Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards At Douglas Cove during CMS and state inspections, most recent first.
A resident with atrial fibrillation experienced a rapid, significant weight gain, progressive bilateral leg swelling, severe pain, and loss of functional abilities over more than a week, during which CNAs and family observed edema, increased assistance needs, and the resident crying out in pain. Although weight records and a weight warning note documented a +7.5% gain and ongoing increases, and staff reported swelling, pain, and suspected fluid retention to nursing, no provider assessment occurred and there was no documented physician notification of the weight gain or associated decline. Practitioner Communication forms led only to scheduled acetaminophen, topical diclofenac, and later a PRN opioid, without conveying the full extent of the resident’s weight gain and edema. The PA later confirmed unawareness of the weight gain and swelling, that no provider assessment occurred during this period, and that reliance on written communication sheets rather than direct phone contact contributed to the physician not evaluating the resident before hospitalization.
A resident with AFIB experienced a significant unexplained weight gain, progressive bilateral leg swelling (left greater than right), severe pain, and loss of functional mobility over more than a week, yet nursing staff did not complete timely assessments or notify a provider of the weight gain and change in condition. Multiple CNAs reported increased swelling, pain, and the resident’s need for much more assistance, and the resident and family repeatedly requested provider evaluation. Communication to the provider was limited to written practitioner communication forms that resulted only in scheduled acetaminophen and topical diclofenac, without assessment of the swelling or weight gain. The provider was not made aware of the 9‑pound weight gain or edema, and no provider assessment occurred during this period, culminating in the resident being sent to the ED with bilateral leg pain and swelling and diagnosed with acute CHF, AFIB with RVR, and bilateral lower extremity edema, requiring a three‑day hospitalization.
Two residents did not receive necessary wound care and PICC line management, resulting in missed dressing changes, lack of documentation, and the development of infection. Staff failed to assess, monitor, and treat wounds as ordered, and care plans were incomplete or inaccurate, leading to deficiencies in care for both residents.
A resident with multiple wounds, including pressure ulcers, did not receive wound care as ordered by the physician, with staff failing to apply the correct dressings and omitting required treatments. The care plan was incomplete, missing documentation of all wounds, and weekly skin observations were not performed as required. These deficiencies resulted in inconsistent and inadequate pressure ulcer prevention and treatment.
Two residents did not receive safe and appropriate respiratory care as required. One resident with COPD and sleep apnea experienced delays in physician orders for CPAP and oxygen, lacked a detailed care plan, and was found without supplemental oxygen due to a non-functioning portable tank and kinked tubing. Another resident with heart failure had discrepancies between physician orders and the TAR, unclear oxygen settings, and oxygen tubing that was not changed as scheduled. Staff interviews revealed confusion about proper respiratory care procedures.
A resident with significant cardiac and pulmonary conditions experienced a cardiac arrest, and staff were unable to use the facility's AED because it would not turn on due to a dead battery. The AED was not regularly checked or included in the crash cart checklist, and there was no documentation of functionality checks or battery monitoring. Staff had to rely on a first responder's AED during the emergency.
The facility did not maintain its dishwasher in working order, leading to the use of Styrofoam containers for meal service for over a month. Staff reported delays in obtaining a replacement due to corporate requirements and credit approval issues. A resident expressed dissatisfaction with the quality of meal service during this period.
Three nurse aides continued to provide resident care without proper CNA certification after more than four months of employment. The facility did not have a clear process for tracking and maintaining CNA licensing records, resulting in aides working without required credentials.
The facility failed to provide meals as per the planned menu, leading to resident dissatisfaction. Observations revealed missing items like breadsticks and substitutions such as tuna noodle casserole instead of tuna melt sandwiches. A resident reported not receiving bacon and milk as listed on the menu. The Dietary Manager cited inventory management issues, including burned bacon and milk conservation, as reasons for these discrepancies.
The facility's kitchen had several deficiencies, including inadequate lighting in walk-in coolers, unsanitary utensil storage, improper food cooling, and equipment maintenance issues. These included black debris accumulation, insufficient cooling of apple crisp, ice buildup preventing freezer door closure, and a compromised vacuum breaker on the dish machine.
