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 Muskegon during CMS and state inspections, most recent first.
A resident with stroke-related deficits, unsteadiness, and dependence for bed mobility fell during incontinent care when a CNA rolled her away from herself while she was near the edge of the bed. The resident struck her head on a nightstand and was sent to the ED with a nasal fracture, facial lacerations, and other abrasions and bruising. The CNA stated she knew she was not supposed to roll the resident away from her when alone but did so while trying to clean her after a large BM.
Food safety and sanitation deficiencies were observed in the kitchen and dining area. An ice machine drain line was not air gapped, a juice dispenser cobrahead had mold growth, and several Mighty Shake containers were held without required date marking. The dishmachine did not display final rinse temperature, and a plate simulator showed a 136°F surface temperature. A dietary employee also cut lettuce without rinsing it first before preparation.
Failure to implement infection prevention and control measures was identified when staff did not follow EBP for residents with an AV fistula and a surgical wound/groin fissure, including missing PPE use and missing room signage. An RN also handled medication doses directly and performed care without PPE, while the ICP was unaware of the resident’s EBP status. The facility also could not confirm the status of unused water lines in a housekeeping area, and a resident’s CPAP machine was left uncleaned with no cleaning schedule or policy guidance in place.
A facility failed to develop and/or implement comprehensive care plans for residents with skin breakdown, pressure injury risk, CPAP needs, and mobility deficits. One resident with ALS and dementia had a heel blister misidentified in the care plan and was repeatedly observed without heel offloading; another resident with multiple wounds had an incomplete wound care plan and was not on the documented APM. A resident who used CPAP had no CPAP care plan, and another resident with a left heel injury had ordered boots and heel offloading listed but was observed without the devices and with both heels on the mattress.
Insufficient staffing on the 400 and 500 Hallways left residents with high care needs without timely assistance. A resident who required a hoyer and 2-person transfers said staff often could not get him up, while another resident said he stopped asking because staff kept telling him no. Staff described very high acuity, limited CNA coverage, and difficulty meeting ADL, feeding, and shower needs; during breakfast, only two aides and one nurse were covering the hallways while several residents needed help at the same time.
Incomplete medical records for three residents involved missing hospice, wound care, and CPAP documentation. One resident receiving hospice services had no hospice order, progress notes, assessments, or hospice contract in the chart, another resident’s wound records did not match the wounds and outside wound clinic care being provided, and a third resident using CPAP had no physician order, RT assessment, RT notes, or care plan for the device.
Premises Maintenance and Cleanliness Deficiencies: The facility failed to maintain general cleanliness and repair in multiple areas, including a hallway restroom sink with no cold-water flow and hot water at 116 degrees F, visible mold growth under an ice machine drain cabinet, missing handrail end caps, a broken corner guard, a missing handrail, holes in a wall with an unsecured ethernet cord, gaps at an exterior door, and a very humid shower room. The MM stated he was not aware of several of these issues.
Failure to Provide Dignified Dining and Private COVID-19 Testing: Residents were not given a dignified dining experience when a resident requesting tomato soup was not offered an alternate choice, other residents’ requests for butter were not addressed at the table, and meal concerns were redirected to a food council meeting. In addition, an RN performed COVID-19 swabbing in the dining room while residents were eating and in full view of others, which the IC nurse said was not appropriate for resident dignity and privacy.
Failure to Address Resident and Family Grievances: A resident with severe malnutrition, nutritional deficiency, and dysphagia and the resident’s family member reported that ordered protein supplements were frequently missing from meal trays and that a paid haircut was unsatisfactory. Observations confirmed missing supplements at meals, and review of concern forms showed the supplement and haircut issues were not documented through the facility’s grievance process.
The facility failed to complete PASARR Level II reviews on time for two residents with serious mental health diagnoses, including schizophrenia and depression. One resident’s Level II was completed late and the other resident’s required annual Level II was not completed when due. Staff reported problems during a company transition, and the RNC stated she was not aware of PASARR concerns or any POC being worked on.
Failure to Complete Baseline Care Plans Within 48 Hours Two residents did not have baseline care plans completed within 48 hours of admission. One resident had multiple pressure injuries, including wounds to the sacrum and both thighs, but the care plan did not address all wounds, turning/positioning, or outside wound clinic care. The resident was observed with wounds and inadequate pressure-relief support, and the care conference was delayed. Another resident had a CPAP machine and respiratory needs noted on admission, but staff did not care plan the CPAP or respiratory care. The UM confirmed CPAP settings were obtained from the hospital, while the SW stated the baseline care plan was completed after admission and was not started until several days later.
A resident with a UTI, COVID, and repeated falls was not consistently monitored for infection or respiratory status, and missed antiviral doses were documented when the pharmacy did not have the ordered medication. The resident later became hypoxic, more altered, and was hospitalized with septic shock and pneumonia, with blood cultures positive for E. coli presumed urinary in origin. A second resident with a history of pressure ulcers had coccyx/buttocks skin breakdown that was documented as a recurring pressure injury, but later assessment showed blanchable purple maceration and denuded skin consistent with MASD, with stool present and no point-of-care evidence that turning and repositioning was being carried out.
Failure to prevent and manage pressure injuries: Three residents with existing skin breakdown or pressure injuries were observed without effective pressure relief measures. One resident with wounds to the sacrum, thighs, and calf was not on an APM and had unclear wound documentation, another resident with a heel DTI was found with heels still resting on the mattress despite boots being ordered, and a third resident with a heel blister had repeated observations showing both heels on the bed or pressed against the footboard despite care plan interventions to offload pressure.
Failure to support a resident’s left arm during mobility and positioning. The resident had hemiplegia/hemiparesis affecting the left side, and staff observed the arm flaccid and unsupported while the resident was in a wheelchair, in bed, and during transport out of the facility. The care plan called for a LUE sling when seated in a wheelchair or standing/ambulating, and OT confirmed the sling was to be used to support the arm. A CNA reported the sling was usually applied before dialysis, but it was not used that day and was later found in the closet under clothes.
A resident had an unapproved nasal spray left at the bedside and another resident had assorted pills and capsules at the bedside without being assessed or ordered for self-administration. The facility also failed to fully investigate and document multiple falls for a resident with limited mobility, including missing neuro checks after unwitnessed falls, incomplete care planning tied to toileting and call-light use, and a documented fall policy that was not followed.
A resident with severe protein-calorie malnutrition, dysphagia, and significant weight loss had care plans ordering Mighty Shake and Magic Cup TID with meals, but the supplements were frequently missing from meal trays. A family member reported they were absent most of the time, staff observed meals without the ordered supplements, and the RD confirmed one supplement was missing even though the MAR-TAR documented it as given.
A resident with a PEG tube had ongoing redness, irritation, and drainage at the insertion site, but skin assessments documented no skin concerns. During observation, an LPN noted reddish clear drainage and a red, crusted site, yet the EMR showed no documentation that the physician was notified or that follow-up occurred.
