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 Lodge At Taylor during CMS and state inspections, most recent first.
Four out of five shower gurneys were found missing required safety pins to secure side rails, with no evidence of routine safety checks or requests for replacement. Staff competency records also lacked education on proper gurney use, despite facility policy requiring safe maintenance of patient care equipment.
A resident with severe cognitive impairment and physical disabilities was found unable to access their call light, which was observed on the floor and out of reach during meal assistance. Staff confirmed the resident could use the call button, and facility policy requires call lights to be accessible at all times. The care plan for this resident included encouraging use of the call light, but this intervention was not followed.
A resident with severe cognitive impairment and multiple health conditions received a wound patch on the right arm without a physician's order or proper documentation. An LPN and the DON confirmed that the wound care was not authorized by a physician and was not documented in the medical record, contrary to facility policy requiring physician-directed wound treatments.
A resident with severe cognitive impairment and a history of impulsive behaviors experienced multiple falls resulting in injuries and hospital visits due to the facility's failure to consistently update and implement effective fall prevention interventions. Despite repeated incidents, care plans were not revised after several falls, and staff did not provide adequate supervision or targeted interventions, particularly during nighttime hours.
The facility failed to consistently provide water to residents, leading to repeated grievances at Resident Council Meetings. Observations showed residents without water at their bedsides, and interviews revealed staff assumptions and lack of resolution. Despite in-services in October, the issue persisted, violating the facility's hydration policy.
The facility failed to maintain over-bed tables in seven resident rooms, with tables exhibiting missing edging, peeling veneer, and exposed particle board, making them difficult to clean. The Maintenance Director relies on staff to report such issues and acknowledged the need for replacement upon inspection.
The facility failed to review and submit PASARR forms for two residents, potentially impacting their mental health care. One resident was admitted with schizophrenia and anoxic brain damage, but the PASARR forms incorrectly indicated a dementia exemption. Another resident with psychosis and metabolic encephalopathy had no PASARR assessment completed. The facility's policy requires coordination with the PASARR program, which was not followed.
A resident with end-stage renal failure and osteomyelitis did not receive prescribed intravenous antibiotics during dialysis on multiple occasions. The facility failed to notify the physician of these missed doses, as confirmed by interviews with the Unit Manager, DON, and nursing staff. The facility's medication administration policy was not followed.
A resident with morbid obesity, type two diabetes, and end-stage renal failure was found to have inadequate foot care, with long, jagged, discolored toenails and debris between toes. Despite the resident's request for podiatry services, the facility failed to register or provide these services, and care plans lacked specific interventions for foot care. Interviews with facility staff confirmed the oversight in providing necessary podiatry services.
A facility failed to communicate effectively with a dialysis provider, resulting in a resident missing seven doses of prescribed antibiotics. The resident, with end-stage renal failure and osteomyelitis, was supposed to receive Cefepime and Vancomycin intravenously after hemodialysis. The DON confirmed the missed doses and identified a lack of communication between nursing staff and the dialysis provider, contrary to facility policy.
A resident with type two diabetes and impaired cognition received medication from an LPN who placed syringes directly on a cluttered bedside table without a barrier, violating facility policy. The DON confirmed this practice increases contamination risk.
A resident with cerebral palsy, epilepsy, and dementia was unable to receive timely assistance due to a malfunctioning bathroom call light. The resident, requiring substantial assistance with toileting, had to self-transfer, risking falls. The call light indicator was not functioning properly, and the Maintenance Director was unaware of the issue, as staff did not report it through the electronic repair order system.
A facility failed to perform proper hand hygiene during wound care for a resident with an open cancer lesion. An LPN did not wash hands before or after removing soiled dressings, relying instead on double gloving. The DON confirmed that hand hygiene should occur before and after wound care, and the facility's policy states gloves do not replace hand hygiene.
A resident with a history of cerebral infarction and hemiplegia was not included on the podiatrist list, leading to overgrown toenails and dissatisfaction with foot care. The resident had to arrange an outside appointment for nail trimming. The EHR showed no podiatry consults since admission, and the facility's nail care policy was not followed.
