Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation At Leonard during CMS and state inspections, most recent first.
Menus were not consistently followed during meal service, resulting in several residents receiving incorrect foods or portions. A resident on a diabetic consistent carb diet was served a full banana instead of 1/2 banana, and two residents with NAS or regular diets each received only 1 sausage link instead of 2. Two residents on mechanical soft diets were served carrots without peas despite the meal ticket indicating peas and carrots, and residents in council reported menu inaccuracies were common, especially at dinner and on weekends.
Meal preferences and diet orders were not consistently followed for several cognitively intact residents. A resident with a dairy intolerance was served butter containing milk instead of the ordered substitute and was also missing other requested items, while other residents were missing ordered beverages, fruit, cereal, or condiments. In resident council, all attendees reported concerns that dietary staff were not following meal tickets, and several said the issue had worsened.
Kitchen sanitation and cooling practices were deficient when surveyors found a can opener blade covered in dried debris, debris under the juice machine spouts, a scoop with dried food residue, and staining and debris inside the milk cooler. The DM also stated leftover soup from lunch might be saved for a couple of days; surveyors later found the soup in a reach-in cooler with the lid ajar and a center temperature of 115F, while the DM was unsure when cooling began and did not know the required cooling time-temperature limits.
PPE and equipment cleaning failures were observed with multiple residents. An LPN provided care to a resident on enhanced barrier precautions without gown or gloves and did not clean the BP cuff after use; staff also performed wound care for a resident with an open pressure ulcer without gowns. During COVID-19 isolation care, a housekeeper and an LPN did not follow posted PPE requirements, handled supplies and shared vitals equipment improperly, and left the monitor unattended before using it on another resident. In addition, an oxygen concentrator and a BiPAP mask were repeatedly observed visibly dirty in residents’ rooms.
A cognitively intact resident with muscle weakness, chronic pain syndrome, and an ADL self-care deficit requiring 2-staff assistance was left calling out for help when the DON and an LPN did not ensure her needs were met or her call light was within reach. The resident reported staff often turned off her call light and said they would return but did not always come back, and she felt some staff did not want to care for her because she was "high maintenance." Resident council interviews and meeting minutes also documented repeated concerns that staff turned off call lights and left before resident needs were addressed.
A cognitively intact resident with muscle weakness and chronic pain syndrome was unable to consistently follow her preferred morning routine of eating breakfast in her room and then getting up in time for morning activities. Staff confirmed she often had to wait until late morning or even lunch time because she required two-person assistance, staffing was limited, and other unit priorities delayed her care, causing her to miss or arrive late to activities.
Rooms and bathrooms were not kept clean and in good repair for several residents. A cognitively intact resident reported distress over damaged walls and exposed metal near her bed and sink, while another resident’s room had repeated gouges and missing paint near the HOB. A third resident also had wall damage beside the bed, and staff acknowledged the issue. Shared bathrooms and spa areas were also observed with urine odor, dried soil, buildup, dirty clothes, wet washcloths, and debris under a shower bed mattress.
A resident with muscle weakness and chronic pain syndrome was transferred to the hospital, but the record did not show written bed hold notice was provided at the time of transfer. The NHA and DON reported that the nurse caring for the resident had not given the required notice.
Failure to provide scheduled bathing and hair care for two residents was identified. One resident with impaired mobility required 2-person ADL assistance and reported missing showers or bed baths; CNAs said low staffing prevented timely care, and the DON confirmed missing bathing documentation. Another resident with depression and seborrheic dermatitis was observed with shiny, soiled hair and reported her hair had not been washed for 2 weeks after a staff helper left, despite a care plan for bathing support and medicated shampoo.
A facility failed to follow resident-specific skin integrity care plans for two residents and failed to prevent a pressure ulcer for one resident. One cognitively intact resident developed foot pressure injuries after her feet repeatedly rested against the foot of the bed while staff noted no set boosting schedule and no room change was considered for a longer bed. Another resident with diabetes, dementia, and partial paralysis had an updated order for Prevalon boots when in bed, but the care plan was not updated and staff observed the boots off and stored away instead of being used as ordered.
Improper Administration of Morphine: An LPN prepared a resident’s ordered morphine and placed it in a cup of juice after reporting the resident refused meds, then left the cup on the meal tray while passing meds to other residents. Staff were aware the morphine was being given in juice or milk, but the LPN did not remain with the resident to directly observe the dose being taken, and the MAR was signed as administered.
A resident with a history of falls, cognitive impairment, and high elopement risk exited the facility unsupervised after exhibiting increased exit-seeking and wandering behaviors. Despite repeated door alarms and staff awareness of the resident's agitation, no increased supervision was implemented, and the resident was able to leave through an alarmed exit, descending multiple stairs to a parking lot without assistance.
