Below average — CMS composite of the measures below.
The next survey window likely opens 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 Manor Of Farmington Hills during CMS and state inspections, most recent first.
Insufficient nursing staffing led to unmet resident care needs when a resident who required a mechanical lift waited hours to be returned to bed and another resident reported not being changed for about 12 hours. Staff said only four CNAs were working the afternoon shift for the entire building instead of the usual six, and managers stayed over to help with basic care tasks such as passing water, dinner trays, answering call lights, and changing residents.
Food service safety standards were not followed when a reach-in cooler in the main kitchen was observed leaking clear liquid from the top fan unit onto food stored below. The CDM reported the cooler was not functioning properly and that repairs were pending, while contaminated items included pesto sauce, shredded cheese, sliced cheese, prepared sandwiches, and pre-made chicken salad stored in the affected area.
A facility failed to maintain resident privacy during ear care and clinical assessments for multiple residents. An NP provided treatment and evaluations with doors and curtains open, and in some cases the care and discussion were audible from the hallway or visible to a roommate. The DON stated staff should close the door or pull the curtain and speak in a manner that ensures privacy, consistent with the facility's privacy policy.
Unsafe wall corner coverings and a damaged handrail were observed outside multiple resident rooms and throughout Unit 1 and Unit 2. Numerous plastic wall edge protectors were broken or missing with splintered, sharp edges at ankle level, and one handrail had a large gap exposing a sharp metal bracket. The Mnt Dir confirmed the conditions, stated the areas were often hit by carts, and documentation reviewed did not show the issues in recent audits or include repair records.
Failure to timely report an allegation of mistreatment. A resident with dementia, psychotic disturbance, anxiety, and dependence on staff for most ADLs told the psych NP she felt mistreated by certain people, but could not identify who or what they were doing. The SW met with the resident but obtained no further details, and staff were unsure whether the allegation had been reported to the State Agency within the required timeframe, despite policy requiring immediate internal reporting and timely external notification.
Failure to Enter NPO Order on Admission: A resident admitted after a CVA was documented as strict NPO with bolus tube feedings, but the NPO physician order was not entered until after admission. Because the diet order was missing, dietary generated a meal ticket and the resident received a lunch tray and ate part of it before staff discovered the error; the nurse then notified the unit manager and MD and a CXR was ordered to rule out aspiration.
A resident with an external fixator and severe left leg pain had an open, bleeding area on the posterior calf that was not promptly assessed, documented, or placed under a treatment order. Staff gave conflicting accounts about the wound, and the wound care coordinator and RN acknowledged the calf wound had not been properly evaluated when first identified. Later, an NP described the area as an acute partial thickness abrasion with drainage.
Failure to Timely Identify and Treat a Pressure Ulcer: A resident with severely impaired cognition and multiple diagnoses developed a facility-acquired Stage 4 pressure ulcer. Staff documented new skin areas during assessment, but the wound was later identified as a Stage 4 ulcer with slough/eschar, and interviews indicated the wound was visible during care and should not have been discovered at that stage.
Medication Left Unsecured and Improperly Discarded: A nurse found an unidentified pill on the hallway floor near a resident room, picked it up with a glove, and discarded it in the resident’s trash can before returning to the med cart. The pill was later observed in the trash can by the Nurse Manager, who removed it. The facility policy stated meds and biologicals must be stored safely and securely and accessible only to authorized staff.
Failure to Complete Ordered Facial X-Ray: A resident developed discoloration and bruising to the left chin/jawline, and the MD ordered skull and facial x-rays. The EMR contained results only for the skull x-ray, with no documentation that the lower left jaw x-ray was completed, and the DON and Nurse Manager confirmed the missing order/result in the record.
A resident with severe cognitive impairment and a physician order for 1:1 feeding assistance was left unsupervised with a meal tray, resulting in choking and death. Staff did not provide the required supervision, and the facility's investigation lacked thorough documentation and a clear timeline of events, despite ongoing concerns from family and hospice staff about inadequate feeding assistance.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
Two residents were not properly assessed or provided with timely admission orders, leading to missed medication doses. One resident with multiple chronic conditions did not receive any of their prescribed medications due to incomplete transcription of hospital discharge orders and lack of an admission nursing assessment. Another resident admitted in the evening did not receive scheduled night-time medications because orders were entered with a start date for the following day. The DON confirmed that nursing staff did not complete required admission procedures in these cases.
A resident who required significant assistance with daily living and had intact cognition was left without a functioning call system due to depleted batteries and lack of timely maintenance notification. The call light indicator was not working, resulting in staff being unaware of the resident's request for help, and the issue persisted over a weekend without resolution.
An LPN allowed their minor daughter to be present during medication preparation, administration, and resident care, including entering resident rooms and observing care activities. Staff and video evidence confirmed the daughter's presence at the medication cart, during medication administration, and behind the nurse's station desk, resulting in a breach of resident privacy and confidentiality of PHI.
Two residents experienced failures in wound prevention, timely identification, and treatment, with one developing multiple untreated wounds that were not documented or addressed until discovered by a family member and the wound care coordinator, and another experiencing numerous omitted wound care treatments for existing pressure ulcers, as confirmed by review of records and staff interviews.
A resident in a long-term care facility hit their head against the wall while being turned by a CNA, who failed to follow the care plan requiring two-person assistance. The incident was investigated, revealing the bed's positioning and the CNA's misunderstanding of the resident's assistance needs. Despite the resident's complaint of a headache, a complete neurological assessment was not documented, contrary to facility policy.
The facility failed to provide effective pressure ulcer care for two residents. One resident did not receive timely treatment for a Stage 3 sacrum wound upon admission, while another had an untreated open area on the left buttock and duplicate treatment orders for the right buttock. The Wound Care Nurse was unaware of these issues, indicating a lack of communication and oversight.
A facility failed to accurately monitor a resident's weight, leading to discrepancies between the facility's records and those from a dialysis center. The resident, with end-stage renal disease and recent amputations, experienced significant weight loss. The facility did not account for the amputations in their weight records, and the Director of Nursing acknowledged the issue but was unsure when it was first identified.
A facility failed to properly assess and monitor an IV catheter and Permacath site for a resident. Observations revealed undated dressings and a lack of documentation or care plans for catheter monitoring. The DON acknowledged the need for policy adherence, but no further documentation was provided. A physician's note confirmed the catheter sites were clean and intact, but lacked additional details.
A resident with a right-hand contracture did not receive appropriate treatment as the facility failed to apply a prescribed hand splint. Despite the resident's inability to apply the splint independently and their repeated requests for assistance, the staff did not help, and the splint was not documented in the care plan or treatment records. The DON and Unit Manager were unaware of the issue until informed by the resident.
A facility failed to implement physician orders for a resident with a colostomy, leading to a deficiency in care. The resident, experiencing abdominal pain, was ordered bisacodyl 5mg via the stoma, but the order was not entered or administered. The resident's condition worsened, resulting in unresponsiveness and death. The DON confirmed the lack of documentation and acknowledged the need for a new order.
A resident with acute and chronic respiratory failure, COPD, and asthma did not receive necessary care at an LTC facility. The facility failed to implement physician orders for supplemental oxygen and CPAP/BiPAP use, leading to respiratory distress, a fall, and ultimately the resident's death. There was no documentation of physician orders or care plans for these interventions, and prescribed antibiotics were not administered. Staff interviews revealed a lack of awareness and communication regarding the resident's care needs.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to four residents, leading to complaints about unexpected private pay charges and inability to appeal. The deficiency was linked to a transition in business office management and communication issues between staff, resulting in residents not being informed of their financial liabilities in a timely manner.
The facility was cited for insufficient staffing, leading to delayed care and unmet needs for residents. Interviews and observations revealed that residents experienced long wait times for assistance, particularly on weekends and night shifts. Staff reported being overwhelmed with high resident-to-staff ratios, impacting their ability to provide timely care. Specific residents with medical needs were notably affected, with reports of inadequate personal hygiene assistance and delayed medication administration.
The facility failed to treat residents with dignity, as staff did not assist a resident in a wheelchair and entered rooms without knocking or announcing themselves. Additionally, a resident was not allowed to keep a personal storage bin due to infection control concerns, despite similar bins being present in other rooms. The facility's policies on resident rights were not upheld.
The facility failed to accommodate the needs and preferences of residents, resulting in discomfort and frustration. A resident was observed with their feet hanging over the end of a too-short bed, while others had water cups placed out of reach, preventing independent hydration. The DON was unaware of these issues until the survey, and the Unit Manager acknowledged that water should be within reach.
A facility failed to protect resident health information when a paper with personal details was left visible at a nursing station, affecting five residents. The unit manager acknowledged the error, which violated the facility's policy on resident privacy and confidentiality.
A facility failed to obtain a physician order for a resident's continuous oxygen therapy and did not monitor the humidifier attached to the oxygen concentrator, which was found empty. The resident reported discomfort due to the dry air, and staff interviews revealed a lack of awareness and responsibility for maintaining the humidifier. No orders for oxygen use or monitoring were documented in the resident's records.
