Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Bloomfield Hill during CMS and state inspections, most recent first.
Failure to readmit a resident after hospitalization: A resident with autism, ADHD, OCD, anxiety, seizures, gastroparesis, and POTS became distressed after being told she would have a roommate and called 911 stating she did not feel safe and had suicidal thoughts. She was sent to the hospital, where records later showed she was medically stable and a safe discharge plan back to the facility was coordinated, but facility leadership refused readmission because of the SI she had expressed. The medical record also lacked documentation of why her needs could no longer be met or the basis for discharge.
A resident was transferred to the hospital and later denied readmission because the facility said it could not accommodate a cecostomy tube. The record showed no notice of transfer/discharge, no discharge summary, and no documentation that the resident or RP received the required appeal-rights information or the reason for the discharge decision.
Surveyors found that the facility failed to maintain an effective infection prevention and control program, including missing gloves in PPE carts for rooms on contact precautions and delayed posting of Enhanced Barrier Precaution signage for a readmitted resident. Several symptomatic residents with documented cough, congestion, fever, leukocytosis, shortness of breath, nausea, vomiting, lethargy, and difficulty with arousal were not tested for COVID-19 despite facility policy and CDC guidance. Staff did not consistently follow contact precautions, hand hygiene, or safe medication handling, including entering a contact precaution room without PPE, touching pills with bare hands, and failing to perform hand hygiene between tasks. Wound care was performed while the nurse flicked unrestrained hair and moved in and out of a contact precaution room without appropriate PPE or hand hygiene. PPE bins contained a heavily soiled mask stored with clean masks and dried brown residue on the exterior, and multiple staff opened and closed these bins without addressing the contamination until later intervention, while the DON acknowledged that these practices were inconsistent with facility expectations.
Improper Food Labeling and Storage in Kitchen: During a kitchen tour, multiple food items were found improperly labeled, undated, or past the use-by date, including thickened water, ground beef rolls, butter, and other frozen items. The Dietary Manager stated that items should be labeled with open and expired dates and noted being out of the facility for over a week.
The facility failed to ensure adequate nursing coverage on an upper-level unit, resulting in multiple residents not receiving their scheduled 9:00 PM medications on time. A complaint alleged there was no nurse on the unit for several evening hours and that help did not arrive until late in the shift. Staffing records and time punches did not align with the posted nurse assignments, with one LPN leaving before the end of the assigned period, a salaried LPN unit manager lacking any time punch, and an RN unit manager clocking in more than two hours after medications were due. Despite this, the RN unit manager documented administration of numerous 9:00 PM medications, including anticoagulants, antihypertensives, insulin, anticonvulsants, and pain medications, after her recorded start time, and the facility could not produce corroborating evidence of her actual work hours or detailed medication administration timing.
The facility failed to maintain an effective antibiotic stewardship program for two residents by not documenting required infection criteria or the appropriateness of prescribed antibiotics. For one resident with psychiatric diagnoses, cephalexin was ordered for a reported UTI and earlier infection signs, but the McGeer criteria form was blank, the record lacked documentation of the stated symptoms, and there was no evidence of review of hospital labs or culture reports. For another resident with serious mental illness, Augmentin was ordered multiple times for UTI, the infection report and McGeer worksheet lacked documented signs and symptoms, and progress notes described behavioral issues without infection complaints, while the MAR showed interrupted and then completed antibiotic courses. The ICP reported verbally reviewing antibiotics with physicians but acknowledged that these reviews were not documented, and no records of such reviews for these residents were produced.
A resident with ESRD, malnutrition, and dialysis dependence had multiple meds stored in the bedside drawer and later in a bag in the room, despite no self-administration assessment being completed. In addition, loose pills were found in several med carts, and staff could not identify the pills; nurses stated the pills should have been discarded and that each nurse was responsible for cleaning their cart.
A bedbound resident with contractures, functional quadriplegia, muscle wasting, unclear speech, severely impaired cognition, and total dependence for ADLs was repeatedly observed with only a standard push-button call light clipped to the blanket, despite being unable to hold or press it. A family member could not confirm the resident’s ability to use the device, and the resident indicated she could not activate it. A unit manager RN initially believed the resident could use the standard call light but, upon direct observation, confirmed she could not and acknowledged the need for a different type of call light. The DON stated residents unable to use a standard call light should be assessed for an appropriate alternative, and facility policy required review of each resident’s unique needs and preferences for call light use, which was not done for this resident.
Surveyors identified that the facility did not maintain a sanitary and homelike environment for three residents. One resident was observed in a room with garbage scattered on the floor and a wall splattered with a brown substance, with no change noted on re-observation later the same day. In another room shared by two residents, the floor on both sides was littered with trash and debris and appeared unmopped, one overbed table was dirty and discolored, a nightstand had dried tube feeding formula on the top and front, and the other overbed table was dirty and sticky. A family member, when asked about room cleaning, pointed to the trash and shrugged, and a later observation with the Maintenance Director confirmed the room remained in the same unclean condition despite a facility policy requiring housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment.
Surveyors found that staff failed to accurately assess, document, and respond to changes in condition for three residents, and failed to ensure and document hospice services for another. One resident with dementia and total ADL dependence had shortness of breath and declining SpO2 reported by the spouse; staff obtained conflicting BP readings including 215/160, did not confirm manually, and documented only a normal manual BP and partial vitals, while EMS later found hypoxia, tachycardia, hypotension, and fever consistent with sepsis. A second resident with cardiac disease and diabetes had nausea, vomiting, poor intake, and abnormal labs faxed to the physician with no evidence of review or new orders, and no additional BP documentation on the day EMS found prolonged hypotension and dehydration. A third resident with prior respiratory failure and hemiplegia had documented SOB, tachycardia, abnormal vitals, and NP/MD orders for labs, IV fluid boluses, and metoprolol adjustments, but labs were not resulted, the IV bolus was not documented as given, metoprolol was administered at a higher total dose than ordered, and undocumented breathing treatments were reportedly given without orders as SpO2 fell below 85% before EMS found the resident unresponsive with severe hypoxia. Separately, a hospice resident with severe cognitive impairment had an active hospice order and care plan, but hospice documentation in the facility lacked names and dates of visiting staff, and no hospice CNA sign-in sheets were found for several weeks despite hospice reporting weekly nurse and CNA visits.
Two residents with pressure injuries did not receive consistent, ordered wound care and preventive interventions. One resident with multiple comorbidities had physician orders for specific heel and ankle wound treatments on scheduled night shifts, but surveyors found dressings dated several days earlier and the TAR showed a missed treatment, with an LPN unable to identify who was responsible or why it was not done. Another resident with documented stage 3 coccyx, sacral, and right buttock pressure injuries had hospital instructions and a care plan calling for a low air-loss or specialty mattress and q2h turning with wedges, yet was observed in bed without a low air-loss mattress or wedges; the resident reported painful wounds, and staff later acknowledged the absence of the ordered mattress and that hospital discharge notes indicating stage 3 wounds and the need for a low air-loss mattress had not been reviewed.
A resident with dementia, osteoporosis, impaired cognition, incontinence, and significant ADL assistance needs experienced two unwitnessed falls from bed. The care plan and IDT documentation identified fall risk and specified interventions including a mattress overlay/bolsters and a non-skid mat at the bedside. During observations, the resident was found on a regular mattress without bolsters or overlay on the bed and no non-skid mat on the floor, while the overlay was seen in the wheelchair. The assigned LPN was unaware of the overlay intervention, the unit manager initially asserted it was in place before acknowledging it was not, and the DON stated interventions would not be documented until implemented, despite existing documentation indicating they were already ordered.
A resident with quadriplegia and dependence for all ADLs was repeatedly documented as weighing about 149 lbs by Hoyer lift, despite appearing very thin on observation. A December weight of 121.6 lbs was crossed out by an LPN as incorrect, and subsequent entries again showed weights near 149 lbs. When surveyors observed staff reweigh the resident with a mechanical lift, the actual weight was 120 lbs, nearly 30 lbs less than the most recently charted value. The RD stated the weights had appeared stable and therefore had not raised concern, and the DON reported that CNAs obtained and entered weights but did not explain the discrepancy. No facility policy on weight management or obtaining accurate weights was provided when requested.
Surveyors observed that two residents received incorrect laxative formulations during routine medication passes, leading to a medication error rate above 5%. One resident was given Senna Plus (senna/docusate) when the order was for senna alone, and another was given Geri-Kot (senna only) when the order was for a senna/docusate combination. In both cases, LPNs prepared and administered medications that did not match the physician orders, and the DON later confirmed that these substitutions were not appropriate under the facility’s medication administration policy.
A resident’s end-of-life wishes were not accurately reflected in the chart. The face sheet listed Full CPR, while an Advance Directive signed by the resident stated DNR. The resident was alert but confused at times and said only family could do CPR, although the resident had a court-appointed guardian and no family legal guardian. Agency CNAs and an RN reviewed the record and identified the resident as Full Code, while the SWD stated the resident was DNR.
Failure to report unexplained bruising to the Administrator. A resident with rheumatoid arthritis, ankylosing spondylitis, and muscle weakness was observed with a dark purple, squarish bruise on the upper arm and stated an aide had been rough during care and that the nurse had been told. The bruise was not documented in the progress notes, skin assessment, or I&A report, and the Administrator/Abuse Coordinator stated she had not been notified.
Failure to coordinate meals around dialysis services for a resident with ESRD, malnutrition, and dialysis dependence. The resident reported a 6:30 AM chair time on M/W/F and stated they had not received breakfast on those days since admission and was still waiting for breakfast when interviewed. The UM stated nurses can arrange early breakfast trays for dialysis residents but was unsure why this resident had not been receiving one.
Delayed Review of Pharmacist Medication Recommendations: The facility failed to ensure timely review of a pharmacist recommendation for a resident with dementia and heart failure who needed total ADL assistance. Monthly pharmacist medication reviews were not documented, and repeated recommendations to the physician to review and consider discontinuing Vitamin C and Zinc supplements had no documentation of physician review; one note included an unsigned D/C notation. The DON and Corporate Clinical Support acknowledged the concern.
A resident with multiple medical conditions developed new and worsening wounds, including a stage IV sacral ulcer, while dependent on staff for all care. The facility did not document notifying the resident's family about these changes, despite the family's involvement in care discussions and the expectation that such notifications should occur.