The facility failed to maintain food safety standards, with observations of unsanitary conditions in the kitchen, improper food storage, and staff not adhering to hand hygiene protocols. Issues included lack of soap and towels at the hand sink, exposed raw burger patties, and outdated or unlabeled food items. Staff were observed not washing hands after glove changes and consuming personal drinks without proper hygiene measures.
The facility failed to implement Enhanced Barrier Precautions and ensure proper use of PPE during resident care, as observed with several residents requiring such precautions. Staff inconsistently wore gowns and gloves during high-contact activities, such as transfers and personal care, despite clear indications of EBP requirements. Additionally, the facility did not maintain equipment and surfaces to prevent bacterial harborage, with issues like leaking fixtures and non-cleanable shelving contributing to potential contamination risks.
The facility failed to update care plans for two residents using assistive devices, resulting in inaccurate care plans. One resident with chronic pain and foot drop was observed using PRAFO braces without corresponding care plan interventions. Another resident with paralysis and muscle atrophy used a hard AFO, also lacking care plan documentation. Staff interviews revealed a lack of communication and documentation, with therapy recommendations not incorporated into care plans.
The facility failed to assist two residents with personal hygiene and clothing changes. One resident, with cognitive impairment and muscle atrophy, was observed disheveled and wearing the same clothes over consecutive days, while another resident with physical limitations reported not being offered shaving assistance for two weeks. Staff interviews revealed inconsistencies in providing expected care during shower days.
A resident with venous ulcers did not receive consistent wound care as per physician orders, leading to a missed treatment. Despite having a care plan for skin integrity, the facility staff failed to adhere to the treatment schedule, with a nurse documenting a missed treatment due to the resident sleeping. Interviews revealed that staff were expected to complete treatments within their shift or communicate any issues, but this protocol was not followed.
A resident with muscle wasting and atrophy was not provided with necessary splints to prevent worsening contractures due to a lack of communication and documentation in the care plan. Staff were unaware of the resident's need for splints, and one splint was found to be broken, highlighting a failure in implementing care plan interventions.
A resident with a tracheostomy experienced breathing difficulties due to inadequate respiratory care. Despite visible distress and an empty oxygen tank, an LPN failed to provide necessary suctioning or replace the oxygen tank, leaving the resident at risk. The resident's medical history included chronic respiratory failure and pneumonia, and orders for suctioning and oxygen were not followed. The incident was not documented, highlighting a deficiency in the facility's care.
A facility failed to provide or correctly use adaptive feeding equipment for a resident with dysphagia, leading to potential risks. The resident, who required a Provale cup to manage swallowing difficulties, was observed with inappropriate drinking vessels like a Styrofoam cup with a straw. Despite staff education on the necessity of the Provale cup, the deficiency persisted, indicating non-compliance with prescribed adaptive equipment needs.
A resident fell and sustained a serious injury due to improper use of a sit-to-stand mechanical lift by a CNA who did not follow the care plan requiring a two-person assist and proper use of straps. The resident was hospitalized and underwent surgery for a distal left femoral fracture.
Menus Not Followed Consistently During Meal Service
Penalty
Summary
Menus were not consistently followed for multiple residents who were served incorrect foods or incorrect serving sizes compared with their diet orders and the facility’s menu spreadsheets. Resident #26 had a diabetic consistent carbohydrate diet order and, during breakfast service, was served a full banana even though the meal ticket and menu spreadsheet indicated she should have received 1/2 a banana. Resident #50 had an NAS diet order and was served only 1 sausage link at breakfast even though the meal ticket and menu spreadsheet indicated 2 sausage links; she reported it was irritating not knowing if her meals would be delivered with everything she was supposed to get. Resident #55, who had a regular diet order, was also served only 1 sausage link instead of 2 and reported his meals were served with inaccuracies approximately 60 percent of the time. Resident #3 had a diabetic consistent carbohydrate, mechanical soft diet order and was served lunch with diced cooked carrots but no peas, even though the meal ticket indicated peas and carrots. The facility’s menu spreadsheet for that meal had been changed the prior afternoon to peas and carrots instead of guacamole, but the tray line had two pans of carrots and no separate pan of peas. The dietary manager stated the facility only had carrots and did not have any peas to prepare or serve. Resident #63, who was on a mechanical soft diet, was also served lunch with only diced cooked carrots and no peas despite the meal ticket indicating peas and carrots. During a confidential resident council interview, 9 of 11 residents reported the menus were not consistently followed and said dinner meals and weekend meals were the worst for menu inaccuracies. Resident council minutes also identified kitchen running out of menu items as an area for improvement. Facility staff described a tray-line process in which tickets were reviewed while meals were plated, but the registered dietitian confirmed that missed items could occur due to a breakdown in communication between dietary staff. The report also noted that on one lunch service, the facility substituted tater tots for curly fries and tapioca pudding for rice pudding because extra products were available, and puree residents were given tomato soup instead of the menu items because the main entrée had not been prepared for puree texture.