The facility failed to maintain consistent dialysis communication documentation for two residents and did not provide a meal for another resident before their hemodialysis appointment. Despite care plans requiring communication forms, these were missing from the EMR. Additionally, a resident reported not receiving a meal before dialysis, despite being at nutritional risk. Staff interviews confirmed these lapses, but no corrective actions were provided before the survey exit.
The facility failed to properly label, store, and discard expired medications and biologicals, with issues observed in four out of seven medication carts. Expired supplements, improper storage of test reagents, and unattended medications were noted. Insulin pens lacked open dates, and a transdermal patch was left unattended. The DON acknowledged the lapses in medication management.
The facility failed to provide menu items listed on meal tickets for several residents, resulting in them not receiving nutritional supplements, desserts, or beverages as indicated. Observations showed that residents did not receive items like nutritional juice, magic cups, or hot beverages. The dietician confirmed that these items should have been provided by the dietary department and CNAs. The facility's policy did not address the responsibility to meet resident food and beverage preferences.
The facility failed to provide fresh water and assistance with consuming fluids to residents, resulting in the potential for dehydration. Observations showed that residents had room temperature water cups with straws still in wrappers, indicating a lack of assistance. The Unit Manager confirmed that staff were supposed to refresh the water throughout the day, but this was not done, violating the facility's oral hydration policy.
The facility failed to serve meals in a timely manner, with lunch and dinner often delayed due to staffing challenges. Residents reported inconsistent meal times, with breakfast sometimes served after 10 AM and lunch and dinner significantly delayed. The Certified Dietary Manager acknowledged the issue, attributing it to call-offs affecting the entire day's schedule.
The facility failed to follow infection control standards, including proper PPE use and hand hygiene, potentially risking infection spread. An LPN did not change gloves or perform hand hygiene during medication administration. Resident care involving a suprapubic catheter was conducted without proper PPE, and a urine-filled catheter bag was improperly disposed of. Another resident with a midline catheter and open wounds was not placed on Enhanced Barrier Precautions as required.
The facility failed to maintain safe and secure handrails in the 100 and 200 hallways, with broken and jagged sections exposing sharp materials. A handrail near the kitchen exit was also detached from the wall. The Maintenance Director admitted to infrequent audits and was unaware of specific issues until the survey. An electronic reporting system for maintenance issues was in place but not effectively used.
A resident in a facility reported not receiving new, sterile urinary catheters, leading to the reuse of catheters and a suspected UTI. Despite expressing concerns to staff and during a care conference, no follow-up actions were taken, such as ordering a urinalysis. Interviews revealed a breakdown in communication and grievance handling, with the Director of Nursing acknowledging the failure to address the resident's concerns.
A resident with multiple medical conditions, including a Wound VAC, reported not receiving adequate assistance from staff to get out of bed or maintain personal hygiene, despite multiple requests. Observations noted the resident in an unkempt state, and discrepancies were found in staff documentation regarding the resident's care. The facility failed to provide necessary care and services consistent with the resident's needs and choices.
A resident with severe cognitive impairment and legal blindness did not receive necessary one-to-one feeding assistance as required by their care plan. Observations showed the resident struggling to eat independently, with food spillage and inadequate staff support. The facility's DON acknowledged the oversight, but no policy on feeding assistance was provided during the survey.
The facility failed to monitor and assess skin changes and implement pressure-relieving interventions for two residents, leading to deficiencies in pressure ulcer management. One resident developed stage 2 pressure ulcers due to lack of monitoring, while another was observed without heel protectors despite being at risk. Staff were unaware of care plan interventions, highlighting oversight in pressure ulcer management.
The facility failed to provide proper catheter care and monitoring for two residents, leading to potential urinary tract infections. One resident reused catheters due to a lack of sterile supplies, while another had abnormal urine observations that were not reported to a physician. Despite having catheter kits in stock, the facility did not ensure their availability to the residents.
A resident with multiple health conditions experienced significant weight fluctuations without timely follow-up or re-weighing by the facility. Despite the resident's risk for nutritional deficiencies, the Registered Dietician and Interdisciplinary Team did not address the weight variations promptly, and there was no updated plan for frequent monitoring. Interviews revealed a lack of coordination and timely response, and the facility's weight monitoring policy was not provided.
The facility failed to provide timely lab services for two residents. One resident did not receive a scheduled valproic acid level test, and another resident, showing UTI symptoms, did not have a urinalysis ordered. Staff confirmed the oversight, and communication issues were identified.
A resident with a history of malignant neoplasm required an MRI for their left thigh, as ordered by their cancer doctor. The facility failed to schedule the MRI within the specified timeframe, and there was no documentation of follow-up actions. Interviews revealed a lack of coordination and documentation by the staff responsible for scheduling, and the facility's policy did not address radiology services.
The facility failed to provide adequate staffing, affecting resident care. Two residents reported issues such as infrequent showers and long wait times for assistance, attributing these to staffing shortages. Interviews with CNAs and staffing personnel confirmed that staffing levels were not adjusted based on resident needs, leading to overworked staff and uncompleted care tasks. The facility had multiple open aide positions, highlighting a significant staffing gap.
A resident was abandoned at a chemotherapy appointment after the facility canceled their return transportation and discharged them without proper communication or arrangements. The resident waited for five hours before family members could pick them up, and they had to stay in a motel overnight before going to the hospital for medical care. Facility staff failed to ensure the resident's safe return and proper care, resulting in significant distress and harm.
The facility failed to ensure that two staff members were properly screened for criminal background checks, allowing them to work without the necessary clearances. Despite multiple requests, the facility could not provide the required documentation, resulting in the potential for abuse or neglect to occur.
A resident with severe cognitive impairment had their PEG tube removed and was started on hypodermoclysis without their guardian being notified. The facility's policy on Notification of Change was not followed, as confirmed by the DON and an LPN.
A facility failed to document and address grievances raised by a resident's family member about inadequate care, resulting in unresolved complaints and frustration. The Social Work Director communicated the concerns to the Director of Nursing, but no follow-up or documentation was completed as required by the facility's grievance policy.
The facility failed to accurately complete assessments for a resident who developed intense pain from a blood clot requiring hospitalization. Despite reporting severe pain and swelling, the nurse only provided pain medication and did not assess the leg or call EMS. The resident was later diagnosed with a blood clot requiring surgery.
Insufficient Nursing Staffing on Afternoon Shift
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and did not have enough nursing staff available on the afternoon shift, affecting residents including R46 and R27. R46, who was cognitively intact and dependent on staff for transfers, reported that on 9/22/25 she asked to be put back to bed around 5:00 PM before dinner, but was told there were not enough staff because she required a mechanical lift and two staff members, and she was not assisted until 9:40 PM. She stated she was tired from sitting in the chair that long and that her bottom hurt. R27, who was cognitively intact and dependent on staff for toileting hygiene, reported she was not changed for about 12 hours on 9/22/25. She said she was changed around 4:00 PM and then not again until early morning on 9/23/25, and was told staff were short. Record review showed 98 residents in the facility and four afternoon assignment sheets that did not document staffing for Unit 3. CNA Z stated there were four CNAs working the afternoon shift for the entire building instead of the usual six and that some care tasks could not be completed with three CNAs for 100 residents. The Administrator and DON stated there were call-ins and that three managers stayed over to help, and the managers confirmed they assisted with passing water, dinner trays, answering call lights, and changing residents, with time punches showing they left at 7:26 PM and 7:27 PM.
Food Stored Under Leaking Reach-In Cooler
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety after surveyors observed a reach-in cooler in the main kitchen with a clear, watery liquid coming from the top fan unit, which was not functioning. The Certified Dietary Manager reported that the cooler was not working properly, that repairs had been attempted about a week earlier, and that a new gasket part and drip pan were still needed. The liquid was reported to be coming from the ceiling area of the cooler where the fan was located. Food stored directly underneath the leaking area was visibly contaminated with the clear liquid. Items observed included a cardboard box soaked with several two-pound tubs of pesto sauce, several large bags of shredded cheese, two packages of sliced cheese, a container of prepared sandwiches with liquid on the outside of the clear sandwich bags and pooled in the bottom of the plastic bin, and a container of pre-made chicken salad covered in clear liquid. When asked why food was stored under the leaking area instead of in other nearby reach-in coolers, the CDM stated the food should not have been stored there and began removing the items to discard them.
