Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Kingsford during CMS and state inspections, most recent first.
A resident with prostate cancer and secondary bone cancer missed multiple doses of ordered Abiraterone Acetate after the medication was mistakenly sent home with another resident at discharge. The MAR showed the doses were not given, the care plan did not address administration of the oral chemo agent, and staff reported the facility could not quickly obtain a replacement supply because the medication was a specialty drug. No med error report was completed.
A resident with prostate cancer and secondary bone cancer missed three doses of oral chemotherapy after the medication was inadvertently sent home with another resident at discharge. The DON and RN confirmed there was no progress note, medication error report, discharge inventory, or other medical record documentation showing the loss, the response, or the steps taken regarding the missing medication, despite the facility policy requiring such documentation.
A resident with neurogenic bladder, paraplegia, a Stage 4 sacral pressure ulcer, and an indwelling Foley catheter was not monitored for urinary output despite dependence on staff for care and a history of UTI, hydronephrosis, and recent nephrostomy tube removal. CNA documentation over several months only coded bladder status as "continence not rated due to indwelling catheter" without recording catheter patency or urine amounts, and the MAR/TAR contained no measured outputs even after catheter changes and irrigations. The resident later experienced hematuria and repeated catheter problems, including leakage, blood in urine, and lack of drainage, culminating in being found soaked in blood with an empty drainage bag and subsequent transfer to the hospital for UTI and anemia. The DON acknowledged that urine output was not routinely measured for catheterized residents unless specifically ordered by a physician, and no such order or measurements were present in the record, contrary to the facility’s catheter monitoring policy and referenced professional standards regarding urine output assessment.
A resident with severe cognitive impairment exited the facility without staff knowledge and entered a nearby business. Staff were alerted and retrieved the resident, but the wander guard device did not alarm at the exit. After the incident, no new interventions were added to the care plan, contrary to facility policy.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
Surveyors found that food items such as cubed cheeses and summer sausage were stored in the main dining room refrigerator without required labels, open dates, or use-by dates, and that storage areas and containers were soiled and unsanitary. An Activity Director reported not knowing about labeling requirements for food used in activities, and facility policy mandates were not followed, resulting in improper food storage and increased risk of cross-contamination.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident was found to be self-administering medications, including acetaminophen and laxatives, without an assessment, physician order, or care plan in place. The medications were kept unsecured in the resident's purse, and nursing staff were unaware of their presence. Facility policy requires an IDT assessment, physician order, care plan documentation, and secure storage for self-administered medications, none of which were followed in this case.
Three residents who were transferred to the hospital did not receive written notification of the bed hold policy, as required by facility policy. Medical records lacked documentation that the bed hold policy was provided to the residents or their representatives during any of their hospital transfers, despite multiple occurrences.
A resident with cognitive impairment and physical limitations was found with visibly soiled hands and encrusted fingernails, despite requiring moderate assistance with personal hygiene. Documentation did not reflect any hand or nail care provided, nor any refusals of such care, and staff were unaware of the resident's condition until it was pointed out. Facility policy required assistance with grooming and hygiene for dependent residents, but this was not provided in this case.
A resident with multiple chronic conditions was found to have an IV site with an undated dressing, and staff could not confirm when it was last changed. Documentation of the IV placement was incomplete, lacking details such as catheter size and resident comfort. Additionally, there was no physician order to change the IV site every 72 hours, contrary to facility policy and standard practice.
A resident with respiratory failure and other conditions was found using a nasal cannula with an empty, undated humidifier and a nebulizer left with condensation and medication residue on their bed and bedside table. Staff interviews and observations confirmed that respiratory equipment was not cleaned, dried, or stored according to facility policy, and humidifiers were not dated or replaced as required.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with intact cognition and multiple diagnoses was found with vitamin gummies left at the bedside without a physician order or completed self-administration assessment. An LPN acknowledged that medications had been left unsupervised and that observation of administration had not previously occurred, leading to a deficiency due to lack of required authorization and assessment.
A resident with intact cognition and multiple medical conditions reported several missing personal items, including jewelry and clothing, over a period of months. Despite submitting multiple written grievances, the facility did not promptly locate or replace the items, and documentation of resolution and resident satisfaction was incomplete. Required inventory procedures were not followed at admission, and the facility's policy for timely investigation and resolution was not met.
A resident's urinary nephrostomy drainage bag was found hanging into a garbage can without a dignity cover, despite care plan interventions requiring proper maintenance and use of a cover. The resident, who has a history of frequent UTIs, confirmed the bag should not be in the garbage, and facility staff acknowledged the infection control issue.
Chronic understaffing led to multiple residents being left wet, soiled, and without adequate grooming or oral care. Staff and family interviews, as well as direct observations, confirmed that care was frequently delayed or omitted due to insufficient CNA and nursing coverage, with agency staff often failing to show up. Residents with significant ADL needs were particularly affected, and concerns about incomplete care were repeatedly raised in resident meetings.
Two residents with significant physical and cognitive impairments did not receive necessary assistance with activities of daily living, including hygiene, grooming, and toileting. Both were observed with poor personal hygiene and, in one case, left wet and soiled for an extended period. Staff and resident interviews attributed these deficiencies to ongoing staffing shortages and unreliable agency staff, resulting in missed or delayed care.
A facility failed to maintain the accuracy and confidentiality of resident records, resulting in incorrect information being sent with a deceased resident's remains to a funeral home. The error involved two residents and was identified by the funeral home, which contacted the facility for clarification. The mistake was attributed to a failure to verify the deceased's identity and cross-check documentation, with two staff members involved in printing the paperwork but no clear verification process in place.
A resident with a penile tear due to chronic catheter use did not receive consistent wound assessments, as required by facility policy. Despite being prescribed lidocaine for pain, there was no documentation of routine evaluations to monitor the wound's healing or identify worsening conditions. The DON could not find any records of wound evaluations, and an LPN was unsure about assessment frequency.
A resident with Parkinson's Disease and severe cognitive impairment, requiring substantial assistance, developed a Stage 3 sacral pressure injury due to the facility's failure to conduct consistent skin assessments. Despite being at high risk, the facility did not perform regular assessments as per policy, leading to unidentified wounds and delayed treatment. The DON confirmed a lack of documentation and assessment, increasing the risk of miscommunication regarding the resident's needs.
The facility failed to provide proper catheter care for two residents, resulting in a urinary collection bag touching the floor and a drainage leg bag being overfilled. A resident's catheter bag was observed without a securement device, risking dislodgement and infection. Another resident's leg bag was not emptied as per policy, causing urine backup. The facility's policies on catheter care were not followed, as confirmed by the DON.
A resident with a history of heart failure and recent cardiac surgery experienced severe respiratory distress and fluid volume overload due to the facility's failure to timely obtain and process physician orders for respiratory assessment and diagnostics. Despite the resident's complaints and a nurse practitioner's order for a chest x-ray, the test was not performed, leading to the resident's hospitalization.
A resident experienced a fall and knee pain due to the inappropriate use of a sit-to-stand mechanical lift instead of the required total mechanical lift. The resident's care plan specified the need for a total mechanical lift with two-person assistance, but CNA staff mistakenly believed the transfer method had been changed. The Therapy Director confirmed the resident was not approved for the sit-to-stand lift. No audits were conducted post-incident to ensure compliance with care plans.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical devices and an open wound. A CNA provided care without wearing a protective gown, contrary to the resident's care plan and physician orders. The CNA was unaware of the EBP requirement due to a lack of signage or PPE cart, leading to potential infection spread.
A resident with multiple health conditions did not receive breakfast due to a lack of assistance and a system to ensure meal delivery. Despite needing help with eating, the resident's meal was not brought to him, and dietary staff noted frequent returns of untouched trays without proper documentation.
