Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Whitmore Lake during CMS and state inspections, most recent first.
Dining Room Closed for Most Meals: The facility failed to maintain a homelike dining experience when the main dining room was closed for breakfast and supper, and at times for all meals, leaving residents to eat in their rooms. Staff stated the room was used for spirit week activities and that it had been closed for breakfast and supper for about 1.5 years because few residents went there. A resident council leader said she was not informed of the closure, and a resident who usually ate lunch in the dining room said she was upset when it was closed and that she wanted the option to eat there for more meals.
The facility failed to ensure RN coverage for 8 consecutive hours daily. Review of schedules and timecards showed no RN coverage could be identified for one day, and the NHA confirmed the facility did not have the required RN coverage. The DON also stated the expectation was for daily consecutive RN coverage to meet resident needs, and the facility policy required RN supervision for 8 consecutive hours a day, 7 days a week, or per state guidance.
Kitchen food storage and hygiene deficiencies were observed when undated butter, jellies, and salad dressings were found in the pantry and walk-in cooler, a box of butter that required refrigeration was left warm in the pantry, and the ice machine had rusty brown debris on the inside lid and top. Three male dietary aides with facial hair were also observed preparing food without beard guards, despite the DM stating beard nets were required.
QAPI failed to identify and address several ongoing issues, including a dining room that had been closed to residents for breakfast and dinner for about 1.5 years without root cause analysis or QA review, staff education and CNA competency requirements that were behind and not monitored through QA, and antibiotic stewardship lapses where residents were started on antibiotics for UTIs without meeting McGeer Criteria. The DON, Staff Educator, Infection Preventionist, and NHA all acknowledged the gaps, and QA minutes showed no documented discussion of the dining room closure or staff development program.
The facility failed to ensure that four of five randomly selected CNAs completed the required 12 hours of annual in-service education. Record review showed the training hours for those CNAs did not total 12 hours, while one CNA’s record did meet the requirement and included dementia and abuse training. The DON stated CNAs are expected to receive 12 hours of annual training, including dementia and abuse training, and the facility policy required no less than 12 hours of in-service education per year.
Failure to Provide Timely Incontinence Care and Preserve Resident Dignity: A cognitively intact resident dependent on staff for toileting reported repeated long waits for brief changes on night shift, sometimes over an hour, and said she often sat in urine because there were not enough staff. She stated this made her feel worthless, while records showed missing documentation for incontinence hygiene and staff interviews confirmed occasions when she was found saturated in urine after night shift.
A resident with HTN, DM, anemia, and ESRD on dialysis was not allowed to determine her shower schedule. Her MDS showed she was cognitively intact and dependent on staff for bathing, yet staff scheduled showers on a dialysis day and did not ask her preference. She reported missed showers, exhaustion after dialysis, rude staff interactions, and no follow-up after filing a grievance. The UM confirmed the schedule was based on room number and the DON stated shower timing should be tailored to resident needs.
An LPN left a medication cart computer open with a resident's private information visible while away from the cart, and another LPN left a computer open with another resident's private information visible to passersby. In one instance, the LPN was cleaning up spilled water and forgot to close the computer; in the other, the LPN said he had worked all night and was tired. One LPN also prepared meds without performing hand hygiene before or after setup.
The facility failed to ensure annual competency evaluations were completed for two CNAs. Record review showed CNA H and CNA I did not have annual performance reviews, and the SE said she had started the reviews but was unable to complete them all after a tracking system change. The DON stated annual performance reviews are expected so CNA training can be adjusted based on areas needing improvement.
Expired drugs and supplies were found on the central supply shelves and had not been removed. Central Supply staff said she stocked the shelves and kept items through the month they expired if they were used often, but if not, they were thrown away. The DON stated there should not be any expired items in central supply, and the facility did not have a policy at the time of inquiry.
Infection Control Lapses During Medication Administration An LPN failed to perform hand hygiene before and after preparing and administering medications for three residents, and also did not perform hand hygiene before putting on gloves or after removing them while checking a resident's blood sugar. The LPN stated he cleaned the glucometer with an alcohol wipe, although facility policy required cleaning equipment and bleach germicidal wipes rather than alcohol wipes.
Failure to monitor antibiotic use and follow UTI criteria: Two residents were started on antibiotics for presumed UTIs even though the IP confirmed they did not meet McGeer Criteria. One resident had an indwelling catheter and was started on Macrobid, while another resident without a catheter was started on Levofloxacin for urinary symptoms. The IP stated risk-benefit analyses were requested but not documented, and the NHA said the QA committee knew about the issue but no improvement plan had been implemented.
A resident who was dependent on staff for bed mobility received catheter and peri care from a CNA using only a one-person assist, contrary to the care plan and Kardex instructions requiring two-person assistance. The CNA rolled the resident away from herself and left the resident close to the edge of the bed without handrails, increasing the risk of falling. The DON confirmed that the care plan required two-person assistance and proper technique, but the CNA had not reviewed the care plan recently.
The facility did not complete the care plan within 7 days of the comprehensive assessment and did not ensure that a team of health professionals prepared, reviewed, and revised the care plan as required.
The facility did not maintain room temperatures within the required 71-81°F range, with multiple areas exceeding this limit. Staff and a resident reported issues with inadequate cooling, old HVAC systems, and portable air conditioners that sometimes tripped circuit breakers. Despite weekly monitoring and use of fans and portable units, surveyors found several rooms and common areas above the regulatory temperature range.
Surveyors found that multiple residents received meals that were often cold, dry, repetitive, and lacking in condiments, with food preferences not consistently honored. Food trays were sometimes left in insulated carts for extended periods, resulting in improper temperatures, and staff did not always follow procedures for tray accuracy. Palatability tests and resident interviews confirmed issues with meal quality, presentation, and portion sizes, affecting residents' willingness to eat and potentially impacting their nutrition.
A resident experienced a delay in receiving their lunch meal, with the tray observed stored in a hallway cart past the usual serving time and not delivered until later by a CNA. This delay was inconsistent with the facility's stated meal service policy and affected up to 116 residents, increasing the likelihood of distress and decreased nutritional intake.
A deficiency was cited due to egress doors being equipped with locks or latches that require a tool or key from the egress side, without meeting the required special locking arrangement standards. The facility did not ensure that all conditions for clinical, security, or special needs locking—such as fail-safe electrical locks and integration with fire protection systems—were met, as observed during the survey.
A deficiency was cited due to corridor doors and doors protecting corridor openings not meeting regulatory requirements for fire and smoke resistance, positive latching hardware, and proper door clearance, as observed during the survey.
A resident with Alzheimer's disease and severe mental impairment was involved in multiple incidents of inappropriate sexual behavior toward female residents. Despite staff attempts to supervise, there was no formal care plan or consistent documentation of one-on-one supervision until after repeated incidents. Staff interviews revealed confusion about supervision requirements, and assignment sheets did not indicate the need for one-on-one monitoring.
A resident with severe cognitive impairment and a history of inappropriate sexual behavior was not consistently provided with one-on-one supervision, despite staff awareness of the need. Staff interviews and documentation review revealed that the supervision plan was not formalized as a physician's order, and assignment sheets did not indicate one-on-one supervision. This lack of clear communication and documentation resulted in repeated incidents where the resident was found unsupervised and engaging in inappropriate behavior with other residents.
The facility failed to prevent and correctly identify pressure ulcers for two residents, leading to misidentification and worsening of their conditions. One resident had a stage III pressure ulcer on the buttock, with incomplete skin assessments and care plans. Another resident had a painful pressure ulcer on the foot and a sacral wound misidentified as unstageable. The facility's interventions were not fully implemented, and staff lacked awareness of the residents' wound conditions.
