Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Haven Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
Failure to Protect Resident from Staff Physical Mistreatment: A resident with stroke-related paralysis, contractures, dementia, and visual impairment reported that a female CNA slapped and scratched him after he used his call light for a brief change. Staff documented facial injuries including scratches, forehead redness/abrasion, and a bruise or discoloration on the nose, while the resident and family reported he felt scared and uncomfortable asking staff for help.
Failure to maintain an active Legionella and OPPP control program was cited after surveyors found capped and unused water lines in the kitchen with no evidence of routine flushing, and a soiled utility hopper with standing water and brown, discolored water from the faucet and spray wand. Record review showed a Legionella plan calling for monthly free chlorine testing and logging of cold and hot water fixtures, but no testing logs were available, and no documentation of an annual review was found.
Unsafe and unsanitary conditions were observed throughout the LTC facility, including grease-encrusted sheet pans, a dish sprayer creating a cross connection, dirty and debris-filled common areas, and a linen room with dust, trash, and used gloves. Multiple resident rooms had repeated soiling, broken blinds, stained walls and floors, missing transition strips, chipped tile, damaged doors, dirty fall mats, and other unclean or broken surfaces. HKs and the HLS stated rooms should be cleaned daily and deep cleaned monthly, and staff acknowledged several of the observed areas should have been cleaned or reported.
Dignity Failures During Dining and Resident Engagement: Two dependent residents were observed being fed by CNAs who stood while assisting them in the dining room, and one CNA spoke on a smart watch during feeding while not acknowledging the resident. Another resident with Parkinson's disease, dementia, and cognitive deficits was repeatedly left at the nurse's station with no water, no meaningful activities, and little to no interaction despite a care plan calling for individualized engagement and one-on-one visits.
Resident Council grievances were not followed up or resolved, with residents reporting that management did not address concerns raised in meetings and that the grievance process was unclear. All residents interviewed said they disliked the food and did not get what they ordered, while council minutes repeatedly documented complaints about flavor, plating, portions, and items still being served despite dislike lists. The Dietary Director said he had not received the council concerns or forms, and the NHA could not locate the forms in the SSD's grievance book.
Residents were not informed of where to find grievance forms or how to file a grievance, and many said they did not know who to go to with concerns. In a Resident Council meeting, most residents reported management did not follow up on concerns, and one resident said the SSD did not respond to grievances. Staff also gave inconsistent answers about where forms were located and who the Grievance Official was, and the forms observed in the hall were unlabeled and did not identify who should receive them.
Activities program was not directed by a qualified professional when the AD had started but was not yet certified and the facility had relied on informal coverage after the prior AD left. A cognitively intact resident whose preferences included church and music said he had only attended one church service since admission, while staff reported weekend activities were limited and church services had not been coming for months despite being on the calendar.
Food Served at Unpalatable Temperatures: A resident with DM, gout, and kidney disease reported repeated cold meals, including cold breakfast items and stone-cold biscuits and gravy. Surveyors observed lunch service starting late after staff said they were behind schedule, and staff stated they did not do test trays or tray audits; a test tray and a resident tray both showed soup temperatures that were low for hot food.
A resident with mental health diagnoses was prescribed PRN hydroxyzine for anxiety without a 14-day stop date, and no provider rationale was documented to justify use beyond this period. The DON confirmed that the required stop dates were not in place for the medication orders.
Failure to implement heel elevation interventions was identified for a resident with DM2, severe malnutrition, and severe cognitive impairment who was at high risk for pressure ulcers. Staff repeatedly observed the resident in bed with her heels directly on the mattress despite a care plan for heel elevation, while a bolster and padded boots were available in the room. An LPN stated the resident should wear the padded boots in bed and applied them, while a CNA said she had not applied them for the prior two days and was unsure if they were required. The DON stated the resident did not need more specific interventions and removed the boots, and the care plan had no documentation for padded boots.
Failure to notify provider when insulin was unavailable: A resident with diabetes and multiple serious wounds missed several doses of long-acting insulin because the medication was not in the cart or backup supply. MAR entries showed the insulin as not administered due to pharmacy delay or lack of stock, but staff did not contact the provider for direction or a new order. RN and LPN interviews confirmed they looked for the medication, contacted pharmacy, and still did not escalate the issue to the provider.
Failure to provide individualized activities for a cognitively intact resident whose care plan and MDS identified religious services and music as very important. The resident said the facility had no Activity Director for about a month, the activity calendar was not followed, and he attended only one Sunday church service despite multiple services being scheduled; activity logs showed limited participation and no church attendance.
Failure to provide vision services and repair broken glasses: A resident with stroke-related hemiplegia and moderate cognitive impairment was observed wearing broken glasses with a missing lens and a fractured frame. The resident said the glasses had been broken for a while and had not been fixed despite repeated requests. Records showed Social Services could not order new glasses because the RX had expired after the resident refused optometry, and there was no documentation of completed repair or replacement efforts by survey exit.
A resident with CVA, L-sided weakness, DM2, and HTN had long fingernails and toenails, including a broken and jagged great toenail, while staff gave conflicting accounts of who could provide nail care for residents with diabetes. The resident said he had asked for help and was told he needed podiatry, but the record had no documentation of podiatry visits, refusal, or completed nail care, and shower documentation did not note nail care needs or services.
Failure to Keep Fluids Readily Available for a Resident at Hydration Risk. A resident with altered mental status, Parkinson's disease, dementia, and other chronic conditions was identified as being at nutritional/hydration risk, with elevated BUN and BUN/Cr ratio. Surveyors observed him multiple times without water or with fluids out of reach, and staff did not consistently offer or assist with drinking; he was later noted to have a dry mouth, white coating on his tongue, and very dry skin with poor skin turgor.
A resident with diabetes and multiple serious wounds missed several doses of ordered long-acting insulin because the medication was not available in the cart or backup supply. Nursing staff checked the cart, backup refrigerator, and pharmacy, but did not contact the provider for direction when the insulin was unavailable, and the MAR documented the doses as not administered. Interviews with the RN, LPN, and DON confirmed the missed doses and that provider notification should have occurred.
A facility failed to properly secure a medication storage refrigerator in 1 of 2 medication rooms. An RN was observed opening the refrigerator without using a key, despite reporting that a controlled substance was stored inside, and then leaving the refrigerator unlocked when exiting the medication room. The RN and DON both stated the medication room refrigerators were expected to always be locked.
Food preferences were not honored for a resident with DM, gout, CKD, lymphedema, DVT, HTN, and RA who was identified as being at nutritional/hydration risk. The resident reported telling dietary staff he disliked several foods, including sweet potatoes, oatmeal, fish, pineapple, and waffles, yet those items continued to appear on his meal trays. The DD stated he had limited specific concerns to work with and had received little feedback from concern forms, Resident Council, or the Food Committee.