A resident with anoxic brain injury and a feeding tube did not receive tube feeding as per physician's orders, resulting in insufficient nutrition. The feeding pump was found alarming, and the feeding bottle was hung at the wrong time, leading to a shortfall of 300 ml in the prescribed amount. The DON and an LPN could not determine the duration of the feeding hold or the total amount infused, indicating a failure to follow the facility's Feeding Tube policy.
A resident with a tracheostomy did not receive the prescribed humidified oxygen due to malfunctioning equipment. The trach collar tubing was connected to a compressor set at 0% humidification, and the water bottle was leaking, causing water to accumulate in a wash basin. The resident, who was non-verbal and cognitively impaired, was not in distress. The facility's policy for tracheostomy care was not followed, as the staff failed to notify the Respiratory Therapist about the issue immediately.
A resident who underwent surgery to improve hand function did not receive the ordered Occupational Therapy (OT) sessions in a timely manner, as the facility failed to provide the required 3-5 sessions per week. The resident received only one session per week for two consecutive weeks, leading to dissatisfaction and the decision to seek therapy elsewhere. Interviews with staff confirmed the oversight, and the facility's policy mandates adherence to therapy orders.
A resident with Type 2 Diabetes and End Stage Renal Disease was found unresponsive with a blood glucose level of 35. Despite physician orders to administer glucose or glucagon for low blood sugar, the facility did not administer glucagon before EMS arrived. The resident had received insulin earlier, and no glucagon was given, leading to hospitalization and subsequent death.
A facility failed to provide accurate resident documents during an emergency hospital transfer. A resident with cognitive impairment and multiple diagnoses was transferred without the correct paperwork, as confirmed by staff interviews. The error was discovered when the hospital reported receiving incorrect information.
The facility failed to immediately report an allegation of sexual abuse involving two residents, both with no cognitive impairment. An incident where one resident was reportedly touched inappropriately by another was not reported to the State Agency until several days later, contrary to the facility's policy requiring immediate reporting. The Nursing Home Administrator did not initially consider the incident an allegation of abuse.
A resident at very high risk for pressure ulcers experienced a significant worsening of an existing stage 4 pressure ulcer due to the facility's failure to follow hospital discharge instructions for wound care. The wound care nurse did not document all dressing changes, and necessary dressing changes after bowel movements were not consistently performed. The resident's condition deteriorated, leading to septic shock and death.
The facility failed to notify the physician of abnormally elevated blood sugar levels for a resident with diabetes mellitus, despite specific orders to do so. The resident's blood sugar values were recorded as 459 and 436, but the physician was not informed, resulting in a deficiency identified during the survey.
The facility failed to ensure a physician's assessment accurately reflected a resident's current diabetes status, resulting in potential delays in appropriate medical treatments. Despite frequent high blood sugar readings, the physician's notes were repetitive and did not reflect updated assessments or adjustments in care. Interviews with staff revealed concerns about the lack of updated evaluations and adherence to the facility's policy on physician visits.
Failure to Maintain Shower Gurney Safety Equipment
Penalty
Summary
The facility failed to ensure the safe maintenance of shower gurneys, as four out of five gurneys observed were missing the required safety pins to secure the side rails. Specifically, one gurney in Hall C and two in Hall B were missing all safety pins, while a gurney in Hall E was missing two out of four pins. Maintenance logs showed no evidence of routine safety assessments for the shower gurneys, and there were no documented requests to replace the missing safety pins. Additionally, review of Certified Nursing Assistant competency forms revealed no education provided regarding the use of shower gurneys. The facility's policy requires all mechanical, electrical, and patient care equipment to be maintained in safe operating condition.
Call Light Accessibility Deficiency
Penalty
Summary
A deficiency occurred when a resident's call button was found on the floor at the head of the bed, out of the resident's reach, while the resident was awake and receiving breakfast assistance from a staff member. The resident had the capacity to use the call button, as confirmed by an LPN, but was unable to access it due to its placement. The staff member assisting with the meal did not ensure the call button was within reach during or after the assistance. The facility's policy requires that call lights be accessible to residents at all times, and the care plan for this resident specifically included encouraging the use of the call light for assistance. The resident involved had a history of atrial fibrillation, morbid obesity, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, but no impairment of the upper extremities was documented. The care plan also identified the resident as being at risk for falls and injury, with interventions including the use of the call light for assistance. Despite these documented needs and interventions, the call light was not accessible, and staff confirmed this during interviews. The Director of Nursing also acknowledged that call lights should be within reach for all residents.