A facility failed to provide palatable and appropriately temperature-controlled food, affecting 119 residents. Observations showed food items were often served below FDA temperature standards, leading to dissatisfaction. Residents reported meals were cold, unappetizing, and repetitive. Despite temperature audits, issues persisted, indicating inadequate resolution of the problem.
The facility failed to maintain and clean food service equipment, affecting 119 residents and increasing the risk of cross-contamination. Observations revealed soiled can opener assemblies and improperly stored scoops in food bins. Additionally, a loose ventilation grill in the dry storage room was noted. The facility's policies on maintenance and sanitation were not effectively implemented, leading to these deficiencies.
The facility did not reassess its ability to meet resident care needs after changes in resident acuity, including pressure ulcers, falls, and catheter care requirements. The assessment incorrectly listed the Administrator as the Governing Body, and the Administrator was unaware of her accountability to the actual Governing Body.
The facility failed to maintain a clean and safe environment, affecting 119 residents. Observations revealed issues such as a damaged smoking area canopy, porous surfaces in the laundry service area, and multiple maintenance deficiencies throughout the facility, including leaking water valves, broken light covers, and missing atmospheric vacuum breakers in shower rooms. The facility's maintenance policies were not effectively implemented, as evidenced by the lack of specific entries in the work order system for the observed concerns.
A resident with dementia reported abuse by a CNA, but the facility failed to report the allegation to the State Agency. Despite the resident's confusion and inability to identify the perpetrator, the facility's policy requires reporting all abuse allegations, substantiated or not, within specified timeframes. The NHA and SW concluded the abuse was unsubstantiated and did not report it, contrary to policy.
The facility failed to develop and implement comprehensive care plans for two residents with pressure ulcers. One resident had a stage III ulcer and moisture-associated skin damage, with care plan deficiencies in addressing refusals and interventions. Another resident, on hospice care, had pressure ulcers deemed unavoidable, but the care plan lacked interventions for refusals and coordination with hospice. Staff interviews revealed inadequate root cause analysis and documentation, highlighting systemic issues in wound care management.
A facility failed to revise the care plan for a resident with hand and muscle contractures. Despite recommendations for the resident to wear hand and elbow splints, observations showed the splints were not used, and staff interviews revealed inconsistencies in offering the splints. The care plan was not updated following therapy recommendations, leading to a deficiency in care.
A resident with dementia did not receive necessary podiatry care despite multiple requests from a family member over five months. The family member struggled to manage the resident's toenail care due to the nails' thickness and curling. Facility staff interviews revealed a lack of communication and responsibility in arranging podiatry services, with the LPN/Unit Manager acknowledging that the condition should have been documented and addressed during routine assessments.
A resident with hand contractures did not receive prescribed hand splints and positioning wedge to maintain range of motion. Despite care plans indicating the need for these interventions, observations showed the splints were not in use, and the resident reported being left on his back without repositioning. Staff interviews revealed inconsistencies in offering and applying the splints, and the care plan lacked updates following therapy recommendations.
A facility failed to ensure a physician documented the review of medication irregularities for a resident with cognitive impairment. The resident was on Divalproex and experienced mental status changes. The pharmacist recommended monitoring certain levels due to potential adverse effects, but there was no documentation of the physician's response. The DON could not find any documentation or explanation for the lack of physician action.
The facility failed to meet the nutritional needs and preferences of two residents, leading to dissatisfaction with meal consistency and adherence to dietary restrictions. One resident reported inconsistencies in receiving a chef salad and received meals with unwanted barbecue sauce. Another resident, who is underweight, experienced cold meals and missing items from their meal ticket. The Dietary Manager acknowledged issues with food availability and preparation, contributing to these deficiencies.
The facility failed to address pressure ulcers through its QAPI committee, resulting in two residents developing stage III or higher pressure ulcers. The wound nurse did not perform root cause analyses, and the DON did not conduct audits or implement plans to prevent further ulcers. The Administrator acknowledged the lack of a performance improvement plan for pressure ulcers.
A resident's social security debit card was misappropriated by an Activities Aide (AA) who was later arrested and charged with felonies for unauthorized use. The resident, with intact cognition, reported the AA as the last known person to have the card. Unauthorized transactions occurred while the resident was hospitalized, leading to the AA's identification through video footage and transaction records. The incident resulted in the resident's brother managing the card, causing a delay in personal purchases.
A resident with severe cognitive impairment was inappropriately restrained in a long-term care facility. Staff used a foam wedge to prevent the resident from leaving the bed and frequently placed him in a geri-chair, restricting his mobility. The resident, who was active and able to propel himself in a manual wheelchair, was often immobilized for convenience. The Director of Nursing acknowledged the misuse of restraints, which were not medically necessary.
A resident with severe cognitive impairment and a history of falls experienced a delay in receiving a stat x-ray for a hip and femur fracture. Despite staff awareness of the resident's condition and attempts to contact radiology, the x-ray was not completed before the resident was transferred to the hospital. The hospital confirmed fractures requiring surgery. The facility's DON acknowledged the delay and the need for supervision during the resident's unwitnessed fall.
A resident with severe cognitive impairment and a history of falls experienced a major injury due to inadequate fall prevention measures and delayed medical imaging. The resident, who was mobile and able to self-propel in a wheelchair, was often placed in a restrictive geri-chair, leading to restlessness and attempts to exit. Staff were unaware of the purpose of a foam wedge used to prevent the resident from exiting the bed, and there was a significant delay in obtaining a stat x-ray after the resident's family reported swelling and bruising.
A resident with a history of medical conditions experienced a fall and fracture due to inadequate supervision and failure to follow care-planned interventions. The resident was not properly positioned in a shower chair and was left unattended, leading to a fall. The incident was not reported immediately, and the care plan requiring a Hoyer lift was not followed, resulting in increased pain and medication needs for the resident.
A resident with Alzheimer's Disease experienced repeated falls due to inadequate supervision and engagement from staff in a locked unit. Despite the presence of CNAs and an RN, there was a lack of interaction with residents, leading to multiple falls. The facility's interventions, such as medication adjustments and diversional activities, were inconsistently implemented, and there was no thorough analysis of the falls' root causes.
A facility failed to provide adequate supervision and care on a unit for residents with cognitive impairments. A nurse took an extended break without ensuring coverage, leaving only an activities aide with the residents. This resulted in residents being unassisted, with some attempting to leave the unit or access restricted areas. The facility's protocol for staff breaks and coverage was not followed, leading to a deficiency in maintaining professional standards of care.
A facility failed to monitor and document a resident's blood pressure before administering amlodipine, as required by the physician's order. The resident, with severely impaired cognition and hypertension, had no recorded blood pressures in May and June 2024, despite receiving the medication daily. The DON confirmed the lack of documentation and improper order entry, violating the facility's medication administration policy.
