Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Resthaven Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
The facility did not provide quarterly financial statements for resident trust accounts to any of the eight residents using these accounts. Instead, statements were only given annually or upon request, and staff confirmed that quarterly statements were not routinely distributed. This resulted in residents not being systematically informed about their personal funds.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that a resident received treatment and supports for daily living in a safe manner. The report does not include further details about the specific circumstances or individuals involved.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights was upheld.
A resident with severe cognitive impairment and an appointed guardian was admitted without a documented code status order for several days. Although the resident's wish to be DNR was known, staff interviews and record review confirmed that no physician order for code status was present until after the deficiency was identified, contrary to facility policy requiring code status documentation at admission.
A resident with mental health diagnoses did not have a required annual PASARR Level I Screening Form completed, as review of records showed the most recent form was from the previous year. Staff interviews confirmed the form was not completed or could not be located, resulting in a deficiency in required documentation.
A resident with dementia and fragile skin was observed with a bandage on her forearm that lacked required date and initials, and without the protective derma sleeves specified in her care plan. Documentation indicated derma sleeves were in use, but this was not observed. There was also no physician order for the dressing applied to the skin tear. Nursing staff confirmed the bandage should have been properly labeled, and the wound nurse was not involved in the care. These actions did not meet professional nursing standards.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Two residents with cognitive impairment and mobility issues were not provided with adequate supervision or safe transfer techniques, resulting in increased risk for falls and injuries. Staff failed to use gait belts during transfers and did not consistently respond to or hear alarms, leading to multiple unwitnessed falls and incidents where residents attempted to self-transfer without assistance.
A resident with severe cognitive impairment and multiple medical conditions, including Barrett's esophagus and diabetes, did not consistently receive meals in accordance with their documented food preferences and dislikes. Despite repeated notifications from the resident's DPOA about the need to avoid spicy foods due to gastrointestinal discomfort, staff continued to serve such items. Dietary staff were unaware of the full scope of the resident's preferences, and meal tickets did not accurately reflect necessary dietary restrictions, leading to ongoing dissatisfaction and potential health concerns.
A resident with Type 1 diabetes required frequent blood glucose monitoring. An LPN failed to clean and disinfect a glucometer after use, placing it back into the medication cart without sanitizing it, which led to potential contamination of other items. Staff interviews and facility policy confirmed that the glucometer should have been cleaned after each use.
The facility failed to maintain sanitary conditions in the kitchen, including improper temperature logging, thawing meat inappropriately, unclean utensils, and improper food storage and labeling. These violations pose a risk of foodborne illness to residents.
The facility failed to properly clean and sanitize shared equipment, ensure PPE was worn by staff and visitors in required areas, and maintain clean laundry bins. Additionally, a resident did not have a dressing applied to their dialysis access site as required.
The facility failed to provide a written notice of transfer for a resident hospitalized for severe abdominal issues, and did not notify the Ombudsman of emergency transfers. Interviews revealed inconsistencies in the notification process, leaving residents and their representatives uninformed and without advocacy support.
The facility failed to provide written notification of the bed hold policy upon transfer to the hospital for a resident with a history of benign prostatic hyperplasia and obstructive uropathy. Despite staff claims of notifying the resident or representative, there was no documentation to confirm this communication, violating the facility's policy.
The facility failed to follow physician orders and implement correct precautions for two residents, leading to a lack of documentation and potential delays in treatment. One resident did not have a daily dressing change for a dialysis port, and another was incorrectly placed on droplet precautions instead of enhanced barrier precautions.
The facility failed to follow orders for monitoring blood sugars for a resident and to follow orders for dressing changes for another resident, resulting in the lack of monitoring and the resident not receiving appropriate interventions. The deficiencies were due to missing schedules in order entries and improper dressing change procedures.
The facility failed to ensure services to maintain and prevent further decrease in ROM for a resident with cerebral palsy, resulting in potential for decreased ROM, contractures, and pain. The resident reported not receiving the prescribed therapy, and observations confirmed that CNAs were not performing the necessary PROM exercises as outlined in the care plan.
The facility failed to ensure physician orders and proper monitoring for two residents requiring dialysis care. Both residents lacked detailed care plans and consistent documentation, and staff were unaware of the dialysis details and monitoring requirements, leading to potential risks for the residents' well-being.
