Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 The Lakeland Center during CMS and state inspections, most recent first.
The facility failed to provide enough CNA staffing to meet resident needs, and staff repeatedly reported that Unit 1 was often covered by only one aide instead of three. Residents described long waits for call lights, delayed toileting and incontinence care, missed showers, delayed repositioning, and being left in bed for hours because two staff were needed for lifts or transfers. One resident with ESRD and DM missed a dialysis appointment because there was no aide available to get her dressed and ready on time, and staff confirmed that nurses were often working as CNAs to cover shortages.
Surveyors found that nursing staff did not receive required annual skills competency evaluations, as five CNAs had competency dates showing lapses beyond the facility’s policy requirement for yearly re-validation. The staff development nurse, who also serves as the Infection Preventionist, confirmed that competencies were checked at hire but stated they were unaware that annual evaluations were required, despite a written policy mandating orientation, annual re-validation, and as-needed skills evaluations.
The facility’s QAPI program failed to identify multiple systemic issues found during survey. The Administrator stated that problems with housekeeping, CNA competency evaluations, the Compliance and Ethics program, staff using electronic signatures and signing residents’ names instead of legal guardians, and lack of risk/benefit education before immunization consent were not identified through QAPI, despite the QAPI plan listing areas such as Maintenance, Housekeeping, Medical Record Integrity, Nursing Services, and Call Light Response.
The facility failed to ensure the required QAA committee members attended meetings at least quarterly. Review of QAPI attendance records showed the ICP was absent from some meetings, the Administrator and ICP were absent from multiple meetings, and there were missing sign-in sheets for two months. The Administrator stated she may have forgotten to sign in and had no explanation for the ICP’s absence on several dates.
Incomplete Water Management Program for Legionella and OPPP Control: The facility did not have an active, ongoing WMP to reduce Legionella and other OPPP risk. The MD said the program was still being put together, with only two maintenance staff on the WMT, daily water temp checks, no flushing protocol, and no chlorine monitoring or other control measures. Tour observations found therapy tubs in shower rooms and hoppers with spray arms in soiled linen rooms, while record review showed a corrosion control/secondary treatment service was in place but not clearly understood by the NHA. The WMP binder lacked key site-specific elements, and the Legionella WMP document was generic, not facility-specific, and not shown to be annually reviewed.
Failure to maintain an effective Compliance and Ethics Program led to staff electronically signing residents’ names on binding arbitration and admission documents. Three residents with legal guardians and who were not able to make informed decisions had arbitration agreements and other consents signed in their names through the EMR, and the AD confirmed the residents did not actually sign the forms. The Administrator reported there was no compliance binder in the office or breakroom, no audits, and no staff education, despite the facility policy describing a formal compliance structure with a Compliance Officer, Compliance Liaison, committee, training, and documentation.
Surveyors identified widespread failures to maintain a clean, safe, and homelike environment, including shower beds with urine‑smelling liquid in soiled liners, dirty and deteriorated shower rooms, and resident rooms with debris, food crumbs, stains, and discarded linens on the floor. Hallways and common areas had strong urine and bowel movement odors, sticky and soiled flooring, heavily soiled and peeling wallpaper, and damaged handrails with exposed sharp edges. A housekeeping closet containing chemicals was found unlocked and unattended, and a shower bed had a broken pin for a rail that had not been reported. Multiple residents reported infrequent room cleaning, persistent unpleasant odors, and dissatisfaction with housekeeping, while facility policies required a clean, sanitary environment, prompt reporting of environmental concerns, and safe chemical storage.
The facility failed to provide and document adequate ADL care, including bathing, personal hygiene, and nail care, for several dependent residents. One resident reported missed bed baths and long waits for assistance, which was supported by gaps in CNA bath documentation. Another resident with severe cognitive impairment and hand contractures was observed in the same gown with foul body and hand odor and long, debris‑filled nails, with only one shower documented in the prior month. A resident with vascular dementia and hemiparesis had family complaints of delayed personal care, remaining in bed undressed, and strong urine odor from the bed, while records showed only one shower in 30 days despite care plan interventions. A cognitively intact resident dependent on staff for bathing reported sometimes receiving only a bed bath or no shower when staffing was low, and documentation showed only three showers in 30 days with no refusals. The DON stated CNAs were to document all bathing in the EMR, and the facility’s ADL policy required services to maintain grooming and personal hygiene.
The facility failed to maintain sufficient licensed nurses and CNAs to meet residents’ ADL needs, as evidenced by staffing patterns that did not match the facility assessment and policy, frequent call‑offs, and unfilled assignments. A resident reported going an entire shift without incontinence care and missing scheduled bed baths, while another missed therapy sessions because staff could not get them ready. A resident described a roommate repeatedly left in bed despite family requests, long waits over 30 minutes for assistance, missed showers, and a weekend when residents were not gotten out of bed and meals were served in rooms. Other residents and council participants reported only one CNA covering large areas, long call‑light response times, being left in bed until early afternoon or for entire weekends, and being forced to accept showers at non‑preferred times. A CNA confirmed that on a short‑staffed weekend, multiple call‑offs occurred, management did not assist, and tasks could not be completed.
Surveyors observed multiple medication administration errors resulting in a 19% error rate. One resident received incorrect doses of magnesium oxide and folic acid, had a gabapentin capsule crushed instead of opened, and did not receive an ordered dose of famotidine. Another resident was given a sennosides tablet instead of the ordered Senna-S combination product. Staff interviews and policy review confirmed that medications were not administered in accordance with the facility’s own medication administration standards and the rights of medication administration.
The facility failed to support resident self-determination and choice for two residents. One resident, who had previously used a wheelchair seatbelt and could unbuckle it independently, repeatedly requested a seatbelt on a new wheelchair but reported being told by staff that the State did not allow it, and the request was not acted upon. Another resident, with frequent hospitalizations, consistently refused OT services from a specific COTA, documented a concern requesting a different OT, and stated willingness to work with another therapist, yet continued to be offered only the same COTA while PT assessments proceeded. The Rehab Director acknowledged the refusals were due to dislike of the assigned COTA and indicated no alternative therapist was arranged, despite a facility policy requiring reasonable accommodation of individual needs and preferences, including adaptive devices and services.
A resident with quadriplegia and multiple comorbidities, using a specialized breath-activated call light, reported that staff were turning off the call light from the nursing station without entering the room or addressing their needs. A prior concern form documented the same allegation, and a nurse had admitted to deactivating the call light from the desk without checking on the resident. During the survey, the resident stated this practice was ongoing and described knowing the call light was turned off when the hallway bell stopped and no staff arrived, indicating a failure to respond appropriately to the resident’s requests for assistance.
The facility failed to accurately and completely report multiple abuse and neglect incidents to the State Agency. In one case, two residents with significant cognitive and physical impairments were involved in a dining room altercation where one resident allegedly grabbed another by the shirt, pulled her from a wheelchair to the floor, and continued swinging, causing reported pain to the victim’s arm and hip; however, the Facility Reported Incident minimized the event as unspecified "physical contact" and omitted these details. In another case, a quadriplegic resident using a breath‑activated call light alleged that staff were turning off the call light from the nurses’ station without responding, and a nurse admitted doing so, but this allegation of neglect was not reported to the State Agency as required by the facility’s abuse policy.
A resident with intact cognition and multiple behavioral and medical diagnoses reported being frightened when another resident entered her room wearing only a brief. In response, her care plan was updated to include a red Velcro stop sign on her door as a visual cue to discourage uninvited entry and to reinforce her rights to privacy and safety. During the survey, no stop sign was observed on her doorway on multiple occasions, despite the intervention remaining active in the care plan and the other resident’s room being directly across the hall. A CNA assigned to the resident reported never having seen such a sign for her, and the DON confirmed that the intervention should have been in place and that the facility had Velcro stop signs available, in contrast to facility policy requiring residents to receive the services and items in their care plans.
Surveyors found that one CNA did not receive the required 12 hours of annual in‑service education, with records showing only 7.75 hours completed. When surveyors requested training documentation for several CNAs, the staff development nurse, who also served as the IP, could only provide incomplete records for this CNA and could not explain why the deficiency had not been identified earlier. No additional documentation was produced, despite a facility policy assigning responsibility to staff development or HR to track in‑service education and to department managers to ensure timely completion.