A resident with multiple medical conditions and a stage IV sacral pressure ulcer developed purulent drainage that was not reported to the physician, despite care plan requirements. No documentation of physician notification or wound treatment was found before the resident was transferred to the hospital, where the wound was found to be infected with multiple organisms.
A resident who was fully dependent on staff and had a chronic Foley catheter did not have consistent documentation of catheter care over several months. The resident was later hospitalized with a urinary tract infection, and facility staff were unable to provide records showing that catheter care was performed as ordered.
A resident dependent on staff for all ADLs and with a PEG tube experienced a clogged tube and significant drainage, with soiled towels left in place and no clear explanation from staff. There was no consistent documentation of PEG care, and no current physician orders were found. Nursing staff failed to document care or incidents related to the PEG tube, resulting in a lack of appropriate and timely care.
Surveyors found unsanitary and unkempt conditions in multiple common areas, including dining rooms, a community room, and a shower room. Observations included dried food spills, debris, personal items stored inappropriately, insect webs, soiled linens, and unlocked cabinets containing PPE and syringes. Facility leadership acknowledged the concerns during the inspection.
A resident's authorized representative, acting for a person with severe dementia, was not provided timely access to requested medical records, including care plans and therapy notes, despite repeated requests and facility policy requiring access within 24 hours. The records were not supplied for over two months, and the delay was documented in both grievance forms and staff interviews.
Two residents did not receive care according to physician orders: one was not scheduled for a dermatology consult despite ongoing skin concerns and repeated requests, while another went multiple days without prescribed medications after hospital readmission due to delays in pharmacy supply and lack of backup medication processes.
A resident with severe cognitive impairment and psychiatric diagnoses had changes made to their Seroquel regimen without informed consent from their representative, and did not receive timely psychiatric evaluations or medication reviews. The facility did not coordinate psychiatric services effectively, as the contracted psychiatrist was not permitted by the family and the psychiatric NP was unable to see the resident due to scheduling conflicts. Social services did not fulfill their responsibility to obtain consent or arrange alternative psychiatric care, resulting in a lack of medically related social services.
A resident with multiple medical conditions was not referred to an oral surgeon for surgical extraction of two decayed molars as ordered by a dentist. Although the dentist provided instructions and an antibiotic prescription, facility staff did not arrange the necessary referral or document any actions taken, contrary to facility policy.
A resident reported repeated delays in receiving scheduled medications, including seizure medications, with audit records confirming multiple instances of late administration outside the facility's one-hour window policy. The DON was made aware of these concerns after the resident expressed frustration and anxiety over the late medication times.
A resident's antipsychotic medication dosage was increased without timely notification to the responsible party. Documentation showed that neither the psychiatric provider nor social services informed the family of the change, and the issue was only addressed after a grievance was filed. Facility policy requires such notifications, but records did not reflect compliance in this case.
A resident's responsible party was not notified or included in care conferences, and the facility failed to provide documentation of care conferences as required by its own policy. This resulted in a deficiency related to the coordination and documentation of care planning.
A resident with significant mobility limitations and multiple diagnoses was found using a non-medical grade heating pad applied by a CNA, with no physician order, care plan, or documentation. Facility staff and leadership were unaware of the device's use, and facility policy did not allow such equipment, resulting in a lack of supervision and accident prevention.
A resident with significant mobility and medical needs did not receive timely incontinence care, resulting in prolonged exposure to soiled bedding and strong urine odor. Staff interviews and documentation revealed that the resident was not changed for over 30 hours, with no evidence of care refusal during that period. Facility policy requiring regular perineal care and proper documentation was not followed, and communication between shifts was lacking, leading to poor hygiene and potential risk for impaired skin integrity and UTI.
A resident in a LTC facility was subjected to a urine toxicity test without their consent, violating their rights. The resident, who was cognitively intact, reported feeling discriminated against and stated that the facility did not explain the reason for the test. Interviews with staff revealed a lack of awareness and documentation regarding the test's purpose and the facility's consent protocol. The facility administrator confirmed the absence of a specific policy on toxicology consent, despite residents' rights to refuse treatment.
A resident with dementia and wandering behaviors was involuntarily secluded by staff in a dining room, restricting their movement. The incident was observed by other residents and staff, who reported that tables were used to trap the resident. The facility's investigation confirmed the inappropriate actions, leading to disciplinary measures against the involved staff.
A resident with dementia was involuntarily secluded by a CNA and an LPN, as reported by another resident. The incident was not reported to the Administrator or State Agency in a timely manner, violating the facility's policy. Two CNAs observed the incident but failed to report it, leading to a delayed investigation.
A resident with chronic anemia and other health issues did not receive a prescribed erythropoietin stimulating agent for several months due to insurance non-coverage, leading to multiple hospitalizations. Despite the resident and family raising concerns, the facility failed to administer the medication or seek alternatives, resulting in avoidable hospitalizations and blood transfusions.
The facility failed to maintain sanitary conditions in the kitchen and pantry refrigerators, with observations of pooled milk, soiled shelving, and expired food items. Additionally, kitchen staff with beards were not wearing beard restraints while handling food, violating FDA Food Code requirements.
The facility did not employ a full-time licensed social worker as required for its size, affecting the psychosocial care of 122 residents. The lapse occurred after a previous social worker's license expired, and attempts to cover the gap with part-time staff were insufficient. The issue was attributed to oversight by HR in tracking license expirations.
The facility failed to employ a qualified full-time social worker and provide necessary medically related social services, affecting all 120 residents. The Administrator was unaware of the issue until informed, and the part-time social worker's license had expired. There was also a lack of coordination for mood and behavior management, psychotropic medication oversight, care plan development, and guardianship follow-through.
The facility failed to maintain a clean and homelike environment, with observations of soiled floors, walls, and pest harborage. Complaints were made about housekeeping not keeping the facility clean. Residents' rooms and common areas were found in poor condition, with unsanitary conditions in dining areas. The administrator acknowledged the issues, but no audits were maintained to monitor them.
The facility failed to provide adequate social services for residents, including mood and behavior management and guardianship coordination. A resident's behaviors due to unaddressed pain were not documented, and care plans for psychotropic medication use were lacking. Another resident with severe cognitive impairment had no legal guardian, and social services did not follow up on guardianship recommendations for two residents.
A resident with severe cognitive impairment was prescribed multiple psychotropic medications without adequate documentation or monitoring of targeted behaviors. The facility failed to implement timely care plans and did not attempt a gradual dose reduction. Interviews revealed a lack of specific details about the resident's symptoms, leading to prolonged unnecessary medication use.
A resident with severe cognitive impairment was not treated with dignity and respect as staff failed to address another resident's inappropriate behavior of telling them to "Shut-up." Despite attempts to redirect the resident, staff were observed laughing and did not intervene appropriately, violating the facility's policy on treating residents with kindness and respect.
A resident with significant cognitive impairment and medical conditions was not provided with an appropriate wheelchair or Geri-chair, despite expressing a desire to get out of bed. Observations showed the resident remained in bed due to the lack of suitable seating, and staff were unaware of this deficiency. Interviews revealed a lack of communication and awareness among staff regarding the resident's needs, and the facility's policy on accommodation of needs was not provided during the survey.
A resident with multiple health issues reported not receiving a prescribed medication for several months, despite raising the concern with facility administration and their physician. The resident's family also communicated the issue through meetings and emails, but the facility failed to document or resolve the grievance. The administrator acknowledged the concerns but did not follow the grievance process, leaving the issue unresolved.
A facility failed to complete an annual OBRA Level II Evaluation for a resident with vascular dementia and bipolar disorder, despite a mental status exam indicating intact cognition. The necessary 3878 dementia exemption form was not completed, and the Social Services Coordinator was unaware of available resources to address the issue.
A facility failed to create resident-specific care plans for a resident with behavior-emotional needs and psychotropic medication use. The resident, with a history of dementia and mood disorders, was observed yelling loudly, yet care plans lacked specific details on mood and behavior management. The facility's policy did not ensure resident-specific care plans, and the interdisciplinary team was noted as responsible for this oversight.
A resident in a non-smoking facility was found to have smoking materials unsecured in their room, despite staff being aware of their smoking habits. The resident, with a history of nicotine dependence, smoked without supervision, contrary to the facility's non-smoking policy. Observations and interviews revealed that staff, including a CNA, knew of the resident's smoking, yet no measures were taken to secure the materials or provide adequate supervision.
A facility failed to maintain a medication error rate below five percent, resulting in an 8.33% error rate. An LPN administered enteric-coated aspirin instead of the prescribed chewable aspirin to three residents, with two receiving crushed enteric-coated aspirin. The DON acknowledged the error, noting that enteric-coated medications should not be crushed and must be administered as per physician orders.
The facility did not provide residents and visitors access to previous survey results, leaving them uninformed of identified deficiencies. The policy on Resident Rights allows residents to examine survey results and correction plans, but the survey information binder lacked documentation from recent surveys. The Administrator acknowledged the binder was not updated and attributed the responsibility to a newly hired Assistant Administrator, without explaining who was responsible before.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization and failed to document the reason for discharge in the medical record. The resident involved had diagnoses including autism spectrum disorder, ADHD, OCD, generalized anxiety disorder, gastroparesis, seizures, and POTS. The record also showed intact cognition and no behaviors on the MDS assessment reviewed by surveyors. The resident became upset after being told she would have a roommate following a room change from a private room to a non-private room on the second floor. Facility notes documented that she repeatedly stated she did not want a roommate, said she would go to the hospital if she had to have one, attempted to remove the roommate’s belongings, and then called 911 stating she did not feel safe. She was sent to the hospital after expressing suicidal thoughts related to the roommate situation. Hospital records showed the resident remained inpatient for an extended period after being medically stable for discharge while placement was coordinated. The hospital documented that she did not want to return to the same facility and that if she were sent back she would kill herself. Later hospital notes documented that no inpatient psychiatric facility could accept her, that a safe discharge plan back to the nursing home had to be coordinated, and that the resident later stated she would return with support and would ask for help or call 911 if suicidal thoughts recurred. Facility leadership reported the final decision not to accept her back was made because of the suicidal ideations she expressed related to the facility, but the record contained no documentation explaining why her needs could no longer be met at the facility or the basis for the discharge.
