Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plainwell Pines Nursing And Rehabilitation Communi during CMS and state inspections, most recent first.
Inadequate staffing and supervision resulted in unmet care needs and resident-to-resident altercations. A male resident with dementia who was exit seeking and wandered into other residents’ rooms required more 1:1 oversight than staff could provide, and staff reported they were unable to keep him safe while covering other duties. He was involved in multiple altercations with another resident when staffing was short. A second resident who required 2-person transfer assistance experienced repeated call light delays, with staff turning off the light before completing care and a 54-minute wait for transfer assistance. Staff and residents reported frequent call-offs, long wait times, missed breaks, and difficulty meeting resident needs when the unit was short-staffed.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: A resident with severe dementia and a known pattern of wandering into rooms and acting aggressively assaulted two other residents, including one resident with PTSD and another with dementia and multiple physical impairments. Staff interviews and records showed the resident struck one resident in the head, slapped and kicked her, and later placed another resident in a headlock/chokehold and punched her in the face several times. The affected residents were frightened and emotionally upset, and the aggressor’s prior behavioral history was not fully explored before admission.
Failure to provide person-centered dementia care interventions for a resident with dementia and Alzheimer’s disease. Staff documented constant wandering, exit seeking, entering other residents’ rooms, and episodes of physical aggression, but the care plan did not address the aggression and staff reported they did not know the resident’s triggers, likes, or effective redirection methods. The resident was repeatedly difficult to supervise, had altercations with other residents and staff, and was ultimately sent back to the hospital after unmanaged behaviors.
Two residents with severe cognitive impairment and a history of wandering were not adequately supervised, resulting in one resident exiting the facility unsupervised and being found outside by another resident. Staff failed to respond promptly to door and Wanderguard alarms, and there was confusion among staff regarding alarm protocols and Wanderguard checks, with insufficient documentation and orientation contributing to the deficiency.
The facility did not maintain an effective training program for all staff, leading to an incident where a resident with dementia exited the building unsupervised due to staff not responding to alarms, and to discrepancies in the administration and documentation of controlled substances for two residents. Agency nurses were not adequately oriented to facility protocols for elopement prevention or narcotic handling, resulting in confusion and incomplete documentation.
Two residents with chronic pain experienced discrepancies in the documentation and reconciliation of their narcotic pain medications. Nurses failed to consistently record administration on both the MAR and proof of use sheets, and shift-to-shift narcotic counts were incomplete or improperly signed, particularly by agency staff. Residents reported missed or unexplained doses and a lack of communication about their medications.
Four residents with significant cognitive and physical impairments were found without access to their call lights, with some also unable to reach water. Observations showed call lights placed out of reach, malfunctioning call light systems, and staff not consistently ensuring accessibility, resulting in residents being unable to call for assistance when needed.
A resident with chronic venous ulcers and cellulitis had wound care performed in a public area by an RN, first at the nurse's station doorway and then with the nurse kneeling in the hallway while the resident was just inside his room. The procedure was conducted without privacy measures or protective chucks, exposing the resident and compromising dignity, as confirmed by staff interviews and direct observation.
A resident with multiple health conditions and legal blindness reported that an LPN inappropriately touched her breasts during an admission assessment, leading her to feel unsafe and leave the facility. The incident was reported to staff, documented by a CNA, and resulted in the LPN's suspension pending investigation.
A resident with multiple chronic conditions did not receive prescribed PRN Percocet doses as documented by an agency LPN, who signed out and recorded administration of the medication while the resident was away at dialysis. Facility records, transportation logs, and interviews confirmed the resident was not present to receive the medication, and the LPN could not account for the discrepancy, resulting in the misappropriation of controlled substances.
A resident with a history of falls and a recent hip fracture did not have their care plan updated to include a fall mattress intervention, despite its documented use and the resident's ongoing risk. Observations showed the fall mattress was not properly positioned, and interviews with the DON confirmed it should have been in place. The care plan revision process did not ensure timely updates to reflect the resident's current needs.
A resident was repeatedly observed using a visibly soiled mobility chair, with dried liquids, ingrained dirt, and food debris present over several days. Shared equipment, including a shower chair and sit-to-stand device, was also found with dried material and debris. Staff interviews revealed confusion and inconsistency regarding cleaning responsibilities, and no clear checklist existed for housekeeping duties in shower areas.
The facility did not employ a properly credentialed staff member to supervise and manage the dietary department, as the Dietary Manager only held a short-term Food Protection Manager certificate and had not completed the required Certified Dietary Manager course. Although a DTR visited weekly and an RD visited periodically, daily management was conducted by an unqualified individual, and the NHA was under the impression that the correct credentials were in place.
Surveyors found multiple instances of improper food labeling, dating, and storage, including expired and unlabeled items in the kitchen, refrigerators, and storage rooms. Despite repeated staff education by the Dietary Manager, the facility failed to follow its own policies and FDA Food Code requirements, creating the potential for foodborne illness among all residents consuming food from the kitchen.
Multiple residents experienced unclean living conditions, including soiled commodes, chairs, and privacy curtains, as well as unaddressed environmental hazards such as damaged handrails and equipment. Two residents reported ongoing sleep disturbances due to excessive nighttime noise from another resident, with no effective interventions provided. Maintenance and housekeeping staff failed to document or address these issues in accordance with facility policy.
Staff failed to consistently follow infection control protocols, including proper cleaning of resident equipment, hand hygiene, and use of PPE and Enhanced Barrier Precautions. A resident's wheelchair and commode were visibly soiled and not properly cleaned, while another resident's catheter bag and tubing were observed dragging on the floor. Multiple staff, including agency and contract workers, did not wear masks as required, and some reported not receiving infection control training. Staff also did not consistently use gowns or perform hand hygiene during high-contact care, despite posted EBP signage and orders.
Two residents with cognitive impairment were not provided privacy or dignity during care. One resident had his legs exposed and wounds discussed in a public area while receiving medications from an LPN without being asked about his preferences. Another resident, unable to communicate effectively, repeatedly asked for help with discomfort and a soiled brief, but staff did not address her needs and instead attempted to distract her with music.
Two residents were found to be self-administering medications without proper assessment, physician orders, or care plan documentation, contrary to facility policy. One resident with severe cognitive impairment kept a prescription nasal spray at the bedside and used it independently, while another cognitively intact resident retained a pill at the bedside for later use. Nursing staff and the DON were unaware of these situations, and no self-administration assessments had been completed.
A resident with significant cardiac conditions was not given the opportunity to review advance directive paperwork upon admission, and their wishes regarding CPR were not accurately documented or processed. The care plan lacked interventions related to code status, the advance directive form was missing from the CPR Binder, and the form was not provided to the physician for signature, resulting in the potential for the resident's preferences to not be honored.
A resident with severe cognitive impairment exited the facility unattended and was found outside by staff. Although a wander guard was applied and the care plan updated, the resident's representative was not notified of the incident or interventions until nearly two weeks later, contrary to expectations for timely notification.
Three residents were administered psychotropic medications without proper medical justification, supporting diagnoses, or documentation of non-pharmacological interventions. In each case, care plans lacked required interventions, and staff acknowledged missing documentation and consent forms, as well as the absence of behavior monitoring to support continued medication use.
A resident with multiple medical conditions was transferred to the hospital on two occasions, but neither the resident nor her legal guardian received the required written bed hold or transfer/discharge notices. Staff interviews and record reviews confirmed that the necessary documentation was missing from the medical record, despite facility policy requiring these notifications and documentation at the time of transfer.
A resident with depression and moderate cognitive impairment experienced ongoing loneliness and social isolation due to the facility's failure to provide meaningful, individualized activities. The resident spent much of his time alone in a dark room, received only brief and infrequent social visits, and had limited access to group or physical activities. Staff did not consistently document or address his requests for social interaction, and the activity calendar lacked variety and personalization, leading to frustration and boredom.
A resident with severe cognitive impairment and multiple dependencies developed a wound on the hand that was not promptly assessed, documented, or treated according to facility policy. The wound nurse was not notified, no skin event was created, and the care plan lacked a specific treatment plan, resulting in delayed care and monitoring.
A resident with severe cognitive impairment and a stage 3 pressure ulcer did not receive a daily wound dressing change as ordered by the physician. The LPN assigned did not perform the treatment, did not inform supervisory staff, and inaccurately documented the resident's refusal. The wound dressing was observed to be outdated and soiled, indicating a lapse in required wound care.
A resident with cognitive impairment and a history of wandering was able to exit the facility unattended due to a lack of specific interventions and inconsistent behavioral monitoring. Additionally, two residents were transported in wheelchairs without footrests, exposing their feet to potential injury, in violation of standard wheelchair safety protocols.
A resident with severe cognitive impairment and urinary retention did not receive proper urinary catheter care, as a required fixation device was not in place during care, and there was no documented assessment or attempt to discontinue the indwelling catheter as per facility policy. Staff interviews confirmed the absence of necessary catheter management practices.
A resident with end stage renal disease requiring dialysis did not have consistent, documented communication between the facility and the contracted dialysis center. Required communication forms detailing vital signs, weights, labs, and dietary concerns were not completed or returned, and staff interviews confirmed the lack of follow-up when forms were missing. The dietitian technician was unable to complete a nutritional assessment due to missing information, and the DON acknowledged the absence of documentation for ongoing communication.