Dining Room Closed for Most Meals
Penalty
Summary
The facility failed to ensure a homelike dining experience for 96 of 115 residents when the main dining room was closed for breakfast and supper, and at times for all meals, leaving residents to eat in their rooms. On 5/12/2026, a sign at the main dining room door stated the dining room was closed for the week for all meals due to a week-long activity from the activity department. The Activity Director stated residents had to eat lunch in their rooms because the dining room was being used for a spirit week activity. On 5/13/2026, residents on the 100 hall were observed being served breakfast in their rooms. CNAs stated that residents ate breakfast and supper in their rooms, with lunch served in the dining room, while another CNA stated the dining room was not open for breakfast or dinner. A CNA also stated the dining room was closed down for spirit week and that no resident could eat any meal in the dining room that week. A resident’s family member stated the resident was very social and would want to eat in the dining room but only got to eat meals in the room. The Activity Director later stated the dining room had been closed since last year because residents stopped going there and said the week of 5/11-5/15/2026 the dining room was closed all day for planned spirit week activities. The resident council president stated she was not told about the closure and that it was not discussed in resident council meetings. She also stated the dining room had been closed for breakfast and supper since last year, that she usually went to the dining room for lunch, and that she was upset when she found it closed. The Dietary Manager, Registered Dietician, and Nursing Home Administrator all stated the dining room had only been open for lunch or had been closed for breakfast and supper because few residents went there, and the NHA stated there was no documentation or QAPI evidence of attempts to reopen the dining room over the prior 1.5 years.
RN Coverage Not Maintained for Required Daily Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week. During review of the actual working schedules for March, April, and May 2026, Scheduler U was unable to identify RN coverage for April 4, 2026. The Timecard Report for that date was then reviewed with the Nursing Home Administrator, who confirmed the facility did not have 8 consecutive hours of RN coverage on April 4, 2026. The NHA stated the expectation was to have 8-hour daily consecutive RN coverage to meet resident needs. The Director of Nursing also stated the expectation was for the facility to have 8-hour daily consecutive RN coverage to meet resident needs. The facility assessment updated 8/15/2026 stated nursing must provide onsite RN coverage 24/7, and the facility policy on Nursing Staffing stated the nursing services department is under the supervision of an RN 8 consecutive hours a day, 7 days a week, or per state guidance.
Kitchen Food Storage and Hygiene Deficiencies
Penalty
Summary
Food was not stored, prepared, and maintained in accordance with professional standards in the kitchen and storage areas. During an initial tour of the kitchen, a tub of individual butter packets was observed in the walk-in cooler without a date, and a box of individual butters in the pantry was marked to keep refrigerated but was found warm; the Dietary Manager stated it should have been stored in the cooler and thrown out. Also observed were undated tubs of mixed individual jellies and assorted individual salad dressings in the pantry, and the Dietary Manager stated these items needed to be labeled and dated. The ice machine was observed with a rusty brown colored debris on the inside lid and inside top, and the Dietary Manager said it looked like mold. The Maintenance Director stated the maintenance department cleaned the ice machine monthly and acknowledged the debris had been cleaned. In addition, three male dietary aides with facial hair were observed preparing food without beard guards, despite the Dietary Manager stating the food code required men with facial hair to wear beard nets. The Nursing Home Administrator stated the expectation was for the ice machine to be clean, for kitchen staff to wear hair and beard nets, and for food to be labeled, dated, and refrigerated as appropriate.
QAPI Failure to Address Dining Room Closure, Staff Education Gaps, and Antibiotic Stewardship Noncompliance
Penalty
Summary
The facility failed through its QAPI/QAA process to identify and correct multiple deficiencies involving dining services, staff education oversight, and antibiotic stewardship. The Nursing Home Administrator stated the dining room had been closed to residents for breakfast and dinner for at least 1.5 years because only a handful of residents used it, and there had been no root cause analysis or QA discussion about reopening it. The administrator also stated there was no QA follow-up to ensure residents’ rights to a homelike dining experience were maintained. The Director of Nursing stated she met with the Staff Educator a few times a month about the staff education program, but had not requested competency audits in a long while. The Staff Educator stated staff competencies and the required 12-hour yearly CNA education were behind and not completed. She also stated she did not bring updates on the staff education program to monthly QAPI meetings, and that the program was never brought up in QA. Review of QA meeting minutes from 3/27/2025 through 4/23/2026 showed no QA notes regarding the dining room closure or the staff development program. The facility also failed to ensure antibiotic use followed McGeer Criteria for urinary tract infections. Resident #30 had diagnoses including dementia, dysphagia, malnutrition, traumatic brain injury, and an indwelling catheter; the infection surveillance report showed a UTI on 04/21/2026 and Macrobid was started, but the Infection Preventionist confirmed the resident did not meet McGeer Criteria. Resident #39, with diagnoses including multiple rib fractures, anxiety, depression, epilepsy, diabetes, and other conditions, had a UTI listed on 04/21/2026 and was started on levofloxacin, but the Infection Preventionist also confirmed McGeer Criteria were not met. The Infection Preventionist stated the facility had not been meeting McGeer Criteria since December 2025 for residents started on antibiotics, and the Nursing Home Administrator stated the Quality Assurance Committee had been made aware of the non-compliance in January 2026 but no improvement plan had been implemented.
Incomplete CNA Annual Training Records
Penalty
Summary
The facility failed to ensure that four of five randomly selected CNAs, identified in the record review as CNA E, CNA F, CNA G, and CNA I, completed the required 12 hours of annual in-service training. During the review of annual nurse aide training records with the Staff Educator, the training hours documented for these CNAs did not add up to 12 hours, while CNA H’s record did meet the 12-hour requirement and included dementia and abuse training. The Staff Educator stated she began the position in August 2025 and that the facility had recently changed to a different staff educator tracking system. The DON stated the expectation was for CNAs to have 12 hours of annual training, including dementia and abuse training. The facility policy stated that nurse aides are to receive no less than 12 hours of in-service education per year from the employee’s date of hire.
Failure to Provide Timely Incontinence Care and Preserve Resident Dignity
Penalty
Summary
The facility failed to promote an environment that ensured dignity for Resident #117 by not providing timely toileting and incontinence care. Resident #117 was a cognitively intact female with diagnoses including hypertension, diabetes, anemia, renal disease, muscle weakness, and depression, and she was dependent on staff for toileting. She reported that on night shift she often had to wait greater than one to two hours for assistance with changing her brief, three to four times weekly, and that she would sometimes void twice in her brief before calling for help because there were not enough staff. She stated that this made her feel worthless while sitting in her own urine, and that her husband had completed two concern forms related to call light wait times and discussed the issue at care conferences without improvement. Record review showed no grievances documented for Resident #117 in the grievance log, and the EMR reflected hospitalizations for UTI with septic shock and altered mental status/UTI. The EMR task report also contained several holes with no documentation for completed tasks, including incontinence hygiene. During interviews, the NHA denied concerns had been reported for the resident and could not explain why rounding logs showed the resident present on dates when she was hospitalized. A CNA reported that on more than one occasion she arrived in the morning and found the resident saturated in urine, with the resident stating night shift had not checked on her all night. The DON stated staff would be expected to document when tasks were completed.
Resident Shower Schedule Not Based on Preference
Penalty
Summary
The facility failed to honor a resident’s right to determine her own shower schedule and to support resident choice. The resident was a female with hypertension, diabetes, anemia, and end stage renal disease requiring dialysis. Her MDS indicated she was cognitively intact and dependent on staff for bathing. During observation and interview, she stated that some staff were rude, that she did not want to be in the facility, and that she had experienced several missed showers because staff wanted her to shower on dialysis days even though she was too exhausted. She also reported that she had completed a grievance form about the concern and had not received follow-up. Record review showed several missed showers in the electronic medical record. The resident reported that her showers were scheduled for Wednesday and Saturday, and that staff had never asked her when she wanted showers. A CNA confirmed that residents with dialysis are usually scheduled for showers on other days because dialysis is too much, and verified that this resident was scheduled for Wednesday and Saturday showers even though Wednesday was a dialysis day. The CNA was not sure why she was scheduled on dialysis days. The UM stated that new admissions were informed of a shower schedule based on room number and did not identify a preference, and verified the resident’s Wednesday and Saturday schedule despite dialysis on Monday, Wednesday, and Friday. The DON stated showers were initially assigned by room and then tailored to resident needs, and expected staff to ask the resident’s preference if a grievance form was completed.