Failure to assess, monitor, and treat a resident's respiratory condition was identified when a resident who used CPAP for breathing support had the machine at bedside but reported no assistance since admission. The UM obtained CPAP settings from the hospital RT and ordered equipment, but there was no physician order, no respiratory assessment, and no RT documentation in the chart; the facility CPAP policy required a physician order before CPAP use.
A resident with ESRD and dependence on dialysis did not receive coordinated dialysis care consistent with professional standards. The facility had incomplete dialysis communication forms, lacked consistent documentation of pre- and post-dialysis BP monitoring, and did not document follow-up when the resident was observed with nausea, lightheadedness, and a BP of 85/45 before transport to dialysis. The resident’s BP meds appeared inconsistent with dialysis-related needs, and Sevelamer was not consistently given with meals as confirmed by the RD and dialysis RN.
Failure to offer and provide Influenza and pneumococcal immunizations for a resident admitted with hydrocephalus, diabetes insipidus, dysphagia, and a communication deficit. The EMR had no vaccination records, no vaccine orders, and no consent request to the responsible party. The IP stated she had not reviewed the resident’s vaccination status or obtained consent because she had been off work, despite confirming that vaccination review and consent attempts are expected on admission.
Failure to offer and document COVID-19 vaccination for a resident with hydrocephalus, diabetes insipidus, dysphagia, and a communication deficit. The EMR had no consent request, no vaccine orders, and no vaccination record, and the IP stated the resident’s records were not reviewed and consent was not attempted because she had been off work.
Survey Binder Missing Required Survey Results: The facility failed to keep Federal or State survey results and any plan of corrections for the past 3 years readily accessible to residents, family members, and legal representatives. A survey binder near the front door was observed without any Federal or State surveys for 2025, and the RNC acknowledged the binder should have contained the last 3 years of surveys but did not.
A resident with significant physical and cognitive impairments was sent alone to an outside medical appointment via contracted transportation, despite rarely getting out of bed and being dependent for mobility. Upon arrival, the resident was found sliding out of the wheelchair, unable to reposition, and in pain, requiring EMS transport back. Facility staff did not assess the need for accompaniment or notify the resident's representative, contrary to facility policy.
A resident with cryptococcus meningoencephalitis missed 19 doses of itraconazole due to the facility's failure to request the medication timely. The facility also did not perform necessary lab tests and an EKG as ordered by the Infectious Disease clinic. Despite procedures to address unavailable medications, the DON was unaware of the issue, and the facility canceled a follow-up appointment without proper documentation.
The facility failed to meet food safety standards, with issues such as inadequate handwashing water temperature, improper food date marking, and unsanitary kitchen conditions. Observations included mislabeled nutritional shakes, improperly thawed ground beef, and debris on equipment. Ice machines had crusted debris and leaks, and refrigeration units were improperly set, leading to discarded milk. Wet pans were not air-dried, violating FDA guidelines.
The facility failed to maintain cleanliness and repair, leading to potential contamination risks. Missing light shields were observed in various areas, including the kitchen and linen rooms. A janitor's closet setup caused undue back pressure on a vacuum breaker, and a non-operational sink in a restroom lacked signage. Items were found on the floor in a storage room, and raw wood shelves in a linen closet were not easily cleanable.
Two residents experienced delays in receiving care, impacting their dignity and self-determination. A resident with a history of stroke reported feeling forgotten due to staff delays in responding to his call light, particularly in the mornings. Another resident, who is cognitively intact, experienced prolonged waits for assistance with changing his brief, especially during the day shift.
A resident with hemiplegia and hemiparesis was not provided with appropriate care planning and follow-up after falls. The facility failed to update the care plan after a reported fall, did not complete required assessments, and inaccurately documented MDS assessments. The resident expressed concerns about his functional capabilities and lack of assistance with ambulation, contrary to his care plan. The facility's fall policy was not adhered to, resulting in fragmented care.
A facility failed to monitor a resident's Stage 4 pressure ulcer for six weeks due to a change in dialysis schedule and staff responsibilities. The resident, with multiple health issues, was admitted with the ulcer, and the care plan required weekly assessments. The oversight occurred as the wound care company visited on a day conflicting with the resident's new schedule, and a new staff member was assigned to wound rounds.
A resident with a history of stroke-related conditions and moderate cognitive impairment was not provided with proper care for enteral feeding and PEG tube site management. A registered nurse disconnected the resident from the feeding infusion without flushing the tube, violating facility policy. Additionally, the dressing at the infusion site was not consistently changed as per physician orders, with no documentation of refusals or communication with the interdisciplinary team.
The facility failed to maintain complete and timely medical records for two residents, leading to potential issues in care continuity. Both residents required updated PASARR Level II Evaluations, but the documentation was delayed, being added to their EMRs months after the evaluations were conducted and only after surveyor requests.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube, as staff did not wear gowns during high-contact activities. The resident's Treatment Administration Record lacked EBP orders for two months, and the Care Plan did not reflect the need for EBP, despite the facility's policy requiring PPE use to prevent MDRO transfer.
The facility failed to ensure effective hot water sanitization of dishware, as the dishwashing machine did not reach the required 160°F surface temperature. Despite the incoming water temperature being 194°F, tests showed dishware temperatures below the required level. Logs from May to July consistently recorded temperatures below 160°F, and no corrective action was documented.
A resident with Parkinson's Disease, Arthritis, and Anxiety, dependent on staff for toilet use, was injured during a mechanical lift transfer. A CNA conducted the transfer alone, contrary to facility policy requiring two staff members. The resident reported the CNA moved too fast and grabbed her hand, resulting in a bruise. An X-ray showed soft tissue swelling. The CNA admitted to performing the transfer alone due to staff unavailability.
