Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Coldwater during CMS and state inspections, most recent first.
A resident with chronic inflammatory demyelinating polyneuritis and bradycardia, who was bedbound but cognitively intact, discovered through her medical record that a restorative nursing program for ankle ROM and bed mobility had been ordered but was rarely provided. She filed a written grievance describing that the restorative therapy, important to her physical health, had not been started as ordered and identified multiple staff who were aware of the issue. The facility could not locate its copy of the grievance, did not have it in recent grievance files, and did not maintain a grievance log, despite a policy requiring timely investigation and tracking of concerns such as missing therapy services. Task logs confirmed that the ordered restorative interventions were documented only a few times over a month, with many entries marked "Not Applicable" or "Resident Refused," and the resident reported receiving the service only a handful of times, with no documented follow-up to her grievance.
Two residents who smoked did not have their smoking care managed according to comprehensive, individualized care plans and the facility’s smoking policy. One resident with severe cognitive impairment and multiple medical conditions was on the smoking list but had no smoking evaluation or smoking care plan, and reported keeping cigarettes and a lighter on her person rather than in staff-controlled storage or designated lockers. Another cognitively intact resident with paraplegia had a smoking evaluation and a care plan stating staff would maintain all smoking paraphernalia, and had signed a policy prohibiting cigarettes and lighters in rooms or on the person except at designated times, yet he reported and was observed keeping his cigarettes and lighter in a fanny pack in his room and on his lap, using them independently without returning them to staff. Staff interviews, including with an LPN and the DON, confirmed that residents generally did not use the lockboxes and instead kept smoking materials in their rooms, and that smoking assessments and care plans were inconsistently developed and not implemented as written.
Two residents did not receive restorative nursing services as ordered to maintain or improve ROM and functional abilities. One resident with chronic inflammatory demyelinating polyneuritis and bradycardia had active orders and an evaluation for passive bilateral ankle ROM and bed mobility to sitting at the edge of the bed, but task logs over a month showed the services were rarely provided, frequently marked as Not Applicable, and often recorded as refused despite the resident reporting only one refusal and stating staff said no one was available to run the program; the resident filed a grievance that the facility could not produce. Another resident with malignant neuroleptic syndrome and catatonic schizophrenia had an order for daily 15‑minute hand‑over‑hand grooming ADLs, yet documentation over a month showed multiple days with no entries, many days where the 15‑minute goal was not met, and numerous Not Applicable entries. The ADON, who oversaw the restorative program and assigned CNAs to complete and document it, confirmed that the documentation reflected that restorative nursing was not being provided as ordered and stated that refusals should be documented in progress notes and that Not Applicable was not an appropriate entry.
A resident with osteomyelitis and multiple stage 4 pressure ulcers of the sacrum, ischium, and hip, who was on hospice and had detailed wound care orders in place, did not have documented routine examinations of these wounds by a licensed medical provider. Wound assessments showed stalled and improving wounds with undermining and tunneling, and an LPN reported that hospice directed treatments focused on comfort and infection control. However, review of progress notes over many months, along with a physician note and a hospice NP face-to-face encounter, showed references to decubitus and non-healing stage 4 ulcers but no documentation that the pressure ulcers were actually examined by a provider, resulting in the cited deficiency.
The facility did not update or revise care plans for multiple residents after incidents of aggression, including altercations between roommates and physical aggression towards a spouse. Despite documented behavioral changes and staff awareness, care plans were not modified to address new risks or interventions, and staff could not provide reasons for these omissions.
A resident with PTSD, anxiety, and a history of physical abuse, who was cognitively intact, was subjected to verbal abuse by a CNA after overhearing staff discuss her care and being accused of faking incontinence. When the resident requested a grievance form and the CNA's name, the CNA refused and responded with profane language, causing emotional distress. The incident was corroborated by another resident and confirmed through staff interviews and facility records.
A resident with severe cognitive impairment and limited upper body control was physically restrained in a wheelchair using a sheet tied by staff, including a CNA and an LPN, to prevent falls. Staff interviews confirmed the restraint was applied for about 15 minutes, and the resident was unable to remove it independently.
Poor Physical Plant Maintenance and Cleaning: Surveyors observed widespread damage and soiling throughout common areas and resident rooms, including worn flooring with exposed sub-surface, loose faucets, damaged countertops, corroded and misaligned doors, damaged drywall, loose commode supports, and heavily soiled privacy curtains. One carpenter ant was seen in a resident room, and the facility’s work order review showed no specific entries for the cited maintenance concerns.