A resident with Alzheimer's disease and a DPOA for medical decisions was not offered or documented as receiving a COVID-19 vaccine, despite facility policy requiring education and offering of the vaccine. The IPRN attempted to contact the DPOA for consent but did not document these efforts, and the Medical Director was not consulted regarding vaccination appropriateness.
The facility did not have an RN on duty for 8 consecutive hours on a weekend day, and attempts to secure agency RN coverage were unsuccessful. The DON or ADON would sometimes cover, but there was no evidence of RN coverage on the date in question.
A sliding glass door in the dining room leading to the courtyard was observed to lack the required 'NO EXIT' signage, making it possible for occupants to mistake it for an exit. The door did not meet exit requirements to the public way, and this deficiency was confirmed with the Maintenance Director.
The facility did not provide documentation of the required quarterly testing for its automatic sprinkler system for one quarter, as confirmed during a records review and interview with the Maintenance Director.
A hasp with a padlock was found on the outside of a kitchen refrigerator/freezer door, creating the potential for someone to be locked inside and violating LSC requirements for egress doors. The Maintenance Director confirmed the finding during the inspection.
A newly installed kitchen stove had a shelf that obstructed the spray nozzles of the hood fire suppression system, violating NFPA 17A requirements. This issue was confirmed by the Maintenance Director during the survey.
A facility failed to protect three residents from abuse by a CNA, resulting in fear, pain, and bruising. A resident with chronic pain reported rough handling during care, confirmed by other CNAs. Another resident suffered a bruise from a forceful transfer, corroborated by the DON. A third resident, requiring assistance, was left in the dark by the CNA, causing distress. The facility's failure to prevent abuse was evident in these incidents.
Two residents in a LTC facility experienced falls and injuries due to inadequate supervision. One resident, with severe cognitive impairment and a history of falls, was often left alone despite needing close monitoring. Another resident, requiring substantial assistance, fell when a sitter momentarily turned away. Staffing constraints prevented continuous supervision, leading to multiple falls and injuries.
The facility failed to maintain cleanliness of food service equipment and properly date mark ready-to-eat food, affecting 33 residents. Observations revealed loose sink fixtures, encrusted residue on a juice machine and refrigerator, and undated milk. These issues increased the risk of cross-contamination and foodborne illness.
The facility failed to maintain a clean and safe environment, affecting 33 residents. Observations revealed non-functional lights, active water leaks, and worn furniture. The maintenance work order system was inadequate, with no recorded entries for these issues over the past 120 days, despite the facility's policy to ensure a clean and comfortable environment.
A resident with cognitive impairment and requiring assistance for toileting was left exposed during incontinence care when one CNA left the room, leaving the resident uncovered for about four minutes. The resident expressed a desire to be covered, and the remaining CNA then covered her. This incident violated the resident's care plan, which emphasized maintaining dignity and privacy.
A resident with dementia and diabetes experienced unmet care needs due to the facility's failure to implement a person-centered care plan. Despite requiring maximal assistance and having a history of falls, the resident's care plan interventions were not consistently followed. Staff were unaware of some interventions, and the resident often remained alone in his room, contrary to care plan instructions. The facility did not update the care plan after the resident's falls, leading to increased fall risk and unmet needs.
The facility failed to provide adequate staffing, resulting in falls and unmet care needs for residents. Staff reported being unable to complete essential tasks due to insufficient personnel, particularly on weekends and night shifts. Residents experienced long call light wait times, leading to incontinence and injuries from falls. Despite care plans requiring close supervision, staff were unable to provide it consistently due to other responsibilities and limited personnel.
A facility failed to follow up on pharmacist recommendations and ensure physician documentation for a resident with moderately impaired cognition. Despite recommendations to monitor CBC monthly due to azathioprine use, the care plan was not updated, and lab tests were delayed. Missing documentation and lack of adherence to the Medication Regimen Review Policy were noted.
The facility failed to conduct gradual dose reductions (GDR) for psychotropic medications for two residents. One resident on citalopram for depression had no GDR attempts documented in 2023 or 2024, despite policy requirements. Another resident on trazodone had a GDR attempt in early 2024, but no documentation in physician notes. Interviews confirmed the lack of GDR attempts, contrary to facility policy.
The facility failed to maintain a double-lock system for a controlled substance in the medication refrigerator, which was found unlocked. Staff interviews revealed that keys to the refrigerator were held by multiple personnel, and the refrigerator contained insulin, vaccines, and Lorazepam. The facility's policy requires a double-lock system for refrigerated controlled substances, which was not followed.
The facility failed to ensure proper infection control practices, including the use of PPE and hand hygiene, during care for two residents. An RN performed a blood glucose test without gloves or hand hygiene, and both an RN and an LPN neglected Enhanced Barrier Precautions while administering IV antibiotics to a resident with a PICC line. Additionally, medication tablets were placed on an unclean surface, risking contamination. These actions indicate a lack of adherence to infection control protocols.
The facility failed to protect residents from mental, verbal, and physical abuse by staff and other residents. One resident was dragged down a hallway by an RN, causing a skin tear, while another resident experienced significant pain and emotional distress due to rough handling by a CNA. Additionally, a resident was struck by another resident and verbally abused by an RN, with no corrective actions taken despite multiple reports.
The facility failed to implement its abuse policy, resulting in verbal and physical abuse of three residents by an RN. Despite multiple reports from CNAs, no corrective actions were taken, leading to ongoing abuse and injuries.
The facility failed to prevent insect bites and did not install window screens, resulting in a significant wound for a resident. The resident, with a history of multiple health issues, developed a wound from a suspected spider bite, requiring extensive treatment and causing increased pain and immobility. Observations and interviews confirmed the absence of window screens and the presence of insects in the facility, violating the facility's pest control policy.
The facility failed to provide individualized care for a resident with dementia, resulting in avoidable stress responses. Despite staff identifying effective personalized interventions, these were not documented in the care plan or communicated effectively, leading to inadequate management of the resident's condition.
Inadequate staffing and supervision led to unmet resident care needs and resident-to-resident altercations
Penalty
Summary
The facility failed to provide adequate staffing to meet resident needs and to have sufficient supervision for residents requiring close monitoring. Resident #22, a male with dementia and a care plan identifying him as at risk for elopement due to memory deficit, confusion, and inability to read or write, was repeatedly described by staff as wandering into other residents’ rooms, going through belongings, and exit seeking. Staff reported that he needed more one-to-one supervision than the facility could provide, especially when staffing was short, and that they could not keep him safe while also completing other resident care tasks. On 5/23/26, staff reported Resident #22 wandered throughout the day and was frequently in and out of other residents’ rooms. The facility schedule showed 1 nurse and 2 CNAs in the building at the time of the incident, although 3 CNAs were scheduled and one had called off. Staff interviews stated that when staffing was short, they were rushing through care, working through lunch, and unable to address psychosocial needs. An incident report documented that Resident #22 initiated a resident-to-resident altercation on 5/23/26 at 3:20 PM. Later, on 5/26/26, the family was told the resident would not receive 1:1 supervision because of staffing issues, and an incident report documented that at 4:44 PM he grabbed a female resident in a choke hold and punched her in the face, chest, and upper back multiple times. The schedule for that time showed 1 nurse and 3 CNAs in the building. Resident #26, who had reduced mobility and used a wheelchair, required a sit-to-stand mechanical lift for transfers and was identified on the care plan as needing care needs met. During observation, he activated his call light repeatedly while waiting to get out of bed, but staff entered, turned off the light, and told him to wait or that they would get help. It took 54 minutes from the first call light activation until two staff members arrived to transfer him from bed to wheelchair. Resident #26 reported that long call light wait times of more than 30 minutes happened regularly and that staff often turned off the light without completing the requested care. Other residents in a confidential meeting also reported long waits for assistance and frequent unsupervised wandering by a resident with advanced dementia. Staff interviews and payroll-based journal information further described repeated staffing shortages, missed breaks, and difficulty covering call-offs, including low weekend staffing.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident. Resident #22, who had severe dementia, confusion, wandering behavior, and a documented pattern of entering other residents’ rooms and becoming aggressive, was involved in multiple resident-to-resident assaults. The record showed he had recently been in a behavioral health hospital for treatment related to severe dementia and had a history of aggression toward others before admission, but the facility did not fully inquire into the behaviors that led to that hospitalization before accepting him. Resident #2, who had diagnoses including major depressive disorder, anxiety disorder, and PTSD, was cognitively intact and had a trauma history documented in the care plan. On 5/23/26, Resident #22 entered Resident #2’s room and struck her in the head, slapped her, and kicked her leg. Staff interviews described Resident #2 as screaming for help, scared, borderline terrified, wide-eyed, and shaking after the incident. Resident #2 reported she was scared to death, did not ever want to see Resident #22 again, and remained worried that he would return and assault her. Social services later confirmed she was emotionally upset and angry after the event. Resident #14, who had dementia, stroke, paralysis, dysphagia, malnutrition, and speech impairment, was also assaulted by Resident #22. On 5/26/26, staff witnessed Resident #22 place Resident #14 in a headlock/chokehold and punch her in the face several times. Progress notes and interviews documented that Resident #14 had redness and bruising under her left eye and soreness to her face, neck, and back. Resident #14 stated that Resident #22 came into her room while she was eating chocolate and hit her, and she would be concerned for her safety if he returned. The record also showed that Resident #22 had continued wandering into rooms, attempting to hit staff, and had already assaulted another resident earlier in the same timeframe, yet the facility still allowed him to remain in a setting where he could access other residents.