The facility failed to post required nurse staffing information daily for all 135 residents, resulting in a lack of available staffing information for residents and visitors. Observations revealed no postings, and interviews with the DON and NHA indicated they were unaware of the requirement. The scheduler responsible for this task had not been working for approximately 8 weeks.
The facility failed to respond to call lights timely for two residents, leading to feelings of neglect and increased anxiety. One resident with multiple diagnoses, including an above-knee amputation, was left unattended after a bowel movement, while another resident with cerebral palsy experienced increased anxiety due to delayed responses. Staff interviews revealed issues with the call light system, and call light reports confirmed multiple instances of delays.
A resident with multiple diagnoses, including cerebral palsy and osteoporosis, fell and sustained minor injuries during a Hoyer lift transfer when the loop came off the hook. The care plan did not indicate the need for a Hoyer lift, and staff were educated on ensuring loops are securely attached before raising residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly financial statements for resident trust accounts to all 8 residents who utilized these accounts. According to interviews and record review, the Accounting Associate reported that financial statements were only provided annually and upon request, and was unaware of any quarterly distribution. The Resident Services Coordinator also confirmed that quarterly statements were not provided, although residents could inquire about their balances at any time. The Nursing Home Administrator acknowledged that the facility did not currently provide quarterly trust fund financial statements, but could issue them upon request. As a result, residents were not systematically informed about the status of their personal funds as required.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Document Advance Directive Code Status on Admission
Penalty
Summary
The facility failed to ensure accurate and timely documentation of advance directives, specifically code status, for one resident upon admission. The resident, who had vascular dementia and Alzheimer's disease and was severely cognitively impaired, was admitted without an order or documentation regarding her code status for the first five days of her stay. Although the resident expressed a wish to be Do Not Resuscitate (DNR), she had an appointed guardian and was unable to make medical decisions herself. Interviews with facility staff revealed that the admitting nurse was responsible for completing advance directive forms and entering code status orders, and that a physician order was required for code status. However, review of the resident's record confirmed that no such order was present during the initial days of admission. Staff interviews further indicated that, according to facility policy, a resident is considered full code until a DNR form is signed by both the resident or their representative and the physician. The absence of a code status order was confirmed by multiple staff members, and the order for full code was only added after the deficiency was identified. The facility's policy required that code status be established and documented as part of the admission process, but this was not followed in the case of this resident, resulting in a lack of clear documentation regarding life-sustaining interventions during a critical period.
Failure to Complete Annual PASARR Level I Screening
Penalty
Summary
The facility failed to ensure that a required annual Preadmission Screening and Resident Review (PASARR) Level I Screening Form (DCH-3877) was completed for a resident with mental health diagnoses, including anxiety disorder, dementia with psychotic disturbance, and delusional disorders. The resident was found to be cognitively intact, as indicated by a BIMS score of 13 out of 15 on a recent MDS assessment. Documentation review revealed that the most recent Level I PASARR form in the resident's record was completed in November of the previous year, with no subsequent annual form found in the electronic medical record. Interviews with facility staff confirmed that the annual PASARR Level I form had not been completed as required. The Social Services Technician acknowledged the oversight, and the responsible Social Worker indicated that the form was marked as completed in their system but could not be located. Further inquiry with the OBRA coordinator also failed to produce a more recent Level I form, confirming the deficiency in maintaining up-to-date PASARR documentation for the resident.
Failure to Follow Professional Standards in Skin Tear Treatment
Penalty
Summary
The facility failed to ensure that professional standards of nursing were followed in the treatment of a skin tear for one resident. The resident, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and pressure-induced deep tissue damage, was care planned for potential skin integrity impairment due to limited mobility and incontinence, with interventions such as derma sleeves for arm protection. However, during multiple observations, the resident was seen with a bandage on her left forearm that lacked a date and initials, and no derma sleeves were present on her arms as required by her care plan. Review of records showed documentation of derma sleeves on the Treatment Administration Record, but this was not consistent with direct observation. Additionally, there was no physician order for a dressing for the resident's left forearm skin tear, despite the presence of a bandage. Interviews with nursing staff confirmed that the bandage should have been dated and initialed, and that the wound nurse was not involved unless the skin tear was significant. The Director of Nursing acknowledged the resident's fragile skin and the need for protective interventions, but these were not observed in practice. These findings indicate a failure to follow professional standards and care plan interventions for skin integrity and wound care.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming.