A resident with Parkinson's Disease experienced delays in receiving critical medication due to the facility's failure to provide timely pharmaceutical services. The resident reported not receiving Amantadine HCl as scheduled, with the first dose significantly delayed on the day of admission. The facility did not notify the physician or pharmacist about the medication's unavailability, contrary to their pharmacy policy.
A facility failed to inform a resident's representative of the grievance policy and did not address all grievances promptly. Despite numerous emails from the representative about care concerns, many were not documented in the grievance log, leading to delays or omissions in responses. The resident had severe cognitive impairment and required specific incontinence care, which was not consistently provided.
A resident with severe cognitive impairment and a history of traumatic brain injury experienced inadequate grooming, dressing, personal hygiene, and toileting due to the facility's failure to adhere to their care plan. The resident was often found in soiled clothing without necessary incontinence briefs, and staff failed to provide consistent assistance with personal hygiene. Interviews confirmed these deficiencies, with staff acknowledging inappropriate handling of the resident's care.
The facility failed to implement a comprehensive wound care program, resulting in the development and worsening of multiple pressure injuries among residents. Observations revealed inadequate wound care techniques, improper use of heel protection, and insufficient documentation and care planning, leading to significant lapses in wound care management.
The facility failed to provide adequate nursing staff, resulting in extended call light wait times and insufficient care. Residents reported delays in receiving assistance with ADLs, with call light logs showing multiple instances of wait times exceeding 15 minutes, and in some cases, over an hour. These issues were particularly prevalent between 5:00 PM and 7:00 AM, as confirmed by resident council members.
The facility failed to ensure the dietary department was staffed with sufficient and properly trained personnel. The Kitchen Manager had not completed the Certified Dietary Manager's course and lacked credentials in food service sanitation. The Registered Dietitian's responsibilities were limited to clinical assessments, with no involvement in kitchen functions. The corporate registered dietitian consulted via phone but had not visited the facility to assist in training.
The facility failed to ensure that menus met the nutritional needs of residents, were followed according to recipes, and were reviewed and approved by a Registered Dietitian. A resident with a healing amputation expressed concerns about inadequate protein in meals, and observations confirmed insufficient protein content in the Mostaccioli dish served. Dietary staff admitted to not following recipes accurately, leading to potential nutritional deficiencies for all 73 residents.
The facility failed to follow menu recipes, resulting in a Mostaccioli dish being served with insufficient cottage cheese. The cook admitted to using only two and a half pounds of cottage cheese instead of the required five pounds for 50 servings. The kitchen manager confirmed that the facility did not maintain records to verify if recipes were followed correctly, potentially leading to nutritional deficiencies for all 73 residents.
A resident with a physician's order for a cardiac diet received inappropriate food items due to the facility's dietary software limitations and lack of a diet manual. The Dietary Manager and Corporate Dietitian were unaware of the differences between diet types, leading to non-compliance with the prescribed diet.
The facility failed to maintain proper food safety and sanitation standards, including improper temperature monitoring of hot food, inadequate dishwashing practices, and unsafe storage of food service items. These deficiencies pose a risk of foodborne illness to the residents.
The facility failed to manage pressure ulcers effectively and provide adequate leadership support during increased staffing needs. The NHA and DON could not provide evidence of QAPI committee activities or data analysis for pressure ulcers. The DON was reported to be under the influence of alcohol and unavailable for emergencies, and the facility lacked an on-call policy for supervision and nursing staff.
The facility failed to conduct and document an annual facility-wide assessment, resulting in the potential for inadequate knowledge of the facility population's needs and resources to care for the 73 residents. The provided Facility Assessment was outdated and reflected previous ownership. The NHA and Regional Clinical Resource nurse were waiting for updated CMS guidelines before updating the assessment.
The facility failed to maintain an effective QAPI program to address and correct deficiencies in the prevention and treatment of pressure ulcers. The QAPI committee did not document performance improvement activities, and the DON could not provide data on pressure ulcer tracking or trending. Weekly meetings to discuss pressure injuries had ceased, leading to a system failure in the skin and wound program.
The facility's QAPI committee failed to meet composition and attendance requirements, with missing sign-in sheets, absent Medical Director, and lack of direct care staff participation, risking ineffective care coordination for 73 residents.
The facility failed to maintain essential kitchen equipment, leading to water overflow from a three-compartment sink and an overheated dish machine. Despite ongoing issues and multiple service attempts, the equipment remained unrepaired, posing potential risks to staff and residents.
The facility failed to follow through with the grievance process initiated by resident representatives and the resident council. Grievances about resident care and the lack of evening snacks were not addressed, and some grievance forms were found in the trash without follow-up. The facility did not adhere to its policy on Investigations of Grievances, resulting in unresolved grievances and a lack of communication with complainants.
The facility failed to provide mandatory QAPI training to four out of seven staff members reviewed. Interviews revealed a lack of awareness and understanding of the facility's quality improvement projects and goals. The facility's policy on Quality Assessment and Process Improvement was outdated and not effectively implemented.
The facility failed to ensure proper care of indwelling urinary catheter equipment for a resident, leading to potential contamination and infection risk. Observations revealed catheter tubing resting on the floor and improper handling of the drainage bag, including failure to disinfect the spout after emptying urine. Both CNAs and the Nurse Manager acknowledged the importance of keeping catheter equipment off the floor and disinfecting the spout to prevent infection.
The facility failed to assess the respiratory status of a resident with COPD and chronic respiratory failure who was receiving as-needed respiratory medications and supplemental oxygen. Despite multiple administrations of respiratory medications, no respiratory assessments or oxygen saturation levels were documented after the initial assessment. The resident's care plan also lacked focus areas and interventions related to their respiratory conditions.
A facility failed to properly administer and document an insulin dose for a resident. An RN administered an incorrect dose of insulin and documented it as the full dose in the MAR. The DON was unaware of the incident, and there was no documentation or physician notification in the EMR.
The facility failed to maintain a medication error rate of 5% or less, resulting in an 8.57% error rate. A nurse administered incorrect doses of Keppra and did not follow proper insulin administration guidelines, as confirmed by facility policies and interviews.
Missed oral cancer medication due to improper medication disposition
Penalty
Summary
The facility failed to ensure the timely acquisition, administration, and disposition of oral targeted cancer medication for one resident with prostate cancer and secondary bone cancer. The resident was cognitively intact, independent with mobility and self-care, and reported that he had taken the cancer medication for years without missing a dose before this event. He stated that after turning the medication over to the facility, he went three days without receiving it and expressed dissatisfaction that he missed doses while in the facility. The resident’s MAR showed that Abiraterone Acetate was not administered on three consecutive days and was documented with a chart code indicating other/see progress notes. The physician order required Abiraterone Acetate 500 mg, two tablets by mouth daily, taken one hour prior to breakfast. The resident’s care plan identified his active cancer diagnosis but did not include an intervention related to administration of the oral chemotherapy agent while in the facility. Facility staff reported that the medication had been sent home with another resident who discharged from the facility, and the medication was not available for the resident who needed it. The DON stated the facility planned to obtain the medication from its pharmacy, but the pharmacy could not provide a short supply because it did not stock the medication, and the DON did not know the specialty pharmacy information or how many pills had been sent home. Staff confirmed no medication inventory was completed at discharge, no medication error report was completed, and the medication was not available until several days later. The oncology RN stated that if the medication was not taken as ordered, its efficacy could not be guaranteed and the resident could be at greater risk for progression of disease.