Wound Care Provided Without Physician Order or Documentation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including atrial fibrillation, morbid obesity, and hemiplegia, was found with a wound patch on the right arm that lacked a corresponding physician's order and proper documentation. During observation, the wound patch was noted to be dated several days prior, and review of the electronic health record confirmed there was no physician's order or nursing note regarding the application of the patch. The resident's care plan had been updated to reflect risks and history of impaired skin integrity, but the specific wound care provided was not documented as required. Interviews with facility staff, including an LPN and the DON, confirmed that the wound patch was applied without a physician's order and that the physician had not been notified about the wound or the treatment provided. The DON acknowledged that all treatments should be documented and that the physician should have directed the wound care. Review of facility policy further indicated that physician authorization is required for wound treatments, but this protocol was not followed in this instance. No additional documentation or information was provided by the facility at the time of the survey.
Failure to Implement Adequate Fall Prevention Interventions
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent multiple falls for a resident with severe cognitive impairment and a history of impulsive behaviors. The resident, who was non-interviewable due to cognitive impairment and had diagnoses including metabolic encephalopathy, seizure disorder, muscle weakness, bipolar disorder, and impulse disorder, experienced numerous falls resulting in injuries and hospital visits. Observations showed the resident attempting to self-propel in a wheelchair and resist redirection from staff, while interviews with the roommate confirmed frequent nighttime activity and falls. Review of the resident's care plan and medical records revealed repeated falls, some resulting in significant injuries such as lacerations requiring stitches and multiple hospital transfers. Despite these incidents, there was a lack of consistent and timely updates to the fall care plan following several falls. The care plan included interventions such as keeping the resident in common areas when awake, providing structured activities, ensuring a hazard-free room, using a mat next to the bed, and a low bed, but these interventions were not consistently revised or augmented after repeated falls. Staff interviews indicated a lack of interventions specifically targeted for nighttime, when many of the falls occurred. The Unit Manager acknowledged the absence of nighttime activities or interventions and suggested that such measures might have helped reduce the number of falls. Additionally, there was no documented follow-up on recommendations for additional safety equipment, such as bed bolsters, and the facility's fall prevention policy requiring assessment and care plan revision was not consistently followed.
Inconsistent Water Pass Leads to Resident Grievances
Penalty
Summary
The facility failed to consistently provide water to residents, as evidenced by repeated grievances reported at ten consecutive monthly Resident Council Meetings. Observations on specific dates revealed that residents were without water or water cups at their bedsides, and some residents expressed frustration over the inconsistency of water delivery. One resident, who was cognitively impaired, was unable to confirm if water had been available, while another resident with intact cognition reported that the issue had been raised multiple times without resolution. The facility's records showed that the concern of inconsistent water pass was documented in Resident Council Meeting minutes from February to November, with no effective resolution implemented. Interviews with staff, including a CNA and the Nursing Home Administrator (NHA), revealed a lack of consistent action to address the water pass issue. The CNA assumed that the previous shift had completed the water pass, while the NHA acknowledged the ongoing concerns but could not explain why no resolutions had been implemented prior to October. The Director of Nursing (DON) confirmed that some residents still did not receive water even after staff in-services were conducted in October. The facility's policy on resident hydration, which mandates daily and routine provision of fluids, was not adhered to, leading to the deficiency.
Failure to Maintain Over-Bed Tables in Resident Rooms
Penalty
Summary
The facility failed to maintain the over-bed tables in seven resident rooms, specifically rooms B4, C2, E4, G2, I11, I12, and J9. During an observation, it was noted that these tables had missing edging, peeling surface veneer, and rough, exposed particle board, making them no longer smooth and easily cleanable. This deficiency was identified during a survey conducted between 2:00 pm and 2:30 pm. In an interview, the Maintenance Director stated that he relies on staff to inform him when a table needs replacement. Upon being shown the table in room C2, which had a top surface lifted away from the particle board, he acknowledged that it was water warped and needed replacement.