The facility failed to implement proper infection control precautions for four residents, leading to potential cross-contamination. A resident with conjunctivitis was not properly isolated, as staff entered without PPE. Another resident's enhanced barrier precautions were not updated after catheter removal, causing staff confusion. A third resident had a contact precautions sign but no PPE cart, and a fourth resident lacked proper signage and PPE use during care. These issues indicate a lack of clear communication and adherence to protocols.
A resident with cognitive impairments experienced a breach of dignity when a Maintenance Assistant adjusted her bed without permission while she was asleep. The MA entered the room without knocking and manipulated the bed's position, ignoring the resident's presence. The resident later expressed discomfort with having her bed moved while she was in it. This incident highlights a failure to respect the resident's right to a dignified existence.
A facility failed to report and investigate a suspected misappropriation of a resident's wallet. The resident, who had diabetes, reported a suspicious bank transaction and a missing wallet to an RN, who informed the NHA. The NHA reported it to the local police, but the case was closed due to jurisdiction issues. The NHA did not pursue further investigation as the wallet was found, leaving the misappropriation allegation unresolved.
A facility failed to implement person-centered, non-pharmacological interventions for a resident with anxiety disorder, major depressive disorder, and dementia, who was prescribed Fluoxetine HCl. The care plan included administering medication and monitoring side effects but lacked individualized interventions. The Social Services Director acknowledged the need for a more individualized approach to address the resident's psychosocial needs.
A resident with COPD missed multiple doses of Xifaxan due to a failure in medication reordering. The LPNs did not reorder the medication in time, and the facility lacked backup stock, resulting in missed doses. The ADON confirmed that nurses are responsible for reordering medications, but the policy was not followed.
A resident with anoxic brain damage, quadriplegia, and dysphagia was not assessed quarterly for nutritional needs as required by facility policy. Despite being at nutritional risk and having a care plan for weight loss, the resident's nutritional status was only assessed three times in the past year. The registered dietitian admitted that a missed assessment could lead to unmet nutritional needs and unaddressed weight loss.
The facility failed to ensure that the attending physician reviewed and responded to the consultant pharmacist's monthly medication regimen review recommendations for two residents. For one resident, a recommendation for a gradual dose reduction of Fluoxetine was not addressed, and for another, a recommendation for a fasting lipid panel due to Risperidone use was not acted upon. The facility could not provide evidence of physician responses, and staff confirmed the recommendations were pending.
A facility failed to attempt a required Gradual Dose Reduction (GDR) for an antidepressant medication, Fluoxetine, for a resident with anxiety disorder, major depressive disorder, and dementia. Despite federal guidelines, there was no documented attempt or contraindication for a GDR in the resident's records. Interviews with staff revealed that the Interdisciplinary Team (IDT) was responsible for reviewing medications for GDRs, but the resident had not been seen by a behavioral health service, and the tracking of GDRs was not effectively managed.
A facility failed to document and offer a COVID-19 vaccination to a resident upon admission, as per CDC guidelines and facility policy. The resident, who was severely cognitively impaired, had not been offered the vaccine due to an oversight during the initial nursing assessment. The facility's policy requires offering the updated COVID-19 vaccine unless contraindicated or refused.