Fall During Incontinent Care Resulted in Facial Injury
Penalty
Summary
The facility failed to prevent a fall with injury for one resident who had a history of cerebral infarction, lack of coordination, muscle spasm, and dependence on staff for bed mobility and toileting hygiene. The resident’s fall risk assessment identified routine incontinence, moderate to severe unsteadiness, multiple medications that increased fall risk, and multiple diseases or conditions that increased fall risk. During incontinent care, the resident was positioned on her side near the edge of the bed while a CNA was providing care. According to the record and interviews, the CNA rolled the resident away from herself while the resident was too close to the edge of the bed. The resident then tried to look at a bruise on the back of her leg, lost balance, and rolled off the bed. The CNA stated she knew she was not supposed to roll the resident away from her when alone, but did so anyway while trying to clean the resident after a large bowel movement. The CNA also stated the bed had been raised to a high height before care began, and the resident’s bedside drawer was open when the fall occurred. The resident struck her head on the nightstand and was found on the floor with a large amount of blood under her head. She was sent to the emergency department and later returned with a closed nasal bone fracture, facial lacerations requiring stitches and adhesive closure, and additional abrasions and bruising documented after the fall. The CNA received a final written warning for carelessness or negligence related to the incident, and the facility’s repositioning policy stated residents should be positioned in the middle of the bed and rolled toward the staff member.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during multiple observations and record reviews. In the dining room, the drain line for the ice machine was observed without an air gap, with the flexible line sitting directly in the drain. During interview, the Maintenance Manager stated he was not aware the drain line was not properly air gapped. In the kitchen, a juice dispenser cobrahead had sugar mold growth on the surface inside the beverage diffuser. The Certified Dietary Manager stated the cobrahead was soaked nightly, but there was no physical agitation of the interior of the beverage diffuser. In the reach-in cooler, several chocolate flavored Mighty Shake containers were observed in a liquid state inside a larger black container without a pull date or facility-applied use-by date. The Certified Dietary Manager stated the shakes had been pulled that day and had not been dated because they were thawing, although the facility’s labeling and dating procedure indicated Mighty Shakes are to be assigned an open date/prepare date and a use-by date. The dishmachine was observed not displaying final rinse temperature during the wash, rinse, and sanitize cycle, making it difficult for staff to determine whether it was working properly. The Certified Dietary Manager stated the sanitizing cycle was validated using a plate simulator to monitor maximum plate surface temperature. When the plate simulator was used, the surface temperature measured 136 degrees F, and the Certified Dietary Manager stopped the dishwashing process and instructed staff to use paper products for the upcoming meal. In addition, a dietary employee was observed cutting tomatoes and then immediately cutting lettuce taken from a plastic bag in a cardboard container without rinsing the lettuce first; when asked, the employee stated the lettuce had not been rinsed and discarded the cut produce.
Failure to Implement Infection Control, EBP, and Water Management Practices
Penalty
Summary
The facility failed to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and its water management program for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During observation, a CNA provided incontinence care to a resident with an AV fistula while wearing only gloves and a surgical mask, despite a sign outside the room indicating EBP and a care plan directing staff to wear a gown and gloves for high-contact care activities. The resident’s physician orders reflected EBP for infection control related to the AV fistula. A second resident with ALS, dementia, a left hip incision, and a right groin fissure was also identified as requiring EBP, with the care plan directing staff to wear a gown and gloves during high-contact resident activities. During observation, an RN prepared medications by touching each pill and tablet after removing them from packaging or pouring stock medication into her hand before placing the dose in the medication cup. The same RN later assisted with an assessment of the resident’s heels without donning PPE. When the resident was repositioned in bed, neither the RN nor the CNA wore PPE, and both stated they did not know the resident required EBP. The room did not have a sign indicating EBP, and the ADON, who served as the Infection Control Preventionist, stated she was not aware the resident required EBP and had not identified that the signage was missing. The facility also had unresolved concerns related to premise plumbing and respiratory equipment. In a housekeeping room on Hall 500, painted water lines remained after removal of a hopper, and staff could not confirm whether the lines were operational or whether they were on the flushing schedule. The facility’s water management program required an annual risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. In addition, a resident with a CPAP machine had the device on the nightstand with the mask attached to the hose and lying on the floor, with water still in the tank and no visible cleaning or storage items. The resident stated the machine had not been cleaned since admission, and the UM reported that no cleaning or use schedule had been established and no record of cleaning could be found. The facility’s CPAP policy did not include instructions or a need for cleaning.
Incomplete Care Plans and Failure to Implement Ordered Pressure Relief and Respiratory Support
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for 4 residents reviewed for care planning, including residents with skin breakdown, respiratory needs, and mobility-related pressure injury risks. For one resident with ALS, unspecified dementia, and a right heel blister on admission, the care plan incorrectly identified the blister as being on the right heel when it was on the left heel, and the resident was repeatedly observed with both heels resting on the mattress or pressed against the footboard despite care plan interventions to offload the heels. The resident also reported that staff do not elevate his heels off the bed to prevent pressure and stated he did not like the total lift used by the facility. Another resident was admitted with diagnoses including pressure-induced deep tissue damage of the sacral region, Alzheimer’s disease, and muscle wasting, and had multiple wounds documented on the sacrum, both thighs, and left calf. The care plan addressed only buttock pressure areas and did not include the thigh and calf wounds, nor did it include instructions for turning, positioning, or use of equipment and pillows for pressure relief. During observation, the resident’s knees were touching, the back of the thighs were in contact with the calves, and wound dressings were present without date or staff initials. The resident was also not on an alternating pressure mattress at the time of observation, despite the care plan listing one. A third resident used CPAP at the hospital and reported that no one had assisted with the CPAP or breathing needs since admission, yet the care plan did not mention CPAP use or respiratory care needs. A fourth resident with hydrocephalus, muscle wasting, unsteadiness on feet, and cognitive communication deficit had a care plan for a left heel deep tissue injury and ADL deficits that included bilateral foot drop boots and heel offloading, but the resident was observed with both heels in contact with the mattress and no boots or splints in the room. The resident said he could not tolerate the boots and was willing to use pillows under his legs, but the care plan did not reflect the observed positioning or the resident’s refusal of boots.
Insufficient Staffing on 400 and 500 Hallways
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of residents on the 400 and 500 Hallways and failed to have staffing that matched the high acuity and psychosocial needs of the residents. The deficiency was identified through observation, interview, and record review for 25 residents, including two residents who reported that they were not getting up from bed because staff said there was not enough help. One resident stated that when he asked to get up, staff made excuses and that he was mostly left in bed with only brief staff contact during the day. Another resident stated that staff could not find enough help to get him up and that he had stopped asking because he was repeatedly told no. Record review showed that one resident had diagnoses including COPD, muscle wasting and atrophy, polyneuropathy, depressive disorder, and anxiety disorder, and required a hoyer lift and two people for transfers. Staff interviews confirmed the heavy care burden on the hallways. An LPN stated that acuity was high and almost everyone on the 400 Hallway was a 2-person hoyer. CNAs reported that there were only limited aides assigned to the hallways, that one aide covered the 400 Hallway, one aide covered the 500 Hallway, and a wrap-around aide from another hallway covered only two rooms on the 400 Hallway. The LPN also stated that staff were struggling because of the level of acuity and that nursing duties, medications, and wound care limited the ability to assist CNAs. The resident needs list provided by the MDS Nurse and Regional MDS Nurse showed that 13 of 25 residents required 2-person assistance for mobility, 4 of 24 required help with eating, and two residents were totally dependent for all ADL care. During breakfast observation, only two aides and one nurse were working the 400 and 500 Hallways, three call lights were on, and three residents needed help with breakfast while aides were hurrying to finish passing trays. One CNA was observed leaving a resident’s room to get another CNA to help boost the resident in bed so breakfast assistance could be provided. Another resident stated he no longer received showers and only got bed baths, and he said he no longer got asked to join activities and spent his days alone with his TV.