Failure to Review and Submit PASARR Forms
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Annual Resident Review (PASARR) forms were properly reviewed, revised, and submitted to the local state agency for two residents, resulting in the potential for these residents not to receive appropriate care and services for their mental health needs. Resident R86 was admitted with diagnoses including paranoid schizophrenia and anoxic brain damage, and the PASARR forms indicated a dementia exemption, which was not supported by the hospital records. The social worker admitted to confusion regarding the dementia exemption and acknowledged that a Level II evaluation request was not submitted. Resident R44 was admitted with unspecified psychosis and metabolic encephalopathy, and was prescribed Risperdal for paranoia. However, there was no PASARR assessment completed upon admission, and the social worker acknowledged that the assessment was missed. The facility's policy requires coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities, but this was not adhered to in these cases.
Failure to Administer Antibiotics and Notify Physician
Penalty
Summary
The facility failed to administer medications as ordered and did not notify the physician of missed doses for a resident with end-stage renal failure and osteomyelitis. The resident was supposed to receive intravenous antibiotics, Cefepime and Vancomycin, on specific days after hemodialysis. However, the Medication Administration Record showed that Vancomycin was not administered on four occasions, and Cefepime was missed on three occasions. There was no documentation indicating that the physician was informed of these missed doses. Interviews with the Unit Manager, Director of Nursing, and nursing staff revealed a lack of awareness and communication regarding the missed doses. The Director of Nursing confirmed the missed doses and stated that the antibiotics should have been administered during dialysis. The nursing staff did not inform the physician about the missed doses until several days later. The facility's policy on medication administration requires that medications be administered as ordered by the physician, but this was not adhered to in this case.
Failure to Provide Adequate Foot Care for a Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as R32, who was observed to have long, jagged, thick, greenish/black toenails, white patches of dry skin, and moist debris encrusted between the toes. Despite R32's expressed desire for podiatry services due to an inability to provide nail care independently, the facility did not register or provide podiatry care for the resident. R32 was admitted with diagnoses of morbid obesity, type two diabetes, and end-stage renal failure, and exhibited dependency with most activities of daily living (ADLs). The facility's policy on nail care, dated August 2024, requires assessments of resident nails upon admission and readmission, with routine cleaning and inspection during ADL care. However, R32's care plans did not contain specific interventions for foot care, and the staff responsible for setting up podiatry services failed to do so in a timely manner. Interviews with the Director of Nursing and the Social Worker confirmed that podiatry services should have been provided, especially given R32's comorbidities, but were not arranged. The Nursing Home Administrator acknowledged that residents should receive foot care from staff and podiatry services when needed.
Failure in Communication with Dialysis Provider Leads to Missed Antibiotic Doses
Penalty
Summary
The facility failed to effectively communicate with a dialysis provider, resulting in a resident not receiving seven doses of prescribed antibiotics. The resident, who was diagnosed with end-stage renal failure and osteomyelitis, was supposed to receive Cefepime and Vancomycin intravenously on specific days after hemodialysis. However, the Medication Administration Record indicated that Vancomycin was not administered on four occasions, and Cefepime was missed three times. The dialysis provider's communication report also showed no documentation of antibiotics being given on these days. Interviews with the Director of Nursing (DON) confirmed the missed doses and highlighted a lack of communication between the nursing staff and the dialysis provider. The facility's policy required nursing staff to report the resident's condition and treatment provisions to the dialysis provider each treatment day and to follow up if no written report was received. However, this protocol was not followed, leading to the deficiency in care for the resident.
Failure to Use Barrier During Medication Administration
Penalty
Summary
The facility failed to apply a barrier while administering medications to a resident, identified as R15, who was observed to have type two diabetes mellitus without complications and impaired cognition with a BIMS score of 10 out of 15. On the morning of 12/11/24, an LPN was seen entering R15's room with two pre-filled syringes of long-acting insulin (Glargine) and one syringe of short-acting insulin (Flasp). The LPN placed all three syringes directly on the resident's bedside table, which was cluttered with various items and debris, without using a barrier. This action was contrary to the facility's medication administration policy, which requires the use of a barrier to prevent contamination and infection. The LPN later acknowledged that the medication should not have been placed directly on the bedside table. The Director of Nursing confirmed that placing medications on surfaces without a barrier is against the facility's policy due to the risk of contamination from concealed body fluids and other unknown contaminants.