Failure to Notify Physician of Resident’s Significant Weight Gain, Edema, and Functional Decline
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition for one cognitively intact resident with atrial fibrillation, who experienced a rapid, unexplained weight gain, progressive lower extremity swelling, increased pain, and loss of functional abilities. The resident gained 9 pounds over 32 days, with an additional 4-pound gain documented shortly thereafter, and a weight change note identified a +7.5% significant weight gain with daily weights ordered for monitoring. Despite this documented significant weight gain and the absence of diuretics, there was no evidence that a provider was notified, and no nursing or physician assessments were completed between late January and early February. Over the course of more than a week, the resident reported unresolved pain, swelling in both lower extremities, and a loss of ability to transfer independently, ultimately insisting on going to the emergency room. The resident stated her pain reached 8/10 and that she repeatedly asked to be seen by a physician but was not evaluated. Family reported they requested a provider evaluation and were told the resident would be seen, but this did not occur; they also observed the resident crying from pain. CNAs reported that between early and mid-February the resident’s legs were swollen and painful, socks left indentations, the resident yelled out during care, grabbed her legs, and required increased assistance with transfers and mobility, and they stated they reported these changes and concerns, including suspected fluid retention, to nursing staff. Nursing documentation and interviews showed that although staff were aware of the resident’s new and worsening symptoms, including leg swelling, increased pain, and decreased mobility, the physician was not notified of the significant weight gain and associated changes. Practitioner Communication forms reflected concerns about swollen knees and pain, with provider responses limited to adding scheduled acetaminophen, topical diclofenac gel, and later a PRN opioid, but there was no indication the provider was informed of the 9‑pound weight gain, bilateral lower extremity swelling, or functional decline. The PA confirmed she was unaware of the resident’s weight gain and leg swelling, that the resident was not assessed by a provider during the relevant period, and that communication sheets placed in provider mailboxes were often overlooked, despite providers being available by telephone 24/7. This sequence of events resulted in the physician not evaluating the resident when she experienced a significant change in condition and was subsequently hospitalized.
Failure to Recognize and Act on Resident’s Change in Condition Leading to Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and assess a significant change in condition for a cognitively intact resident with atrial fibrillation, resulting in unmanaged pain, swelling, decreased functional ability, and hospitalization. The resident had a history of unspecified atrial fibrillation and was care planned for potential pain related to AFIB, with interventions to administer analgesics per orders and evaluate pain interventions. However, the care plan did not include any focus, goals, or interventions related to monitoring swelling, daily weights, or use of a cardiac monitor. A Minimum Data Set (MDS) dated 1/23/26 showed the resident was largely independent or required only supervision for bed mobility and transfers, but a subsequent MDS dated 2/13/26, after a hospitalization, showed a decline to requiring maximal assistance for transfers and bed mobility. Over the period from late January to early February, the resident experienced a 9‑pound weight gain between 12/30/25 and 2/1/26, with an additional 4‑pound gain documented on 2/6/26. A nutrition note on 2/4/26 identified the weight increase and placed the resident on daily weights for seven days, and a weight change note on 2/5/26 documented a significant 7.5% weight gain with no diuretics ordered. The DON later confirmed that the physician was not notified of this weight gain and that the resident was not evaluated by a provider between 2/1/26 and 2/10/26. Review of assessments and progress notes showed no nursing or physician assessments between 1/27/26 and 2/8/26 and no documentation that a provider was contacted regarding the unexplained weight gain during 2/1–2/10/26. During the first part of February, multiple CNAs observed and reported changes in the resident’s condition, including bilateral leg swelling (left greater than right), increased pain, yelling out with movement, and a need for significantly more physical assistance with transfers and mobility. CNAs reported that the resident, who typically tried to remain independent, now required help lifting her legs into bed and for all transfers, and they noted sock indentations and suspected fluid retention. The resident and a family member reported that for more than a week prior to hospitalization, the resident had unresolved pain and swelling in both lower extremities, decreased mobility, and loss of ability to transfer independently, and that they requested provider evaluation. A practitioner communication form dated 2/2/26 documented a concern about swollen knees, with a provider response on 2/3/26 ordering scheduled acetaminophen and diclofenac gel; a second communication form dated 2/9/26 documented ongoing pain, especially in the lower extremities, and family requests for different pain medications, with a provider response dated 2/17/26 adding an opioid PRN. The PA later stated she was aware of leg pain but not of swelling or the 9‑pound weight gain, and confirmed the resident was not assessed by a provider between 2/1/26 and 2/10/26. On 2/10/26, the resident went to the emergency department with bilateral leg pain and swelling, was found to have bilateral pitting edema and presumed new congestive heart failure with atrial fibrillation with rapid ventricular response, and was hospitalized for three days. Following the hospitalization, discharge instructions documented diagnoses of acute CHF, AFIB with RVR, and bilateral lower extremity edema, with orders for daily weights and notification of the physician for specified weight gains, and a cardiac monitor placed at discharge. Upon return, the resident required maximal assistance for transfers and bed mobility compared to her prior status. The DON and nursing staff acknowledged that the significant unexplained weight gain, leg swelling, increased pain, and functional decline should have prompted further medical assessment and provider notification, and that the communication method used (written communication sheets placed in a mailbox) was ineffective and contrary to prior education to call providers by phone. The failure to recognize and act on the resident’s change in condition, including not notifying the physician of significant weight gain and progressive symptoms, led to unmanaged pain, swelling, decreased functional ability, and the subsequent hospitalization.