Multiple cognitively intact residents reported that meals were consistently unappetizing, cold, or otherwise unpalatable, with some stating they had to supplement with outside food. Surveyors confirmed through direct observation and temperature checks that food was often served outside safe and appetizing temperature ranges, and palatability tests found meals to be bland and unappealing. Facility policies for meal quality and temperature monitoring were not effectively followed, leading to widespread dissatisfaction among residents.
A resident with a signed DNR order was incorrectly listed as full code on the face sheet of the medical record. The discrepancy occurred after the resident returned from the hospital, and staff acknowledged the code status was not updated as required.
Two residents receiving antipsychotic medications were not appropriately monitored for orthostatic hypotension, despite physician orders requiring such monitoring. Review of medical records showed no documentation of orthostatic blood pressure readings for either resident, and the DON confirmed that this monitoring and documentation was expected.
A resident with multiple health conditions and at risk for pressure injuries had a physician's order for protective boots to be worn while in bed, but this intervention was not added to the care plan or the CNA Kardex during the care plan's revision. The DON confirmed the omission despite the existing order.
A resident with multiple chronic conditions did not have a pharmacy medication regimen review recommendation properly followed up. The pharmacy recommended discontinuing loratadine-D due to hypertension, but there was no documented physician response or required signatures, and the DON reported not receiving the recommendation in time to act.
A medication cart was left unattended and unlocked in a hallway with several residents present. An LPN had left the area to use the restroom and forgot to secure the cart, which contained drugs and biologicals. The cart remained unlocked until the LPN returned and was notified of the oversight. Facility policy requires medication carts to be locked when not in use, and the DON confirmed this was not standard practice.
A facility failed to immediately report abuse allegations involving a resident with severe cognitive impairment. An LPN shouted at the resident during an incident, which was witnessed by two CNAs. The incident was not reported to the NHA or State Agency in a timely manner, violating the facility's abuse prohibition policy. The delay in reporting was not addressed through re-education or disciplinary action for the CNAs involved.
The facility failed to maintain clean kitchen equipment, leading to potential foodborne illness risks for residents. Observations revealed fruit flies, sticky floors, soiled sinks, and improperly stored food trays. Dietary staff confirmed inadequate cleaning practices, and pest control services were called due to the infestation. The 2017 FDA Food Code requirements for cleanliness and pest control were not met.
The facility failed to maintain a clean and homelike environment, with several resident rooms and common areas found in unsanitary conditions. A resident's room had a strong odor, stained mattress, and flies, while other areas had peeling paint, loose handrails, and pest issues. Residents were observed in unclean conditions, with dirty wheelchairs and long, unkempt facial hair. Housekeeping staff acknowledged the issues, and the housekeeping manager admitted to not having a documented deep cleaning schedule.
A resident with severe cognitive impairment was found with a bruise of unknown origin near the left eye. The bruise was reported by the resident's family to the DON, but no incident report or investigation was conducted. The Nurse Manager did not complete an incident report, and the DON acknowledged the oversight. The NHA was unaware of the incident until later and confirmed it should have been reported as an allegation of abuse.
A resident with severe cognitive impairment was found with a bruise of unknown origin, which was not investigated or reported as an allegation of abuse by the LTC facility. The DON and Nurse Manager failed to complete an incident report or conduct a thorough investigation, and the Nursing Home Administrator was unaware of the incident until later informed.
A resident with hearing impairments experienced unmet needs due to the facility's failure to implement an effective care plan. Despite having hearing aids, the resident struggled to hear staff, and staff were unaware of the aids' existence. An audiology consult recommended ear drops and irrigation for impacted cerumen, but no physician orders were found, and no cerumen removal was documented.
The facility failed to update care plans for two residents, leading to deficiencies in care management. One resident's care plan did not reflect a dialysis graft in her left arm, causing confusion among staff about her dialysis access. Another resident's care plan was outdated, missing recent diagnoses of pneumonia and rib fractures. Interviews with staff revealed that care plans should have been updated to reflect these changes, but they were not.
Two residents in an LTC facility did not receive adequate hygiene and grooming care. One resident with hemiplegia and reduced mobility was found with unkempt facial hair and dirty fingernails, unsure of the last time he received care. Another resident with major depressive disorder and multiple sclerosis had long facial hair coated in food and a soiled shirt. Both residents' rooms were infested with flies and gnats. Facility records showed refusals of showers without proper documentation or follow-up, and standard grooming care was not consistently provided.
The facility failed to follow physician orders and provide necessary interventions for three residents. A resident with constipation did not receive appropriate interventions despite having a bowel program in place. Another resident with hearing loss was not provided with functioning hearing aids, and no action was taken for impacted cerumen. A third resident did not receive prescribed testosterone injections, with no documentation or physician notification of missed doses.