Failure to Maintain Functioning Bathroom Call Light
Penalty
Summary
The facility failed to ensure that a bathroom call light was in working order for a resident, leading to unmet care needs and potential delays in responding to emergency situations. On the specified date, the resident, who was observed in the bathroom, expressed frustration that staff did not respond to the call light. The resident, who has a history of cerebral palsy, epilepsy, and dementia, required assistance with toileting but had to self-transfer due to the lack of response. The bathroom call light indicator was activated, but the indicator outside the door was not, preventing staff from being alerted. The resident's care plan indicated a need for substantial assistance with toileting due to various health conditions, including seizures and poor balance. Despite monthly audits of call light functionality, the Maintenance Director was unaware of the malfunctioning call light in the resident's bathroom. Staff are expected to use an electronic repair order system to report issues, but this was not done in this case, resulting in the deficiency.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident. On the specified date, an LPN was observed performing wound care for a resident with an open cancer lesion on the left breast. The LPN entered the resident's room and did not perform hand hygiene despite the presence of a hand sink. The LPN applied two pairs of gloves to each hand, removed the soiled dressings, and then removed all gloves without performing hand hygiene. The LPN then applied two more pairs of gloves to each hand to complete the wound care and again failed to perform hand hygiene after removing the gloves. During an interview, the LPN acknowledged that hand hygiene should have been performed when transitioning from dirty to clean dressings but did not do so because of double gloving. The Director of Nursing confirmed that hand hygiene should be performed before starting wound care, after removing soiled dressings, and after completing the treatment, and that double gloving should not replace hand hygiene. The facility's hand hygiene policy also states that gloves do not replace hand hygiene, and hand hygiene should be performed before donning and after removing gloves.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to include a resident on the podiatrist list, resulting in the resident having overgrown toenails and dissatisfaction with foot care. The resident, who had a history of cerebral infarction and hemiplegia affecting the left dominant side, reported not being seen by the foot doctor and having to make an outside appointment for nail trimming. An observation confirmed that the resident's great toenails had grown past the end of the toes. The resident's Electronic Health Record (EHR) showed no podiatry consults since admission, and there was no documentation of nail care being administered. The Social Worker indicated that a complete referral to the podiatry group was not sent, and the Director of Nursing acknowledged that a referral should have been made. The facility's policy on nail care emphasized the need for regular assessment and care, which was not followed in this case.
Failure to Administer Tube Feeding Per Physician's Orders
Penalty
Summary
The facility failed to administer tube feeding in accordance with physician's orders for a resident with a feeding tube, resulting in the tube feeding being on hold for an undetermined amount of time. This led to the resident receiving less nutrition than prescribed, with the potential for insufficient nutrition, hydration, and weight loss. The resident, who had anoxic brain injury and required a feeding tube, was observed with a tube feeding pump that was alarming, indicating the feeding was on hold. The feeding bottle, containing Jevity 1.5 Cal, was hung at 9:00 PM, contrary to the physician's order to start at 12:00 PM, and only 550 ml had been infused instead of the expected 876 ml. The Director of Nursing (DON) and the resident's nurse, an LPN, were unable to determine how long the feeding had been on hold or the total amount infused over 24 hours. The facility's Feeding Tube policy requires that feeding tubes be used according to physician's orders and that the administration of enteral nutrition is consistent with these orders. However, the discrepancy in the timing and amount of feeding administered indicates a failure to adhere to these standards, as the resident was approximately 300 ml short of the prescribed amount at the time of observation.
Inadequate Tracheostomy Care Due to Equipment Malfunction
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, identified as R510, who required humidified oxygen due to an anoxic brain injury. During an observation, it was noted that the trach collar tubing was connected to a compressor set at 0% humidification, contrary to the physician's orders of 5 L/28%. Additionally, the compressor's water bottle was leaking, causing water to accumulate in a plastic wash basin where the trach collection bag and some tubing were submerged. The resident, who was severely cognitively impaired and non-verbal, did not appear to be in distress at the time of observation. The Director of Nursing and a Respiratory Therapist acknowledged the incorrect humidification setting and the improper handling of the leaking equipment. The Respiratory Therapist adjusted the humidification setting and addressed the water leakage issue. The facility's policy mandates that tracheostomy care should be consistent with professional standards and the resident's care plan, which was not adhered to in this instance. The Director of Nursing noted that the staff should have notified the Respiratory Therapist immediately about the leaking equipment instead of allowing it to continue leaking.