Failure to Provide Adequate Wound and PICC Line Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents requiring specialized wound and intravenous (IV) care. One resident was admitted with diagnoses including infective endocarditis and a surgical wound on the right foot, requiring daily wound dressing changes and long-term IV antibiotics via a PICC line. Upon review, it was found that the resident did not receive appropriate wound care or PICC line management following admission. The wound dressing applied at the hospital remained unchanged for several days, and the PICC line was observed without a protective cap, increasing the risk of infection. Orders for wound care and PICC line dressing changes were either not entered or entered incorrectly into the facility’s records, resulting in missed treatments and lack of monitoring. Nursing staff failed to document the condition of the wound or the PICC line, and weekly skin assessments did not reflect the resident’s actual needs or current conditions. Another resident with diabetes, dementia, and multiple wounds, including a diabetic ulcer and pressure ulcers, was also not provided with adequate wound care. The resident was observed without dressings on several wounds, and a wound on the bottom of the left foot was not assessed, monitored, or treated by facility staff. This wound was not documented in the facility’s records or skin assessments, despite being noted by an outside nurse from a community day center. The lack of documentation and treatment led to the development of a wound infection, as confirmed by subsequent medical notes and the need for antibiotic therapy. Interviews with facility staff, including the DON and LPNs, revealed a lack of awareness and communication regarding the residents’ wound care needs and PICC line management. Staff relied on incomplete or incorrect documentation, resulting in missed treatments and failure to identify or address new and existing wounds. The facility’s care plans and treatment administration records were not resident-centered and did not include specific interventions or monitoring for the residents’ conditions, directly contributing to the deficiencies in care.
Failure to Provide Pressure Ulcer Care per Physician Orders and Protocols
Penalty
Summary
The facility failed to provide quality care and treatment for pressure ulcers in accordance with professional standards for one resident. The resident, who had a history of bilateral below-knee amputations and spinal fractures, was observed with multiple wounds, including a large dressing on the sacrum that was not fully intact, an open and actively bleeding wound on the right buttock without a dressing, and a dressing on the right knee. During wound care, it was noted that the prescribed calcium alginate with silver was not applied to the right knee or sacrum wounds, and the dressings used did not match physician orders. The right buttock wound was not covered with the required hydrocolloid dressing, and the LPN providing care was unaware of the specific dressing requirements outlined in the treatment orders. Further review revealed that the resident's care plan did not include all current wounds, specifically omitting the stage 2 pressure ulcers on the coccyx and right knee. Weekly skin observations and documentation were also lacking, with no entries for the past three weeks. The CNA staff relied on incomplete care plans for direct care, and the treatment administration record indicated inconsistencies between ordered and provided wound care. These actions and omissions resulted in a failure to follow physician orders and facility protocols for pressure ulcer prevention and treatment.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents, resulting in deficiencies related to the administration and monitoring of oxygen and CPAP therapy. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, physician orders for CPAP and continuous oxygen therapy were not entered until several days after admission. The care plan did not specify the type or amount of oxygen, nor did it include a plan for CPAP use. Staff interviews revealed that the resident required constant supplemental oxygen, and an incident occurred where the resident arrived at a community day center short of breath with a blood oxygen level of 80% due to a portable oxygen tank not being turned on and kinked tubing, resulting in the resident being without supplemental oxygen for at least 25 minutes. For another resident with heart failure, there was a discrepancy between the physician's order for oxygen and the transcription of that order to the treatment administration record (TAR), leading to uncertainty among staff regarding the correct oxygen setting. Additionally, the oxygen tubing was not changed according to the schedule indicated in the TAR, as the tubing observed in the resident's room was last changed over a week prior, despite documentation stating otherwise. Staff interviews confirmed a lack of clarity regarding the resident's oxygen settings and the required frequency for changing oxygen tubing.