Meal Preferences and Diet Orders Not Consistently Followed
Penalty
Summary
The facility failed to ensure that resident food preferences, allergies, and intolerances were consistently honored for multiple residents reviewed for dining. Resident #26, who was cognitively intact, reported that meal tickets were not followed consistently. During breakfast observation, her tray ticket indicated she should receive 6 ounces of coffee and 8 ounces of sugar-free punch, but neither beverage was served and milk was the only beverage provided with the meal. Resident #1, who was cognitively intact, had a regular diet order with no milk, and his nutrition care plan documented milk as a dislike, lactose intolerance, and no snacks with milk per his request. He reported the facility served dairy-containing items in error about once per meal and said staff were not following his meal ticket. During breakfast observations, his ticket indicated a margarine pat and later a peanut butter packet, but he was served salted butter containing milk instead of margarine and did not receive the peanut butter packet. Resident #24, who was cognitively intact, was observed at breakfast with a meal ticket indicating a banana, but no banana was served. Resident #50, who was cognitively intact and had a NAS diet order with regular texture and thin consistency, was observed at breakfast with a meal ticket indicating cream of wheat, no added salt, and specified creamer and sugar packets. Her tray was served with an added salt packet and without the cream of wheat, and she reported having to request additional creamer and sugar. On another breakfast observation, her ticket indicated frosted flakes and no salt packet, but she was served a different cereal and a salt packet. During a confidential resident council interview, all 11 residents in attendance reported concerns that meal ticket preferences were not being followed, and several said the problem had gotten worse recently.
Kitchen Sanitation and Cooling Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after surveyors observed multiple sanitation issues during a kitchen tour with the Dietary Manager. The can opener on the preparation table had a blade covered in dried red debris, the underside of the juice machine had accumulations of debris where the spouts were mounted, one clean mechanical scoop had dried food debris in the ladle portion, and the inside of the milk cooler showed increased accumulation of white and yellow staining and debris on the bottom and sides. The Dietary Manager acknowledged the debris on the juice machine and stated it should be cleaned daily. During the same survey, the Dietary Manager stated that some items from lunch service might be saved if there was enough and indicated that the soup would probably be kept for another couple of days. Later, surveyors found a 12-quart container of Lemon Chicken and [NAME] soup from lunch in the two-door reach-in cooler with the lid ajar for venting, and the soup temperature was 115F in the center of the container. The Dietary Manager stated the soup had been saved after lunch but was unsure when cooling started and was unsure of the time-temperature frequency for proper cooling, stating only that it needed to get down to 41F. The report cited the 2022 FDA Food Code requirements for clean food-contact surfaces and for cooling cooked TCS food within the required time and temperature limits.
PPE, Shared Equipment, and Respiratory Device Cleaning Failures
Penalty
Summary
The facility failed to ensure proper use of PPE for enhanced barrier precautions and transmission-based precautions, failed to clean shared resident equipment, and failed to clean respiratory equipment for multiple residents. These failures were observed during resident care, room cleaning, and equipment use, and involved staff entering rooms, handling wound care, using shared monitoring equipment, and leaving respiratory devices visibly soiled in resident rooms. Resident #39 had an indwelling medical device and a care plan that directed staff to wear a gown and gloves during high-contact resident activities. During an observation, an LPN assisted the resident with repositioning and took a blood pressure reading without wearing a gown or gloves. After leaving the room, the LPN placed the blood pressure cuff on the medication cart without cleaning it. Resident #5 had a stage 3 pressure ulcer to the right shoulder, but the care plan did not include enhanced barrier precautions. During wound care, the UM and wound care NP removed the dressing, cleaned the wound, measured it, and took photos, but neither staff member wore gowns during the treatment. The UM stated the facility had not initiated enhanced barrier precautions because the wound drainage was not the type that would require precautions, and confirmed the resident had an open wound. Resident #17 was on airborne and contact precautions for active COVID-19 infection, with signage on the door directing staff to wear an N95 or higher-level respirator, gown, gloves, and eye protection. During observations, a housekeeper entered the room without goggles, left and re-entered the room multiple times while wearing the same PPE, kept the room door open, and handled supplies from a hallway cart with unwashed hands before putting on new gloves. An LPN later entered the room with a portable vitals monitor without goggles or a face shield, then left the monitor unattended in the hallway and later used the same shared monitor on another resident before parking it near the medication cart again. Staff interviews confirmed that PPE should have been worn and that shared equipment should have been disinfected after use. Resident #30 had an oxygen concentrator in the room that was visibly covered with dried splatters, dirt, dust, debris, and material resembling food crumbs on repeated observations. The respiratory therapist stated the concentrator was dirty, had sent a picture to the equipment company, and did not clean it or notify facility staff. Resident #50 had BiPAP orders and used the device nightly, but the BiPAP face mask remained visibly soiled with white debris and red flakes over several days while stored in the room. The resident reported staff helped with the mask, and the RT confirmed that visibly soiled BiPAP or CPAP masks should be cleaned before the scheduled weekly cleaning.