Surveyors found that two CNAs did not receive the required annual 12 hours of in‑service education, specifically lacking mandated abuse prevention and dementia care training. Documentation showed one CNA had not had abuse and dementia education for an extended period, and another had no documented dementia care education. The Infection Preventionist/Staff Development nurse, responsible for tracking in‑service hours, could not account for these omissions and reported uncertainty about possible electronic record issues. Despite corporate oversight and a facility policy assigning responsibility for tracking and ensuring timely completion of in‑services, no additional documentation was produced to demonstrate that the required training had been completed.
A facility failed to ensure court-appointed guardians exercised decision-making for three residents with severely impaired cognition and inability to participate in interviews. Residents with diagnoses including tracheostomy/feeding tube dependence, parkinsonism, schizophrenia, dementia, aphasia, and hemiplegia had admission consents and binding arbitration agreements electronically signed and initialed by the residents instead of their legal guardians; the AD stated the EMR automatically entered the resident's name when no legal representative was selected.
Failure to Thoroughly Investigate Allegation of Mistreatment: A resident with quadriplegia and total ADL dependence reported that an aide improperly transferred them into an EZ stand, left them strapped in the standing position while changing a brief, and caused ongoing pain. The Administrator had no incident documentation, only an unrelated concern form, and the resident's allegation was not found in the medical record. Therapy notes referenced discomfort with standing transfers and the need for staff education, while a CNA denied involvement and the DON only vaguely recalled a hoyer incident.
Failure to complete required social services assessments for a resident with severe cognitive impairment and multiple complex diagnoses. The resident’s record showed the last social services assessment was completed on admission, with the last quarterly note documented later in the record, but the SW later confirmed the resident had not been assessed since 2022. The Administrator stated a quarterly assessment should have been completed, and only an admission assessment policy was available during survey.
Failure to document annual Influenza vaccine education and offering to two residents. One resident’s record showed a family refusal years earlier, but there was no documentation that the resident, who was their own responsible party, was educated or offered the vaccine since then. Another resident’s chart showed a refusal, but there was no documentation that the granddaughter/POA was educated or offered the vaccine. The facility also did not provide its Influenza and pneumococcal policies for review.
Two residents were observed to have non-functioning call light systems, as repeated attempts to activate the call bell did not result in the indicator light outside their doors turning on. An LPN confirmed the malfunction, and interviews with the nurse unit manager, DON, and administrator revealed they were either unaware of ongoing issues or believed previous problems had been resolved. No additional documentation or explanation was provided during the survey.
A resident with a history of stroke and limited mobility, identified as requiring two-person assistance for bed mobility, was turned in bed by a single aide despite warnings from the resident. This resulted in a fall, head injury, increased pain, and trauma. The aide, who was newly hired, did not follow proper positioning techniques, and the care plan was not clearly specified in the Kardex, leading to the deficiency.
A resident with quadriplegia who required a 20 French suprapubic catheter did not receive the correct catheter size because the facility ran out of supplies and failed to track inventory effectively. An 18 French catheter was used temporarily, but the correct size was not available for two days, leading to leakage, discomfort, and ultimately a UTI that required hospitalization. The care plan and physician orders lacked clear documentation of catheter size, and there were communication gaps between nursing, supply staff, and leadership, resulting in delayed intervention and inadequate care.
Multiple residents with high acuity needs experienced significant delays in care, such as waiting up to an hour for assistance with transfers, toileting, and water, due to insufficient CNA staffing. Staff and residents reported that care was frequently delayed, showers were missed, and basic needs were unmet, especially when units were staffed below the expected levels. Documentation confirmed that the facility was routinely understaffed for its census and acuity, and issues with linen availability further impacted timely care.
The facility failed to provide sufficient nursing staff, resulting in delayed care and services for residents. Observations and interviews revealed inadequate staffing, particularly during evening and night shifts, with residents reporting unanswered call bells and delays in receiving medication. Staffing data indicated low weekend staffing, and assignment sheets showed multiple shifts with insufficient staff. Residents expressed concerns about long waits for assistance, and the facility's reliance on census rather than acuity for scheduling contributed to the issue.
The facility's kitchen was found to be unsanitary, with improperly labeled and stored food items. Unsealed and undated packages of sausage patties, chicken breasts, and hot dogs with ice crystals were observed in the freezer. Additionally, pans were improperly stored with water inside them. The Dietary Manager acknowledged these issues, which contradict the facility's sanitation policy.
The facility failed to properly implement transmission-based precautions for several residents, leading to potential infection spread. Observations showed discrepancies in Enhanced Barrier Precautions (EBP) signage and orders, with some residents' rooms displaying EBP signs without corresponding clinical orders. A nurse was seen providing care without required PPE, and a resident was placed on contact precautions without documented orders. The facility's protocol for reviewing referrals and discharge records was not consistently followed, resulting in improper infection control measures.
A facility failed to update a resident's care plan to include non-pharmacological interventions for managing depression and insomnia. Despite a psychiatric evaluation recommending techniques like increased sunlight exposure and regular human contact, the care plan lacked these individualized interventions. The social worker acknowledged the omission and the need to revise the care plan.
The facility failed to meet professional standards in medication administration for two residents. One resident refused Miralax, but the nurse incorrectly documented it as given. Another resident reported late insulin administration, with records showing it was given much later than scheduled. Facility policy requires accurate documentation and timely administration, which were not followed.
A resident with diabetes experienced multiple instances of elevated blood glucose levels exceeding 400, yet the facility failed to consistently notify the physician or document additional insulin orders as required. Interviews with nursing staff revealed a lack of documentation and communication regarding these elevated levels, despite the facility's policy on change in condition notification.
A facility failed to ensure accurate physician documentation for a resident, leading to discrepancies in progress notes and an incorrect discharge summary. The resident, who expired in the facility, had missing documentation regarding a fall and an erroneous discharge note. The physician attributed the error to the electronic medical record system and their workload across multiple facilities.
A facility failed to implement individualized non-pharmacological interventions for a resident prescribed psychotropic medications for depression and insomnia. The resident's care plans and records lacked targeted behaviors and non-pharmacological strategies, and no gradual dose reductions were attempted. The social worker confirmed the absence of a care plan addressing these issues, leading to a deficiency finding.
The facility exceeded the acceptable medication error rate with two errors observed during medication administration. A nurse incorrectly measured Miralax using a liquid medication cup, leading to an inaccurate dose. Another nurse administered a lower dose of Vitamin D than prescribed, giving 400 IU instead of the required 1000 IU. These errors resulted in a 7.69% medication error rate.
A facility failed to properly store and manage medications, as a resident had a tube of hemorrhoid cream on their nightstand without a self-administration assessment. Additionally, a medication cart inspection revealed a loose pill, expired medications, and insulin pens not managed according to policy and manufacturer guidelines.
A resident in an LTC facility was involved in an altercation where they hit another resident. Despite the incident being reported to staff, the facility failed to notify the abuse coordinator and the State Agency as required. The aggressor had a history of severe cognitive impairment, and the victim required assistance with daily activities. The facility's policy mandates immediate reporting of such incidents, which was not adhered to in this case.
A facility failed to provide adequate supervision and implement elopement policies, resulting in a severely cognitively impaired resident being unsupervised and found miles away. The resident exited through an unlocked gate used as a main entrance due to repairs, with staff untrained in monitoring responsibilities. Another resident with wandering behaviors accessed a construction zone multiple times, with ineffective interventions and insufficient staff awareness.