Failure to Maintain AED Functionality During Cardiac Emergency
Penalty
Summary
The facility failed to ensure the regular checking and maintenance of its automatic external defibrillator (AED), resulting in the device being inoperable during a critical cardiac arrest emergency involving a female resident with a history of heart disease, pulmonary embolism, and mediastinal cancer. When the resident was found unresponsive and a Code Blue was called, staff attempted to use the facility's AED, but it would not turn on due to a dead battery. There was no backup battery available at the time, and the staff had to rely on an AED provided by a first responder. Interviews and record reviews revealed that the AED was not included in the routine crash cart checklist, and there was no documentation of regular functionality checks or battery monitoring. The Director of Nursing and Maintenance Director both confirmed the absence of a process or evidence for AED checks, and the AED Inspection Log showed the last inspection was not recent. The lack of established procedures and documentation for AED maintenance directly led to the device's failure during the emergency.
Failure to Maintain Operable Dishwasher Resulting in Prolonged Use of Disposable Meal Containers
Penalty
Summary
The facility failed to maintain its dishwasher in an operable condition, resulting in the use of Styrofoam containers for meal service to all residents. Staff interviews revealed that the dishwasher had been out of service for over 30 days, with the Dietary Manager noting the initial order of Styrofoam containers in mid-February. The previous Maintenance Director confirmed that the dishwasher was too old to repair cost-effectively and that parts were unavailable. Documentation showed that the facility began seeking quotes for repair or replacement in late January, but delays occurred due to the corporate requirement to obtain three quotes and issues with credit approval for leasing a new dishwasher. During this period, residents were served meals in Styrofoam containers, with at least one resident expressing dissatisfaction with the prolonged use of disposable containers and the resulting cold or lukewarm food. Staff interviews indicated uncertainty and delays in the procurement process, with the Administrator and Dietary Manager both referencing ongoing efforts to secure a replacement dishwasher but facing obstacles related to corporate approval and financing. There was no mention of a COVID outbreak necessitating the use of disposable containers.
Failure to Ensure CNA Certification for Nurse Aides Within Required Timeframe
Penalty
Summary
The facility failed to ensure that three nurse aides employed for more than four months were properly certified before continuing to provide resident care. A review of the Nurse Aide Public Registry revealed that three nurse aides did not have a Certified Nursing Assistant (CNA) license on file. One aide had not paid the required fee to have her license placed in the licensing system, and the facility had not received a copy of her CNA license. Another aide, after completing the facility-paid nursing assistant class, failed the certification test but continued to work full-time providing resident care. The third aide transitioned from assisted living to long-term care, attended CNA training paid for by the facility, but did not have a CNA license on record. Interviews with human resources and administrative staff indicated a lack of clarity regarding responsibility for tracking and maintaining CNA licensing records. The scheduler was responsible for enrolling staff in CNA training, but there was uncertainty about who ensured that licensing requirements were met and documented. This lack of oversight resulted in nurse aides working beyond the four-month training period without proper certification, as required.
Failure to Adhere to Planned Menu
Penalty
Summary
The facility failed to ensure that residents received meals as outlined on the planned and posted menu, leading to potential dissatisfaction and frustration among residents. On 7/16/24, during a dining observation, it was noted that meal trays did not contain breadsticks as specified on the menu. The Dietary Manager (DM) confirmed that breadsticks were not served because they were not pulled from the freezer. Additionally, a planned tuna melt sandwich for supper was substituted with tuna noodle casserole without updating the posted menu. Resident #39 reported not receiving bacon for breakfast and milk for lunch, which were both listed on the menu. The DM explained that the bacon was burned the previous day, resulting in a shortage, and milk was conserved for breakfast due to purchasing challenges. Resident #16 also reported that the kitchen occasionally ran out of items, leading to deviations from the menu. The Resident Council Meeting Minutes from 7/12/24 indicated that residents felt the food served was different from the menu. The DM, new to the position, acknowledged difficulties in managing inventory, particularly with milk, and instructed staff to conserve milk for breakfast if supplies were low. These issues highlight the facility's failure to adhere to the planned menu, affecting the residents' meal satisfaction and nutritional intake.