Failure to Maintain Resident Privacy During Care and Clinical Assessments
Penalty
Summary
The facility failed to ensure residents' right to personal privacy during clinical assessment and provision of care for five residents reviewed for privacy. On 9/23/25, an ancillary ear care NP was observed providing ear wax removal to one resident from the hallway without closing the door or pulling the privacy curtain. At the same time, another resident was observed lying in bed watching a roommate receive ear care, and the door and curtain were not closed to ensure privacy. Later that morning, a PMR NP entered another resident's room and did not close the door or pull the privacy curtain; the evaluation could be heard from across the hallway, including discussion of when the resident last had a bowel movement. Another resident was also seen with the door and curtain open during an evaluation, and the evaluation was heard from the hallway outside the room. The residents involved had diagnoses including vascular dementia with psychotic disturbance, cerebral infarction, ruptured abdominal aortic aneurysm, peripheral vascular disease, essential hypertension, orthopedic aftercare following surgical amputation, femur fracture, type 2 diabetes mellitus, schizoaffective disorder, autistic disorder, bipolar disorder, and diabetic polyneuropathy. One resident had moderately impaired cognition per MDS. During interview, the DON stated that privacy is privacy and that staff should close the door or pull the curtain and speak in a manner that ensures privacy. The facility policy titled Resident Dignity & Personal Privacy stated that each resident's right to personal privacy includes confidentiality of personal and clinical affairs, that residents should be examined and treated in a manner that maintains privacy, and that a closed door, drawn curtain, or both should be used during personal care and treatment procedures.
Unsafe Wall Corner Coverings and Damaged Handrail
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 14 resident rooms and throughout the hallways on Unit 1 and Unit 2. On observation, numerous broken-off plastic wall corner edges were seen outside resident room doorways, with splintered and sharp edges, and most of the broken or missing pieces were at ankle level. A handrail outside one resident room was also observed to have a large gap of about two inches that exposed a sharp metal bracket inside the plastic covering. During interview, the Maintenance Director stated that environmental concerns were monitored through audits and that staff entered concerns into the electronic reporting system. The Maintenance Director confirmed the broken, sharp wall edge coverings and stated those areas were often hit by carts and easily broken, and that repairs could take a while because parts were not always easy to get right away. The Maintenance Director also confirmed the sharp-edged handrail gap but was not aware it could happen and was unable to pull the handrail pieces together. Review of documentation showed only kitchen repairs, no electronic reports from the past six months, no maintenance audit identification of the broken wall edge coverings or handrail, and no invoices or requests for previous orders of the plastic wall corner edging.
Failure to Timely Report Allegation of Mistreatment
Penalty
Summary
The facility failed to report an allegation of mistreatment to the Abuse Coordinator and/or the State Agency within the required time frame for one resident. The resident had been admitted and later readmitted with diagnoses including acute respiratory distress syndrome, vascular dementia with psychotic disturbance, delusional disorders, generalized anxiety disorder, and adult failure to thrive. The MDS assessment showed moderately impaired cognition and dependence on staff for most ADLs. In a psych NP note, the resident stated she wanted to go home, did not like the facility, and felt she was being mistreated by certain people, though she could not identify who or what they were doing. The social worker met with the resident the next day after being notified of the allegation, but the resident did not provide further details and said, "I can't think right now." During interview, the social worker stated the administrator had been notified by email, but was unsure whether the allegation had been reported to the State Agency. The administrator later stated they were not aware of the allegation and had not yet reviewed the email. The facility policy required staff to immediately report allegations or suspicions of mistreatment, abuse, neglect, exploitation, misappropriation of property, and injuries of unknown source to the Administrator and DON, and required notification to state or federal agencies within the required time frames.
Failure to Enter NPO Order on Admission
Penalty
Summary
The facility failed to ensure appropriate diet orders were entered upon admission for a resident admitted after a stroke with aphasia and right-sided weakness who was documented as strict NPO with bolus tube feedings. The admission nursing summary stated the resident was strict NPO, but the physician's order for Nothing By Mouth was not entered until the afternoon of 9/19/25, after the resident had already been admitted. A facility policy stated physician orders are obtained to provide clear direction in the care of the resident and are transcribed into the EMR by the receiving licensed nurse once verified. On 9/19/25, the resident was observed with a lunch meal tray at the bedside and was documented to have consumed part of the tray despite being strict NPO. The nurse documented that the meal tray was removed, the resident was assessed, the unit manager and physician were notified, and a chest x-ray was ordered to rule out aspiration. Interviews with the LPN, DON, and dietary staff showed the diet order had not been entered on admission, dietary created a meal ticket because there was no indication the resident was NPO, and staff identified miscommunication between nursing and dietary regarding the resident's diet status.
Untreated calf wound lacked timely assessment and order
Penalty
Summary
The facility failed to assess and treat a skin impairment in a timely manner for a resident with an external fixation device to the left lower extremity and significant pain with limited movement of the left leg. The resident was observed with an open area to the back of the left calf that was pink with two red bleeding areas in the center, and no dressing was in place at the time of observation. The resident reported the wound had been present since the hospital stay, that it was painful and bleeding, and that he had been trying to get it covered since early that morning. Record review showed the resident was admitted with diagnoses including hypotension and acute embolism and thrombosis of the right lower extremity. A nursing summary documented a skin assessment on admission that noted the external fixation device and severe pain, and a later nursing note documented a skin tear to the posterior left calf with a dry gauze dressing in place. However, there was no documented assessment of the calf wound on the date it was first noted, no wound assessment for that area in the record, and no physician order for treatment to the left calf. The record contained wound assessments for the surgical wounds to the front of the left leg, but not for the calf wound. Staff interviews showed confusion about who was responsible for identifying, assessing, documenting, and ordering treatment for new wounds. The RN who observed the wound stated it was not assessed when seen that morning. The wound treatment nurse stated she had not seen the wound and that a new wound should be assessed, documented, and reported to the wound coordinator and provider, but she also stated she had not been notified about the calf wound until later. The wound care coordinator stated she did not know about the calf wound until the day of the survey and acknowledged there was no documented assessment of it. A later NP visit identified the wound as an acute partial thickness abrasion on the posterior left calf with a small amount of serous drainage.
Failure to Timely Identify and Treat a Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to timely identify and treat a facility-acquired pressure ulcer for one resident, resulting in the resident acquiring a Stage 4 pressure ulcer. The resident had diagnoses including hypertensive urgency, fracture of the left pubis, and stroke, and the MDS indicated severely impaired cognition. The resident’s skin care plan directed weekly head-to-toe skin assessments and notification of the nurse for any new skin breakdown noted during care. A Skin/Wound Progress note documented that during a skin assessment, the resident was observed with three new areas, not including sacral MASD already being treated. A Skin & Wound Evaluation identified a new in-house acquired Stage 4 pressure ulcer on the right gluteal fold, measuring 6.4 cm by 1.8 cm and 100% filled with slough, with the wound documented as new and acquired on 8/15/25. The attached picture showed an open wound completely obscured by slough on the left gluteal fold, although the evaluation documented the wound as right gluteal fold. On later observation, the left gluteal fold wound was seen uncovered and appeared approximately 4 cm by 3 cm with eschar, and the resident also had a sacral wound previously identified as MASD. Staff interviews indicated the wound should not have been discovered at Stage 4 and that the wound was visible during care, while the DON stated pressure ulcers should be identified and treated timely.
Medication Left Unsecured and Improperly Discarded
Penalty
Summary
Medication was not stored in a secure and safe manner, and proper disposal of medication was not ensured for one of three medication carts observed. On 9/23/25 at 11:16 AM, a large green pill was observed on the hallway flooring just outside of a resident's room. A nurse was several doors away at the medication cart and came over when asked. The nurse confirmed the pill was on the floor, could not identify what it was or who it belonged to, and used a disposable glove to pick it up and inspect it. The nurse reported there were no markings on the pill and that it looked similar to a seizure pill, though the seizure pill was blue. The nurse then discarded the pill and the glove in the resident's trash can inside the room and returned to the medication cart to continue medication administration. At 11:27 AM, the Nurse Manager observed the pill in the trash can and stated they would have to re-educate the nurse immediately, then removed the pill from the trash can. The facility policy titled Medication Storage, dated 7/23/2019, stated that medications and biologicals are to be stored safely, securely, and properly, and that medication supply is accessible only to authorized personnel.
Failure to Complete Ordered Facial X-Ray
Penalty
Summary
The facility failed to obtain physician-ordered x-rays for one resident who was reviewed for radiology and diagnostic services after staff observed discoloration and bruising to the left side of the chin/jawline. Nursing documentation noted the resident had discoloration to the left side of the chin, the MD was notified, and a skull x-ray was ordered. A physician note later documented that the resident was seen after staff reported bruising on the left side of the chin and that an x-ray would be ordered. Review of the physician orders showed an x-ray order for a skull x-ray related to swelling and discoloration of the chin and another order for a facial x-ray of the lower left jaw. The EMR contained radiology results only for the skull x-ray, and there was no documentation that the lower left jaw x-ray had been completed as ordered. The EMR also did not explain why the x-rays were documented as ordered on one date but created on a later date. During interview, the DON and Nurse Manager confirmed that only the skull x-ray was in the record and that the lower left jaw x-ray order could not be located or verified as completed.