Failure to Respond to Call Lights and Meet Resident Needs
Penalty
Summary
The facility failed to provide care and services that promoted dignity and respect for Resident #39, a cognitively intact resident with muscle weakness, chronic pain syndrome, and an ADL self-care deficit related to impaired mobility who required assistance from two staff members for ADLs. During observation, the resident was calling out for help from bed, and the DON entered the room, told the resident someone would come help, and left without obtaining assistance from the LPN or CNA on the hall. The resident’s call light was not on when the DON left, and the resident later reported that she had asked to be straightened up in bed and was left waiting for help. The resident continued to yell for help, and an LPN who was nearby did not check on her. When the surveyor entered the room, the resident was lying in bed leaning over the side near her tray table, and her call light was on the ground under the bed and out of reach. The resident stated she was yelling because she did not have her call light. On another observation, the resident spilled water on the floor around her bed and again yelled for help. An LPN entered, told the resident she would turn on the call light so someone could clean it up, and left the room. When the LPN returned later, the call light was off but the water had still not been cleaned up. The resident reported that some staff did not care for her or want to take care of her because she was "high maintenance," explaining that she needed two staff for ADL care and therefore required more staff time. She also reported that staff would often turn off her call light and say they would return but would not always come back, and that staff sometimes forgot to give her a call light so she had to yell out for help. A CNA reported that staff often turned off call lights without addressing residents’ needs and that residents had complained about having to turn their call lights back on. Resident council interviews and meeting minutes also documented repeated concerns that staff turned off call lights, left before needs were met, and returned only after residents had to call again.
Failure to Honor Resident’s Preferred Morning Routine
Penalty
Summary
The facility failed to honor Resident #39’s preferences for customary routines and activities. Resident #39 was admitted with diagnoses including muscle weakness and chronic pain syndrome, and her MDS assessment showed a BIMS score of 15/15, indicating she was cognitively intact. Her care plan included assistance with ADLs due to impaired mobility and assistance/escort to activities because of physical limitations and weakness in a wheelchair. Resident #39 stated that she preferred to eat breakfast in her room and then get up for the day so she could attend morning activities, which usually began at 10:00 AM. She reported that she often was not able to get up until 10:00 AM to 12:00 PM and believed staff sometimes waited to provide her care because she required two staff members for assistance. During observation, staff entered her room at 10:16 AM to assist with morning care. Multiple staff members confirmed that Resident #39 frequently had to wait to get up because she required two-person assistance and staffing was difficult. Staff reported that call-ins, the need to pick up breakfast trays, other residents needing two-person assistance, and residents leaving for dialysis contributed to delays. Staff also confirmed that Resident #39 sometimes had to wait until lunch time to get up and that she occasionally missed or arrived late to morning activities because she was waiting for staff.