Failure to Provide Adequate Supervision and Safe Transfer Techniques
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate transfer techniques for two residents, resulting in increased risk for falls and injuries. One resident with severe cognitive impairment and dementia required supervision or light assistance for transfers. During an observation, two CNAs assisted this resident from a low recliner by placing their forearms under her armpits and lifting her without the use of a gait belt, contrary to facility policy and expectations. Both the physical therapist and nursing home administrator confirmed that a gait belt should always be used for such transfers to ensure safety and prevent injury. Another resident with dementia, Parkinson's disease, and a history of falls experienced multiple unwitnessed falls and incidents of attempting to self-transfer. Documentation revealed repeated episodes where the resident was found on the floor or attempting to get up from a recliner without adequate staff supervision. Alarms intended to alert staff to the resident's movements were not always functional or audible in all areas, and staff were not consistently present or able to respond promptly. Interviews with staff and family members indicated lapses in supervision, with staff sometimes unavailable or not carrying necessary alert devices, and family expressing concerns about the lack of staff presence and responsiveness. Facility policies required the use of gait belts for transfers and outlined interventions for fall prevention, including increased supervision and use of alarms. However, observations and record reviews demonstrated that these policies were not consistently followed. The lack of proper transfer technique and insufficient supervision contributed to repeated falls and near-miss incidents, highlighting failures in implementing established safety protocols for residents at risk of accidents.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure that a resident received food items in accordance with their documented preferences, resulting in dissatisfaction and the potential for nutritional decline and gastrointestinal upset. The resident in question had a history of vascular dementia, Barrett's esophagus with dysplasia, diabetes mellitus, and dysphagia, and was severely cognitively impaired. The care plan and Kardex indicated specific food preferences, including a dislike for spicy foods and mac n cheese, and a preference for seafood and tomato juice at meals. Despite these documented preferences, the resident continued to receive spicy foods, which the resident's Durable Power of Attorney (DPOA) reported caused heartburn and gastrointestinal discomfort. The DPOA had repeatedly informed staff of these preferences, but the issue persisted, and the resident was observed to reject spicy food items such as potato wedges. Interviews with dietary staff revealed a lack of awareness and communication regarding the resident's food preferences. The dietary aide responsible for meal preparation stated that she was only aware of the restriction on tomato juice and was not informed of other preferences or dislikes. The Registered Dietician (RD) confirmed that food preferences were recorded at admission and updated as needed, but relied on floor staff or the interdisciplinary team to communicate any changes. The RD was not aware of the DPOA's concerns and did not routinely reach out to family members unless there were significant nutritional issues, such as weight loss or ongoing gastrointestinal upset. The meal tickets for the resident did not reflect the documented dislikes or the need to avoid spicy foods. Facility policy required dietary staff to obtain food preferences, allergies, or intolerances within 72 hours of admission and to update this information as needed. However, the process for updating and communicating these preferences was not effectively implemented, resulting in the resident receiving meals that did not align with their documented needs and preferences. This failure was confirmed through observation, interviews, and record review.
Failure to Sanitize Glucometer Between Resident Uses
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to properly sanitize a glucometer after checking the blood sugar of a female resident with Type 1 diabetes. The resident required blood glucose monitoring before every meal and at bedtime. After performing a blood sugar check, the LPN placed the used glucometer into a drawer of the medication cart without cleaning or disinfecting it, contrary to facility policy and manufacturer instructions. The glucometer came into contact with other items in the drawer, potentially contaminating them. Interviews with multiple LPNs and the Education and Infection Control Nurse confirmed that the expectation was for the glucometer to be cleaned after each use and before storage. The facility's policy also required cleaning and disinfection of the glucometer between residents. The LPN acknowledged the failure to clean the device and recognized that the items in the drawer were now contaminated as a result.
