Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Fulton during CMS and state inspections, most recent first.
A resident with dementia, HTN, anxiety, and a history of falls had an active order for amlodipine with instructions to hold if SBP was below 120. Nursing staff documented the medication as administered each morning, but the EHR did not show BP checks before administration, and the ADON confirmed there was no documentation of BP checks because the order had not been entered correctly into the EHR.
Failure to provide meaningful activities for two residents. One resident with dementia and cognitive communication deficit was repeatedly observed in bed with no meaningful activities in his room, and his record showed multiple activity tasks with no documented attendance and several days with no activity offers recorded. Another resident with spastic quadriplegic CP and a developmental speech/language disorder was observed in bed and in a wheelchair watching cartoons at very low volume, but staff could not verify daily out-of-room assistance, TV volume adjustment, or attendance at the activities listed in her record.
Failure to inform the responsible party before starting a psychotropic medication. A resident with Dementia and Alzheimer's Disease and severe cognitive impairment received a PRN order for Lorazepam for anxiety/agitation, but the EMR showed informed consent was documented later and the DON acknowledged the responsible party had not given informed consent for the initiation of the medication.
A resident with severe cognitive impairment, dementia, and Alzheimer’s disease fell, and the medical provider was notified, but the spouse/responsible party was not informed for several days. The spouse reported being upset about the delay, and the DON acknowledged the responsible party should have been notified sooner.
Failure to report and investigate resident-to-resident abuse allegation. The facility did not have an adequate abuse policy with reporting instructions, and staff failed to document, investigate, or notify representatives after one resident entered another resident’s room with his pants down. One resident with dementia and wandering behaviors was involved, and the other resident was very distressed and reported yelling for a prolonged period.
The facility failed to investigate and report an alleged abuse incident involving two residents. A wandering resident entered another resident’s room with his pants down, and the resident later reported that he came into her room and exposed himself, leaving her very upset and in pain from screaming. The DON and NHA confirmed the event was not documented in the resident’s record, no witness statements or investigation had been completed, the residents were not assessed, and their representatives were not notified.
Failure to maintain and timely submit the Acute Transfer Log. The NHA stated that SW G completes the log for residents transferred to an acute care facility and emails it to the State Ombudsman, while SW G stated the NHA completes and emails the log. An email from the Ombudsman showed the State Ombudsman office had not received the log from the facility since September 2023.
A facility failed to develop, implement, and update individualized care plans for two residents. One resident with a catheter had tubing stretched tight and not secured to her leg despite a care plan noting the need to secure it. Another resident with a laryngectomy had care plans that referred to the device as a trach, did not reflect the current tube type, and did not include the behaviors that led staff to store the backup tube in the med cart instead of at the bedside.
A resident with dementia and severe cognitive impairment exhibited wandering, exit-seeking, and agitation, but the care plan was not revised to reflect the behaviors or documented non-pharmacological interventions. The record showed Lorazepam was added for anxiety/agitation without documentation that the resident had anxiety or that a basis for psychoactive medication use was established, and the behavior and activities care plans were not updated in a timely manner to address the resident’s changing condition.
Failure to provide documented walking assistance: A resident with weakness and coordination problems was supposed to be encouraged to ambulate with a walker and walk to dine, but records showed only limited assisted walks, multiple refusals, and many missed documentation entries. A CNA could not recall the last time she had seen the resident walk, and the DON confirmed there was no documentation that CNAs were assisting her daily or that refusals were being fully documented or communicated to the LPN/RN or MD.
Failure to Provide Adequate 1:1 Supervision: A resident with Alzheimer’s disease, dementia, and visual hallucinations required 1:1 supervision per the care plan, but was found on the floor while assigned staff was charting at the nurses’ station. Records and staff interviews showed the resident was in a wheelchair under 1:1 supervision when the fall occurred during shift change, despite the facility’s fall management policy calling for adequate supervision to minimize fall risk.
A resident with dementia and severe cognitive impairment was given psychoactive medication for wandering, exit seeking, and agitation without documented rationale, target behaviors, or treatment goals. The record did not show that non-pharmacological interventions were tried before Lorazepam was started, and the RP was not informed of the medication’s indications, risks, benefits, or goals until after initiation. Care plans were not updated to reflect the behavior management approach or medication use, and facility interviews confirmed the missing documentation.