Failure to Provide Person-Centered Dementia Care Interventions
Penalty
Summary
The facility failed to develop and implement person-centered dementia care interventions for a resident with unspecified dementia and Alzheimer’s disease who displayed ongoing wandering, exit seeking, physical aggression toward others, and eventual rehospitalization. The resident’s care plan addressed impaired cognition and elopement risk with general approaches such as administering medications as ordered, avoiding too many choices, maintaining routine, calmly redirecting, and offering diversions, but it did not address the resident’s episodes of physical aggression toward others. Social services staff reported they did not really know the resident well, did not know his likes and dislikes, and had not yet added a useful redirection statement to the care plan. The resident wandered nearly constantly from admission, repeatedly triggered the exit alarm near his room, and was observed going in and out of other residents’ rooms. Staff reported they did not monitor him on admission to determine what triggered his wandering or other behaviors, and when asked about the causes of his restlessness, wandering, and aggression, social services stated it was just his dementia and they did not know. Staff also reported he had two episodes of physical aggression toward other residents and several toward staff before being discharged back to the hospital because his behaviors were not managed. One LPN reported that on one occasion the resident wandered all day, entered another resident’s doorway, became physically aggressive, and then urinated in the hallway immediately afterward; the LPN stated he could not verbalize his needs and may have been stressed because he needed to urinate and did not know where his bathroom was. Additional staff interviews described the resident as constantly wandering, entering other residents’ rooms, attempting to remove his pants, and being difficult to supervise. A CNA reported trying to engage him in activities to reduce wandering without success, while another LPN reported the resident would benefit from more one-to-one staffing. Family reported the resident had previously been admitted to a behavioral health hospital for physical aggression and had been open with the facility about his need for dementia care interventions and close supervision. The resident had also been evaluated for behavioral health services by the facility’s contractual provider, and staff noted that interventions such as familiar items from home and individualized redirection had not been incorporated into his care plan. The record also showed staff education gaps related to dementia care training, including person-centered care plans and dementia-related behaviors.
Failure to Prevent Elopement and Inadequate Response to Alarms
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent elopement and respond appropriately to door and Wanderguard alarms for two residents identified as being at risk for elopement. One resident with severe cognitive impairment and a history of exit-seeking behavior was able to exit the facility through an employee entrance door after following a CNA who was leaving for break. The resident was found outside by another resident approximately ten minutes later, attempting to re-enter the building. Staff did not respond to the door alarm in a timely manner, and there was confusion among staff regarding the source and significance of the alarms, with some staff assuming the alarms were related to shift change and not investigating further. The resident who eloped had a documented history of wandering, elopement risk, and severe dementia, with care plans and assessments indicating the need for close supervision and the use of a Wanderguard device. Despite these interventions, the resident was able to leave the building unsupervised. Staff interviews revealed a lack of familiarity with alarm systems, Wanderguard functionality, and facility protocols, particularly among agency staff and new hires. There was also a lack of clear documentation and communication regarding the checking and maintenance of Wanderguard devices for another resident at risk for elopement, with no evidence that required checks were being performed or documented. Facility policies and orientation materials did not provide sufficient guidance on responding to alarms, identifying alarm sources, or the use of Wanderguard devices. Agency staff were not consistently oriented to these procedures, and there was no verification that required orientation or competency checks had been completed. The combination of inadequate staff response, insufficient training, and lack of documentation contributed to the failure to prevent the elopement and ensure the safety of residents at risk.
Removal Plan
- Resident #101 was placed on 1:1 supervision until further interventions could be implemented. Law Enforcement, physician and Director of Nursing notified. The Administrator notified the brother of the incident.
- The EVS (environmental services) Director assessed the facility doors for proper function of the alarm system.
- The Administrator reviewed the elopement binder.
- The Elopement and Wandering Policy was reviewed by the facility Administrator.
- Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, pain assessment and vital signs were obtained.
- Care Plan was updated with proper interventions to reduce future risk of elopement.
- The facility audited residents who were determined to be at risk for elopement. The Facility completed an elopement risk observation, reviewed and/or updated the elopement care plan and ensured appropriate interventions.
- Resident #104's orders were put in place to ensure Wanderguard functionality would be checked.
- Agency LPN's and staff Cena's were educated by the DON, Maintenance and Administrator on the facility's policy on elopement and wandering. An elopement drill was completed.
- Education of elopement and wandering policy was initiated; any staff member who did not receive education will receive education prior to the start of their next shift.
- All Staff have been educated.
- Agency Staff have received the education prior to working their next shift.
- Agency staff education will include an in-person orientation with new agency staff that will include how to determine where the alarm is coming from, how the doors function, Wanderguard usage, door codes, and expectations for responding to a door alarm.
Failure to Maintain Effective Staff Training on Resident Safety and Medication Management
Penalty
Summary
The facility failed to maintain an effective training program for both facility and agency staff, resulting in multiple deficiencies related to resident safety and medication management. In one incident, a resident with severe cognitive impairment and a history of elopement risk was able to exit the facility unsupervised. Staff did not respond to door and Wanderguard alarms in a timely manner, and agency staff were unfamiliar with the alarm systems and elopement protocols. Interviews revealed that staff were unsure of procedures during the incident, and agency nurses had not received adequate orientation or training on facility-specific safety protocols, including the use of alarms and elopement response. In separate incidents involving the administration of controlled substances, discrepancies were found in the documentation and handling of narcotic medications for two residents. There were inconsistencies between the medication administration records (MAR) and proof of use sheets, with doses recorded on one document but not the other. Agency nurses were not properly educated on the facility's narcotic handling procedures, and shift-to-shift narcotic counts were not always completed or documented correctly. Some agency staff signed narcotic count sheets with only the word "agency" instead of their names, and there were missing counts on certain days. Interviews with staff and review of orientation materials revealed that agency nurses did not consistently receive or complete required training on critical facility policies, including those related to elopement and controlled substances. The orientation checklist for agency personnel did not include post-tests or detailed information on door alarms, Wanderguard systems, door codes, or controlled substance administration. As a result, both new and existing staff, including agency personnel, were inadequately prepared to ensure resident safety and proper medication management.
Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to maintain accurate medication records and properly reconcile controlled substances for two residents who were prescribed narcotic pain medications. For one resident with chronic pain, discrepancies were found between the number of Oxycodone pills documented on the proof of use sheet and the actual count in the medication card. The medication administration record (MAR) indicated that more doses were administered than were recorded on the proof of use sheet. Additionally, there were instances where agency nurses documented administration on the MAR but did not sign the proof of use sheet, leading to inconsistencies in the controlled substance count. Another resident, also with chronic pain, experienced similar documentation issues. During medication administration, the nurse prepared and administered Oxycodone without reconciling the medication card with the proof of use sheet. The MAR showed that more doses were given than were recorded on the proof of use sheet. Furthermore, the nurse did not discuss the resident's pain level or inform the resident about the medications being administered. There were also missing or incomplete narcotic shift-to-shift counts, with agency nurses failing to properly sign the count sheets or record their names. Interviews with staff revealed a lack of awareness regarding proper documentation procedures and incomplete education for agency nurses on narcotic handling. Residents reported inconsistencies in receiving their pain medications and a lack of communication from nursing staff about the medications being administered. These failures resulted in inaccurate accounting of controlled substances and incomplete medication records for the residents involved.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to four residents, resulting in their inability to call for assistance and the potential for unmet care needs. Observations revealed that one female resident with Alzheimer's disease, diabetes, bilateral femur fractures, and dementia was found in her room with her call light hung over the back of her bed's headboard and her water out of reach. She was observed sliding down in her chair and attempting to get up without assistance. When the call light was pressed, it did not illuminate in the hallway, and staff had to be hailed from the nurse's station. The Maintenance Director later discovered that the call light system was malfunctioning, with bulbs blowing and the panel not lighting up, and noted the system was very old and in disrepair. Another male resident with a history of femur fracture, stroke, and poor cognition was observed lying in bed with his call light not visible and his water out of reach. He was later seen leaning out of bed, attempting to hand a cup to the surveyor, with his call light found under the foot of his bed. Staff interviews indicated that the call light had been given to him earlier, but it was not in reach when needed. The Assistant Director of Nursing confirmed that staff were expected to ensure call lights were in reach when leaving residents' rooms. A third male resident with dementia, diabetes, and muscle weakness experienced an unwitnessed fall from bed. Staff found his call light bunched up behind his blankets at the foot of the bed, out of reach. A fourth male resident with dementia and a history of falls was observed multiple times seated in a chair or wheelchair with his call light placed on the bed or hanging off the side of the bed, out of his reach. Staff interviews confirmed that call lights and water should be placed within reach, but this was not consistently done for these residents.