Insufficient CNA Staffing Resulted in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, with multiple interviews, observations, and record reviews showing that Unit 1 was frequently staffed with only one CNA when three CNAs were expected. Facility staff, including an RN, CNA, NM, DON, and Administrator, acknowledged ongoing shortages, frequent call-offs, late arrivals, and difficulty filling the schedule. Staff reported that the facility did not use staffing agencies to cover vacancies and sometimes used a nurse to work as a CNA. Resident council minutes also documented concerns about long wait times for help and delays getting out of bed. Residents described direct effects of the staffing shortages. One resident reported being left in bed for hours because staff were unavailable to get them up in the morning and stated that two staff members were needed for a mechanical lift. The resident also reported waiting hours for incontinence care. Another resident, who was quadriplegic, reported waiting hours for call lights to be answered, remaining in a wheelchair all day because staff were unavailable to put them back to bed, and having a catheter bag full of urine for hours because no one was available to empty it. A third resident reported that staff shortages caused long waits to be dressed and transported for dialysis, missed showers, delayed repositioning, and delayed incontinence care. Record review and interviews also showed that one resident with end stage renal disease, dependence on renal dialysis, and diabetes missed a dialysis appointment because there was no aide available to get her dressed and ready on time. The dialysis center confirmed she did not arrive that day. Other staff stated that on some mornings there was only one CNA on the unit, that nurses had to work as CNAs, and that residents were often not gotten up at their preferred times. The facility staffing review documented that the facility was supposed to provide sufficient staff with the skills and competency necessary to meet resident care needs, but the evidence showed repeated understaffing and delayed care for multiple residents.
Failure to Complete Required Annual CNA Skills Competency Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff received required skills, competencies, and performance evaluations for five of five CNAs reviewed for education and training. Surveyors requested CNA skills competency documentation for five CNAs and found that the most recent evaluations were not consistently completed on an annual basis. Specifically, CNA Y’s most recent skills competency evaluation was dated 7/18/24, CNA Z’s was dated 8/8/24, CNA AA’s was dated 1/23/24, CNA BB’s was dated 11/2/22, and CNA CC’s was dated 6/27/24. These dates showed that at least one CNA had not had a skills competency evaluation for more than a year. During an interview, the Infection Preventionist/Staff Development nurse stated they had been in the staff development role since mid-October 2025 and described the process as reconciling that skills competencies were done upon hire. When asked about annual skills competency evaluations to determine areas needing improvement, the nurse reported they were not aware that annual evaluations were required. When asked about corporate oversight or support, the nurse stated that such oversight existed but could not provide further explanation. The facility’s own policy titled “Skills Evaluations,” dated 2/9/2024, states that skills evaluation checklists are to be completed during job-specific orientation, re-validated annually, and completed as needed, which was not followed for the CNAs reviewed.
QAPI Program Failed to Identify Multiple Systemic Issues
Penalty
Summary
The facility failed to maintain an effective QAPI program that identified multiple systemic issues needing improvement and correction. During an interview with the Administrator, it was confirmed that several issues found during survey were not identified through the facility’s QAPI process, including the facility’s environment/housekeeping, competency evaluations not being completed for CNAs, the absence of a Compliance and Ethics program that met regulatory requirements and facility policy, staff using electronic signatures and signing residents’ names instead of legal guardians, and the lack of risk/benefit education before obtaining consent for immunizations. A review of the facility’s QAPI Plan, dated 10/15/18, showed that the scope of QAPI included Maintenance, Housekeeping, Medical Record Integrity, Nursing Services, and Call Light Response, and that performance improvement opportunities were to be prioritized based on safety and prevalence, including high-risk, high-volume, or problem-prone areas. Despite these stated areas and priorities, the Administrator stated the cited issues were not identified through QAPI.
QAA Committee Lacked Required Members at Meetings
Penalty
Summary
The facility failed to ensure the required Quality Assessment and Assurance (QAA) committee members attended QAA meetings at least quarterly. A review of the facility’s QAPI policy showed the QA Committee was required to be interdisciplinary and include, at a minimum, the DON, the Medical Director or designee, at least three other staff members including at least one administrator or other leadership role, and the infection control and prevention (ICP) officer or designee. During an interview, the Administrator stated the QAA committee met monthly. Review of QAPI Committee attendance sign-in sheets from May 2025 through January 2026 showed the ICP did not attend the May 2025 meeting, the Administrator and ICP did not attend the June 2025 meeting, there were no sign-in sheets for July 2025 or August 2025, and the Administrator and ICP did not attend the September, October, or November 2025 meetings. The Administrator stated she may have forgotten to sign in and reported the facility did not have an ICP in May 2025, but had no explanation for the ICP’s absence on the other dates.
Incomplete Water Management Program for Legionella and OPPP Control
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 interview, the Maintenance Director stated that the Water Management Program was still being put together, identified only himself and one other maintenance staff member as the Water Management Team, and reported daily water temperature checks throughout the facility. He also stated there were no flushing protocols to prevent stagnant water, that hot water tanks were drained and refilled monthly, and that there was no monitoring of chlorine levels or other control measures at that time. During building tour, therapy tubs were observed in the Unit 2 and Unit 3 shower rooms, and the Housekeeping Director stated he had not seen them used. Soiled linen rooms on Units 1 through 4 had hoppers with spray arm attachments; three of the four hoppers worked when flushed, while the Unit 1 hopper had a sign indicating do not use and the water had been turned off because it did not flush. Record review showed monthly reports from 2023 through 2025 from a water treatment contractor indicating a corrosion control/secondary treatment service was in place, but the Nursing Home Administrator was not aware of a treatment system and believed the contractor was only providing testing. Later interview with the former Maintenance Director confirmed the corrosion control system had been in place since before 2021, and observation confirmed the treatment system was operating with sodium silicate injection into the cold water distribution piping. The Water Management Program binder also lacked several elements, including a text description of the water system, a comprehensive assessment of where Legionella and other opportunistic waterborne pathogens can grow and spread, measures based on nationally accepted standards, and documentation of visible inspections, disinfectant levels, or flushing protocols. The Legionella Water Management Program document in the binder was revised July 2017, did not contain the facility name or site-specific information, and did not show evidence of annual review and update.
Failure to Maintain an Effective Compliance and Ethics Program
Penalty
Summary
The facility failed to maintain and implement an effective and operational Compliance and Ethics Program. During record review and interviews, the facility’s policy described a compliance structure that included a Compliance Officer, a Compliance Committee, the Administrator as the onsite Compliance Liaison, regular staff education, audits, and a binder of compliance documentation in the Administrator’s office and breakroom. However, when the Administrator was interviewed, she reported that she did not have the binder in her office or the breakroom, did not conduct audits, and did not provide any education. Three residents, R3, R6, and R88, were reviewed in relation to binding arbitration and admission documents. Each of these residents had legal guardians and were deemed incompetent to make informed decisions for themselves. Their arbitration agreements were electronically signed with the residents’ names, and additional admission documents also contained electronic signatures in the residents’ names, including a Consent to Medical Care and Treatment form for R3 and financial and medical consents and documents for R6. The Admissions Director stated that when the signature section was clicked in the EMR, it automatically electronically signed the forms with the residents’ names, and confirmed that R3, R6, and R88 did not actually sign the forms themselves. The Administrator was unaware that residents with legal guardians who could not make their own decisions had their names electronically signed by staff on legally binding agreements and stated staff should never sign a resident’s name on any agreement or contract. The Corporate Compliance and Security Officer reported she was revising and updating compliance policies and that the Administrator would have additional information about facility-specific education, audits, and compliance documentation, but no additional documents were provided before the end of the survey.