A resident with Alzheimer’s disease, dementia, and visual hallucinations had a signed DNR status, but the EHR lacked a DNR physician order and DNR alert. The record also did not include a hospice order, and the resident’s 1:1 safety observation was not documented in the EHR when it began; staff confirmed the missing documentation during record review.
A resident with cognitive impairment and a history of exit-seeking behavior was identified as being at risk for elopement but did not have a required alarming device in place. Staff were unaware when the resident left the facility, and the resident was only returned after being found by a CNA outside the facility. The lack of the alarming device and staff awareness led to the resident's unauthorized exit.
A resident with multiple health issues, including hemiplegia and muscle weakness, fell during a transfer using an incorrect lift device, resulting in a fracture and hospitalization. The care plan inaccurately included ambulation interventions and lacked specific transfer instructions, contributing to the incident. Staff interviews revealed that transfer recommendations were not documented in the care plan, and the resident was diagnosed with metabolic encephalopathy and sepsis due to a UTI.
Two residents in an LTC facility experienced preventable pressure injuries due to the facility's failure to implement its pressure injury management policy. One resident, with multiple chronic conditions, did not receive timely wound assessments or treatment orders, and was observed without necessary offloading devices. Another resident, with schizoaffective disorder and cerebral palsy, had an open area on the coccyx, but the care plan did not address pressure offloading needs. Both cases lacked proper documentation and communication, leading to the development and worsening of pressure injuries.
Two residents in an LTC facility suffered serious injuries due to inadequate supervision and monitoring following significant medical and medication changes. One resident, with a history of multiple health issues, fell and sustained a fractured arm and brain bleed after medication adjustments without proper monitoring. Another resident, weakened by pneumonia, fell and fractured her arm due to a lack of updated safety interventions despite requiring increased assistance.
The facility failed to implement an effective infection prevention and control program, with missing documentation for staff illness surveillance from April to July 2024 and incomplete tracking of staff illnesses in November 2024. A resident with a UTI was not listed in the infection surveillance reports, and the facility's policy on infection prevention was not fully executed, leading to deficiencies.
A facility failed to document Medication Regimen Reviews and physician responses for a resident on psychotropic medications. Despite pharmacist recommendations for regular lab tests, these were not completed, and there was no documentation of the physician's rationale for discontinuing the tests. The DON confirmed the absence of necessary documentation and lab tests, contrary to the facility's policy on Psychoactive Medication Management.
The facility failed to implement an antibiotic stewardship program and ensure accurate monitoring of infections for three residents. A resident with dementia was prescribed antibiotics without documented symptoms or rationale. Another resident with multiple sclerosis received an ineffective antibiotic before culture results showed resistance. A third resident with lupus was also given an antibiotic without prior culture results, which later showed resistance. The facility's use of McGeer Criteria was not documented, leading to inappropriate antibiotic use.
A facility failed to provide a single occupancy room with the required 100 square feet, as a room was measured to be only 97 square feet. The Maintenance Director confirmed no changes to the room's size, and room sheets verified the measurements. No negative outcomes were noted for the resident.
A facility failed to timely report an abuse allegation involving two residents with dementia. An incident where one resident placed his hand inside another's shirt was reported late to the State Agency and not at all to local law enforcement. The Nursing Home Administrator misunderstood the reporting requirements, believing there was permissible contact between the residents.
Failure to Document Blood Pressure Checks Before Antihypertensive Administration
Penalty
Summary
The facility failed to provide medication according to professional standards of practice for one resident, who was admitted with dementia, hypertension, anxiety, and a history of falls. The resident had an active physician order for amlodipine besylate 10 mg daily, with instructions to hold the medication if systolic blood pressure was less than 120. Review of the electronic medical record showed nursing staff were not documenting blood pressure checks before administering the medication since the order start date, and the medication was documented as given each morning without evidence that the blood pressure was checked to confirm it met the ordered parameters. The Assistant Director of Nursing reviewed the record and was unable to find documentation of any blood pressure checks prior to the amlodipine administrations, and stated the order had not been entered correctly into the electronic record, which normally prompts staff to check and document the blood pressure at the time of administration.