Failure to Protect Resident Record Privacy
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential for two residents. For R92, during an observation and interview, the computer on the medication cart was left open with R92's personal private information and confidentiality of records visible to anyone walking by, and no nurse was in sight of the cart. The LPN returned from cleaning up spilled water and closed the computer after it was pointed out that it had been left open. For R97, an LPN prepared medications without performing hand hygiene before setting up the medications or after the medications were prepared, then walked into R97's room with the medication cup. The LPN also left the computer open on the medication cart with R97's personal private information and confidentiality of records visible to anyone passing by, and stated he did not know why it was left open because he had worked all night and was tired.
Failure to Complete Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that two of five Certified Nurse Aides, CNA H and CNA I, had annual competency evaluations completed to verify adequate resident care. Record review on 5/14/2026 showed that CNA H, hired on 4/15/2015, did not have an annual performance review, and CNA I, hired on 8/3/2022, also did not have an annual performance review. During interview on 5/14/2026, the Staff Educator stated she started in August 2025 and that the facility had recently changed to a different staff educator tracking system; she said she had started the CNA performance reviews but was not able to complete them all. The DON stated on 5/15/2026 that CNAs are expected to have an annual performance review so trainings can be adjusted to cover areas of needed improvement. The facility policy stated that a competency evaluation will be completed annually for all certified nurse aides and that training will be added to the calendar based on weaknesses identified.
Expired Items Left in Central Supply
Penalty
Summary
The facility failed to ensure that expired drugs and supplies were removed from the central supply room. During an observation and interview, Central Supply staff U stated she stocked the shelves with over-the-counter medications, wound care dressing supplies, supplemental feeding supplements, and basic personal care items, and that she monitored expiration dates by checking whether items expiring that month were used frequently before deciding whether to discard them. On observation, four expired items were still on the shelf for use: Derma Pak-it packing strips expired on 08/01/24, two bottles of Skintegrity wound cleaner expired on 04/30/25, and Aquasonic 100 ultrasound gel packs expired on 09/11/25. During interview, the DON stated there should not be any expired medications or items in the central supply room and said she would have to look for a policy when asked about use of medications during the month they expire; the facility did not have a policy at the time of inquiry.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to follow infection control measures during medication administration for three residents, including R97, R66, and R65. During observation on 05/15/2026 at 7:00 AM, an LPN stated he had already given some patients their medication but had not signed them out and was still trying to catch up on medication administration. The LPN prepared medications for R97 without performing hand hygiene before setting up the medications or after they were prepared, then took the medication cup from the cart into R97's room. The LPN donned gloves and checked R97's blood sugar on the left hand first finger while wearing gloves, reading 119, and did not perform hand hygiene before putting on gloves or after removing them. During observation at 7:15 AM, the LPN prepared medications for R66 without hand hygiene before or after prepping the medication, administered the medication in the resident's room, and exited without hand hygiene. During the same observation period, the LPN prepared medication for R65 by removing it from the over-the-counter supply in the top drawer and placing it in a medication cup, then entered R65's room to administer it and returned to the medication cart without hand hygiene before or after administration. When asked about cleaning the glucometer, the LPN stated he cleaned it with an alcohol wipe, while facility policy stated cleaning equipment and bleach germicidal wipes are to be used, not alcohol wipes.
Failure to Monitor Antibiotic Use and Follow UTI Criteria
Penalty
Summary
The facility failed to follow its antibiotic stewardship program, including antibiotic use protocols and a system to monitor antibiotic use, for two residents reviewed. Resident #30 was admitted with multiple diagnoses including peripheral vascular disease, dementia with severe mood disturbance, dysphagia, malnutrition, traumatic brain injury, and an indwelling urinary catheter. The Infection Surveillance Report showed a urinary tract infection with urinary complaints and drainage noted in the catheter, and the resident was started on Macrobid 100 mg oral capsule. The Infection Preventionist confirmed that Resident #30 did not meet McGeer Criteria for a UTI and stated that a risk-benefit analysis had been requested but not documented. Resident #39 was admitted with diagnoses including multiple rib fractures, anxiety, depression, hypothyroidism, obstructive sleep apnea, epilepsy, type 2 diabetes, hypertension, and other chronic conditions. The Infection Surveillance Report showed a urinary tract infection with new or marked increase in incontinence and suprapubic pain, and the resident was started on Levofloxacin 500 mg oral tablet. The Infection Preventionist confirmed that Resident #39 did not meet McGeer Criteria for a UTI and stated that a risk-benefit analysis had been requested but not documented. The Infection Preventionist also stated that the facility had been out of compliance with McGeer Criteria since December 2025 for residents started on antibiotics, and the Nursing Home Administrator stated the Quality Assurance Committee was aware of the issue in January 2026 but no improvement plan had been implemented.
Failure to Provide Two-Person Assist for Bed Mobility as Directed by Care Plan
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided activities of daily living (ADL) care to a resident who was dependent on staff for bed mobility, as documented in the resident's care plan and Kardex. The care plan specified that the resident required the assistance of two staff members for all bed mobility tasks, including rolling side to side. However, during an observation, the CNA performed catheter and peri care with only a one-person assist, instructing the resident to roll independently and rolling the resident away from herself rather than towards herself. The resident was observed to be very close to the edge of the bed during this process, and there were no handrails present to prevent a fall. Further review of the resident's records confirmed the requirement for two-person assistance with bed mobility. In interviews, the CNA stated she believed the resident was a one-person assist and had last reviewed the care plan three days prior. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and that staff should roll residents towards themselves, not away. The failure to follow the established care plan and facility protocols for bed mobility assistance led to the deficiency.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. Additionally, the care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the surveyor's review of facility practices and documentation.
Failure to Maintain Safe Ambient Temperatures for Residents
Penalty
Summary
The facility failed to maintain ambient room temperatures within the regulatory range of 71-81 degrees Fahrenheit, affecting 116 residents. Observations and interviews revealed that certain resident rooms and common areas, particularly those exposed to direct sunlight, consistently exceeded the maximum allowable temperature, with readings as high as 88 degrees Fahrenheit. Staff reported that the facility's rooftop air conditioning units were old and insufficient, leading to the use of portable air conditioning units and fans. However, these portable units initially caused circuit breakers to trip, requiring adjustments to their placement. Temperature checks were reportedly conducted early in the morning, before outside temperatures rose, and weekly monitoring was performed by the maintenance director. A resident reported having to unplug personal devices to use a portable air conditioner, which would sometimes trip the circuit breaker. Despite the facility's efforts to supplement cooling with portable units and fans, multiple areas remained above the required temperature range during surveyor checks. Review of the facility's temperature monitoring logs for the previous 75 days did not show any recorded temperatures outside the regulatory parameters, despite surveyor findings to the contrary.