Widespread Environmental and Housekeeping Failures Affecting Resident Living Areas and Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, comfortable, and homelike environment throughout multiple resident care areas, including shower rooms and resident rooms on several units. During a building tour, surveyors observed shower rooms with vinyl fabric liners under shower beds filled with cloudy liquid that smelled of urine; when tipped, the liquid drained through a liner drain hole with attached tubing. These liners were visibly soiled and stained brown, and the Director of Housekeeping & Laundry stated they were not laundered and that CNAs were responsible for cleaning them. In multiple shower rooms, floors were visibly soiled with buildup under and around therapy tubs, caulk at the floor/wall juncture was torn or missing and soiled with a black substance, and a lower plastic shelf under a shower bed was visibly soiled. The Director of Housekeeping acknowledged the need for re‑caulking and cleaning and reported that shower rooms were supposed to be cleaned daily with monthly deep cleaning, but the observed conditions did not reflect that schedule. Additional observations in resident rooms showed widespread uncleanliness and lack of routine housekeeping. One resident’s room had a floor littered with debris and numerous stains near the head of the bed and around the nightstand. Another resident’s room had dried purple streaks on the closet door and adjacent walls. A different room was cluttered, with a sticky floor scattered with debris that appeared not to have been mopped. A shared room had dirty floors with food crumbs, including scrambled eggs, and trash around both beds, and these conditions persisted on re‑observation the following day, when the bathroom was also found with two wheelchairs stored inside, a pink stain on the toilet seat, discolored toilet water with a film, and black stains in the bowl. In another room, the bed linens had been stripped and thrown on the floor under the window, and the floor at the foot of the bed had copious skin flakes and light brown sticky stains near the nightstand. One resident reported that housekeeping used to sweep and mop daily but recently only came about once a week, described the environment as not sanitary, and stated that unpleasant odors were frequent and sometimes prompted them to go to dialysis just to get away from the smell. Common areas and hallways also showed environmental deficiencies. Surveyors noted very strong urine and bowel movement odors throughout hallways on two units, including near a central shower room where no specific source was identified. Flooring outside and inside one resident’s room was covered with a clear, sticky substance that remained in place on subsequent observation, with a mechanical lift stored directly over it. The same room had a strong urine odor, heavily damaged walls with deep grooves, peeling floor molding with exposed debris, and scattered food debris and trash. Wallpaper throughout the hallways was heavily soiled with purple and brown splatters and peeling away from the walls. Handrails across from a housekeeping closet and near a main lounge had separated sections and missing end caps, exposing sharp metal and plastic edges; a resident was observed propelling their wheelchair by pulling along the exposed area. A housekeeping closet containing several cleaning chemicals was found open and unsecured with no housekeeping staff nearby, and a housekeeper acknowledged it should have been locked. The Maintenance Director confirmed the presence of sharp handrails, missing end caps, peeling wallpaper, and peeled floor molding, and identified a broken pin under a shower bed that should have secured a bed rail, stating it should have been reported and the bed should not have been available for use. The Director of Housekeeping, in place for about a month, reported staffing vacancies, stated that rooms were supposed to be cleaned daily using a checklist, acknowledged housekeeping concerns and the stained hallways, and confirmed that the housekeeping closet should remain locked. Review of the facility’s electronic reporting system from late September through early February showed no entries for the observed environmental issues, despite facility policies requiring a clean, sanitary, orderly environment, pleasant neutral scents, and safe chemical storage. The facility’s own policies on a homelike environment and chemical storage state that staff are to provide a clean, sanitary, and orderly environment with pleasant, neutral scents, and that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Staff are directed to report lingering odors, bathrooms needing cleaning, and unresolved environmental concerns to administration, and chemicals are to be stored safely. Despite these policies, surveyors documented persistent odors of urine and bowel movements, visible dirt and debris in resident rooms and hallways, stained and soiled surfaces, improperly maintained shower equipment, unsecured chemicals, and unreported maintenance issues such as damaged handrails, peeling wallpaper, and broken shower bed components. Residents interviewed reported decreased frequency of housekeeping services and dissatisfaction with cleanliness and odors in the facility, aligning with the environmental conditions observed during the survey.
Failure to Provide and Document Adequate ADL Hygiene and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate ADL care, including personal hygiene, bathing, and nail care, for multiple dependent residents. One resident reported that there were sometimes not enough aides on the unit and stated it took a long time to get assistance, resulting in missed scheduled bed baths and going about a week without a bed bath. Review of this resident’s CNA task documentation over a 30‑day period showed a bed bath on 1/21/26, with the next not until 1/28/26, and the last documented bed bath on 2/3/26. Another resident with severely impaired cognition, dependent on staff for all ADLs, was repeatedly observed in the same hospital gown with a persistent foul, sour body odor in the room. This resident’s fingernails were long, with debris under the nails, and the fingers were contracted into the palms. When the unit manager partially opened the contracted hand, a very strong foul, bitter, sour odor emanated from the palm, which the manager confirmed. The unit manager stated the resident was scheduled for a shower later that day and reported that about a month earlier the therapy department had worked with the resident to clean the palm of the hand. Review of this resident’s CNA bathing task documentation for the prior 30 days showed the last scheduled shower documented on 2/3/26. A third resident, with vascular dementia, hemiparesis, ROM impairment, and dependent for showers/baths and personal hygiene, had family concern forms documenting delays in personal care, including being left in bed undressed and in the same facility gown with a strong urine smell from the bed, suggesting unchanged linens. The ADL care plan called for assistance with scheduled and as‑needed bathing/showering via gurney with two‑person assist, but shower/bath documentation for the past 30 days showed only one shower, with no refusals documented. A fourth resident, cognitively intact and dependent on staff for toileting hygiene and bathing, reported preferring showers but stated that when there was not enough nursing staff they received a bed bath or no shower. Review of this resident’s record showed only three showers documented in the past 30 days, with no refusals, despite a care plan specifying assistance with ADLs and a preference for a specific shower chair. The DON stated that CNAs were instructed to document all showers/baths in the electronic medical record and that no additional shower forms were used. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Insufficient Nursing Staff Leading to Missed and Delayed ADL Care
Penalty
Summary
Surveyors identified a failure to provide sufficient nursing staff to meet residents' needs, particularly on the second floor, resulting in delayed or missed ADL care such as incontinence care, dressing, showers, and getting residents out of bed. The facility’s own facility assessment, last updated 1/15/26, outlined expected daily staffing levels for licensed nurses and CNAs on each unit, but review of assignment sheets, census, and time punch reports for specific dates showed multiple call‑offs and staffing that did not meet those levels. The DON acknowledged that Unit 1 should have three CNAs on day shift and that the staffing documentation confirmed this was not consistently achieved. The facility’s staffing policy stated that licensed nurses and nursing assistants would be available 24/7 and that staffing numbers would be based on resident needs and the facility assessment, but the actual staffing patterns did not align with these standards. Multiple residents reported that inadequate staffing led to missed or delayed care. One resident stated they had been left an entire shift without incontinence care, especially on night shift, and that they did not receive their scheduled bed baths. Another resident reported missing therapy sessions because there were not enough staff to get them ready, and therapy documentation showed at least one missed session due to the resident having a bowel movement and later dinner, and another session where the resident remained supine in bed in a gown, requesting in‑room therapy because they were not yet dressed. A resident reported that their roommate’s family repeatedly requested that the roommate be gotten out of bed, but staff left her in bed every day; the same resident described frequent situations with only one nurse and two aides for the hallway, long waits for assistance over 30 minutes, missed showers, and a recent weekend when residents were not gotten out of bed and meals were served in rooms. Additional interviews corroborated ongoing staffing shortages and their impact on care. On a morning when three CNAs were scheduled for Unit 1, one CNA was not present, and the nurse could not explain who was covering that CNA’s assignments; residents listed as “early get up” were still in bed, undressed, and in hospital gowns. Another resident reported that sometimes there was only one CNA for all of Unit 1 and part of Unit 2, resulting in long waits and a missed scheduled shower or bed bath the prior week. During a resident council meeting, several residents reported untimely call light response, being forced to accept showers at times chosen by CNAs rather than their preferred times, being left in bed until early afternoon or for entire weekends, and a night shift that “disappears” with call lights going unanswered for hours. A CNA reported multiple call‑offs on a recent Sunday, no management assistance that day, and an inability to complete all assigned tasks when working short. The DON and Administrator both acknowledged challenges with staffing and excessive call‑offs, and HR reported ongoing hiring efforts and instability in the scheduler position.
Medication Pass Errors Resulting in 19% Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 25 opportunities (19%) during a medication pass involving three residents. For one resident (R57), a nurse prepared and administered a set of morning medications, including magnesium oxide 400 mg, folic acid 400 mcg, and gabapentin 100 mg. The nurse crushed all medications, including the gabapentin capsule, and mixed them with applesauce before administration, then confirmed all medications due had been given. Subsequent reconciliation with the physician’s orders showed that the ordered dose of magnesium oxide was 440 mg, and the ordered dose of folic acid was 1 mg, not 400 mcg as administered. It was also discovered that an ordered dose of famotidine 20 mg for this resident was not prepared or administered at that time. For another resident (R92), a nurse prepared and administered medications that included a sennosides 8.6 mg tablet. When the administered medications were reconciled with the physician’s orders, it was found that the resident did not have an order for sennosides alone, but instead had an order for Senna-S, a combination product containing sennosides 8.6 mg and docusate sodium 50 mg. During an interview, the DON stated that gabapentin capsules should not be crushed but opened and the contents emptied, and that nurses are expected to follow the rights of medication administration (right resident, medication, dose, route, time). The facility’s medication administration policy, reviewed in 2/2026, requires safe and accurate preparation and administration of medications according to physician orders and professional standards, adherence to the rights of medication administration, and not crushing medications when contraindicated or without a physician’s order.