Failure to Provide Transfer/Discharge Notice and Summary
Penalty
Summary
The facility failed to issue a notice of transfer/discharge and a discharge summary for one resident, R901, when the facility decided not to permit the resident to return after a hospital transfer. R901 had been admitted with diagnoses including schizoaffective disorder and chronic obstructive pulmonary disease, and the MDS indicated the resident needed assistance with most ADLs. The resident’s BIMS score was 15, indicating intact cognition. A progress note documented that EMS transported R901 to the hospital and that a bed-hold policy was given. However, the record did not contain documentation that R901 or the responsible party received a transfer/discharge notice or discharge summary when the facility determined the resident would not be readmitted. The resident reported by phone that the facility did not allow return after stabilization at the hospital, that there was no chance to state a case for return, and that no notice or records had been sent to the new facility. Facility communication with the hospital showed the facility stated it could not accept the resident back because of a cecostomy tube and that the tube would need to be discontinued before return. Hospital staff asked whether the tube could be accommodated and indicated the resident was medically cleared and preferred to return. Facility leadership stated the facility had no plan of care or policy/procedure for that specific device and therefore would not permit the resident to return while the tube remained in place. The administrator later confirmed the facility could not provide documentation that a notice of transfer/discharge had been given to the resident or responsible party.
Failure to Maintain Effective Infection Prevention, Surveillance, and PPE Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an ongoing infection prevention and control surveillance system and to consistently implement its own infection control policies and procedures. Surveyors observed multiple lapses in the use and availability of personal protective equipment (PPE) for residents on Contact Precautions and Enhanced Barrier Precautions (EBP). For one resident on contact precautions, signage required staff to don gown and gloves before entering, but the PPE cart outside the room contained no gloves; another PPE cart across the hall was also missing gloves, which was confirmed by the unit manager. A resident readmitted from the hospital over a weekend was placed on EBP only after the surveyor had already entered the room, and the unit manager could not explain why the required signage had not been posted earlier, later stating that nurses were responsible for ensuring orders were entered correctly upon readmission. The infection surveillance program did not ensure that symptomatic residents were tested for COVID-19 in accordance with facility policy and CDC guidance. Infection report forms and clinical notes documented that several residents had symptoms consistent with respiratory infection and possible COVID-19, including cough, congestion, wheezing, productive cough, stuffy nose, headache, fever of 101.5°F, leukocytosis, shortness of breath, nausea, vomiting, loose stools, lethargy, and difficulty with arousal. Despite these documented symptoms for multiple residents, their medical records contained no documentation that they had been tested for COVID-19 as required by the facility’s COVID-19 policy and CDC testing guidance. When interviewed, the Infection Control Preventionist stated that symptomatic residents should be tested and that the facility followed CDC guidance and its own policy, but was unable to explain why these particular symptomatic residents were not tested. Additional infection control failures were observed in the implementation of contact precautions, hand hygiene, medication handling, and environmental cleanliness. A resident on contact precautions for CRE in the urine had a sign on the door, but the isolation cart outside the room had no gloves. Another resident on contact precautions reported that staff were not wearing gowns and gloves when entering the room, and there was no garbage can in the room or bathroom for disposal of PPE. During medication administration, one LPN moved between units, used a computer, retrieved backup medications, and administered them without performing hand hygiene. Another LPN picked up a pill that had fallen onto a resident’s lap with a bare hand and returned it to the medication cup, and also poured a pill from a stock bottle into the palm of an ungloved hand before administration. During wound care, the wound treatment nurse flicked unrestrained long hair away from the face and continued wound treatment with the same gloves, and for a resident on contact precautions, entered the room and placed wound care supplies on a dresser without PPE, then later removed gown and gloves to obtain more supplies without performing hand hygiene. Surveyors also identified failures related to EBP signage and PPE bin sanitation. One resident’s door initially had no indication of any precautions, and CNAs entered with a mechanical lift and provided care without PPE; upon exiting, an EBP sign had been placed on the door requiring gown, gloves, and mask for all staff providing care. An agency CNA stated it was their first day back and that the sign had not been on the door before entering. On the same unit, a PPE bin contained a heavily soiled mask with dried brown and orange stains stored among clean masks, and another bin had a dried brown substance on the outside that had to be touched to open the drawers. Multiple CNAs opened the contaminated bin drawers and closed them without removing the soiled mask or discarding the clean masks stored with it, until an LPN removed the soiled mask and threw it away. Central supply staff later stated that all clean masks in the bin had to be disposed of and the bins sanitized, noting that one bin had an odor. When interviewed, the DON acknowledged that nurses should not touch pills with bare hands, that hand hygiene should be performed using soap and water when visibly soiled or alcohol-based hand rub otherwise, and that gloves should be kept in the isolation cart, while also stating understanding of the concerns raised by these observations.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
Food items were not properly labeled, dated, or stored during an initial kitchen tour with the Dietary Manager. In the standard refrigerator, an open box of thickened water with a use-by date of 1/7/26 was observed. In the walk-in freezer, four large ground beef rolls were found without labels or dates, along with a cake and two packages that appeared to be waffles. In the walk-in cooler, two defrosted large ground beef rolls were observed without labels and/or dates, and a loosely wrapped open pound of butter that appeared to be one quarter used was also present. When asked who was responsible for monitoring food items for proper storage, labeling, and discarding, the Dietary Manager stated that items should be labeled with open and expired dates and noted that they had been out of the facility for over a week. The report cites FDA Food Code section 3-501.17 regarding date marking for ready-to-eat, potentially hazardous food held under refrigeration.
Insufficient Nursing Staff Leading to Delayed Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff on the 2 [NAME] Unit, resulting in residents not receiving medications according to physician orders. A complaint alleged that on the evening of 12/25/25, the unit was short staffed from 7:00 PM to 11:00 PM, with no nurse present during that time and residents not receiving medications timely. The complainant reported that staff said help would be sent, but no one arrived until 11:20 PM. During interviews, the Staffing Coordinator stated that two night nurses had called in and that nurse managers came in to cover, including a salaried unit manager who was not required to punch in. The Administrator and Staffing Coordinator later identified nurses assigned to the unit based on an assignment sheet, but time punch records did not fully support those assignments. Review of the 12/25/25 assignment sheet for the 2 [NAME] and 2 East Units showed that a unit manager LPN and another LPN were assigned from 7:00 PM to 11:00 PM, and a unit manager RN and another RN were assigned from 11:00 PM to 7:00 AM, with the RN also listed as assigned to 2 East during the same time. Time punch records revealed that the LPN listed for 7:00 PM to 11:00 PM had actually punched out at 8:59 PM, and the salaried LPN unit manager had no time punch. The RN unit manager assigned from 11:00 PM to 7:00 AM did not punch in until 11:15 PM, and the other RN assigned to that shift punched out at 11:45 PM. No missed punch documentation was provided to reconcile these discrepancies, and the facility could not produce evidence of the exact hours worked by the nurse managers. Record review of residents on the 2 [NAME] Unit showed that three residents had multiple medications scheduled for administration at 9:00 PM on 12/25/25, including atorvastatin, Colace, Eliquis, metoprolol tartrate, tizanidine, divalproex sodium, Voltaren gel, Lantus insulin, and gabapentin. All of these 9:00 PM medications for the three residents were documented as administered by the RN unit manager who did not punch in until 11:15 PM, more than two hours after the scheduled administration time. During interview, the DON stated he had not been aware of staffing challenges that day, while the ADON reported that nurse managers came in. The RN unit manager later reported she had come in early but did not punch in until 11:15 PM and had not requested a missed punch because she was a manager, and she could not provide evidence of her arrival and departure times. The facility reported that corporate staff were unable to access an audit report of medication administration times, and no further documentation was provided before the end of the survey.
Failure to Maintain Effective Antibiotic Stewardship and Document Appropriateness of Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective antibiotic stewardship program and to monitor the appropriateness of antibiotic use for two residents. For one resident with a history of anxiety disorder, bipolar disorder, and adjustment disorder, an Infection Report Form dated with an onset of 12/16 documented mental status change, lethargy, and fever, and initiation of cephalexin 500 mg three times daily for 10 days. However, the attached McGeer Criteria Worksheet was left blank, and the medical record contained no documentation supporting the reported mental status change, lethargy, or fever. Nursing notes instead described the resident calling 911 due to perceived mold on the floors and difficulty breathing, with normal vital signs and lung sounds, and multiple entries reflecting disruptive behaviors, yelling, refusals of care, irritability, agitation, and frustration that appeared to be baseline. After the resident was transferred to the hospital and returned, new orders were received for cephalexin 500 mg three times daily for 10 days for a mild UTI, but there was no documentation in the record of any review of the appropriateness of the antibiotic or of hospital labs or culture reports. For the second resident, with diagnoses including paranoid schizophrenia, psychotic disorder with hallucinations, and adjustment disorder, an Infection Report Form with onset 12/11 listed Augmentin 500-125 mg every 12 hours but left the signs and symptoms section blank, and the attached McGeer Criteria Worksheet was also blank. A UA and culture showed E. coli >100,000 in the urine, but a NP note on the same date documented the resident as somewhat irate and wanting to go home, with no complaints, no respiratory distress, no discomfort, and no pain, and referenced recent verbal and physical aggression and a history of behavioral issues. The December MAR showed multiple Augmentin orders for UTI with start and stop dates resulting in incomplete courses before a full 7‑day regimen was completed, yet the record contained no documentation that the resident met infection criteria or that the appropriateness of the antibiotic therapy was reviewed. During interview, the ICP stated they run a daily report of residents on antibiotics and contact the physician to review antibiotics but acknowledged they had just realized such reviews should be documented, and no documentation of antibiotic appropriateness review for these two residents was provided by the end of the survey.
