Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency At Grand Blanc during CMS and state inspections, most recent first.
Kitchen sanitation, pest control, and food storage deficiencies were identified when ice buildup was observed in the walk-in freezer, ready-to-eat foods were date marked in the grill refrigerator, and a damaged whisk and a dirty dish were found in clean storage. The wiping cloth sanitizer bucket tested at 0 ppm twice, gnats and a fly were seen in food service areas, and the ice machine drain line was observed sitting directly into a pump and a drain in nourishment rooms.
Improper waste disposal and dumpster area maintenance were observed when a partially ripped garbage bag was hanging from the dumpster and trash was falling onto the surrounding area. Dirty cups, lids, residue, and fast food wrappers were also found around and behind the dumpster, despite the CDM stating the area is checked and cleaned daily. The facility’s Trash policy requires trash removal on a schedule and the dumpster area to remain free of debris.
A resident with CHF, anxiety, DM, CKD, A-fib, and lymphedema had a room floor with dry skin and debris and reported that housekeeping had not cleaned the room for a few days. Housekeeping staff said resident rooms were supposed to be vacuumed or mopped daily, but one housekeeper admitted missing the room on multiple days while managing a heavy assignment load, and her assignment sheets showed repeated missed room cleanings.
Failure to provide showering and shaving assistance for a resident who was dependent on staff for ADLs. The resident, who had intact cognition, reported preferring showers and close shaving but received bed baths instead and no shaving help despite tremors that prevented self-care. Staff documentation showed bathing refusals without clear follow-up or rescheduling, and the UM and DON stated showers and shaving should be offered and refusals documented.
Failure to Report Skin Injury and Improper PEG Tube Medication Administration: A resident with stroke-related deficits developed a swollen, bruised arm that staff noticed at different times but did not promptly report, despite care plan directions to report new skin findings and positioning concerns. In a separate event, staff improperly administered meds via a PEG by crushing and mixing meds together, skipping placement and residual checks, not flushing the tube first, using poor technique, and spilling medication onto the bed; the ICP nurse later agreed the standard of care was not followed.
Pressure ulcer care and treatment were not consistently implemented for a resident with multiple facility-acquired pressure injuries, severe cognitive impairment, and total dependence for several ADLs. An air mattress was found turned off and not providing alternating air, and the resident’s coccyx wound was observed without a dressing despite staff reporting it should have been covered. CNA staff reported the missing dressing had already been noted earlier in the shift, and the resident also had unstageable pressure injuries to both heels and a coccyx wound that had progressed from stage II to stage III.
A resident’s nebulizer equipment was observed stored in a bag while still wet, with the resident reporting that staff were putting the assembled device back in the bag after treatments without cleaning or drying it. Another resident was observed on an oxygen concentrator set at 6 L/min despite an order for 0.5 to 4 L/min via NC, and nursing staff could not find documentation supporting the higher flow rate.
Failure to Follow EBP PPE and Laundry Standards: Staff did not wear the required gown and gloves during PEG tube care and medication administration for residents on EBP, and staff also did not wear a gown when administering IV medication via a PICC line. In addition, kitchen cleaning cloths were laundered in a way that did not sanitize or disinfect them, and the detergent used was confirmed not to have sanitizing or disinfecting properties.
A resident with multiple diagnoses, including heart disease, prediabetes, dementia, anxiety, depression, anemia, and a cough, had a PCV20 refusal documented in the EMR, but no more recent consent or declination was found. The ICP stated the vaccine had last been offered in 2024, and when she later spoke with the resident, he again declined but refused to sign the form.
The facility failed to ensure staff received a current COVID-19 VIS for vaccination education. Review of employee records showed two nurses had declination forms, while a newly hired nurse had only an education form and no consent or declination form. The VIS used by the facility was dated 10/19/2023, even though a newer CDC VIS dated 1/31/2025 was available, and the ICP stated she was unaware of the updated version.
A resident with rheumatoid arthritis, morbid obesity, non-ambulatory status, and osteoarthritis, care planned as requiring a 2-person assist for bed mobility, was provided peri-care by a single CNA. The CNA positioned the resident to hold the side rail and then moved to the opposite side of the bed to continue care. While the CNA was on the other side, the resident lifted a leg to uncross her ankles, shifted her body weight, and rolled off the low bed to the floor, resulting in a bruised right knee and an x-ray-confirmed recent impacted healing right knee fracture. Both the CNA and the DON acknowledged that the care should have been provided with two staff, in accordance with the care plan and fall management policy.
A resident with multiple comorbidities, including recent hip fracture repair, DM, dementia, and cardiac history, expired in the facility, and nursing staff failed to document the event according to facility policy. The night-shift RN who initiated SQ hydration did not record a full assessment prior to CPR, did not document absence of pulse, BP, or respirations, and omitted the specific times CPR was started, EMS arrived, and resuscitation ended, noting only that the resident coded and was pronounced by EMS with family and provider notified. In a separate issue, another nurse later entered a sepsis screening with normal VS and no infection indicators for this same resident on a date after the resident’s death, without labeling it as a late entry or correcting it via strike-out or addendum, contrary to the facility’s documentation expectations policy.
Two residents with significant respiratory conditions did not receive safe and appropriate respiratory care when staff failed to perform and document thorough respiratory assessments and to maintain complete oxygen orders. One resident with acute respiratory failure and pneumonia had inconsistent and incomplete lung assessments despite low SpO2 readings, increased O2 needs, abnormal lung sounds, and ongoing antibiotic and nebulizer therapy; oxygen was restarted after desaturation without a new provider order, and documentation conflicted regarding infection status and respiratory findings. Another resident on continuous O2 via concentrator had an order that omitted the prescribed liter flow, leaving the oxygen therapy parameters incomplete despite diagnoses of acute respiratory failure with hypoxia, pneumonia, and end-stage disease.
Five residents' wheelchairs and motorized mobility devices were found to be visibly soiled, with packed substances, worn cushions, and debris, despite documentation indicating regular cleaning. Residents reported their wheelchairs were not cleaned regularly and could not recall the last cleaning, while the Environmental Services Director confirmed that cleaning was not consistently performed as required.
Multiple residents with respiratory conditions were found with nebulizer equipment containing residual fluid left at the bedside and oxygen tubing that was not labeled or dated as required. Staff confirmed that equipment was not cleaned, separated, or stored according to facility policy, and care plans for respiratory treatments were missing or incomplete.