Inaccurate MDS Assessment Submission: An MDS assessment for a resident with DM, gout, stage 4 CKD, chronic RLE lymphedema, HTN, DVT, and RA was rejected by CMS because the re-entry admission date kept the original admission date instead of the correct date. The MDS nurse acknowledged he received the validation report, forgot to follow up on the rejection, and later found the error while reviewing the assessment; the resident had originally been admitted earlier and was not a new admission.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unnoticed, despite being identified as an elopement risk. Staff were aware of the resident's patterns, such as checking doors and expressing a desire to leave, but there was no individualized documentation or consistent monitoring of these behaviors prior to the incident. The resident was found walking along a busy road by a staff member and returned to the facility.
Two residents with severe cognitive impairment and a history of exit-seeking behaviors were not provided with individualized care plans. Instead, generic interventions were used, and specific behaviors such as fixation on cars and cigarettes were not addressed. One resident was able to leave the facility unsupervised, and staff interviews revealed a lack of documentation and monitoring for escalating behaviors, with care plans relying on non-individualized templates.
The facility lacks a full-time Registered Dietitian or Certified Dietary Manager to oversee nutritional services. The Dietary Supervisor, in the role for two years, is not yet certified but is taking classes. A dietitian visits only a couple of times a week, increasing the risk of food service sanitation failures and inadequate assessment of high-risk residents.
A long-term care facility was found to have multiple deficiencies in food safety and sanitation during a survey. The kitchen had issues with unlabeled and undated food items, dirty equipment, and improper storage practices. The walk-in cooler and dry storage areas contained items without proper labeling, and the kitchen equipment was not maintained in a clean condition. Additionally, the refrigeration unit in the resident area was at an unsafe temperature, posing a risk of foodborne illness.
The facility failed to maintain an effective water management plan and infection control program. The Maintenance Director was unsure of control measures beyond routine flushing and had not conducted water testing. The Infection Preventionist missed resident vaccinations, lacked a tracking process, and failed to ensure staff training on infection control. The infection control log was incomplete, and there was no clear responsibility for infection monitoring, indicating deficiencies in both programs.
A facility failed to implement an antibiotic stewardship program and monitor antibiotic use for a resident. The Infection Preventionist (IP) did not assess antibiotic use according to Mcgeer's criteria and lacked documentation on antibiotic indications, dosages, or durations. The IP also did not follow up on outcomes or provide feedback on antibiotic use, relying on nursing staff documentation. The Director of Nursing (DON) did not oversee the stewardship program, leaving all responsibilities to the IP, resulting in potential inappropriate antibiotic use and resistance.
The facility failed to maintain cleanliness and repair, affecting resident rooms and common areas. Observations revealed dust and debris in rooms, stained ceiling tiles, and disrepair in utility spaces. Residents with chronic obstructive pulmonary disease were exposed to dusty fans, and one resident had to clean her own bathroom due to dissatisfaction with housekeeping. Damaged and dirty wheelchairs were also noted, with inconsistencies in cleaning schedules and maintenance awareness.
A resident with cognitive impairment and physical limitations was repeatedly found with the call light out of reach, preventing them from calling for assistance. Despite the care plan's directive to keep the call light accessible, observations showed it was often on the floor or under the bed.
A facility failed to create a comprehensive care plan for a resident on Eliquis, an anticoagulant prescribed for deep vein thrombosis. Despite the resident's diagnoses of congestive heart failure and hypertension, no care plan was in place to address the potential side effects of the medication. The MDS Coordinator and DON both acknowledged the oversight, emphasizing the importance of care plans for high-risk medications.
A facility failed to implement care plan interventions for a resident with muscle contracture, as the resident was observed not wearing prescribed splints on multiple occasions. Despite occupational therapy recommendations and care plan documentation, staff interviews revealed a lack of awareness and adherence to the care plan, leading to the potential for worsening contractures.
A resident with dementia and a history of falls experienced a fall resulting in facial injuries due to inadequate supervision and failure to implement safety interventions. The resident, who self-ambulated in a wheelchair, fell near a chapel ramp without caution signs, despite this being part of her care plan. Observations showed the resident was often left unattended, and staff admitted to not applying necessary safety measures.
A facility failed to attempt a required Gradual Dose Reduction (GDR) for a resident's antidepressant and antipsychotic medications, potentially leading to unnecessary dosing. The resident, with a diagnosis of unspecified mood affective disorder, was prescribed Olanzapine and Sertaline. Despite the care plan indicating a need for dose reduction, there was no documentation of GDR attempts or justification for not attempting one. Interviews revealed a lack of awareness and documentation regarding GDR attempts, with reliance on a local mental health provider without evidence of collaboration or follow-up visits.
A resident with diabetes received an incorrect dose of insulin due to a new nurse's error, leading to a significant drop in blood sugar levels. The nurse, who was still in orientation, administered 32 units of short-acting insulin instead of the prescribed doses, causing the resident to experience severe symptoms and miss a dialysis appointment. The error was reported and investigated by the facility's staff.
A facility failed to administer a pneumococcal vaccine to a resident with chronic obstructive pulmonary disease, despite consent from the guardian and the resident being due for the vaccine. The Infection Preventionist acknowledged the oversight, citing staff turnover and a backlog in the vaccine program as contributing factors.
A facility failed to offer a COVID-19 vaccination to a resident with chronic obstructive pulmonary disease, as there was no record of vaccination in their Electronic Health Record. The Infection Preventionist admitted to not screening or offering the vaccine to the resident and lacked a systematic approach to ensure staff were educated and offered the vaccine, relying only on posted signs during clinics.
The facility failed to ensure timely care and services for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth. One resident reported waiting up to two hours for assistance, while another's family member noted frequent delays and clutter. A third resident in extreme pain also experienced delays in receiving care.
A resident with cognitive impairments reported being punched by a CNA after using racial slurs. The facility's investigation revealed inconsistencies in staff and resident accounts, and the incident was not adequately documented. The deficiency highlights a lapse in protecting the resident from potential abuse and the need for improved adherence to abuse prevention policies.
The facility failed to ensure physician orders for scheduled pain medications were in place and did not accurately document the administration of controlled medications for a resident with terminal cancer. This resulted in inadequate pain management and potential drug diversion.
The facility failed to maintain safe infection control practices for a resident on Enhanced Barrier Precautions due to chronic wounds and a Foley catheter. Staff were observed handling the resident's catheter bag and transferring the resident without wearing the required PPE, and there was a lack of hand hygiene and PPE availability, leading to potential cross-contamination.
Failure to Protect Resident from Staff Physical Mistreatment
Penalty
Summary
The facility failed to protect a resident from staff-to-resident physical mistreatment. Resident #100 was a male with paralysis on his right side from a stroke, contractures of the right hand/wrist and both knees, Alzheimer’s disease, blindness in one eye with low vision in the other, weakness, and a need for assistance with personal care. His profile identified him as a one-person assist for bed mobility, and multiple staff described him as needing help to roll and reposition because of his contractures, right-sided weakness, and limited use of his left arm. On the day of the incident, the resident reported that he pressed his call light because he needed to be changed. He stated that a female CNA came into his room, had an attitude, and after an argument about care, slapped and scratched him while providing care. The resident later told staff and police that he had been struck in the face multiple times and that he felt scared and unsafe. Family members reported that he sounded scared and confused when he called them using a smart device in his room, and they came to the facility after learning of the allegation. Staff interviews and record review documented facial injuries after the event, including scratches under the eye and above the eyebrow, redness and abrasion on the forehead, and bruising or discoloration on the nose. The resident’s wife and daughter reported the injuries were new, and photos showed a scratch below the right eye, a scratch above the eyebrow with blood present, forehead redness and swelling, and a deep red-purple area on the nose. Although the CNA denied striking him and suggested his face may have scraped against the bed rail, the resident consistently reported that he had been hit, and social services documented that he was uncomfortable using his call light because he did not want to upset staff.