Improper Medication Storage and Loose Pills in Medication Carts
Penalty
Summary
Medications were found improperly stored in a resident’s room, and the resident reported that a nurse had instructed them to administer their own medications from the drawer of the bedside table. On 1/12/26, Eliquis 5 mg, Atorvastatin calcium 80 mg, Midodrine HCL 10 mg, and Gabapentin 100 mg were observed in the drawer, with pills identified in all of the medication bottles. The resident’s record showed no self-administration assessment had been completed. The resident was admitted with diagnoses including end stage renal disease, moderate protein-calorie malnutrition, and dependence on dialysis. The Unit Manager later found the same medications in the resident’s bag and stated they should not have been in the room and should have been stored by staff. Loose pills were also found in multiple medication carts during observations of the 1 East floor cart, the 2 East high hall cart, and the 2 East center cart. One cart had three loose pills in the second drawer and one loose pill in the third drawer; another had one loose pill in the bottom of the second drawer; and the third had one loose pill in the second drawer and one loose pill in the third drawer. Staff could not identify the loose pills, and nurses stated the pills should have been discarded and that nurses were responsible for cleaning the carts. The DON stated the carts had been cleaned and organized, that each nurse was responsible for their own cart, and that the expectation was for medication carts to be clean and not have loose pills.
Failure to Provide Usable Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate, usable call light for a bedbound resident with significant physical and cognitive impairments. A complaint to the State Agency alleged that this resident, who was unable to use her hands, did not have a proper call light and that it was difficult for staff to know when she needed assistance. On two separate observations, the resident was seen lying in bed with her head leaned to the left and a standard push-button call light clipped to her blanket. During one observation, a family member present could not confirm whether the resident was able to use the call light. During another observation, the resident indicated by slightly shaking her head that she could not press the call light button. In an interview, the unit manager RN initially stated the resident could use a standard push-button call light, but upon direct observation with the resident, the RN attempted to place the call light in the resident’s hand and was unable to do so, acknowledging the resident could not hold it and would need a different type of call light. The DON reported that if staff noticed a resident was unable to use a standard call light, the resident should be assessed for an appropriate call light. Record review showed the resident was admitted with contractures, functional quadriplegia, and muscle wasting and atrophy, and an MDS assessment documented unclear speech, severely impaired cognition, and total dependence on staff for all ADLs. The facility’s own policy on call light accessibility stated that each resident would be reviewed for unique needs and preferences to determine any special accommodation needed to utilize the call light system, but this was not carried out for this resident.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents. During an initial tour, one resident was observed lying in bed in a room where several items of garbage were scattered on the floor and the wall across from the bed was splattered with a brown substance; a follow-up observation later that day showed the room remained in the same condition. In a separate room shared by two other residents, the floor on both sides of the room was littered with trash and debris and appeared as if it had not been mopped, one resident’s overbed table appeared dirty and discolored, and that resident’s nightstand had multiple dried spots of tube feeding formula on the top and dried formula that had dripped down the front. The other resident’s overbed table appeared dirty and sticky. When asked about room cleaning, a family member of one resident pointed to the trash on the floor and shrugged. A subsequent observation of the same room with the Maintenance Director showed that the floor, nightstand, and overbed tables remained in the same unclean condition, and the Maintenance Director acknowledged the room needed cleaning and that one overbed table needed replacement. The facility’s Homelike Environment policy stated that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
Failure to Accurately Assess, Treat, and Document Changes in Condition and Hospice Services
Penalty
Summary
The deficiency involves failures to complete accurate assessments, document and act on vital signs and lab results, administer ordered medications and IV fluids, and communicate accurate clinical information to physicians for timely treatment or transfer, as well as failures in hospice communication and documentation. For one resident with dementia, seizures, and total dependence for ADLs, nursing staff documented a change in condition with shortness of breath and declining SpO2 after the spouse reported the resident did not look well and requested hospital transfer. The spouse reported that the physician initially refused transfer and threatened the nurse’s job, and that staff had difficulty obtaining accurate blood pressure readings. A photograph taken by the spouse showed a BP of 215/160, which the assigned RN confirmed seeing but did not document, stating they believed it was inaccurate and did not obtain a manual confirmation. The vital signs entered in the record instead showed a BP of 100/61, pulse 79, respirations 22, and SpO2 91% without a temperature, and the RN could not explain why a full set of vitals, including temperature, was not obtained or why the more abnormal values were not documented. EMS later documented the resident as hypoxic with SpO2 80% on room air, tachycardic at 140 bpm, hypotensive, febrile at 101.4°F, and with rhonchi in all lung fields, and the hospital documented sepsis, hypotension, tachycardia, and high fever on admission. For a second resident with coronary heart disease, schizophrenia, type II diabetes, and intact cognition, nursing notes documented nausea, vomiting, and poor oral intake, with an SBAR indicating a change in condition and a recommendation for blood tests. Labs drawn on one day showed elevated WBC and low RBC and hemoglobin, and were placed in the physician log and faxed, but there was no documentation that the physician reviewed the results or issued new orders. Subsequent notes documented a nosebleed and an order for a CBC for the following Monday, but no additional blood pressure readings were recorded on the day the resident was transferred to the hospital. EMS documented that the resident had hypotension persisting for three hours, with a reported BP of 80/59 prior to EMS arrival, and the hospital documented dehydration, low blood pressure with initial readings in the 50s and 70s/40s, a week of not eating or drinking, and vomiting. The agency nurse who arranged the transfer reported that they had difficulty obtaining blood pressures with two different machines, recalled one low reading but could not recall the value, and stated they were not aware of the prior vomiting and bleeding because, as an agency nurse, not all information was provided. For a third resident with cerebral infarction, acute respiratory failure with hypoxia, and hemiplegia, nursing notes documented a change in condition with audible fluid in the lungs, cough, elevated BP, and low-grade fever, with Tylenol and IM Lasix administered and the physician and family notified. Subsequent notes described shortness of breath and tachycardia, with an NP assessment of acute respiratory failure, multiple wounds, pneumonia, and decreased responsiveness, and orders to monitor vitals, SpO2, and for labs (CBC and CMP). The record contained no results for the ordered labs. Another NP note documented tachycardia, tachypnea, diminished breath sounds, a temperature of 99.6°F, heart rate 114, SpO2 98% on 3L, and an order for a 1L normal saline IV fluid bolus, but the MAR/TAR showed no documentation that the IV bolus was administered. A later MD note ordered a 1L normal saline IV bolus at 80 cc/hr and an increase in metoprolol to 50 mg twice daily, while the MAR/TAR showed that the new 50 mg dose was given in addition to the existing 25 mg twice daily, resulting in 75 mg twice daily being administered. Nursing notes documented episodes of shortness of breath, SpO2 dropping to 88% on 3L, and later to below 85% despite increasing oxygen to 5L and then a non-rebreather at 15L, with RR 26–30 and BP 168/89, but there was no documentation of the breathing treatments the RN stated were given, no physician order for those treatments, and no documentation of exact SpO2 values during the decline. The RN reported calling the physician and leaving a message without a callback, providing an undocumented breathing treatment without an order, and then calling 911; EMS found the resident unresponsive with GCS 3, SpO2 59% on NRB at 15L, respirations 30, and bilateral rales. The deficiency also includes failure to ensure hospice communication and care were provided and appropriately documented for a resident with anorexia, type II diabetes, dementia, and severe cognitive impairment who had an order to be admitted to hospice. The resident’s care plan identified a hospice focus with an intervention to collaborate with the hospice company and specified hospice visits with days and services. When asked, an RN located a thin binder near the nurse’s station, but the documents did not include the names and dates of hospice representatives visiting the resident. During an interview and record review with the DON and corporate clinical support nurse, hospice reported that the resident was to receive weekly visits from both a nurse and a CNA, and provided the caregivers’ names. However, front desk staff could not locate any hospice CNA sign-in sheets for the prior three weeks, and the corporate clinical support nurse stated it would be in the resident’s best interest to obtain new hospice services because the current hospice was not performing necessary visits. The facility’s hospice policy required that hospice provide the most recent hospice plan of care, that the facility communicate with hospice and document such communication, and that hospice information be available within the facility, but the documentation and sign-in records for this resident’s hospice services were incomplete or missing. Additionally, the surveyors requested an audit of actual administration times for the third resident’s January medications to clarify whether ordered treatments, including IV fluids and metoprolol dosing, were administered as scheduled. Multiple requests were made to the DON, administrator, and corporate clinical support nurse throughout the day, but the facility repeatedly reported that they did not have access to the audit data and did not provide the requested audit before the end of the survey. The facility’s change in condition policy required nurses to notify the physician when there is a significant change in physical status or a need to alter medical treatment, and to document assessments, notifications, interventions, and responses, but the records for the residents with changes in condition contained missing or incomplete vital signs, undocumented or uncompleted labs and treatments, and incomplete documentation of physician communication.
Failure to Provide Ordered Pressure Ulcer Treatments and Support Surfaces
Penalty
Summary
The facility failed to consistently implement ordered pressure ulcer treatments and preventive interventions for two residents with pressure injuries. For one resident with end stage renal disease, moderate protein-calorie malnutrition, dependence on dialysis, and prediabetes, surveyors observed on 1/13/26 that both feet were wrapped in gauze bandages dated 1/10, even though the Treatment Administration Record (TAR) showed the last documented treatments as completed on 1/9/26. Physician orders directed that the left heel deep tissue injury be cleansed with wound cleanser, treated with moist betadine gauze, covered with an ABD pad, and wrapped with kerlix, and that the right lateral ankle pressure ulcer be cleansed with wound cleanser, treated with Medihoney, covered with an ABD pad, and wrapped with kerlix, to be done on the night shift every Monday, Wednesday, and Friday. The January 2026 TAR showed that the ordered treatments for both the left heel and right lateral ankle were not completed on 1/12/26. When questioned, an LPN confirmed the dressings were dated 1/10, was unsure whose responsibility it was to complete the treatment, and could not explain why the 1/12/26 treatment was missed. For another resident initially admitted with coronary heart disease, paranoid schizophrenia, type II diabetes, and a psychotic disorder, the clinical record and hospital documentation showed stage 3 pressure injuries of the coccyx, sacrum, and right buttock, with hospital instructions for a low air-loss specialty mattress, turning every two hours with wedges, and avoidance of adult briefs to limit moisture. The resident’s care plan included an alternating pressure mattress for pressure ulcers on the coccyx related to immobility. Hospital records from two separate stays documented stage 3 pressure injuries and specified use of a low air-loss mattress and q2h turning with positioning devices. During observation, the resident was found lying on their back in bed without a low air-loss mattress and without a wedge in the room or bed; the resident reported having a painful wound on their bottom and wounds on their heels and recalled a hospital stay for the wound. A nurse later confirmed the resident did not have a low air-loss mattress and stated the wound nurse had said the wound was stage 2 and did not require it. The wound nurse reported that low air-loss mattresses are generally used for stage 3 or above and acknowledged not reviewing the hospital discharge notes that documented stage 3 pressure injuries and the need for a low air-loss mattress.