Surveyors found unsanitary conditions in the kitchen, including a misaligned ice machine causing water pooling, dirty equipment such as a microwave and refrigerator, soiled cereal dispensers, and improper storage of clean items. The dish machine failed to consistently reach the required sanitizing temperature, with no documentation of corrective actions. Staff confirmed lapses in cleaning and maintenance, in violation of facility policy.
Multiple residents experienced a lack of dignity and respect when call lights were not accessible and staff response times were excessively long. One resident who is blind and at risk for falls could not locate his call light, which was found on the floor, while another resident requiring substantial toileting assistance was left unattended in the hallway and remained in soiled clothing due to delayed help. Family members also reported repeated issues with call light accessibility and long wait times for assistance.
A resident who was cognitively intact and made their own decisions was moved to a new room without being given advance written notice or an explanation for the change. The resident discovered their belongings had been moved after returning from therapy and expressed distress over not being informed. Staff contacted the resident's son instead of the resident, and no policy on room change notification was provided during the survey.
Two residents with severe cognitive and mobility impairments experienced multiple falls, including one resulting in a hip fracture, due to inadequate supervision and lack of effective fall prevention interventions. Care plans were not individualized or consistently implemented, residents were left unsupervised without call lights or activities, and incident documentation was incomplete, leading to preventable injuries.
Two residents did not receive timely changes to their medication regimens after pharmacy recommendations were accepted by practitioners. In one case, a resident continued to receive aspirin for months after it was recommended for discontinuation, and a dose reduction for famotidine was not implemented or documented. In another case, a resident's insulin regimen was not updated for two months after agreement to adjust, and the decision to maintain the current regimen was not documented. The facility's policy addressed review of recommendations but not the timeliness of implementing agreed-upon changes.
Two residents were found with medications stored at bedside without proper assessment for self-administration, and staff were unaware of the facility's policies regarding medication storage. One resident self-administered over-the-counter pain relief and hydrocortisone cream, while another had topical pain relief gel at bedside despite cognitive impairment and no assessment in place. Required policies and procedures were not provided during the survey.
Two residents developed new or worsening pressure ulcers due to the facility's failure to implement timely preventive measures, such as regular turning, repositioning, and skin assessments, and to update care plans with appropriate interventions. Delays in wound care and lack of preventive devices contributed to the deficiencies, despite both residents being at high risk for skin breakdown.
The facility did not promptly notify emergency contacts and physicians following significant changes in condition and incidents involving two residents with moderate cognitive impairment. In one case, a resident's family and physician were informed of a fall nearly ten hours after it occurred. In another, a resident's emergency contact was not notified of a hospital transfer and only discovered it during a visit. Staff interviews and documentation confirmed delays and lapses in required notifications.
A resident with multiple medical conditions and a history of falls developed a laceration on the left lower leg. Although a practitioner ordered the wound to be monitored due to the resident's use of a blood thinner, there was no documentation in the TAR of wound assessment, monitoring, or a care plan. Nursing notes referenced dressing changes but lacked detailed wound descriptions, and the discharge summary omitted the resident's skin condition and clear wound care instructions. The facility did not follow its own skin management policy for assessment, monitoring, and documentation.
A resident developed pressure wounds on both heels and buttocks due to inadequate interventions and lack of evaluation for effectiveness. Despite being at risk, the resident's care plan was not effectively implemented, with inconsistencies in repositioning and use of heel boots. The facility's documentation and staff interviews revealed conflicting reports about the resident's compliance with interventions, leading to the development and worsening of pressure wounds.
A facility failed to honor a resident's right to self-determination by not accommodating her dietary preferences, despite her expressed wishes and involvement of her family in medical decisions. The resident, with a history of dysphagia, was kept on an NPO status based on a previous failed swallow study, without being given the opportunity to make an informed decision about her dietary intake. The facility's policies on resident rights were not upheld, leading to a deficiency in honoring the resident's rights.
A resident with pressure ulcers and moderate malnutrition did not receive proper care as outlined in their care plan. Observations showed the resident lacked a pressure reduction cushion in their wheelchair and did not have their heels elevated or protected while in bed. The care plan was not linked to the Kardex, leading to CNAs not having the necessary information to provide appropriate care.
A facility failed to maintain a carpet in a resident's room, resulting in a persistent urine odor. Despite frequent shampooing, the odor remained, affecting air quality. The issue was reported by family members, but no grievance forms were completed. The maintenance director was unaware of prior complaints until reviewing logs. Plans to remove the carpet were confirmed by the nursing home administrator.
A resident at risk of aspiration pneumonia received tube feeding at an incorrect rate of 130 ml/hr instead of the ordered 65 ml/hr, leading to emesis and potential fluid overload. The error was discovered by a family member, and the resident was transferred to the hospital. The LPN responsible did not verify the feeding rate against the physician's order.
Kitchen sanitation, pest control, and food storage deficiencies
Penalty
Summary
The facility failed to properly store food, control pests, and maintain sanitizer concentrations in the food service area. During the initial kitchen tour, a buildup of ice was observed at the back of the walk-in freezer. In the grill refrigerator, chopped peppers, chopped onion, diced and sliced tomato, and diced cucumber were date marked 7/10-7/17, and the Certified Dietary Manager stated that the prep date is counted as Day 1 and food is kept for a maximum of 7 days. Additional observations identified food-contact and sanitation concerns in the kitchen. A whisk utensil had burn marks and pitting on the handle near the metal prongs, and a dark green sticky residue was observed on a clean dish stored in the clean storage rack. The wiping cloth sanitizer bucket at the three-compartment sink tested at zero parts per million for quaternary ammonia on two separate observations, despite the Certified Dietary Manager stating the sanitizer should be changed every two hours and maintained at 150-200 ppm. Pest activity and equipment/drainage concerns were also observed. Gnats were seen flying around the clean dish storage area, underneath the microwave area, and underneath the prep sink area near the rice storage container, and a fly was observed flying around the food prep area during lunch. The ice machine drain line in two nourishment rooms was observed sitting directly into a pump and directly in a drain. The report also cites the FDA Food Code standards related to cleaning frequency, date marking, utensil condition, sanitation, pest control, and backflow prevention.