Incomplete Documentation of Missing Chemotherapy Medication
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with prostate cancer and secondary bone cancer when his oral chemotherapy medication, Abiraterone Acetate, was not administered for three consecutive days. The resident, who had intact cognition and was independent with mobility, self-care, and functional cognitive tasks, reported that he had turned over his cancer medication to the facility and then went without it for three days after having taken it consistently for years. Review of the MAR showed Abiraterone Acetate was not given on three days in May 2026, and the physician order required the medication daily. The DON stated the medication had gone home with another resident who was discharged from the facility, but acknowledged that this was not specifically documented in the resident’s medical record. The DON also stated there was no documentation showing when the loss was identified, how the medication would be obtained, or that a medication error report had been completed. RN/Unit Manager A confirmed the medication had been sent home with the other resident and stated there was no discharge inventory showing which medications were given to that resident. RN A also stated she had called the oncologist’s office but did not enter a progress note, did not complete a medication error report, and did not document education to involved nursing staff in the medical record. The facility’s medication error policy required incident and medication error information, including the factual description, actions taken, resident response, and notifications, to be documented in the resident’s clinical record, but those details were absent.
Failure to Monitor and Document Urinary Output for Catheterized Resident
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document urinary output for a resident with an indwelling urinary catheter. The resident had multiple significant diagnoses, including neurogenic bladder, diabetes, paraplegia, and a Stage 4 sacral pressure ulcer, and was dependent on staff for toileting hygiene, bed mobility, and transfers. The MDS documented the presence of an indwelling urinary catheter, and the MAR/TAR included an order to maintain the Foley catheter and provide care every shift for urinary retention beginning in late October 2025. Despite this, the EMR contained no documented measured amounts of urine output from the catheter over the review period. From late October through mid-December 2025, CNA point-of-care documentation consistently coded the resident as "3 - Continence not rated due to indwelling catheter" under bladder elimination, with no entries describing catheter patency or the amount and character of urine output. There was also no documentation of measured urine output after the nephrostomy tube was clamped and then removed by urology on 10/27/2025, even though the urology note indicated uncertainty about how much had been draining from the nephrostomy tube and referenced prior sepsis and hydronephrosis. The facility’s own catheter use policy required ongoing monitoring for changes in condition related to potential catheter-associated UTIs, including recognizing, reporting, and addressing such changes, but the record lacked objective urine output measurements. Progress notes show that the resident had a recent history of UTI requiring six weeks of cefepime and vancomycin, and later developed moderate to severe hematuria. On 12/16/2025, staff documented multiple issues with the catheter, including urine leaking around the catheter, blood mixed with urine, lack of patency, and repeated need for flushing. That afternoon, the resident was found soaked in blood from the catheter insertion site with no urine in the drainage bag, prompting transfer to the ED. Subsequent documentation indicated the resident was hospitalized with heart rhythm issues, UTI treated with antibiotics, and anemia requiring blood transfusions. Interviews with the DON revealed inconsistent statements about whether urinary output for catheterized residents should be measured routinely, and the DON ultimately stated that output was only measured when ordered by a physician, even for residents with a history of UTI and hydronephrosis and recent nephrostomy tube removal. No physician order for urine output measurement was obtained, and no such measurements were documented.
Failure to Update Care Plan and Supervision After Resident Elopement
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and diagnoses including anxiety disorder, depression, and non-Alzheimer's dementia, was admitted to the facility. The resident was able to leave the facility unattended, as observed by the Admissions Director, who saw the resident exiting the building with visitors and subsequently entering a nearby business. Staff were alerted via two-way radio, and a registered nurse located the resident at the business and accompanied him. The resident's wander guard device did not alarm at the facility entrance, which was the point of exit. Following the elopement, there was no evidence that the resident's care plan was updated with new interventions to address the incident, despite facility policy requiring such updates after an elopement. Multiple staff interviews confirmed that no new interventions were added to the care plan after the event. The facility's policy on elopement, which includes updating the care plan and interventions after a resident is located, was not followed in this instance.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Improper Food Storage, Labeling, and Sanitation in Food Service Areas
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility's main dining room. An individual cup of brown sugar was found uncovered and exposed to air in a cabinet drawer containing various condiments, with the drawer itself soiled by food crumbs and sticky substances. A storage container of popcorn kernels was discovered in a cupboard above the refrigerator; the container was yellowing, sticky, greasy, and lacked any date or label. In the refrigerator, several packages of cubed cheeses and summer sausage were present without any labels, open dates, or use-by dates. A gallon-sized bag of sliced summer sausage, approximately half full and appearing dried out, was also found without any identifying information. These food items had been used for a recent event and were not properly labeled or dated as required by facility policy. Interviews revealed that the Activity Director was unaware of the requirement to label and date food items ordered through the kitchen for activities. A review of the facility's Food and Nutrition Services policy confirmed that all food removed from original packaging must be labeled with arrival and open dates, and that leftover foods must be labeled, dated, and either frozen or discarded within 72 hours if refrigerated. The observed practices did not comply with these policies, resulting in improper food storage, inadequate labeling, and unsanitary conditions that could contribute to cross-contamination and foodborne illness.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Assess and Authorize Safe Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering medications, including acetaminophen, a stool softener, and a laxative, without an appropriate assessment or physician order authorizing self-administration. The resident reported taking acetaminophen every four hours for pain related to a recent shingles episode and kept these medications in her purse, which had been brought in by her daughter. The resident demonstrated knowledge of her medication regimen and showed the surveyor the medications in her possession. However, there was no documentation of an assessment for self-administration, no physician order permitting this practice, and the medications were not stored in a secure location as required by facility policy. Interviews with nursing staff confirmed they were unaware the resident had medications in her room and that no assessment or care plan for self-administration had been completed. Review of the resident's physician orders and medication administration record showed an order for acetaminophen with specific dosing instructions, but the resident was self-administering a different strength and frequency than ordered. Facility policy requires an interdisciplinary team assessment, physician order, care plan documentation, and secure storage for self-administered medications, none of which were in place for this resident.
Failure to Provide Written Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to three residents who were transferred to the hospital. Specifically, interviews and medical record reviews revealed that these residents had multiple hospital transfers during their stays, but there was no documentation indicating that either the residents or their responsible parties received the required written notice of the bed hold policy at the time of transfer. The facility's own policy states that the Admissions Director or designee is responsible for sending the bed hold policy and transfer notice to the resident's representative when a resident is admitted to the hospital. For each of the three residents reviewed, the medical records did not contain evidence that the bed hold policy, including the duration of the bed hold, was provided during any of their hospital transfers. The residents themselves were unsure of the exact dates of their hospitalizations, but confirmed that they had been transferred out to the hospital on more than one occasion. The lack of documentation and notification was consistent across all reviewed cases, indicating a failure to follow the facility's established procedures for informing residents and their representatives about bed hold policies during hospital transfers.
Failure to Provide Hand and Nail Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with metabolic encephalopathy, liver cancer, muscle weakness, and moderate cognitive impairment was observed with visibly soiled hands and brown-colored substance encrusted under the fingernails of both hands. The resident required moderate assistance with personal hygiene and was frequently incontinent of bowel and bladder. The care plan and Kardex specified that nail care should be provided on bath days and as necessary, but there was no documentation in the electronic medical record (EMR) or progress notes regarding fingernail or hand hygiene. The resident's care plan also indicated a need for one-person staff assistance with personal hygiene, and there was no documentation of the resident refusing care related to hand or fingernail hygiene. During interviews, the resident reported not receiving help with hand hygiene, and a CNA confirmed that while the resident sometimes refused care, there was no recollection of refusals related to hand and fingernail hygiene. The CNA was unaware of the resident's soiled hands and nails until prompted and acknowledged that the hands and fingernails would be cleaned immediately. The facility's policy required that residents unable to perform activities of daily living independently receive necessary services to maintain grooming and personal hygiene, but this was not followed in this instance.