Sanitation and Cooling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, it was observed that the walk-in coolers were inadequately lit, making it difficult to see the heavy accumulation of black debris on the floor perimeter and around the storage shelves. The clean utensil drawers under the preparation table contained excess crumb debris, and the parchment paper used as a barrier was old and discolored. The Dietary Manager was unaware of when the paper was last changed. Additionally, the light intensity in the walk-in cooler and freezer was below the required levels, with readings between 0.5-2.1 foot candles at the back of the units. The facility also failed to properly cool food, as evidenced by a gallon container of apple crisp stored in the walk-in cooler with heavy condensation and a temperature of 95.5°F. Upon a return visit, the apple crisp had not cooled adequately, with a temperature of 69.8°F, failing to meet the required cooling standards. Other issues included ice accumulation impeding the walk-in freezer door's ability to close, large rips and tears in the gasket seal of a cooler door, and a missing top cap on the atmospheric vacuum breaker of the dish machine, compromising its integrity. These deficiencies indicate a lack of adherence to the 2017 FDA Food Code requirements for equipment cleanliness, cooling methods, and facility maintenance.
Inadequate Implementation of Infection Control Precautions
Penalty
Summary
The facility failed to properly implement enhanced barrier and contact isolation precautions and the use of personal protective equipment (PPE) for four residents, leading to potential cross-contamination and spread of infection. Resident #33, who was cognitively intact and had an eye infection, was placed on contact isolation precautions. However, during an observation, the Activity Director entered the resident's room without wearing PPE, handled the resident's electronic device, and only used hand sanitizer upon exiting. This was contrary to the facility's policy, which required staff to wear a gown, gloves, and mask when entering the room and handling the resident's belongings. Resident #8 was initially placed on enhanced barrier precautions due to having a catheter, which was later removed. Despite the catheter's removal, there was confusion among the staff regarding the continuation of these precautions. The facility's process for initiating and discontinuing enhanced barrier precautions was unclear, leading to inconsistent practices. The resident's electronic health record (EHR) lacked orders for these precautions, and staff were unsure if they were still required to follow them. Resident #9 was observed to have a contact precautions sign on their door, but there was no PPE cart available. Staff were uncertain about the resident's current precaution status, as there were no orders in the EHR for initiation or discontinuation. Similarly, Resident #41 had a PPE cart in their room but lacked a sign indicating the type of precautions required. The resident's EHR was missing an order for enhanced barrier precautions, and staff were observed not wearing appropriate PPE during medication administration. These deficiencies highlight a lack of clear communication and adherence to infection control protocols within the facility.
Failure to Maintain Resident Dignity During Bed Maintenance
Penalty
Summary
The facility failed to maintain the dignity of Resident #29 by conducting maintenance work on her bed while she was asleep, without her permission. The Maintenance Assistant (MA) entered the resident's room without knocking and adjusted the bed's position multiple times while the resident was in it, without acknowledging her presence. This action was observed by a Registered Nurse (RN), who laughed with the MA about the situation, indicating a lack of respect for the resident's dignity. Resident #29, who has diagnoses including major depressive disorder, Alzheimer's disease, and cognitive communication deficit, expressed that she did not like having her bed moved while she was in it. The MA admitted to performing maintenance on beds with residents in them, especially if they were cognitively impaired and unlikely to voice concerns. This behavior disregarded the resident's right to a dignified existence and self-determination, potentially leading to feelings of frustration, fear, and dehumanization.
Failure to Report and Investigate Suspected Misappropriation
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency involved a resident who was admitted with a diagnosis of diabetes. The resident received a notification from their bank about a suspicious purchase, leading to the discovery that their wallet was missing. The resident reported the missing wallet to a registered nurse, who then informed the Nursing Home Administrator (NHA). The NHA reported the incident to the local police department. However, the local police closed the case because the incident occurred in a different county. The NHA did not contact the appropriate police department to open a new investigation, as the wallet was found, and thus, the allegation of misappropriation was not thoroughly investigated.