Failure to Provide Meaningful Activities
Penalty
Summary
The facility failed to provide meaningful activities for two residents, both of whom had care plans and activity preferences documented in the record. Resident 2 was admitted with diagnoses including wandering, vascular dementia, and cognitive communication deficit, and was not his own responsible party. He was observed multiple times in bed with his breakfast tray present, awake or sleeping, with his walker out of reach and no television, books, or other meaningful activities visible in his room. When asked what activities he liked, he said he had not tried any yet. Resident 2’s activity care plan stated that he enjoyed a variety of activities, loved to chat, had been a former bar owner, and was very involved in his community, but would need reminders, encouragement, and some assistance due to cognition. The care plan interventions included escorting him to activities and inviting and reminding him of available and upcoming activities. However, review of the electronic record showed activity tasks such as women’s club, busy hands, and cooking club, and there was no indication that he attended any of these activities or any other activities during the last 30 days. The Activities Director stated he did not like group activities and liked to sit and watch people by the nurse’s station, but a report showed 8 days in the month when he was not offered any activities and no refusals were documented. Resident 6 was admitted with diagnoses including spastic quadriplegic cerebral palsy and developmental disorder of speech and language, and was not her own responsible party. She was observed in bed and later in a wheelchair with cartoons on the television at a very low volume, and she did not respond to questions. The RN confirmed she liked cartoons and should have the volume adjusted, and said that when she was up in her wheelchair she should be assisted out of her room daily, but could not verify that this was happening. Her care plan stated she showed little awareness of programming, would benefit from small group awareness and sensory stimulation, enjoyed favored staff and co-guests, liked watching cartoons and engaging with manipulatives and stuffed animals, and required staff to anticipate activities and get her to and from them. Her record listed activities such as gardening, games, happy hour, cooking club, and arts and crafts, but there was no indication she attended any of these activities, and the Activities Director reported 8 days in the month with missing activity documentation and no way to verify daily assistance out of her room or television volume adjustments.
Failure to Inform Responsible Party Before Starting Psychotropic Medication
Penalty
Summary
The facility failed to inform the responsible party of the initiation of a psychotropic medication for a cognitively impaired resident. The resident was admitted with diagnoses including Dementia and Alzheimer's Disease, and the MDS reflected a BIMS score of 4 out of 15, indicating severe cognitive impairment. The medical record identified the spouse as the designated responsible party. The EMR showed a telephone order on 8/12/25 for Lorazepam 0.5 mg every 4 hours as needed for anxiety/agitation. The record also contained a Psychotropic Medication Informed Consent dated 9/10/25 showing the guardian had been informed of the risks and benefits and consented to Lorazepam after the initial order date. During an interview on 12/17/25, the DON acknowledged that the responsible party had not given informed consent for the initiation of Lorazepam. The facility policy stated that before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives in advance.
Failure to Timely Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to timely inform the responsible party of a fall sustained by a resident who was severely cognitively impaired and had diagnoses including dementia and Alzheimer’s disease. The resident’s spouse was the designated responsible party and emergency contact. The resident fell on 8/16/25 at 2:15 AM, and the electronic medical record documented that the medical provider was notified, but the responsible party was not notified at that time. The spouse later reported during interview that he was not contacted for several days after the fall and was upset that he had not been informed. The incident report showed the responsible party was not contacted until 8/18/25 at 6:21 PM. The facility policy titled Fall Management stated the licensed nurse would notify the attending physician and the responsible party of a fall and document the notification in the medical record. The DON acknowledged the responsible party should have been notified sooner.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prohibition policy and did not have a policy that included examples of abuse allegations, who to report abuse to, or the reporting process to the State Agency. The policy stated that allegations of abuse, exploitation, neglect, misappropriation of property, adverse events, or mistreatment were to be thoroughly investigated and documented by the Administrator and reported to the appropriate state agencies, physician, families, and/or representative. The report also stated that residents were to be educated on the facility’s commitment to deal quickly and effectively with abuse or suspected abuse incidents on admission and at least annually thereafter. Resident #2 was admitted with diagnoses including wandering, vascular dementia, and cognitive communication deficit, and was not his own responsible party. His care plan identified him as at risk for exit seeking/wandering and noted confusion that increased in the evening and afternoon. A progress note documented that he was wandering in the hallway and went into another resident’s room with his pants pulled down to his knees, after which he was redirected. Staff later confirmed that this resident was the one who entered another resident’s room with his pants down. Resident #24 was admitted with diagnoses including muscle weakness, lack of coordination, and weakness, and was not her own responsible party. She reported that another resident came into her room with his pants down and that she was very distressed, stating she had been yelling for a long time and that her right ear hurt from screaming. Staff confirmed the incident was reported to the DON, but the event was not documented in Resident #24’s medical record, her representative was not notified, no investigation or witness statements had been taken, neither resident was assessed, and no interventions were implemented to ensure Resident #24’s safety.