Improper Waste Disposal and Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area free of debris. On observation, a partially ripped garbage bag full of trash was hanging from the dumpster, and its contents were falling onto the surrounding area. Dirty cups, lids, and a buildup of residue were observed on the ground around the dumpster, and fast food wrappers were found behind it. During the observation, the Certified Dietary Manager stated the dumpster area is checked multiple times a day and cleaned every day. Record review showed the facility’s Trash policy requires trash to be removed on a specific schedule to prevent spillage and odors and states the area surrounding the dumpster will be kept free of debris.
Failure to Maintain Clean Resident Room Conditions
Penalty
Summary
The facility failed to maintain clean and homelike room conditions for Resident #82, who was admitted with diagnoses including CHF, anxiety, diabetes, CKD, atrial fibrillation, and lymphedema. During Resident Council, the resident asked how often housekeeping should mop resident rooms. A review of her room and interviews with housekeeping staff and the housekeeping supervisor showed that her room had dry skin and other debris on the floor and had not been cleaned for a few days before the supervisor swept and mopped it. The resident reported that floor cleaning had been a continuous issue and that, before the supervisor cleaned it, her room had not been cleaned in a few days. Housekeeping staff reported that resident room floors were supposed to be vacuumed or mopped daily, but staffing and workload issues affected completion of assignments. One housekeeper stated she was assigned about 22 rooms per day, including discharges and common areas, and admitted she had not cleaned Resident #82’s room for a few days because she was moving slower and focusing on being thorough in other rooms. Review of her assignment sheets showed multiple dates when she did not clean several assigned resident rooms, including Resident #82’s room on multiple days. The housekeeping supervisor stated that when rooms are not completed, staff are supposed to communicate that and return to them the next day, but he was not aware that this had been happening.
Failure to Provide Showering and Shaving Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for one resident who was unable to complete grooming and bathing independently. The resident was admitted with diagnoses including acquired absence of the right leg above the knee, atherosclerosis of the arteries of both legs, polyneuropathy, history of falling, and disorders of muscle. The Minimum Data Set showed intact cognition with a Brief Interview of Mental Status score of 15/15, and the resident was dependent on staff for showering and bathing, toileting hygiene, and required substantial to maximal assistance with transfers. During interview and observation, the resident was seen with a full beard and long mustache and stated a preference to be close shaven with a mustache. The resident reported having a trimmer from home, asked staff for shaving assistance, and said he could not shave himself because of tremors in his upper extremities. The resident also stated he preferred showers but had received bed baths instead, and reported that after one attempt by CNA staff following therapy, the CNA left and the shower was not rescheduled. The resident said he had been admitted on June 23 and had not received a shower or shaving assistance since admission. Record review and staff interviews showed bathing tasks were documented as refused on multiple dates, but the progress notes lacked documentation of the refusals, the refusal on 7/13, or any rescheduling of bathing. The Unit Manager stated residents should receive showers rather than bed baths unless they refuse, and that refusals should be discussed with the resident and documented. The DON stated that refusals should be documented with a custom alert and followed up, and that shaving should be offered during personal care with refusal documented and reported. The facility policy stated residents are to receive assistance to maintain grooming and personal/oral hygiene, with showers scheduled according to person-centered care and daily hygiene including shaving.
Failure to Report Skin Injury and Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure prompt reporting of a newly identified skin issue for a resident with stroke-related hemiplegia, atrial fibrillation, a pacemaker, hyponatremia, and dementia. The resident was dependent for care and had care plan interventions for abnormal bruising, impaired skin integrity, pain, and functional deficits. During the morning of the event, a CNA observed the resident leaning to the left in a wheelchair and adjusted her with pillows, but did not ask about pain or report the positioning concern. Later, a CNA noticed the resident’s left forearm was swollen and bruised through her shirt and notified a nurse, but the finding had not been reported during shift change. The resident was later observed with extensive dark purple bruising and swelling from above the wrist to the elbow, and she could not explain how the injury occurred. Interviews showed that multiple staff members had different accounts of when the arm condition was first noticed and whether it had been reported. One CNA stated she saw the arm swelling during morning care and did not report it because she assumed others already knew. Another CNA stated she noticed the resident leaning to the left during her shift and repeatedly repositioned her, but did not report the issue. A nurse on the day shift stated she had not observed any arm issue and had not received report about it. The nurse who responded after the finding was reported stated the arm was warm, swollen, and dark purple, and the resident winced when touched. The resident’s family member reported the facility called and said a CNA had noticed the arm swelling and discoloration, and a practitioner later told the family the injury was caused by tissue trauma. The facility also failed to properly handle and use a PEG tube for another resident who had a PEG, ASHD, GERD, dysphagia, and a history of esophageal obstruction, and who was severely cognitively impaired and dependent on care. During observed medication administration, a nurse crushed medications and mixed them together in red guaifenesin liquid for PEG administration. The nurse entered the room without a clean barrier, did not check tube placement or residuals, and did not flush the PEG before attempting administration. The medication would not drain properly, the stopcock was not positioned correctly, and medication spilled onto the bed. The nurse left the room to get help, and subsequent observation showed continued attempts to force the medication through the PEG without proper technique. The infection control nurse later agreed that the standard of care was not followed, including not mixing medications for PEG administration and not assessing or flushing the tube before use.
Pressure Ulcer Care and Treatment Not Implemented
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility failed to implement interventions and treatments for pressure ulcer management for one resident with multiple wounds. The resident had diagnoses including pressure ulcer of the sacral region, right heel and left heel, anxiety disorder, noninfective gastroenteritis and colitis, short bowel syndrome, end stage renal disease, and dependence on renal dialysis. The resident’s MDS showed severely impaired cognition, dependence for bathing, toileting hygiene, and transfers, and urinary and bowel incontinence documented as always incontinent. On observation, the resident was lying in bed on her back with an air mattress in place, but the air mattress machine was not functioning. The resident stated she did not think the mattress was deflated underneath her. A nurse later observed that the air mattress machine was not on, turned it on, and reported there were no alarm sounds. The nurse stated it may have been shut off by accident and was unsure how long it had been off. The unit manager later stated there would be no reason to turn it off and that, while the mattress would not collapse, it would not provide the benefit of alternating air. During wound care, the resident’s coccyx wound was observed without a dressing in place. The nurse performing wound care stated there should have been a dressing on the wound and was unsure why it was not there. A CNA reported that during incontinence care earlier in the shift, the resident did not have a dressing on the coccyx wound and that she had told the nurse at that time. The CNA also reported that when she changed the resident again later, the dressing was still absent. The resident had facility-acquired unstageable pressure wounds to both heels and a facility-acquired coccyx pressure wound that had progressed from stage II to stage III, and the facility’s skin management policy stated residents with wounds and/or pressure injury are to be identified, evaluated, and provided appropriate treatment to promote prevention and healing.