Failure to Maintain Legionella and Water Pathogen Control Program
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During a kitchen tour, a hot water fixture by the coffee area was found capped off with no evidence of routine flushing, and two other water lines protruding from the wall near the walk-in cooler door also had no evidence of regular flushing. When asked about the maintenance director, staff stated he had been off for a couple of weeks, and when asked whether anyone regularly flushed the kitchen water lines, staff did not think so. In the 200-hall soiled utility room, the hopper bowl contained brown and yellow debris with water sitting low in the bowl, and when the cold and hot water fixtures were turned on, brown and discolored water came out for a couple of seconds before running clear. Brown and discolored water also came momentarily from the spray wand. Record review found a Legionella Plan Overview Control Measures and Corrective Actions document stating maintenance or designee would conduct monthly free chlorine testing and log samples from cold and hot water fixtures, but no logs or documentation of ongoing free chlorine testing were observed. Another document, Water Pathogen Risk Reduction, described stagnant water and biofilm, but no documentation showing an annual review was found.
Unsafe and Unsanitary Facility Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment. Survey observations found sheet pans stored under a counter with black encrusted grease on the inside seams and corners, and an overhead sprayer next to the dish machine positioned below the overflow rim of the sink, creating a cross connection between potable water and wastewater. In the family room and front lobby, furniture had accumulations of trash, crumbs, wrappers, food debris, and other items, and the lobby furniture also contained scratched off tickets, nail clippers, taco sauce, and a grocery receipt. Multiple common areas were observed with dirt, debris, and staining. The 400-hall shower room had black debris and staining at the floor and wall juncture between the commode and wall, and the 400-hall linen room had heavy dust and debris under the wire rack used for clean linen storage, along with used gloves, paper trash, and packages of crackers. In interviews, the NHA stated the facility had been working on repairs and updates and planned to repaint resident rooms over the next year, while the Housekeeping/Laundry Supervisor stated rooms should be cleaned daily and deep cleaned monthly. Several resident rooms were observed with repeated soiling, damaged surfaces, and poor housekeeping. Findings included broken blinds, dried milk-like splatter on dresser fronts, spillage and streaking on walls, soiled garbage cans, dirty fall mats, cobwebs, ash or drywall dust on windowsills, missing transition strips, chipped and broken tile, splattered liquid on walls and baseboards, peeled wallpaper, black marks on walls, soiled tray tables, broken door pieces, missing paint, rust spots, exposed foam in cracked fall mats, and dirt and debris caked along floor transitions. Housekeeping staff and the Housekeeping/Laundry Supervisor stated that dressers, walls, floors, beds, tables, enabler bars, and other room surfaces were their responsibility to clean, that rooms should be cleaned every day, and that deep cleaning should occur about once a month. When several of the observed dirty or damaged areas were pointed out, staff stated they should have been cleaned or reported as needing repair.
Dignity Failures During Dining and Resident Engagement
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were dependent on staff for feeding. Resident #1 was a male with diagnoses including delayed milestone in childhood, need for assistance with personal care, feeding difficulties, and encephalopathy. His MDS showed he was dependent for eating, and during lunch he was observed being fed by a CNA who was standing next to his wheelchair rather than sitting. The CNA later acknowledged she should not have been standing while assisting residents to eat in the dining room and confirmed she had stood while feeding Resident #19 as well. Resident #19 was a male with diagnoses including anoxic brain damage, dementia, and quadriplegia. His MDS showed he was dependent for eating. He was observed in the dining room without a tray in front of him while other residents at the table were eating. When his meal was served, the plate was left covered on the table, and CNAs were observed standing between his wheelchair and the table while feeding him. On another occasion, a CNA fed him while standing and answered a phone call on her smart watch, speaking out loud in the dining room and discussing open shift coverage while continuing to feed him without acknowledging him. The DON stated staff should sit down when feeding a resident and should feed one resident at a time. The facility also failed to maintain an environment that promoted dignity for Resident #25, a male with altered mental status, cognitive communication deficit, Parkinson's disease, dementia, depression, mood disorder, and need for assistance with personal care. His care plan included preferred activities such as music, TV, one-on-one visits, and other individualized engagement. He was observed seated at the nurse's station with no water and no activities, only a fuzzy blanket, and later remained there without activities or one-to-one interaction. During one observation, he was assisted with eating but was left with an open supplement that he did not drink, and staff did not offer him a drink or assist him with it. At another time, he was again seated at the nurse's station with no activities, no music, and no television in sight.
Resident Council Grievances Not Followed Up
Penalty
Summary
The facility failed to address and resolve grievances raised in Resident Council meetings, as residents reported during a confidential council meeting that management did not follow up on concerns brought to the meetings or on individual concerns that came from them. Nine of nine residents stated they did not like the food and did not receive what they ordered, and they said these concerns had been brought up in Resident Council without any change. One resident stated the food was horrible and said nothing would change because follow-up on concerns was not being completed. Two residents were unsure whether the Grievance Official was the NHA or the SSD, and one resident stated the SSD did not respond to grievances and was like talking to a wall. Resident Council minutes from multiple meetings documented repeated dietary complaints, including lack of flavor, thin gravy, hard toast, poor presentation, items still being served despite being on dislike lists, and small portions. The minutes also showed that concerns were noted as being reviewed or to be addressed through ambassador rounds, but there were no concern forms associated with several meetings. During interviews, the Dietary Director stated he had not received Resident Council concerns or forms about the food and only had one food-related concern form from June. The NHA stated she could not locate the concern forms from Resident Council because they were not in the SSD's grievance book and said follow-up from Resident Council probably was not documented.