Incomplete medical records for hospice, wound care, and CPAP treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident with hemiplegia and hemiparesis following cerebrovascular disease, muscle wasting and atrophy, and dementia, the record showed only a hospice consult order, but did not contain a hospice care order, progress notes, assessments, or a hospice services agreement/contract. Staff observed that the resident was being seen by hospice and receiving care from hospice CNAs, yet the resident’s chart did not reflect the hospice services being provided, and a regional nurse consultant stated the facility did not have a contract in the building for that hospice provider. For another resident admitted with pressure-induced deep tissue damage of the sacral region, Alzheimer’s disease, and muscle wasting, the wound documentation did not match the resident’s actual wounds and treatment. The unit manager stated the resident had multiple wounds on the backs of both thighs and calves on admission, but documented them in a way that did not identify the number of wounds, only the amount of space involved. The wound care record also reflected buttock pressure injury care, but did not indicate the skin issues on the thighs and calves, and the care plan did not show that the resident was being treated by an outside wound clinic even though staff were aware of outside wound care involvement. For a third resident admitted with muscle wasting and atrophy, burns involving 10-19% of body surface, and unsteady gait, the medical record did not contain physician orders, respiratory assessments, respiratory therapist documentation, or a care plan for CPAP use. The resident had a CPAP machine at the bedside and stated he normally used it when sleeping, but staff reported he had not come with the machine from the hospital and that the unit manager obtained CPAP settings from the hospital respiratory therapist and ordered equipment without contacting the physician or locating documentation supporting its use in the facility record.
Premises Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises affecting halls 100, 200, and 400. On Hall 100, the hallway restroom hand sink had no cold-water flow, and all water at the sink came from the hot-water line at 116 degrees F. In the dining room on Hall 400, visible mold growth was observed at the bottom of the cabinet where the ice machine drain was located. On Hall 100 and near a room on Hall 400, the end caps on handrails were missing, a wall had holes less than a half inch in diameter with an unsecured ethernet cord coming out of the hole, and a broken plastic corner guard was observed by a room door. On Hall 100, a handrail was missing in office spaces prior to a room, with the connectors still attached to the wall. The Maintenance Manager stated he was not aware of the missing handrail parts, corner guards, or the missing handrail and had started the position that day. On Hall 200, an exterior door by the therapy room had gaps larger than 1/4 inch at the bottom, and the Maintenance Manager stated he was not aware of the gaps. On Hall 300, the shower room felt very humid even though the shower did not appear to have recently been in use and the shower tiles were dry.
Failure to Provide Dignified Dining and Private COVID-19 Testing
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the dining/activity room. During the noon meal, R79 and her husband voiced complaints about being served cabbage too frequently and stated she would have preferred tomato soup, but staff did not respond by offering the alternate soup choice. R79 and her husband said they had been told no in the past when asking for substitutions and were told meal choices had to be made before 10:00 AM for lunch. At the same meal, R94 and other residents were heard discussing that they could not get butter with their vegetables and that staff were not concerned about their meal concerns. The facility RD was present, told R94 she would add butter to his meal ticket, and told the other residents to take their concerns to the food council meeting, but staff did not bring butter to the table for the other residents who requested it. The facility also failed to maintain resident dignity during COVID-19 testing in the dining room. While R19 was eating lunch with two guests seated at his table, an RN approached him in the dining room and announced he needed to be tested for COVID-19, then swabbed both nostrils in full view of others. The RN later returned and swabbed an unknown female resident seated at another table across from R19 while she was eating with three other residents, again in full view of several residents and staff. The IC nurse stated that COVID-19 testing should not be done in a public area out of respect for each resident's dignity and privacy.
Failure to Address Resident and Family Grievances
Penalty
Summary
The facility failed to follow its concern/grievance process and address resident and family concerns for one resident who was admitted with severe protein-calorie malnutrition, nutritional deficiency, and dysphagia. The resident’s family member reported that the ordered Magic Cup and Mighty Shake supplements were not on the resident’s meal tray about 75% of the time and said this had been complained about many times because of the resident’s significant weight loss. The resident also reported frustration that the nutritional supplements were not consistently provided with meals as ordered. The resident and family member also reported being unsatisfied with a haircut paid for through the facility beautician, stating the haircut did not match what was requested and that staff had not resolved the issue. Observations showed the resident’s noon meal was served without the ordered supplements on one occasion, and on another occasion the Magic Cup was present but the Mighty Shake was missing despite the tray ticket indicating it should have been provided. Review of concern forms showed only one form for the resident, and it did not address the haircut or supplement concerns. The activity director reported the haircut issue was not new and that the resident was scheduled for another haircut, while the regional nurse consultant stated staff who were made aware of the concerns should have followed the facility grievance process.
Late PASARR Level II Reviews for Two Residents
Penalty
Summary
The facility failed to address PASARR requirements in a timely manner for 2 residents, R11 and R12, resulting in late completion of required Level II reviews. The facility policy stated that the Social Service employee or designee was responsible for verifying PAS and/or ARR processes were completed appropriately and timely, including prior to admission, after a significant change, and at least annually. The policy also stated annual reviews are due within one year of the previous submission or as indicated on the Level II evaluation, and may be completed no sooner than 90 days before the due date. R11 had diagnoses including Anxiety Disorder, Schizophrenia, Major Depressive Disorder, Obsessive Compulsive Disorder, and Post-Traumatic Stress Disorder. R11’s prior Level II indicated the next Level II was due by 7/24/25, but the facility did not have a completed Level II in the record when reviewed, and Social Worker B later confirmed it was completed late on 8/18/25. R12 had diagnoses of Disorganized Schizophrenia and depression, and the record showed a Level II letter stating the next evaluation was needed by 12/01/25; however, the 2025 Level II was not completed. Social Worker B stated the facility had problems with timely Level I and Level II completion during a company transition, had started a tracking sheet, and said the missed Level II reviews had been an issue since November. The Regional Nurse Consultant stated she was not aware of concerns regarding PASARRs and that the facility was not working on a plan of correction regarding PASARRs.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for two residents, R23 and R25. For R23, the admission record showed diagnoses including pressure-induced deep tissue damage of the sacral region, Alzheimer's disease, and muscle wasting, and she was not her own responsible party. Her records documented multiple wounds, including pressure injuries to the right thigh, left thigh, and sacrum, with wound measurements and staging noted in the admission evaluation and skin assessment. During observation, she was found in bed with her knees touching, her thighs and calves in contact, and an open wound visible on the back of her left thigh without a dressing in place at one point. Later observation showed she was not on an alternating pressure mattress, and the dressing on her buttock lacked a date or staff initials. R23's care plan did not include the thigh and calf wounds, did not reflect the use of an outside wound clinic, and did not include instructions for turning, positioning, or use of pillows or equipment for pressure relief. The social worker stated that baseline care plans were done during the initial care conferences, but R23's care conference was not held until 5 days after admission, and there was no indication the care plan was reviewed with her responsible party. The wound consultant was also unaware that R23 was receiving wound treatment at an outside clinic, and no wound clinic notes were located in the record. For R25, the admission record showed diagnoses including muscle wasting and atrophy, burns involving 10-19% of body surface, and unsteady on feet. He was observed with his CPAP machine on the nightstand and stated that he normally uses it when sleeping but had not been assisted with his CPAP or breathing needs since admission. The unit manager confirmed the hospital discharge summary indicated CPAP use, obtained CPAP settings from the hospital respiratory therapist, and stated she did not care plan his CPAP machine or respiratory care needs. The care plan contained no mention of CPAP or respiratory care, and the social worker confirmed the baseline care plan was completed after admission and that the care plan was not started until several days later, with no indication that R25 or his advocate were aware of it.