Failure to Document and Maintain IV Site per Standards of Practice
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including diabetes mellitus, dementia, urinary tract infection with an indwelling catheter, and heart failure, was observed to have an intravenous (IV) site in the left forearm with a dressing that was not dated. During a medication pass, staff could not determine how long the IV site had been in place due to the missing date, and the responsible LPN acknowledged that the site should be replaced if undated. Review of the resident's electronic medical record showed that the documentation of the IV placement lacked details such as the size of the catheter, number of attempts, and the resident's comfort during the procedure. Further review of the resident's physician orders for the relevant month revealed there was no order to change the IV site every 72 hours, as required by standards of practice. The facility's policy on catheter insertion and care indicated that administration sets and tubing should be changed at specific intervals to prevent infection, but this was not reflected in the resident's care. The Nursing Home Administrator confirmed that the expectation was for IV dressings to be dated and sites to be changed every 72 hours or sooner if indicated, but this was not followed in this instance.
Failure to Maintain and Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a sanitary manner for a resident with multiple diagnoses, including dementia, respiratory failure, depression, and heart failure. Observations revealed that the resident was using a nasal cannula connected to an oxygen concentrator with a humidifier that was empty and not dated. Additionally, a nebulizer with visible condensation and residual medication was found lying on the resident's bed and bedside table during multiple observations. The resident reported that staff only added medication to the nebulizer and turned it on, without rinsing it out after use. The resident also mentioned experiencing a bloody nose, possibly related to the empty humidifier. Interviews with nursing staff indicated that humidifiers were replaced weekly, but there was no evidence that the humidifier in use was dated or replaced as required. Facility policy required daily checks and weekly replacement of humidifiers, as well as rinsing and air-drying nebulizers after each use, with proper storage. However, the observed practices did not align with these policies, as the equipment was not cleaned, dried, or stored appropriately, and humidifiers were not dated or maintained according to protocol.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Ensure Proper Authorization for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple diagnoses including cancer, neurogenic bladder, anxiety disorder, depression, and an unspecified mood disorder, was observed with a cup of vitamin gummies left at the bedside. The resident reported to an LPN that the number of gummies was inconsistent with what was expected, and the LPN acknowledged that she had not previously observed the resident taking the gummies. The LPN then stayed to observe the resident consume the gummies, which prompted the resident to question why observation was necessary, as it had not been done before. Further investigation revealed that there was no physician order in place for the resident to self-administer medication, nor had a Self-Administration of Medication Assessment been completed prior to the incident. The facility's staff confirmed that medications had been left at the bedside without the required physician order or assessment, and that these were only implemented after the surveyor's observation. The deficiency was identified due to the lack of proper authorization and assessment for self-administration of medication, resulting in unsupervised medication being left at the resident's bedside.
Failure to Promptly Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to promptly resolve grievances for a resident who reported multiple missing personal items, including valuable jewelry, clothing, and sentimental belongings. The resident, who was cognitively intact and had a history of cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder, reported the loss of these items over a period of months. Despite submitting at least three written complaints and concern forms, the facility did not locate or replace the missing items in a timely manner. Documentation showed that the resident was instructed to select replacement items, but there was no evidence that the process was completed or that the resident was notified of a resolution or expressed satisfaction with the outcome. Review of facility records revealed that the required Personal Effect Inventory was not completed at the time of the resident's admission, but only after multiple complaints had been filed. The facility's policy required that missing items be investigated and resolved within two weeks, but this was not adhered to in the resident's case. Interviews with staff and the Nursing Home Administrator confirmed that the process for investigating and resolving grievances was not consistently followed, and key documentation regarding resolution and resident satisfaction was missing.
Improper Maintenance of Nephrostomy Drainage Bag Leading to Infection Control Concern
Penalty
Summary
A urinary nephrostomy drainage bag for one resident was observed clipped to the bed linen, with the bag hanging down into the resident's garbage can, which contained various garbage items. The drainage bag did not have a privacy or dignity cover, and the weight of the urine caused the bag to lower further into the garbage. When questioned, the resident confirmed that the bag should not be in the garbage can and reported a history of frequent urinary tract infections, including a recent severe episode requiring IV antibiotics. The resident's care plan included interventions to be mindful of the nephrostomy tubes, ensure they are fully closed after flushing, and provide a collection bag cover at all times. Despite these interventions, the drainage bag was not properly maintained, resulting in direct contact with contaminated surfaces. Facility staff, including the Nursing Home Administrator and Assistant Director of Nursing, acknowledged the infection control concern when made aware of the situation.
Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of residents, resulting in multiple instances where care was not delivered in a timely or adequate manner. Several staff members, including RNs, LPNs, and CNAs, reported chronic understaffing, frequent agency staff no-shows, and the need to prioritize essential care over routine grooming and hygiene. Observations and interviews revealed that residents were left wet and soiled for extended periods, did not receive regular oral care or grooming, and were often disheveled. Staff described being unable to keep up with documentation, emergencies, and admissions due to being pulled in multiple directions and covering for absent colleagues. Specific residents were directly affected by these staffing shortages. One resident, who required two-person assistance for toileting and ADLs due to hemiplegia following a stroke, was found multiple times in soiled clothing and bedding, with visible signs of neglect such as unbrushed hair, dirty fingernails, and dried substances around the mouth. Another resident with severe cognitive impairment and a history of stroke was observed with poor oral hygiene, including dried saliva and food buildup, and was not consistently provided with necessary assistance. A third resident, also with hemiplegia, reported waiting over an hour for help, experiencing catheter leaks, and not receiving regular denture care or showers. These residents did not have a documented history of refusing care, indicating the deficiencies were due to staffing issues rather than resident choice. Additional evidence of the deficiency included observations of residents waiting extended periods for meals and drinks in the dining room, family members stepping in to provide basic care, and repeated concerns raised in Resident Council meetings about inadequate staffing and incomplete care. Facility records confirmed numerous open CNA and nursing positions across all shifts, with reliance on agency staff who frequently failed to report for duty. The facility's own staffing policy emphasized the need for appropriate staffing at all times, yet the documented events and staff interviews demonstrated a consistent failure to meet this standard, directly impacting resident care and dignity.
Failure to Provide Timely and Adequate ADL Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with a history of stroke and hemiplegia, reported significant delays in receiving help to get out of bed, having their catheter emptied, and assistance with personal hygiene such as denture care and nail trimming. Observations confirmed that this resident's fingernails were visibly soiled, and the resident stated it had been several days since proper oral care was provided. The resident also described witnessing other residents left unattended, uncleaned after meals, and not receiving scheduled showers, especially during periods of staff shortages and high reliance on agency staff. Another resident, also with a history of stroke and moderate cognitive impairment, was observed with poor hygiene, including soiled hands, chipped and dirty fingernails, unbrushed hair, and food particles on clothing. This resident was found by staff crying out for help after being left wet and cold in urine-soaked bedding and clothing, which had not been changed for an extended period. Staff interviews corroborated that the resident required assistance with all ADLs and that these needs were not consistently met due to staffing shortages. Staff also reported that many residents on the unit required two-person assistance, and that showers, nail care, and grooming were often missed or delayed. Multiple staff members, including CNAs, RNs, and a physical therapist, confirmed ongoing issues with inadequate staffing, particularly with agency staff not showing up or canceling shifts at the last minute. These staffing issues directly impacted the ability to provide timely and adequate ADL care, resulting in residents being left soiled, unkempt, and without proper hygiene. Facility policy required that residents unable to perform ADLs independently receive necessary assistance, but observations and interviews demonstrated that this standard was not consistently met for the residents involved.
Confidentiality Breach in Resident Records
Penalty
Summary
The facility failed to ensure the accuracy and confidentiality of resident records, resulting in the release of incorrect resident information accompanying a deceased resident's remains to the funeral home. Specifically, the body of Resident #6 was transferred to the funeral home with documentation that incorrectly identified the deceased as Resident #9. This included the face sheet with full name, date of birth, and medical history of Resident #9. The error was identified by the funeral home representative, who contacted the facility to clarify the discrepancies in the records provided. Interviews conducted revealed that the mistake occurred due to a failure to verify the identity of the deceased and cross-check documentation before releasing the body. The primary nurse was responsible for printing the information to accompany the resident to the funeral home, but it was noted that two staff members were involved in printing the paperwork. However, there was no verification of who double-checked the paperwork, leading to the error. The incident occurred in the middle of the night, which was suggested as a possible contributing factor to the mistake.