Grievance Forms and Official Not Clearly Identified
Penalty
Summary
The facility failed to notify residents of where to find grievance forms and how to file a grievance. During a confidential Resident Council meeting, 7 of 9 residents stated they did not know where grievance forms were located or how to file one, and they also said they did not know who to go to with concerns. Nine of 9 residents stated that management does not follow up on individual concerns brought up by residents. Two residents stated they were not sure whether the Grievance Official was the NHA or the SSD. One resident stated that the SSD does not respond to grievances and described speaking with the SSD about grievances as like talking to a wall because nothing is done with them. These statements reflected resident confusion about the grievance process and dissatisfaction with how concerns were handled. Staff interviews showed inconsistent knowledge of the grievance process and where forms were located. A CNA stated he did not know where grievance forms were located and would tell the nurse about resident concerns. An RN stated she was not sure where the forms were located and thought they were outside the SSD's office, but forms could not be located there during observation. The forms were later observed hanging in a wire basket on the wall at the corner of the 200 and 300 Hall, unlabeled and without information identifying the Grievance Official or who to turn the forms into. Additional staff gave differing answers about the location of the forms and who the Grievance Official was, while the NHA stated the SSD was the Grievance Official and then reported she would take over that role.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. Review of the facility’s staffing and activity program records showed that the new Activity Director (AD) had started on 12/15/2025 but was not yet certified as an AD. The Human Resource Director stated the facility planned to enroll her in the Activity Director certification course, and the Nursing Home Administrator stated the sister facility was overseeing activities and training her until she was full time in the building on 12/29/2025. The facility’s Activity Program Staffing Policy stated the activity program must be under the direct supervision of a qualified professional meeting specified qualifications. Resident #59 was a cognitively intact male with a BIMS score of 15 out of 15. His activity assessment and care plan showed he preferred to self-direct his activities, stayed in his room, and enjoyed reading, writing, watching TV, listening to music, working on the internet, and participating in religious services. His MDS indicated that listening to music and participating in religious services or practices were very important to him. During interview, he stated he loved attending church on Sundays, but he had only attended one Sunday service since admission, and the facility had not followed the calendar during the period when there was no Activity Director. Record review and staff interviews showed the facility had scheduled church services on the November and December calendars, but R59 attended none of the December church services and only one church service since admission. R59 reported that he and a few residents sometimes gathered in the chapel on other Sundays to sing hymns and read Bible passages without staff assistance. Staff stated that the church had not been coming on Sundays for months, that weekend activities were limited mostly to BINGO, and that the previous AD had been supposed to look into why church was not coming but left before doing so. The facility also had a period of about a month without an AD, during which staff said activities were covered informally by other staff.
Food Served at Unpalatable Temperatures
Penalty
Summary
Food and drink were not provided at a palatable temperature for Resident #75 and for residents receiving meals. Resident #75 was a male with diagnoses including diabetes, gout, and kidney disease, and his care plan identified him as at nutritional/hydration risk related to chronic lymphedema, high blood pressure, DVT, diabetes, stage 4 kidney disease, rheumatoid arthritis, and diuretic therapy. He reported that the facility’s Thursday biscuits and gravy were "stone cold," that meals were cold 5 out of 7 days, and that breakfast items such as scrambled eggs and a bagel were cold on another morning. During observation and interview, lunch was scheduled to start at 11:45 AM, but staff reported they were behind schedule and still finishing tasks before service. Lunch did not start until 12:40 PM, and staff stated they did not currently do test trays or tray audits on meals. A test tray placed on the cart showed hot food temperatures that included vegetable soup at 128F after delivery, and a resident’s lunch tray observed later had soup measured at 122F with a rapid read thermometer.
Failure to Limit PRN Psychotropic Medication to 14 Days Without Provider Rationale
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications for a resident included a stop date not exceeding 14 days, as required. A male resident with diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder was prescribed hydroxyzine, an antihistamine also used for anxiety, on a PRN basis. The medication orders were written with start and discontinue dates that exceeded the 14-day limit for PRN psychotropic medications, and there was no documentation of a provider rationale to justify extending the use beyond this period. During an interview, the Director of Nursing (DON) confirmed that PRN psychotropic medications should be limited to 14 days unless a provider documents a rationale for extension. Review of the resident's orders showed that the required 14-day stop dates were not implemented for both instances of the hydroxyzine prescription, and no provider rationale for the extended use was provided by the time of the survey exit.
Failure to Implement Heel Elevation Interventions
Penalty
Summary
Failure to implement care plan interventions for skin breakdown prevention was identified for Resident #7, a female admitted with diagnoses including type 2 diabetes, history of falling, and severe protein-calorie malnutrition. Her MDS assessment dated 11/26/25 showed a BIMS score of 2/15, indicating severe cognitive impairment. Her care plan identified her as at risk for skin breakdown and included elevation of heels, with a start date of 4/30/25. A Braden Scale evaluation dated 8/4/25 scored her at 11, indicating high risk for pressure ulcers. During multiple observations on 12/15/25 and 12/16/25, Resident #7 was seen in bed with her heel directly on the mattress under the blankets and no pillow used to elevate her heels, despite a bolster and padded boots being present in the room. An LPN later stated the resident’s feet should not be on the mattress and should be elevated, and applied the padded boots to both feet. A CNA reported the resident should wear the padded boots in bed but had not applied them in the prior two days and was unsure whether the boots were required. The DON stated the resident was to have her feet elevated off the mattress as she allowed, said the resident did not need more specific interventions because she had no wounds and was not at risk for skin breakdown, and removed the boots because she believed the feet should be on a pillow. The care plan contained no documentation regarding padded boots for bilateral feet.
Failure to Notify Provider When Insulin Was Unavailable
Penalty
Summary
The facility failed to follow professional standards of nursing practice for physician notification of a change in condition and medication administration for one resident with diabetes, foot ulcer, stage 4 left buttock pressure ulcer, stage 3 right buttock pressure ulcer, osteomyelitis, sepsis, and paralysis from the chest down. The resident’s care plan directed staff to administer diabetic medications as ordered and observe for signs of hypo/hyperglycemia. During interview, the resident reported he did not receive his long-acting insulin because the facility did not have it in the medication cart or backup refrigerator. Review of the December 2025 MAR showed the resident did not receive degludec insulin on four consecutive nights. The MAR documented the medication as not administered because it was on order from pharmacy or unavailable, with comments such as delivery pending or pharmacy delivery pending. The record did not show that the provider was contacted when the insulin became unavailable, and there was no provider direction or new order to replace the medication or place it on hold. Staff interviews confirmed the medication was not available and that the provider was not contacted when doses were missed. An RN stated she looked for the insulin in the cart and refrigerator, saw it had been ordered, but did not administer it and should have contacted the provider. An LPN stated she called the pharmacy, believed the insulin would arrive, and did not contact the provider despite repeated missed doses. The DON stated nurses were to check the backup box, contact the provider when medication was unavailable, and document that the provider was contacted, and she confirmed the resident missed degludec insulin from 12/11 through 12/15.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities based on resident preferences, needs, and abilities for one resident, a cognitively intact man with a BIMS score of 15 out of 15. The resident’s activity assessment and care plan documented that he preferred to self-direct his activities, stayed in his room, and enjoyed reading, writing, watching TV, keeping up with the news, listening to music, arranging music, playing in a band, performing music at facilities, working on the internet, and participating in religious services. His MDS also indicated that listening to music and participating in religious services or practices were very important to him. During interview, the resident stated there had not been an Activity Director at the facility for about a month and that staff helped with activities here and there, but the calendar had not been followed during that time. He said his main interest was attending church and that he had only attended one Sunday service since admission, despite the November and December calendars showing six church services scheduled every Sunday since his admission. The activity log showed he attended activities on only 3 days since admission, and none were church services; the December log also indicated he did not attend any church services provided by the facility, although he led church services with a few residents on one occasion.