Failure to Monitor Infection and Skin Breakdown
Penalty
Summary
The facility failed to monitor care to potentially prevent sepsis and hospitalization for one resident with multiple acute illnesses and failed to assess and monitor moisture associated skin damage for another resident with skin breakdown. One resident was admitted with diagnoses including a displaced right femur fracture, emphysema, and mental disorder, later developed sepsis and pneumonia, and had an 8/21/25 fall while trying to urinate. The resident was found on the floor in front of a radiator with a small laceration to the back of the head and was sent to the emergency room because he was taking Eliquis. The hospital record documented a urinary tract infection with positive urinalysis findings and treatment with Keflex, but the facility had no documentation of follow-up on the urine culture or ongoing assessment and monitoring of signs and symptoms of infection after the UTI diagnosis. The same resident later tested positive for COVID and was ordered Molnupiravir, but the medication was unavailable from the pharmacy and several doses were missed before the order was changed to Paxlovid. The record did not show ongoing respiratory assessments after the COVID diagnosis. The resident then fell again while attempting to dress himself, with his call light not in reach and his shorts down at his ankles. He was assessed at the facility, started on neuro checks, and later transferred to the hospital, where he was noted to be hypoxic, progressively altered, and admitted to the ICU for septic shock secondary to bacterial pneumonia. The hospital discharge summary documented COVID-19 pneumonia and septic shock, with blood cultures positive for E. coli presumed to be from a urinary source. For the second resident, the record showed a history of osteomyelitis, pressure ulcers, and acute kidney failure. Nursing documentation identified an open area on the coccyx with purple tissue and surrounding red non-blanchable skin, and later notes described a recurring pressure ulcer on the coccyx and a new buttocks skin issue. The January treatment record included orders for the left heel and buttocks wound care, and the care plan addressed a left heel wound and recurring pressure ulcer to the sacrum. However, during observation the resident was found sitting in stool, and nursing assessed the buttocks as having purple maceration and denuded skin consistent with MASD. The resident also had documented loose stools/diarrhea, and the record showed no point-of-care documentation that turning and repositioning tasks were being completed.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide care and services according to professional standards to prevent the development and/or worsening of pressure injuries for three residents reviewed for pressure injuries. One resident had multiple wounds on the sacrum, both thighs, and a calf, with documentation showing pressure injuries on admission and later assessments noting a sacral wound with undermining and wounds on the backs of both thighs and the left calf. During observation, the resident was in bed with knees touching and the back of the thighs in contact with the calves, and there was no dressing on one thigh wound. The resident was not on an alternating pressure mattress at the time of observation, and the wound care documentation did not clearly reflect all wound locations or the involvement of outside wound services. A second resident was admitted with diagnoses including hydrocephalus, muscle wasting, unsteadiness on feet, and cognitive communication deficit, and had a deep tissue injury of the left heel. The care plan included use of bilateral PROFO boots while in bed and turning/repositioning, but the resident was observed with both heels in contact with the mattress and no boots or splints in the room. The resident stated he could not tolerate the weight of the boots and was willing to use a pillow under his legs to float the heels, but later observation showed pillows bunched under the knees while both heels remained in full contact with the mattress. The DON confirmed the pillows under the knees did not remove pressure from the heels. A third resident admitted with ALS, dementia, and developmental impairment had a right heel blister on admission assessment, while the care plan identified the blister as being on the right heel even though the blister was documented on the left heel. The resident was assessed as at risk for pressure ulcers and had care plan interventions to turn and reposition and use a pressure reducing surface, with additional interventions to offload the heels. However, repeated observations showed both heels resting on the mattress or feet pressed against the footboard, with no offloading devices or additional pillows in the room. The resident stated staff do not elevate his heels off the bed to prevent pressure, and the RNC stated the expectation was that the heels would be positioned to relieve pressure with a heels-up device and the bed extended with the footboard removed.
Failure to Support Resident’s Left Arm During Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason was not met when the facility failed to ensure proper positioning and support for one resident with left-sided weakness. The resident had diagnoses including hemiplegia and hemiparesis affecting the left side and chronic kidney disease. During observation, the resident was seen transporting down the hall in a wheelchair with the left arm flaccid and not supported, and later was observed in bed without support for the left arm. The resident was then transferred to a wheelchair for an appointment, and the left arm remained unsupported and hanging down in the lap while being transported out of the facility. The care plan included an intervention for a left upper extremity sling when seated in a wheelchair or standing/ambulating as the resident would allow, and the occupational therapist stated the resident was to have a sling in place to support the left upper arm. A CNA reported the resident usually had a sling put on before dialysis, but since dialysis was not scheduled that day, the sling was not on, and it was later found buried under clothes in the closet.
Unsafe bedside medications and inadequate fall supervision
Penalty
Summary
The facility failed to prevent unsafe self-administration of medications left at the bedside for two residents. One resident, who was her own responsible party and had diagnoses including acute kidney failure, muscle wasting, unsteadiness on feet, bipolar disorder, and chronic pain syndrome, had a bottle of nasal spray on her bedside table during a medication pass observation. She stated she had been taking the nasal spray since admission, said she took it daily, and denied reporting it to nursing staff. The DON later stated the nasal spray was secured and the provider was notified, and also stated the resident had not been assessed to administer the medication independently. Review of the resident’s current medication orders showed no order for the nasal spray found at the bedside. The facility also failed to prevent falls for a resident with a history of displaced right femur fracture, emphysema, and mental disorder. After an unwitnessed fall in which the resident was found sitting on the floor in front of a radiator after trying to use a urinal while standing, the incident investigation did not include when toileting needs were last met or an intervention to address the resident’s need to stand up unassisted to use the urinal. No neuro checks were documented in the EMR after that fall. The resident’s care plan included assistance with toileting and dressing, and the fall care plan identified poor safety awareness, debility, decreased mobility, muscle weakness, unsteady gait, and a history of self-transferring, but the interventions focused on keeping the resident in a common view area and did not address the toileting-related cause of the fall. The same resident had additional unwitnessed falls. In one event, the resident was found on his knees leaning on his bed and stated he was trying to fix the bed because the head of bed was not working; the bed was replaced, but there was no investigation or staff statement about the malfunction or when the resident’s needs were last met, and no neuro checks were initiated. In another event, the resident was found on the floor next to his bed with skin tears and stated he had hit his head. The resident’s call light was not in reach, and the record noted he normally used the call light when needing assistance. The resident was later started on neuro checks, but the documented neurological evaluation did not follow the facility’s fall policy. The care plan did not include a focus for anticoagulant use or elopement, and there were no wander guard interventions or call-light-related interventions documented. The facility also failed to ensure safe medication handling for another resident who was cognitively intact with a BIMS score of 12/15 and admitted with depression, anxiety, and dysphagia. During observation, the resident was seen with a cup containing assorted pills and capsules on the overbed table, and one purple pill had fallen to the floor. The resident stated the medications were hers, and a CNA picked up the pill and said he would report it to the nurse. Review of the care plan and physician orders did not show that the resident had been assessed as safe to self-administer medications or authorized to do so. The DON stated the facility did not have any residents assessed as safe to self-administer medications and could not identify whether the resident had received all ordered morning medications.