Failure to Investigate and Report Alleged Abuse Involving Two Residents
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving two residents. R2 was admitted with diagnoses including wandering, vascular dementia, and cognitive communication deficit, and his care plan identified him as at risk for exit seeking and wandering. A progress note documented that R2 was wandering in the hallway and went into another resident’s room with his pants pulled down to his knees, after which he was redirected. R24, who was admitted with diagnoses including muscle weakness, lack of coordination, and weakness, later reported that a man came into her room after her smoke break with his pants down and that she screamed for a long time, causing pain in her right ear. The social services note documented that R24 was distressed about a male guest entering her room and exposing himself to her. During interviews, LPN C confirmed she documented R2 being in another resident’s room with his pants down and stated the DON was informed, but no note was entered in R24’s record. The DON and NHA confirmed the event was not documented in R24’s medical record, R2 and R24’s representatives were not notified, no investigation or witness statements had been taken, neither resident was assessed, and no interventions were implemented to ensure R24’s safety. The NHA stated he would start the investigation and report it to the State Agency.
Failure to Maintain and Submit Acute Transfer Log
Penalty
Summary
The facility failed to complete and maintain an Acute Transfer Log and failed to provide the log to the State Ombudsman in a timely manner. During an interview, the Nursing Home Administrator stated that Social Worker G completes the Acute Transfer Log, which is maintained for residents transferred to an acute care facility, and emails it to the State Ombudsman. In a separate interview, Social Worker G stated that the Nursing Home Administrator completes the Acute Transfer Log and emails it to the State Ombudsman. Review of an email from Ombudsman V showed that the State Ombudsman office had not received an Acute Transfer Log from the facility since September 2023.
Care Plans Were Not Individualized or Kept Current for Two Residents
Penalty
Summary
The facility failed to develop, implement, and update individualized care plans for 2 residents reviewed, R6 and R8. R6 was admitted with diagnoses including spastic quadriplegic cerebral palsy, hydronephrosis with renal and ureteral calculous obstruction, malignant neoplasm of the bladder, and developmental disorder of speech and language. Her catheter care plan identified her as at risk for UTI and catheter-related trauma related to urostomy and a history of MDROs, with an intervention to ensure catheter tubing was secured. During observation, the foley bag was secured to the side of the bed and the tubing was stretched tight, and R6 did not have the catheter tubing secured to her leg. RN B stated that securing the tubing was facility policy. R8 was admitted with diagnoses including acute respiratory failure with hypoxia, speech disturbances, dysphagia, malignant neoplasm of the larynx, tracheostomy, and major depressive disorder. Her cognition care plan stated she had intact cognition, and her respiratory care plan identified a potential for difficulty breathing and respiratory complications related to the trach and acute respiratory failure with hypoxia. During observation and interview, R8 could not locate her backup tracheostomy tube in her room, and RN D stated the backup tube was in the medication cart rather than at the bedside. Regional Nurse A stated R8 actually had a laryngectomy tube, not a tracheostomy tube, and that the backup laryngectomy tube was stored in the medication cart because of behaviors including throwing things away. The current care plans referred to the laryngectomy tube as a tracheostomy and did not identify the behaviors that led staff to move the backup tube from the bedside to the medication cart.