Failure to Provide Vision Services and Repair Broken Glasses
Penalty
Summary
The facility failed to ensure vision services and assistive devices were provided to maintain adequate vision for Resident #24, a male with hemiplegia and hemiparesis following a cerebrovascular disease affecting his left non-dominant side and a BIMS score of 11/15 indicating moderate cognitive impairment. During observation and interview, his glasses were found with the left lens missing and the frame broken through near the left nose piece. The resident stated the lens was in his drawer, the glasses would not stay in the frame, the glasses had been broken for a while, and he had asked several times for them to be fixed. Record review showed Social Services documented that the resident broke his glasses and that new glasses could not be ordered because his prescription had expired after he refused to see the optometrist. The note stated he would be seen at the next visit to renew the prescription. The DON reported Social Services was responsible for vision services and that vision services were offered quarterly, while also stating the resident had refused optometry and that any repair attempts would be coordinated by Social Services. The NHA reported the resident had repeatedly refused attempts to repair his glasses and optometry services for a new prescription, and that he was scheduled for an optometry visit. No other documentation was provided by survey exit showing scheduled optometry appointments, refusals of services, or attempts to repair or replace the glasses after they were noted to be broken.
Inadequate Foot and Nail Care for Resident with Diabetes
Penalty
Summary
Provide appropriate foot care was not ensured for Resident #5, a cognitively intact male with a history of cerebral infarction with left side weakness, type 2 diabetes, and hypertension. The resident told staff he was concerned about his fingernails and toenails being clipped and reported he had offered to do it himself but was not given clippers or scissors. He also stated that he had been told he needed to see a podiatrist for foot care because of diabetes, that someone occasionally looked at his feet, but that no one had ever cut his toenails. On observation, the resident’s fingernails were long and extended well past the ends of his fingers, and the toenails on his right foot were long, extended beyond the toes, curved along the toes, and the great toenail was broken, jagged, and long. Staff interviews showed conflicting practices regarding nail care: one LPN stated CNA staff were not allowed to cut nails for residents with diabetes and that nurses or podiatrists should provide that care, while a CNA stated nail care could be done during showers and that activities aides provided nail care, but she did not document when nail care was needed or when the nurse was notified. Shower sheets reviewed for the resident contained no documentation of nail care. The DON stated nails should be evaluated with every shower and bed bath, but was unsure whether the resident had been seen by podiatry. The NHA later reported the resident had signed consent for podiatry services, but the record contained no documentation of podiatry services, refusal of podiatry services, completion of nail care, or refusal of nail care by the time of exit.
Failure to Keep Fluids Readily Available for a Resident at Hydration Risk
Penalty
Summary
The facility failed to ensure hydration was readily available for Resident #25, a male with altered mental status, cognitive communication deficit, Parkinson's disease, dementia, depression, mood disorder, and a need for assistance with personal care. His care plan identified him as at nutritional/hydration risk related to a history of UTI, Parkinson's, COPD, FE anemia, GERD, CAD, HLD, dementia, antipsychotic therapy, and weight fluctuations, with interventions to encourage fluids at bedside, offer refreshments between meals, and observe for signs of fluid imbalance. Lab results dated 9/23/25 showed an elevated BUN of 30 and BUN/Creatinine ratio of 41. During observations, Resident #25 was repeatedly found without fluids within reach or without fluids being offered. He was seated at the nurse's station with no water on multiple occasions, was observed at one point with an open drink supplement that staff left on the table without offering assistance, and was later found in bed with water on a tray table positioned out of reach. On another observation, he had only a small amount of fluid in a cup, and later he was seated at the desk with no fluid to drink. On 12/17/25, his mouth was observed to be dry appearing, his tongue had a white coating, and his skin appeared very dry with poor skin turgor. The DON stated that if a resident could not express the need for fluids, staff were responsible for offering fluids at least every 2 hours and providing mouth swabs or mouth care when needed.
Missed Insulin Doses Due to Failure to Notify Provider
Penalty
Summary
The facility failed to ensure a resident received degludec insulin at the ordered dose when the medication was not administered for multiple consecutive days because it was unavailable in the medication cart and backup refrigerator. The resident was a male with diabetes, a diabetic foot ulcer, stage 4 and stage 3 pressure ulcers, osteomyelitis, sepsis, and paralysis from the chest down. His care plan identified a risk for hypo/hyperglycemia and directed staff to administer diabetic medications as ordered and observe for effectiveness and adverse side effects. Record review showed the resident did not receive degludec insulin on several days, with the MAR documenting the doses as not administered due to the medication being unavailable or pending delivery from the pharmacy. The record also showed the provider was not contacted or informed when the insulin was unavailable, and there was no provider direction or new order documented for the missed doses. Nursing staff stated they checked the cart and backup refrigerator, contacted the pharmacy, and waited for delivery, but did not contact the provider when the insulin was not available. Interviews with nursing staff and the DON confirmed that when a medication is not in the cart or backup supply, the nurse is expected to contact the provider and document the communication. The RN and LPN involved acknowledged they should have contacted the provider when the insulin was not available and that they did not do so. The DON confirmed the resident missed long-acting insulin doses over several days and noted the resident’s blood sugars were often in the 200s during that period, with one reading in the 300s.
Unsecured Medication Refrigerator in Medication Room
Penalty
Summary
The facility failed to properly store controlled substance medications in a secure manner in 1 of 2 medication rooms. On 12/17/25 at 8:29 am, the lock on the medication storage refrigerator in the west unit medication room was observed hanging on the latch and was not secured. RN DD was observed handling the lock, flipping it off the latch, and opening the refrigerator door without using a key to unlock it. RN DD reported that a controlled substance was stored in the refrigerator. RN DD then replaced the lock on the latch but did not lock it before exiting the medication room, leaving the refrigerator unlocked. RN DD later confirmed the refrigerator was unlocked and stated she returned to the medication room and locked it. RN DD and the DON both reported that refrigerators in the medication rooms were expected to always be locked.
Food Preferences Not Honored
Penalty
Summary
The facility failed to ensure resident food choices were obtained and honored for Resident #75, a male with diabetes, gout, kidney disease, chronic lymphedema of the right lower extremity, high blood pressure, deep vein thrombosis, stage 4 kidney disease, rheumatoid arthritis, and diuretic therapy in place. His care plan identified him as being at nutritional/hydration risk and included interventions to offer available substitutes if he had problems with served food, honor food preferences within acceptable dietary limits, and offer substitutes if he consumed less than 50% of a meal. Review of the lunch dining slip showed preferences to not receive pineapples, Mexican food, and sweet potatoes. During interview, the resident stated he had told dietary staff he did not like sweet potatoes, malt-o-meal, oatmeal, fish, pineapple, and waffles, but he was still receiving those items on his meal trays. He reported that fish was served every Friday and that he did not eat it, though he ate the rest of the meal. The Dietary Director stated he knew about some food concerns but did not have specific items to work with, had received only one concern form since starting at the facility, and had not received concerns from Resident Council or the monthly Food Committee meetings.
