.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 321 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corewell Health Rehabilitation & Nursing Center - | 1.2 mi | ★★★★★ | 7 | 0 |
| Holland Home Breton Rehabilitation & Living Centre | 1.8 mi | ★★★★★ | 0 | 0 |
| Beacon Hill At Eastgate | 2 mi | — | 2 | 0 |
| Holland Home - Raybrook Manor | 2.1 mi | ★★★★★ | 11 | 0 |
| Optalis Health & Rehabilitation At Kent-crossing | 2.1 mi | ★★★★★ | 33 | 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.