Rooms and Bathrooms Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were kept clean and in good repair for Resident #21, Resident #22, and Resident #30. Resident #21 was cognitively intact with a BIMS score of 15/15 and was independent with self-propelling her wheelchair up to 50 feet. During observation, her room walls were noted to be in disrepair, with multiple dime-sized holes, deep gouges, scraped-off paint exposing drywall, and an area near the sink with extensive scrapes and peeling paint. Exposed metal corner bead was visible in several areas from the floor to about 3 feet high, and Resident #21 stated she did not like the condition of the walls and found them depressing. Resident #21 also reported concern about the exposed metal corner near her sink because she wore clothing that left her legs exposed and her skin broke open easily. In the shared bathroom between rooms [ROOM NUMBERS], dried brown drops were observed on wall tiles behind the toilet, a strong urine odor was present, and thick brown buildup was noted around the toilet base sealant. On a later tour, the same bathroom remained soiled with additional dried brown drops on the tiles and the same buildup around the toilet base. The Housekeeping Manager confirmed resident bathrooms should be cleaned daily. Resident #22 had severe cognitive impairment with a BIMS score of 7 and was observed in bed with the wall near the head of the bed showing approximately 10 areas of gouges and missing paint, including scratches and an area of missing paint about 8 inches long by half an inch wide. The condition remained unchanged on a later observation. Resident #30 was cognitively intact with a BIMS score of 13/15 and stated the wall beside the bed did not look good and should be painted. Observations and interviews with Maintenance and the DON confirmed the wall had gouges and peeling or missing paint, and staff described beds being moved into walls during care in the small rooms. Additional tours found multiple rooms with gouges and scratches near the head of the bed, and the spa areas contained wet washcloths, dirty clothes, and debris under the shower bed mattress.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that proper discharge notifications were completed for Resident #39, resulting in the resident not receiving written notice of bed hold when transferred from the facility to the hospital. Resident #39 was originally admitted with diagnoses including muscle weakness and chronic pain syndrome, and the electronic medical record showed the resident was transferred to the hospital on 1/16/26. Review of the record did not locate documentation of written notice of bed hold for that transfer. During interview, the Nursing Home Administrator and Director of Nursing reported that the nurse caring for Resident #39 on the day of transfer had not given the resident written notice of a bed hold. The report also states that the facility identified the failure to provide the written notice and clarified that the Admissions Coordinator was responsible for initiating contact with the hospital and/or responsible party within 24 hours of transfer.
Failure to Provide Scheduled Bathing and Hair Care
Penalty
Summary
The facility failed to provide appropriate ADL care, including showers and hair washing, for two residents who were dependent on staff assistance. One resident had an ADL self-care deficit related to impaired mobility, required assistance from two staff members, and had a care plan directing ADL assistance, bathing or showering as preferred, and sponge baths when a full bath or shower could not be tolerated. During interview, the resident stated she did not always receive adequate ADL care and missed showers or bed baths at times, and her hair was observed to be disheveled and greasy. Bathing documentation for this resident showed limited completed showers and bed baths across the reviewed months, with refusals also documented, and the shower sheets reflected only a few showers and bed baths over that period. CNAs reported that when staffing was low, residents who required longer assistance did not get showers or bed baths, and that this resident required two-person assistance and a long shower, making it difficult to complete her care when fewer than five CNAs were on day or evening shift. The DON reviewed the bathing documentation and confirmed the facility was missing documentation to verify the resident was receiving scheduled twice-weekly showers or baths or refusals. A second resident had diagnoses including adjustment disorder with depressed mood and seborrheic dermatitis, a BIMS score of 15/15, and a care plan calling for bathing or showering as preferred and medicated shampoo. The resident was observed with shiny, soiled hair, distinct comb lines, and hair sticking together, and reported that her hair had not been washed in two weeks and that she was bothered by its condition. She stated a staff member who had previously helped wash her hair had left, and her hair remained dirty, oily, and itchy; she later reported her scalp was very itchy before her hair was washed the evening prior to the interview. The shower record showed she received assistance with showering four times during the month reviewed.
Failure to implement pressure injury care plans and protect residents from skin breakdown
Penalty
Summary
The facility failed to implement resident-specific comprehensive care plans for two residents and failed to prevent the development of a pressure ulcer for one resident. Resident #13 was admitted with limitations in activities due to disability and had a BIMS score of 15/15, indicating cognitive intactness. Her care plan included interventions for ADL self-care deficit and, after pressure injury formation was identified, frequent turning and repositioning. Wound orders were in place for intact blisters on both 5th metatarsal areas, and later documentation noted the left foot wound was deteriorating with the superficial layer lifting. During multiple observations, Resident #13 was found lying in bed with her feet directly against the foot of the bed while wearing Prevalon boots. She reported that she developed pressure ulcers on her feet because she was too tall for the bed and her feet would lie directly on the foot of the bed. Staff interviews confirmed that she had developed both wounds at the facility because her bed was too small for her, that boosting was not done on a set schedule, and that the facility had not considered moving her to a room that could accommodate a larger bed. The wound care nurse practitioner also confirmed that the left foot wound was deteriorating and that the treatment order needed to be updated because the blister had detached. Resident #52 had diagnoses including diabetes, traumatic brain dysfunction, arthritis, non-Alzheimer's dementia, and partial paralysis of the right arm and leg, and was dependent on staff for ADLs. His MDS indicated he was at risk for pressure ulcers, and his care plan addressed skin integrity with interventions including elevating heels off the bed surface and Prevalon boots on at all times. However, the record later showed the order changed to Prevalon boots on when in bed for pressure relief at bedtime, and the care plan did not include this updated order. Observations showed the boots were not on the resident, with the boots found on the closet floor during one observation and the resident in bed or in his wheelchair without them during others. Staff stated he did not need to wear the boots, and the unit manager acknowledged that therapy discontinued the order but the care plan was not updated.