Failure to Implement Ordered Fall-Prevention Interventions After Repeated Bed Falls
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a resident with dementia, osteoporosis, essential hypertension, moderately impaired cognition, and total incontinence. The resident required substantial/maximal assistance for bed mobility and transfers and had experienced a decline in ADL function, needing 1–2 person assistance with dressing, ambulating, and toileting. Progress notes documented two unwitnessed falls from bed on consecutive days, with the resident found on the floor near the bed on both occasions and unable to describe the events. The falls care plan, initiated earlier, identified the resident as at risk for falls due to decreased mobility, cognitive impairment, incontinence, and medication side effects. Despite this identified risk and the documented falls, required interventions were not in place at the time of surveyor observations. The care plan and IDT documentation called for bolsters or an overlay barrier to the mattress and a non-skid mat to the right side of the bed. However, on multiple observations, the resident was found lying on a regular mattress without bolsters or mattress overlay applied to the bed, and no non-skid mat was present on the floor. The mattress overlay was instead observed in the resident’s wheelchair. When interviewed, the assigned LPN did not know what the mattress overlay was or that it should be on the bed, and the unit manager initially stated the overlay was in place before acknowledging it was not. The DON stated interventions would not be documented until in place, despite the care plan and IDT notes already reflecting these interventions, and did not provide an explanation for their absence at the bedside.
Failure to Obtain Accurate Weights Resulting in Undetected Severe Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain accurate weights and complete accurate nutritional assessments for one resident, resulting in a significant, previously unrecognized weight loss. The resident, who was cognitively intact, quadriplegic, and dependent on staff for all ADLs, was observed on multiple occasions to appear very thin, with visible ribs and thin arms and legs while lying in bed. Review of the clinical record showed a series of monthly weights from July through early January consistently documented around 148–149 lbs using a Hoyer lift. A weight of 121.6 lbs recorded in December was crossed out by an LPN with the notation “Incorrect Documentation,” and subsequent documentation again reflected a weight in the 149 lb range. When asked, the resident reported being weighed only occasionally and estimated his own weight at about 132 lbs, with a height of 6 feet 1 inch. On direct observation of staff weighing the resident with a mechanical lift, the resident’s actual weight was found to be 120.0 lbs, which was 29.6 lbs less than the most recently documented weight of 149.6 lbs recorded five days earlier. The RD reported that the resident’s weights had not triggered concern because they appeared stable in the record and stated she was in the process of working on the resident’s nutrition evaluation. After being informed of the observed 120.0 lb weight, the RD acknowledged that the resident did not look like he would weigh 149.6 lbs. The DON stated that CNAs obtained resident weights and entered them into the chart but did not provide an explanation for the large discrepancy between the documented and observed weights before the end of the survey. When surveyors requested a facility policy on weight management and obtaining accurate weights, no policy was provided prior to the end of the survey.
Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent during a medication administration observation, resulting in a 7.41 percent error rate. On 1/13/26 at 8:16 AM, an LPN prepared seven medications for resident R110, including Senna Plus 8.6-50 mg, and administered all seven medications to the resident. Later record review at 3:43 PM showed that R110’s physician order was for Senna 8.6 mg only, not Senna Plus, meaning the resident received an additional component (docusate) that was not ordered. The facility’s Medication Administration policy dated 8/7/23 required safe and accurate preparation and administration of medications according to physician orders, including the right medication. On the same date at 8:31 AM, another LPN prepared eleven medications for resident R70, including Geri-Kot 8.6 mg, and administered all eleven medications to the resident. Subsequent reconciliation of R70’s physician orders at 3:30 PM revealed an order for Sennosides-Docusate Sodium 8.6-50 mg, while the medication given (Geri-Kot) did not contain docusate. During an interview on 1/14/26 at 8:40 AM, the DON confirmed that Senna Plus could not be given when only Senna was ordered because it also contained docusate, and that Geri-Kot could not be given when Sennosides-Docusate was ordered because it lacked docusate. These two observed medication administration errors out of 27 opportunities resulted in a medication error rate above the 5 percent threshold.
Code Status Not Clearly Reflected in Resident Record
Penalty
Summary
The facility failed to ensure a resident’s end-of-life wishes were accurately and clearly reflected in the medical record. The resident was admitted with diagnoses including coronary heart disease, paranoid schizophrenia, type II diabetes, and psychotic disorder. The face sheet listed the resident’s code status as Full CPR, but an Advance Directive form dated and signed by the resident stated that the resident had chosen DNR. During observation, the resident was lying in bed, alert but confused at times, and stated that only their family could perform CPR, not anyone else. The resident had a court-appointed guardian through a company and no family members acting as legal guardian. When staff were interviewed and asked how they determined code status, two agency CNAs said they used the face sheet and identified the resident as Full Code. A nurse also reviewed the record and reported the resident was Full Code, while the Social Work Director stated the resident was DNR.
Failure to Report Unexplained Bruising to the Administrator
Penalty
Summary
The facility failed to report an injury of unknown origin to the Administrator in a timely manner for one resident. On 1/12/25 at 11:48 AM, the resident was observed lying in bed with a dark purple, squarish bruise approximately 1 inch by 1 inch on the outside of the left upper arm. When asked how the bruise occurred, the resident stated that an aide had been rough during care a couple of days earlier, and said the nurse had been told about it. The resident’s record showed diagnoses including rheumatoid arthritis, ankylosing spondylitis, and muscle weakness, and the most recent MDS indicated the resident was cognitively intact and required staff assistance for all ADLs. Review of the progress notes showed a general note later that day documenting ADL care and bed change, but there was no documentation of the bruise in the progress notes. The most recent skin assessment, completed on 1/7/26, did not mention bruising, and the facility’s Incident & Accident reports did not include the bruise. When the Administrator, who was also the Abuse Coordinator, was asked whether she had been notified of the bruise, she stated that she had not. The facility’s abuse policy identified suspicious or unexplained injuries, including bruises or patterned appearances such as a handprint, belt, or ring mark, as possible indicators of abuse.
Failure to Coordinate Meals Around Dialysis
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to coordinate meals around dialysis for one resident. The resident was admitted with end stage renal disease, moderate protein-calorie malnutrition, and dependence on dialysis, and stated that their chair time was 6:30 AM every Monday, Wednesday, and Friday. During observation, the resident was sitting in a wheelchair in their room and reported that they had not received breakfast on any of those dialysis days since admission and had not yet received breakfast at the time of the interview, stating they were hungry. After the interview, the Unit Manager was alerted to the resident’s need for a meal. The Unit Manager later stated that nurses can ensure early breakfast trays for dialysis residents and was unsure why this resident had not been receiving a tray.
Delayed Review of Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure timely review of a pharmacist recommendation for one resident, R65, who was admitted with diagnoses including dementia and heart failure and required staff assistance for all ADLs. R65 had a BIMS score of 8, indicating moderately impaired cognition. The medical record did not contain documentation that the monthly pharmacist medication reviews were conducted. A review of the pharmacist medication reviews showed repeated recommendations in August, September, October, and November 2025 for the physician to review and consider discontinuing R65's Vitamin C 500 mg and Zinc 50 mg supplements. There was no documentation that the physician reviewed these recommendations, and the November 2025 recommendation included a D/C notation for 12/4 with no signature. Review of physician, NP, and clinician notes also found no documentation that the pharmacist recommendations were reviewed. The DON and Corporate Clinical Support acknowledged concern when asked about the repeated recommendations without timely physician review.
Failure to Notify Family of New and Worsening Wounds
Penalty
Summary
The facility failed to consistently notify and update a resident's family regarding newly identified wounds and the worsening of existing wounds. The resident in question was admitted with significant medical conditions, including cerebral infarction and multiple myeloma, and was dependent on staff for all activities of daily living. Documentation showed that a new wound was identified on the resident's left hip, and a sacral wound progressed to a stage IV ulcer with exudate and bone exposure. Despite these developments, there was no documentation that the resident's emergency contact, their daughter, was notified about the new or worsening wounds. Progress notes indicated that the daughter was involved in care discussions and plan modifications, but specific notifications about the skin issues were not documented. The lack of communication became evident when the daughter called emergency services to have the resident transported to the hospital, where multiple wounds were identified, including a stage IV sacral ulcer and additional pressure wounds. Interviews with facility staff confirmed that family and physicians should be notified of such changes, but no evidence of notification was provided.
Failure to Report and Treat Decline in Pressure Ulcer
Penalty
Summary
A resident with diagnoses including cerebral infarction and multiple myeloma, who was dependent on staff for all activities of daily living, was admitted with a sacral stage IV pressure ulcer. On 10/24/25, a wound consultation documented the ulcer as full-thickness with moderate exudate but no signs of infection or inflammation. However, a skin issues note from the same day described purulent exudate and a moderately saturated dressing, indicating the presence of pus. The resident's care plan required monitoring for significant changes in the wound and notifying the physician of any such changes. Despite these findings, there was no documentation that the physician or wound clinician was notified of the purulent drainage. No further documentation regarding the sacral wound was found between 10/24/25 and 10/29/25, when the resident was transferred to the hospital. Hospital records indicated the presence of a stage IV decubitus ulcer with surrounding erythema and purulent discharge, and wound cultures revealed infection with Methicillin-Sensitive Staphylococcus aureus and Pseudomonas aeruginosa. Facility staff, including the wound nurse and DON, confirmed they were not informed of the purulent drainage prior to the resident's hospital transfer, and no additional explanation or documentation was provided.