Sanitary Violations in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential foodborne illness risks for residents. During an initial tour, it was observed that the Blueair Refrigeration unit had an external digital thermometer reading 34F, but the internal temperature of an open half-gallon of milk was 55F. The Kitchen Supervisor admitted that the temperature logged earlier was based on the external thermometer, and all food in the unit was discarded. Additionally, eight packages of beef roasts were found thawing in the wash compartment of a three-compartment sink, which is against FDA guidelines as it can lead to contamination of equipment and utensils. The drain line from the wash compartment was directly connected to the wastewater line, further increasing the risk of contamination. The inspection also revealed several instances of unclean equipment and surfaces. A green mechanical scoop with stuck-on food debris was stored with clean utensils, and juice dispensers had dried sticky debris on the underside of the spouts. In the Borsma Cottage kitchen, the resident silverware drawer contained food crumbs and debris, and some utensil drawers were pitting and chipping, making them difficult to clean. These conditions violate FDA guidelines that require food-contact surfaces and utensils to be clean to sight and touch. Further observations found issues with the storage and labeling of food items. In Rachel's Kitchen, a container of shake supplements had smeared writing and illegible discard dates, with some past their discard date. Thickened water and juice containers were not dated for discard once opened, and a package of sliced ham had a smeared date. In the [NAME] kitchen area, shell eggs were stored above ready-to-eat products, risking cross-contamination. These practices violate FDA guidelines for date marking and separation of raw and ready-to-eat foods, posing a significant risk to resident safety.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure resident shared equipment was properly cleaned and sanitized between each use. During an observation, an LPN was noted taking vitals on multiple residents without cleaning and sanitizing the vitals machine between uses. The LPN acknowledged that the vitals machine should have been cleaned and sanitized between each use to prevent the spread of infection. The Infection Control Nurse confirmed that resident shared equipment should be cleaned and sanitized between every resident every time to prevent the spread of infection. The facility also failed to ensure that personal protective equipment (PPE) was worn by staff and visitors in care units where required. Despite clear signage indicating the need for masks due to a respiratory infection outbreak, visitors and staff were observed not wearing masks in the affected areas. Staff members, including a Clinical Manager and an LPN, did not direct visitors to don surgical masks, even after being queried about the requirement. The Infection Control Nurse reiterated that all staff and visitors were expected to wear surgical masks in the affected units to prevent the spread of the virus. Additionally, the facility failed to ensure clean laundry bins used for transport were free from dirt and debris. During a tour of the laundry room, it was observed that clean laundry bins contained debris, including socks, paper trash, rubber bands, and an accumulation of dirt and crumbs. Furthermore, the facility did not ensure that a resident sampled for dialysis had a dressing applied to their dialysis access site. The resident's medical records indicated a daily dressing change order, but this order was not reflected in the Medication Administration Record/Treatment Administration Record, and the resident was observed without a dressing on the dialysis port, which had small openings that were scabbed over.
Failure to Provide Written Notice of Transfer and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was hospitalized, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Specifically, Resident #98, who had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and a suprapubic catheter, was sent to a local hospital for severe abdominal distention, pain, and fever. The family was notified, but there was no documentation that a written notice of transfer was provided to the resident or their representative. Additionally, the local Ombudsman had not received transfer notices since 2022, indicating a systemic issue with notification procedures. Interviews with facility staff, including an LPN, Clinical Manager, Social Worker, and Director of Nursing, revealed inconsistencies and gaps in the transfer notification process. The LPN reported that a packet, including bed hold information, was sent with the ambulance service, but there was no confirmation that the resident or representative received a written notice. The Clinical Manager and Social Worker were unsure if the necessary forms were sent, and the Director of Nursing admitted there was no documentation in the medical record confirming communication about the bed hold. This lack of proper notification and documentation left residents and their representatives uninformed and without advocacy support from the Ombudsman.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy upon transfer to the hospital for a resident, resulting in the potential for residents and/or their representatives to be unaware of their rights regarding facility bed holds. The deficiency was identified during the review of Resident #98's records and interviews with staff. Resident #98, who had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and a suprapubic catheter, was transferred to a local hospital for severe abdominal distention, pain, and fever. Despite the transfer, there was no documentation in the medical record indicating that the resident or their representative had been provided with written notice of the bed hold policy as required by the facility's policy. Interviews with various staff members, including LPNs, Clinical Managers, and the Director of Nursing, revealed inconsistencies in the process of notifying residents or their representatives about the bed hold policy. While some staff mentioned that a packet including the bed hold information was handed to the ambulance service, others stated that the admissions coordinator would contact the resident or representative to discuss the bed hold. However, there was no documentation to confirm that these communications had occurred. The facility's policy required that written notice of the bed hold policy be provided upon transfer and that all attempts to reach the resident's representative be documented, which was not adhered to in this case.