Failure to Follow Up on Resident Grievance Regarding Restorative Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow up on and process a resident grievance regarding ordered restorative therapy services. An alert and oriented resident, with a Brief Interview for Mental Status (BIMS) score of 14/15, reported that a friend had reviewed her electronic medical record and identified an order for a restorative therapy program intended to start on January 1, 2026. The resident stated she had only received the restorative service a total of five times since that date and had been told by staff that there was no one available to run the program. In response, the resident completed a written grievance on 3/25/2026, specifying that restorative therapy ordered in late December 2025 had not been initiated as expected and explaining that this was important to her physical health. The resident’s grievance form, photographed and provided by the resident, documented her concern about not receiving restorative therapy, identified multiple staff and a PA who were aware of the issue, and suggested using CNAs to provide the therapy and then float to assist elsewhere. The facility was unable to locate or provide its own copy of this grievance prior to survey exit, and the grievance was not found among the paper copies of grievances for the prior three months. The Environmental Manager, who oversees grievances, confirmed that the resident’s grievance was not in the available grievance files and reported that she did not maintain a grievance log, though she believed the policy required resolution within 5–7 days. Record review showed the resident had diagnoses including chronic inflammatory demyelinating polyneuritis and bradycardia, and required substantial/maximal assistance for bed mobility and was dependent for lower body dressing. A restorative evaluation dated 12/24/2025 identified functional deficits in bilateral ankle ROM and repositioning from supine to sitting at the edge of the bed, and a physician order directed participation in a nursing restorative program with daily passive ROM of both ankles and/or positional changes from supine to sitting for 15 minutes per 24 hours, with documentation. Task logs for the 30‑day look‑back period showed the passive ROM program was documented only six times, with numerous entries marked “Not Applicable” and some “Resident Refused,” and the bed mobility program was documented only three times, also with many “Not Applicable” and “Resident Refused” entries. The facility’s compliance policy required concerns such as services not provided by a vendor (including therapy) to be reported to the Facility Compliance Officer and investigated within five working days, and for all concerns to be tracked in the electronic system and summarized monthly for QAPI, but the resident’s substantiated concern about not receiving restorative therapy was not followed up through this process.
Failure to Develop and Implement Comprehensive Smoking Care Plans and Controls for Smoking Paraphernalia
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans addressing residents’ smoking status and management of smoking paraphernalia, as required by regulation and by the facility’s own smoking policy. For one resident with severe cognitive impairment and multiple medical diagnoses, including COPD, heart failure, dementia, cellulitis, difficulty walking, and anxiety, the record showed she was on the facility’s smoking list but had no smoking evaluation completed on admission and no smoking problem or interventions on her care plan. During interview, this resident stated she kept her cigarettes and lighter with her, either in her purse or on her person, and that staff did not store these items in the medication cart, medication room, or smoking-area lockers. Staff interviews confirmed that the facility was not following its stated process for managing smoking materials. An LPN reported that residents were supposed to use lockers in the smoking area for their smoking devices but acknowledged that residents did not use them and that staff did not keep extra smoking devices in the medication room. The DON stated he did not know who developed smoking care plans, was unaware that residents had smoking devices on them, and acknowledged that the resident in question was on the smoking list. The DON further explained that smoking assessments were done variably, often only when residents changed their minds about smoking after admission, indicating an inconsistent approach to assessment and care planning for smokers. For another resident with paraplegia who was cognitively intact, the record contained a smoking evaluation indicating the resident was a safe smoker who could smoke independently and a care plan stating that staff would maintain all smoking paraphernalia for both safe and unsafe smokers. The facility’s written smoking policy, which this resident had signed, specified that residents were not permitted to have cigarettes or lighters in their rooms or on their person except at designated smoking times, and that all smoking paraphernalia would be turned in to staff when smoking was finished. However, this resident reported keeping cigarettes and a lighter in a fanny pack in his room and on his lap, did not lock up or return smoking materials to staff, and was observed self-propelling to the smoking area with his fanny pack and smoking outside. An LPN and the DON both acknowledged that, contrary to policy and care plan interventions, residents generally kept their smoking paraphernalia in their rooms and did not use the lockboxes, demonstrating a failure to implement the care-planned and policy-required controls over smoking materials.