Resident Privacy Compromised During Wound Care
Penalty
Summary
A male resident with chronic venous ulcers, cellulitis, and significant skin issues to both lower extremities was observed having his wound dressing changed in a public area of the facility. The resident, who had recently returned from a whirlpool treatment to provide moisture to his lower legs, was initially positioned in his wheelchair in the hallway. A registered nurse began to perform wound care at the doorway of the nurse's station, in view of others, before being instructed by the Director of Nursing to move the resident to his room. The nurse stated that the resident's room was too small to perform the dressing change, but ultimately directed the resident to self-propel to his room, where the dressing change continued with the nurse kneeling in the hallway and the resident just inside his doorway. During the dressing change, there were no protective chucks placed under the resident's feet, despite the presence of dry, flaky, and peeling skin, as well as visible blood between the toes and on the tops of the feet. The dressing itself showed spots of fresh blood. Interviews with facility staff confirmed that wound care should not have been performed in a public area, as this compromised the resident's privacy and dignity. The incident was directly observed by surveyors and corroborated by staff interviews and record review.
Failure to Protect Resident from Sexual Abuse During Admission Assessment
Penalty
Summary
A newly admitted female resident with multiple medical conditions, including diabetes, chronic pain, congestive heart failure, and legal blindness, reported an incident of sexual abuse by an LPN during her admission assessment. The resident stated that during a physical assessment, the LPN lifted her top and pinched and rubbed her nipples, which made her feel extremely uncomfortable and unsafe. The resident immediately contacted her son, who arrived at the facility and took her home before the administrator could speak with her in person. The resident reported the incident to another staff member, a CNA, who assisted her in filing a complaint. The CNA documented the resident's statement and reassured her until her son arrived. The resident expressed that she felt there was no medical reason for the LPN to touch her breasts in that manner and that she could not remain at the facility after the incident. The resident also indicated that, due to her legal blindness, she was able to perceive shapes and colors but was certain about the inappropriate contact. Interviews with facility staff revealed that the LPN denied the allegations, stating he was only assessing bruising on the resident's torso and did not touch her breasts. The Assistant Director of Nursing confirmed that most of the admission assessments had already been completed and that only a final set of vital signs was needed. The administrator began an investigation into the allegation, and the LPN was suspended pending the outcome. The incident was reported to local authorities and the medical director.
Misappropriation of Resident's Narcotic Pain Medication
Penalty
Summary
A facility failed to prevent the misappropriation of a resident's narcotic pain medication, resulting in the theft of controlled substances and the potential for delayed pain treatment. The resident involved had multiple significant medical conditions, including multiple sclerosis, polyneuropathy, heart failure, end stage renal disease, and osteoarthritis, and was prescribed Percocet (oxycodone-acetaminophen) to be administered as needed for pain. On the day in question, the resident was away from the facility for dialysis during the time a dose of Percocet was documented as administered to him. Interviews and record reviews revealed that an agency LPN signed out two doses of PRN pain medication for the resident, one at 2:00 PM and another at 8:00 PM. However, transportation logs and staff interviews confirmed that the resident was not present in the facility at 2:00 PM, making it impossible for him to have received the medication at that time. The resident also reported not receiving the 8:00 PM dose, despite it being documented as given. The LPN in question denied misappropriation but could not provide a satisfactory explanation for the discrepancies in the medication administration records. The facility's internal investigation, including review of narcotic count sheets, medication administration records, and transportation documentation, corroborated that the medication was signed out and documented as administered when the resident was not present. The medication count remained correct, indicating that the medication was removed from the cart but not given to the resident, constituting misappropriation of the resident's property.
Failure to Timely Update Care Plan with Fall Prevention Interventions
Penalty
Summary
The facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for a resident with multiple complex medical conditions, including a history of falls and a recent hip fracture. The resident's care plan, last revised on 12/2/24, included interventions such as a parameter mattress, enabler bars, and ensuring the call light was within reach, but did not include the use of a fall mattress as an intervention. Documentation and observation revealed that a floor mattress was in use as of 8/12/25, but this intervention was not reflected in the resident's care plan. During observation, the fall mattress was found leaning against the resident's wheelchair rather than being positioned by the bed as required, and the resident reported not getting up for breakfast. Interviews with the DON confirmed that the fall mattress should have been in place due to the resident's history of falls and hip fracture. The DON also described the process for updating care plans and communicating changes, but the care plan was not revised to include the fall mattress intervention, despite changes in the resident's status and needs.
Failure to Maintain Clean and Sanitary Shared Medical Equipment and Resident Areas
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for shared medical equipment and resident areas, as evidenced by multiple observations of visibly soiled equipment and unclean resident rooms. One resident was repeatedly observed in a dirty scoot/Broda chair with dried liquid material, ingrained dirt, and body oils on the padding, as well as food debris and smeared substances on the armrests and seat. The resident's room also had visible dirt, debris, and food particles on the floor over several days. Additionally, a shower chair was observed in the hallway and shower room with encrusted dried brown and white material, and the shower room itself had missing tiles, cracked surfaces, and debris on the floor. Other shared equipment, such as a sit-to-stand device, was also found with dirt and dried material on various surfaces. Interviews with staff revealed inconsistent understanding and execution of cleaning responsibilities. CNAs reported that they were responsible for cleaning shower chairs and resident chairs, with a cleaning schedule in place for third shift CNAs. However, there was confusion among housekeeping and maintenance staff regarding who was responsible for cleaning heavily soiled equipment, and no checklist existed for housekeeping duties in the shower rooms. The DON confirmed that shared equipment should be cleaned after each use and when visibly soiled, but observations indicated that this was not consistently done.
Lack of Qualified Dietary Department Supervision
Penalty
Summary
The facility failed to employ a staff member with the appropriate credentials to supervise and manage the dietary department. The Dietary Manager had been working at the facility for over a year and only possessed a Food Protection Manager certificate, which is a short-term certification rather than a comprehensive management course. The Dietary Manager admitted to not having completed the Certified Dietary Manager course due to being busy with facility duties. Although a Dietetic Technician, Registered, visited weekly for clinical work and a Registered Dietitian visited every few months, the day-to-day supervision and management of the dietary department were handled by an individual without the required qualifications. The Nursing Home Administrator believed the Dietary Manager had the correct credentials, but review of records confirmed otherwise.
Improper Food Labeling, Dating, and Storage in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple instances of improper food labeling, dating, and storage in the facility's kitchen and related storage areas. During the initial and subsequent tours, items such as a pitcher of iced tea with an expired use-by date, trays of individual juices without labels or dates, and open drink packets and cereal lacking proper labeling and dating were found. Additionally, an open container of ham base and a single serving of ice cream were discovered without appropriate labeling or with expired use-by dates. A frozen water bottle was also found stuck to the bottom of the nurses station freezer. These findings indicate that the facility did not consistently follow its own storage procedures or the FDA Food Code requirements for labeling and dating ready-to-eat, time/temperature control for safety foods. The Dietary Manager confirmed during an interview that staff had received repeated education on proper labeling, dating, and discarding of food past use-by dates, but the issues persisted. The facility's policy required all refrigerated leftovers to be used within 5-7 days and all foods in the freezer to be labeled and dated, in accordance with food code requirements. The failure to adhere to these standards resulted in the potential for foodborne illness among all residents consuming food from the kitchen.
Failure to Maintain Clean, Safe, and Homelike Environment and Manage Noise Levels
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for multiple residents, as evidenced by repeated observations of unaddressed environmental hazards and unclean conditions. During facility tours, surveyors observed a handrail with a hole and sharp, jagged plastic outside a resident room, as well as another cracked handrail, both of which maintenance staff were unaware of and had not been documented for repair. The work order system was not being properly utilized, with maintenance staff relying on verbal requests rather than written documentation, resulting in needed repairs being overlooked. Additionally, a weight scale in the family lounge had a torn and flaking grip pad that had not been addressed despite being visible to maintenance staff. Several residents' rooms and equipment were found to be unclean over multiple days. One resident's bedside commode had a dried-brown substance resembling fecal matter on its frame, which was not properly cleaned by staff and remained soiled for several days. Another resident's straight-backed chair had a brown streak resembling fecal matter smeared on the seat, which housekeeping staff acknowledged was a recurring issue. A third resident reported that her bedside commode was full of urine and feces, with urine spilled onto the floor, and that it had not been emptied or cleaned for several hours despite her being cognitively intact and able to report the issue. The Director of Nursing and Regional Clinical Consultant confirmed that staff were responsible for regularly checking and cleaning commodes, regardless of the resident's level of independence. Noise levels at night were not adequately managed, affecting residents' ability to rest. Two residents reported being repeatedly disturbed by a vocal resident across the hall, with one stating he was unable to sleep and had not been offered earplugs or other interventions to reduce the noise, despite the facility having such items available. Staff confirmed that the noisy resident was routinely awake and vocal at night, and that other residents had complained about the noise. Additionally, privacy curtains in two residents' rooms were observed to be soiled with a dried, reddish-brown liquid, and residents expressed concern that these were not promptly cleaned or removed. Facility policy required a clean, comfortable, and homelike environment, including cleanliness and comfortable noise levels, but these standards were not met.