Failure to Provide Required 1:1 Feeding Assistance and Incomplete Incident Investigation
Penalty
Summary
A resident with severe cognitive impairment, dementia, and a history of significant weight loss was assessed as requiring 1:1 feeding assistance during meals, as documented in the care plan and physician orders. Despite this, the resident was left unsupervised with a meal tray during lunch in the dining room. The tray was placed in front of the resident without a staff member present to provide the required 1:1 assistance. Multiple staff interviews and documentation revealed that no one was directly assisting or supervising the resident at the time the choking incident occurred. The resident began to choke on corned beef, and the event was not immediately witnessed by staff assigned to provide feeding assistance. When the choking was noticed, staff responded with chest thrusts, back blows, suctioning, and oxygen administration, but the resident ultimately expired shortly thereafter. Interviews with staff, hospice personnel, and the resident's family indicated ongoing concerns and previous reports that the resident was not consistently receiving the required 1:1 feeding assistance, despite repeated notifications to facility administration. The facility's investigation into the incident was incomplete, lacking thorough documentation of staff interviews and a clear timeline of events. There was no evidence that all potential witnesses were interviewed or that a comprehensive root cause analysis was conducted. The facility's own policy required documentation and interviews for incidents and accidents, but these steps were not fully carried out. The failure to provide the ordered 1:1 feeding assistance and to conduct a thorough investigation contributed to the deficiency cited.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and goals of the resident. Specific details regarding the resident’s medical history and condition at the time of the deficiency were not provided in the report.
Failure to Complete Timely Admission Orders and Assessments Resulting in Missed Medications
Penalty
Summary
The facility failed to ensure timely admission orders and nursing assessments for two residents upon admission, resulting in missed medication administration. For one resident with diagnoses including Type 2 Diabetes and Congestive Heart Failure, the hospital discharge orders listed multiple medications to be administered upon admission. However, only two medications were transcribed into the facility's physician order summary, and the resident did not receive any medications during their stay. Additionally, there was no nursing assessment completed at the time of admission for this resident. For another resident admitted in the evening with diagnoses of pneumonia, diabetes, heart disease, and high blood pressure, hospital discharge instructions required administration of night-time medications, including atorvastatin and Lantus insulin. Although these medications were ordered in the facility's system, the start dates were set for the day after admission, resulting in the resident not receiving their scheduled night-time medications on the day of admission. The DON confirmed that the expectation was for nursing staff to complete initial assessments and transcribe medication lists promptly upon admission, which did not occur in these cases.
Failure to Maintain Operational Call System in Resident Room
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's call system was operational. The resident, who had diagnoses including dysphagia, end stage renal disease, and congestive heart failure, required assistance with most activities of daily living and had intact cognition. The resident reported that their call light was not answered in a timely manner, sometimes waiting hours or not being answered at all. During observation, the resident activated their call light to request water, but after 45 minutes, no staff had responded, and the indicator light above the doorway was not illuminated. A Certified Nursing Assistant confirmed that the call light button was working, but the indicator light was out, so staff were unaware of the resident's request. The CNA stated that the call light had been broken all weekend and that there was no maintenance staff available on weekends. The Maintenance Director later explained that the batteries in the call light system were depleted and needed replacement, but maintenance was not notified of the issue until the following morning. Facility policy required staff to notify maintenance if a call light was not working, but this procedure was not followed.
Unauthorized Individual Present During Resident Care and Medication Administration
Penalty
Summary
A deficiency occurred when an LPN brought their 15-year-old daughter onto the 300 Hall unit during their shift, allowing her to be present while preparing and administering medications, as well as providing resident care. The daughter was introduced to other staff, escorted the LPN into resident rooms, and observed the LPN taking a resident's blood pressure and administering medications to residents, including a male resident in the hallway. The LPN admitted to asking a female resident for permission for her daughter to observe care and acknowledged the inappropriateness of the situation, recognizing it as a violation of HIPAA regulations. Multiple staff members confirmed the daughter's presence and involvement, and video footage corroborated that the daughter was at the medication cart, observed medication administration, and was behind the nurse's station desk. The Nursing Home Administrator and Director of Nursing reviewed the footage and acknowledged that the LPN's actions had the potential to violate resident privacy and confidentiality of protected health information (PHI), as required by federal regulations.
Plan Of Correction
F-583 ELEMENT I Residents residing on Unit 300 hall (short stay rehab unit) on May 24, 2025, no longer reside in the facility. LPN “D” is no longer employed at the facility. ELEMENT II Residents residing within the facility have the potential to be affected. Residents residing on Unit 300 hall with the potential for unauthorized disclosure of protected health information had no negative effects due to this practice. Rounds were made throughout the facility to validate that no HIPAA-related information is discussed or visible in non-confidential areas; no concerns were noted. ELEMENT III The facility policies with respect to HIPAA, Standard of Nursing Practice, and Notice of Privacy were reviewed and deemed appropriate. Active staff were re-educated on the facility's policy regarding HIPAA to ensure compliance with maintaining personal privacy and medical records in accordance with CFR (s): 483.10(h)(1)-(3)(i)(ii). In addition, the professional license nurses were re-educated on the Standard of Nursing Practice. ELEMENT IV The DON/designee will audit the resident areas to validate that no HIPAA-related information is discussed or visible in non-confidential areas weekly for 4 weeks and monthly for 2 months. Any areas of concern will be addressed immediately. Findings from the audit will be brought to the Monthly QAPI Meeting for further review and recommendations. The DON is responsible for obtaining and maintaining compliance.
Failure to Prevent, Identify, and Treat Wounds and Complete Wound Care Documentation
Penalty
Summary
The facility failed to prevent the development of new wounds, provide timely wound care, and accurately document new skin impairments for two residents. One resident, with diagnoses including peripheral vascular disease, dementia, and malnutrition, was at high risk for skin breakdown and required staff assistance for care. Despite care plans specifying weekly head-to-toe skin assessments and immediate reporting of new skin issues, there were significant lapses in documentation and assessment. Multiple wounds, including on the right lateral hip, heel, toes, lateral ankle, and lateral foot, were not identified or treated in a timely manner. There were gaps in weekly skin assessments, and no treatment orders or documentation of wound care were present until after the wounds were discovered by the resident’s daughter and the wound care coordinator. Another resident, dependent on staff for all activities of daily living and diagnosed with multiple sclerosis, had multiple pressure wounds, including stage 3 and 4 ulcers. Review of medication and treatment administration records revealed numerous omitted wound care treatments over several months. The wound nurse reported that when assigned to work as a floor nurse, other nurses were responsible for wound care, but treatments were often not completed as required. The facility’s own policy required identification, evaluation, and appropriate treatment for residents with wounds or at risk for skin compromise, but this was not consistently followed. Interviews with the wound care nurse and DON confirmed ongoing issues with timely and accurate skin assessments, reporting of changes in condition, and completion of wound care treatments. The facility acknowledged problems with staff not completing required wound care and documentation, leading to delays in treatment and lack of adherence to physician orders and care plans for residents with wounds.
Failure to Provide Adequate Supervision and Care During Resident Turning
Penalty
Summary
The facility failed to ensure proper care and supervision for a resident, identified as R702, which resulted in an accident. On the date of the incident, R702 was being turned by a Certified Nursing Assistant (CNA) when they hit their head against the wall. The resident reported that the CNA should have used a second person to assist with the turning. The CNA involved in the incident was described by the resident, who noted that the CNA is no longer allowed to care for them. The resident also mentioned that they would hold onto a large stuffed animal to protect their head in the future. The facility's investigation into the incident revealed that the resident's bed was positioned against the wall, and the CNA admitted to hearing the resident complain of a headache after being turned. The CNA believed the resident was a one-person assist, contrary to the care plan, which required two-person assistance for bed mobility. The facility's investigation concluded that the resident's head was likely hit unintentionally due to the bed's positioning and the presence of many items on the bed. The facility's records showed that R702 had a history of disability and required assistance with self-care and mobility. Despite the incident, there was no complete neurological assessment documented in the resident's record, which is against the facility's policy for evaluating a resident's neurologic status after a potential head injury. The Administrator and Director of Nursing acknowledged the lack of documentation and noted that only partial neurochecks were provided at the end of the survey.
Failure to Implement Effective Pressure Ulcer Care
Penalty
Summary
The facility failed to implement effective interventions and accurate wound treatments for two residents with pressure injuries. For the first resident, R901, the facility did not initiate treatment orders for a Stage 3 sacrum wound upon admission. The resident was admitted with a pressure ulcer, but treatment orders were not implemented until four days later. The Wound Care Nurse acknowledged that the admitting nurse should have contacted the doctor to implement a treatment order immediately upon admission. For the second resident, R902, the facility failed to provide adequate care to prevent a pressure wound. During an observation, an open area with maceration was identified on the left buttock, but no treatment was applied. Additionally, there were duplicate treatment orders for the right buttock, which were not clarified or corrected until after the surveyor's observation. The Wound Care Nurse was unaware of the left buttock impairment and the duplicate orders, indicating a lack of communication and oversight in wound care management. Both cases highlight the facility's failure to ensure timely and appropriate wound care interventions, as well as the lack of proper documentation and communication among staff. The Director of Nursing confirmed that all skin impairments should be reported to the physician and have treatment in place, but this protocol was not followed in these instances.