Respiratory Equipment Storage and Oxygen Order Not Followed
Penalty
Summary
Safe and appropriate respiratory care was not provided when nebulizer equipment for one resident with pneumonia was found stored in a bag while still wet inside the medication chamber. The resident had an admission and readmission history that included left tibia fracture, heart failure, and diabetes, and the MDS showed moderately impaired cognition. The resident’s record showed a 7/9/26 progress note documenting pneumonia management, wheezing in both lungs, cough with mucus, and a new order for albuterol sulfate nebulization solution three times daily for 7 days. On observation, the nebulizer mask and medication chamber were assembled together and placed in a bag hanging on the bedside table drawer handle, with the chamber visibly wet inside. When interviewed, the resident stated that one nurse washed the equipment and set it out to dry, but other nurses were putting it back in the bag after treatments without cleaning it or letting it dry. The facility also failed to follow a physician’s oxygen order for another resident. That resident had diagnoses including pleural effusion, chronic respiratory failure with hypoxia, pulmonary heart disease, COPD, and CHF, and the MDS showed intact cognition. The resident was observed wearing a nasal cannula connected to an oxygen concentrator set at 6 L/min, even though the order was for 0.5 to 4 L/min via nasal cannula to maintain oxygen saturation above 89%. The concentrator was not within the resident’s reach, the resident reported dry nose and that staff sometimes removed the oxygen because of bleeding, and the resident stated the oxygen had been at 3 L/min but was turned down to 2. Nursing staff could not find documentation supporting a change to 6 L/min, and the DON confirmed the facility policy required verifying the practitioner’s order and adjusting the oxygen flow rate as ordered.
Failure to Follow EBP PPE Requirements and Proper Laundering of Kitchen Cleaning Cloths
Penalty
Summary
The facility failed to follow Infection Prevention and Control standards of practice during care and medication administration for residents with feeding tubes and a PICC line while they were on Enhanced Barrier Precautions (EBP). For one resident with a PEG tube, the record showed diagnoses including PEG tube, ASHD, GERD, dysphasia, and a history of esophageal obstruction, and the MDS indicated severe cognitive impairment with a BIMS score of 1 of 15 and dependence for care. During observed tube feeding and medication administration, Nurse A prepared the formula at the medication cart without gloves, placed the uncapped connection end directly on the cart without a barrier, handled the PEG tube with an open end, inserted the syringe into the tube, and manipulated the stop cock multiple times without wearing a gown or using a clean barrier. When the medication administration was unsuccessful, Nurse A returned with another nurse and later with the ICP nurse, and still did not wear the required gown during direct care. Another observation of the same resident showed Nurse L administering medication via PEG tube with gloves only and no gown, despite the EBP sign indicating gloves and gown were required for feeding tube care or use. A second resident with a PICC line for IV vancomycin and MDRO history was also observed on EBP. The resident’s MDS showed cognitive intactness with a BIMS score of 15 of 15. During IV medication administration via the PICC line, Nurse G wore gloves only and did not wear a gown. Nurse G stated she believed a gown was not needed for IV medication administration through the PICC line and identified the line as a mid-line rather than a central line. The ICP nurse initially stated that a gown was not needed for medication administration through the PICC line because staff were not in direct contact with the resident, but later stated she was wrong and that staff were required to wear gown and gloves when accessing the PICC line for medication administration. The facility policy and posted CDC EBP signage both identified central line and feeding tube care or use as high-contact resident care activities requiring gloves and gowns. The facility also failed to ensure kitchen cleaning cloths were laundered in a manner that sanitized or disinfected them. In the laundry area, washcloths used as kitchen cleaning cloths were observed hanging to dry after being washed in a separate smaller machine with no bleach. Maintenance staff explained the smaller machine was used for resident items that could not tolerate higher heat or bleach, and that the kitchen cloths were being laundered this way because of a prior fire at another facility. The detergent used, Sunburst ultimate solid laundry detergent, did not identify sanitizing or disinfecting properties on the SDS, and the ICP nurse stated she could not find information showing the detergent sanitized or disinfected the cloths. The Maintenance Director later confirmed the detergent did not sanitize or disinfect, and the facility continued to launder the kitchen washcloths without sanitizing or heat drying them, despite the facility policy stating cleaning towels were to be used for cleaning and sanitization and laundered separately.
Failure to Document Pneumococcal Vaccine Offer and Declination
Penalty
Summary
The facility failed to ensure pneumococcal vaccinations were offered and that acceptance or declination was documented for one resident. The Infection Control Practitioner stated that residents are assessed for vaccinations on admission, that the pneumococcal vaccine is offered if the resident has not received the most updated dose, and that acceptance or declination is documented on a consent form and placed in the medical record. The facility policy also stated that each resident's pneumococcal immunization status is to be determined upon admission or soon afterward, documented in the medical record, and re-evaluated annually if declined. Resident #44 was admitted and later readmitted with diagnoses including heart disease, prediabetes, dementia, anxiety, depression, anemia, and a cough. Review of the electronic medical record showed a refusal of a PCV20 pneumonia vaccination and a declination signed on 3/5/2024 stating the resident did not want the pneumonia vaccination. No additional consents or declinations were found in the record. When interviewed, the Infection Control Practitioner could not locate a more recent consent or declination for the resident and stated the last time the vaccine was offered was in 2024; she later spoke with the resident on 7/15/2026, and he declined the vaccination but refused to sign the form.
Outdated COVID-19 VIS Provided to Staff
Penalty
Summary
The facility failed to ensure staff were provided a current Vaccine Information Sheet (VIS) for COVID-19 vaccinations for 3 staff members reviewed. During interview, the Infection Control Practitioner stated that COVID-19 vaccinations were discussed with employees on hire, staff were given educational information about the vaccine, and they were told where they could obtain it, but the facility did not provide COVID-19 vaccinations to staff. The facility maintained employee consent forms documenting whether staff chose to receive or decline the vaccine. Record review showed Nurse DD and Nurse EE each had COVID-19 employee vaccine consent forms indicating they declined vaccination, with forms signed on 9/24/2025. Nurse FF, who was newly hired on 6/9/2026, did not have a consent or declination form for COVID-19 vaccination. She signed a COVID-19 Vaccine Staff Education form stating she had been educated using the CDC VIS sheet. The facility provided staff a COVID-19 VIS dated 10/19/2023, but the most recent CDC COVID-19 VIS available was dated 1/31/2025. When interviewed about the outdated VIS, the Infection Control Practitioner stated she did not realize there was a newer COVID-19 VIS.