Improper Administration of Morphine
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration for a resident with unspecified dementia and severe cognitive impairment, as shown by a BIMS score of 00/15. The resident had a care plan addressing behavioral concerns related to dementia and was ordered morphine sulfate oral solution 20 mg/mL, 0.25 mL by mouth three times daily for chronic pain. During a medication administration observation, an LPN prepared the morphine dose and placed the syringe into an 8-ounce cup of cranberry juice after reporting that the resident refused medications and that hospice had obtained an order to give the morphine in juice. The LPN then placed the cup on the resident’s breakfast tray on the meal cart rather than taking it to the resident’s room and remaining with the resident during administration. The LPN marked the morphine as administered in the MAR and then left the medication cart to pass medications to other residents while the resident was eating and drinking in her room. The observation and interviews showed that CNA staff were aware the resident was receiving medication in juice, and one CNA stated the resident drank all of the cranberry juice before the LPN returned to check on her. Another CNA reported that nurses sometimes put the resident’s morphine in milk, while a different CNA said she had no knowledge that medications were being placed in the resident’s drinks. The UM stated the resident had not been assessed to self-administer medications and that nurses were expected to follow the rights of medication administration and supervise residents while they took medications. The DON stated she was not aware that nurses were administering morphine in cups of juice or milk and that nurses were supposed to observe residents when administering medications.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Elopement
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, delusional disorder, Parkinson's disease, and Alzheimer's disease, who was assessed as a high risk for wandering and elopement, exited the facility unsupervised. The resident had been actively exit seeking and displaying increased agitation and wandering behaviors for at least two days prior to the incident. Despite these behaviors, staff did not implement increased supervision or additional interventions beyond closing doors and attempting redirection. The resident was able to leave the facility through a dining room exit door, which led to a series of steep concrete stairs and a parking lot. On the night of the incident, staff observed the resident wandering the halls, testing doors, and expressing a desire to leave the facility. The resident was given PRN pain and anti-anxiety medications and was believed to be resting in bed shortly before the elopement. However, the resident managed to exit her room, traverse the facility, and open the dining room exit door, which triggered an alarm. Staff responded to the alarm and found the resident outside in the parking lot, having descended multiple flights of stairs without her walker, in cold weather conditions. Interviews with staff revealed that the resident had been exhibiting increased exit-seeking behaviors, including setting off door alarms and attempting to leave through various exits. Staff assignments and coverage were limited due to short staffing, and staff were not present on the resident's hall at the time of the elopement. The resident had a recent history of unwitnessed falls and was not considered safe to ambulate unsupervised, yet no increased supervision was implemented during the period of heightened exit-seeking behavior.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. At the only hand sink in the kitchen, there was no soap or paper towels available, which are essential for proper hand hygiene. The Food Services Director acknowledged the absence of soap, stating it had run out and needed to be replenished from the basement. Additionally, a box of raw burger patties was found open and exposed in the freezer, contrary to food safety standards that require food to be stored in covered containers to prevent cross-contamination. Further observations revealed unsanitary conditions in various areas of the kitchen. The door gasket seals on a two-door unit and the milk cooler were found with an accumulation of black debris. The dish machine area had debris on its top surfaces and wet debris underneath. A mechanical scoop hanging above the three-compartment sink was found with dried-on food debris, indicating a failure to maintain clean food-contact surfaces. In the pantry, several food items were improperly labeled or outdated, including salsa without a label or date, a mac and cheese product past its best-by date, and various other items that exceeded safe consumption dates. During meal service, a staff member was observed not washing hands after changing gloves and using a wiping cloth to clean gloves, which is against food safety protocols. Another staff member drank from a personal drink and returned to the serving line without washing hands or changing gloves. These actions violate the FDA Food Code, which mandates handwashing after certain activities to prevent contamination. The report highlights multiple deficiencies in food safety practices that could potentially lead to foodborne illness among residents.
Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and ensure the use of Personal Protective Equipment (PPE) when providing direct care to residents, as observed in multiple instances. For Resident #9, who required EBP due to a urinary catheter and tube feeding, staff members were observed assisting with transfers without wearing gowns or gloves, despite signs indicating EBP requirements. Interviews with staff revealed a lack of understanding and inconsistent practices regarding when PPE should be worn, particularly during transfers. Similarly, Resident #35, who was on EBP due to unhealed surgical wounds, was transferred by CNAs who did not wear gowns, only gloves. The CNAs engaged in direct contact with the resident during the transfer process, including adjusting clothing and changing a soiled shirt, without adhering to the full PPE requirements. This inconsistency in PPE usage was also noted with Resident #24, who had multiple chronic ulcers and a urinary catheter, and Resident #10, who had a catheter and required assistance with personal care. In both cases, staff did not don gowns during high-contact activities such as repositioning and transferring. Additionally, the facility failed to maintain equipment and surfaces in a manner that would reduce the risk of bacterial harborage. Observations revealed issues such as a leaking hopper sprayer, a slow leak behind a toilet causing discoloration, and the use of press board shelving in the central supply room, which is not easily cleanable. These deficiencies in maintaining sanitary conditions further increased the risk of contamination and infection spread within the facility.
Failure to Update Care Plans for Assistive Devices
Penalty
Summary
The facility failed to update and revise the person-centered care plans in a timely manner for two residents, resulting in an inaccurate reflection of their current status and needs. Resident #3, diagnosed with chronic pain syndrome, muscle weakness, back pain, diabetes with neuropathy, and osteoporosis, was observed wearing bilateral PRAFO braces due to foot drop. However, there was no focus or intervention for these devices in the care plan, nor was there an order for the device. Despite multiple observations confirming the use of the PRAFO devices, the care plan remained unchanged, and the CNA was unaware of the intervention due to its absence in the care guide. Similarly, Resident #25, with a history of paralysis, stroke, heart failure, and muscle atrophy, was observed using a hard AFO on the left lower leg. The care plan for this resident also lacked any focus or intervention for the AFO, and there was no order for the device. Interviews with staff, including the CNA, DPT, and UM, revealed a lack of communication and documentation regarding the use of these devices, as therapy recommendations were not incorporated into the care plans. The DON was unaware of the absence of these interventions in the care plans, indicating a breakdown in the process of updating and revising care plans based on residents' current needs and therapy recommendations.
Failure to Assist Residents with Personal Hygiene and Clothing Changes
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the areas of personal hygiene and changing clothes. Resident #13, who was moderately cognitively impaired and had muscle wasting and atrophy, was observed on multiple occasions to be disheveled, with messy hair and long chin hairs, and wearing the same clothes over consecutive days. Despite the care plan indicating a need for assistance with daily care needs, there was no documentation of shaving being offered, and the resident expressed a desire for help with shaving and changing clothes daily. Resident #54, who had significant physical limitations due to muscle wasting, paralysis, and other conditions, reported not being offered assistance with shaving for two weeks. Observations confirmed that the resident remained unshaven despite having shower days scheduled. Interviews with staff, including a CNA and RN, revealed an expectation that shaving should be offered during shower days, but this was not consistently done. The Director of Nursing also confirmed that shaving should be completed during showers if residents desired it.
Failure to Implement Consistent Wound Care Interventions
Penalty
Summary
The facility failed to consistently implement venous ulcer interventions, monitoring, and treatments as per physician orders for a resident with wounds. The resident, who was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and peripheral vascular disease, had a care plan that included specific interventions for skin integrity and wound care. Despite these orders, the facility did not adhere to the prescribed treatment schedule, resulting in a missed wound care treatment. Interviews with facility staff revealed inconsistencies in the execution of wound care treatments. The former unit manager expressed concerns about nurses not completing wound treatments, while a registered nurse incorrectly reported that the resident did not have any wounds. The unit manager confirmed that the resident had wound care orders that were not followed, as a treatment scheduled for a specific date was missed because the resident was sleeping, and the nurse did not attempt to complete the treatment later or communicate the missed treatment to the next shift. The director of nursing and other staff confirmed that it was unacceptable to skip treatments due to a resident sleeping and emphasized the expectation for nurses to complete all treatments within their shift or communicate any issues. The director also noted that there were sufficient staff available to assist with treatments if needed, indicating that the missed treatment was due to a lack of adherence to protocol rather than staffing issues.