Failure to Accurately Monitor Resident's Weight
Penalty
Summary
The facility failed to accurately obtain and monitor weights for a resident, identified as R902, who was reviewed for weight loss. The resident was readmitted to the facility with diagnoses including end-stage renal disease and dependence on renal dialysis. During an observation, R902 was seen eating without assistance, despite having food scattered on a towel covering their chest. The resident mentioned that staff had offered help, but they declined. A review of the resident's weight summary showed significant discrepancies between the facility's recorded weights and those documented by the dialysis center. The facility's records did not account for the resident's amputations, which affected their baseline weights. An interview with the Director of Nursing (DON) revealed that the facility had not identified the inaccurate weights obtained for September and October 2024. The DON acknowledged the discrepancies and mentioned that a strategy was being implemented to ensure accurate and consistent weight measurements. However, the DON was unsure of when the issue was first recognized, and no further explanation or documentation was provided regarding the failure to compare weights with those from the dialysis center.
Failure to Monitor and Document IV Catheter Care
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of an IV catheter and Permacath site for a resident reviewed for wounds. During an observation, it was noted that the resident had a split catheter on the right side of the chest with a dressing dated two weeks prior, and an IV port on the left side with no date on the dressing. The medical chart lacked documentation, physician orders, or a care plan identifying the type and location of each catheter, as well as orders or care plans for monitoring and assessing the catheter sites. The Director of Nursing (DON) was interviewed and acknowledged that staff should follow policies regarding IV care and that each dressing should be dated. However, no additional explanation or documentation was provided by the end of the survey. A physician's progress note on the day of the survey indicated that both catheter sites were clean, dry, and intact, but no further documentation was available to clarify the care and monitoring of the catheter sites.
Failure to Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to provide appropriate treatment and interdisciplinary collaboration to prevent further decrease in range of motion for a resident with a right-hand contracture. The resident, who was moderately cognitively impaired and had a history of stroke, heart failure, diabetes, and other conditions, was observed in their room with their right hand contracted and the prescribed hand brace/splint not applied. The resident expressed frustration, stating that the staff had not assisted in applying the brace since their transfer from a previous facility, despite their inability to do so independently. A review of the resident's care plan and treatment records revealed that an order for a right-hand splint was placed, but it was not included in the care plan interventions, nor was there documentation of its application in the Treatment Administration Record for several months. The Director of Nursing and Unit Manager were informed by the resident about the lack of application, and they appeared unaware of the situation. An occupational therapist later assessed the resident and created a new order for the splint, indicating a lapse in communication and documentation regarding the resident's care needs.
Failure to Implement Physician Orders for Resident with Colostomy
Penalty
Summary
The facility failed to ensure that physician orders were transcribed and implemented for a resident with a colostomy, leading to a deficiency in care. The resident, who had diagnoses including constipation and colostomy status, was experiencing abdominal pain and was evaluated by a Nurse Practitioner. The evaluation resulted in orders for an abdominal X-ray, monitoring of vital signs, and administration of bisacodyl 5mg via the stoma for constipation. However, the bisacodyl order was not entered into the resident's medical record, and there was no documentation of its administration. Despite the physician's order for bisacodyl to be administered via the stoma, the medication was not given, and the resident's condition worsened, leading to unresponsiveness and eventual death. The Director of Nursing confirmed the lack of documentation and acknowledged that a new order should have been entered and administered. The failure to implement the physician's order for bisacodyl contributed to the deficiency identified during the survey.
Failure to Implement Respiratory Care Orders
Penalty
Summary
The facility failed to ensure the implementation of physician orders and care plans for a resident with acute and chronic respiratory failure, COPD, and asthma. Upon admission, the resident was supposed to receive supplemental oxygen and use a CPAP machine as per the hospital's discharge instructions. However, there was no documentation of a physician order for the CPAP or oxygen administration, and the resident refused to use the CPAP due to discomfort. The facility did not notify the physician or interdisciplinary team about the CPAP settings issue or the resident's refusal, nor did they document any interventions to address the discomfort or explore alternative treatments. The facility also failed to administer prescribed antibiotics and did not provide the necessary CPAP/BiPAP ventilation as needed. The resident experienced multiple incidents of respiratory distress, leading to a fall and a fracture, which ultimately resulted in the resident's death. The medical record lacked documentation of the CPAP or BiPAP being applied while the resident was resting, and there were no physician orders for these devices or for oxygen administration. Additionally, the facility staff did not administer the resident's antibiotic on two occasions as prescribed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's care needs. The nurse who readmitted the resident was unaware of the CPAP/BiPAP requirements, and the Director of Nursing was not informed about the CPAP settings issue or the failure to implement necessary orders. The facility's centralized admission personnel and the DON were responsible for reviewing referral packets to ensure the facility could provide the required care, but this process failed in this instance. The facility did not have care plans or interventions in place for the resident's primary diagnosis of respiratory failure and the use of supplemental oxygen and CPAP/BiPAP.
Failure to Provide Timely Beneficiary Notices
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to four residents, resulting in complaints about not being informed timely of private pay charges and the inability to file an appeal. The deficiency was identified during a survey, where it was found that the facility did not provide these notices to residents R169, R27, R42, and R62. The lack of timely notification affected the residents' ability to understand their financial liability and to appeal the decision if desired. Resident R169 was admitted under Medicare A and later became private pay without any documented discussion of costs or billing details in the clinical record. The facility failed to provide any NOMNC or SNFABN forms for R169, resulting in a current amount due of $5,306.00. Similarly, resident R27's NOMNC form was signed after the services ended, and the SNFABN was not signed until the day financial liability began, preventing the resident from appealing the decision. Resident R42's NOMNC form was signed on the day services ended, with no prior notification documented, and the SNFABN was not signed at all. For resident R62, the facility did not provide the NOMNC or SNFABN forms, citing the absence of the previous Business Office Manager as the reason. The facility's administrator acknowledged the issues with beneficiary notices, attributing them to the transition in the business office management and communication problems between the business office and clinical staff. Despite requests, the facility did not provide their policy regarding beneficiary notices by the end of the survey.
Staffing Shortages Lead to Delayed Care and Unmet Needs
Penalty
Summary
The facility was cited for failing to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations, interviews, and record reviews. Residents and staff reported significant staffing shortages, particularly on weekends and during night shifts, leading to delays in care and unmet needs. Residents expressed concerns about long wait times for call light responses, assistance with getting out of bed, and receiving scheduled showers. These issues were corroborated by resident council meeting minutes, which documented ongoing staffing concerns over several months. Interviews with Certified Nurse Aides (CNAs) and other staff members revealed that they were often assigned an excessive number of residents, making it difficult to provide adequate care. CNAs reported having to prioritize tasks and sometimes resorting to bed baths instead of showers due to time constraints. The staffing coordinator and Director of Nursing acknowledged the staffing challenges and efforts to recruit and retain staff, but the issues persisted, affecting the quality of care provided to residents. Specific residents, such as those with significant medical needs or cognitive impairments, were observed to be particularly affected by the staffing shortages. For instance, one resident with a wound VAC and cognitive impairment reported not receiving adequate assistance with personal hygiene, despite repeated requests. Another resident expressed frustration over delays in receiving pain medication and assistance with dressing. These deficiencies highlight the facility's failure to maintain adequate staffing levels to ensure timely and appropriate care for all residents.
Deficiencies in Resident Dignity and Personal Possessions
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple observations of staff not assisting a resident in a wheelchair and entering rooms without knocking or announcing themselves. One resident was observed struggling to propel themselves in a wheelchair due to engaged brakes, with several staff members passing by without offering assistance. Additionally, a CNA was seen entering and exiting resident rooms without knocking or wearing a name badge, which is against the facility's policy. The Director of Nursing acknowledged that staff should knock and announce themselves before entering rooms and wear name badges, but noted issues with temporary badges for new staff. The facility also failed to respect a resident's right to personal possessions. A resident expressed frustration over not being allowed to keep a plastic storage bin they had purchased, which was stored at the receptionist's desk. The facility's Administrator cited infection control concerns due to the bin not having wheels, despite similar bins being present in other rooms. The facility's policy states residents have the right to retain personal possessions unless it infringes on the rights or safety of others, but no specific safety concerns were identified in this case.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents, leading to discomfort and frustration. Resident R170, who was 74 inches tall and weighed 241 pounds, was observed on multiple occasions with their feet hanging over the end of the bed, indicating that the bed was too short. Despite the resident's complaints of discomfort, there was no record of staff addressing the issue or communicating it to the administrative team. The Director of Nursing was unaware of the concern until it was brought to their attention during the survey. Additionally, residents R34, R76, and R89 were observed with their water cups placed out of reach, preventing them from hydrating independently. R34, who had severe cognitive impairment and was not ambulatory, had their water cup placed approximately six feet away. Similarly, R76 and R89 had their water cups placed out of reach, with R76 having no fluids available at the bedside at one point. The Unit Manager acknowledged that water should be within the residents' reach, but this was not consistently ensured.