Inadequate Wound Assessment for Resident
Penalty
Summary
The facility failed to ensure appropriate and consistent assessment of a penile tear for a resident, resulting in the potential for unidentified worsening of the wound and delay in treatment. The resident, who had diagnoses including obstructive uropathy, benign prostatic hyperplasia, and dementia, was admitted to the facility and required substantial assistance for toileting hygiene and was dependent for showering and bathing. The resident was prescribed topical lidocaine for pain related to a slit on the head of his penis caused by chronic use of an indwelling urinary catheter. However, there was no documentation of routine wound evaluations, which are necessary to track healing progression or identify worsening conditions. During an interview, an LPN was unsure about the frequency of wound assessments, and the Director of Nursing was unable to find documentation of wound evaluations for the resident's penile tear. Observations revealed the resident had a penile tear through the dorsal aspect of the glans, and he reported pain at the wound site during the application of lidocaine cream. The facility's policy required weekly evaluations of skin alterations, but the electronic medical record did not contain any weekly evaluations of the resident's penile wound, including measurements, wound description, or signs and symptoms of infection.
Failure to Conduct Consistent Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to conduct consistent skin and risk assessments for a resident at risk for pressure injuries, leading to the potential for unidentified wounds and delayed treatment. The resident, who had Parkinson's Disease and severe cognitive impairment, required substantial assistance for movement and was dependent on staff for transfers. Despite being at high risk for pressure injuries, as indicated by the Minimum Data Set (MDS) assessment, the facility did not perform regular skin assessments as per their policy. The resident developed a new, in-house acquired Stage 3 sacral pressure injury, which was identified on 12/26/2024. The facility's policy required weekly skin assessments using the Braden Scale for the first four weeks after admission and then quarterly. However, there were no documented assessments from 12/09/2024 to 12/26/2024, and the Director of Nursing confirmed that a skin evaluation was signed off but not documented in the electronic medical record. This lack of documentation and assessment increased the risk of unidentified skin issues and miscommunication regarding the resident's needs. The facility's failure to adhere to its policy and professional standards of practice resulted in a deficiency citation.
Deficiency in Catheter Care and Management
Penalty
Summary
The facility failed to ensure proper care for residents with urinary catheters, as evidenced by observations and interviews. Resident #4 was found with a urinary catheter collection bag touching the floor without a barrier, and no securement device was in place to prevent catheter dislodgement or urethral trauma. Despite the care plan indicating the need for a securement device, none was observed, and the collection bag was improperly positioned, risking infection. Resident #2, who has obstructive uropathy, benign prostatic hyperplasia, and dementia, was observed with a urinary drainage leg bag that was completely full, causing urine to back up into the catheter tubing. The facility's policy requires drainage bags to be emptied when half to three-fourths full, but this was not adhered to, leading to potential discomfort and infection risk. The LPN acknowledged the need for more frequent emptying due to the resident's tendency to remove the catheter anchor device. The facility's policies on catheter care and securement were not followed, as evidenced by the observations of the residents' catheter management. The Director of Nursing confirmed the expectation for securement devices and proper bag placement, which were not met in these cases, highlighting a failure in adhering to professional standards of practice for catheter care.
Failure to Process Physician Orders Leads to Resident Hospitalization
Penalty
Summary
The facility failed to timely obtain and process physician orders for respiratory assessment, treatment, and radiology diagnostics for a resident, leading to severe respiratory distress and fluid volume overload. The resident, who had a history of heart failure, renal insufficiency, and recent cardiac surgery, was admitted without receiving a diuretic and had intact cognition. Despite the resident's complaints of worsening cough and fluid retention, a chest x-ray ordered by the nurse practitioner was not performed, and the resident's condition deteriorated over the weekend. The resident's progress notes indicated respiratory distress and a request for daily weight monitoring due to congestive heart failure, but these were not consistently documented or acted upon. The facility's failure to document and execute physician orders for a chest x-ray and daily weights contributed to the resident's decline. The resident experienced significant respiratory distress, with oxygen saturation dropping to critical levels, leading to hospitalization for respiratory distress, fluid volume overload, and COVID. Interviews with staff revealed miscommunication and a lack of follow-through on physician orders. The nurse practitioner and other staff failed to ensure the chest x-ray order was entered into the electronic medication administration record, leaving nursing and scheduling staff unaware of the need for the diagnostic test. Additionally, routine lung sound assessments were not conducted, and the resident's care plans were not updated to reflect necessary interventions until the day of the resident's transfer to the hospital.
Failure to Use Appropriate Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure the appropriate use of a mechanical lift for a resident, resulting in a fall and subsequent knee pain. The resident, who was cognitively intact and dependent on staff for all transfers, was supposed to be transferred using a total mechanical lift as per her care plan. However, during an attempted transfer using a sit-to-stand mechanical lift, the resident's feet fell off the lift platform, causing her to fall on her knees. This incident occurred despite the resident's care plan clearly indicating the need for a total mechanical lift with two-person assistance. The incident was attributed to a miscommunication regarding the resident's transfer status. CNA staff believed the resident's transfer method had been changed by the therapy department, although the care plan had not been updated to reflect such a change. The Therapy Director confirmed that the resident had never been approved for the sit-to-stand lift due to her inability to bear weight. Despite the education provided to the CNAs following the fall, no audits were conducted to ensure compliance with care plans or to identify other residents who might have been affected.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with multiple medical conditions, including anal cancer, an open peri-anal surgical wound, colostomy, nephrostomy, and a suprapubic catheter. The resident was dependent on staff for personal hygiene and management of these medical devices. During an observation, a Certified Nursing Assistant (CNA) was seen providing care to the resident without wearing a protective gown, despite the resident's care plan and physician orders requiring EBP, including gown and glove use, for high-contact activities. The CNA was unaware of the EBP requirement, as there was no signage or personal protective equipment cart outside the resident's room to indicate the need for such precautions. The facility's policy on EBP, which aims to reduce the transmission of multidrug-resistant organisms, was not followed. This oversight resulted in the potential for the spread of infections, as the CNA did not adhere to the prescribed infection control measures during the resident's care.
Failure to Provide Meal and Assistance to Resident
Penalty
Summary
The facility failed to provide a meal and necessary assistance to a resident, identified as R13, who required help with eating. On the morning of September 25, 2024, R13 was heard calling out for breakfast, stating that staff refused to bring him his meal. The Speech Language Pathologist present at the time acknowledged the situation and intended to address it. R13, who had multiple diagnoses including diabetes and heart failure, was on a care plan that required extensive assistance with meals. Despite this, he did not receive breakfast because he was not in the dining room when meals were distributed, and staff did not bring him his tray. Further investigation revealed that the facility lacked a consistent system for ensuring all residents received their meals and for documenting reasons when meals were not consumed. Dietary staff reported that trays often returned untouched, sometimes without any notation of refusal. R13 was specifically noted to frequently have uneaten trays returned to the kitchen. The Dietary Manager occasionally informed nursing staff of uneaten trays, but there was no standard procedure to ensure all meals were offered and reasons for uneaten meals were recorded.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident with Parkinson's Disease, resulting in missed doses of a critical medication. The resident, who had been admitted with a primary diagnosis of Parkinson's Disease with dyskinesia, reported not receiving his Parkinson's medications upon admission and experienced delays in receiving them on subsequent days. Specifically, the resident did not receive the prescribed Amantadine HCl oral capsule 100 MG at the scheduled time on multiple occasions, including a significant delay on the morning of 9/25/24. The medical record review revealed that the first dose of Amantadine was not administered until 8:28 PM on the day of admission, despite being ordered for 7:00 AM. Additionally, there was no documentation of notification to the physician or pharmacist regarding the unavailability of the medication, which was an expectation according to the Registered Nurse Consultant. The facility's pharmacy policy indicated that medications needed before the next scheduled delivery should be ordered and requested STAT if not available in the emergency supply, which was not adhered to in this case.