Failure to Implement Effective Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper cleaning of resident equipment, inadequate hand hygiene, and inconsistent use of personal protective equipment (PPE) and Enhanced Barrier Precautions (EBP). Upon entry, staff were observed not wearing masks in resident areas despite a recent positive COVID-19 case among staff, and some staff only donned masks when they noticed the surveyor. Additionally, agency staff reported not receiving infection control training from the facility. For one resident admitted for rehabilitation after a stroke and with a pressure wound, a high-backed wheelchair was found with dried substances and debris, lacking a resident identifier. The same resident's bedside commode had visible dried brown residue, and a CNA was observed wiping the commode seat with a dry paper towel while wearing the same gloves used to empty a urine bucket, without performing hand hygiene or cleaning the commode frame. Both the physician and CNA involved in this resident's care did not perform hand hygiene before donning gloves, and neither knew the reason for the resident's EBP status. Another resident with a stage 3 pressure wound and indwelling catheter was observed with a catheter bag dragging on the floor and not properly placed in a privacy bag. Staff, including a therapist and CNAs, failed to perform hand hygiene before donning PPE and did not consistently wear gowns during high-contact care, despite EBP signage and orders. The resident's catheter tubing was repeatedly seen resting on the floor in common areas, and staff acknowledged that proper infection control procedures were not followed during care activities.
Failure to Maintain Resident Dignity and Address Expressed Needs
Penalty
Summary
The facility failed to maintain resident dignity for two individuals with significant cognitive impairment. One resident, who was severely cognitively impaired and required a wheelchair for mobility, was observed sitting in a congested common area near the nursing station. Without being provided privacy, a therapist exposed both of the resident's legs to discuss his wounds in front of others, and an LPN administered oral medications in the same public setting, using the medication cup to open the resident's mouth. The LPN stated that she had not considered the appropriateness of administering medications in a common area and had not asked the resident about his preference for medication administration location. The resident's care plan did not include any specific interventions regarding medication administration in a common area. Another resident, also cognitively impaired and unable to complete a mental status interview, was observed repeatedly asking for help while seated in a high-backed wheelchair in front of the nursing station. The resident expressed discomfort and a desire to leave the area, but staff responded by turning on music and moving her in front of the radio before walking away. Later, the resident voiced that her pad was soiled, which, according to her care plan, indicated a bowel movement, but her needs were not addressed at that time. The care plan for this resident included interventions to support communication and ensure her needs were met when voiced, but these interventions were not followed during the observed incidents.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the clinical appropriateness of self-administering medications, as required by policy. In the case of one resident with dementia and severe cognitive impairment, a prescription nasal spray was found at the bedside without an active order, completed self-administration assessment, or documentation in the care plan. The resident reported using the nasal spray independently, and nursing staff, including the RN, LPN, and DON, were unaware of the medication being kept at the bedside or of any assessment having been completed for self-administration. Another resident, who was cognitively intact, was observed with a medication cup containing a pill on the bedside dresser. The resident stated that a nurse had given the pill to be taken as needed and had kept it at the bedside for several days before self-administering it. There was no order for self-administration, no assessment completed, and no care plan documentation for self-administration of medications for this resident. Nursing staff and the DON confirmed that the resident was not approved to self-administer medications and that no assessment had been performed. Facility policy requires that residents requesting to self-administer medications must be assessed by a licensed nurse, reviewed by the interdisciplinary team, and, if approved, have a physician's order and a care plan in place. The policy also states that medications should not be left unattended at the bedside unless these steps are completed. In both cases, these procedures were not followed, resulting in unsupervised medication administration and lack of appropriate documentation.
Failure to Accurately Document and Process Advance Directives
Penalty
Summary
The facility failed to accurately and completely document and process advance directives for one resident. Upon review, the resident's care plan did not include any focus, goals, or interventions related to the resident's wishes for cardiopulmonary resuscitation (CPR), despite the presence of significant cardiac diagnoses. The facility's policy required that advance directive forms be reviewed with the resident upon admission and forwarded to the physician for signature, but this process was not followed. The resident's physician orders and initial history indicated a full code status, but the actual advance directive form was not present in the facility's CPR Binder, which staff rely on during emergencies. Interviews revealed that the resident was not given the opportunity to review advance directive paperwork upon admission and later expressed a desire to be DNR (do not resuscitate), which was not reflected in the documentation available to staff. The social worker acknowledged that the advance directive form had not been provided to the physician for signature, meaning the resident's wishes would not be honored in the event of a cardiac or respiratory arrest. This series of omissions resulted in the potential for the resident's preferences regarding life-sustaining treatment to not be followed.
Failure to Timely Notify Resident Representative of Elopement Incident
Penalty
Summary
The facility failed to notify the resident representative of a significant change in a resident's condition when a resident with severe cognitive impairment exited the facility unattended. The resident, who had diagnoses of schizoaffective disorder and dementia and required supervision or assistance for ambulation, was observed by staff outside the facility after opening an exit door. Following this incident, a wander guard was applied to the resident, and the care plan was updated to address the elopement risk. Despite these interventions, the resident's representative was not informed of the incident or the new safety measures until nearly two weeks later, after the recertification survey had begun. Documentation and staff interviews confirmed that the expectation was for timely notification of the resident's representative or guardian in such situations, but this did not occur in this case.
Failure to Ensure Appropriate Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were only used when medically indicated and that appropriate documentation and non-pharmacological interventions were in place for three residents. For one resident with depression and metabolic encephalopathy, multiple psychotropic medications were administered without supporting diagnoses or care plan interventions, and the pharmacy had raised concerns about the lack of justification for these medications. The social worker confirmed that there were no known medical conditions to justify the use of these medications and that this issue should have been addressed prior to admission. Another resident, admitted with spinal stenosis and a history of falls, was prescribed antipsychotic and antidepressant medications following a hospital stay for delirium. However, there was no documentation of a diagnosis supporting the continued use of these medications, and consent for the antidepressant was not obtained as required. Both the director of nursing and the pharmacist acknowledged that delirium is a symptom rather than a diagnosis and that the necessary documentation and non-pharmacological interventions were missing. Behavior monitoring logs and medication administration records showed no documented behaviors to justify the ongoing use of these medications. A third resident with severe cognitive impairment and diagnoses of dementia, mood disturbance, and anxiety was prescribed an antimanic medication. The care plan did not include any non-pharmacological interventions, and progress notes described behavioral issues without listing alternative approaches. The director of nursing stated that monitoring for adverse side effects should be done per shift, but the facility's policy required that psychotropic medications only be initiated after non-pharmacological interventions had been attempted, which was not followed in these cases.
Failure to Provide Bed Hold and Transfer/Discharge Notices During Hospitalization
Penalty
Summary
The facility failed to provide required written bed hold notices and transfer/discharge notifications to a resident and her legal guardian during two separate hospitalizations. The resident, who was cognitively intact and had a legal financial guardian, was transferred to the hospital on two occasions due to hypoglycemia, seizure-like activity, chest pain, and coughing. Upon review of the resident's chart, there was no documentation that bed hold notices or transfer/discharge notices were given to either the resident or her guardian for either hospitalization event. Interviews with facility staff, including an LPN, the Nursing Home Administrator, and the Director of Nursing, confirmed that the necessary paperwork was not located in the resident's record and that staff could not recall if the required notifications were provided. The facility's own policies require that bed hold and transfer/discharge notices be given to residents and/or their representatives at the time of transfer, and that documentation of these actions be maintained in the medical record. However, these procedures were not followed in this case, as verified by staff and policy review.
Failure to Provide Meaningful Activities Resulting in Resident Isolation
Penalty
Summary
The facility failed to provide meaningful activities to promote psychosocial well-being for one resident with a history of depression and moderate cognitive impairment. The resident reported feelings of loneliness and depression after admission and stated that staff had not addressed his repeated expressions of loneliness. He attempted to participate in group activities but was unable to remain due to physical discomfort, and staff interactions were minimal, with the resident noting that staff socialized with his roommate but not with him. Observations confirmed the resident spent significant time alone in a darkened room, and he reported that his only positive social experiences occurred in the rehabilitation gym. The activity assessment for the resident did not identify any leisure interests, and the care plan noted the resident's lack of engagement in scheduled activities, with approaches limited to offering activities in his room, going outside, and providing social visits. However, the Activity Director reported only brief, infrequent one-on-one visits and did not track their frequency or duration. The facility lacked volunteers to supplement social visits, and weekend and evening activity programming was minimal or absent. The activity calendar showed a lack of variety, with few physical, outdoor, or social activities offered, and no documentation of efforts to tailor activities to the resident's interests or needs. Interviews with staff revealed that the resident's requests for regular staff visits were not consistently documented or implemented, and there was no evidence of systematic efforts to address his psychosocial needs. The facility's own policies required daily, individualized activity programming, but these were not followed, resulting in the resident experiencing social isolation, loneliness, frustration, and boredom.
Failure to Assess and Treat Resident's Skin Condition Promptly
Penalty
Summary
A resident with severe cognitive impairment, dependent on care and mobility, and diagnosed with Alzheimer's disease and dementia, developed a scabbed area on the top of her right hand. The wound was first noted in a progress note, which described pus oozing from the scab when touched, and the area was cleansed and bandaged. However, there was no immediate physician order for wound treatment, and the care plan did not include a resident-specific treatment plan for the injury. The wound was not assessed or documented according to facility policy, and the dressing applied was not dated initially. The Assistant Director of Nursing, who is responsible for wound care, was not notified of the wound until several days after its discovery, and no skin event was created as required by policy. The Director of Nursing confirmed that the origin and timing of the wound were unknown, and the wound nurse was unaware of the incident until after the survey began. The facility's policy requires prompt assessment, documentation, and notification of skin impairments, but these steps were not followed, resulting in a delay in assessment and treatment of the resident's wound.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for wound care for a resident with a stage 3 pressure ulcer on the right trochanter. The resident, who was severely cognitively impaired and diagnosed with dementia and anxiety, had a wound that required daily dressing changes with Medihoney as ordered by the physician. Documentation showed that the dressing was not changed as ordered, and the wound dressing observed was dated two days prior, with visible wound drainage through the gauze. The resident's care plan specified the need for daily treatment to promote healing and prevent infection, but this was not carried out as required. Interviews with facility staff revealed that the LPN assigned to the resident did not perform the wound care on the specified day, citing being too busy, and did not notify the DON or another nurse. The medical record inaccurately reflected that the resident refused the treatment, which was not corroborated by the LPN. The ADON confirmed the importance of daily Medihoney application for wound healing and acknowledged that the missed treatment could impede the healing process. The failure to provide the ordered wound care represented a missed opportunity to support healing and prevent infection for the resident.