Resident Health Information Privacy Breach
Penalty
Summary
The facility failed to maintain the confidentiality of resident health information, as observed on 8/20/24. A piece of paper containing personal resident information, including room numbers, names, current weights, and types of scales used, was taped to the nursing station desk in a manner visible to anyone passing by. This breach of privacy affected five residents, identified as R119, R120, R121, R122, and R123, whose sensitive information was exposed. During an interview conducted on the same day, the unit manager, Nurse 'A', acknowledged the inappropriate display of resident information, stating it should not have been left in such a manner. The facility's policy on resident rights and responsibilities, dated 5/14/2024, clearly states that residents have the right to personal privacy and confidentiality of their personal and medical records. The failure to adhere to this policy resulted in a deficiency concerning the protection of resident privacy.
Failure to Obtain Physician Order and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician order for the use of supplemental oxygen was obtained for a resident, identified as R42, who was receiving continuous oxygen therapy via nasal cannula from an oxygen concentrator with humidified air. Upon observation, it was noted that the humidifier attached to the oxygen concentrator was empty, and the resident reported having to remind staff to fill it, as their nose became dry and sore. Despite the resident's continuous use of oxygen since admission, there were no physician orders for oxygen use or monitoring of the resident's respiratory status documented in the clinical records. Interviews with nursing staff revealed a lack of awareness and responsibility for maintaining the humidifier's water level. Nurse 'K', assigned to R42, acknowledged not noticing the empty humidifier and admitted it should have been filled. The Unit Manager, Nurse 'L', confirmed the absence of orders for oxygen use and monitoring in the resident's records and stated that nurses were responsible for monitoring the humidification level. The facility's documentation for respiratory care did not address resident care but focused on staff fit testing and requirements.
Deficiencies in Dialysis Communication and Meal Provision
Penalty
Summary
The facility failed to ensure consistent dialysis communication documentation and assessments for two residents, R94 and R270, who required hemodialysis. Both residents had been long-term residents with diagnoses including end-stage renal disease. The facility's care plan required the use of a dialysis communication form to communicate with the dialysis center, but a review of the electronic medical records (EMR) revealed a lack of recent communication forms. The last documented communication for R94 was approximately five months ago, and for R270, it was about seven months ago. Interviews with staff, including a Licensed Practical Nurse (LPN), Unit Manager (UM), and Director of Nursing (DON), confirmed the absence of these forms in the EMR, indicating a lapse in the facility's communication process with the dialysis provider. Additionally, the facility failed to provide a meal for resident R269 before their hemodialysis appointment. R269, admitted for short-term skilled nursing and rehabilitation, reported not having eaten since the previous night and expressed frustration over the situation. The resident's EMR included a physician order indicating nutritional risk, yet the nursing progress note only documented the resident's leave of absence to dialysis. An interview with the Registered Dietician (RD) revealed that bagged meals were prepared the night before and left in the kitchen fridge for nursing staff to distribute, but it was unclear why R269 did not receive their meal. The report highlights the facility's failure to maintain proper communication with the dialysis center and ensure residents received necessary meals before dialysis appointments. Despite the facility's policy requiring communication forms to be sent and reviewed, the absence of these forms in the EMR and the lack of a meal for R269 indicate significant lapses in the facility's processes. Interviews with various staff members, including the DON, confirmed awareness of these issues, but no additional information or corrective actions were provided before the survey exit.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label, store, and discard expired medications and biologicals, as observed in four out of seven medication carts. Specific issues included the presence of expired fish oil and [NAME] oil supplements, a COVID-19 test reagent stored with oral medications, and a bag of potato chips in a medication cart. Additionally, bleach disinfecting wipes were stored with oral medications, and a vial of Aplisol Tuberculin Purified Protein Derivative was not stored at the required refrigerated temperature. Furthermore, insulin flex pens were found without open dates, and a transdermal lidocaine patch was left unattended on a medication cart. The report also noted that a Breo Ellipta inhaler and vials of albuterol inhalation solution were left on top of unattended medication carts. An orange round pill, identified as aspirin, was found on a trash shield of a medication cart, with the LPN unable to explain its presence. The Director of Nursing acknowledged that medications should not be left unattended, highlighting a lack of adherence to the facility's policy on medication storage and expiration dating.
Failure to Provide Menu Items as Listed on Meal Tickets
Penalty
Summary
The facility failed to ensure that menu items listed on meal tickets were provided to seven residents during meal services. Observations revealed that several residents did not receive the nutritional supplements, desserts, or beverages as indicated on their meal tickets. For instance, one resident was supposed to receive a nutritional juice supplement but did not receive it during the meal service. Another resident was to be provided a magic cup supplement, which was also not observed during the meal service. Additionally, a resident's meal ticket indicated a double dessert and a nutritional juice supplement, but they only received a single dessert and no juice. Further observations highlighted that residents were not provided with coffee or tea as indicated on their meal tickets. During breakfast service, it was noted that there were no coffee mugs or disposable foam cups available for serving hot beverages, resulting in residents not receiving their requested coffee or tea. Interviews with the dietician revealed that the dietary department was responsible for placing items on trays during the tray line, and Certified Nurse Aides were responsible for providing coffee and tea at the point of service. The facility's policy on food preferences did not address the responsibility to provide food and beverages per resident preferences.
Failure to Provide Adequate Hydration Assistance
Penalty
Summary
The facility failed to ensure that residents received fresh water and assistance with consuming fluids, which is essential for maintaining adequate hydration. Observations revealed that four residents had foam cups of water at their bedsides that were room temperature and lacked ice. The cups were dated with the previous night's shift time, indicating they had not been refreshed throughout the day. Additionally, the straws in the cups remained in their paper wrappers, suggesting that residents were not assisted in drinking the water provided. Interviews with the Unit Manager revealed that the midnight shift was responsible for providing the cups, and staff were expected to refresh them with ice and water throughout the day. However, the Unit Manager acknowledged the concern that the staff had not been fulfilling this responsibility, as evidenced by the room temperature water and the untouched straw wrappers. The facility's policy on oral hydration, revised in November 2021, states that it is the facility's policy to assist residents in maintaining adequate hydration, which was not adhered to in this instance.
Inconsistent Meal Service Times Lead to Resident Dissatisfaction
Penalty
Summary
The facility failed to ensure meals were served in a timely manner and in accordance with the scheduled mealtimes for residents, leading to late meals and resident dissatisfaction. On a specific day, the first lunch cart left the kitchen at 1:05 PM, and the last cart left at 1:55 PM, which was significantly later than the scheduled lunch time of 12:30 PM. The Certified Dietary Manager (CDM) explained that a call-in for the morning shift caused delays throughout the day. This issue was not isolated, as a confidential resident group meeting revealed that residents frequently experienced inconsistent meal times, with breakfast sometimes served as late as after 10 AM, depending on who was cooking in the kitchen. Individual interviews with residents and family members corroborated these findings, with reports of lunch being served between 2:30 PM and 3:00 PM and dinner around 8:00 PM on multiple occasions. The CDM acknowledged the residents' concerns and attributed the delays to staffing challenges, particularly when there were call-offs for breakfast shifts. These delays in meal service were consistent across different meals and days, contributing to ongoing dissatisfaction among residents.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection control standards and practices, specifically in the use of Personal Protective Equipment (PPE) and hand hygiene, which could potentially lead to the spread of infection among residents. On August 21, 2024, a Licensed Practical Nurse (LPN X) was observed administering medication without performing hand hygiene. The LPN donned gloves to administer eye drops but failed to change gloves and perform hand hygiene after picking up a resident's phone from the floor. The LPN acknowledged the oversight when prompted. Resident 15, who was admitted to the facility with severe cognitive impairment and a history of urinary tract infections, was observed receiving care from LPN F without the proper PPE as required by Enhanced Barrier Precautions (EBP). LPN F manipulated the resident's suprapubic catheter without wearing a gown and did not perform hand hygiene before and after the procedure. Additionally, LPN F disposed of a urine-filled catheter bag improperly, carrying it through the facility without performing hand hygiene after removing gloves. Another resident, R172, was found to have a midline catheter and open wounds but was not placed on EBP upon admission. Despite having orders for IV antibiotics, there was no signage or PPE indicating EBP. The Unit Manager and Director of Nursing acknowledged that EBP should have been implemented upon admission, but the process was not followed. The facility's policy requires EBP for residents with wounds or indwelling medical devices, but this was not adhered to for R172.