Ordered Nutritional Supplements Not Provided as Documented
Penalty
Summary
The facility failed to ensure ordered nutritional supplements were provided to a resident with significant weight loss and diagnoses including severe protein-calorie malnutrition, dysphagia, CHF, CKD stage 3A, dementia, and nutritional deficiency. The resident’s care plan identified poor nutritional intake related to dysphagia and directed staff to provide diet and supplements per physician order, with another care plan noting the resident was at unavoidable nutritional risk and ordered Mighty Shake and Magic Cup three times daily with meals. An alert note documented a current body weight of 127 pounds and significant weight loss since admission, with the resident on a regular diet with mechanical soft textures and nectar thick liquids and receiving supplements to support nutritional status. During interview, the resident’s family member reported the ordered Magic Cup and Mighty Shake were not on the meal tray as ordered with every meal and were missing about 75% of the time. During observation, the resident was served meals without the ordered supplements on one occasion, and on another occasion the Magic Cup was present but the Mighty Shake was not, despite the tray ticket showing it should have been served. The registered dietitian confirmed the resident did not have the Mighty Shake but did have the Magic Cup. Review of the January 2026 MAR-TAR showed staff documented the resident received the supplements as ordered during the noon meal on 1/12/2026 even though the supplement was not served on the tray.
PEG Site Irritation and Drainage Not Properly Monitored
Penalty
Summary
The facility failed to assess and monitor ongoing irritation and drainage at a PEG tube insertion site for one resident reviewed for tube feedings. A progress note documented that the resident’s PEG site was red and irritated, and that it was cleansed with normal saline and treated with skin guard cream and a split sponge. However, a skin assessment recorded no skin concerns, despite the documented redness and irritation around the PEG site. During observation, the PEG site had reddish clear drainage on the split gauze, and the insertion site was red, about nickel-sized, and crusted with clear drainage. An LPN stated she had changed the dressing the day before and that the night shift nurse usually changes it. When questioned, the LPN said the site was concerning and that she would notify the physician, but the EMR contained no documentation that the physician was notified and no follow-up was recorded. A subsequent skin assessment again documented no skin concerns.
Failure to Assess and Order CPAP Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident who had diagnoses including muscle wasting and atrophy, burns involving 10-19% of body surface with 0% to 9% third degree burns, and unsteady on feet. The resident was observed in bed with a CPAP machine on the nightstand and stated that he normally uses the machine when sleeping to help him breathe, but he could not use it every night. He also stated that no one had assisted him with his CPAP or breathing needs since admission. The unit manager stated the resident's hospital discharge summary indicated CPAP use, but the resident arrived at the facility without the machine. The unit manager contacted the respiratory therapist who treated the resident at the hospital and obtained the CPAP settings and treatment information, then ordered the equipment, but did not contact the physician or obtain orders for its use. The record review found no physician orders for CPAP use, no respiratory assessments in the facility medical record, and no respiratory therapist documentation. The facility CPAP policy required verification of a physician order before obtaining CPAP equipment and supplies, with settings ordered by the physician.
Dialysis Care Coordination and Medication Monitoring Failure
Penalty
Summary
The facility failed to coordinate dialysis care consistent with professional standards of practice for a resident with ESRD, heart failure, and dependence on renal dialysis. Review of the resident’s record showed the last dialysis communication in the EMR was 12/30/25, and several communication forms in December did not contain dialysis center information or any indication that they had been received. These dates also did not reflect the resident’s three-times-weekly dialysis schedule. The resident reported going to dialysis on Tuesdays, Thursdays, and Saturdays and stated she usually has high potassium and high phosphorus levels. During an observation, the resident was preparing for transport to dialysis and complained of nausea and lightheadedness. Her BP was 85/45 and pulse 60, and the LPN reported not understanding why the resident received both high and low BP medications. There was no documentation in the EMR and no practitioner follow-up regarding this incident. The record also showed Midodrine ordered for hypotension, Metoprolol and Amlodipine ordered for hypertension with hold parameters, but no consistent BP documentation at the point of administration. The Dialysis RN reported the nephrologist had decreased Metoprolol and Norvasc in December and stated the resident was to be on Midodrine, but it was unclear whether she was taking it. The resident was also receiving Sevelamer 800 mg three times daily, but it was scheduled for 8:00 AM, 12:00 PM, and 4:00 PM rather than with meals. The RD confirmed Sevelamer should be given with meals, and the Dialysis RN stated it should be given with the first bite of food. Real-time observation showed the medication was given up to an hour before and up to two hours after meals. The dialysis care plan included medication administration and coordination with the dialysis center, but it did not include a care plan for BP issues or high phosphorus levels. Facility staff reported missing or incomplete communication forms, lack of consistent documentation, and no documented concerns or medication changes communicated from the dialysis center.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and provide Influenza and Pneumococcal immunizations for 1 resident, R54, out of 5 residents sampled for immunizations. R54 was a [AGE]-year-old male admitted on [DATE] with diagnoses including hydrocephalus, diabetes insipidus, dysphagia, and communication deficit, and he was not his own responsible party. Review of his electronic medical record showed no request for consent for vaccinations, no orders for vaccinations, and no vaccination records. During interview, the Infection Preventionist stated she did not review R54’s vaccination records or obtain consent forms from his responsible party because she had been off work for a few weeks, and she confirmed that vaccination records are to be reviewed on admission and consent should be attempted on admission. She also acknowledged the facility had recently admitted residents who were positive for Influenza. Review of the facility’s Pneumococcal Vaccine Policy stated that upon admission residents will be evaluated for eligibility to receive the pneumococcal vaccine series.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer and provide a COVID-19 vaccination to one resident, R54, out of five residents sampled for COVID-19 vaccinations. R54 was a [AGE]-year-old male admitted on [DATE] with diagnoses including hydrocephalus, diabetes insipidus, dysphagia, and communication deficit, and he was not his own responsible party. Review of his electronic medical record showed no request for consent for COVID-19 vaccinations, no orders for COVID-19 vaccinations, and no vaccination records. During interview, the Infection Preventionist stated that R54's vaccination records were not reviewed and consent forms were not sent to his responsible party for COVID vaccinations because she had been off work for a few weeks, and she confirmed that vaccination records are to be reviewed on admission and consent should be attempted on admission.