Failure to Provide Palatable, Appetizing, and Properly Tempered Meals
Penalty
Summary
Surveyors identified a deficiency in the facility's food service, specifically related to the palatability, temperature, and presentation of meals provided to residents. Multiple residents reported that food was often served cold, dry, or unappetizing, with specific complaints about hard waffles, cold biscuits and gravy, dry bread, and repetitive menus. Observations confirmed that food trays were sometimes left in insulated carts for extended periods before being delivered, resulting in meals being served at improper temperatures. Temperature checks revealed that hot foods were not consistently maintained at safe temperatures, and cold items such as juice were served above recommended temperatures. Additionally, condiments and food preferences were frequently not honored, with residents receiving items they had previously declined or not receiving requested items such as peanut butter sandwiches or condiments like butter, salt, and pepper. Interviews with dietary staff and review of facility policies revealed that while there were procedures in place for tray accuracy and honoring food preferences, these were not consistently followed. Staff acknowledged that condiments should be included based on tray tickets, but residents routinely reported missing condiments. The dietary manager and registered dietitian indicated that audits to ensure tray accuracy were planned but had not yet been implemented. Bread deliveries were only made once a week, contributing to complaints about stale and hard bread. Food palatability tests conducted by the surveyor further confirmed issues with meal presentation, taste, and portion sizes, with meals described as bland, overcooked, and lacking in visual appeal. The deficiency affected a significant number of residents who rely on the facility for their nutritional needs, with reports of decreased food acceptance and the potential for nutritional decline. Residents expressed dissatisfaction with the quality and variety of meals, and some reported skipping facility meals altogether. The facility's failure to consistently provide palatable, appetizing, and appropriately tempered food, as well as to honor resident preferences and provide necessary condiments, directly contributed to the deficiency cited by surveyors.
Delayed Meal Service and Failure to Meet Resident Preferences
Penalty
Summary
The facility failed to provide timely meal service in accordance with residents' needs, preferences, and requests, as evidenced by observations, interviews, and record reviews. One resident reported that breakfast was served around 9:00 - 9:30 A.M., lunch from 1:00 - 1:30 P.M., and dinner from 6:00 - 6:30 P.M. On the day of observation, the resident's lunch tray was seen stored in an insulated transport cart in the hallway at 1:57 P.M., and was not delivered until 2:04 P.M. by a CNA, who then assisted the resident with feeding. The facility's policy indicated that lunch should be served between 12:00 and 2:00 P.M. This delay in meal delivery affected up to 116 residents who consume food at the facility, increasing the likelihood of delayed meal service, emotional or psychosocial distress, and decreased food acceptance or nutritional decline. The deficiency was identified through direct observation of meal service practices, interviews with residents, and review of facility policies and procedures regarding meal times and the availability of alternative meals and snacks.
Deficiency in Egress Door Locking Arrangements
Penalty
Summary
A deficiency was identified regarding the facility's egress doors, which are part of the required means of egress. The doors were found to be equipped with latches or locks that require the use of a tool or key from the egress side, which is not permitted unless specific special locking arrangements are in place. The report outlines that for clinical needs or security threat locking, only one locking device is allowed per door, and staff must have reliable means for rapid removal of occupants, such as remote control, keyed access, or other reliable methods. Additionally, for special needs locking arrangements, the locks must be electrical and fail-safe, releasing upon power loss, and the area must be protected by both a supervised automatic sprinkler system and a complete smoke detection system, with both systems arranged to unlock the doors upon activation. The report further details that delayed-egress, access-controlled, and elevator lobby exit access locking arrangements are only permitted under specific conditions, such as the presence of approved fire detection and sprinkler systems. The deficiency was cited because the facility did not meet these requirements as evidenced by the survey findings. No specific information about individual residents or their medical conditions is provided in the report.
Noncompliance with Corridor Door Fire and Smoke Resistance Requirements
Penalty
Summary
A deficiency was identified regarding corridor doors and doors protecting corridor openings, which did not meet regulatory requirements for resisting the passage of smoke and fire. The report notes that doors in areas other than required enclosures of vertical openings, exits, or hazardous areas must be constructed of 1 3/4 inch solid-bonded core wood or other approved materials capable of resisting fire for at least 20 minutes, unless the smoke compartment is fully sprinklered, in which case only smoke resistance is required. Additionally, corridor doors and doors to rooms containing flammable or combustible materials must have positive latching hardware, and roller latches are prohibited. The clearance between the bottom of the door and the floor covering must not exceed 1 inch, and there must be no impediment to the closing of the doors. The report also specifies requirements for powered doors, hold open devices, protective plates, Dutch doors, and door frames. The deficiency was cited due to noncompliance with one or more of these requirements, as evidenced by the survey findings.
Failure to Timely Revise Care Plan for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan addressing a resident's sexual behaviors following a significant incident. The resident, who had Alzheimer's disease and was deemed incompetent to make medical decisions, exhibited severe mental impairment as indicated by low BIMS scores. On one occasion, the resident was found in bed with a female resident, with his hand down her pants. Although staff attempted to keep the resident separated from female residents and initiated one-on-one supervision, this intervention was not formalized through a physician's order or documented in the care plan. There was no clear communication or documentation to ensure all staff were aware of the supervision requirement. Subsequent incidents occurred, including the resident being found naked in bed with another female resident, again without evidence of one-on-one supervision being in place. Interviews with staff revealed confusion and lack of awareness regarding the supervision status, and assignment sheets did not reflect any one-on-one supervision for the resident. The care plan was not updated to address the resident's sexual behaviors and the need for one-on-one supervision until after these incidents had occurred, indicating a failure to timely revise the care plan in response to the resident's behaviors.
Failure to Provide One-on-One Supervision for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide one-on-one supervision for a resident with severe mental impairment and a diagnosis of Alzheimer's disease, despite documented incidents of inappropriate sexual behavior with other residents. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe impairment and was deemed incompetent to make medical decisions. Progress notes revealed that staff had been attempting to keep the resident separated from female residents, but the resident was found in bed with a female resident on multiple occasions, including incidents where inappropriate sexual contact occurred. Although a plan for one-on-one supervision was mentioned in progress notes, it was not formalized as a physician's order, and there was no consistent documentation or communication to ensure all staff were aware of the supervision requirement. Interviews with staff indicated a lack of clarity and documentation regarding the implementation of one-on-one supervision. Some staff members were unaware of the supervision requirement, and assignment sheets did not reflect that one-on-one supervision was in place for the resident. Additionally, behavior monitoring logs and daily assignment sheets lacked documentation of the resident's behaviors and supervision status. The absence of clear orders, documentation, and communication led to repeated incidents where the resident was unsupervised and engaged in inappropriate behavior with other residents.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to prevent and correctly identify pressure ulcers for two residents, leading to misidentification and worsening of their conditions. Resident 101, who had a spinal cord injury and contractures, was observed to have a stage III pressure ulcer on the right buttock, which was initially documented as new. However, the facility's documentation was inconsistent, with no granulation observed in the wound photos, and the resident's skin assessments were incomplete, missing several months. The care plan for Resident 101 did not address the moisture-associated skin damage (MASD) or the stage III pressure ulcer, and the resident's refusals of care were not adequately managed or documented. Resident 108, who had been residing in the facility since October 2024, reported having a painful pressure ulcer on the right foot and another on the buttock. The facility's documentation showed inconsistencies in staging the sacral wound, which was initially identified as unstageable but was later observed to be a stage IV wound. The care plan for Resident 108 did not address the resident's refusals to reposition or coordinate care with Hospice, despite the resident's high risk for skin breakdown due to malnutrition and terminal diagnosis. The facility's interventions were not fully implemented, and there was a lack of documentation on the coordination of care with Hospice. Interviews with staff revealed a lack of awareness and understanding of the residents' wound conditions and the appropriate staging of pressure ulcers. The wound care nurse and the Director of Nursing did not perform root cause analyses or develop plans to prevent further pressure ulcers. The facility's failure to conduct regular skin assessments, update care plans, and implement effective interventions contributed to the deterioration of the residents' pressure ulcers.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food to its residents, affecting 119 individuals. Observations and interviews revealed that food items were often served at temperatures below the standards set by the 2022 FDA Model Food Code. For instance, during meal service, items such as hamburgers, mashed potatoes, and broccoli were recorded at temperatures below the required 135°F, leading to dissatisfaction among residents. Additionally, beverages like apple juice were served at temperatures above the recommended 41°F, further contributing to the issue. Residents expressed dissatisfaction with the quality and temperature of the food. Several residents reported that meals were often cold, unappetizing, and lacked flavor. Some residents mentioned that the food was tough and difficult to cut, while others noted that the meals were repetitive and of poor quality. Interviews with residents revealed that these concerns had been ongoing, with some residents stating that they had raised these issues with the dietician, but little had changed. The facility's dietary management practices were also scrutinized. The Dietary Manager and Registered Dietician acknowledged receiving complaints about cold food and had instituted temperature audits. However, the audits revealed consistent issues with food temperatures, as documented in the Test Tray Audit Worksheet. Despite these audits, residents continued to report dissatisfaction with the food, indicating a lack of effective resolution to the problem. The facility's failure to address these concerns adequately resulted in a deficiency in providing palatable and safe meals to its residents.