Failure to Provide Ordered Restorative Nursing Services for ROM and Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as ordered to maintain or improve range of motion (ROM) and mobility for two residents. For one resident with chronic inflammatory demyelinating polyneuritis and bradycardia, the clinical record showed an active physician order for a restorative program including passive ROM of both ankles and progression to positional changes from supine to sitting at the edge of the bed for 15 minutes per 24 hours, with daily documentation. A restorative initial evaluation identified functional deficits in independent bilateral ankle ROM and repositioning from supine to upright sitting, and stated that the restorative program would prevent decline or possibly improve the resident’s abilities. However, task logs over a 30‑day look‑back period showed that passive ROM was documented as provided only 6 times, with 49 entries marked Not Applicable and 8 as Resident Refused, and bed mobility was documented as provided only 3 times, with 53 Not Applicable entries and 9 Resident Refused. During observation and interview, this resident was found lying in bed and reported that a friend had reviewed her electronic medical record and identified a restorative therapy order intended to start on January 1. The resident stated she had only received the service about five times since that date and had been told by staff that there was no one available to run the program. She reported filing a grievance about not receiving restorative therapy as ordered and stated she had not received any follow‑up. She also reported only one refusal of restorative therapy, on a day when she had a urinary tract infection and felt too dizzy to safely sit at the edge of the bed, and she adamantly denied any other refusals. The resident provided a photo of the grievance form, which documented her concern that restorative therapy ordered to start on January 1 had still not occurred and identified that she had discussed the issue with nurses, CNAs, a PA, and physical therapy. The facility was unable to locate or provide a copy of this grievance prior to survey exit. For a second resident with malignant neuroleptic syndrome and catatonic schizophrenia, the MDS showed severely impaired cognition and dependence for personal hygiene. This resident had an active physician order to participate in a nursing restorative program for 15 minutes daily, seven days a week, to assist staff with performing hand‑over‑hand grooming ADLs such as hair brushing/combing, teeth brushing, and face washing. Review of the task log for a 30‑day look‑back period showed seven days with no documentation of the service being provided or refused, 19 days when the 15‑minute goal was not met, and 47 entries marked Not Applicable. In an interview, the ADON, who was overseeing the restorative program after the prior restorative nurse quit, confirmed that CNAs were responsible for completing and documenting restorative therapy each shift, acknowledged that the documentation showed the first resident was not regularly receiving restorative nursing as ordered, and stated that refusals should be reported to the nurse and documented in a progress note and that there was no circumstance where Not Applicable would be appropriate for restorative documentation. The facility’s restorative nursing policy required daily documentation of minutes and initials by nursing assistants on days the program is delivered.
Failure to Ensure Provider Examination of Stage 4 Pressure Ulcers for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed medical provider routinely examined a resident’s stage 4 pressure ulcers, despite the resident being under hospice care and having multiple complex wounds. The resident was admitted and later readmitted with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, and stage 4 pressure ulcers of the sacral region, right buttock, and left buttock. The resident’s MDS showed moderate cognitive impairment and four stage 4 pressure ulcers, two of which were present on admission or reentry. Wound assessments dated 3/11/26 documented stage 4 pressure ulcers on the left and right ischium, sacrum, and left rear hip, with some wounds described as stalled and others improving, and with undermining and tunneling present. Physician orders were in place for specific wound care treatments, including cleansing, packing, and application of Dakins-moistened gauze and foam dressings. During the survey, the wound care LPN reported that the resident was receiving hospice services and that hospice directed the wound treatments, focusing on comfort and infection control rather than healing. However, review of the resident’s progress notes from 5/1/25 through 3/12/26 did not show documentation that a provider had examined the resident’s stage 4 pressure ulcers during that period. When the surveyor requested the most recent date a provider evaluated the wounds, the facility produced a physician progress note from 6/26/25 and a hospice NP face-to-face encounter note from 2/28/26. Both documents referenced the presence of decubitus ulcers and non-healing stage 4 pressure ulcers, but neither documented an actual examination of the pressure ulcers. This lack of documented provider examination of the resident’s stage 4 pressure ulcers led to the cited deficiency.
Failure to Update Care Plans Following Resident Aggression
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four out of eleven residents following incidents of aggression or behavioral changes. For one resident with a history of psychosis, insomnia, and major depressive disorder, an altercation with a roommate involving threats and aggressive behavior was documented. Despite this incident, the resident's care plan was not updated to address the new aggression, and no new interventions were added. The last care plan revision occurred months prior to the incident, and no additional care plan addressing aggression towards other residents was found in the electronic medical record. Two other residents were involved in a physical altercation after a disagreement over a room light. Both residents engaged in shoving and striking each other, and one was subsequently moved to another room. However, neither resident's care plan was updated to reflect the aggressive behavior or to include interventions to prevent further incidents. The care plans for both residents had not been revised since before the incident, and no new interventions addressing aggression were documented. Another resident was observed pushing his wife, also a resident, in her wheelchair and using physical force while shouting at her. The incident included yelling, grabbing, and striking, resulting in the wife being moved to another room. Despite this, there was no care plan created or updated to address the resident's aggression or the change in living arrangements. Interviews with facility staff confirmed that care plans should have been updated following these incidents, but the updates were not completed, and staff could not explain why the care plans were missed.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. A resident with diagnoses including PTSD, anxiety, and a history of physical abuse, and who was cognitively intact, overheard two CNAs discussing her care, with one CNA alleging the resident was faking her incontinence. The resident requested a grievance form and asked one of the CNAs for her name, which the CNA refused to provide. The CNA then used profane and abusive language towards the resident, raising her voice and swearing at her. The incident caused the resident emotional distress, and another resident corroborated the account of verbal abuse. Multiple interviews confirmed that the CNA used inappropriate language and refused to provide her name when requested by the resident. The incident was witnessed by another resident and reported by staff, with documentation in the facility's incident and investigation report. The CNA involved had recently completed training on abuse prevention, but still engaged in verbally abusive behavior towards the resident, violating the resident's right to be free from abuse.
Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
Staff failed to ensure that a resident was free from the use of a physical restraint. The resident, who had severe cognitive impairment and multiple medical diagnoses including alcohol-induced persisting dementia, pathological fractures, and anxiety disorder, was observed to have limited upper body control and had experienced multiple falls. On the night in question, staff observed the resident slumped over in a wheelchair, unable to maintain an upright position. In response, a CNA suggested and, with the agreement of an LPN, wrapped a sheet around the resident and tied it to the wheelchair handles to prevent the resident from falling. Another CNA witnessed the resident being tied to the wheelchair and confirmed that the resident could not get out of the restraint, which was in place for approximately 15 minutes. Staff interviews revealed that the decision to use the sheet as a restraint was made out of concern for the resident's safety, despite awareness that such an action constituted the use of a physical restraint and was not in compliance with regulations. The LPN acknowledged that restraints were not permitted but allowed the use of the sheet to prevent a fall. The resident was later returned to bed and remained there until a subsequent fall was discovered. The incident was later confirmed by the facility's administrator during an investigation.
Poor Physical Plant Maintenance and Cleaning
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant for 130 residents. During a common area environmental tour with the Environmental Services Director, multiple areas were observed with damaged, worn, or soiled surfaces, including etched and scored vinyl flooring tiles with exposed concrete, a loose hand sink faucet assembly, an air gap at a courtyard entrance threshold, missing Formica countertop edges, corroded door frames and slabs, and a hallway double-door assembly that did not completely close without manual assistance. The Environmental Services Director stated she would contact maintenance for repairs as soon as possible for several of these concerns. During the tour of sampled resident rooms, numerous rooms were observed with damaged drywall surfaces adjacent to beds and headboards, stained or particulate-covered commode base caulking, and loose-to-mount commode supports in several restrooms. In room 104, the privacy curtain between Bed A and Bed B was soiled with accumulated and encrusted food debris. In room 106, the privacy curtain was heavily soiled with accumulated and encrusted food residue, the flooring was soiled with accumulated and encrusted dust, dirt, and food debris, and one carpenter ant was observed foraging between the beds. Additional rooms had similar drywall damage and restroom fixture issues, including commode supports that could be moved side-to-side several inches. Record review showed the facility’s Housekeeping Services policy required daily cleaning of non-carpeted floors and other horizontal surfaces in resident care areas, and more frequently if spillage or visible soiling occurred. Review of the Direct Supply TELS work orders for the prior 60 days revealed no specific entries related to the maintenance concerns identified during the survey. The Environmental Services Director stated the facility used the TELS system for work orders.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of palatable, attractive, and appropriately tempered food and drink to residents. Multiple residents, all cognitively intact per their BIMS scores, reported that meals were consistently unappetizing, cold, or otherwise unpalatable. Observations included residents eating cold cereal, reporting never having received a hot meal or cold milk, and describing the food as 'nasty,' 'horrible,' or 'terrible.' Several residents stated they had to supplement with food from outside the facility due to dissatisfaction with the meals provided. Residents also reported that complaints about food temperature and quality had been made to staff without resolution. Direct observations and palatability tests conducted by surveyors confirmed the residents' reports. Lunch trays sampled during the survey were found to be lukewarm, bland, and lacking in flavor. Specific items such as breaded chicken patties, mashed potatoes, and spinach were described as bland, flavorless, and unappetizing. Food product temperatures were measured and found to be outside the safe and appetizing range, with hot foods served below the required 135°F and cold foods above the required 41°F, as per the 2022 FDA Model Food Code. For example, chef salads and milk were served at temperatures above 41°F, and hot dogs were served below 135°F. Review of facility policies revealed that the facility had established procedures to ensure a pleasant dining experience and proper food temperatures, including periodic test trays and monitoring by nutrition professionals. However, the observations, interviews, and temperature records indicated that these policies were not being effectively implemented, resulting in widespread dissatisfaction and potential nutritional decline among residents who rely on facility-provided meals.