Failure to Honor Resident Choice for Wheelchair Seatbelt and OT Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor resident self-determination and support resident choice for two residents regarding adaptive equipment and therapy provider preferences. One resident reported that they previously used a wheelchair seatbelt at an outpatient day program, which provided a sense of security and safety. After discontinuing the day program and receiving a different wheelchair in the facility, the resident repeatedly requested a seatbelt but stated the facility refused to equip the new wheelchair with one. The resident reported being physically able to unbuckle the seatbelt independently and said staff told them they could not have a seatbelt because “the State doesn’t allow it,” which the resident believed was untrue. Surveyors interviewed the Rehab Director, who initially denied knowledge of the resident’s request for a seatbelt and indicated they would look into the request and perform an assessment. The Administrator was later informed that the resident had been told the State did not allow a seatbelt and acknowledged that this was an inappropriate response. The report notes that the facility’s own policy on Accommodation of Needs requires evaluation and reasonable accommodation of residents’ individual needs and preferences, including adaptive devices, upon admission and on an ongoing basis. The second resident expressed ongoing complaints about rehabilitation services, specifically regarding OT. This resident stated that after frequent hospital transfers, PT would assess them upon return, but they refused OT assessments because they did not want PT services and preferred OT services from someone other than the current COTA. The resident reported disliking the assigned COTA and refusing treatment from that individual, while being willing to work with another therapist. Documentation showed the resident had previously filed a concern form requesting a different OT, and progress notes recorded repeated refusals of OT evaluations, with the resident stating they would wait until a new therapist was hired. The Rehab Director confirmed the refusals were due to the resident’s dislike of the COTA and stated they did not think the contract company would send another COTA for one resident. The Administrator later stated they were not aware of the resident’s ongoing concerns but acknowledged they should have been informed and that something should have been done to accommodate the resident’s preferences.
Neglect Related to Call Light Response for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to neglect when a resident with quadriplegia reported that staff were turning off their call light from the nursing station without responding to their needs or requests. A facility Concern Form dated 8/4/25 documented that the resident alleged staff turned off the call light from the desk without completing the requested task. During the facility’s internal inquiry, a nurse admitted to turning off the resident’s call light from the nursing station without going to the room to determine why the call light had been activated. During the survey on 2/11/26, the resident was observed in bed using a specialized, breath-activated call light designed for individuals with limited or no motor skills. In an interview at that time, the resident stated that staff were still turning off the call light from the nursing station without coming to the room. The resident explained they could tell the call light was deactivated from the desk because the hallway bell would stop sounding and no one would enter the room. The resident also reported that, in the past, the Administrator had been present in the room, activated the call light, and witnessed staff deactivating it from the nursing station without checking on the resident. The resident’s clinical record showed diagnoses including quadriplegia, peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular dysfunction of the bladder, presence of a suprapubic catheter, and urinary tract infections. The facility’s abuse policy defined neglect as the failure of the facility or its employees to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Failure to Accurately Report Resident Abuse and Alleged Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely report a resident‑to‑resident physical abuse incident to the Abuse Coordinator and State Agency. The Facility Reported Incident submitted on 11/3/25 described only that physical contact was made by one resident toward another, that one‑on‑one supervision was initiated, and that an investigation began, but it did not document the type of physical contact. In contrast, the nursing progress note for the involved resident documented that a CNA reported one resident rolled up to another in the dining area, grabbed the resident by the collar, pulled her to the floor, and that the resident had pain in her right arm and hip. The internal investigation file further documented that the incident occurred in the dining room, that the resident fell from the wheelchair related to the incident, and that the aggressor approached from behind and made physical contact resulting in the fall. During interview, the CNA witness stated that the aggressor grabbed the other resident out of the chair by her shirt, would not let go, the resident fell to the floor, and the aggressor continued swinging with one arm until separated by staff. The Administrator, who served as Abuse Coordinator, acknowledged that the report to the State Agency should have contained more detail to explain what actually happened. The deficiency also includes the facility’s failure to report an allegation of neglect involving staff response to a resident’s call light. A Concern Form dated 8/4/25 documented that a resident alleged when the call light was pressed, staff turned off the call light from the desk without completing the requested task. The form recorded a verbal statement from a nurse during the Administrator’s investigation in which the nurse admitted to turning off the call light without addressing the resident’s issues. In a subsequent interview, the Administrator confirmed recalling the incident, identified the nurse who admitted to turning off the call light from the nursing station without checking on the resident, and stated that this allegation of neglect was not reported to the State Agency. The residents involved had significant medical and functional impairments. One resident in the abuse incident had diagnoses including lupus, anxiety disorder, major depressive disorder, auditory hallucinations, cerebral palsy, and legal blindness, with an MDS showing moderately impaired cognition. The other resident in that incident had a history of brain injury and epilepsy with severely impaired cognition. The resident alleging neglect of call light response had quadriplegia and used a specialized breath‑activated call light, with additional diagnoses including peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular bladder dysfunction, and a suprapubic catheter. This resident reported that staff were still turning off the call light from the nursing station, explaining that the hallway bell would stop sounding and no one would come to the room, indicating the light had been deactivated from the desk. The facility’s abuse policy required that all allegations of abuse and neglect be reported immediately to the Administrator and to the State Survey Agency within specified time frames, but the described events were not reported in accordance with that policy and regulatory expectations.
Failure to Implement Care-Planned Safety and Privacy Intervention After Resident-to-Resident Incident
Penalty
Summary
Surveyors found that the facility failed to implement a care-planned intervention for a resident who had requested enhanced safety and privacy measures after a resident-to-resident incident. A complaint reported to the State Agency documented that one resident entered another resident's room wearing only a brief and frightened the resident. The affected resident had diagnoses including generalized anxiety disorder, recurrent moderate major depressive disorder, adjustment disorder, osteochondrodysplasia with defects of growth of tubular bones and spine, short stature due to an unspecified endocrine disorder, and neuralgia and neuritis, and was assessed as having intact cognition. In response to the resident’s expressed desire for enhanced safety and privacy, the care plan initiated by a former MDS coordinator included placing a red stop sign on the resident’s door as a visual cue to discourage uninvited entry and reinforcing the resident’s rights to privacy and safety. During multiple observations on different days, surveyors noted that there was no Velcro stop sign placed within the resident’s doorway, despite the care plan intervention remaining active and not discontinued. Another resident involved in the prior incident was observed lying in bed in a room located directly across from the affected resident’s room. In an interview, the CNA assigned to the resident stated they had worked at the facility for a year and had never seen a Velcro stop sign for that resident. The DON, who began employment after the incident and after the care plan was initiated, confirmed that if the intervention was in the care plan it should have been in place, and acknowledged that Velcro stop signs were available in the facility. The facility’s policy on comprehensive care plans stated that each resident has the right to receive the services and items included in their plan of care.
Failure to Ensure Required Annual In‑Service Hours for a CNA
Penalty
Summary
The facility failed to ensure that one of five reviewed CNAs, identified as CNA AA, received the required 12 hours of annual in‑service training, as documentation showed only 7.75 hours of education completed for 2024. On the morning of 2/11/26, surveyors requested in‑service/education training hour records for five CNAs (Y, Z, AA, BB, and CC), and the records provided demonstrated the shortfall for CNA AA. During an interview later that day, the Infection Preventionist/Staff Development nurse (Nurse C), who had been in the staff development role since mid‑October 2025, stated they were responsible for reconciling education hours and suggested there might have been an electronic system issue, but confirmed that the documentation provided was all they could locate. Nurse C reported there was corporate oversight but could not explain why the facility had not identified CNA AA’s lack of required education/training, and no additional documentation was produced by survey exit. The facility’s own policy, “In‑Service Tracking” dated 2/4/2024, states that the Administrator will appoint a Staff Development Nurse or HR representative to track in‑service education and that department managers will assure timely completion of student in‑service education.