Failure to Provide Ordered Occupational Therapy Sessions
Penalty
Summary
The facility failed to provide Occupational Therapy (OT) sessions as ordered for a resident, identified as R501, who was reviewed for physical rehabilitation. R501 had undergone surgery to lengthen tendons in the left forearm to improve hand function. Despite the physician's orders for OT sessions 3-5 times per week for 30 days, the facility's records showed that R501 received only one OT session during the week of 6/2/24 and one session during the week of 6/9/24, with no documented reasons for the missed sessions. This lack of therapy led to the resident's dissatisfaction and the decision to seek therapy outside the facility. Interviews with the Occupational Therapist and the Director of Nursing confirmed that R501 should have been seen at least three times a week as per the therapy plan. The facility's policy on Rehabilitation Therapy and Services, which was reviewed in 2022, states that therapy should be provided according to physician orders and be necessary to improve or maintain the resident's condition. The failure to adhere to these orders and the therapy plan resulted in missed therapy sessions for R501, contributing to the resident's dissatisfaction with the care provided.
Failure to Administer Glucagon for Hypoglycemia
Penalty
Summary
The facility failed to implement appropriate interventions for a resident experiencing hypoglycemia, which led to the resident's hospitalization and subsequent death. The resident, who had a diagnosis of End Stage Renal Disease and Type 2 Diabetes, was found unresponsive with a blood glucose level of 35. Despite having physician orders to administer glucose or glucagon for blood sugar levels below 70, the facility did not administer glucagon before the arrival of emergency medical services (EMS). The resident had received insulin earlier that morning, and there was no documentation of glucagon administration. Interviews with staff revealed that the resident was found unconscious, and CPR was initiated until EMS arrived. The Director of Nursing confirmed that glucagon was not administered, despite it being available in the backup medication system. The facility's diabetic protocol required immediate treatment for hypoglycemia, but the staff did not follow these guidelines. The resident was transported to the hospital with a glucose level of 13 and a chief complaint of cardiac arrest.
Failure to Provide Accurate Transfer Documentation
Penalty
Summary
The facility failed to provide accurate resident identifying documents and medical records during an emergency transfer to the hospital for one resident. This deficiency was identified through interviews and record reviews, revealing that the resident, who had cognitive impairment and pertinent diagnoses including End Stage Renal, Type 2 Diabetes, and Dysphagia, was transferred to the hospital due to a change in mental status and blood pressure monitoring. However, the necessary documentation, including the SBAR Communication Form and face sheet, was not correctly sent with the EMS personnel. Interviews with facility staff, including an LPN and the DON, confirmed that incorrect paperwork was sent with the resident during the transfer. The DON reported that two nurses were involved in the transfer process, and one of them mistakenly printed and provided the wrong paperwork to EMS. This error was only discovered when the hospital contacted the facility hours later to report that they had received another resident's information instead of the correct details for the transferred resident.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving two residents, R601 and R603. R601, who was admitted with diagnoses including anxiety, bipolar disorder, and paranoid schizophrenia, had no cognitive impairment as indicated by a BIMS score of 15 out of 15. A progress note dated 4/18/24 documented an incident from the previous night where R601 was reportedly touched under her shirt by another resident, R603. R603, who was legally blind and had a depressed mood and adjustment disorder, also had no cognitive impairment with a BIMS score of 15 out of 15. Despite the incident occurring on 4/17/24, it was not reported to the State Agency (SA) until 4/22/24 by the Nursing Home Administrator (NHA). The NHA, during an interview on 6/6/24, stated that the incident was not reported immediately because she did not consider it an allegation of abuse. However, the facility's policy on Abuse, Neglect, and Exploitation, revised on 1/10/24, requires that allegations involving abuse be reported immediately, but not later than two hours after the allegation is made. The failure to report the incident in a timely manner resulted in unreported allegations of abuse and the potential for further allegations to go unreported.