Failure to Accurately Update Advance Directive Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive status was accurately reflected in all parts of the medical record. One resident, who was cognitively intact and had multiple diagnoses including respiratory failure, dementia, lung cancer, and COPD, had a Do Not Resuscitate (DNR) order signed and witnessed in the electronic medical record. However, the resident's face sheet, also known as the banner, incorrectly listed the resident as full code rather than DNR. This discrepancy was identified during a record review and interview, where a social service worker acknowledged that the code status had not been updated following the resident's recent return from the hospital.
Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring for two residents who were receiving psychotropic medications. For one resident with vascular dementia and hypotension due to drugs, there was an active physician order for Seroquel, an antipsychotic, with instructions to monitor for side effects including orthostatic hypotension. However, there was no physician order for orthostatic blood pressure readings, and a review of the electronic medical record showed that no orthostatic blood pressures had been documented. The Director of Nursing confirmed that the expectation was to monitor and document orthostatic blood pressures. Another resident with diagnoses including type 2 diabetes, malnutrition, schizoaffective disorder, major depressive disorder, and anxiety was receiving Abilify, an antipsychotic, with a physician order to monitor for side effects such as orthostatic hypotension. The resident was cognitively intact according to the most recent assessment. Despite the order, the medical record did not reflect evidence of routine orthostatic blood pressure monitoring, and the DON stated that such documentation would be found in the vital signs section or progress notes, but none was present.
Failure to Revise Care Plan to Include Physician-Ordered Skin Integrity Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include the use of protective boots as ordered by a physician. The resident, who had multiple diagnoses including Alzheimer's dementia, anemia, diabetes, hypertension, bipolar disorder, impaired cognition, incontinence, psychotropic drug use, and protein calorie malnutrition, was identified as being at risk for impaired skin integrity and pressure injury. Although there was a physician's order for the resident to wear specialized boots to both feet while in bed to maintain skin integrity, this intervention was not added to the resident's care plan during its most recent revision. Additionally, the use of the boots was not documented on the Certified Nurse Aid (CNA) Kardex, which serves as the CNA's plan of care. The Director of Nursing confirmed that the boots were not listed on either the care plan or the CNA Kardex, despite the presence of a physician's order. The expectation, as stated by the DON, was that physician-ordered interventions should be reflected in both the care plan and the CNA Kardex.
Failure to Follow Up on Pharmacy Medication Regimen Review
Penalty
Summary
The facility failed to ensure proper follow-up on a monthly pharmacy medication regimen review for one resident. The resident, who had diagnoses including type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder, and anxiety, was cognitively intact according to the most recent assessment. The pharmacy review for this resident dated 1/31/25 included a recommendation to consider discontinuing loratadine-D due to its potential to worsen hypertension, and to consider an alternative antihistamine if needed. However, the pharmacy consultation report did not have a documented response from the physician, nor did it include signatures from the physician or the Director of Nursing (DON). Further review revealed that the recommendation was not followed up on, as the DON reported only receiving the blank pharmacy recommendation after the fact. The lack of documented follow-up and absence of required signatures indicated that the facility did not ensure the pharmacy's recommendation was addressed in a timely manner, as required by policy and procedure.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located in the 100 hall was observed to be left unattended and unlocked for approximately six minutes, during which time no nurse was present in the area and several residents were seen wandering nearby. The cart contained drugs and biologicals, and it was not secured until an LPN returned and was informed that the cart was unlocked. The LPN stated she had left to use the restroom and forgot to lock the cart. Review of the facility's policy indicated that medication carts are to remain locked except during medication or treatment administration. The Director of Nursing confirmed that leaving the cart unlocked was not consistent with facility policy and that staff are expected to lock the cart when it is unattended.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of abuse involving a resident with severe cognitive impairment. On the evening of November 26, 2024, an LPN attempted to assist a resident with a bloody nose in the memory care unit. During the interaction, the resident, who had dementia and scored 3/15 on a mental status exam, became agitated and verbally aggressive. The LPN responded by shouting at the resident, which was witnessed by two CNAs. The incident was not reported to the Nursing Home Administrator (NHA) or the State Agency in a timely manner, as required by the facility's abuse prohibition policy. The CNAs involved reported the incident to the most senior nurse on duty, but it was not escalated to the NHA until the following morning. The facility's policy mandates immediate reporting of abuse allegations to the administrator, but this protocol was not followed. The delay in reporting was not addressed through re-education or disciplinary action for the CNAs involved. The failure to report the incident promptly resulted in a deficiency, as it increased the potential for further unreported abuse allegations.