Failure to Provide Required Annual CNA In‑Service Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that required annual in‑service education, including abuse prevention and dementia care, was completed for two of five reviewed CNAs. Surveyors requested documentation of in‑service/education training hours for five CNAs, and the records showed that one CNA (AA) last received abuse and dementia care education nearly two years prior, and another CNA (CC) had no documented dementia care education at all. These gaps meant the CNAs did not meet the requirement for 12 hours of in‑service training within the required time period, specifically lacking the mandated topics of abuse prevention and dementia care. During an interview, the Infection Preventionist/Staff Development nurse stated they had been in the staff development role since mid‑October and were responsible for reconciling in‑service hours. They indicated uncertainty about whether the electronic system was malfunctioning and confirmed that the documentation provided to surveyors was all they were able to locate. The nurse reported there was corporate oversight but could not explain why the facility had not identified CNA AA’s lack of required education/training. No additional documentation was produced by survey exit. The facility’s own policy on In‑Service Tracking assigns responsibility to the Administrator’s designee (Staff Development Nurse or HR) for tracking in‑service education and to department managers for assuring timely completion, but the documented lapses showed this process did not ensure compliance for the CNAs involved.
Resident and guardian consent documents were signed by residents who lacked decision-making capacity
Penalty
Summary
The facility failed to ensure decision making was exercised by residents' court-appointed representatives for three residents reviewed for arbitration and admission documents. R3 had a tracheostomy and feeding tube, was unable to participate in an interview, and had diagnoses including epilepsy, respiratory failure, aphasia, and dysphagia. The record showed severely impaired cognition and dependence on staff for all activities of daily living. Although R3 had a court-appointed legal guardian who made decisions because the resident was incapable of making their own decisions, the Consent to Medical Care and Treatment form was electronically signed by R3 rather than the guardian, and the Arbitration Agreement was also electronically signed and initialed by R3 on 9/16/25. There was no evidence the legal guardian was provided these documents. R6 was observed lying in bed, awake and alert, but unable to have a sensical conversation and unable to be interviewed. R6's record showed diagnoses including secondary parkinsonism, paranoid schizophrenia, dysphagia, epilepsy, and bipolar disorder, along with severely impaired cognition on MDS assessment. The resident also had a court-appointed legal guardian due to incapacity. The Arbitration Agreement for R6 was electronically signed and initialed by R6 rather than the legal guardian on 10/31/25, and the form was then signed by Admissions Director A. R88 was observed lying in bed and was unable to be interviewed. The record showed diagnoses including dementia, diabetes, hypertension, aphasia, and hemiplegia, with severely impaired cognition on MDS assessment. R88 also had a court-appointed legal guardian who made decisions for the resident due to incapacity. The admission packet showed all consent and admission documents, including financial consent and medical consents, were signed by R88 rather than the guardian on 10/22/25, and the Arbitration Agreement was signed and initialed by R88 instead of the guardian. During interview, Admissions Director A stated that if a resident had a legal guardian, the documents would be discussed with them and they would be responsible to sign, but also stated the electronic record automatically entered the resident's name and E-signed it when there was no legal representative and there was no option to opt out.
Failure to Thoroughly Investigate Allegation of Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate an allegation of mistreatment involving a resident who was admitted with diagnoses including quadriplegia and required staff assistance for all ADLs. The resident reported that in May 2025 an aide entered the room, stated they were going to get the resident up, and then transferred the resident into a sit-to-stand machine while the resident was trying to explain the proper transfer method. The resident stated the aide left them strapped in the standing position while changing the resident's brief, and that the position caused pain the resident still experienced from the incident. The resident stated they called the police about the incident and were denied the opportunity to file charges, and that the Administrator told them the matter would be handled internally. When the Administrator was asked for grievances and Incident and Accident reports for the resident from May 2025 to the present, only one concern form was produced and it was not related to the allegation the resident described. The medical record contained no documentation that the incident had been identified or occurred. Therapy documentation from the resident's occupational therapy discharge summary noted concerns about discomfort and limited ability to optimize standing with use of some slings and various staff members, and stated direct care staff needed education related to use of the EZ stand and the resident's specific needs. The Therapy Director could not recall the names of the staff involved. The Administrator denied knowledge of the incident and later stated there was no documentation to provide. A CNA identified by the resident denied being involved and said they had been told they were suspended because the resident called police, but the schedule showed that CNA was not assigned to the resident that weekend. The former DON remembered a hoyer incident involving the resident but only vaguely recalled the details.
Failure to Complete Required Social Services Assessments
Penalty
Summary
The facility failed to adequately assess one resident for medically related social services to ensure appropriate services were provided. The resident was admitted with diagnoses including right-sided hemiplegia, motor vehicle accident injury, hypothyroidism, aphasia, dysphagia, epilepsy, brain injury, depression, and anxiety, and an MDS assessment indicated severely impaired cognition. The resident’s annual and quarterly Social Services Assessments showed the last assessment was completed on the admission date, and the last quarterly social services progress note was documented in 2023. During interview, the Social Services Director stated that full social services assessments were completed on admission, readmission, with a change in condition, and quarterly, but after reviewing the record acknowledged the resident had not been assessed since 2022. The Administrator also stated there should have been a quarterly assessment, and only an admission assessment policy was provided by the end of the survey.
Failure to Document Influenza Vaccine Education and Offerings
Penalty
Summary
The facility failed to ensure documentation that residents or their responsible parties were educated about and offered the Influenza vaccine annually. For one resident, the medical record and immunization profile showed the family refused the Influenza vaccine on 10/01/2021, and this was the only documentation on the profile. The record also identified the resident as their own responsible party, but there was no documentation that the resident had been educated or offered the Influenza vaccine since 2021. For another resident, the immunization profile documented a refusal of the Influenza vaccine on 12/23/25. The medical record identified the granddaughter as the resident’s responsible party and power of attorney for care, but there was no documentation that the granddaughter had been provided education or given the option to have the resident vaccinated. The facility administration did not provide the requested Influenza and Pneumococcal policies and procedures for review, and the Infection Preventionist stated the facility reviews immunization reports for new admissions and offers vaccines annually to residents, while also indicating they would look into the two residents’ records and the education provided.
Non-Functioning Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that the resident call light system was fully operable and functioning for two of three residents observed during an onsite investigation. During the survey, a call bell function test was conducted in the presence of an LPN, where the call light indicator outside a resident's door did not activate despite multiple attempts. The LPN confirmed that the call bell/light was not working. A similar observation was made with another resident, who also pressed their call bell several times without the indicator light activating outside their door, even after repeated attempts. Interviews with facility staff revealed that the nurse unit manager stated staff are alerted to call lights by beeping at the nurse's station or by the lights outside residents' doors, but denied being informed of any issues with the system. The DON acknowledged awareness of a previous issue with the call light system in July, which was believed to have been resolved the same day, and denied knowledge of any ongoing problems. The administrator also stated they were previously unaware of concerns with the call light system. No further explanation or documentation regarding the call light system's operability was provided by the end of the survey.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, limited range of motion, and classified as a two-person assist for bed mobility was not provided the required level of assistance during care. Despite the resident's explicit warning to the aide that they were a fall risk and required two staff for turning, only one aide proceeded to turn the resident in bed. This resulted in the resident falling from the bed, hitting their head, and experiencing significant pain and trauma. The resident was subsequently sent to the hospital for evaluation and treatment. The resident's care plan and Kardex indicated a need for two-person assistance for bed mobility, but this was not followed at the time of the incident. The aide involved was newly hired and, according to facility records, had received bed mobility training during orientation. However, the aide did not use proper positioning techniques and rolled the resident away from themselves, leading to the fall. The incident report and facility investigation confirmed that improper positioning and failure to follow the two-person assist requirement directly contributed to the resident's fall and injury. Following the fall, the resident experienced increased pain, anxiety, and a decline in participation in daily activities. The resident reported ongoing pain, fear of being moved, and a reluctance to engage with staff. Medical records documented increased requests for pain medication and new orders for scheduled pain management. The facility's review of the incident identified that the Kardex allowed aides to choose the level of assistance, which should have been specified by therapy, contributing to the confusion and subsequent failure to provide adequate supervision and assistance.