Failure to Address Grievances and Inform Resident Representative
Penalty
Summary
The facility failed to inform a resident's representative of the grievance policy and procedure and did not promptly address all grievances submitted by the representative. This deficiency was identified during an abbreviated survey conducted in response to complaints about the facility's failure to provide staff assistance with personal hygiene and incontinence care for a resident. The resident, who had severe cognitive impairment and multiple medical conditions, was admitted with a care plan specifying the need for incontinence briefs in a specific location. Despite numerous emails from the resident's representative regarding care concerns, many were not documented in the facility's grievance log, leading to delays or omissions in grievance responses. The facility's grievance policy requires that all concerns be documented and addressed promptly, with the Administrator serving as the Grievance Officer responsible for overseeing the process. However, during the survey, it was revealed that the facility did not have grievance forms for all concerns identified in the emails from the resident's representative. The facility's policy mandates that written complaints be transcribed onto a concern form for follow-up, but this was not consistently done, resulting in a lack of evidence that all grievances were reviewed and resolved.
Failure to Maintain Resident's ADL Abilities
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain a resident's ability to perform activities of daily living (ADLs), resulting in inadequate grooming, dressing, personal hygiene, and toileting for the resident. The resident, who has severe cognitive impairment and a history of traumatic brain injury, was not provided with the necessary assistance and resources as outlined in their care plan. This included maintaining an adequate stock of incontinence briefs in a specified location, which was not adhered to, leading to the resident being found without briefs and in soiled clothing on multiple occasions. The resident's care plan, developed in collaboration with their representative, included specific interventions such as maintaining a preferred routine, ensuring the availability of briefs, and providing assistance with personal hygiene and toileting. Despite these interventions, the facility staff failed to consistently implement them, as evidenced by multiple complaints from the resident's representative. These complaints highlighted issues such as the resident wearing soiled clothes, not being shaved, and having a strong odor due to inadequate personal hygiene care. Interviews with facility staff confirmed the deficiencies in care. A CNA acknowledged that the resident was made to walk down a hallway with visible feces stains on their pants, which was inappropriate. The Nursing Home Administrator also acknowledged the ongoing concerns related to the provision of ADL treatment and services. The facility's failure to adhere to the care plan and provide necessary assistance resulted in the resident's inability to maintain personal hygiene and dignity.
Failure to Implement Comprehensive Wound Care Program
Penalty
Summary
The facility failed to implement a comprehensive wound care program, resulting in the development and worsening of multiple pressure injuries among residents. Resident R4 developed two facility-acquired unstageable/Stage 3 pressure injuries. Resident R19 developed a right heel wound infection requiring surgical debridement and IV antibiotics, and a new left heel deep tissue injury without proper interventions to prevent worsening. Resident R38's pressure injury deteriorated from Moisture Associated Skin Damage (MASD) to a Stage 4 pressure injury, requiring antibiotics for a subsequent wound infection. Resident R48 experienced worsening of a Stage IV sacral injury and was observed receiving inadequate wound care to prevent infection. Observations revealed that R19 was often found with his heels resting directly on the mattress or a flattened pillow, contrary to physician orders for heel protection boots and offloading heels. Despite orders for heel protection boots on both feet, R19 was frequently observed without the necessary protection on his left foot. Additionally, R19's wound care was inadequately performed, with improper wound dressing techniques and lack of adherence to Enhanced Barrier Precautions (EBP). R19's medical records showed inconsistencies in documenting care, including turning and repositioning, offloading heels, and pain management prior to appointments. The facility's documentation and care planning were found to be insufficient in addressing the residents' needs. R19's care plan lacked specific interventions recommended by the wound care physician, and there were no documented orders for offloading pressure from R19's heels prior to his hospitalization. The facility also failed to obtain and document wound clinic visit notes, which are crucial for ensuring continuity of care. These deficiencies highlight significant lapses in the facility's wound care management and documentation practices, leading to the deterioration of residents' conditions.
Inadequate Nursing Staff and Extended Call Light Wait Times
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, resulting in extended call light wait times and insufficient care. Multiple complaints were reported to the State Agency, indicating that residents were not receiving timely assistance with activities of daily living (ADLs) such as bathing, toileting, and oral care. Specific instances included a resident whose soiled linens were not changed promptly, causing embarrassment, and another resident who waited over 25 minutes for assistance after activating the call light. Additionally, a resident's representative reported excessive wait times for repositioning, toileting, and grooming, with call light logs showing multiple instances of wait times exceeding 15 minutes, and in some cases, over an hour. These issues were particularly prevalent between 5:00 PM and 7:00 AM, as confirmed by resident council members who noted a lack of staff after 2:00 PM daily. Interviews with residents and their representatives highlighted the emotional impact of these delays, with one resident feeling uncared for and like a nuisance to the staff. Attempts to interview CNAs and nursing staff about staffing issues were unsuccessful due to their fear of job loss. The facility's policy on call light response requires staff to answer call lights within 15 minutes, but this standard was not consistently met. The Nursing Home Administrator acknowledged instances where staff forgot to turn off call lights or left them on if they could not immediately resolve the requests, further contributing to the extended wait times.
Insufficient and Improperly Trained Dietary Staff
Penalty
Summary
The facility failed to ensure the dietary department was staffed with sufficient and properly trained personnel to carry out the functions and duties of the nutritional services department. During an interview, it was revealed that the Kitchen Manager (KM) had not completed the Certified Dietary Manager's (CDM) course and lacked credentials in food service sanitation, such as ServeSafe or Certified Food Service Manager (CFM). The KM had only completed about half of the CDM coursework. Additionally, the Registered Dietitian (RD) stated that his responsibilities were limited to clinical assessments and interventions, with no involvement in kitchen functions. The facility also had a corporate registered dietitian who consulted via phone but had not visited the facility to assist in training the KM for kitchen sanitation, menu, and recipe adherence, or other kitchen duties. The FDA Food Code 2017 requires that the person in charge demonstrate knowledge of foodborne disease prevention, application of Hazard Analysis and Critical Control Point (HACCP) principles, and the requirements of the code. This can be demonstrated by having no violations of priority items during the current inspection, being a certified food protection manager, or correctly responding to inspector's questions. The facility's failure to comply with these requirements has the potential to result in inadequate nutrition for all 73 residents.
Failure to Ensure Nutritional Adequacy and RD Approval of Menus
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of the residents, were followed and prepared according to the recipes, and were reviewed and approved by a Registered Dietitian (RD). On 5/20/24, it was observed that the facility's menus lacked evidence of RD review and approval. The Kitchen Manager (KM) confirmed that the menus were not formally approved by the corporate RD, and changes made to the menus were not approved by the RD. Additionally, the noon meal served on 5/20/24 did not meet the recipe requirements for protein content, as the Mostaccioli dish was prepared with only half the required amount of cottage cheese, resulting in insufficient protein for the residents. The cook responsible for preparing the dish admitted to not following the recipe accurately and not measuring the ingredients properly. Resident #22, who had a healing below-the-knee amputation and required adequate protein for healing, expressed concerns about the lack of protein in the meals. The resident showed the surveyor protein supplements she had ordered due to the facility's inadequate protein servings. The resident's medical records confirmed her need for a protein-rich diet due to her medical conditions, including amputation, anemia, and diabetes. The resident's lunch tray on 5/20/24 contained Mostaccioli with minimal visible cottage cheese, further supporting her claim of insufficient protein in the meals. Interviews with dietary staff revealed that the recipe for Mostaccioli was not followed correctly, and there was no proper documentation of the amount of food prepared and served. The Dietary Manager confirmed that the production cook did not always follow the recipes. The local Consulting RD also acknowledged the issue of inadequate protein in the facility meals, as raised by Resident #22. The facility's failure to ensure proper menu planning, recipe adherence, and RD approval resulted in potential nutritional deficiencies for all 73 residents.