Deficiencies in Food Service Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 119 residents and increasing the likelihood of cross-contamination and bacterial harborage. During an initial tour of the food service area, it was observed that two can opener assemblies and their mounting brackets were soiled with accumulated and encrusted food residue. The Dietary Manager acknowledged the issue and indicated that staff would clean and sanitize the equipment. Additionally, clear plastic scoops used for dry food products like flour and oatmeal were stored improperly within the food product storage bins, contrary to the 2022 FDA Model Food Code requirements. Further observations revealed that the dry storage room's return-air-ventilation grill was loose, with five of six mounting screws missing, which could compromise the facility's physical integrity. The facility's policies on maintenance and repairs, as well as dietary cleaning and sanitation, were reviewed, indicating that malfunctions and repair needs should be reported promptly, and that the kitchen should be maintained to minimize microorganism growth. However, these policies were not effectively implemented, leading to the noted deficiencies.
Failure to Reassess Facility Needs and Involve Governing Body
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that included input from the Governing Body and did not reassess the facility's ability to meet resident care needs following a change in resident acuity status. The last assessment was conducted on 7/16/2023 and was valid through 7/15/2024. However, within the last 30 days, the facility experienced seven pressure ulcers requiring treatment, 42 resident falls with two resulting in major injuries, and 13 residents requiring catheter care. Despite these changes, the facility did not reassess its capacity to meet these care needs. Additionally, the assessment incorrectly listed the Administrator as the Governing Body, rather than the owner, CEO, or other legally responsible individuals. The Administrator was unaware that she was accountable to the Governing Body and not the Governing Body herself.
Facility Maintenance Deficiencies Affect Resident Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 119 residents, as evidenced by multiple deficiencies observed during an environmental tour. The outdoor smoking area canopy was found to be worn, warped, and missing, allowing weather elements to enter the space. A resident reported that the canopy had been in poor condition for the entire three years of their stay. Additionally, the laundry service area had issues such as a porous folding table surface, cracked light lens covers, and non-functional light assemblies, which could lead to bacterial harborage and decreased air quality. Further observations revealed numerous maintenance issues throughout the facility, including leaking water valves, broken light covers, and non-functional light assemblies in soiled utility rooms. The occupational therapy/physical therapy area had a corroded microwave oven, and the staff/visitor restroom had deteriorated caulking. The nurses' station restroom had an ill-fitting commode seat, and the PPE storage room had flooring issues. Shower rooms were missing atmospheric vacuum breakers, and several areas had cracked or missing tiles, contributing to potential cross-contamination risks. The facility's maintenance department policies were reviewed, revealing a lack of specific entries related to the observed maintenance concerns in the Direct Supply TELS Work Orders for the last 85 days. This indicates a failure in the ongoing monitoring and reporting system for necessary repairs, as outlined in the facility's maintenance and housekeeping policies. The environmental services supervisor acknowledged the issues and indicated plans to contact maintenance for repairs, but the deficiencies remained unaddressed at the time of the survey.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency involving a resident with moderate cognitive impairment due to dementia. The resident reported being physically and verbally abused by a Certified Nursing Assistant, and the Nursing Home Administrator (NHA) and Social Worker (SW) were notified. Despite the resident's inability to provide a physical description or name of the alleged perpetrator, the SW interviewed the resident and their spouse, concluding that the abuse was not substantiated due to the resident's confusion. Consequently, the incident was not documented in the clinical record nor reported to the State Agency. During interviews, the SW indicated that the decision not to report was made by the NHA, who also confirmed the incident was not reported because it was deemed unsubstantiated. However, the facility's policy requires reporting all allegations of abuse to the State Agency within specified timeframes, regardless of substantiation. The NHA acknowledged that the facility frequently self-reports to the State Agency, even when abuse is unsubstantiated, but could not explain why this particular incident was not reported. The facility's policy mandates that the results of any investigation, substantiated or not, be reported to the State Agency within five working days, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their skin integrity needs. Resident 101, who had a spinal cord injury and contractures, developed a stage III pressure ulcer on the buttocks, which was not adequately addressed in the care plan. The care plan was outdated and did not include interventions for the resident's moisture-associated skin damage (MASD) or the pressure ulcer. Additionally, the resident's refusals of care, such as turning and repositioning, were not documented or addressed in the care plan. Resident 108, who was on hospice care and had a high risk for skin breakdown, developed pressure ulcers on the right foot and sacrum. The facility's documentation indicated that these pressure ulcers were unavoidable due to the resident's malnutrition and terminal diagnosis. However, the care plan did not include interventions to address the resident's refusals to reposition or coordinate care with hospice services. The facility also failed to document interventions such as off-loading bony prominences and using positioning devices, which were noted in other documents but not in the care plan. Interviews with facility staff revealed a lack of root cause analysis and documentation regarding the residents' pressure ulcers. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved in wound care did not perform thorough assessments or document discussions about the residents' wounds in Quality Assurance Performance Improvement (QAPI) meetings. The Director of Nursing (DON) acknowledged the lack of audits and root cause analysis to ensure the healing of current wounds and prevention of further wounds, indicating systemic issues in the facility's approach to wound care management.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to appropriately revise the care plan interventions for one resident, identified as R101, who had been residing at the facility since April 2023. R101 had diagnoses including contractures of the right and left hand and muscles. A care plan dated January 2025 indicated that R101 had contractures in bilateral ankles, wrists/hands, and elbows, with interventions to provide assistive devices such as hand and elbow splints. However, observations on multiple occasions in March 2025 revealed that R101 was not wearing the prescribed splints, and they were found lying on the over-bed table instead. R101 reported that the splints no longer fit because staff did not put them on, and a washcloth was observed in R101's left hand instead of the splints. Interviews with staff, including a CNA, LPN, and a Certified Occupational Therapy Assistant (COTA), revealed inconsistencies in the implementation of the care plan. The CNA mentioned that R101 was offered the splints every two hours but may refuse them, while the LPN was unaware of how often the splints were offered. The COTA stated that R101 was evaluated in March 2025, and it was recommended that R101 wear bilateral hand/wrist splints since November 2024. However, the COTA was not informed of any refusal by R101 to wear the splints. The care plan had not been updated with new interventions following the therapy's recommendations in March 2025, indicating a failure to revise the care plan appropriately based on the resident's current needs and therapy recommendations.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to provide necessary podiatry care for a resident diagnosed with dementia, who was admitted with moderate cognitive impairment. The resident's family member, who visited daily, expressed frustration over the facility's inaction despite multiple requests for podiatry services over approximately five months. The family member had been attempting to manage the resident's toenail care themselves, despite the difficulty due to the thickness and curling of the nails. During an observation, the resident's second toenail was noted to be excessively long and curled under the toe, covering the pad of the toe. Interviews with facility staff revealed a lack of communication and responsibility regarding the arrangement of podiatry services. The social worker claimed no responsibility for arranging ancillary services and did not acknowledge the family's requests. The medical records staff confirmed receiving a request for podiatry care from the family member about a month prior but had not ensured the resident was seen by a podiatrist. The LPN/Unit Manager was unaware of the resident's need for podiatry care and acknowledged that the nursing staff should have documented and addressed the condition of the resident's toenails during routine assessments.