Survey Binder Missing Required Survey Results
Penalty
Summary
The facility failed to ensure that surveys conducted by Federal or State surveyors and any plan of corrections in effect for the past 3 years were readily accessible to residents, family members, and legal representatives. On 1/14/26 at 11:35 AM, a survey binder located near the front door was observed and did not contain any Federal or State surveys for 2025. During an interview on 1/14/25 at 1:58 PM, the Regional Nurse Consultant stated the survey binder should have the last 3 years of surveys in it and acknowledged that they were not present.
Failure to Assess Resident's Appropriateness for Unaccompanied Transfer to Medical Appointment
Penalty
Summary
The facility failed to properly assess whether a resident was appropriate for lone transfer to an outside medical appointment, as required by professional standards of care. The resident in question had a history of functional quadriplegia, chronic pain syndrome, morbid obesity, mobility deficits, and moderate cognitive impairment, as evidenced by a BIMS score of 10 out of 15. Therapy notes indicated the resident was dependent for mobility and self-care, rarely got out of bed, and frequently refused therapy. Despite these factors, the resident was sent alone via a contracted medical transportation company to a dermatology appointment, seated in a standard large facility wheelchair. Upon arrival at the appointment, the resident was found sliding out of the wheelchair, with wet feet and only socks on, and was unable to reposition themselves. It required four people to assist the resident back into the wheelchair, but the resident continued to slide out and cried out in pain. The dermatologist's office refused to see the resident, and EMS was contacted to transport the resident back to the facility. There was no progress note in the medical record documenting the resident's status or the fact that they left the facility for the appointment on the day of the incident. Interviews with facility staff and the resident's representative revealed that the resident rarely, if ever, got out of bed or used a wheelchair for any length of time, and staff expressed uncertainty about the resident's ability to safely use a wheelchair or understand how to reposition themselves. The facility's own policy required assessment of the need for accompaniment to outside appointments based on cognitive and physical status, but this was not followed. The resident's representative was not notified of the appointment or transportation arrangements, and only learned of the incident after being contacted by the emergency department.
Failure to Administer Medication and Conduct Required Monitoring
Penalty
Summary
The facility failed to adhere to professional standards by not administering a physician-ordered medication, itraconazole, to a resident diagnosed with cryptococcus meningoencephalitis. The resident missed 19 doses of the medication from the date of admission to the facility until 10 days later. The pharmacy did not receive a request for the medication until the 10th day, and the Director of Nursing (DON) was unaware of the medication's unavailability despite procedures in place to address such issues. Additionally, the facility did not obtain necessary labs and tests to monitor the medication's efficacy and safety, as ordered by the Infectious Disease clinic. The facility also failed to maintain communication with the Infectious Disease clinic, which had faxed orders for lab tests and an EKG, and had scheduled a follow-up appointment for the resident. The facility canceled the appointment citing transportation issues but did not document the reason for the cancellation in the resident's electronic health record. The Infectious Disease clinic made multiple attempts to contact the facility regarding the missed doses and the need for lab tests, but the facility did not respond adequately.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. The hand wash sink near the dish machine did not have hot water, with the temperature only reaching 66°F, contrary to the FDA Food Code requirement of at least 100°F. Additionally, the facility did not properly date mark ready-to-eat foods, with items such as sliced turkey, tomato soup, and hot dogs either lacking discard dates or exceeding the safe consumption period. Nutritional shakes were mislabeled and stored improperly, and raw ground beef was thawed incorrectly in a pot of water without running water, violating FDA guidelines. The kitchen inspection also revealed unsanitary conditions and improper equipment maintenance. The meat slicer had dried debris on the blade, and the bottom of a cold hold unit was covered in spilled juice. Clean utensils were stored in a drawer with crumb debris, and ice scoops were stored in a manner that allowed stagnant water accumulation. Ice machines in nourishment rooms had crusted and slimy debris, with one machine leaking water onto the counter and floor, and disposable straws were stored in a contaminated area. Further deficiencies included improper storage and handling of food and equipment. The internal thermometer of a refrigeration unit read 50°F, leading to the disposal of milk cartons, and the unit was set to the lowest setting. Wet pans were stacked without proper air drying, contrary to FDA requirements. These observations indicate a failure to maintain food safety and sanitation standards, potentially leading to foodborne illnesses among residents.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises, which increased the potential for contamination and possibly decreased resident satisfaction. During a kitchen tour, it was observed that some non-LED lights were missing their light shields over the preparation and serving area. In the 300 hall, a janitor's closet had a Y valve connected to the sink spout with both valves closed and the sink left on, creating undue back pressure on the faucet's internal vacuum breaker. Additionally, the clean linen room and soiled utility room in the 300 hall had missing light shields, exposing clean linens to potential contamination. An outside hose bib connection near trash containers was left on with a spray handle connected, also causing undue back pressure on the vacuum breaker. Further observations included numerous items on the floor in the 500 hall nursing storage room, such as foley insertion trays, pill bottles, and dust debris. A mop sink faucet and valve were found sticking out of the wall, and upon testing, it was discovered they were still connected to the potable water supply. In the 400 hall linen closet, two shelves were made of raw wood boards, which were not smooth or easily cleanable. The laundry room had a missing light shield over the washing machines. Lastly, a restroom in the 300 hall had a non-operational sink with no signage indicating it was out of order, preventing proper handwashing.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents, as observed in the report. Resident #73, who has a history of stroke, hemiplegia, and dysphagia, reported frequent delays in staff response to his call light, particularly in the mornings. He expressed feelings of being forgotten when staff would turn off his call light and not return promptly. During an observation, an LPN informed him that his shower would be delayed until after lunch due to staff scheduling issues, which caused distress to the resident. Resident #57, who is cognitively intact but has a history of repeated falls and coordination issues, also reported delays in staff response to his call light. He described situations where he would wait for extended periods, sometimes up to two hours, for assistance with changing his brief. The resident noted that the day shift was particularly slow in responding to his needs, often turning off the call light and not returning for significant periods, especially when he required a brief change.