Inaccurate MDS Assessment Submission
Penalty
Summary
The facility failed to complete an accurate assessment for one resident reviewed for assessments, resulting in an inaccurate reflection of the resident’s status. Resident #75 was a male with diagnoses including diabetes, gout, stage 4 kidney disease, chronic lymphedema of the right lower extremity, high blood pressure, deep vein thrombosis, and rheumatoid arthritis. The resident had originally been admitted to the facility on 7/25/2024, which did not qualify him as a new admission to the facility, despite not appearing on the MDS data submitted by the facility before the survey start date. Review of the resident’s MDS assessments showed that he had discharged from the facility with the expectation to return on 10/31/25, and the assessment was rejected by CMS. In interview, the MDS Nurse reported receiving a validation report showing the rejection, stated the corporate MDS Nurse could submit a transfer file, and acknowledged that he had forgotten to follow up on why the assessment was rejected and correct it. He later determined the rejection was caused by the re-entry admission date retaining the original admission date and needing to be physically changed to the correct date. He also stated the resident had managed care insurance and that the 5 Day Entry assessment was considered a placeholder indicating the re-entry date, was not required by CMS, and was completed but not submitted.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety and prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including unspecified dementia, unspecified mood disorder, unsteadiness on feet, and required assistance with personal care, was severely cognitively impaired as indicated by a BIMS score of 3/15. Despite being identified as an elopement risk and having a care plan that included interventions such as alarms and monitoring, the resident was able to leave the facility premises unnoticed by staff. The resident was last seen by staff approximately 15 minutes before being found outside the facility, walking along a road without a sidewalk, by a staff member who happened to be driving by. Multiple staff interviews revealed that the resident had a known pattern of exit-seeking behaviors, including frequently checking doors, setting off alarms, and expressing a desire to leave the facility for cigarettes or to see white cars. Staff also reported that the resident's behaviors would escalate, but there was no documentation or consistent monitoring of these behaviors in the resident's medical record prior to the elopement event. Although the facility had a blanket behavior monitoring order for all residents, it was not individualized or specific to the resident's known behaviors. Communication about the resident's increased exit-seeking behaviors was primarily verbal and not consistently documented or shared with all staff. There was no evidence of behavior logs or specific interventions being implemented or documented in response to the resident's escalating behaviors prior to the incident, which contributed to the failure to prevent the elopement.
Failure to Individualize Care Plans for Residents at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with severe cognitive impairment and a history of exit-seeking behaviors. For one male resident with dementia and a BIMS score indicating severe cognitive impairment, the care plan included generic interventions such as door alarms, quarterly elopement assessments, and offering distractions. However, the care plan did not address the resident's specific behaviors, such as his fixation on white cars and cigarettes, or his pattern of looking out windows and attempting to exit the building. Multiple staff interviews confirmed that the resident routinely checked doors, set off alarms, and expressed a desire to leave the facility for cigarettes or to return home, but these behaviors were not specifically documented or communicated in his care plan. On one occasion, this resident was able to leave the facility unsupervised and was found walking alone along a road by a staff member, who then returned him to the facility. Staff interviews revealed that while staff were aware of the resident's exit-seeking tendencies and specific interests, such as white cars and cigarettes, this information was not consistently documented or included in the care plan. The Director of Nursing and other staff acknowledged that care plans were not individualized and that there was no system in place to monitor or document escalating behaviors that could lead to elopement. A second female resident with dementia and severe cognitive impairment was also identified as an elopement risk, with a history of looking for family and attempting to leave the facility. Her care plan similarly relied on template interventions and did not include specific, individualized strategies to address her behaviors. Staff interviews indicated a lack of awareness and monitoring for elopement risk, and the care plan was not customized to reflect the resident's unique needs or patterns of behavior. The facility's practice of using pre-selected, non-individualized care plan templates contributed to the failure to adequately address and manage the elopement risks for both residents.
Lack of Full-Time Dietitian or Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, the Dietary Supervisor (DS) revealed that the facility only has a dietitian who visits a couple of times a week. The DS, who has been in the role for about two years, is not yet a Certified Dietary Manager but is currently taking classes to become one. She mentioned that it has been challenging to fit the classes into her schedule, and she is seeking an extension to complete them. This deficiency increases the potential for food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents among all residents.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed during a kitchen tour. The kitchen was found to have multiple areas of concern, including a dishwasher area with spilled powdered detergent and discoloration from dripping water. The dish area had a leaking three-compartment sink with a container to catch leaks, and a bucket of liquid detergent covered with dirt and debris. The kitchen prep area had clean utensil drawers with crumbs and debris, cracked spatulas, and equipment with excess buildup and dried food debris. The walk-in cooler contained several items without labeling or dating, such as raw onion, butter, creamed corn, and various other food items. The dry storage area also had unlabeled and undated items, including dry cereal, quick oats, and various mixes. The facility's failure to properly label and date food items, as well as maintain cleanliness and organization in storage areas, poses a risk of foodborne illness among residents. Additionally, the facility's equipment and surfaces were not maintained in a clean and sanitary condition. The can opener, microwave, and ice machine area had significant dirt and debris accumulation. The dish machine area had a cross-connection that could contaminate the potable water supply, and the refrigeration unit in the Bunny Patch resident area was found to be at an unsafe temperature. These deficiencies indicate a lack of adherence to the 2017 FDA Food Code, which outlines necessary standards for food safety and equipment maintenance.
Deficiencies in Water Management and Infection Control Programs
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an interview, the Maintenance Director was unable to specify control measures beyond routine flushing of domestic fixtures and admitted to not conducting water testing due to waiting on a tester. Additionally, the water line in the family room was not being flushed. The Water Management Plan had not been reviewed with the administrator, and the facility's Water Pathogen Risk Reduction document lacked a date, indicating a lack of comprehensive implementation and documentation. The facility's infection control program was found to be ineffective, as the Infection Preventionist (IP) reported missing resident vaccinations and lacking a thorough tracking process. The IP was unable to confirm staff training on cleaning and disinfecting reusable medical equipment and environmental cleaning. The IP also failed to provide examples of infection control education for staff and could not explain how infection control audits were conducted or tracked. The facility's infection control policies and procedures were not regularly reviewed or updated, and there was no clear process for tracking employee illness or early detection of potential infectious residents. The IP's infection control log for September 2024 was incomplete, only tracking residents prescribed antibiotics, and lacked detailed information on symptoms, diagnosis, and monitoring. The IP relied on nursing staff for infection monitoring and did not ensure all staff received necessary education. The Director of Nursing (DON) reported that the IP was responsible for the infection control program, but the IP was still being assisted by the DON, indicating a lack of clear responsibility and oversight in the infection control program.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program, as well as to monitor the appropriate use of antibiotics for a resident. The deficiency was identified during a review of the records and an interview with the Infection Preventionist (IP) C, who was responsible for ensuring that Mcgeer's criteria were used when prescribing antibiotics. However, IP C admitted to missing the assessment of antibiotic use for a resident who had been on antibiotics in September 2024. Furthermore, IP C was unable to provide a list of residents on antibiotics or documentation regarding the indication, dosage, or duration of antibiotic use. Additionally, IP C did not follow up on the outcomes of residents prescribed antibiotics, relying instead on nursing staff documentation. There was no established process for providing feedback on antibiotic use, resistance patterns, or prescribing practices. IP C, being new to the position, was still receiving assistance from the Director of Nursing (DON) B, who reported not overseeing or monitoring the facility's antibiotic stewardship, leaving all responsibilities to IP C. This lack of oversight and documentation resulted in the potential for inappropriate antibiotic utilization and resistance.