Failure to Provide Proper Catheter Care Due to Supply and Communication Issues
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, who required a 20 French suprapubic catheter per physician order, was not provided with the correct catheter size due to the facility running out of supplies. Instead, an 18 French catheter was used as a temporary measure following a physician's order, with instructions to replace it with the correct size the next day. However, the 20 French catheter was not available for two days, and the resident continued with the smaller catheter, which led to leakage and discomfort. The facility's supply management process was found to be inadequate, as the staff responsible for ordering supplies did not track inventory systematically and relied on visual checks and staff notifications, resulting in the unavailability of the required catheter size. The resident's care plan and physician orders did not consistently specify the required catheter size, and there was a lack of clear documentation regarding the catheter size in use. Communication gaps were identified between nursing staff, central supply, and facility leadership, which contributed to the delay in obtaining the correct catheter. Additionally, there was confusion regarding the responsibility for ordering and tracking supplies, and the central supply clerk did not maintain a log or tracking system for inventory needs. The Director of Nursing (DON) and Nurse Practitioner (NP) were not promptly notified or did not conduct timely in-person assessments, and there was no documentation of a physician or NP visit during the critical period when the catheter issue occurred. As a result of the delay in providing the correct catheter size and the lack of timely intervention, the resident developed a urinary tract infection (UTI) and required hospitalization. The hospital records indicated that the suprapubic catheter tract closed, necessitating the placement of a urethral catheter and antibiotic treatment. The resident expressed dissatisfaction with the care received, noting that they were not kept informed about the availability of the correct catheter and did not see a physician during the incident. The facility's policies and procedures did not adequately address catheter sizing or supply management, contributing to the deficiency.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the care needs of residents, as evidenced by multiple observations, interviews, and record reviews. Staff and residents reported that there were often not enough CNAs on duty, particularly on units with higher acuity residents who required full care and mechanical lifts for transfers. Staff described being unable to meet residents' needs in a timely manner, with some residents waiting up to an hour for assistance with basic care such as being put to bed after dialysis, toileting, or receiving water. The issue was compounded by inconsistent staffing, frequent staff turnover, and management staff assuming additional duties due to vacancies. Residents directly affected by the staffing shortages included individuals with significant medical needs, such as heart failure, renal failure, stroke, and paralysis, who were dependent on staff for bed mobility, transfers, and toileting. These residents reported feeling neglected, frustrated, and angry due to long wait times for care, missed showers, and delays in receiving water. Some residents also noted that their personal belongings, such as clothing, were not attended to for several days, and that their families were unable to reach staff to address concerns. Staff confirmed that care was often delayed, especially when only two aides were present on units where three were needed to meet the acuity and volume of care required. Documentation and staff postings revealed that the facility was routinely staffed below the expected number of CNAs for the census and acuity of residents. On several reviewed dates, there were only six or seven CNAs present on the day shift, despite a census of over 85 residents and a facility assessment indicating a need for more staff. Additionally, issues with linen availability further delayed care, as aides sometimes hid linens in resident rooms or sent clean linens to laundry, making them less accessible. Management acknowledged the staffing concerns and the impact on resident care, but the deficiency persisted at the time of the survey.
Inadequate Staffing Leads to Delayed Care and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in complaints of delayed care and services. Observations and interviews revealed that staffing levels were inadequate, particularly during evening and night shifts. A resident reported that one nurse was responsible for two units, leading to unanswered call bells and delays in receiving pain medication and care. Staff members also confirmed that the facility was short-staffed, especially on weekends, affecting the timeliness of care provided to residents. The facility's staffing data from the PBJ system indicated low weekend staffing for the second quarter of 2024. Review of assignment sheets and call-in records showed multiple shifts with low staffing, including instances where units were left without a nurse. The facility's census on a specific date documented 66 residents, with several requiring extensive assistance, yet staffing was insufficient to meet their needs. Interviews with staff highlighted the reliance on census rather than resident acuity for scheduling, which contributed to the staffing issues. During a group meeting, residents expressed concerns about staffing levels, reporting long waits for assistance and medication due to short staffing. The facility's Staffing Coordinator and DON acknowledged the issue, noting that staffing was based on census rather than acuity. They also provided a list of current open positions, indicating a significant number of vacancies for both nurses and CNAs, further exacerbating the staffing challenges.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure that potentially hazardous food items were properly labeled and stored. During a kitchen tour, surveyors observed unsealed and undated packages of sausage patties, chicken breasts, and hot dogs in the reach-in freezer, all with ice crystals accumulated on them. When questioned, the Dietary Manager acknowledged that these meats would need to be discarded. Additionally, pans were found stored on dry racks with water puddled inside them, and the Dietary Manager confirmed that pans should not be stacked until they are dry. A review of the facility's policy on kitchen sanitation, dated February 2023, indicated that food service employees are expected to practice good sanitation in accordance with state and US Food Codes to minimize the risk of cross-contamination and illness spread through food.
Inadequate Implementation of Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to transmission-based precautions (TBP) for five residents, resulting in the potential for the spread of infection. Observations revealed discrepancies in the implementation of Enhanced Barrier Precautions (EBP) for residents. For instance, a resident's room continued to display EBP signage despite the removal of an indwelling urinary catheter, which was the initial reason for the precautions. Another resident's room had EBP signage without any corresponding order in their clinical record. Additionally, a nurse was observed providing care to a resident on EBP without wearing the required isolation gown. Further issues were identified with a resident who was placed on contact precautions without any documented order or indication for such precautions. The resident's room lacked adequate personal protective equipment (PPE), and the assigned nurse was unable to find documentation supporting the need for contact precautions. The facility's Director of Nursing acknowledged these discrepancies and indicated that the facility's protocol for reviewing referrals and hospital discharge records was not consistently followed, leading to improper implementation of infection control measures.
Failure to Revise Care Plan for Non-Pharmacological Interventions
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as R42, to include non-pharmacological interventions for managing depression and insomnia. R42 was admitted with diagnoses including major depressive disorder and required assistance with most activities of daily living. A psychiatric evaluation noted the continuation of medications such as trazodone for sleep and Wellbutrin for depression, alongside recommendations for non-pharmaceutical techniques like increasing sunlight exposure and regular human contact. However, the care plan did not reflect these non-pharmacological interventions. Upon review, it was found that the care plans for R42 did not address the resident's depression or insomnia with individualized, person-centered non-pharmacological interventions. The social worker acknowledged the absence of a care plan for these conditions and indicated the need to add such interventions. This oversight highlights a deficiency in ensuring that the care plan was comprehensive and updated to reflect the resident's needs and the psychiatric provider's recommendations.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medication administration met professional standards for two residents. For one resident, a nurse prepared multiple medications, including Miralax, but the resident refused the Miralax. Despite this, the nurse signed the medication administration record (MAR) as if the Miralax had been given. The facility's policy requires that any refusal of medication be documented as such on the MAR, which was not followed in this instance. For another resident, there was a concern about the late administration of insulin. The resident reported that a newer nurse administered their insulin late, causing anxiety about missing the dose. The medical record showed that the insulin was administered at 4:45 AM, which was significantly later than the resident's usual schedule. The nurse involved claimed they were busy with another resident and signed the MAR late, but maintained that the insulin was given on time. The facility's policy requires medications to be administered according to the physician's schedule, with a one-hour window before or after the scheduled time, which was not adhered to in this case.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to consistently follow physician's orders for notifying abnormal blood glucose levels and obtaining additional treatment orders for a resident with diabetes. The resident reported that their blood glucose levels were as high as 400 and 500, which is significantly above the recommended levels. The physician's orders required the nurse to contact the physician if a blood glucose level over 400 was obtained. However, a review of the resident's blood glucose levels revealed multiple instances where levels exceeded 400, yet there was no documented evidence that the physician or nurse practitioner was notified, nor were there any additional insulin orders documented or administered. Interviews with nursing staff revealed inconsistencies in communication and documentation practices. Some nurses claimed to have notified the physician, but there was no documentation to support these claims. The Nurse Practitioner stated they were aware of the elevated blood sugars and had been changing insulin orders, but there was no record of additional insulin coverage being ordered or given. The Director of Nursing acknowledged that staff were likely notifying the physician but failing to document these interactions, which is contrary to the facility's policy on change in condition notification.