Failure to Implement Care Plan for Contracture Management
Penalty
Summary
The facility failed to implement care plan interventions to prevent the worsening of contractures for a resident, resulting in the potential for worsening of contractures. The resident, who was moderately cognitively impaired and had a history of muscle wasting and atrophy, was observed with a contracted left hand. The resident reported that she used to wear a splint on her hand and arm, but staff had not put them on her lately, despite her preference to wear them. The care plan and orders for the resident did not include any orders for splints or braces for her left hand, although there were pictures and instructions for applying the splint in her room. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for splints. The Director of Rehab indicated that the resident was supposed to wear a modified splint for 2-4 hours daily, but therapy staff relied on nursing staff to enter orders, which were not present in the resident's chart. The therapy communication book listed the resident as needing splints, but nursing staff were unaware of this requirement. The Unit Manager and a CNA were unaware of the resident's need for splints, and it was discovered that one of the splints was missing a piece, rendering it unusable. The Director of Nursing acknowledged the oversight in ensuring the resident wore her splints daily due to therapy staff not entering their own orders or care plans.
Inadequate Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with a tracheostomy, leading to breathing complications and a risk of infection. The resident, who had a history of stroke, traumatic brain injury, chronic respiratory failure, and pneumonia, was observed struggling to clear phlegm from his throat while seated in his wheelchair. Despite the resident's visible distress and inability to clear his airway, a Licensed Practical Nurse (LPN) walked past without offering assistance and later returned only to check the resident's oxygen saturation, which was at 97 percent, but did not replace the empty oxygen tank or provide suctioning. The resident continued to experience difficulty breathing, and the LPN left the room to finish her break without addressing the resident's immediate needs, such as replacing the oxygen tank or suctioning the tracheostomy site. The resident's medical record showed no documentation of this event, and interviews with other staff members revealed that the resident should have been monitored closely due to his history of aspiration pneumonia and continuous coughing. The Director of Nursing (DON) and Unit Manager (UM) both acknowledged that the LPN should have taken immediate action to address the resident's respiratory distress. The resident expressed fear during the incident, and it was noted that he had been hospitalized multiple times for pneumonia and sepsis. Orders for suctioning and oxygen administration were not followed, as evidenced by the lack of suctioning recorded in the Medication Administration Record (MAR) and the empty oxygen tank. The failure to provide timely and appropriate respiratory care, as well as the lack of documentation, contributed to the deficiency identified in the facility's care for this resident.
Failure to Provide Correct Adaptive Feeding Equipment
Penalty
Summary
The facility failed to provide or correctly use adaptive feeding equipment for a resident with dysphagia, resulting in the potential for decreased independence in consuming food and fluids and weight loss. The resident, who has a swallowing disorder, was observed multiple times with inappropriate drinking equipment, such as a Styrofoam cup with a straw, despite having orders for a Provale cup only. The care plan and dietary meal slips specified the use of a Provale cup to manage the resident's swallowing difficulties and prevent aspiration. Interviews with staff, including a CNA and a Speech Language Pathologist, revealed that the resident was at increased risk of aspiration and required the Provale cup to control the bolus size when drinking fluids. Despite this, the resident was consistently provided with inappropriate drinking vessels, indicating a failure in adhering to the prescribed adaptive equipment needs. The Speech Language Pathologist confirmed that the facility had educated staff and the resident on the necessity of using the Provale cup, yet the deficiency persisted.
Failure to Safely Transfer Resident Resulting in Serious Injury
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a fall and serious injury. Resident #101, who was cognitively intact with a BIMS score of 14, was being transferred using a sit-to-stand mechanical lift by a CNA. The CNA did not follow the care plan, which required a two-person assist and the use of chest and leg straps. During the transfer, the resident let go of the grips, slid out of the sling, and fell to the floor, resulting in a distal left femoral fracture that required surgery. The resident reported that the straps were not buckled around her chest or legs, causing the sling to slide up her back and squeeze her lungs, leading to her fainting and falling hard onto the floor. The incident report confirmed that the CNA was alone during the transfer and did not follow the care plan instructions. The resident was immediately sent to the hospital, where she underwent surgery to repair the fracture and was discharged five days later. Interviews with staff revealed that the resident was not wearing appropriate footwear during the transfer, which is required for safe use of the sit-to-stand lift. The CNA involved was suspended and later terminated for failing to adhere to the facility's policies and procedures related to mechanical lifts. The facility's policy on mechanical lifts mandates that two staff members assist with transfers, ensuring the sling is properly placed for support. The facility identified that the failure to follow this policy led to the resident's fall and injury.
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.
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What surveyors actually found near you
We read the 320 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Grand Rapids | 0.4 mi | ★★★★★ | 2 | 1 |
| Corewell Health Grand Rapids Hospitals Rehabilitat | 0.6 mi | ★★★★★ | 10 | 0 |
| Corewell Health Rehabilitation & Nursing Center - | 1.4 mi | ★★★★★ | 0 | 0 |
| Mary Free Bed Sub-acute Rehabilitation | 2.2 mi | ★★★★★ | 2 | 0 |
| Clark Retirement Community | 2.5 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.