Failure to Implement Prescribed ROM Interventions for Resident
Penalty
Summary
The facility failed to ensure that a resident, who had been diagnosed with contractures of the right and left hands and muscles, received appropriate care to maintain or improve range of motion. The resident, who had been residing at the facility since April 2023, was observed on multiple occasions without the prescribed hand splints and positioning wedge in place. The care plan and CNA Kardex indicated that the resident should have been provided with right and left hand splints and elbow splints, but these were not being utilized. The resident reported that staff never turned him, and he was always on his back, with the wedge meant for repositioning left unused on the bedside table. Interviews with staff revealed inconsistencies in the application of the splints. A CNA mentioned that the resident was offered the splints every two hours but may refuse them, although no specific reason was provided for the resident's refusal. The LPN was unaware of how often the splints were offered, and the COTA stated that the resident should have been wearing the splints since they were recommended in November 2024. The therapy plan of treatment recommended the use of resting hand and elbow extension splints for four hours on and four hours off to improve passive range of motion, but the care plan had not been updated with these recommendations.
Failure to Document Physician Review of Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of identified medication irregularities, the actions taken, or the rationale for not making changes to the medications for a resident. The resident, who was admitted for long-term care and resided in the facility's secured dementia unit, had a low score on the Brief Interview for Mental Status, indicating cognitive impairment. The Monthly Medication Review noted that the resident was receiving Divalproex and had experienced recent mental status changes, including agitation and anxiety. The pharmacist recommended monitoring serum ammonia concentration and valproic acid levels due to potential adverse effects, but the physician did not document any response to these recommendations. During an interview, the Director of Nursing (DON) explained the process for handling pharmacist recommendations, which involved electronic delivery, printing, and placement in a binder for the physician or nurse practitioner to review and sign. However, the DON was unable to find any documentation from the provider regarding lab orders for valproic acid or any agreement or disagreement with the pharmacist's recommendations. The provider's signed pharmacy recommendation was also missing, and the DON could not explain why the physician had not addressed the recommendation.
Failure to Meet Residents' Nutritional Needs and Preferences
Penalty
Summary
The facility failed to meet the nutritional needs and food preferences of two residents, R28 and R117, as observed during a survey. Resident 28 expressed dissatisfaction with the inconsistency in receiving a chef salad, which was supposed to be a regular part of their meal plan. Despite having a standing order for a chef salad, R28 reported receiving it only about once a week, and sometimes it was just plain lettuce without the desired toppings. Additionally, R28 received a meal with barbecue sauce, which was listed as a dislike on their meal ticket, indicating a failure to adhere to dietary restrictions. Resident 117, who has a history of depression, anxiety, COPD, and congestive heart failure, was found to be underweight with a BMI of 13.6. R117 reported that meals were often served cold and did not match the items listed on their meal ticket, such as side salad, fresh grapes, and nutritional juice. The resident also noted that the meal cart sat in the hallway for extended periods before trays were distributed, contributing to the cold meals. Despite having standing orders for certain items, these were not consistently provided, and the resident expressed frustration over the lack of oversight in meal preparation and delivery. The Dietary Manager acknowledged issues with food availability and preparation, citing instances where fresh produce was not available and substitutions were not communicated to residents. The manager also confirmed that certain items, like grapes, were out of stock, and admitted that the staff might have rushed meal preparation, leading to errors in fulfilling residents' meal preferences. The facility's policy on food preferences was not effectively implemented, resulting in residents not receiving appropriate meals as per their dietary needs and preferences.
Failure to Address Pressure Ulcers in QAPI Committee
Penalty
Summary
The facility failed to identify the need for an action plan for pressure ulcers through its Quality Assurance Performance Improvement (QAPI) committee. During an onsite survey, it was found that two out of six residents reviewed had developed facility-acquired pressure ulcers at stage III or higher. The facility's policy requires the QAPI committee to meet regularly to develop and implement plans to correct quality deficiencies, but this was not done for pressure ulcers. The wound nurse, LPN K, admitted to not performing a root cause analysis for the pressure ulcers and only verbally discussing the residents' wounds in QAPI meetings without documentation. The Director of Nursing (DON B) stated that she assisted the wound care nurses in obtaining necessary equipment but did not conduct audits or root cause analyses to prevent further pressure ulcers. The Administrator acknowledged that the QAPI committee was working on assessing residents' risk for skin breakdown but had not identified residents with current pressure ulcers or developed a performance improvement plan. There were no audits or assessments available for residents with pressure ulcers, indicating a lack of systematic approach to address and prevent pressure ulcers in the facility.
Failure to Prevent Misappropriation of Resident's Debit Card
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's belongings, specifically a social security debit card, which resulted in feelings of loss of independence and potential mistrust. The resident, who had intact cognition, reported that an Activities Aide (AA) had assisted him with an online purchase and was the last known person to have possession of his debit card. The resident was informed by the police that the AA was arrested and charged with felonies for unauthorized use of the card. The resident expressed a desire for restitution rather than punishment for the AA, as the incident led to his brother managing the card, causing a delay in his ability to make personal purchases. The facility's investigation revealed that the resident's debit card was missing after he returned from a hospital stay. The police were notified, and a report was filed. The investigation showed unauthorized transactions, including online gaming purchases and fast-food orders, made while the resident was hospitalized. The police identified the AA as the perpetrator through video footage and transaction records. Despite the facility's initial inability to substantiate the misappropriation, the police investigation confirmed the AA's involvement, leading to his arrest and termination from the facility.
Inappropriate Use of Restraints on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for convenience rather than medical necessity. The resident, who had severe cognitive impairment and required assistance for mobility, was observed attempting to exit his bed independently. A foam wedge was placed under the fitted sheet, seemingly to prevent the resident from leaving the bed, which restricted his mobility. Staff members, including a CNA and an LPN, were unsure of the purpose of the wedge, indicating a lack of clear communication and understanding of its use. The resident had a history of falls and was known to be active, often propelling himself around the unit in a manual wheelchair. However, staff frequently placed him in a geri-chair, which he could not propel, further restricting his movement. The resident's care plan included interventions to prevent falls, such as positioning him in view of staff, but these were not effectively implemented. Interviews with staff and family members revealed that the resident was often kept in the geri-chair to prevent him from moving, and a standard chair was used to immobilize the geri-chair's footrest, indicating the use of restraints for convenience. The Director of Nursing acknowledged that the wedge should be used for positioning and that the resident should be allowed to move freely in a manual wheelchair when awake and active. Despite this, the resident was often restrained in a geri-chair, and there was no work order for the chair, suggesting it may have been broken. The facility's actions and inactions led to the inappropriate use of restraints, restricting the resident's mobility and potentially impacting his physical and psychosocial well-being.