Facility Fails to Maintain Cleanliness and Repair
Penalty
Summary
The facility failed to maintain cleanliness and repair in several areas, affecting both resident rooms and common utility spaces. Observations revealed dust and debris accumulation in resident rooms, with specific issues such as stained ceiling tiles indicating possible roof leaks. Shared bathrooms were found with dirt accumulations, and utility rooms had cabinets in disrepair, making them difficult to clean. Additionally, a janitor's closet had a leaking hot water valve and an unlabeled spray bottle, while the central supply room was missing a light shield. Residents were directly impacted by these deficiencies. For instance, two residents with chronic obstructive pulmonary disease were exposed to dusty fans blowing directly towards them, which were not cleaned regularly as per the facility's protocol. Another resident expressed concerns about the cleanliness of her shared bathroom, which was often found with feces on the floor and toilet, despite being cleaned by housekeeping. The resident resorted to cleaning the bathroom herself due to dissatisfaction with the facility's cleaning efforts. Further issues included damaged and dirty wheelchairs, with exposed foam on arm covers and dirt on the wheels and frames. Housekeeping and maintenance staff interviews revealed inconsistencies in cleaning schedules and a lack of awareness about certain deficiencies, such as missing window screens and cracked walls. These observations highlight a systemic issue in maintaining a clean and safe environment for residents, staff, and visitors.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, resulting in the inability to call for staff assistance. The resident, who was moderately cognitively impaired with a history of cerebrovascular accident and left-sided weakness, was observed multiple times with the call light out of reach. On one occasion, the call light was on the floor, and on another, it was under the bed, both times making it inaccessible to the resident. The resident reported using the call light to request help but sometimes could not find it. A Certified Nursing Assistant confirmed that the resident used the call light to ask for assistance. Despite the care plan specifying that the call light should be within reach, observations over several days showed that this was not consistently ensured, leading to potential unmet care needs.
Failure to Implement Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anticoagulant medication, Eliquis, for a history of deep vein thrombosis. The resident, a female with diagnoses of congestive heart failure and hypertension, did not have a care plan that addressed her anticoagulant therapy, which is crucial due to the potential side effects such as heavy bruising. The MDS Coordinator, responsible for creating care plans for high-risk medications, acknowledged the absence of a care plan for the resident's anticoagulant therapy during an interview and record review. The Director of Nursing also confirmed that care plans should be in place for high-risk medications to ensure staff are aware of and monitor potential side effects.
Failure to Implement Care Plan for Contracture Prevention
Penalty
Summary
The facility failed to implement care plan interventions to prevent the worsening of contractures for a resident with a diagnosis of muscle contracture. The resident was admitted with pertinent diagnoses, including contracture of muscles, and had been discharged from occupational therapy with specific recommendations for wearing a right hand T bar splint and a left upper extremity hand roll or gauze during the day as tolerated. These recommendations were documented in the resident's care plan, which specified the use of these assistive devices during morning care and their removal at lunch or as tolerated. Observations on multiple occasions revealed that the resident was not wearing the prescribed splints on the right hand, left hand, or elbow while sitting in a wheelchair in the dining room or lying in bed. Interviews with facility staff, including a Physical Therapy Assistant and a Certified Nursing Assistant, confirmed that the expectation was for the CNAs to place the splints on the resident during morning care. However, the CNA reported being unaware of the requirement for the resident to wear the splints during the day, indicating a lapse in communication or adherence to the care plan, leading to the potential for worsening of the resident's contractures.
Failure to Implement Safety Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and implement necessary safety interventions for a resident, identified as R15, who was at high risk for falls due to cognitive impairment and a history of falls. R15, who had dementia and was able to self-ambulate in a wheelchair, experienced a fall resulting in facial bruising and a laceration that required sutures. The fall occurred when R15 was self-ambulating near the chapel, an area with a ramp that posed a hazard, and there were no yellow caution signs or strips in place to warn of the descent, despite this being an intervention listed in the resident's care plan. The resident's care plan, which identified her as at risk for falls due to dementia, altered mental status, and limited mobility, included interventions such as keeping her in high traffic areas and applying yellow caution strips at the start of the ramp to the chapel. However, these interventions were not consistently implemented. Observations revealed that R15 was often left unattended in her wheelchair, both in the dining room and near the nursing station, where she attempted to self-ambulate, leading to her legs becoming tangled in the wheelchair's foot pedals. Interviews with staff and family members highlighted concerns about the lack of supervision and the failure to implement safety measures. Family members questioned why R15 was left unsupervised, and staff acknowledged that the resident was known to self-ambulate throughout the facility. The Director of Nursing admitted that the yellow caution strips were never applied, despite being part of the care plan, and the resident continued to be at risk for falls due to inadequate supervision and environmental hazards.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a required Gradual Dose Reduction (GDR) of antidepressant and antipsychotic medications for a resident, resulting in the potential that the resident was receiving the medication at an unnecessary dose or for an unnecessary length of time. The resident was admitted with diagnoses including unspecified mood affective disorder and was prescribed Olanzapine and Sertaline. The care plan indicated a need for dose reduction, but there was no documentation of any attempts for GDRs or justification for not attempting a GDR since October 2023. Interviews with the Director of Nursing (DON) and the Social Worker (SW) revealed a lack of awareness and documentation regarding the resident's GDR attempts. The DON could not report the last GDR attempt or any clinical indication for not attempting a GDR. The SW indicated reliance on a local mental health provider for managing the resident's psychotropic medications, but there was no evidence of collaboration or follow-up visits for nearly a year. The facility was unable to provide documentation justifying the absence of GDR attempts prior to the survey exit.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. A resident, who was cognitively intact and had a diagnosis of diabetes, reported receiving an incorrect dose of insulin. The error occurred when a new nurse, who was still in her orientation period, administered 32 units of short-acting insulin instead of the prescribed 2 units of short-acting and 30 units of long-acting insulin. This mistake was attributed to the nurse being nervous and in a rush, leading her to not verify the correct type of insulin before administration. As a result of the medication error, the resident experienced a significant drop in blood sugar levels, leading to symptoms such as fatigue, inability to keep her eyes open, and verbal non-responsiveness. The resident's blood sugar dropped to 54, prompting immediate intervention with carbohydrates and milk to stabilize her condition. The error also caused the resident to miss a dialysis appointment. The incident was reported by the physical therapist and investigated by the Director of Nursing, who confirmed the error and provided education to the nurse involved.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive pneumococcal vaccinations, specifically for one resident among those reviewed. Resident #22, who was admitted with chronic obstructive pulmonary disease, had a consent form signed by their guardian indicating a willingness to receive the pneumococcal vaccine, provided it had been more than three years since the last dose. The Michigan Care Improvement Registry showed that Resident #22 was due for a pneumococcal vaccine on 9/7/22, but this was not administered. During an interview, the Infection Preventionist (IP C) confirmed responsibility for screening and administering vaccines and acknowledged that Resident #22 was due for an updated pneumococcal vaccine. However, IP C could not explain why the vaccine had not been administered, attributing the oversight to the facility's vaccine program being behind schedule due to staff turnover and her recent assumption of the IP position in March 2024. This lapse resulted in the potential risk of acquiring or transmitting pneumococcal pneumonia.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered to a resident, leading to a deficiency in their vaccination protocol. Resident #51, who was admitted with chronic obstructive pulmonary disease, did not have any record of receiving a COVID-19 vaccination in their Electronic Health Record. Although a Vaccine Consent Form indicated that the resident had previously received a COVID-19 vaccination, it did not specify if additional doses were desired. During an interview, the Infection Preventionist (IP) admitted to not having offered the COVID-19 vaccine to Resident #51 and acknowledged a lapse in tracking and offering vaccinations to both residents and staff. The IP also reported that there was no systematic approach to ensure staff were screened, educated, and offered the vaccine annually, relying instead on posting signs during clinics without further follow-up.