Failure to Provide Consistent Indwelling Catheter Care
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate indwelling catheter care for a resident who was dependent on staff for all activities of daily living and had a history of cerebral infarction and multiple myeloma. Observation revealed the resident was in bed with a urinary Foley bag containing bright yellow, cloudy urine. Review of the medical record showed a physician order for catheter care every shift starting on 6/28/25, but there was no documentation that catheter care was consistently completed until 11/6/25. The Treatment Administration Record for November 2025 indicated staff documented catheter care twice daily, but there was no supporting documentation for the period from June to November 2025. Further review revealed that on 10/29/25, the resident was transported to the hospital, where the primary diagnosis was a urinary tract infection. Hospital records documented the presence of a chronic indwelling Foley catheter, a positive urinalysis for infection, and the need for intravenous antibiotics. Facility staff, including the Unit Manager and DON, were unable to provide documentation of catheter care for the resident during the specified period, and no further explanation or records were provided by the end of the survey.
Failure to Provide Consistent PEG Tube Care and Documentation
Penalty
Summary
The facility failed to ensure consistent and appropriate care for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who was dependent on staff for all activities of daily living and had diagnoses including cerebral infarction and multiple myeloma, experienced a clogged PEG tube, which was unsuccessfully addressed by nursing staff and ultimately required hospital intervention. Observations revealed soiled towels with large amounts of yellow and brown drainage left on and under the resident, and staff present during the observation were unable to explain the source of the drainage or why the towels had not been changed. There was no documentation in the medical record of abnormal drainage or incidents that morning. Further review of the resident's medical record showed a lack of consistent documentation regarding PEG care, and no current physician orders for PEG care were found. Previous orders for PEG site management had been discontinued without a documented date, and staff interviews confirmed uncertainty about the status of PEG care orders. The nurse assigned to the resident on the day of observation had not documented any PEG care or the events that occurred, despite being aware of the PEG tube leaking and the resident being sent to the hospital. These findings indicate a failure to provide and document necessary PEG tube care as required.
Failure to Maintain Sanitary and Homelike Environment in Common Areas
Penalty
Summary
Surveyors observed multiple unsanitary and unkempt conditions throughout the facility's first and second floor common areas, including dining rooms, a community room, and a community shower room. In the Two-West dining room, dried food spills, crumbs, debris, and personal items such as purses and tote bags were found in unlocked cabinets, along with old food and partially consumed beverages. The area also contained cleaning equipment, a baseball cap, food wrappers, and loose carpet pieces. The Two-East dining room had similar issues, with dried spills, food debris, insect webs, spiders, and unkempt cabinets containing personal items and used utensils with unknown substances. The kitchen area was noted to have liquid spills and dried food matter on surfaces. Common hallways on the second floor were observed to have moderate debris, spills, and an overall unkempt appearance, including sticky smudges and discarded items on windowsills. The first-floor community shower room, used by residents, contained soiled linens, a crumbled Hoyer lift tarp, and opened bathing wipes. The floor was dirty, with piles of human hair, broken razor caps, and insects present. The shower bed had tangled hair on its wheels, and the shower chair and seat were unclean, with multiple half-used shower gels and black discoloration in the creases. The first-floor community room, accessible to residents, staff, and visitors, had unlocked cabinets storing PPE and hypodermic syringes, as well as tables containing used bottles, electrical equipment, cracker crumbs, and a toothbrush. Food crumbs and debris were present throughout the carpeted room. Facility leadership, including the Nursing Home Administrator and Housekeeping Director, acknowledged the unkempt conditions during a tour of the affected areas.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident's medical records to the resident's authorized representative, as required by federal regulations and facility policy. The resident's representative had requested specific documents, including the most recent care plan, therapy notes, medication lists, and care guides, and had been waiting for over two months without receiving the requested records. Documentation showed that the representative communicated multiple times with facility administrators, expressing frustration over the delay and stating that no care conference would be scheduled until the records were provided. The facility's own grievance documentation noted the ongoing request and the representative's refusal to attend a care conference until the records were released. The resident in question had a diagnosis of dementia and was assessed as having severely impaired cognition, with the representative designated as the medical decision maker. Despite repeated requests and assurances from facility staff that the records would be provided, there was no evidence that the medical records staff received the request, and the records were not supplied until several months after the initial request. The facility's policy required access to records within 24 hours during business hours, but this was not met in this case.
Failure to Follow Physician Orders for Consults and Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders were followed and that residents received appropriate treatment and care according to those orders and the residents’ preferences and goals. For one resident with chronic dermatological concerns, a nurse practitioner ordered a dermatology consult to address ongoing skin issues. Although the order was confirmed by nursing staff, the consult was never scheduled. The medical records/unit clerk admitted to not scheduling the appointment and could not provide a reason for the omission, despite the resident’s repeated requests and ongoing skin concerns. Another resident, who was readmitted from the hospital, did not receive multiple prescribed medications for several days. The resident reported going days without medications upon return to the facility. Medical record review confirmed that numerous medications, including those for seizures, pain, rash, and other chronic conditions, were not available or administered as ordered. Documentation showed repeated notations of medications being on order, awaiting pharmacy delivery, or not available, spanning several days and affecting a range of essential treatments. Interviews with facility staff, including the DON, revealed that there were established processes intended to ensure medication availability, such as using backup supplies and expedited pharmacy delivery. However, these processes were not effectively implemented, resulting in significant lapses in medication administration. The failure to schedule a specialist consult and to provide timely access to prescribed medications directly contravened physician orders and the standard of care expected for residents.
Failure to Obtain Consent and Coordinate Psychiatric Services for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide medically related social services by not obtaining informed consent from the resident representative prior to changing a resident's psychotropic medication regimen and by not coordinating necessary psychiatric services. The resident in question had diagnoses including dementia, paranoid schizophrenia, and anxiety disorder, and was prescribed Seroquel for management of psychiatric symptoms. Despite the resident's representative being designated as the medical decision maker, there was no documentation that consent was obtained or that the representative was informed prior to a reduction in the Seroquel dose. Progress notes and interviews confirmed that the medication change occurred without the required communication or consent. Additionally, the facility did not ensure ongoing psychiatric oversight for the resident. After a hospitalization and subsequent readmission, there were no documented psychiatry visits or medication reviews by a psychiatric practitioner for several months, despite the resident's complex behavioral health needs and ongoing use of antipsychotic medication. The facility's contracted psychiatrist was not permitted by the family to see the resident, and the psychiatric nurse practitioner was unable to see the resident due to scheduling conflicts with dialysis appointments. Virtual visits were mentioned as a solution, but had not yet been implemented at the time of the survey. Facility policy required social services to obtain informed consent for psychotropic medications and to coordinate psychiatric or counseling services. However, interviews with the DON and social worker confirmed that these responsibilities were not fulfilled. The social worker acknowledged that no conversation occurred with the resident representative regarding the medication change, and the required documentation and coordination of psychiatric services were lacking. This resulted in a failure to provide the necessary medically related social services to help the resident achieve the highest possible quality of life.
Failure to Obtain Ordered Oral Surgery for Resident
Penalty
Summary
A deficiency occurred when the facility failed to obtain and follow through with ordered dental services for a resident who required surgical extraction of two severely decayed molars. The resident, who had multiple medical diagnoses including diabetes, morbid obesity, heart disease, seborrheic dermatitis, and schizoaffective disorder, was seen by a dentist at bedside for tooth pain. The dentist documented that the resident needed surgical extractions of teeth #30 and #31 with sedation due to agitation, and provided a prescription for Clindamycin. The dentist also instructed that a referral to an oral surgeon be made for the extractions. Despite these orders, there was no evidence that the facility arranged the required referral or appointment with an oral surgeon. The DON, who ordered the antibiotic, could not confirm why the referral was not completed or documented, especially after the resident was sent to the hospital and subsequently readmitted. The facility's own policy required assistance with making dental appointments and documentation of any delays, but the record lacked evidence of these actions being taken for this resident.
Failure to Administer Medications Timely and per Resident Preference
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner and according to a resident's preferences and goals. One resident expressed complaints about receiving medications late, particularly noting that nurses would go on their breaks before administering medications, resulting in delays. The resident specifically mentioned feeling nervous about not receiving seizure medications on time, especially during the night. A review of the medication administration audit report revealed multiple instances where medications scheduled for specific times were administered significantly late, sometimes by several hours or even the following day. The facility's policy requires medications to be administered within one hour before or after the scheduled time, but the audit showed repeated deviations from this standard. The DON acknowledged awareness of the concerns regarding late medication administration for this resident.
Failure to Notify Responsible Party of Antipsychotic Medication Change
Penalty
Summary
The facility failed to notify the responsible party of a change in antipsychotic medication dosage for one resident. Specifically, the psychiatric service provider increased the resident's Seroquel dosage from 25 mg to 50 mg twice daily for mood instability and psychosis, as documented in a note dated December 2024. There was no documentation indicating that the resident's responsible party was informed of this medication change at the time it occurred. The facility's social services progress notes also lacked any evidence of notification, with the last entry predating the medication change by several months. The issue came to light when the resident's daughter contacted the facility administrator with concerns about the medication increase, expressing that the family was upset about not being informed. The facility's grievance form confirmed that neither the psychiatric service provider nor the social services department had contacted the responsible party until after the grievance was filed. During an interview, the assistant administrator acknowledged the lack of timely notification, and facility policy was reviewed, which requires informing residents and their representatives of changes in health status and treatment.
Failure to Include Responsible Party in Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were coordinated with the inclusion of the responsible party for one resident, as required. A complaint was received by the State Agency alleging that the resident's responsible party was not notified or included in care conferences. During an interview, the Social Worker stated that documentation of care conferences would be entered as a progress note in the resident's record. However, a review of the resident's Social Services Progress notes revealed that the last documented mention of a care conference was several months prior, and a review of the resident's assessments showed no evidence of care conferences. When the facility was asked to provide any documented evidence of care conferences for the resident, no documentation was provided by the end of the survey. The facility's own policy requires that care conferences be scheduled according to the MDS schedule, with invitations provided to the patient and/or responsible party, and that all attendees and discussions be documented. The lack of documentation and failure to include the responsible party in care conferences led to the deficiency cited in the report.