Facility Fails to Maintain Clean Kitchen Equipment, Increasing Foodborne Illness Risk
Penalty
Summary
The facility failed to maintain clean equipment in the kitchen and dining areas, leading to potential foodborne illness risks for all residents consuming food from the kitchen. Observations revealed numerous fruit flies near the handwashing sink and dishwasher, sticky floors, brown liquid stains on countertops, and soiled sinks with hard water buildup. The cupboards were sticky and warped from water damage, and portable steam table pans contained water and food debris. Food trays were improperly stored on a folding chair, and fruit flies were noted near the sink. In the B dining room kitchenette, similar issues were observed, including soiled countertops, food debris on the plate warmer, and soiled utensils stored in cupboards. The cupboards under the sink were warped and soiled with spider webs and particles. Interviews with dietary staff and management revealed that the steam tables were not cleaned after each use, contrary to the facility's procedures. Pest control services were called due to the fruit fly infestation, and recommendations were made to clean and sanitize the sink and drains, clean the grease trap, and address caulking needs. The Registered Dietician was not involved in assessing the kitchen's condition. The 2017 FDA Food Code was referenced, highlighting the requirement for equipment and surfaces to be clean and free of food residue, and for premises to be maintained free of pests.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms and common areas, as observed during a survey. In one instance, a resident's room was found with multiple cleanliness issues, including a strong foul odor, stained mattress, and floors, as well as the presence of flies and cobwebs. The resident reported frequent urinary incontinence, and despite housekeeping efforts, the room remained unclean over several days. Housekeeping staff acknowledged the persistent odor and stains, and the housekeeping manager admitted to not having a documented deep cleaning schedule. Other rooms and common areas also exhibited significant cleanliness and maintenance issues. Observations included smeared substances resembling blood on walls, peeling paint, loose toilet handrails, sticky debris on floors, and gaps around air conditioners allowing insect entry. Residents reported discomfort and dissatisfaction with the cleanliness and maintenance of their living spaces, including issues with ants and other pests. Additionally, several residents were observed in unclean conditions, with dirty wheelchairs, long and unkempt facial hair, and fingernails caked with debris. Some residents were unsure of when they last received grooming or nail care, and their personal spaces were cluttered and grimy. The presence of houseflies and gnats was noted in multiple rooms, further contributing to the unsanitary conditions.
Failure to Report and Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse involving a bruise of unknown origin for a resident with severe cognitive impairment. The resident, who had multiple diagnoses including a stroke, atrial fibrillation, and cognitive communication deficit, was observed with a bruise near the left eye. The resident's family member noticed the bruise and reported it to the Director of Nursing, but did not receive any information about the cause or corrective actions taken. A progress note indicated the bruise was possibly caused by a medical device during care, but no incident report was completed. Interviews with facility staff revealed that the Nurse Manager who documented the bruise did not complete an incident report, believing it was unnecessary. The Director of Nursing acknowledged that an incident report should have been completed and an investigation conducted, but neither occurred. The Nursing Home Administrator was unaware of the bruise until informed by the Director of Nursing, and confirmed that the bruise should have been reported as an allegation of abuse to the appropriate agency.
Failure to Investigate and Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate, implement preventive measures, and take corrective action for an allegation of abuse concerning a resident who was admitted with multiple diagnoses, including severe cognitive impairment. The resident was observed with a bruise of unknown origin on the outer corner of the left eye, which was noted in a progress note. The resident's family member reported the bruise to the Director of Nursing (DON), but no definitive cause or corrective action was communicated to the family. The progress note suggested a possible cause related to repositioning, but no incident report was completed, and the bruise was not investigated further. Interviews with facility staff revealed that the Nurse Manager did not complete an incident report, believing it was unnecessary, and did not conduct a thorough investigation by speaking with other staff members. The DON acknowledged that an incident report should have been completed and an investigation conducted, but neither occurred. The Nursing Home Administrator was unaware of the bruise until informed by the DON and confirmed that the incident was not reported as an allegation of abuse to the appropriate agency.