Deficiency in Physician Documentation for Resident Care
Penalty
Summary
The facility failed to ensure that the physician's notes were accurately entered into the resident's record at each visit, specifically for one resident. The resident, who was admitted to the facility and later expired there, had several progress notes entered by the facility physician, Dr. 'J', with discrepancies in the timing and content of the documentation. Notably, there was a lack of documentation regarding a fall that required the resident to be transferred to the emergency department, and a discharge summary was inaccurately completed more than 30 days after the resident's death, indicating a discharge home with home health care, which was incorrect. Interviews with Dr. 'J' revealed that they typically documented progress notes within 30 days of a visit but preferred to do so on the same day. Dr. 'J' acknowledged the mistake in the discharge summary, attributing it to the high volume of facilities they visit and an error in the electronic medical record system that allowed such documentation. The facility's administrator was aware of the issue and indicated they would investigate further. The facility's policy requires physicians to evaluate the resident's condition and document a progress note during required visits, which was not adhered to in this case.
Lack of Individualized Non-Pharmacological Interventions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure individualized and person-centered non-pharmacological interventions were in place for a resident who was prescribed psychotropic medications. The resident, who was admitted with a diagnosis of major depressive disorder-recurrent, was receiving Wellbutrin and Trazodone for depression and insomnia, respectively. However, the medical record review revealed that there were no targeted personalized behaviors identified for the resident's insomnia or depression. Additionally, the care plans, physician orders, and medication administration records did not include any individualized non-pharmacological interventions aimed at reducing the use of these psychotropic medications. Furthermore, the facility did not attempt any gradual dose reductions of the resident's Trazodone or bupropion since their admission. The social worker confirmed that there was no plan of care addressing the use of the medications, individualized non-pharmacological interventions, or reduction of the medications. This lack of action and planning led to the deficiency identified during the survey.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors observed during a medication administration observation involving four residents. The first error involved a nurse incorrectly measuring a dose of Miralax for a resident by using a medication cup intended for liquids, rather than the bottle cap designed to measure the correct 17 grams of powder. This resulted in an inaccurate dosage being administered to the resident. The second error occurred when a registered nurse administered an incorrect dose of Vitamin D to another resident. The nurse dispensed a 10 mcg tablet, equivalent to 400 IU, instead of the prescribed 1000 IU as documented in the resident's Medication Administration Record. The discrepancy was acknowledged by the nurse, who indicated they would follow up according to the facility's protocol. Both errors contributed to a medication error rate of 7.69%, exceeding the acceptable threshold.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications, as evidenced by several observations and record reviews. A resident was found with a tube of hemorrhoid cream on their nightstand, which was not stored in a locked compartment as required by facility policy. The resident indicated that they were unable to apply the cream themselves, and there was no assessment in their medical record for self-administration of the medication. This indicates a lapse in adherence to the facility's policy on medication storage and administration. Additionally, during an inspection of a medication cart, a loose pill was found and disposed of without verification of its identity. The cart also contained expired medications, including a bottle of fish oil and loratadine, which were not disposed of according to the facility's policy. Furthermore, an insulin pen was found in use beyond the recommended 28-day period, and another insulin pen lacked an open date, contravening both the facility's policy and the manufacturer's guidelines. These findings highlight deficiencies in medication management and storage practices within the facility.
Failure to Report Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse was immediately reported to the abuse coordinator and the State Agency for three residents involved in an incident. On July 1, 2024, a concern was submitted to the State Agency alleging that one resident, R902, hit another resident, R903. During an observation and conversation, R901, another resident, confirmed witnessing the incident and reported it to the facility staff. Despite this, the facility did not report the incident to the State Agency as required. R903, who was involved in the altercation, was observed in a wheelchair and confirmed being hit by R902 on the side of the face and arm. R903 reported the incident to their nurse, but the facility's records did not show that the abuse coordinator or the State Agency was notified. R903's medical records indicated a history of dementia and adjustment disorder with anxiety, and they required assistance with most activities of daily living. The progress notes documented the altercation, but there was no evidence of immediate reporting to the necessary authorities. R902, who was identified as the aggressor, had a history of Huntington's disease, dementia, and bipolar disorder, with severely impaired cognition. The progress notes for R902 detailed the incident and the subsequent actions taken by the staff, including administering medication and maintaining one-on-one supervision. However, the Incident and Accident report did not indicate that the abuse coordinator was notified, and a review of the State of Michigan Facility Reported Incidents system showed no report for the incident. The facility's policy required immediate reporting of such incidents, which was not followed in this case.
Inadequate Supervision and Elopement Policy Implementation
Penalty
Summary
The facility failed to provide adequate supervision and implement elopement policies for a severely cognitively impaired resident, resulting in the resident being let out of a secured door to the patio by an unknown staff member. The resident was unsupervised and found approximately 36 hours later, about five miles away from the facility. The incident began when the resident exited the facility through an unlocked gate on the patio, which was being used as the main entrance due to repairs. The staff responsible for monitoring the patio area, including a housekeeper temporarily covering for the receptionist, were not adequately trained or informed of their responsibilities, leading to a lack of supervision. The facility's failure to maintain a log of residents entering and exiting the patio area and the absence of a doorbell or buzzer contributed to the resident's unsupervised departure. Interviews with staff revealed that the resident was not accounted for during shift changes, and assumptions were made about the resident's whereabouts without verification. The facility's elopement policy was not effectively implemented, as staff did not report the resident's absence promptly, and there was a lack of communication and coordination among staff members regarding the resident's status. Additionally, the facility failed to adequately supervise and implement effective interventions for another resident with a history of wandering behaviors. This resident used the elevator multiple times to leave the unit and enter a construction zone on the first floor, which was off-limits to residents. Despite having a wander alert bracelet, the resident was able to access the first floor without triggering alarms, and staff were not consistently aware of the resident's movements. The care plan for this resident did not include updated interventions to address the wandering behavior, and staff reported challenges in providing constant supervision due to staffing limitations.
Removal Plan
- Resident was missing in the facility, and after initiating the procedure for a missing resident and searching the facility, the resident could not be located. The receptionist who was responsible for supervising the resident while on the patio alone was immediately suspended, pending investigation. The resident has been returned to the facility, evaluated, and deemed stable with no negative outcomes.
- Residents who reside in the facility who are at risk for elopement have the potential to be affected. A facility-wide audit was conducted and residents in the facility had an elopement assessment completed to establish elopement risk, and wander guards were applied to residents as appropriate, with physician orders and care plans updated.
- Facility doors were checked by the Maintenance Department.
- The facility process changed and residents must be attended to on the patio by staff or family.
- The facility gate has been locked and will be observed by 1:1 staff member until a door camera is installed. The gate will remain locked at all times.
- Education was initiated for the facility staff by the Director of Nursing, Assistant Director of Nursing, and designee. Staff are educated on elopement policy, procedures for a missing resident, that residents are not allowed on the patio without being attended by staff or family, and that nurses are to complete a head count of their assignment at the start of their shift. Additionally, Nurse Aides and Nurses received an in-service to visualize residents throughout the shift to ensure residents are safe and accounted for. In the event that a resident cannot be located, a staff member will notify the nurse supervisor, administrator, or director of nursing of the possibility that a resident is missing. The supervisor will coordinate and document the search efforts. Any staff member and/or contracted staff who has not been educated will be educated before working their next shift.
- Patio gate will remain locked and secured.
- Director of Nursing, or designee, will audit 5x weekly to ensure that residents are not on the patio without being attended by staff or family, and that nurses are completing a head count of their assignment at the start of their shift, to ensure that all residents are in the facility and accounted for.
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 1,218 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Southfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lahser Hills Care Centre | 1.5 mi | ★★★★★ | 0 | 0 |
| Evergreen Health And Rehabilitation Center | 3 mi | ★★★★★ | 18 | 0 |
| Beaconshire Nursing Centre | 3.6 mi | ★★★★★ | 4 | 0 |
| The Manor Of Farmington Hills | 3.7 mi | ★★★★★ | 14 | 0 |
| Corewell Health Rehab & Nursing Center-commons Far | 3.9 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Lakeland Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.