Failure to Supervise Use of Non-Medical Heating Pad
Penalty
Summary
Facility staff failed to provide appropriate supervision and accident prevention for a long-term resident with multiple medical conditions, including rheumatoid arthritis, ankylosing spondylitis, contractures, and intractable pain. The resident, who had intact cognition but required extensive assistance with mobility and ADLs, was found using a non-medical grade heating pad on their knees. The heating pad, brought from home by a family member, was applied by a CNA and left on for a couple of hours. The resident was unable to reach or adjust the heating pad independently due to physical limitations. There was no documentation in the resident's electronic medical record regarding the use of the heating pad, no physician order, and no care plan addressing its use. Facility staff, including the CNA, Unit Manager, RN, and DON, were unaware of the heating pad's presence or use, and facility policy did not permit such devices in resident rooms. The facility's risk management policy required the environment to be free from accident hazards and for residents to receive adequate supervision, but these protocols were not followed in this instance.
Failure to Provide Timely Incontinence Care and Maintain Resident Hygiene
Penalty
Summary
A deficiency occurred when a resident with a history of rheumatoid arthritis, ankylosing spondylitis, contractures, overactive bladder, and prior urinary tract infections did not receive timely incontinence care. The resident, who was cognitively intact and required extensive assistance with activities of daily living, reported not being changed overnight and was found lying in bed with a strong urine odor, wearing a soiled brief and lying on bedding with dried brown stains. Observations confirmed the presence of a strong odor and visible soiling of the bedding and mattress overlay, with staff interviews corroborating that the resident had not been changed for an extended period. Documentation and interviews revealed inconsistencies regarding care provided during the night shift. The CNA task report indicated the resident was last assisted with toileting in the early morning, with no further assistance documented for over 30 hours. Staff interviews indicated that the resident did not refuse care during the night in question, and there was no documentation of refusal in the medical record for that period. Both CNAs and the RN assigned to the resident acknowledged that the level of care observed was unacceptable, and the process for addressing refusals of care was not followed as documented in facility policy. The facility's policy required perineal care every two hours and documentation of all care provided, including attempts to re-approach residents who refuse care and notification of nursing staff. However, staff failed to provide timely incontinence care, did not document refusals or re-approach attempts, and did not communicate the resident's condition during shift changes. The lack of timely care and communication resulted in the resident remaining soiled for an extended period, with associated hygiene concerns noted by both the resident and hospital records.
Failure to Obtain Consent for Urine Toxicology Test
Penalty
Summary
The facility failed to adhere to a resident's right to decline a urine toxicity test, as evidenced by the case of a resident who was subjected to a urine sample collection without their consent. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15/15, reported feeling discriminated against and stated that the facility took a urine sample without permission and did not explain the reason for the test. The resident's clinical record showed orders for urine toxicology testing, but there was no documentation indicating the purpose of the test. The resident was observed to be alert and able to answer questions, and they expressed that staff had previously accused their visitors of smoking marijuana in their room, which they denied. Interviews with facility staff, including a social worker, nurse, physician, and the Director of Nursing, revealed a lack of awareness and documentation regarding the reason for the toxicology test and the facility's consent protocol. The nurse involved in the urine collection admitted to following physician orders without obtaining the resident's consent, as the resident was asleep at the time of collection. The physician who ordered the test cited concerns about the resident's behavior upon returning from a leave, but there was no documentation to support these concerns. The facility administrator acknowledged the absence of a specific policy on toxicology consent and confirmed that residents have the right to refuse treatment and testing, yet this right was not upheld in this instance.
Resident Involuntarily Secluded by Staff
Penalty
Summary
The facility failed to ensure freedom of movement for a resident, identified as R903, who was involuntarily secluded by staff members. On the date of the incident, R903 was placed behind three tables in the dining room, restricting their movement. This action was observed by other residents and staff members, who reported that the tables were positioned in a way that trapped R903, preventing them from moving freely. The incident was reported to the facility's administration the following day. R903 had a medical history that included generalized anxiety disorder, dementia, and delirium, and was known to exhibit wandering behaviors. The resident's care plan identified them as an elopement risk due to their wandering tendencies and confusion. Despite this, the staff members involved, including a CNA and an LPN, took measures to restrict R903's movement by placing them behind tables, which was not in line with the resident's care plan or their rights. Witnesses, including other residents and staff, confirmed the incident, and it was reported that the staff involved acted to avoid supervising R903. The facility's investigation revealed that the staff members involved were aware of the inappropriate nature of their actions, as evidenced by one CNA's attempt to persuade another to corroborate a false account of the event. The facility took disciplinary action against the staff involved following the investigation.
Failure to Timely Report Involuntary Seclusion Incident
Penalty
Summary
The facility failed to report an allegation of involuntary seclusion in a timely manner involving a resident diagnosed with generalized anxiety disorder, dementia, and delirium. The incident occurred when the resident was allegedly trapped between tables in the dining room by a CNA and an LPN, as reported by another resident who sent a picture to the Assistant Administrator. The Assistant Administrator received the report the following morning and informed the Administrator, who then initiated an investigation. The resident's movement was restricted, and the intent of the table positioning was believed to be to limit the resident's movement. The investigation revealed that two CNAs observed the incident but failed to report it. One CNA initially lied about the incident but later confirmed the restriction of movement during a follow-up interview. The facility's policy mandates immediate reporting of any abuse allegations to the Administrator or their designee, and the failure to adhere to this policy resulted in the delayed reporting of the incident to the State Agency. The facility's policy emphasizes providing care in an environment free from abuse, including involuntary seclusion, and requires immediate reporting of any allegations to the appropriate authorities.
Failure to Administer Prescribed Medication Leads to Hospitalizations
Penalty
Summary
The facility failed to administer an erythropoietin stimulating agent (ESA) as ordered by the physician for a resident, leading to multiple avoidable hospitalizations due to critically low hemoglobin levels. The resident, who had chronic normocytic anemia, chronic kidney disease, and other health issues, was supposed to receive the medication weekly. However, the medication was not administered for several months, despite the resident and their family repeatedly bringing the issue to the attention of the facility's administration. The resident's electronic medical record (EMR) showed that the medication was discontinued due to insurance non-coverage, and no alternative treatment was sought. The facility staff and providers were aware of the physician's order for the medication, yet there was no evidence of attempts to obtain it or communicate with the resident about the issue. The resident experienced multiple hospitalizations and blood transfusions due to low hemoglobin levels, which could have been prevented if the medication had been administered as ordered. Interviews with facility staff, including the nurse practitioner, unit manager, director of nursing, and administrator, revealed a lack of communication and follow-up regarding the resident's medication needs. The facility's policy required medications to be administered as prescribed, but this was not adhered to in the resident's case. The failure to provide the ordered medication resulted in significant distress and diminished quality of life for the resident.
Sanitation and Food Handling Deficiencies in Kitchen and Pantries
Penalty
Summary
The facility failed to maintain the kitchen and pantry refrigerators on the 1st and 2nd floors in a sanitary manner, which had the potential to affect all residents consuming food. During an initial tour of the kitchen, pooled milk was observed on the floor near milk crates in the walk-in cooler, and the shelving rack used for storing spices and food items had a heavy buildup of grease, food debris, and dust. The 1st floor pantry refrigerator was heavily soiled with dried food spills, and the microwave was soiled with splattered food debris. The 2nd floor pantry refrigerator contained various undated and expired food items, including moldy meat and rice, a moldy bag of fruit, and other perishable foods that were not stored according to the facility's policy. Additionally, three male kitchen staff members were observed with beards but were not wearing beard restraints while prepping food, serving from the steam table, and assembling trays for lunch service. This was confirmed by the Dietary Manager, who acknowledged that all kitchen staff with beards should wear beard restraints. These observations indicate a failure to adhere to the 2017 FDA Food Code requirements for maintaining cleanliness and proper food handling practices in the facility.
Failure to Employ Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker to meet the psychosocial, mental, and behavioral health care needs of its residents, as required for facilities with more than 120 beds. During a recertification survey, it was identified that the facility, certified for 159 beds, did not have a full-time licensed social worker from the time a previous social worker's license expired until a new hire was made. This deficiency was noted to potentially affect all 122 residents residing in the facility. The facility's job descriptions for social work positions did not specify the licensing requirements for a full-time social worker in a facility of its size. Interviews with the Administrator revealed that the facility attempted to cover the gap with part-time and contingent social workers, but none were full-time or had valid licenses during the period in question. The Administrator acknowledged that the lapse in maintaining a full-time licensed social worker was due to oversight by Human Resources, which failed to track the expiration of licenses and ensure compliance with staffing requirements.
Failure to Employ Full-Time Social Worker and Provide Social Services
Penalty
Summary
The facility failed to establish an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) plan, which led to sub-standard quality of care. Specifically, the facility did not employ a qualified full-time social worker and failed to provide necessary medically related social services. This deficiency had the potential to affect all 120 residents of the facility. The facility was previously found to be out of compliance for similar issues during an abbreviated survey, but the concern was not addressed effectively. The Administrator was unaware of the lack of a full-time licensed social worker until it was brought to their attention. The part-time social worker's license had expired, and another part-time social worker from a sister facility was assisting, but neither was full-time. The facility's Human Resources department failed to monitor the social worker's licensing status. Additionally, there was a lack of coordination for mood and behavior management, psychotropic medication oversight, care plan development, and guardianship follow-through, which were not addressed by the facility's QAA and QAPI processes.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by observations of soiled floors, walls, and visible pest harborage. Complaints were reported to the State Agency regarding the facility's housekeeping staff not keeping the facility clean, including resident rooms. The facility's policies on maintaining a homelike environment and cleaning were not adhered to, as seen in the conditions of the residents' rooms and common areas. In one instance, a resident's room was observed with a dried substance splattered on the wall and a soiled tube feeding pole. Another resident's daughter reported concerns about the cleanliness of the room, which included a leaking CPAP machine, a used disposable wipe with fecal matter, and debris scattered throughout the room. The administrator acknowledged the poor conditions and confirmed that some areas needed replacement or repair, but no audits were maintained to monitor these issues. Further observations revealed unsanitary conditions in dining areas, with dirty tabletops, unkempt floors, and food trays with insects. The administrator and housekeeping supervisor confirmed these observations, indicating a lack of proper cleaning and maintenance. The facility was under receivership, and the administrator noted recent changes in housekeeping management, but these issues persisted, affecting the residents' living conditions.