Failure to Follow Menu Recipes and Maintain Nutritional Standards
Penalty
Summary
The facility failed to follow menu recipes to ensure the nutritional value of the food served to residents. During an observation of the noon meal, it was noted that the Mostaccioli being served did not contain the required amount of cottage cheese as per the recipe. The cook admitted to using only two and a half pounds of cottage cheese instead of the required five pounds for 50 servings. This discrepancy was confirmed through an interview with the kitchen manager, who also revealed that the facility did not maintain any records related to the amount of food used for meals, making it impossible to verify if recipes were being followed correctly. The facility's Menu Policy, which was reviewed, indicated that corporate menus are planned by a Corporate Registered Dietitian and can be altered with the approval of the facility or corporate RD. However, the facility failed to adhere to these guidelines, as evidenced by the lack of proper documentation and adherence to the recipe. This deficiency has the potential to result in nutritional deficiencies for all 73 residents of the facility.
Failure to Provide Physician-Prescribed Diets
Penalty
Summary
The facility failed to ensure that residents received diets as prescribed by a physician, specifically for one resident reviewed for therapeutic diets. Resident #25, who had a physician's order for a cardiac diet with regular texture and thin consistency, was observed receiving a meal that did not comply with the prescribed diet. The lunch tray included ham, cheesy potatoes, and caramel bread pudding, which are not appropriate for a cardiac diet. The facility's dietary software only supported a 2-gram sodium diet, which was not equivalent to the prescribed cardiac diet. The Dietary Manager was unaware of the differences between the diets and admitted that the facility did not have a diet manual to guide dietary choices. Additionally, there was no evidence that the menus had been reviewed by a Registered Dietitian (RD). Interviews with the Corporate Dietitian and the local Consulting Dietitian revealed that the facility's corporate software and lack of a diet manual contributed to the issue. The Corporate Dietitian admitted that the facility used a 2-gram sodium diet across the board to simplify procurement, despite the physician's specific order for a cardiac diet. The local Consulting Dietitian was unaware of this substitution and acknowledged the discrepancy. The facility's policy required that diet orders be entered electronically and menus be assigned accordingly, but the lack of a proper diet manual and RD review led to the deficient practice.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, Cook B was found to be preparing hot food, including a pan of Mostaccioli, which was measured to have temperatures significantly below the required 135°F. Despite Cook B's claim that the food was at 178°F, subsequent measurements showed temperatures between 120°F and 128°F. This discrepancy indicates improper temperature monitoring and potential risk for foodborne illness among the residents. Additionally, the facility's dishwashing practices were found to be inadequate. The mechanical high-temperature dish machine was not functioning correctly, with the sanitizing cycle failing to reach the required 160°F. Staff were observed pulling trays out of the machine before the cycle was complete, further compromising the sanitization process. Following a fire that rendered the dish machine inoperable, the facility resorted to using a three-compartment sink for dishwashing. However, the sanitizing solution was improperly tested, and the sink area lacked adequate space for soiled dish storage and drying, leading to unsanitary conditions. Further observations revealed that food service items were stored directly below unshielded cast iron sewer lines, posing a contamination risk. The Maintenance Manager was unaware of this storage issue. The facility's Kitchen Manager also admitted to a lack of training regarding the proper use and testing of sanitizing chemicals. These deficiencies highlight significant lapses in food safety and sanitation practices, potentially endangering the health of all 73 residents.
Deficiency in Pressure Ulcer Management and Leadership Support
Penalty
Summary
The facility failed to identify, assess, treat, and implement interventions to prevent and manage pressure ulcers effectively. The Nursing Home Administrator (NHA) could not provide evidence that the Quality Assurance and Performance Improvement (QAPI) committee had addressed skin and wound issues. The Director of Nursing (DON) presented a binder with incomplete documentation, lacking data analysis, action items, and tracking of pressure ulcers. The facility's policy on Quality Assessment and Process Improvement was outdated and not followed, as weekly meetings to discuss pressure ulcers were not held consistently, and there was no evidence of systematic identification, investigation, or analysis of pressure ulcer data. Additionally, the facility failed to provide adequate leadership resources to support nursing staff during increased staffing needs. The DON was reported to be under the influence of alcohol and unavailable for emergencies after hours. On one occasion, the DON was unable to come to the facility due to being four hours away, and the NHA was also unavailable until the next day. The facility did not have an on-call policy for supervision and nursing staff, and staff reported concerns about administration's lack of response to their requests for assistance and fear of retaliation. The facility's failure to administer its policies, practices, and procedures effectively and efficiently impacted the achievement and maintenance of the highest practicable physical, mental, and psychosocial well-being of each resident. The lack of proper documentation, data analysis, and leadership support contributed to the deficiency in managing pressure ulcers and addressing staffing needs during emergencies.
Failure to Conduct and Document Annual Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document an annual facility-wide assessment, resulting in the potential for inadequate knowledge of the facility population's needs and resources to care for the 73 residents. The Nursing Home Administrator (NHA) provided a Facility Assessment that was outdated and reflected the previous ownership. The NHA stated that the assessment had been reviewed and signed on 10/16/23, but it did not reflect the current resident population. The Minimum Data Set (MDS) Resident Population Profile was dated 10/28/21-10/27/22, and the Patient Population was dated 10/2022, which did not reflect the current resident population. The NHA and Regional Clinical Resource nurse mentioned they were waiting for updated guidelines from the Centers for Medicare and Medicaid Services (CMS) before updating the Facility Assessment.
Failure to Maintain Effective QAPI Program for Pressure Ulcers
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance & Performance Improvement (QAPI) program to address and correct identified quality deficiencies. During an interview, the Nursing Home Administrator (NHA) stated that the QAPI committee met monthly to discuss departmental projects and systems improvements. However, there was no evidence that the committee had addressed skin and wound issues, specifically the prevention and treatment of pressure ulcers. The NHA could not provide documentation demonstrating performance improvement activities in this area, and the QAPI committee minutes lacked analysis of data tracking and trending or system improvements related to pressure ulcers. The survey team identified an immediate jeopardy situation due to the facility's failure to identify, assess, treat, and implement interventions to prevent and heal pressure ulcers. The Director of Nursing (DON) presented a binder on pressure injuries, which included an undated education sign-in sheet and a policy but lacked data analysis or action items. The DON could not provide data on the tracking or trending of pressure ulcers for several months, nor could they confirm how many pressure ulcers were currently present. There was no evidence that this topic had been reported to the QAPI committee or was part of the QAPI program. The facility's policy on Quality Assessment and Process Improvement indicated that pressure injuries should be discussed weekly, but the DON confirmed that weekly meetings had ceased. The policy also stated that all identified problems, especially high-risk areas like pressure ulcers, should be addressed through systematic identification, investigation, and analysis. However, the facility failed to adhere to these guidelines, resulting in a system failure in the skin and wound program, which had the potential to affect all 73 residents in the facility.