Failure to Prevent Elopement and Ensure Wheelchair Safety
Penalty
Summary
The facility failed to implement adequate interventions to ensure a safe environment for a resident with cognitive impairment and a history of wandering and behavioral disturbances. The resident, diagnosed with dementia, schizoaffective disorder, and bipolar disorder, was observed attempting to exit the facility and later successfully eloped by opening an exit door and leaving unattended. Prior to the elopement, the resident's care plan did not include specific interventions to prevent exit-seeking behavior, and behavioral monitoring was inconsistently documented, with no records immediately before or after the incident to track the resident's risk of elopement. Additionally, the facility did not ensure the safety of two residents during wheelchair transport. One resident, with an above-the-knee amputation and using a wheelchair for mobility, was observed being pushed by an RN without footrests, resulting in the resident's bare foot brushing against the floor. Another resident, cognitively intact, was also transported in a wheelchair without footrests by a CNA, with her bare toes skimming the floor. These actions were contrary to established wheelchair safety protocols, which require residents' feet to be on footrests during transport to prevent injury.
Failure to Provide Adequate Catheter Care and Assessment
Penalty
Summary
The facility failed to provide adequate urinary catheter care and assessment for the need of an indwelling catheter for a resident with severe cognitive impairment and a diagnosis of urinary retention. Documentation showed that licensed nurses verified the presence of a catheter fixation device for several days, but direct observation revealed that no leg fixation device was in place during incontinence care. Certified Nursing Assistants confirmed that a fixation device should be used to prevent accidental tugging, especially since the resident was known to attempt to pull out the catheter if it was uncomfortable. The Director of Nursing also acknowledged that leg straps or fixation devices are required to prevent the catheter from being pulled out. Additionally, there was no evidence that the facility had assessed the ongoing need for the indwelling catheter or attempted a voiding trial, as required by facility policy. The Director of Nursing stated that the resident had arrived with a catheter and that no voiding trial had been discussed or attempted within the first month of admission. Facility policy mandates periodic assessment and documentation to justify continued catheter use, as well as involvement of the resident or representative in discussions about catheter removal, but these steps were not completed.
Failure to Maintain Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration with the contracted dialysis center for a resident with end stage renal disease who was dependent on dialysis. According to facility policy, there should be weekly communication between the facility and the dialysis center, including sharing of pre- and post-dialysis weights, laboratory results, and dietary concerns. However, review of the dialysis communication binder revealed no recent communication sheets for the resident, and the facility was unable to provide any completed communication forms for the resident in question. Interviews with staff confirmed that the required communication forms were not consistently completed or returned, and there was no documentation to show that the facility followed up with the dialysis center when forms were missing. The resident reported receiving monthly reports from the dialysis facility's dietitian but was unsure if this information was shared with the facility's dietitian. The facility's dietitian technician stated that she relied on the dialysis communication forms to coordinate nutritional services and that the resident's nutritional assessment was pending due to lack of information. The DON acknowledged that the absence of documented communication increased the risk of unmet medical needs for the resident. The deficiency was identified through observation, interviews, and record review, which demonstrated a lack of adherence to the facility's own policy and procedures regarding dialysis care communication.
Failure to Offer and Document COVID-19 Vaccination for Eligible Resident
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered to a resident who was eligible for vaccination. The resident, who had Alzheimer's disease and was unable to complete a mental status assessment, had a durable power of attorney (DPOA) for medical decision making. The resident's records showed no documentation of receiving a COVID-19 vaccine during the current admission period. The Infection Preventionist/Registered Nurse (IPRN) reported attempting to contact the resident's DPOA by phone to obtain consent for vaccination but did not receive a response and had no documentation of these attempts. Additionally, the Regional Clinical Consultant (RCC) indicated that the facility should have consulted the Medical Director regarding the appropriateness of administering the COVID-19 vaccine, especially since the resident had previously received the vaccine before admission. The facility's policy required education and offering of the COVID-19 vaccine to residents and staff, but there was no evidence that these steps were completed for this resident, resulting in a failure to comply with the facility's own procedures.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, seven days a week, as required. Review of the weekend schedule for October 2024 revealed that there was no RN coverage on Sunday, October 20, 2024. During interviews, the scheduler stated that when an RN was not available to work on the weekend, attempts were made to secure agency RN coverage, and if unsuccessful, either the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would go into the facility. However, the Regional Clinical Consultant confirmed that there was no evidence of an RN working on the specified date.
Missing 'NO EXIT' Signage on Dining Room Sliding Door
Penalty
Summary
During an observation, it was found that the sliding glass door in the dining room, which leads to the courtyard, could be mistaken for an exit. The door did not meet the requirements for an exit to the public way and lacked the required 'NO EXIT' signage as specified by Life Safety Code (LSC) 7.10.8.3.1. This issue was identified because the door's appearance could cause confusion during an emergency, and the necessary signage to prevent this confusion was not present. The findings were confirmed in an interview with the Maintenance Director at the time of observation. No information about specific residents, their medical history, or their condition at the time of the deficiency is included in the report.
Plan Of Correction
K293 Exit Signage Element 1: No residents were harmed due to this deficient practice. All residents and staff have the potential to be affected by this deficient practice. Proper signage was installed on the sliding glass door in the dining room leading out to the courtyard, stating that “Not An Exit”. Element 2: An audit was completed of exit doors that are not emergency exits to ensure that proper signage is in place. No concerns were identified. Element 3: Education was provided to the maintenance director on exit and directional signage displayed properly in the facility. Element 4: The Maintenance Director or Designee will audit the exit doors one-time weekly for 4 weeks then monthly times three months to ensure that the exit doors have proper exit signage in place. Any concerns will be addressed at the time they are discovered. Audit findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.
Failure to Document Quarterly Sprinkler System Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler system in accordance with Life Safety Code (LSC) Sections 19.7.6, 4.6.12, 9.7.5, and NFPA 25. During a review of facility records, it was found that there was no documentation available for the required quarterly testing of the sprinkler system for the fourth quarter of 2024. This lack of documentation was confirmed during an interview with the Maintenance Director at the time of the records review. No information was provided regarding any specific patients or their medical conditions in relation to this deficiency.
Plan Of Correction
K353 Sprinkler System- Maintenance and Testing Element 1 No residents were harmed due to this deficient practice. All residents and staff have the potential to be affected by this deficient practice. Element 2 Testing of the sprinkler system took place on Jan 29, 2025, and April 15, 2025. Element 3 Education was provided to the Maintenance Director regarding scheduling and monitoring to ensure the Quarterly testing of the sprinkler system occurs timely, and documentation of the test is available for review. Element 4 The Quarterly Sprinkler System Test schedule and documentation will be audited monthly by the Maintenance Director to ensure it is scheduled and performed timely and that the documentation of the inspection is available for review. The Quarterly Sprinkler System Test schedule and documentation of the test findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.
Improper Locking Device on Kitchen Refrigerator/Freezer Egress Door
Penalty
Summary
A deficiency was identified when a hasp with a padlock was observed mounted to the outside of the refrigerator/freezer door in the kitchen. This setup created the potential for someone to be locked inside the refrigerator/freezer, which is a violation of Life Safety Code (LSC) section 7.2.1.5.3. The presence of the padlock and hasp on the egress door did not comply with the requirements for approved exit access, as doors in a required means of egress should not require a tool or key for exit unless specific special locking arrangements are met. The observation was made during a facility inspection, and the findings were confirmed in an interview with the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time, nor does it provide details about any medical history or conditions of individuals involved. The deficiency was limited to the physical environment and the improper installation of a locking device on an egress door in the kitchen area.
Plan Of Correction
K222 Egress Doors Element 1 No residents were harmed due to this deficient practice. All staff have the potential to be affected by this deficient practice. The hasp with a padlock mounted to the outside of the refrigerator/freezer door was removed in order to prevent accidental locking of someone inside. Element 2 The Maintenance Director audited other refrigerators and freezers in the facility to ensure that all opened and closed properly without the threat of accidentally locking someone inside. No concerns were identified. Element 3 Education was provided to the maintenance director on refrigerator and freezer doors that need to open and close properly per K222. Element 4 The Maintenance Director or Designee will audit the refrigerator/freezer doors one-time weekly times 4 weeks then monthly times three months to ensure that the doors are closing and locking properly. Any concerns will be addressed at the time they are discovered. Audit findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.