Delay in X-ray Leads to Untimely Treatment for Resident's Fracture
Penalty
Summary
The facility failed to obtain a timely x-ray for a resident, resulting in a delay in treatment for a hip and femur fracture. The resident, who had severe cognitive impairment and was a known fall risk, experienced multiple falls within the facility. Despite interventions to position the resident in view of staff, the resident continued to fall, including an unwitnessed fall on 9/20/24. Following this fall, significant bruising and swelling were observed, and a stat x-ray was ordered on 9/24/24. However, the x-ray was not completed promptly. The nursing staff noted the resident's condition, including swelling and inability to move the left leg, and contacted the radiology service for a status update. Despite these efforts, the x-ray service did not arrive until after the resident was transferred to the hospital on 9/25/24. The hospital confirmed the resident had a femoral shaft fracture and a chronic femoral neck fracture, requiring operative fixation. Interviews with staff revealed that the resident was often restless and attempted to get out of bed, leading to the use of a wedge to prevent falls. The Director of Nursing acknowledged the delay in obtaining the x-ray and the need for staff supervision during the resident's unwitnessed fall. The interdisciplinary team was discussing the concerns regarding the delay in obtaining the x-ray.
Failure to Prevent Falls and Delay in Medical Imaging
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent falls for a resident, resulting in a fall with a major injury. The resident, who had severe cognitive impairment and required assistance for transfers, was observed attempting to get out of bed independently. The only measure in place to prevent the resident from exiting the bed was a foam wedge, which was not properly positioned. Staff members, including a CNA and an LPN, were unaware of the purpose of the foam wedge, indicating a lack of communication and understanding of the resident's care plan. The resident had a history of falls, with multiple incidents reported in the months leading up to the major injury. Despite these falls, the interventions listed in the care plan were inadequate, such as encouraging positioning near staff in the day room. The resident was known to be mobile and able to self-propel in a wheelchair, yet was often placed in a geri-chair, which restricted movement and contributed to the resident's restlessness and attempts to exit the chair. The use of a standard chair to immobilize the geri-chair's footrest further limited the resident's ability to move safely. Additionally, there was a significant delay in obtaining a stat x-ray after the resident's family reported swelling and bruising, which was indicative of a fracture. The x-ray was ordered but not completed in a timely manner, leading to a delay in the resident's transfer to the hospital for appropriate care. Interviews with staff revealed a lack of consistent supervision and inadequate fall prevention strategies, contributing to the resident's fall and subsequent injury.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident, resulting in a fall and subsequent injury. The resident, a cognitively intact female with a history of cerebral vascular accident and other medical conditions, was not properly positioned in a shower chair by a CNA. The CNA left the resident unattended to seek assistance, during which time the resident began to slide forward and was lowered to the floor. Despite the fall, the resident was moved back into the shower chair and the shower was completed without notifying a nurse or conducting an immediate assessment. The incident was not reported to the nursing staff until approximately two hours later when the resident's husband alerted the nurse to the resident's pain. The resident was found to have a swollen left knee and was later diagnosed with a left distal femur fracture. The facility's care plan, which required a Hoyer lift for transfers, was not followed, and the incident report lacked a thorough investigation. The resident experienced increased pain and required additional pain medication following the fall. Interviews with staff revealed a lack of adherence to the facility's fall management policy, which mandates that residents not be moved after a fall until assessed by a nurse. The CNA involved in the incident was terminated, and the facility acknowledged past non-compliance with fall supervision. Despite the facility's policy and staff education on fall prevention, the incident highlighted deficiencies in communication and adherence to care plans.
Failure to Prevent Repeated Falls Due to Lack of Supervision
Penalty
Summary
The facility failed to implement effective interventions to prevent repeated falls for a resident with Alzheimer's Disease, who was reviewed for accidents and supervision. The resident, who had severely impaired cognition and a history of falls, was observed multiple times in the day room without adequate supervision or engagement from staff. Despite the presence of staff, including CNAs and an RN, there was a lack of interaction with the residents, which was noted during several observations by the surveyor. The resident had a history of ten falls since March 2024, with incidents occurring in various locations such as the day room, hallway, and her room. The falls were often related to the resident's behavior of moving furniture or attempting to stand unassisted. Although some interventions were documented, such as medication adjustments and providing diversional activities, there was no in-depth analysis of the root causes of the falls or consistent implementation of interventions. For instance, a recommended chair by the exit door was not observed during the surveyor's visits. The Director of Nursing acknowledged the need for more engagement and interaction with residents to prevent falls but did not provide a response regarding the evaluation of staffing needs or the implementation of interventions. The facility's fall management policy emphasized identifying hazards and implementing interventions to minimize falls, but the observations and documentation indicated a failure to adhere to this policy effectively.
Inadequate Supervision and Care on Unit 3
Penalty
Summary
The facility failed to ensure adequate care and supervision on Unit 3, which housed residents with cognitive impairments, including a resident with Alzheimer's Disease who had a history of falls and impaired cognition. On the day of the incident, a complaint was submitted regarding the absence of staff on the unit, which was observed by a family member returning a resident from an overnight leave of absence. The family member noted that there was no nurse present to receive the resident's medications, and the only visible staff was an activities aide in the day room. This lack of supervision led to residents being unassisted, with some attempting to leave the unit or access restricted areas. The investigation revealed that the assigned Registered Nurse (RN) for Unit 3, RN 'F', had taken an extended break without ensuring proper coverage. RN 'F' combined her lunch and two 15-minute breaks, leaving the unit for approximately an hour without informing another nurse or handing over the medication cart keys. During her absence, the Certified Nursing Assistants (CNAs) assigned to the unit were also not present, as one CNA had left to inform another unit of her departure time, leaving only the activities aide with the residents. This lack of coordination and communication among staff resulted in inadequate supervision and care for the residents. The Director of Nursing (DON) confirmed that the facility's protocol was not followed, as RN 'F' did not report her extended break to another nurse or ensure the medication cart was accessible. Additionally, CNA 'K' did not remain on the unit or seek assistance from another nurse when the family expressed concerns. The failure to adhere to established protocols for staff breaks and coverage led to a deficiency in maintaining professional standards of care and supervision for the residents on Unit 3.
Failure to Monitor Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to monitor and document blood pressures for a resident with hypertension, which was necessary to ensure the proper administration of prescribed medication. The resident, who had severely impaired cognition, was admitted with a physician's order for amlodipine, a medication to be held if the systolic blood pressure was less than 100 mmHg. However, the Medication Administration Record for May and June 2024 showed no documentation of the resident's blood pressure, despite the medication being administered daily since the order was given. Interviews and record reviews revealed that the Director of Nursing acknowledged the lack of consistent documentation of the resident's blood pressures in the clinical record. The order was not properly entered to ensure monitoring before administering the medication. The facility's policy on medication administration required vital signs to be taken prior to administering doses when applicable, but this was not followed, leading to the deficiency.
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 523 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 Whitmore Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Lyon Senior Care And Rehab Center | 5.1 mi | ★★★★★ | 5 | 0 |
| Caretel Inns Of Brighton | 6.3 mi | ★★★★★ | 6 | 0 |
| Regency At Bluffs Park | 9.3 mi | ★★★★★ | 6 | 0 |
| Wellbridge Of Pinckney | 9.6 mi | ★★★★★ | 4 | 0 |
| Wellbridge Of Brighton | 10.2 mi | ★★★★★ | 5 | 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.