Failure to Follow Physician Orders and Implement Correct Precautions
Penalty
Summary
The facility failed to ensure professional standards of practice for physician orders were obtained and followed for two residents, resulting in a lack of documentation and potential delays in treatment. For Resident 91, who required a fistula/port for dialysis due to chronic kidney disease stage V, the order to change the dressing at the hemodialysis site daily was not included in the Medication Administration Record/Treatment Administration Record (MAR/TAR) from February 23, 2023, through June 5, 2024. This oversight was confirmed by both a Licensed Practical Nurse (LPN) and the Clinical Manager, who acknowledged that the order was missed during the routine checks and double-checks of the resident's care plan and orders. An observation revealed that the resident's dialysis port had no dressing and had three small scabbed-over openings, indicating a lack of proper care and documentation. For Resident 291, who had multiple diagnoses including lung cancer, heart failure, pneumonia, asthma, sepsis, MRSA, diabetes, muscle wasting, and low back pain, the facility failed to properly document and implement the correct precautions. Although the resident was placed on droplet precautions with full personal protective equipment (PPE) upon admission, there was no corresponding order in the medical record. The Infection Control Nurse (ICN) and Director of Nursing (DON) confirmed that the order checks were improperly completed by the same nurse on the same day, and the resident should have been placed on enhanced barrier precautions (EBP) instead. The ICN noted that the staff was confused about implementing EBP, leading to the incorrect application of droplet precautions. The Director of Nursing explained that the admission paperwork process involved multiple checks by different staff members, but in this case, the necessary precautions were not correctly documented or communicated. The failure to accurately document and follow physician orders for both residents highlights significant lapses in the facility's adherence to professional standards of care, resulting in potential risks to the residents' health and safety.
Failure to Follow Physician Orders for Blood Sugar Monitoring and Dressing Changes
Penalty
Summary
The facility failed to follow orders for monitoring blood sugars for one resident and to follow orders for dressing changes for another resident, resulting in the lack of monitoring and the resident not receiving appropriate interventions. For Resident #292, the facility did not perform the required blood sugar checks before breakfast and dinner for five days as ordered. The order was entered without a routine or schedule, which prevented it from transferring to the medication administration record (MAR), leading to the omission of blood sugar monitoring. Interviews with the LPN, Clinical Manager, and Director of Nursing confirmed that the order was not properly checked and did not prompt the nurses to complete the blood sugar checks due to the missing schedule in the order entry system. For Resident #119, the facility did not follow the prescribed procedure for changing the dressing on a wound on the resident's head. The LPN did not allow the wound to drain for 10 minutes before applying a new bandage and did not use the specified coban wrap. Additionally, the LPN did not wear a gown during the dressing change. Interviews with the LPN, RN, and DON revealed that the proper procedure was not followed, and the wound dressing change was not performed according to the physician's order. The DON also noted that the resident's spouse was permitted to change the dressing using hospice supplies, but there was no current order to support this practice. These deficiencies highlight a lack of adherence to physician orders and proper procedures, resulting in potential risks to the residents' health. The failure to monitor blood sugars and perform dressing changes as ordered could lead to worsening health conditions for the affected residents.
Failure to Maintain Range of Motion for Resident
Penalty
Summary
The facility failed to ensure services to maintain and prevent further decrease in range of motion (ROM) for a resident with cerebral palsy, resulting in the potential for decreased ROM, contractures, and pain. The resident, who was cognitively intact, reported increasing pain and cramps in her legs and stated that she was not receiving the prescribed therapy for her arms and legs. Observations and interviews revealed that the CNAs were not performing the prescribed passive ROM (PROM) exercises as outlined in the resident's care plan. Instead, they considered dressing the resident as fulfilling the ROM requirement, which did not involve the necessary repetitions of bending the arms and legs. Interviews with the clinical manager and CNA manager confirmed that the CNAs were expected to perform PROM exercises per the care plan, but this was not being done correctly. Documentation over the past 30 days showed inconsistent performance of PROM exercises, with the resident tolerating them well only 12 out of 30 days. The facility's policy on ROM exercises emphasized the need for gentle, smooth, and repetitive movements to maintain function and prevent decline, which was not being adhered to in this case.