Failure to Follow Two-Person Assist Care Plan Resulting in Fall From Bed
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan and implement required fall-prevention interventions for a resident who required assistance from two staff for bed mobility. The resident, an older adult with rheumatoid arthritis, morbid obesity, inability to ambulate, and primary generalized osteoarthritis, had a care plan in the EMR indicating dependence on two staff for bed mobility. On the date of the incident, a CNA provided peri-care to this resident alone, without a second staff member, despite the Kardex specifying a two-person assist for bed mobility. During peri-care, the CNA positioned the resident by pulling her toward the side rail so she could hold it, as had been done previously, and then moved to the opposite side of the bed to continue care. While the CNA was on the other side, the resident, whose ankles were crossed, lifted her leg to uncross them, and her body weight shifted, causing her to roll over the side of the bed and fall to the floor. The bed was in a low position, but the resident sustained bruising to the right knee, and an x-ray later revealed a recent impacted healing right knee fracture. The CNA acknowledged that she should have had another staff member assisting her, and the DON confirmed that two staff should have been used for this care, consistent with the resident’s care plan and the facility’s fall management policy requiring interventions related to identified fall risks.
Incomplete and Inaccurate Clinical Documentation at Time of Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely clinical documentation for a resident who was admitted with multiple serious medical conditions and later expired at the facility. The resident had a history of a recent hip fracture with surgical repair, Diabetes Mellitus, Dementia, Anxiety Disorder, coronary angioplasty with stents, and malignant neoplasm of the eye, among other diagnoses. A Medical Examiner’s report determined the death to be from natural causes and ruled out foul play. On the night of the resident’s death, Nurse A worked the 11:00 PM to 7:30 AM shift and had initiated subcutaneous hydration before her shift. She reported that the 3–11 nurse had told her the resident had shallow breathing and appeared pale. The nursing assistant confirmed the resident was still breathing at around 1:00 AM, and at approximately 2:30 AM the resident was found unresponsive, a code was overhead paged, and CPR was started. Nurse A acknowledged that she did not follow standards of nursing documentation: she failed to document the assessment findings prior to CPR (such as absence of pulse, blood pressure, and respirations), the time CPR was started, the time EMS arrived and took over, and when resuscitation was stopped. Her only progress note entry at 3:16 AM stated that the resident coded at approximately 2:30, that 911 was alerted, the resident was pronounced at 2:44 AM by EMS, and that the provider group and daughter were notified, without the detailed assessment and pronouncement information required by the facility’s “Death of a Resident” and “Documentation Expectations” policies. A separate documentation issue was identified with Nurse B, who completed a Sepsis Screening Evaluation in the electronic record for this resident on a date after the resident had already been deceased for several days, with no indication that the entry was a late entry or an error. The sepsis screen documented normal vital signs, no suspected infection, and no antibiotic therapy, and was electronically signed on that later date without any strike-out or late-entry notation. In interview, Nurse B stated she was unaware she had documented an assessment on the resident after death, reported she did not have access to the strike-out function, and suggested it might have been for another patient or a late entry with an incorrect date, but she could not recall the specifics. The DON confirmed that the resident had passed away before the date of Nurse B’s documented assessment and stated they were not sure what happened with that entry. These actions and omissions conflicted with the facility’s policies requiring contemporaneous, accurate documentation, proper correction of errors via strike-out or addendum, and clear identification of late entries.
Failure to Perform Thorough Respiratory Assessments and Maintain Complete Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not completing thorough respiratory assessments and not maintaining complete oxygen orders for two residents. One resident was admitted with multiple diagnoses including acute respiratory failure and later developed pneumonia, with radiology showing right upper lobe infiltrate and subsequent worsening bilateral opacities concerning for pneumonia. Nursing progress notes documented intermittent cough, shortness of breath (SOB), and use of supplemental O2, but lung assessments were inconsistently documented and often lacked detailed respiratory findings such as lung sounds. Although the resident’s oxygen was discontinued after initial improvement, when oxygen saturations later dropped into the low 80s on room air, oxygen therapy was restarted without a corresponding new physician order being entered into the medical record. During the period when the resident had pneumonia twice, documentation showed minimal thorough respiratory assessments despite ongoing respiratory symptoms and treatment with antibiotics, inhalers, and nebulizer treatments. Notes indicated low SpO2 readings, increased O2 requirements, and abnormal lung findings such as diminished sounds and wheezing, but the chart lacked consistent, detailed lung assessments across shifts. A skilled care note on one day listed the resident’s respiratory status as “None,” and a sepsis screening completed almost simultaneously indicated no documented infection or antibiotic therapy, which conflicted with the resident’s active pneumonia diagnosis and antibiotic treatment. A nurse working an evening shift reported that she did not assess lung sounds at any time during her shift, including before or after administering a breathing treatment, despite having been told in report that the resident “did not sound too good.” The sequence of events leading up to the resident’s transfer to the hospital included rising oxygen needs, low oxygen saturations despite increased O2 flow, and abnormal lung sounds described by night-shift staff, but the timing and progression of the change in condition could not be clearly determined from the record due to inconsistent and incomplete respiratory documentation. The Infection Preventionist acknowledged that charting during this period was inconsistent and did not provide an accurate depiction of the resident’s respiratory status, and agreed that lung sounds would have been abnormal given the pneumonia diagnosis. Hospital records later documented that the resident had needed more oxygen than her baseline and was admitted with extensive bilateral pneumonia, acute-on-chronic respiratory failure, and other complications, ultimately leading to death. A second resident was observed using supplemental oxygen via concentrator, with the device set at 2 L, but the corresponding physician order only stated to provide O2 via nasal cannula to maintain SpO2 greater than 89% and did not specify the liter flow or range. The unit manager confirmed that the liter amount was not listed in the order. This omission meant that the oxygen order for this resident was incomplete, as it lacked a defined flow rate despite the resident having diagnoses including acute respiratory failure with hypoxia, pneumonia, and end-stage disease.