Deficiencies in Care Planning and Fall Management
Penalty
Summary
The facility failed to develop, implement, and evaluate the effectiveness of care planned interventions for a resident who was admitted following a stroke, resulting in hemiplegia and hemiparesis. The resident expressed concerns about understanding his functional capabilities and reported that staff were not assisting him with ambulation as part of a restorative program, despite his care plan indicating the need for assistance with ambulation using a quad cane and one-person assist. The care plan was not updated after the resident reported a fall on 8/31/24, and there was no documentation of staff assisting the resident with ambulation in the electronic medical record. The facility also failed to complete required assessments and follow-up after the resident experienced falls. The resident reported two falls, one on 8/9/24 and another on 8/31/24, but the Director of Nursing was only aware of the first fall. The second fall was not documented in an incident report, and there were no post-fall assessments or updated care plan interventions addressing this fall. Additionally, the x-ray ordered on 9/1/24 did not have a documented indication, and the results led to new orders for antibiotics without clear respiratory assessment findings. Furthermore, the facility did not accurately complete Minimum Data Set (MDS) assessments, as the quarterly MDS assessment did not reflect the resident's two falls, including one with injury. This omission meant that pertinent data was not available for care planning decisions and quality measures. The facility's fall policy, which requires evaluation of injury, documentation, and updating care plans after falls, was not followed, leading to fragmented care and potential delays or omissions in care.
Failure to Monitor Pressure Ulcer
Penalty
Summary
The facility failed to assess and monitor a pressure ulcer for a resident over a period of six weeks, which could have led to the worsening of the condition. The resident, a female with multiple diagnoses including osteomyelitis, end-stage renal disease, and cognitive impairment, was admitted with a Stage 4 pressure ulcer. The care plan required weekly assessments of the wound, but there was a significant gap in documentation from September 11 to October 30, during which no evaluations were recorded. The deficiency occurred due to a change in the resident's dialysis schedule and a transition in staff responsibilities for wound care assessments. The Director of Nursing (DON) acknowledged that the resident's wound assessments were missed because the wound care company visited on a day that conflicted with the resident's new dialysis schedule. Additionally, a new staff member was assigned to conduct wound rounds, which contributed to the oversight. The DON confirmed that the resident was the only one affected by this lapse in wound evaluation.
Deficiency in Enteral Feeding and PEG Tube Care
Penalty
Summary
The facility failed to ensure that licensed staff adhered to physician orders and professional standards for the care of a resident receiving enteral feeding. The resident, who was moderately cognitively impaired and had a history of stroke-related conditions, was observed being disconnected from his tube feeding infusion by a registered nurse without the required flushing of the tube with water. This action was contrary to the facility's policy, which mandates tube irrigation before and after interruptions in feeding to maintain patency and hydration. Additionally, the facility did not consistently follow physician orders for the care of the resident's PEG tube site. The dressing at the infusion site was not dated or initialed, and records indicated that the dressing was not changed on several occasions. The treatment administration record showed that the dressing was not changed on nine out of twenty-nine days, with no documentation of the resident's refusals or any attempts to re-approach or educate the resident about the importance of the dressing change. There was also no evidence of communication with the interdisciplinary team or physician regarding these refusals.
Incomplete and Delayed Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R8 and R12, which could potentially prevent providers from having a comprehensive understanding of the residents' conditions and care needs. For R8, the facility's records showed that a PASARR Level I Screening indicated the need for a Level II Evaluation, but the most recent Level II Evaluation in the electronic medical record (EMR) was outdated. The necessary documentation for the updated Level II Evaluation was only added to R8's EMR three months after it was conducted and after the surveyor requested it during the annual survey. Similarly, for R12, the facility's records indicated that a PASARR Level I Screening required a Level II Evaluation, but the last recorded Level II Evaluation was expired. The updated Level II Evaluation documentation was added to R12's EMR nine months after it was conducted and after the surveyor's request. This delay in documentation could interfere with the ability of healthcare professionals not directly involved in the residents' care to make informed decisions, as timely, accurate, and complete documentation is crucial for continuity of care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to its policy for a resident with specific medical needs. The resident, who was moderately cognitively impaired and had a history of stroke, hemiplegia, and dysphagia, was admitted with a wound on the right ankle and a PEG tube for enteral feeding. Despite these conditions, the Treatment Administration Record (TAR) for August and September did not reflect an order for EBP, and the order was only entered on October 30, 2024. Additionally, the comprehensive Care Plan did not include the requirement for EBP, even though it addressed the resident's need for enteral feeding and wound care. Observations revealed that staff did not adhere to the EBP policy. A sign indicating EBP was present on the resident's door, but staff members were observed not wearing gowns during high-contact activities. Specifically, a registered nurse was seen disconnecting the resident from tube feeding without donning a gown, and both an LPN and RN assisted the resident in bed without using any PPE. The facility's policy, revised in March 2024, mandates the use of gowns and gloves during high-contact activities to prevent the transfer of multi-drug resistant organisms, yet this was not followed, as confirmed by the Director of Nursing's communication.
Failure in Dishware Sanitization Due to Faulty Equipment
Penalty
Summary
The facility failed to ensure effective hot water sanitization of resident dishes, utensils, and facility cookware, as required by the 2017 Food Code. During an observation, interview, and record review, it was found that the dishwashing machine did not achieve the necessary surface temperature of 160 degrees Fahrenheit for effective sanitization. The temperature gauge of the incoming hot water showed 194 degrees Fahrenheit, but the surface temperature of the dishware was recorded at 149.5 degrees Fahrenheit and 155.6 degrees Fahrenheit in repeated tests. The facility's High Temperature Dish Machine Logs from May to July 2024 consistently recorded temperatures below the required 160 degrees Fahrenheit, with some readings in the low 140-degree Fahrenheit range. The Dietary Manager (DM) attempted to address the issue by obtaining a different puck and temperature strips from a sister facility to re-test the dishwashing cycle. The re-test confirmed that the original facility puck was faulty. However, there was no documentation provided to show that corrective action had been taken when the logs consistently recorded temperatures below the required minimum. The facility's logs included a printed directive indicating that staff should have been aware of the requirement for a puck temperature of 160 degrees Fahrenheit or higher.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to implement the mechanical lift transfer policy for a resident, resulting in an accident hazard. The resident, who was admitted with diagnoses including Parkinson's Disease, Arthritis, and Anxiety, was dependent on staff assistance for toilet use. On a specific date, the resident complained of a bruise on her left hand after being transferred by a mechanical lift by a CNA. The CNA admitted to using the lift alone, despite knowing that the facility policy required two staff members for such transfers. The resident reported that the CNA was moving too fast and grabbed her hand, causing the bruise. The facility's investigation revealed that the CNA conducted the transfer alone because the other CNA was on a break and the nurse was unavailable. The CNA claimed that the resident insisted on being taken to the bathroom immediately and denied touching the resident's hand. An X-ray confirmed soft tissue swelling but no fracture. The facility's policy clearly stated that two staff members should assist with mechanical lift transfers, with one controlling the lift and the other supporting the resident. This policy was not followed, leading to the incident.
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Illustrative
What surveyors actually found near you
We read the 165 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Muskegon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roosevelt Park Nursing And Rehabilitation Communit | 0.8 mi | ★★★★★ | 3 | 0 |
| Harbor Terrace Senior Living | 1.7 mi | ★★★★★ | 10 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Hillcrest Nursing And Rehabilitation Community | 4.1 mi | ★★★★★ | 12 | 0 |
| Christian Care Nursing Center | 4.3 mi | ★★★★★ | 5 | 0 |
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