Failure to Implement Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to implement adequate interventions in a timely manner for a resident deemed to be at very high risk for pressure ulcers, resulting in the worsening of an existing stage 4 pressure ulcer. The resident, who had severe cognitive impairment and multiple medical conditions including end-stage renal disease and MRSA, was admitted with a stage 4 pressure ulcer on the sacral region. Despite the hospital discharge instructions specifying that the wound should be cleaned and dressed twice daily and as needed, the facility did not consistently follow these orders. The wound care nurse did not document all dressing changes, and there were instances where the dressing was not changed after the resident had a bowel movement, which was necessary to maintain wound cleanliness and integrity. The resident's clinical records showed a significant increase in the size of the sacral wound within a week, indicating that the wound care provided was insufficient. The wound measurements increased from 7.4 cm in length, 5.2 cm in width, and 4.5 cm in depth to 12.3 cm in length, 13.1 cm in width, and 5.2 cm in depth. The percentage of slough in the wound also increased from 50% to 60%. The facility's documentation revealed that the wound care nurse did not complete all scheduled dressing changes, and there was a lack of documentation for additional dressing changes that should have been performed after bowel movements. Interviews with the wound care nurse and the Director of Nursing confirmed that the wound care orders were not fully followed, and the necessary documentation was incomplete. The resident's death certificate indicated that septic shock and an infected sacral decubitus ulcer were the direct causes of death, with the chain of events leading to death beginning approximately 14 days prior. The facility's policy on pressure injury prevention and management emphasized the need for prompt assessment and treatment, but this was not adequately implemented for the resident, leading to the worsening of the pressure ulcer and contributing to the resident's death.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician and report abnormally elevated blood sugar levels for a resident with diabetes mellitus, resulting in the physician not having the opportunity to timely participate in medical decisions regarding care and treatment. The resident, who had multiple complex diagnoses including end-stage renal disease, acute respiratory failure, and type 2 diabetes mellitus, had a care plan that included monitoring glucose levels per orders. The physician's orders specified that for blood sugars above 401, the physician should be called. However, on January 17, 2024, the resident's blood sugar values were recorded as 459 and 436 at 12:00 AM and 6:00 AM, respectively, and the physician was not notified as required by the orders. During interviews, the LPN stated that nurses are to follow the guidelines for contacting the physician based on the physician's orders, and the DON confirmed that the physician should have been notified about the hyperglycemia. The DON reviewed the clinical record and acknowledged that there was no documentation indicating that the physician had been called. The failure to notify the physician about the elevated blood sugar levels was identified as a deficiency during the survey, and the facility did not provide any additional documentation or information to address this issue during the exit conference.
Failure to Accurately Reflect Diabetes Status in Physician's Assessment
Penalty
Summary
The facility failed to ensure a physician's assessment accurately reflected the current diabetes mellitus status for one resident, resulting in the potential for delayed execution of appropriate medical treatments and medical needs. The resident, who had a diagnosis of type 2 diabetes mellitus with diabetic peripheral angiopathy, was observed to have fluctuating blood sugar levels that were not adequately addressed by the physician. Despite the resident's blood sugar levels frequently exceeding 150 mg/dl, the physician's notes were repetitive and did not reflect an updated assessment or adjustment in the resident's care plan. The resident's Medication Administration Record (MAR) for February and March 2024 showed that blood sugar levels were monitored multiple times a day, with many readings above the threshold that would typically require insulin coverage. However, the scheduled insulin and additional insulin coverage had been discontinued. The physician's notes from February and March 2024 were found to be repetitive and did not indicate any new evaluation or adjustment based on the resident's current condition. Interviews with the Unit Manager and the Director of Nursing (DON) revealed concerns about the physician's lack of updated assessment and the repetitive nature of the clinical notes. The physician admitted to not being aware of any acute episodes regarding the resident's diabetes and stated that he should be contacted by the facility if blood sugars are low or high. The facility's policy on physician visits emphasized the need for active supervision and evaluation of the resident's condition, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 944 citations issued within 25 miles in the last 12 months — including the 5 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Taylor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Taylor | 0.3 mi | ★★★★★ | 15 | 0 |
| Regency, A Villa Center | 0.6 mi | ★★★★★ | 16 | 0 |
| Optalis Health And Rehabilitation Of Allen Park | 2.8 mi | ★★★★★ | 1 | 0 |
| The Orchards At Southgate | 3.5 mi | ★★★★★ | 8 | 0 |
| Rivergate Terrace | 3.7 mi | ★★★★★ | 13 | 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.