Obstruction of Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to protect cooking facilities in accordance with Life Safety Code (LSC) 19.3.2.5 and NFPA 17A. During an observation, it was found that the shelf of a newly acquired kitchen stove would obstruct the spray nozzles of the hood fire suppression system if activated. This configuration violates NFPA 17A 10.2.7.3, as the obstruction could prevent the suppression system from functioning as intended. The deficiency was confirmed during an interview with the Maintenance Director at the time of observation. No information about specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
K324 Cooking Facilities Element 1 No residents were harmed due to this deficient practice. All residents and staff have the potential to be affected by this deficient practice. The shelf of the newly installed kitchen stove was removed so that it does not obstruct the spray nozzles of the hood fire suppression system if activated. Element 2 An audit was completed by the maintenance director to ensure that there are no other objects within the kitchen that could obstruct the spray nozzles of the fire suppression system. No other concerns were identified. Element 3 Education was provided to the maintenance director regarding the requirement that there should be no objects obstructing the spray nozzles of the fire suppression system. Element 4 The Maintenance Director or Designee will audit the kitchen one-time weekly for 4 weeks, then monthly times three months, to ensure that there are no objects obstructing the spray nozzles of the fire suppression system. Any concerns will be addressed at the time they are discovered. Audit findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to provide an environment free from abuse for three residents, resulting in fear, avoidable pain, bruising, and potential for more serious injury. Resident #100, who was moderately cognitively impaired and suffered from chronic pain, reported that CNA P was rough during care, causing significant pain by dropping her leg onto the bed. Witnesses, including other CNAs, confirmed that CNA P did not heed the resident's requests to be gentle, leading to the resident feeling unsafe and worthless. Resident #101, who was cognitively intact and had a history of chronic pain, reported that CNA P handled him roughly during a transfer, resulting in a bruise on his hand. The resident described being thrown into bed and having his genitals bumped during a rough check, which left him feeling angry and vulnerable. The former Nursing Home Administrator and the Director of Nursing confirmed the resident's account and observed the bruise, which was consistent with the reported rough handling. Resident #102, who was moderately cognitively impaired and required assistance with activities of daily living, reported that CNA P refused to assist her to the bathroom and left her in the dark. Although the resident could not recall specific details later, her legal guardian and a trusted LPN confirmed the resident's distress and described CNA P's actions as cruel. The facility's failure to protect these residents from abuse by CNA P was evident in the consistent reports and observations of rough and neglectful care.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, resulting in falls with fractures and other injuries. Resident #26, who was severely cognitively impaired and had a history of falls, was not adequately supervised despite being at high risk for falls. The resident's care plan did not incorporate crucial information about his fall history and need for close supervision, as reported by his daughter. Observations revealed that Resident #26 was often left alone in his room with the door closed, and staff were unable to provide the necessary supervision due to staffing constraints. Resident #7 also experienced inadequate supervision, leading to multiple falls. Despite requiring substantial assistance due to cognitive impairment and mobility issues, the resident was not consistently provided with 1:1 supervision. An incident occurred when a sitter momentarily turned away, resulting in a fall and injury. Staff interviews indicated that the resident was impulsive and required close monitoring, but staffing limitations prevented continuous supervision. Both residents suffered injuries due to the lack of adequate supervision, highlighting the facility's failure to ensure a safe environment. Staff members expressed concerns about insufficient staffing to meet the residents' needs, and observations confirmed that residents were left unattended, increasing the risk of falls and injuries.
Deficiencies in Food Service Equipment Maintenance and Food Date Marking
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and properly date mark potentially hazardous ready-to-eat food products, affecting 33 residents. During an initial tour of the food service area, it was observed that one of the hand sink faucet assemblies was loose, and the pre-wash sink overhead spray arm handheld valve assembly was improperly positioned. Additionally, the juice machine and the nursing station refrigerator were found with accumulated and encrusted food residue on both interior and exterior surfaces. These conditions were not in compliance with the 2017 FDA Model Food Code, which requires equipment food-contact surfaces and utensils to be clean to sight and touch. Furthermore, a gallon of milk was found without an effective open or use-by-date, contrary to the facility's policy of marking milk with a use-by-date of three days from opening. The mop sink basin was also heavily soiled with accumulated dust and dirt deposits. The facility's policies and procedures for storage and cleaning were reviewed, revealing that leftovers should be refrigerated immediately and used within 5-7 days, and that reach-in refrigerators and freezers should be cleaned and sanitized regularly. These deficiencies increased the likelihood of cross-contamination, bacterial harborage, and resident foodborne illness.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 33 residents and increasing the likelihood of cross-contamination and bacterial harborage. During an environmental tour, several deficiencies were noted, including non-functional overhead light assemblies in various areas such as the East Hall housekeeping closet and resident rooms. Active water leaks were observed in the Nursing Station restroom and the Occupational/Physical Therapy area, with moisture-stained ceiling tiles in the Clean Linen Room. Additionally, the Nursing Station had worn and torn chairs, and the Employee Lounge contained a corroded microwave oven. The Beauty Shop had a broken lockset hasp and heavily soiled cleaning equipment. The facility's maintenance work order system was found to be inadequate, as no specific entries related to the observed maintenance concerns were recorded in the Maintenance Request Log Sheets for the past 120 days. The facility's policy on housekeeping and laundry staff, which lacked a date, stated that the facility would provide effective housekeeping and maintenance services to ensure a clean, sanitary, orderly, comfortable, and home-like environment. However, the observations during the survey indicated a failure to adhere to this policy, as evidenced by the numerous maintenance issues and lack of recorded maintenance requests.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to maintain resident dignity for a resident who was unable to complete a mental status interview due to cognitive impairment and required substantial assistance for toileting. During an observation, the resident was left exposed from the waist down while receiving incontinence care in bed. One of the two CNAs providing care left the room to call a nurse, leaving the resident uncovered for approximately four minutes. When asked by a surveyor if she wanted to be covered, the resident expressed a desire to be covered, and the remaining CNA then covered her. The resident's care plan highlighted the importance of maintaining dignity and privacy during personal care, but this was not adhered to during the incident.
Failure to Implement Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with a history of falling, unspecified dementia, and type 1 diabetes mellitus with diabetic retinopathy. The resident was severely cognitively impaired and required maximal assistance for transfers. The care plan included interventions to reduce fall risk, such as keeping the call light within reach, maintaining clutter-free paths, and assisting with toileting before and after meals. However, these interventions were not consistently implemented, as staff were unaware of some of the required actions, and the resident experienced two falls, one resulting in a fracture. Observations revealed that the resident often remained alone in his room with the door closed, contrary to the care plan's instructions to keep the door open unless providing personal care. The resident preferred to stay in his room and listen to music rather than participate in activities or eat in the dining room, where he would have more supervision. Staff interviews indicated a lack of awareness and implementation of the care plan interventions, such as encouraging the resident to eat in the dining room and providing activities after dinner. The facility's failure to update the care plan with new interventions after the resident's falls and the lack of staff adherence to existing interventions contributed to unmet care needs. The resident's preferences, such as keeping the room dark at night and staying in his room, were not adequately addressed in the care plan, leading to inconsistencies in care delivery. The observations and interviews highlighted a disconnect between the care plan and its execution, resulting in the resident's increased risk of falls and unmet care needs.
Inadequate Staffing Leads to Resident Falls and Unmet Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, resulting in falls with injuries and unmet care needs. Interviews with staff, including CNAs and RNs, revealed that the facility often operated with inadequate staffing levels, particularly during weekends and night shifts. CNAs reported being unable to complete essential tasks such as showers and ADLs due to the lack of staff, and RNs expressed concerns about not having enough time to administer medications and treatments properly. The Nursing Home Administrator acknowledged using agency staff but was unaware of recent staffing concerns. Resident #20, who has cerebral palsy and dementia, reported experiencing long call light wait times, leading to incontinence and feelings of embarrassment. The resident expressed concern about the cleanliness of her bed and the potential burnout of staff due to extra hours. Similarly, Resident #26, with a history of falls and severe cognitive impairment, suffered multiple falls resulting in injuries such as a hip fracture and a wrist fracture. Staff interviews indicated that Resident #26 required close supervision, which was not possible due to insufficient staffing. Resident #7, who has cognitive impairment and requires substantial assistance for ADLs, experienced numerous falls, including one that resulted in a hand fracture. The resident's care plan included 1:1 supervision, but staff were unable to provide this consistently due to other responsibilities and limited personnel. The Director of Nursing and other staff members highlighted the need for more CNAs to ensure adequate supervision and care, but staffing decisions were constrained by budgetary considerations.
Failure to Follow Up on Pharmacist Recommendations and Document Physician Review
Penalty
Summary
The facility failed to follow up on pharmacist recommendations and ensure the physician documented review of pharmacy recommendations for a resident reviewed for unnecessary medication use. The resident, who was admitted to the facility with diagnoses including hallucinations, cognitive communication deficit, depression, and anxiety, had a moderately impaired cognition score. During an interview, the resident appeared pleasant but confused. A Pharmacy Consultation Report from January 2024 recommended monitoring a CBC with differential monthly due to the resident's use of azathioprine, which has a boxed warning for increased risk of malignancy. The facility physician agreed with these recommendations, but the resident's care plan was not updated accordingly, and a CBC was not completed until March 2024, with the next one in June 2024. Further review revealed that a Pharmacy Consultation Report from February 2024 could not be located, and the Director of Nursing did not sign the May 2024 report, which noted missing lab values. The facility's Medication Regimen Review Policy outlines procedures for acting upon pharmacist recommendations, including documentation by the attending physician and timely addressing of recommendations. However, the facility did not adhere to these procedures, as evidenced by the lack of documentation and follow-up on the pharmacist's recommendations for the resident.