Deficient Handrail Maintenance in Facility Hallways
Penalty
Summary
The facility failed to ensure that all corridor areas used by residents were equipped with safe and secure handrails. During observations conducted over two days, surveyors noted multiple sections of handrails and hard plastic corner caps/molding in the 100 and 200 hallways were broken, jagged, or missing, exposing sharp plastic and metal. Additionally, a handrail near the exit hallway closest to the kitchen was found to be pulled away and down from the wall. An interview with the Maintenance Director revealed that audits of the facility's handrails were not conducted regularly, with checks occurring infrequently. The Maintenance Director acknowledged awareness of some broken areas but was unaware of the specific issues identified during the survey. The facility uses an electronic system for staff to report maintenance issues, but it appears this system was not effectively utilized to address the handrail deficiencies.
Failure to Address Resident Grievances Regarding Catheter Supply
Penalty
Summary
The facility failed to address grievances for a resident who expressed concerns about not receiving new, sterile urinary catheters, leading to the reuse of catheters and a suspected urinary tract infection (UTI). The resident reported experiencing pain, burning, and cloudy urine, indicative of a UTI, and had communicated these concerns to the facility staff. Despite the resident's complaints during a care conference and the nurse's documentation of the issue, there was no follow-up action taken, such as ordering a urinalysis or addressing the catheter supply issue. Interviews with the staff revealed a breakdown in communication and grievance handling. Nurse 'J' claimed to have informed the unit managers and left a note for the physician, but the Unit Manager 'E' was unaware of the resident's concerns. The Director of Nursing acknowledged that the concerns should have been communicated and addressed promptly. The facility's policy on resident rights and grievance resolution was not followed, resulting in unresolved concerns for the resident.
Failure to Provide Adequate Personal Care and Assistance
Penalty
Summary
The facility failed to provide necessary care and services consistent with the needs and choices of a resident, identified as R47, who was admitted with multiple medical conditions including hypertension, heart disease, peripheral vascular disease, diabetes, and multiple myeloma. R47 underwent a debridement and partial calcanectomy of the left foot, requiring a Wound VAC and antibiotic treatment. Despite being care planned for a decline in ambulation and requiring substantial assistance, R47 reported not receiving adequate help from staff to get out of bed or maintain personal hygiene. Observations noted R47 in an unkempt state, wearing a food-stained gown, and expressing frustration over not receiving a bath or assistance to clean up, despite multiple requests. The report highlights discrepancies in documentation and communication among staff regarding R47's care. On one occasion, a CNA documented that R47 refused to get out of bed, which R47 disputed, stating they were finishing breakfast and requested assistance later. Further, the facility's shower/bathing task records showed inconsistent documentation, with a CNA marking both 'Yes' and 'No' for a bed bath, which R47 denied receiving. The Director of Nursing and other staff were informed of the situation, but R47 continued to report not being cleaned up, indicating a failure in the facility's care processes and documentation practices.
Failure to Provide Meal Assistance to Legally Blind Resident
Penalty
Summary
The facility failed to provide necessary meal set-up and one-to-one feeding assistance for a resident who was legally blind and had severe cognitive impairment. Observations revealed that the resident was left to eat independently despite requiring assistance, as indicated on their meal ticket and care plan. The resident was seen struggling to consume meals, using their fingers to eat, and spilling food on themselves and their surroundings. Interviews with the resident's roommate and family confirmed that staff did not regularly assist the resident with eating, and the family had to adjust their visits to help during meal times. The resident's clinical record showed a history of dysphagia, stroke, falls, and legal blindness, with a care plan specifying the need for one-to-one assistance with meals. Despite these documented needs, staff, including a CNA, failed to provide the required assistance during multiple meal observations. The facility's Director of Nursing acknowledged that assistance should have been provided, but a policy on one-to-one feeding assistance was not made available during the survey.
Deficiencies in Pressure Ulcer Management
Penalty
Summary
The facility failed to provide consistent monitoring and assessment of changes in skin condition and implement pressure-relieving interventions for two residents, leading to deficiencies in pressure ulcer management. One resident, admitted with multiple health conditions including diabetes and peripheral vascular disease, had a wound VAC applied to their left foot. Despite being care planned for a decline in ambulation and requiring assistance, the resident reported being left in bed and developed sores on their lower back and buttock area. A skin assessment identified non-blanchable redness, but no further monitoring or evaluation was documented, resulting in the development of stage 2 pressure ulcers. Another resident, with severe cognitive impairment and multiple diagnoses including vascular dementia and seizures, was observed without heel protectors despite being at risk for pressure ulcers. The resident's care plan included the use of soft heel protector boots, but these were not implemented. Staff members, including a CNA and a unit manager, were unaware of the intervention, and the heel protectors were found unused in the medication room. The facility's failure to adhere to its skin management policy, which mandates the identification, evaluation, and treatment of residents at risk for skin compromise, contributed to the development and worsening of pressure ulcers in these residents. The lack of documentation and implementation of care plan interventions highlights a significant oversight in the facility's pressure ulcer management practices.
Failure to Provide Proper Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and provision of supplies for two residents using urinary catheters, leading to potential urinary tract infections. One resident, who self-catheterizes due to paraplegia, reported reusing catheters because the facility did not regularly supply new, sterile ones. Despite the resident's complaints of pain and discharge, indicating a possible urinary tract infection, no catheter kits were observed in their room. The facility had catheter kits in stock, but the resident was not provided with them, and staff were unaware of the resident's concerns. Another resident, managed under hospice care with a history of neurogenic bladder dysfunction, was observed with cloudy, white milky sediment in their catheter tubing over several days. Despite the care plan's directive to report signs of urinary tract infection, there was no documentation of physician notification regarding the abnormal urine observations. The resident's urine was noted to be dark amber, suggesting dehydration, but the facility failed to act on these observations.
Failure to Monitor Resident's Weight Consistently
Penalty
Summary
The facility failed to consistently monitor the weight of a long-term resident, identified as R29, who was at risk for nutritional deficiencies due to multiple health conditions including seizures, hemiplegia, diabetes, dysphagia, and chronic pain. R29 exhibited significant weight fluctuations over several months, with variations ranging from a loss of 19 pounds to a gain of 9 pounds. Despite these fluctuations, there was no timely follow-up or re-weighing to ensure the accuracy of the recorded weights. The facility's Registered Dietician (RD) and Interdisciplinary Team (IDT) did not address these variations promptly, and there was no updated plan to monitor R29's weight more frequently. Observations revealed that R29 did not consume their breakfast, which was consistent with their mechanical soft diet, and reported not being hungry. The dietary progress notes indicated a significant weight loss over 180 days, but there was no updated intervention plan. The RD's notes highlighted concerns about the accuracy of the weights and the lack of timely follow-up, yet no corrective actions were taken. The facility's process for ensuring weight accuracy was questioned, and the RD admitted to being aware of the weight fluctuations but did not provide a satisfactory explanation for the lack of frequent monitoring. Interviews with the RD and the Director of Nursing (DON) revealed a lack of coordination and timely response to R29's weight issues. The RD mentioned that any weight variation of 5 pounds should trigger a re-weight, but this was not consistently followed. The DON acknowledged the concerns but did not provide evidence of a systematic approach to address the significant weight loss and ensure accurate monitoring. The facility's weight monitoring policy was requested but not provided before the survey exit, indicating a potential gap in procedural adherence.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to deficiencies in care. One resident, who had a physician's order for routine valproic acid level checks every six months, did not have the required lab tests completed in June 2024. Despite the presence of a physician's order dated December 2023, the lab results were not found in the resident's clinical record, and the facility staff, including an LPN and a Unit Manager, confirmed the oversight. The Unit Manager later reported that the lab order was not completed and took steps to contact the physician for an immediate order. Another resident, who experienced symptoms indicative of a urinary tract infection (UTI), did not have a urinalysis ordered or conducted in a timely manner. The resident reported reusing urinary catheters due to a lack of new supplies, which they believed led to a UTI. Despite the resident's complaints of pain and symptoms, and a progress note by a nurse indicating the need for a urinalysis, no order was found in the resident's records. The Unit Manager and the Director of Nursing acknowledged the communication breakdown and the failure to notify the physician for necessary lab orders.