Failure to Implement Effective Hearing Care Plan
Penalty
Summary
The facility failed to develop and implement an effective care plan for a resident with hearing impairments, resulting in unmet needs. The resident, who was cognitively intact, had a history of hearing loss and was observed struggling to hear staff despite having hearing aids. The care plan included interventions to encourage the use of hearing aids and ensure their functionality, but staff were unaware of the resident's hearing aids and could not locate them. The resident's hearing aids were eventually found, but the resident reported they were ineffective. Further review revealed that the resident had moderate to severe hearing loss and impacted cerumen, which was noted in an audiology consult and an ear care visit. The consult recommended ear drops and ear irrigation for cerumen removal, but there were no physician orders for these treatments, and no documentation indicated that the primary care physician was notified or that any cerumen removal procedure was performed. This lack of action contributed to the resident's continued hearing difficulties.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care management. Resident #68, who was admitted with a diagnosis of dependence on renal dialysis, had a care plan that did not reflect the presence of a dialysis graft in her left arm. Despite having a clear dressing on her right chest, staff were confused about the location of her dialysis access, as evidenced by conflicting reports from a CNA and an LPN. The care plan did not include specific instructions regarding the dialysis graft, such as avoiding blood pressure measurements on the arm with the graft, which was crucial for her care. Resident #88, who was readmitted to the facility with multiple diagnoses including pneumonia and rib fractures, had a care plan that was outdated and did not reflect his current medical conditions. The plan of care had not been updated to include his recent fall, which resulted in rib fractures, or his pneumonia diagnosis. Interviews with the Nurse Manager, MDS nurse, and DON revealed that the care plan should have been updated to include these significant changes in his health status, but it was not. The failure to update the care plans for both residents indicates a lapse in the facility's process for ensuring that care plans accurately reflect residents' current medical needs. This deficiency was identified through observations, interviews, and record reviews, highlighting the need for timely and accurate updates to care plans to ensure appropriate care and interventions for residents.
Failure to Provide Adequate Hygiene and Grooming Care
Penalty
Summary
The facility failed to meet the hygiene, grooming, and activities of daily living (ADL) needs for two residents, resulting in unmet care needs. Resident #38, who has hemiplegia, hemiparesis, aphasia, and reduced mobility, was observed with unkempt facial hair, long fingernails, and brown debris under his nails. He was unsure of the last time he received a shower or nail care and did not refuse grooming or nail care. His room was infested with houseflies and gnats, and his wheelchair was dirty. The facility's records showed that Resident #38 had refused all showers for the past thirty days, but there was no documentation explaining the refusals or if alternative care was provided. Resident #86, diagnosed with major depressive disorder, muscle weakness, and multiple sclerosis, was observed with long facial hair coated in food, a soiled shirt, and long fingernails with debris. His room was also infested with houseflies and gnats. He reported that showers were seldom offered, and he had not received assistance with facial hair or nail care. The facility's records indicated that Resident #86 was marked as refusing all offered showers for the past thirty days, with only one progress note documenting a refusal. Interviews with staff revealed that the expectation was to offer showers or bed baths three times, and if refused, nursing staff should be informed, and a note should be entered into the electronic medical record. However, there was a lack of consistent documentation and follow-up on refusals, and standard grooming care was not consistently provided. This resulted in the residents not receiving ADL care according to their individual preferences, with the potential for feelings of shame or embarrassment.
Failure to Follow Physician Orders and Provide Necessary Interventions
Penalty
Summary
The facility failed to follow physician orders and provide necessary interventions for three residents, leading to deficiencies in their care. Resident #27 was readmitted to the facility with multiple diagnoses, including bipolar disorder and type 2 diabetes. Despite having an order for Polyethylene Glycol 3350 for constipation, the resident had not had a bowel movement since readmission, and no interventions were taken. The facility's bowel program, which should have alerted staff after three days without a bowel movement, was not followed, and no bowel protocol was in place. Resident #24, who has a history of hearing loss and uses hearing aids, was observed unable to hear staff despite having a hearing aid in place. The resident's care plan included ensuring the availability and functioning of hearing aids, but staff were unaware of the resident's need for them. An audiology consult had recommended ear drops for impacted cerumen, but no physician order for these drops was found, and the primary care physician was not notified of the issue. Resident #102, diagnosed with paraplegia and major depressive disorder, reported not receiving his prescribed testosterone injections. The medication administration record showed missed doses, with no documentation or notification to the physician about the missed injections. The resident often left the facility, but the medication should have been administered upon return. The facility failed to provide accurate documentation and follow-up on the missed medication, leading to a deficiency in care.
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 93 citations issued within 25 miles in the last 12 months — including the 2 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 Coldwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Lawn Medical Care Facility | 0.7 mi | ★★★★★ | 8 | 0 |
| Hillsdale County Medical Care Facility | 17.4 mi | ★★★★★ | 14 | 0 |
| Hillsdale Hospital Mcguire & Macritchie Long Term | 18 mi | ★★★★★ | 2 | 0 |
| Northern Lakes Nursing And Rehabilitation Center | 20.7 mi | ★★★★★ | 9 | 2 |
| Lakeland Rehab And Healthcare Center | 20.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.