Failure to Revise Care Plan for Behaviors and Psychoactive Medication Use
Penalty
Summary
The facility failed to revise the care plan for a cognitively impaired resident with dementia and Alzheimer’s disease who exhibited wandering, exit-seeking, and agitation, and who was prescribed psychoactive medications. The resident was admitted with severe cognitive impairment, and early progress notes described the resident as pleasantly confused, exit seeking, wandering, and later becoming agitated with staff having difficulty redirecting the resident. The documentation for the agitation episode did not reflect what non-pharmacological interventions or diversions were attempted to calm or redirect the resident. Hospice documentation reflected that the facility called about increased exit-seeking and agitation, and a doctor’s order for Ativan was implemented. A later medical provider entry added Lorazepam 0.5 mg PRN for anxiety/agitation, but the record did not show the resident had exhibited or been evaluated for anxiety, and no documentation was found to support the basis for psychoactive medication use. The care plan for wandering and behavior was initiated on admission but was not revised until later, despite the documented behaviors and the initiation of psychoactive medication. The behavior care plan referenced providing activities of interest, but the activities care plan was not initiated until after admission and after pharmacological intervention, and no care plan for antipsychotic or psychoactive medication use was found after the Lorazepam order or after a later Depakote order for behavior modification.
Failure to Provide Documented Walking Assistance
Penalty
Summary
The facility failed to ensure a resident with muscle weakness, lack of coordination, and weakness received the walking assistance and encouragement documented in her care plan to maintain her ability to walk. The resident was admitted as not her own responsible party and, during observation, required physical assistance to stand and transfer from bed to wheelchair. She had a wheeled walker in her room, and a CNA stated the resident required assistance to walk but could not recall the last time she had seen her walk. The resident said she did not want to walk because her right shoulder was sore. Review of the resident’s Kardex showed she was able to ambulate with a wheeled walker, used a wheelchair for long-distance mobility, and should be encouraged to walk to dine. However, the task record for walking showed only three instances where she was assisted to walk, with no indication of how far she walked, and multiple entries where she refused to walk. There were also many dates with no documentation showing she was assisted or encouraged to walk to dine. The DON stated the CNAs should assist the resident to walk daily and that refusals should be documented in the medical record, with a licensed nurse documenting why she was refusing to walk. The DON also stated there was no documentation showing the resident had been assisted to walk or refused to walk since physical therapy ended, and prior to exit the facility provided refusal documentation but no documentation that licensed nurses or the physician were aware of the refusals or that any follow-up occurred to determine why she was refusing.
Failure to Provide Adequate 1:1 Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the fall of one resident who was reviewed for falls. The resident had diagnoses including Alzheimer’s disease, dementia, and visual hallucinations, and a current fall care plan initiated on 12/13/2025 stated the resident required one-on-one supervision in anticipation of care needs. During an observation, the resident was seen resting in bed with a CNA at the bedside providing 1:1 supervision. Review of the resident’s nurses notes and fall incident report showed that while the resident was sitting in a wheelchair at the nurses’ station under 1:1 supervision, he was found on the floor on hands and knees, face first. The notes stated the resident was at the nurses’ station while 1:1 staff was charting, and the incident occurred during shift change. In interview, the CNA assigned to 1:1 supervision reported she was documenting at a computer when the resident was found on the floor. The ADON reported the CNA received written counseling regarding how to provide 1:1 supervision, and the facility’s fall management policy stated residents are to be provided adequate supervision to minimize fall risk.
Failure to Document Rationale and Goals for Psychoactive Medication Use
Penalty
Summary
The facility failed to evaluate one cognitively impaired resident and document the rationale for use of a psychoactive medication, define target behaviors, and establish goals for treatment. The resident was admitted with diagnoses including Dementia and Alzheimer’s Disease, and the MDS reflected severe cognitive impairment. The record showed the resident was pleasantly confused, exit seeking, wandering, and at times becoming agitated, but the documentation did not identify a historical review, justification, or specific goal for prescribing Lorazepam for anxiety/agitation. Progress notes showed the resident was redirectable at times, and later staff documented difficulty redirecting the resident and that the resident was becoming agitated. The note did not reflect what non-pharmacological interventions or diversions were attempted or implemented before the medication was started. Hospice documentation reflected a call from the facility about exit seeking and increased agitation, and a doctor’s order for Ativan was implemented, with Hospice suggesting ideas to help keep the resident entertained. The medical record did not show that the responsible party was informed of the indications for use, rationale, risks and benefits, or goal of the psychoactive medication until after the medication had already been initiated. The care plan for wandering and behavior was initiated on admission but was not revised until later despite the documented behaviors and medication use, and no antipsychotic medication care plan had been initiated after the Lorazepam order or after a later order for Depakote for behavior modification. Facility interviews confirmed the lack of documentation for rationale and goals, and no additional supporting documentation was provided by survey exit.