Failure to Ensure Proper Dialysis Care and Monitoring
Penalty
Summary
The facility failed to ensure physician orders were in place for dialysis treatment and monitoring, and post-dialysis assessments were documented for two residents requiring dialysis care. Resident #65, who was admitted with stage 4 chronic kidney disease, reported not seeing any facility staff after returning from dialysis and was unsure who was responsible for changing the dressing on his dialysis port. The care plan for Resident #65 did not specify the type of dialysis, the schedule, or monitoring requirements, and there were no physician orders or treatment records for dialysis in his file. Additionally, vital signs were not consistently recorded, particularly on dialysis days, and the facility staff were unaware of the dialysis details and monitoring requirements for Resident #65's port site. Resident #91, who required dialysis for chronic kidney disease stage V, also lacked physician orders for dialysis, including the schedule and designated dialysis facility. The care plan for Resident #91 mentioned the need for dialysis three times a week but did not specify the days or the dialysis facility. During an interview, Resident #91 confirmed his dialysis schedule, but the Clinical Manager could not find any orders for dialysis in his records. The facility's policy on dialysis care, which includes detailed requirements for physician orders and monitoring, was not followed for both residents. The facility's failure to adhere to its dialysis care policy resulted in a lack of proper documentation and monitoring for both residents. This included missing physician orders, incomplete care plans, and inconsistent recording of vital signs. The staff interviews revealed a lack of awareness and understanding of the residents' dialysis needs and the necessary monitoring protocols, leading to potential risks for the residents' well-being.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information on a daily basis for all 135 residents, resulting in a lack of available staffing information for residents and visitors. During multiple observations on 06/04/24 and 06/05/24, no postings indicating the daily nurse staffing hours were found throughout the facility halls and common areas. In interviews, both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported that they were unaware of the requirement to post nurse staffing hours. The DON further mentioned that the responsibility for posting the daily nurse staffing hours was assigned to the scheduler, who had not been working in the facility for approximately 8 weeks.
Failure to Respond to Call Lights Timely
Penalty
Summary
The facility failed to provide an environment that promoted a dignified experience and respond to resident call lights timely for two residents, resulting in feelings of humiliation, embarrassment, and concern about receiving timely assistance in the event of a medical emergency. Resident #100, a male with multiple diagnoses including muscle wasting, dementia, and an above-knee amputation, reported feeling neglected and disrespected by the staff. He recounted an incident where he had a loose bowel movement and was left unattended for an extended period, causing him significant distress. Call light reports confirmed multiple instances where his call light was on for 30 minutes or more. Resident #103, a female with cerebral palsy and other conditions, also experienced delays in call light responses, which increased her anxiety and worry. She expressed that staff could have communicated better by informing her they would be there soon. Call light reports for her also showed multiple occasions where the call light was on for over 30 minutes. Interviews with staff revealed issues with the call light system, including phones being turned down or off, and a lack of consistent monitoring of call light alerts. The facility's policy stated that call lights should be answered within 7 to 15 minutes, but this was not consistently followed. The failure to respond to call lights in a timely manner negatively impacted the residents' quality of life and sense of dignity.
Failure to Ensure Resident Safety During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure resident safety during a Hoyer lift transfer, resulting in a fall with minor injury for Resident #103. Resident #103, who has diagnoses including cerebral palsy, pain, anxiety, embolism, abnormal posture, anemia, and osteoporosis, was being transferred from her wheelchair to her bed when the incident occurred. The care plan for Resident #103 did not indicate the need for a Hoyer lift for transfers, and the Minimum Data Set (MDS) indicated that the resident was dependent on helpers for transfers. During the transfer, the Hoyer loop came off the hook, causing the resident to fall and hit her head, resulting in a lump on the back of her head and an abrasion on her back. The incident was reported by the resident's spouse and documented in the facility's records, including an Incident/Accident/Unusual Occurrence Progress Note and an Incident Report. Interviews with staff members revealed that two CNAs were assisting with the transfer when the loop slipped off, and the resident fell to the floor. The CNAs were educated on ensuring the loops were securely attached before raising the resident. The facility's policy on safe handling and transfers requires two staff members for full-body lifts and adherence to the manufacturer's instructions for using the mechanical lift. The procedure for transferring clients with a mechanical lift includes steps to ensure the resident's safety, such as checking that all hooks remain secure and raising the resident only a few inches above the chair before moving them to the bed. However, in this case, the failure to properly secure the Hoyer loop led to the resident's fall and injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Inn At Freedom Village | 2.4 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Holland | 3.6 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Zeeland | 6.5 mi | ★★★★★ | 6 | 0 |
| Heritage Nursing And Rehabilitation Community | 6.6 mi | ★★★★★ | 19 | 0 |
| The Orchards At Douglas Cove | 9.7 mi | ★★★★★ | 5 | 0 |
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