Failure to Maintain Clean and Sanitary Wheelchairs for Multiple Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for five residents by not ensuring their wheelchairs and motorized mobility devices were regularly cleaned, sanitized, and free from damage. During a Resident Council meeting, multiple residents reported that their wheelchairs were not cleaned on a regular basis and could not recall the last time cleaning occurred. Observations revealed that the wheelchairs had packed substances in crevices, worn cushions, dried-on substances, and visible dust and debris. Documentation indicated that cleaning was supposed to occur weekly, but the observed condition of the wheelchairs did not align with these records. Further interviews and observations with the Environmental Services Director confirmed that staff typically inspect and clean wheelchairs monthly, which contradicted the documented weekly cleaning schedule. Specific examples included wheelchairs with ripped seat cushions, thick buildup of substances, and crusted-on debris. Residents consistently reported not recalling when their wheelchairs were last cleaned, and the Environmental Services Director acknowledged that regular cleaning was not being addressed as required.
Failure to Ensure Proper Respiratory Equipment Care and Labeling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents by not ensuring proper storage, cleaning, and labeling of respiratory equipment. Observations revealed that several residents had nebulizer masks or medication chambers with visible fluid left in them after use, and the equipment was not properly cleaned, separated, or stored as per facility policy. In one case, a resident's nebulizer mask was left on the dresser with fluid in the medication cup, and there was no care plan or intervention documented for nebulizer use. Other residents were found with nebulizer equipment containing fluid days after their last treatment, and staff confirmed that the equipment should have been cleaned and stored appropriately but was not. Additionally, a resident receiving oxygen therapy had tubing that was not labeled or dated as required by facility policy, and staff acknowledged that labeling should have occurred upon admission but did not. The residents involved had various diagnoses including COPD, asthma, respiratory failure, heart failure, and mental health conditions. At the time of the deficiencies, some residents were no longer receiving nebulizer treatments, yet equipment with residual medication was still present at the bedside. Staff interviews confirmed that the observed practices did not align with facility policies, which require cleaning, drying, and proper storage of nebulizer equipment, as well as labeling and dating of oxygen tubing. The lack of adherence to these procedures was directly observed and verified by nursing management.
Deficient Sanitation and Equipment Maintenance in Food Service Area
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to the maintenance and sanitation of kitchen equipment and the environment. During a kitchen tour, several unsanitary conditions were observed, including a puddle of water behind the ice machine, a drain grate with dark orange/brown discoloration, and tubing covered in visible brown dust. The microwave had food splatters inside, and the cook's refrigerator contained dried food particles and smudges both inside and outside the door. The cereal dispenser chutes had a film of debris, and the tray line refrigerator had a loose door seal and ice/frost buildup. Additionally, the drain/grate under the sink was soiled, ready-to-use cups were stored against a soiled step stool, and baking sheets were found wet. The walk-in freezer also had ice/frost buildup on the fan blades. Dishwashing practices were also found to be deficient. The dish machine required eight racks to reach the required final rinse temperature of 180°F, and review of temperature logs showed multiple days where the rinse temperature was below the minimum standard, with no documentation of corrective actions taken. Staff interviews confirmed that the ice machine was not properly aligned with the drain, causing water to pool, and that certain cleaning tasks, such as cleaning the drain covers, had not been performed by environmental services staff. The facility's policy required proper cleaning and sanitizing of food service equipment, but these standards were not met as evidenced by the observations and record review.
Failure to Ensure Call Light Accessibility and Timely Response Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity and safety by not making call lights accessible, resulting in extended response times and lack of respectful treatment for multiple residents. One resident, who is blind and has a history of falls and moderate cognitive impairment, reported difficulty locating his call light, often having to feel around his bed to find it. During observation, his call light was found on the floor under the bed, and staff acknowledged that it was not placed within his reach as required by his care plan. Another resident, who is cognitively intact and requires substantial assistance with toileting, reported being left alone in the hallway for an extended period after lunch without access to a call light. She experienced incontinence and remained in soiled clothing for a prolonged time. Her son confirmed that the call light was often found on the floor and that response times to her requests for assistance were excessively long, sometimes up to two hours. The resident's care plan specified the need for frequent checks and prompt toileting assistance, which was not followed.
Failure to Provide Advance Written Notice and Obtain Consent for Room Change
Penalty
Summary
A cognitively intact resident who was capable of making their own medical and financial decisions was moved to a different room without being provided advanced written notification or the rationale for the change. The resident reported returning from therapy to find all personal belongings had been moved, and expressed anger and confusion about not being informed beforehand. Certified Nursing Assistants confirmed the resident was upset and did not understand why the move occurred, and no staff could provide an explanation at the time. Review of the resident's records showed that the Notice of Room Change assessment form indicated only the resident's son was contacted, despite the resident being their own responsible party. The form was signed by social services staff after the move had already occurred. During interviews, social services staff admitted to routinely contacting next of kin rather than the resident, and acknowledged not notifying the resident prior to the move. The facility was unable to provide a policy or procedure related to notification of room changes by the end of the survey.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of meaningful interventions to prevent falls for two residents with severe cognitive impairment and significant mobility deficits. One resident, who was under hospice care with multiple diagnoses including congestive heart failure, diabetes with neuropathy, vascular dementia, and end-stage renal disease, required substantial assistance for mobility and transfers and had visual impairment. Despite these needs, the resident's care plan did not address safety and monitoring after dialysis or when left unsupervised in a chair. The resident experienced an unwitnessed fall after returning from dialysis, with the wheelchair brakes found unlocked and no documentation of supervision, call light accessibility, or recent toileting. Staff interviews revealed uncertainty about the resident's supervision and lack of clear interventions to prevent falls after dialysis. Another resident with a history of falls, severe cognitive impairment, and substantial assistance needs for transfers and mobility experienced multiple falls, including one resulting in a hip fracture. The care plan included general fall prevention interventions, but documentation and staff interviews indicated that these were not consistently or effectively implemented. The resident was frequently left unsupervised near the nurses' station without activities or a call light, and staff were not always present or able to observe the resident. Incident and accident forms lacked critical details such as last toileting, footwear, continence status, and staff presence at the time of falls. Post-fall evaluations and investigations were incomplete, with discrepancies in documentation and unclear root causes for the falls. Staff interviews and record reviews highlighted gaps in supervision, incomplete investigations, and insufficient communication regarding interventions and staff assignments. The facility did not provide adequate documentation of staff presence or actions taken at the time of the incidents, and there was a lack of meaningful, individualized interventions following repeated falls. The failure to provide adequate supervision and implement effective fall prevention strategies resulted in preventable injuries, including a hip fracture, for residents at high risk due to cognitive and physical impairments.