Failure to Conduct Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication by not completing gradual dose reductions (GDR) for two residents. Resident #6, who was admitted with diagnoses including hallucinations, depression, and anxiety, was on citalopram for depression since admission. Despite the requirement for GDR attempts within the first year of medication use, there was no documentation of any GDR attempts for citalopram in 2023 or 2024. Interviews with the Nursing Home Administrator and Regional Clinical Nurse confirmed the absence of GDR attempts for this medication. Resident #22, admitted with dementia and depression, was on trazodone. The last GDR attempt for trazodone was documented in early 2024, with the next scheduled for late 2024. However, there was no documentation in the physician notes regarding GDR attempts for trazodone. The Social Services Manager indicated that GDR recommendations come from the pharmacist, and the Director of Nursing confirmed that the pharmacy sends GDR recommendations to the facility. The facility's policy requires GDR attempts within the first year of medication use and annually thereafter, unless clinically contraindicated, but these were not documented for the residents in question.
Failure to Secure Controlled Substances in Medication Refrigerator
Penalty
Summary
The facility failed to ensure a double-lock system for a controlled substance in the medication refrigerator, which was observed to be unlocked. On the morning of June 27, the medication room refrigerator was seen unlocked through the window of the medication room. An MDS RN was observed using another RN's keys to enter the medication room without supervision, and the refrigerator remained unlocked. Inside the refrigerator were vials and pens of insulin, vaccines, and a container holding doses of Lorazepam, a controlled substance. Interviews with staff revealed that the keys to the medication refrigerator were held by the RN, the DON, and the ADON. The RN acknowledged that the refrigerator should be kept locked due to the presence of narcotics. The MDS RN admitted to borrowing keys to access the room for storing aspirin and Tylenol. The DON confirmed that only the nurse assigned to the medication cart and the DON should have access to the keys. The facility's policy, updated in September 2022, mandates a double-lock system for refrigerated controlled substances, which was not adhered to in this instance.
Infection Control Deficiencies in PPE Use and Medication Handling
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during care for two residents, leading to potential cross-contamination and exposure to bloodborne pathogens. In one instance, a registered nurse (RN) performed a blood glucose test on a resident without wearing gloves or performing hand hygiene before and after the procedure. This action was contrary to the guidelines provided by the Center for Disease Control and Prevention (CDC), which emphasize the importance of glove use and hand hygiene to prevent the transmission of bloodborne viruses. Another deficiency was observed in the care of a resident with a peripherally inserted central catheter (PICC) line. The RN and a licensed practical nurse (LPN) failed to adhere to Enhanced Barrier Precautions (EBP) by not wearing gowns and gloves while administering intravenous (IV) antibiotics. Additionally, the IV tubing and bags were not labeled or dated, and hand hygiene was not performed during the procedure. The resident's room had CDC EBP signage, indicating the need for specific PPE, which was ignored by the staff, increasing the risk of infection. Furthermore, medication administration practices were found to be inadequate. An RN was observed placing medication tablets directly onto the top of a medication cart without a clean barrier, which could lead to contamination. The Director of Nursing (DON) confirmed that medications dropped on unclean surfaces should be discarded and replaced. These actions demonstrate a lack of adherence to infection control protocols, potentially compromising resident safety.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from mental, verbal, and physical abuse by staff and other residents. Resident #101, who was severely cognitively impaired, was physically abused by RN T, who dragged her 70 feet down a hallway, resulting in a skin tear on her buttocks. Despite multiple reports of RN T's abusive behavior, including verbal abuse and threats, no corrective action was taken prior to the incident. Resident #101's court-appointed guardian confirmed that the abuse caused psychosocial harm to the resident. Resident #103, who was cognitively intact, reported feeling mistreated when CNA F yanked on her leg during care, causing significant pain and emotional distress. Despite Resident #103's complaints, CNA F dismissed her concerns and continued to provide care in a hurried and rough manner. This left Resident #103 feeling fearful and humiliated throughout her stay at the facility. Resident #105, who was moderately cognitively impaired, was struck in the face by Resident #101, resulting in redness and emotional distress. Additionally, RN T was reported to have verbally abused Resident #105 on multiple occasions, including telling her to shut up and go to sleep, and turning off her lights despite her fear of the dark. These actions were reported to the former Director of Nursing, but no actions were taken to address the abusive behavior. Resident #106, who was severely cognitively impaired, was also found with multiple bruises on her arms and legs, and there were reports of her being dragged down the hallway by staff, causing further emotional and physical harm.
Failure to Implement Abuse Policy and Protect Residents
Penalty
Summary
The facility failed to thoroughly implement its abuse policy to protect, investigate, report, and prevent staff-to-resident abuse and bruises of unknown origin for three residents. Resident #101, who was severely cognitively impaired, was subjected to verbal and physical abuse by RN T. Incidents included RN T dragging Resident #101 down the hallway, causing a skin tear, and verbally abusing her. Despite multiple reports from CNAs to the former Director of Nursing (FDON) C, no actions were taken to address the abuse, and RN T continued his abusive behavior until he was suspended on 2/25/24. Resident #105, who was moderately cognitively impaired, also experienced verbal abuse from RN T. Multiple CNAs reported witnessing RN T yelling at Resident #105, turning off her lights, and closing her door while she screamed in fear. Despite these reports, FDON C did not take any corrective actions, and the verbal abuse continued. Resident #105 expressed feeling scared and angry due to RN T's actions, which included denying her over-the-counter pain medication at night. Resident #106, who was severely cognitively impaired, was found with extensive bruising on her arms and legs. Family Member W reported that Resident #106 was sent to the hospital with bruises covering her forearms and lower legs. Despite the severity of the injuries, there were no incident reports or documentation of how Resident #106 sustained these injuries. The facility's failure to investigate and document the injuries, as well as the lack of corrective action against RN T, highlights significant lapses in the facility's abuse prevention and reporting protocols.
Failure to Prevent Insect Bites and Install Window Screens
Penalty
Summary
The facility failed to prevent residents from insect bites and did not install window screens, resulting in a significant wound for Resident #108. Resident #108, who had a history of cerebral infarction, aphasia, depression, hemiplegia, generalized anxiety disorder, and pain, was admitted to the facility and later developed a wound on her right thigh from a suspected spider bite. The wound required debridement, antibiotic treatment, and ongoing wound care, causing increased pain and immobility for the resident. Observations revealed that the resident's room window was open without a screen, and the facility had issues with ants, spiders, and other insects inside the building. Interviews with the resident, family members, and staff confirmed that Resident #108 preferred to keep her window open for fresh air, but no screen was present to prevent insect entry. The resident reported significant pain from the wound, which affected her ability to move and tolerate touch. Family members and staff also noted the absence of window screens and the presence of insects in the facility. Maintenance staff admitted to removing all window screens in the fall of 2023 due to damage and had not yet replaced them all. The facility's pest control policy required windows to be screened at all times, but this was not followed. A pest control inspection confirmed the absence of screens and the presence of insects. The facility's failure to maintain window screens and control pests directly led to Resident #108's insect bite and subsequent wound, highlighting a significant deficiency in the facility's quality of care and environmental safety measures.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility failed to ensure individualized approaches were provided to a resident diagnosed with dementia, resulting in avoidable stress responses to care interventions. Resident #101, who was severely cognitively impaired with diagnoses including vascular dementia, aphasia, delusional disorder, psychotic disorder, and anxiety disorder, experienced stress responses due to the lack of effective, personalized interventions. The care plan for Resident #101 included general interventions such as maintaining a calm environment and reporting behaviors to the Director of Nursing, but these were not effective in managing the resident's stress responses. Staff members, including CNAs and RNs, identified specific interventions that worked well for Resident #101, such as gentle physical touch, providing a portable snack, and reading certain children's books, but these were not documented in the care plan or communicated effectively among the staff. The behavior tracking log also showed a lack of documentation of effective interventions, with only general approaches like calm approach and reassurance being recorded, which were often ineffective. Interviews with staff revealed that while they had discovered effective personalized interventions for Resident #101, these were not reflected in the care plan or consistently implemented. CNA L found that rubbing the resident's hands, cheek, and hair helped calm her, while RN X discovered that providing a portable snack and reading children's books from the 1960s were effective. CNA Y noted that offering ice cream and lightly scratching the resident's head helped reduce stress. Despite these findings, the care plan remained unchanged, and the facility's policy on dementia care, which emphasized individualized interventions, was not followed. The Social Services staff confirmed that behavior documentation was incomplete and not well-documented in the electronic medical record, contributing to the deficiency in providing appropriate care for Resident #101.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 286 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plainwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Plainwell | 5.6 mi | ★★★★★ | 20 | 0 |
| Villa At Borgess Place | 6.3 mi | ★★★★★ | 45 | 0 |
| Medilodge Of Westwood | 7.9 mi | ★★★★★ | 2 | 0 |
| Alamo Nursing Home Inc | 8.3 mi | ★★★★★ | 11 | 0 |
| Friendship Village | 8.5 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.