Failure to Provide Adequate Social Services and Guardianship Coordination
Penalty
Summary
The facility failed to provide adequate medically-related social services to address the psychosocial and mental health needs of residents, specifically in the areas of mood and behavior management, patient advocacy, and guardianship coordination. This deficiency was identified during a survey, which revealed that the facility did not follow up on the psychosocial needs of three residents, R22, R25, and R117, who were reviewed for social services. The facility had previously been found out of compliance for similar issues during an earlier survey. For resident R22, the facility did not document or address the resident's behaviors, which were reportedly due to pain that the resident could not verbalize. Despite being on multiple psychotropic medications, there were no care plans implemented to monitor specific behaviors or symptoms, and no documentation from social services regarding the resident's behavior or medication use. The facility's policy required monitoring and documentation of behaviors and symptoms for residents on psychotropic medications, but this was not followed for R22. Resident R117 had severe cognitive impairment but no designated power of attorney or legal guardian, despite the need for one. The social services staff left a voicemail for the resident's granddaughter regarding guardianship but did not follow up further. Similarly, for resident R25, who was determined unable to make medical or financial decisions, social services recommended guardianship to the resident's daughter but did not document any follow-up after the initial recommendation. These lapses in social services coordination and follow-up contributed to the facility's failure to meet the residents' psychosocial and mental health needs.
Inadequate Documentation and Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure adequate documentation and monitoring for a resident prescribed psychotropic medication, leading to prolonged unnecessary use. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and anxiety, was observed exhibiting behaviors such as yelling out. However, there was no documentation linking these behaviors to specific targeted symptoms that would justify the continued use of psychotropic medications. The facility did not attempt a gradual dose reduction (GDR) for the resident's medications, and the care plans lacked specific interventions or monitoring for the resident's behaviors. The resident's clinical records showed they were on multiple psychotropic medications, including antipsychotic, antianxiety, and antidepressant drugs, without adequate documentation of the behaviors these medications were intended to address. The facility's care plans were not implemented in a timely manner, and when they were, they did not include specific details about the resident's symptoms or behaviors. The facility's policy required documentation of behaviors and symptoms, but the records were incomplete, with some months showing no entries or lacking specific details. Interviews with the resident's family and healthcare providers revealed a lack of communication and understanding of the resident's behaviors. The Psych Nurse Practitioner and Attending Physician acknowledged the need for improvements but were unable to provide specific details about the resident's delusions or the rationale for continuing the medications. The facility's failure to document and monitor the resident's behaviors and the effectiveness of the psychotropic medications resulted in a deficiency in care, as outlined in the facility's policy for behavior and psychotropic medication monitoring.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as R22, who was observed seated behind the nursing station and repeatedly yelling out loudly. Despite attempts by staff to redirect the resident with a magazine and informing them that their daughter was out of town, the resident continued to yell. During these episodes, another resident in a nearby room yelled back for R22 to "Shut-up," and staff members were observed laughing immediately after this interaction. The staff did not verbally respond or attempt to redirect the resident who yelled at R22, nor did they address the situation appropriately. R22, who had severe cognitive impairment and was diagnosed with unspecified dementia, epilepsy, generalized anxiety disorder, major depressive disorder, and vascular dementia, was not treated with the dignity and respect outlined in the facility's policy. The facility's policy mandates that residents be treated with kindness, dignity, and respect, and any violations should be reported to the Director of Nursing Services or the Administrator. However, during the surveyor's observations, staff failed to address the inappropriate behavior directed at R22, and the facility's video surveillance was inadequate to provide clear evidence of the incident.
Failure to Provide Appropriate Mobility Equipment for Resident
Penalty
Summary
The facility failed to provide an appropriate wheelchair or Geri-chair for a resident with significant cognitive impairment and multiple medical conditions, including respiratory failure, stroke with right hemiplegia, and a tracheostomy tube. The resident was dependent on staff assistance for mobility and transfers and expressed a desire to get out of bed. However, observations revealed that the resident did not have a suitable chair in their room to facilitate this. Despite the resident's repeated requests to get out of bed, staff were unaware of the lack of a Geri-chair, and the resident remained in bed for several days. Interviews with staff, including an LPN and CNAs, indicated a lack of awareness and communication regarding the resident's need for a Geri-chair. The Director of Rehabilitation acknowledged the limited availability of Geri-chairs and confirmed that the resident used one. The Director of Nursing stated that staff were expected to assist residents in getting out of bed as they chose, but multiple observations showed this was not happening for the resident in question. The facility's policy on accommodation of needs was requested but not provided before the survey exit.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances reported by a long-term resident, identified as R104, and their family. R104, who had intact cognition, had multiple hospitalizations and was diagnosed with chronic normocytic anemia, CKD, respiratory failure, dry gangrene, and diabetes. The resident reported not receiving a prescribed medication to maintain hemoglobin levels for several months, despite addressing the issue with the facility administration and attending physician. The resident's family also raised the concern during a meeting with the facility administration and followed up with emails, but the issue remained unresolved. The facility administrator did not document any grievances for R104, despite multiple communications from the resident and their family. The family sent follow-up emails to the administrator on several occasions, expressing concerns about the medication, insurance paperwork, and therapy. The administrator responded once, acknowledging the emails but providing no specific resolution. The administrator claimed they were not present when the events occurred and were trying to get answers, but no further follow-up was conducted, and the medication issue persisted. During interviews, the administrator acknowledged the meeting with R104 and their family but dismissed the family's involvement as meddling. The administrator described the facility's grievance process, which involves staff initiating grievance forms and department leaders addressing concerns. However, the administrator did not explain why grievances from R104 or their family were not documented or addressed, indicating a failure to adhere to the facility's grievance policy.
Failure to Complete Annual OBRA Level II Evaluation
Penalty
Summary
The facility failed to complete an annual OBRA Level II Evaluation for a resident who was reviewed for PASARR. The resident was admitted with conditions including hemiparesis following a stroke, heart failure, diabetes, hypertension, vascular dementia, and bipolar disorder. Despite a Brief Interview for Mental Status indicating the resident was cognitively intact, there was no evidence of a Level II evaluation being completed. Instead, two 3877 forms were submitted, but the necessary 3878 dementia exemption form was not completed for either date. The Assistant Administrator indicated they were waiting for a physician's signature for the 3878 form, while the Social Services Coordinator was unable to locate the form in the resident's medical record or electronic portal. The Coordinator was also unaware of the option to reach out to the local OBRA Coordinator for assistance. The Social Services Coordinator acknowledged the failure to submit the forms timely, as the current forms were due by July 2024, and could not provide documentation of an exemption or a Level II PASARR.
Failure to Develop Resident-Specific Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop resident-specific comprehensive care plans for a resident with behavior-emotional needs and the use of psychotropic medications. The resident, who was observed yelling loudly while seated in a wheelchair, had a history of unspecified dementia with mood disturbance, generalized anxiety disorder, depression, and severe vascular dementia with agitation. Despite these diagnoses, the care plans lacked specific details about the resident's mood and behaviors, as well as targeted behaviors to monitor or approaches to de-escalate the resident. The care plans for the resident's use of psychotropic medications were not implemented until several months after the resident's readmission. The facility's policy on care planning, dated January 2020, did not ensure that care plans were resident-specific. During an interview, the Corporate Clinical Nurse indicated that the interdisciplinary team was responsible for ensuring care plans were specific to the resident's needs, but this was not reflected in the care plans reviewed.
Failure to Secure Smoking Materials in Non-Smoking Facility
Penalty
Summary
The facility failed to secure smoking materials for a resident, R15, who was reviewed for smoking, despite being a non-smoking facility. During an entrance conference, the administrator stated that the facility did not have any current smokers. However, observations and interviews revealed that R15, who had a history of nicotine dependence and other medical conditions, kept smoking supplies hidden in their room and smoked without staff assistance or monitoring. R15 was observed sitting in their power wheelchair and reported that they would go out to smoke, keeping cigarettes and a lighter in their coat pocket. Staff, including a CNA, were aware of R15's smoking habits, yet no proper supervision or security of smoking materials was in place. The facility's records, including physician and social worker notes, indicated that R15 was a current smoker and had been informed of the non-smoking policy. Despite this, the unit manager and administrator were unaware of R15's smoking activities until notified by surveyors. The unit manager initially claimed there were no smokers in the facility, and the administrator acknowledged the concern only after being informed of the observations. The lack of proper supervision and failure to secure smoking materials posed a potential risk of burns from smoking materials that were unsecured.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an observed error rate of 8.33%. This deficiency was identified during a medication administration observation involving three residents. The Licensed Practical Nurse (LPN) was observed administering enteric-coated aspirin instead of the prescribed chewable aspirin to three residents. Specifically, the LPN crushed and administered enteric-coated aspirin to two residents and administered it without crushing to another resident, contrary to the physician's orders. The Director of Nursing acknowledged that the LPN should have administered the correct medication as ordered and that enteric-coated medications should not be crushed for administration. The facility's policy on medication administration, dated December 2019, requires medications to be administered in accordance with the physician's written orders.
Lack of Access to Survey Results for Residents and Visitors
Penalty
Summary
The facility failed to ensure that residents and visitors had access to previous survey results, which resulted in them being uninformed of deficiencies identified in the facility. The facility's policy on Resident Rights, dated 7/11/2018, states that residents have the right to examine the results of the Nursing Center's most recent survey and the plan of correction prepared in response. However, a review of the survey information binder revealed that there was no documentation available from surveys conducted on 12/20/23, 5/8/24, 6/17/24, and 7/30/24 since the last recertification survey on 10/12/23. During environmental rounds, the Administrator confirmed that the binder had not been updated and mentioned that an Assistant Administrator, hired on 9/9/24, was responsible for this task. The Administrator did not provide an explanation for who was responsible for updating the binder prior to the recent hire. Further review of the binder on 10/2/24 showed no updates since the discussion with the Administrator.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bloomfield Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodward Hills Health And Rehabilitation Center | 1.7 mi | ★★★★★ | 19 | 0 |
| Regency At Troy | 2.3 mi | ★★★★★ | 18 | 0 |
| Pomeroy Living Rochester Skilled Rehabilitation | 3.1 mi | ★★★★★ | 13 | 0 |
| Harmony Village Of Clawson | 4 mi | ★★★★★ | 3 | 1 |
| Harmony Village Of Beverly Hills | 4.1 mi | — | 15 | 1 |
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