Delayed Response to Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to timely respond to pharmacy recommendations for two residents regarding unnecessary medications, as identified through observation, interview, and record review. For one resident with chronic respiratory failure, major depressive disorder, adjustment disorder, anxiety, and GERD, the pharmacist recommended reevaluating the use of both Eliquis and low-dose aspirin due to her low hemoglobin, and the practitioner agreed to discuss and adjust the treatment. However, there was a delay in discontinuing aspirin, and after a hospital readmission, aspirin was restarted and continued for several months before being discontinued again. Additionally, the pharmacist recommended reducing the dose of famotidine due to potential adverse effects, but the practitioner disagreed, citing a previous unsuccessful gradual dose reduction, which was later confirmed by the DON to have not been completed or documented. For another resident with diabetes, anxiety disorder, chronic kidney disease, hypertension, bipolar disorder, and dementia, the pharmacist recommended increasing the Humalog dose and discontinuing sliding scale insulin, as prolonged use of sliding scale insulin is not recommended. The practitioner agreed to discuss and adjust the insulin regimen, but the order was not updated for two months. Documentation did not reflect the intended changes, and the practitioner later stated that after discussing with the resident, it was decided to maintain the current insulin regimen, but this was not documented in the progress notes or medication review. The facility's policy required practitioners to review and sign off on pharmacist recommendations within 14 days but did not address the timeliness of implementing agreed-upon changes. In both cases, there was either a delay or lack of documentation in acting upon pharmacy recommendations that were accepted by practitioners, resulting in continued administration of medications that were recommended for change or discontinuation.
Failure to Ensure Safe Bedside Medication Storage and Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles, specifically regarding bedside medication storage and self-administration assessments. For one resident with diagnoses including bipolar disorder, depression, anxiety, and a colostomy, over-the-counter migraine pain relief and hydrocortisone cream were found on the overbed table. The resident reported self-administering these medications for pain and a rash, and stated that the medications had been kept at bedside for several months without staff intervention. The acting DON confirmed that a self-administration assessment and provision of a lock box should have been completed, but these steps were not taken. Another resident with heart disease, arthritis, and a history of falls, who was moderately cognitively impaired, was observed with Biofreeze (a topical pain relief gel) and individual packets of the same medication on their overbed table. The acting DON acknowledged that Biofreeze is considered a medication and that the resident was not permitted to self-administer medications. There was no care plan or assessment in place for self-administration for this resident. Additionally, the facility failed to provide requested policies and procedures related to medication storage and self-administration by the conclusion of the survey.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide services to prevent the development of new pressure ulcers and did not implement appropriate skin care interventions for two residents with pressure ulcers. One resident, who was admitted with multiple diagnoses including spinal stenosis, recent spinal fusion, and diabetes, was dependent on staff for most activities of daily living and was at risk for pressure ulcers. Despite being identified as at risk, there was no evidence of preventive measures such as turning, repositioning, or frequent skin assessments upon admission. The resident developed new pressure wounds on the buttocks, which were not identified until several days after admission, and preventive interventions were only implemented after the wounds were discovered. Another resident, admitted with diabetes, acute kidney failure, cellulitis, and neuromuscular dysfunction of the bladder, also experienced inadequate wound care. This resident had a history of wounds on the lower extremities and developed additional pressure wounds on the buttocks and a new wound on the right big toe during their stay. The care plan for this resident was not updated with new interventions after the discovery of new wounds, and there was a delay in dressing changes and implementation of preventive devices, despite requests from the resident's family. The facility's own skin management policy requires identification and implementation of preventive measures for residents at risk of pressure injuries, as well as timely documentation and care planning. In both cases, the facility did not follow these protocols, resulting in the development and worsening of pressure ulcers, and a lack of timely and appropriate interventions to promote healing and prevent further skin breakdown.
Failure to Timely Notify Emergency Contacts and Physicians of Resident Incidents
Penalty
Summary
The facility failed to immediately notify the emergency contact and physician regarding significant changes in condition and incidents affecting two residents. In one case, a resident with moderate cognitive impairment and a history of falls experienced an unwitnessed fall in the early morning. Documentation showed that the physician and family were not notified until approximately ten hours after the incident, despite the resident being found confused and requiring treatment for an aggravated area on the leg. The nurse's notes included late entries, and the author was not identified, limiting the ability to verify the accuracy of the documentation and the timeliness of notifications. In another instance, a resident with moderate cognitive impairment and multiple medical diagnoses, including heart failure and a history of falls, experienced a significant change in mental status and was transferred to the hospital. The resident's emergency contact, her son, was not notified of the hospital transfer and only learned of it upon visiting the facility. Staff interviews confirmed that the responsible nurse did not notify the emergency contact, and the nurse practitioner did not make the notification either, as it was not her responsibility. These failures to promptly notify emergency contacts and physicians of changes in condition, falls, and hospital transfers were identified during the survey. The lack of timely communication was confirmed through record reviews, incident reports, and staff and family interviews, demonstrating a deficiency in the facility's adherence to notification requirements.
Failure to Assess, Monitor, and Document Wound Care After Resident Fall
Penalty
Summary
A resident with multiple complex medical diagnoses, including dysphagia, malignant neoplasm of the lung, and hemiplegia, experienced several falls during their stay. Following a fall, the resident sustained a laceration on the left lower leg. The nurse practitioner assessed the wound and ordered it to be left open to air and monitored for bleeding, given the resident's use of a blood thinner (Apixaban), which increased the risk of bleeding. Despite these orders, there was no documentation in the Treatment Administration Record (TAR) of any assessment, monitoring, or specific treatment orders for the left lower leg wound. Additionally, no care plan was established to address the wound or its monitoring needs. Nursing progress notes indicated that the resident aggravated the left lower leg wound by rubbing at night, and a dressing was applied to prevent further injury. However, the TAR did not reflect any daily or frequent monitoring of the wound as recommended. Subsequent nursing notes referenced the application of a xeroform dressing but lacked detailed documentation regarding the wound's characteristics, such as size, depth, or presence of swelling, discoloration, or discharge. There was also a lack of consistent and thorough documentation of the wound's status and any changes over time. Upon discharge, the post-discharge summary failed to document the resident's skin condition at the time of discharge and did not provide clear instructions for ongoing wound care. The facility's own skin management policy requires identification, evaluation, and appropriate treatment of wounds, as well as ongoing monitoring and documentation, none of which were consistently followed in this case. The lack of proper assessment, monitoring, documentation, and care planning for the resident's wound constituted a failure to provide appropriate treatment and care according to orders and the resident's needs.
Inadequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate and appropriate interventions to prevent the development and healing of pressure wounds for a resident, resulting in the resident developing pressure wounds on both heels and buttocks. Upon admission, the resident was at risk for pressure ulcers but did not have any unhealed pressure ulcers. The resident's medical record indicated a decline in condition, including poor oral intake, decreased mobility, and a preference to remain in bed, which contributed to the development of pressure wounds. The resident's care plan included interventions such as encouraging out-of-bed activity, side-lying positioning, and the use of soft boots or pillows to elevate heels. However, there was a lack of evaluation for the effectiveness of these interventions, and they were not revised to address the resident's non-compliance. Interviews with family members and staff revealed inconsistencies in repositioning practices and the use of heel boots, with the resident often found lying on their back without the prescribed interventions in place. The facility's documentation and interviews with staff indicated that the resident did not exhibit behaviors of care refusal, yet there were conflicting reports about the resident's compliance with repositioning and other interventions. The facility's policies on skin management and nursing practice emphasize the importance of evaluating and updating care plans, but these were not effectively implemented for the resident, leading to the development and worsening of pressure wounds.
Facility Fails to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating her dietary preferences, despite her expressed wishes and involvement of her family in medical decisions. The resident, a 77-year-old female with a history of dysphagia and other medical conditions, was admitted to the facility with a PEG tube for nutrition due to her inability to safely swallow liquids and solids. Despite her desire to eat food orally, the facility staff adhered strictly to the NPO (nothing by mouth) order based on a previous failed swallow study, without offering the resident the opportunity to make an informed decision about her dietary intake. The resident's sister, who held medical power of attorney, was actively involved in her care and had requested a second opinion from an ENT specialist. The ENT recommended further swallow evaluations, but the facility did not initially accommodate the resident's request for oral intake, citing safety concerns. The resident expressed sadness and frustration over being denied food by mouth, which she had requested multiple times since her admission. The facility's speech therapist and medical director decided to discharge the resident from speech therapy, maintaining the NPO status without considering the resident's right to make informed choices about her care. The facility's policies on resident rights, including the right to refuse treatment and make choices about their care, were not upheld in this case. The resident's advanced directive and the involvement of her family in decision-making were not adequately considered, leading to a deficiency in honoring the resident's rights. The facility's failure to provide the resident with the opportunity to make informed decisions about her dietary preferences, despite her cognitive ability to understand the risks, resulted in a violation of her rights to self-determination and choice.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was admitted with moderate protein-calorie malnutrition and had pressure ulcers on their coccyx and left heel. The resident was observed in a high back wheelchair without a pressure reduction cushion, which was supposed to be in place according to their care plan. The cushion was found on the bed instead of the wheelchair, and the resident reported significant pain from their wounds. Additionally, the Kardex, which guides CNA care, did not mention the need for a wheelchair cushion or dycem, leading to a lack of proper implementation of the care plan. Further observations revealed that the resident's heels were not elevated while in bed, and protective boots were not used as required. The Kardex indicated that the resident's heels should be floated on a pillow or protected with heel protectors, but this was not followed. A CNA was observed providing care alone, contrary to the care plan that required two-person assistance for bed mobility. The Unit Manager confirmed the discrepancies, noting that the care plan was not linked to the Kardex, which contributed to the CNAs not having the necessary information to provide appropriate care.
Persistent Urine Odor Due to Ineffective Carpet Maintenance
Penalty
Summary
The facility failed to effectively clean and maintain the carpet in a specific room, leading to a persistent and strong odor of urine. This issue was initially reported by a family member who noted the odor when their loved one was admitted to the room. Despite the resident being moved, the odor persisted, affecting the current occupant. Housekeeping staff confirmed the difficulty in removing odors from old carpets, even with frequent shampooing. The maintenance director was unaware of prior complaints until reviewing the maintenance work log, which showed multiple reports of the odor issue. The maintenance director acknowledged the lack of a follow-up system to ensure the issue was resolved, as the only action taken was to shampoo the carpet, which did not eliminate the odor. The facility's maintenance records indicated that the odor was reported by different families on separate occasions, but no grievance forms were completed. The nursing home administrator confirmed plans to remove the carpet from the affected room, although the facility was unable to replace all carpets at once. The persistent odor was noted during multiple observations, and the air quality in the room was affected, with a humid and chemical smell present.
Failure to Administer Tube Feeding at Correct Rate
Penalty
Summary
The facility failed to ensure that a resident, who was at risk of aspiration pneumonia, received tube feeding according to the physician's order. The resident, who had a history of extradural and subdural abscess, sepsis, morbid obesity, dysphagia, weakness, reduced mobility, and a history of COVID-19 with respiratory failure, was supposed to receive tube feeding at a rate of 65 ml/hr. However, the feeding was administered at a doubled rate of 130 ml/hr, leading to an episode of emesis and the potential for fluid overload. This error was discovered by a family member, who found the feeding rate set incorrectly and insisted on transferring the resident to the hospital for evaluation. The incident occurred when Nurse LPN C, who was responsible for administering the tube feeding, did not verify the rate of the feeding pump against the physician's order. The nurse admitted to not checking the rate when hanging a new bag of feeding, which may have been pre-programmed incorrectly. The facility's records and interviews confirmed that the nurse did not follow the proper procedure of verifying the rate and volume with every dose, as emphasized in a subsequent nurses' meeting. The resident was found supine with clinical indicators of aspiration pneumonia, which was confirmed by hospital records.
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 270 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Blanc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Grand Blanc | 4.1 mi | ★★★★★ | 20 | 0 |
| Wellbridge Of Grand Blanc | 4.2 mi | ★★★★★ | 1 | 0 |
| The Oaks At Woodfield | 5.6 mi | ★★★★★ | 12 | 0 |
| Villa At Beecher Place | 6.7 mi | ★★★★★ | 14 | 1 |
| Willowbrook Manor | 6.7 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.