QAPI Committee Composition and Attendance Deficiency
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required members and met the necessary attendance criteria. During an interview, the Nursing Home Administrator (NHA) stated that the QAPI committee met monthly and included each department head. However, a review of the Quality Assurance and Performance Improvement Committee Meeting Attendance Record sign-in sheets revealed several deficiencies. On multiple occasions, the Medical Director was absent, and other department heads were not present to report on issues in their areas. Additionally, there were no sign-in sheets for several quarters, and the meetings did not include direct care staff as required by the facility's policy. The facility's policy on Quality Assessment and Process Improvement, dated 10/15/2018, mandates that quarterly QAPI meetings be documented with sign-in sheets and minutes, and that direct care staff be present to provide feedback and insight. The policy also specifies that the QAPI committee should be interdisciplinary and include the Director of Nursing, a physician, at least three other staff members, and the Infection Prevention and Control Officer. The facility's failure to adhere to these requirements resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 73 residents at risk for quality care concerns.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, leading to multiple deficiencies. On 5/19/24, water was observed on the floor under the three-compartment sink and refrigerator, attributed to an overflowing drain that could not handle the flow from the sinks. Cook C and Kitchen Manager A confirmed this issue had been ongoing. Maintenance Manager E also acknowledged the long-standing problem with the kitchen drain. Additionally, on 5/19/24, a smoke odor was detected near the nurses' desk, traced back to an overheated mechanical dish machine in the kitchen. The machine had been malfunctioning since its installation in February, requiring frequent servicing. A sensor from the soap dispenser was found burnt and disconnected, contributing to the overheating event. Despite assurances from the vendor, the machine remained unrepaired by 5/21/24, leaving the facility without a working dish machine. These deficiencies highlight the facility's failure to ensure proper maintenance of essential kitchen equipment, posing potential risks to staff and residents. The ongoing issues with the kitchen drain and the malfunctioning dish machine were confirmed through multiple interviews with kitchen and maintenance staff. The lack of timely and effective repairs exacerbated the situation, leading to unsafe conditions in the kitchen area.
Failure to Follow Grievance Process
Penalty
Summary
The facility failed to follow through with the grievance process initiated by resident representatives and the resident council. Resident representatives voiced concerns that their grievances were not addressed, and they had not been notified of any action taken. A specific grievance filed by a resident's representatives on 2/7/24 was marked as resolved, but follow-up interviews revealed that no follow-up had been conducted. Additionally, the resident council had repeatedly raised concerns about the lack of evening snacks in their meetings from January to April 2024, but these grievances were not addressed either. The activities director confirmed that the grievances were filed, but the residents still did not receive their evening snacks regularly. Confidential staff also reported that some grievance forms were found in the trash in the Nursing Home Administrator's office without any follow-up being completed, raising concerns about the adherence to the grievance process. The facility's policy on Investigations of Grievances, dated 10/1/22, states that concerns should be forwarded to the relevant department for resolution and that the Director of Nursing is responsible for ensuring proper investigation and follow-up. The Administrator, as the designated grievance official, is responsible for reviewing each written grievance for proper investigation, follow-up, and resolution. However, the facility failed to adhere to this policy, resulting in unresolved grievances and a lack of communication with the complainants. This deficiency affected the residents' ability to have their concerns addressed and resolved, particularly regarding the provision of evening snacks.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to four out of seven staff members reviewed. The computerized software education for QAPI was not found for Staff N, P, R, and Q. Interviews with various staff members, including housekeeping staff, CNAs, and an RN, revealed a lack of awareness and understanding of the facility's quality improvement projects and goals. Staff members reported receiving papers to read and sign without any formal classes or retaining copies, and they were generally unaware of the specific quality projects and goals the facility was working on. The facility's policy on Quality Assessment and Process Improvement, dated 10/15/2018, was found to be outdated and lacked recent review dates and necessary approvals. The policy suggested various communication methods to keep staff informed, such as communication boards, staff meetings, newsletters, and drop boxes for improvement ideas. However, these methods were not effectively implemented, as evidenced by the staff's lack of knowledge about the facility's quality improvement initiatives. The NHA acknowledged the deficiency, confirming that the computerized software education logs indicated incomplete training for the identified staff members.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure the appropriate care of indwelling urinary catheter equipment for one resident, resulting in the potential for contamination and urinary tract infection. The resident, who was admitted with diagnoses including diabetes and urethritis, was observed with catheter tubing resting directly on the floor. Additionally, during preparation for an outside appointment, a CNA placed a plastic cylinder on the floor beneath the drainage bag and emptied the urine without disinfecting the spout, citing a lack of access to alcohol swabs. The drainage bag subsequently fell to the floor and was picked up by another CNA, who placed it back in the cover and hooked it to the bed frame without disinfecting it. Both CNAs acknowledged that catheter drainage bags and tubing should not touch the floor to reduce infection risk. The Nurse Manager confirmed that the facility's standards of practice require catheter drainage bags and tubing to be positioned so that no portion touches the floor and that the drainage spout should be disinfected after emptying urine. The facility's policy on catheter care and the CDC guidelines for preventing catheter-associated urinary tract infections both emphasize the importance of keeping catheter equipment off the floor and disinfecting the drainage spout to prevent bacterial contamination. The observations and interviews revealed a failure to adhere to these standards, posing a risk of infection to the resident.
Failure to Assess Respiratory Status for Resident Receiving As-Needed Respiratory Medications
Penalty
Summary
The facility failed to assess the respiratory status of a resident (R168) who was receiving as-needed respiratory medications and supplemental oxygen, according to professional standards of practice. R168, who had diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed using a nasal cannula connected to a portable oxygen concentrator and had a nebulizer on the nightstand. Despite the resident's continuous use of supplemental oxygen and as-needed use of the nebulizer, there were no documented respiratory assessments or oxygen saturation levels recorded after the initial assessment on the date of admission. The review of R168's Medication Administration Record (MAR) and Electronic Medical Record (EMR) revealed multiple instances of administered respiratory medications without corresponding respiratory assessments. Interviews with Registered Nurses (RN) K and J confirmed that respiratory assessments are a standard practice when administering as-needed respiratory medications, but no such assessments were documented. Additionally, R168's care plan lacked focus areas, measurable goals, or interventions related to COPD and the use of continuous oxygen or as-needed respiratory medications. The facility's policies on baseline care plans and oxygen administration did not include procedures for respiratory assessments after the administration of supplemental oxygen.
Failure to Properly Administer and Document Insulin Dose
Penalty
Summary
The facility failed to ensure the proper administration and documentation of an insulin dose for a resident. During an observation, a Registered Nurse (RN) was seen preparing to administer 36 units of Lantus Solostar insulin to a resident. The RN did not have a secure grip on the insulin pen, resulting in only 26 units being administered initially. The RN then attempted to administer the remaining 10 units but only managed to deliver 5 units. Despite these errors, the RN documented in the Medication Administration Record (MAR) that the full 36 units were administered. The Director of Nursing (DON) was unaware of the incident and confirmed that the attending physician should have been notified and the correct dosage documented. A review of the resident's Electronic Medical Record (EMR) revealed no documentation or physician notification regarding the incorrect insulin dose. The DON stated that the facility's procedure is to alert the attending physician when medication errors occur and to assess the resident for any ill effects. The failure to document the correct dosage and notify the physician could lead to potential issues with the resident's glucose levels and future insulin dosage adjustments.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less, resulting in a medication error rate of 8.57%. During an observation, a Registered Nurse (RN) prepared and administered medications to a resident, including Keppra, Toujeo Max Solostar, and Humalog. The RN administered only 500 mg of Keppra instead of the prescribed 1000 mg. Additionally, the RN did not hold the insulin needles in place for the required five seconds, withdrawing them after only three seconds. This was confirmed by the RN's own admission and the facility's policy, which aligns with the manufacturer's guidelines for insulin administration. Further interviews revealed that the Nurse Manager was unaware of the correct duration for holding insulin needles in place and had to contact the pharmacy for the manufacturer's instructions. The facility's policies on medication and insulin administration were reviewed and found to require adherence to the manufacturer's guidelines, which were not followed in this instance. This led to the observed medication errors and the resulting citation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kingsford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Freeman Nursing & Rehabilitation Community | 0.6 mi | ★★★★★ | 5 | 0 |
| Maryhill Manor | 4.2 mi | ★★★★★ | 7 | 0 |
| Florence Health Services | 11.5 mi | ★★★★★ | 28 | 0 |
| Iron County Medical Care Facility | 24.2 mi | ★★★★★ | 0 | 0 |
| Pinecrest Medical Care Facility | 28.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.