Incomplete EHR Documentation for DNR, Hospice, and 1:1 Observation
Penalty
Summary
The facility failed to maintain an accurate Electronic Health Record (EHR) for one resident who was reviewed for medical record accuracy. The resident had diagnoses including Alzheimer’s disease, dementia, and visual hallucinations. His resident code status, signed 12/10/2025, showed he was Do Not Resuscitate (DNR), but the EHR did not contain a DNR physician order or a DNR alert. RN D reviewed the record and confirmed there was no DNR alert or physician order, and reported that a resident who was DNR should have both documented in the EHR. Assistant Director of Nursing N also reviewed the EHR and reported there was no physician order for DNR or hospice care and no DNR alert, even though the resident’s DNR status had been signed 12/10/25. N stated the physician order and alert should have been placed in the EHR at that time, and reported the resident had signed into hospice when he admitted to the facility. The Director of Nursing reported the resident had been on 1:1 observation for safety from within 24 hours of admission, but this intervention was not documented in the EHR until it was placed in the care plan on 12/13/2025. The DON also reported there was no documentation showing staff had been completing the 1:1 observation, and Regional Clinical Nurse A stated the 1:1 intervention should have been documented on the care plan when initiated and under tasks.
Failure to Implement Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Dementia with Mood Disturbance, and Major Depressive Disorder was admitted to the facility and assessed as being at risk for elopement. The resident was cognitively moderately impaired, independently ambulatory, and had recently returned from inpatient psychiatric treatment. An elopement risk assessment completed upon reentry indicated a high risk for wandering and exit-seeking behaviors, with documentation noting the resident verbalized a desire to leave the facility and scored above the threshold for elopement risk. Despite the identified risk, the resident did not have a personal alarming device in place, which was an intervention indicated for residents at risk of elopement. On the day of the incident, staff were unaware that the resident had left the facility until a CNA arriving for her shift observed the resident walking down a rural road. The CNA recognized the resident, engaged her, and transported her back to the facility, at which point other staff members assisted in escorting the resident inside. Multiple staff interviews confirmed that the resident was last seen at the nurse's station shortly before being found outside and that the required alarming device was not in use at the time of the incident. The failure to implement the necessary safety intervention for a resident known to be at risk for elopement resulted in the resident leaving the facility without staff knowledge. The absence of the alarming device, which would have triggered an alert and prevented the resident from exiting, directly contributed to the unauthorized leave of absence.
Removal Plan
- Re-assessed the elopement risk for R101 and implemented measures to prevent recurrence.
- Performed a resident count to ensure no other residents had eloped.
- Assessed all facility residents for risk of elopement for any previously unidentified residents at risk and ensured appropriate safety measures were in place.
- Reviewed and updated the facility Missing Guest/Elopement book.
- Re-education of the Elopement policy was initiated for all staff.
- Re-education of the Missing Guest Procedure for all staff was initiated.
- The Nursing Home Administrator was re-educated on the facility elopement policy and the expected information to be ascertained to ensure compliance with the facility policy across disciplines.
Failure to Revise Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the comprehensive care plan for a resident was reviewed and revised, resulting in a hospitalization due to a fracture sustained after a fall. The resident, who was admitted with diagnoses including generalized osteoarthritis, hemiplegia, and muscle weakness, was dependent on staff for transfers and did not ambulate. Despite this, the care plan in place at the time of the fall inaccurately included interventions for ambulation with a walker, conflicting with the resident's actual needs as indicated in the Minimum Data Set (MDS) assessments. The incident occurred when the resident, who was cognitively intact, fell during a transfer using a sit-to-stand lift. The resident reported feeling weak and tired from low blood pressures and suspected a urinary tract infection, which contributed to the fall. The fall incident report indicated that the resident should have been transferred using a Hoyer lift instead of a sit-to-stand lift, especially when tired. However, the care plan did not specify the number of staff or assistive devices required for transfers, and the recommendation for using a Hoyer lift was not documented in the care plan. Interviews with staff revealed that the resident was on the therapy caseload for deconditioning but was cut from services due to lack of progress. The Physical Therapy Assistant provided transfer status recommendations to nursing staff, but these were not reflected in the care plan. The Director of Nursing confirmed that the care plan lacked specific directions for transfers and acknowledged that the resident did not use a walker. The resident was hospitalized with a fracture and diagnosed with metabolic encephalopathy and sepsis due to a urinary tract infection.