Failure to Coordinate MRI Services for Resident
Penalty
Summary
The facility failed to coordinate and obtain radiology services for a resident, identified as R42, who required an MRI for their left thigh as per their cancer doctor's recommendation. The resident, who had a history of malignant neoplasm of connective and soft tissue of the left lower limb, expressed concerns about the delay in scheduling the MRI, which was ordered to be scheduled within 48 hours. Despite the active order for the MRI being in place since July, there was no documentation indicating that the MRI had been scheduled or completed by the time of the survey. Interviews with the Director of Nursing and Staff 'W', who was responsible for scheduling, revealed a lack of follow-up and documentation regarding the MRI appointment. Staff 'W' admitted to waiting for a call back from the hospital but failed to document the date of the initial call or any subsequent follow-up actions. The facility's policy on coordination with outside providers did not address radiology services, contributing to the oversight. The only documented appointment for the resident was with a cardiologist, indicating a lapse in the facility's process for ensuring timely diagnostic services.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by observations, interviews, and record reviews. Two residents, identified as R303 and R304, reported inadequate care due to staffing shortages. R303 expressed that they did not receive regular showers and were unable to have their facial hair shaved due to aides being rushed. R304 reported long wait times for call light responses and having to sit in urine for extended periods, which affected the healing of a wound. Both residents attributed these issues to the facility being short-staffed. Interviews with staff members, including CNAs and the staffing personnel (SP A), revealed that the facility did not adjust staffing levels based on resident census or acuity, instead following standard numbers. SP A confirmed that staffing numbers remained constant regardless of changes in resident needs. CNAs reported being overworked and unable to complete all care tasks, such as providing showers, due to insufficient staffing. The facility had 12 open aide positions, indicating a significant staffing gap. The Director of Nursing acknowledged the staffing concerns and stated efforts were ongoing to improve and retain staff.
Resident Abandoned at Chemotherapy Appointment
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in the resident being abandoned at a chemotherapy appointment. The resident, who had diagnoses including malignant neoplasm of the breast and cerebrovascular disease, was left waiting for approximately five hours without transportation, shelter, or medical care. The resident had to rely on family members to pick them up and was forced to stay in a motel overnight before being able to go to the hospital for medical care. This incident occurred because the facility canceled the return transportation and discharged the resident while they were at their chemotherapy appointment, without proper communication or arrangements for their return or further care. The resident reported that after their chemotherapy appointment, they called the transportation company, which informed them that there was no order to pick them up. When the resident contacted the facility, they were told by a nurse that they had been discharged and could not return. The resident's belongings were still in their room, and the nurse suggested that someone could come to pick them up later. The resident's family had to intervene, with the resident's niece eventually picking them up around 10 PM and taking them to a motel for the night. The resident experienced severe pain and incontinence during the night and had to go to the emergency room the next morning. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's transportation and discharge. Nurse B, who was involved in the incident, admitted to canceling the return transportation and calling the physician to send the resident to the hospital due to the resident's aggressive behavior and pain. However, Nurse B was unaware of the resident's chemotherapy appointment and did not review the facility's communication dashboard. The Director of Nursing and the Administrator were also involved but failed to ensure the resident's safe return and proper care. The facility's actions left the resident without necessary medical assistance and supervision, resulting in significant distress and harm to the resident.
Removal Plan
- Resident # 611 is scheduled to return. The Administrator has been suspended pending investigation.
- The facility currently has 104 residents residing in the facility, the administrative nurses reviewed residents with scheduled appointments to ensure transportation was set/confirmed to ensure residents are returned back to the facility. In addition, newly admitted residents or readmitted residents, will be reviewed M-F during the clinical meetings; to ensure residents who requires transportation to scheduled appointments are set/confirmed to ensure residents are being returned back to the facility safely. As well as, communicated on the dashboard.
- The License Professional Nurses education began and they were re-educated on the facility's Routine Resident Care Policy, Medication Administration Policy, and the Standard of Nursing Practice Policy to residents' needs are met. There are 44 Licensed Nurses who will be in-serviced on Routine Resident care Policy, Medication Administration Policy and Standards of Nursing Practice Policy. 40 nurses have been in-serviced and in-servicing continues. This will be on-going until all licensed nurses have been re-educated. The remaining nurses will receive education on the above policies on or before their next scheduled day.
- The Certified Nursing Assistances (CNA/CENA) education began and they were re-educated on the facility's Routine Resident Care Policy to ensure residents' needs are met. There are 46 CENA'S who will be in-serviced on the Routine Resident Care Policy. 38 CENA'S have been in-serviced and in-servicing continues. This will be on-going until all licensed nurses have been re-educated. The remaining CENA'S will receive education on the above policies on or before their next scheduled day.
- Scheduler, Receptionist, and Central Supply was educated on residents who have scheduled appointments will ensure transportation is set/confirmed to ensure residents are returned back to the facility.
- The DON/Admin Nurses reviewed the appointment book to ensure upcoming scheduled appointments, were confirmed for pick-up and return trip to the facility.
- Any areas of concern will be addressed. Finding will be taken to the monthly QAPI (quality assurance process improvement) meeting for further review and recommendations. The DON is responsible obtaining and maintaining compliance.
- DON will sustain and maintain compliance.
Failure to Ensure Proper Background Checks for Staff
Penalty
Summary
The facility failed to ensure that two of six staff members reviewed for criminal background checks were properly screened for eligibility to work in a nursing home. This failure was identified during a survey on 5/22/24. The facility was asked to provide personnel files, including background checks, for six employees. While the facility provided most of the requested documentation, it failed to provide completed background checks for two nurses, Nurse B and Nurse H. Nurse H's file was missing education, training, and a background check with fingerprint results. Nurse B's background check was only completed on the day of the request, and Nurse H's background check was outdated. Both nurses were allowed to work without the necessary background clearance, and Nurse B did not sign a conditional letter of employment pending the results of the fingerprint check. The Director of Nursing and Human Resources confirmed that staff should not work without a completed background check clearance. Despite multiple requests for additional documentation and explanations, the facility was unable to provide the necessary background clearances and hire dates for Nurse B and Nurse H. This oversight resulted in the potential for abuse or neglect to occur, affecting all residents in the facility. The facility's failure to ensure proper background checks for these employees was confirmed by the administration and corporate staff, who acknowledged that the staff should have had completed background checks before working their shifts. No further information was received by the exit of the survey.
Failure to Notify Guardian of Significant Changes in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's guardian of significant changes in the resident's condition. Specifically, the resident, who had severe cognitive impairment and required assistance with activities of daily living, had their percutaneous endoscopic gastrostomy (PEG) tube removed. There was no documentation of how or when the PEG tube was removed, who removed it, or that the resident's guardian was notified of the removal. Additionally, the resident was started on hypodermoclysis for fluid administration without the guardian's notification or consent. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the guardian should have been notified but admitted that no such notification was made or documented. The resident's medical history included diabetes, depression, and stroke, and they were admitted to the facility with these diagnoses. The facility's policy on Notification of Change, which requires informing the resident, consulting with the resident's practitioner, and notifying the resident's representative of significant changes in status, was not followed. The failure to notify the guardian of the PEG tube removal and the initiation of hypodermoclysis represents a significant lapse in communication and adherence to the facility's policies.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to document and address grievances raised by a resident's family member, resulting in verbalized complaints and frustration. The family member reported concerns about the resident being left wet and soiled for five hours and not being placed back into bed, but no follow-up was conducted by the facility administration. The Social Work Director acknowledged receiving the complaint and verbally communicated it to the Director of Nursing, who left the facility shortly afterward. However, the complaint was not documented as required by the facility's grievance policy. The resident's medical record indicated that they had intact cognition and required partial assistance with personal hygiene. Despite the family member's efforts to communicate their concerns, no grievance or concern forms were completed, and no investigation was conducted. The facility's compliance program mandates that all concerns be documented and investigated promptly, but this procedure was not followed in this case. The lack of documentation and follow-up led to unresolved grievances and frustration for the resident's family.
Failure to Accurately Complete Assessments for Resident with Blood Clot
Penalty
Summary
The facility failed to accurately complete assessments for a resident (R703) who developed intense pain from a blood clot requiring hospitalization. R703, who was admitted for rehabilitation from back surgery, reported severe pain, swelling, and a warm sensation in the left leg during the early hours of 01/17/24. Despite pressing the call light and requesting help, the nurse only provided pain medication and did not assess the leg or call Emergency Medical Services (EMS) as requested by R703. The nurse indicated that the doctor would assess the leg in the morning, but R703 insisted on being taken to the hospital, where they were diagnosed with a blood clot requiring surgery to remove it. A review of the clinical records revealed that the medication administration record (MAR) documented the pain medication as ineffective, and the Situation, Background, Appearance, and Review (SBAR) Evaluation form was incomplete, lacking specific details about R703's leg pain and assessment. There was no further documentation of assessments, progress notes, or communication between the nurse, physician, and EMS transfer. The Director of Nursing (DON) confirmed that nursing should have assessed for a possible blood clot given the symptoms. Hospital records indicated that R703 arrived at the Emergency Department with severe pain and swelling in the left leg, which was diagnosed as an extensive blood clot requiring immediate surgical intervention.
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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 Farmington Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Livonia | 0.3 mi | ★★★★★ | 10 | 0 |
| Corewell Health Rehab & Nursing Center-commons Far | 0.8 mi | ★★★★★ | 15 | 0 |
| The Orchards At Redford | 2.3 mi | ★★★★★ | 20 | 0 |
| Medilodge Of Farmington | 3 mi | ★★★★★ | 23 | 0 |
| Regency At Livonia | 3.5 mi | ★★★★★ | 12 | 0 |
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