Failure to Ensure Timely Care and Services
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth, sadness, and frustration. Resident #200, who was cognitively intact, reported waiting up to two hours for assistance with repositioning and an hour for help with changing and getting ready for bed. The Director of Nursing and Unit Manager were unaware of any staffing issues that could explain the delays, and the facility lacked a specific policy or timeframe for responding to call lights. Resident #201's family member reported that the resident often had to wait up to an hour for call lights to be answered and was frequently found lying in bed with food on him and in a soiled brief. The room was observed to be cluttered with various items. Resident #202, who was in extreme pain from terminal cancer, also experienced delays in receiving pain medication and toileting assistance, with staff appearing bothered when asked for help. Observations of the nurses' station revealed outdated and incomplete information on a dry erase board, further indicating a lack of attention to detail and resident care needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. Resident #201, who was moderately cognitively impaired and had a history of stroke, weakness, depression, anxiety, and dementia, reported being punched by a CNA. The incident was initially reported by a hospice worker who observed a bruise on the resident's right upper arm. The facility's Director of Nursing (DON) confirmed the presence of the bruise but did not document it with measurements or photographs. The resident admitted to using racial slurs towards the CNA, which led to the alleged physical altercation. Multiple staff members, including the CNA involved, reported that the resident had been combative during care, but other staff and family members noted that the resident was typically pleasant and non-combative. The facility's investigation included interviews with the resident, staff, and family members, but there were inconsistencies in the accounts of the resident's behavior and the events leading to the bruise. The facility's abuse prevention policy explicitly states that striking a combative resident is not an appropriate response, yet the investigation did not conclusively determine whether the CNA's actions constituted abuse. The care plan for the resident was updated after the incident to address his behavioral symptoms, including negative racial statements and combativeness during care. However, the facility's failure to adequately document and investigate the incident, as well as the conflicting reports from staff and the resident, indicate a deficiency in protecting the resident from potential abuse. The facility's policy on abuse prevention emphasizes the importance of professional behavior and the safety and well-being of residents, but the handling of this incident suggests a lapse in adherence to these standards. The deficiency highlights the need for more thorough documentation and consistent application of abuse prevention protocols to ensure resident safety. The facility's response to the incident, including the lack of immediate documentation and the delayed care plan update, underscores the importance of timely and accurate reporting in abuse investigations. The conflicting accounts from staff and the resident further complicate the investigation, making it difficult to determine the exact nature of the incident and whether the resident's rights were adequately protected. The facility's failure to protect the resident from potential abuse and the inconsistencies in the investigation process indicate a need for improved training and adherence to abuse prevention policies. The incident underscores the importance of maintaining a safe and respectful environment for all residents, particularly those with cognitive impairments and behavioral challenges. The facility must take steps to ensure that all staff are trained in appropriate responses to combative behavior and that incidents of potential abuse are thoroughly documented and investigated. The deficiency in this case highlights the need for ongoing monitoring and quality improvement efforts to protect residents from harm and uphold their rights to a safe and dignified living environment.
Failure to Implement Physician Orders and Document Controlled Medications
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not ensuring physician orders were in place for scheduled pain medications and not accurately documenting the administration of controlled medications for a resident with terminal cancer. The resident, who was in extreme pain, had a physician's order to change his narcotic pain medication from PRN (as needed) to a scheduled dose. However, this change was not implemented until days later, resulting in the resident receiving inadequate pain management during his stay at the facility. The resident's family member reported that the call light for pain medication often went unanswered, and the resident was eventually transferred to a hospital where he passed away shortly after. The Director of Nursing (DON) confirmed that new orders should go into effect immediately and acknowledged past issues with the physician responsible for the resident's care. Additionally, the controlled substance sign-out sheets revealed that the resident received multiple doses of pain medication that were not recorded in the Medication Administration Record (MAR), indicating a failure in proper documentation and potential drug diversion. Interviews with the facility staff, including the DON, Unit Manager (UM), and Assistant Director of Nursing (ADON), revealed confusion and lack of documentation regarding the resident's pain medication orders. The ADON could not recall why the medication order was changed days after the physician's visit, and the DON confirmed that the doses of pain medication administered were not recorded in the MAR. This lack of accurate documentation and timely implementation of physician orders led to the resident experiencing unmanaged pain and highlighted significant deficiencies in the facility's medication management and documentation practices.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain safe infection control practices for Resident #200, who was on Enhanced Barrier Precautions (EBP) due to chronic macerated wounds and a Foley catheter. During an observation, a CNA and an LPN were seen handling the resident's catheter bag and transferring the resident without wearing the required PPE, such as gowns and goggles. Additionally, the CNA did not perform hand hygiene after removing gloves, and there was no PPE cart in sight. The resident had multiple superficial open wounds on his thighs that were not adequately covered by dressings, and the staff continued to handle the resident and his equipment without changing gloves or donning additional PPE, even when the resident had a bowel movement and required assistance with a bedpan. Interviews with staff revealed a lack of awareness and adherence to the EBP requirements. One CNA was unaware of the reason for the EBP and noted that gowns were not available in the resident's room. The Director of Nursing confirmed that staff should wear gowns, gloves, and goggles when providing direct care to Resident #200, especially when managing his catheter bag. The failure to follow proper infection control protocols resulted in the potential for cross-contamination and the spread of multi-drug resistant bacteria.
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 48 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 South Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Douglas Cove | 17 mi | ★★★★★ | 2 | 0 |
| Ely Manor | 21.8 mi | ★★★★★ | 38 | 0 |
| Allegan County Medical Care Facility | 22.4 mi | ★★★★★ | 8 | 0 |
| Coventry House Inn | 25.7 mi | ★★★★★ | 14 | 0 |
| Royalton Manor, Llc | 25.9 mi | ★★★★★ | 5 | 0 |
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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 August 2026) and official state health department websites.