Failure in Pressure Ulcer Management and Prevention
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management, resulting in preventable pressure injuries and worsening wounds for two residents. One resident, a female with chronic respiratory failure, heart failure, and diabetes, was dependent on staff for all activities of daily living. Upon readmission, her skin was noted to be reddened, but no comprehensive wound assessment or treatment orders were promptly initiated. Observations revealed that the resident was frequently left without offloading devices, and her urinary catheter was not properly secured, leading to skin breakdown and a new pressure injury. Another resident, with diagnoses including schizoaffective disorder and cerebral palsy, was found to have a sore and open area on the coccygeal region. Despite being at risk for pressure ulcers, the resident's care plan did not adequately address the need for pressure offloading while seated in a wheelchair. The resident was not repositioned frequently enough, and there was a lack of documentation and timely notification to the physician and guardian regarding the skin impairment. Both cases highlight the facility's failure to conduct comprehensive wound assessments, implement timely interventions, and ensure proper documentation and communication regarding skin integrity issues. These deficiencies contributed to the development and worsening of pressure injuries, indicating a lack of adherence to established care protocols and policies.
Inadequate Supervision and Monitoring Leads to Resident Injuries
Penalty
Summary
The facility failed to provide enhanced supervision and assistance to residents experiencing acute medical changes and significant medication adjustments, leading to serious injuries for two residents. Resident #32, a female with a history of seizure disorder, stroke, congestive heart failure, and other conditions, was at risk for falls due to her medical conditions and medication side effects. Despite these risks, her fall risk assessment indicated no risk for falls. She experienced a fall resulting in a fractured left arm and a brain bleed after her medications, including Oxycodone and Lasix, were increased without adequate monitoring for side effects such as dizziness and sedation. Resident #16, a female with muscle weakness, anxiety disorder, developmental disorder, congestive heart failure, and dementia, also suffered from inadequate supervision. After being diagnosed with pneumonia and starting on Clindamycin, she became weak and required increased assistance for ambulation. Despite these changes, no new safety interventions were implemented in her care plan. She fell and fractured her right arm while being weak and unsteady on her feet. The facility's failure to adjust care plans and provide necessary supervision and monitoring for these residents with significant medical and medication changes resulted in severe injuries. The lack of appropriate interventions and monitoring for side effects contributed to the accidents, highlighting deficiencies in the facility's care and supervision protocols.
Deficiency in Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically in the area of staff illness surveillance. From April to July 2024, there was no completion of the Employee Infection Log, and no Infection Prevention Committee Meeting notes were available for review. This lack of documentation continued into August 2024, where the section on employee health and outbreaks was left blank. The November 2024 Staff Case List revealed incomplete tracking of staff illnesses, with missing details such as the unit worked, residents contacted, and dates of illness resolution and return to work. The facility's infection surveillance system also failed to adequately track resident infections. A resident with dementia and schizophrenia, who was diagnosed with a UTI in the emergency department and discharged with an antibiotic, was not listed in the August and September 2024 Infection Surveillance Monthly Report. The resident's laboratory results and antibiotic use were not documented for tracking and trending purposes. The Infection Control Preventionist (ICP) confirmed that residents prescribed antibiotics were included in the report, but those with symptoms not prescribed antibiotics were not. Interviews with the ICP and the Director of Nursing (DON) revealed that residents exhibiting symptoms of infection were tracked using a separate Resident at Risk list and discussed in weekly meetings, rather than being included in the Infection Surveillance Monthly Report. The facility's policy outlined the responsibilities of the Infection Preventionist, including collecting and analyzing infection data, but these responsibilities were not fully executed, leading to deficiencies in the infection prevention program.
Failure to Document Medication Regimen Reviews and Physician Responses
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) were properly documented in the resident's clinical record, specifically lacking documentation of the physician's response to the pharmacist's recommendations for one resident. The resident, a male with schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder, was on multiple psychotropic medications, including Quetiapine Fumarate, Venlafaxine HCL ER, and Depakote. Despite the pharmacist's recommendations for regular laboratory tests to monitor the effects of these medications, the necessary tests were not completed, and there was no documentation of the physician's rationale for discontinuing these tests. The pharmacy Consultation Reports for the resident indicated missing lab values and recommended that the facility ensure these labs were obtained. However, the reports lacked signatures or initials from the provider to confirm that they were notified of these recommendations. The Director of Nursing (DON) confirmed that the MRRs were not in the resident's Electronic Medical Record (EMR) and were only obtained from the pharmacy upon request. The DON also acknowledged that the recommended laboratory tests were not completed and that there was no documentation or rationale for the discontinuation of the routine laboratory tests by the provider. The facility's policy on Psychoactive Medication Management emphasizes the importance of monitoring residents receiving psychoactive medications for efficacy, side effects, and adverse consequences. However, the facility did not adhere to this policy, as evidenced by the lack of follow-through on the pharmacist's recommendations and the absence of documentation in the resident's medical record. This oversight could potentially impact the resident's health, given the known side effects and necessary monitoring associated with the medications prescribed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program, as well as ensure accurate monitoring and documentation of infections for three residents. Resident #23, a female with dementia and schizophrenia, was admitted with a UTI diagnosis from the Emergency Department and prescribed an antibiotic. However, there was no documentation of UTI symptoms, onset of symptoms, or rationale for the antibiotic use in her medical record. The microbiology report later revealed no significant pathogens, yet the antibiotic course was completed without provider review until after completion. Resident #30, a female with overactive bladder and multiple sclerosis, was sent to the ER due to vaginal bleeding and abdominal pain. She was started on an antibiotic for a UTI without documented McGeer Criteria or rationale prior to culture results. The initial antibiotic was found to be resistant, and a new antibiotic was started after several doses of the ineffective one had been administered. Similarly, Resident #192, a female with lupus and a history of kidney stones, was sent to the ER for flank pain and started on an antibiotic for a UTI without prior culture results. The initial antibiotic was also found to be resistant, and a new one was started after several doses. Interviews with the Infection Control Preventionist and Director of Nursing revealed that the facility uses McGeer Criteria for antibiotic stewardship, but it was not documented in the Electronic Medical Record. The facility's policy requires antibiotics to be prescribed only when appropriate, with follow-up on culture results to ensure the correct antibiotic is used. However, the documentation and adherence to these protocols were lacking, as evidenced by the cases of the three residents. The facility's failure to document symptoms and follow McGeer Criteria contributed to the inappropriate use of antibiotics.
Room Size Deficiency Identified
Penalty
Summary
The facility failed to ensure that a resident's room met the required square footage for single occupancy, which is 100 square feet. During an observation on November 18, 2024, at 10:00 AM, the room was measured to be 9 feet 6 inches by 10 feet 3 inches, totaling only 97 square feet. An interview with the Maintenance Director confirmed that there had been no changes to the room's size or configuration. A review of the room sheets corroborated the measurements and bed occupancy. No negative outcomes were identified for the resident residing in the room.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime and ensuring timely reporting of abuse allegations to the State Agency. An incident occurred where a resident was reported to have placed his hand inside the shirt of another resident. This incident was discovered on the evening of 8/7/24 but was not reported to the State Agency until the following afternoon, exceeding the two-hour reporting requirement. Additionally, the incident was not reported to local law enforcement, as the Nursing Home Administrator believed there was some type of contact allowed between the two residents involved. The residents involved in the incident had been diagnosed with unspecified dementia, with one having additional behavioral disturbances. Both residents had guardians or activated Durable Power of Attorney, but there was no documented assessment of their capacity to consent to sexual relationships. The Nursing Home Administrator was aware of the incident within an hour of its occurrence but delayed reporting to the State Agency due to a lack of details, misunderstanding the reporting requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Perrinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Carson City | 7.7 mi | ★★★★★ | 1 | 0 |
| Ashley Healthcare Center | 11.3 mi | ★★★★★ | 20 | 0 |
| Hazel I Findlay Country Manor | 13.6 mi | ★★★★★ | 12 | 0 |
| Michigan Masonic Home | 16.3 mi | ★★★★★ | 17 | 0 |
| Riverside Healthcare Center | 17.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.