Failure to Implement Person-Centered Interventions for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to identify and implement person-centered, non-pharmacological interventions for a resident receiving psychotropic medication. Resident #17, a female with diagnoses including anxiety disorder, major depressive disorder, and dementia, was prescribed Fluoxetine HCl for depression. The care plan for Resident #17 included administering antidepressant medications as ordered and monitoring for side effects and effectiveness every shift. However, the care plan lacked individualized, non-pharmacological interventions to address the resident's depression. During an interview, the Social Services Director (SSD) acknowledged responsibility for developing care plans for residents on psychotropic medications. The SSD admitted that the care plan for Resident #17 needed to be more individualized with person-centered, non-pharmacological approaches. The SSD noted that interventions could be added or revised as more information about the resident was learned, indicating a deficiency in the current care plan's ability to meet the resident's psychosocial needs.
Medication Reordering Failure
Penalty
Summary
The facility failed to ensure that Resident #245 received ordered medications as scheduled, which resulted in the potential for worsening health conditions. Resident #245, who was admitted with chronic obstructive pulmonary disease (COPD), had an order for Xifaxan Oral Tablet 550 MG to be administered twice daily for diarrhea. However, the medication was not available, and the resident missed two doses on 7/16/24 and one dose on 7/17/24. Licensed Practical Nurse (LPN) N reported that the medication had not been re-ordered and was not available in the facility's backup stock, requiring contact with the pharmacy for delivery. The Assistant Director of Nursing (ADON) D and LPN L confirmed that nurses were responsible for reordering medications before they ran out and contacting the pharmacy if a medication was missing. Despite this, LPN L did not contact the pharmacy or physician when the medication was discovered missing on 7/16/24. The facility's Medication Reordering Policy, last revised in 12/2023, outlines that medications should be reordered when six or fewer doses remain, but this procedure was not followed, leading to the deficiency.
Failure to Conduct Timely Nutritional Assessments
Penalty
Summary
The facility failed to ensure timely and consistent assessment, monitoring, or reassessment of a resident's nutritional and hydration status, leading to a deficiency in nutritional care and services. The resident, who was admitted with diagnoses including anoxic brain damage, quadriplegia, and dysphagia, was identified as being at nutritional risk. Despite being cognitively intact and on a mechanically altered diet, the resident's care plan noted unplanned weight loss related to variable meal intake and supplement refusals. The care plan included interventions such as monitoring weight loss, food intake, and having a registered dietitian evaluate and recommend diet changes. However, the facility's policy required a comprehensive nutritional assessment by a dietitian within 72 hours of admission, annually, and upon significant change in condition, with follow-up assessments as needed. The resident's nutritional needs were assessed only three times in the last twelve months, missing the quarterly assessment required by the facility's policy. The registered dietitian acknowledged that an assessment should have been completed in December 2023 but was not, resulting in the potential for unmet nutritional needs and unaddressed weight loss, which could worsen the resident's overall health.
Failure to Address Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and responded to the consultant pharmacist's monthly medication regimen review (MRR) irregularity report recommendations for two residents. This deficiency was identified during a survey, where it was found that the registered pharmacist's recommendations were not addressed, leading to the potential for negative medication side effects. The facility's policy requires that any irregularities noted by the pharmacist during the MRR must be documented and acted upon by the attending physician, with the physician's response recorded in the resident's medical record. For Resident #17, the pharmacist recommended a gradual dose reduction (GDR) for the medication Fluoxetine, as per federal guidelines. However, the physician's response section on the pharmacy recommendation report was left blank, indicating that the recommendation was not reviewed or acted upon. Despite multiple requests from the surveyor, the facility was unable to provide evidence of the physician's response to the recommendation, and the consultant pharmacist confirmed that the recommendation was still pending. Similarly, for Resident #8, the pharmacist recommended obtaining a fasting lipid panel due to the use of the antipsychotic medication Risperidone, which may induce hyperlipidemia. The physician's response to this recommendation was also incomplete, and the facility could not provide evidence that the recommendation had been reviewed or acted upon. Interviews with facility staff, including the Assistant Director of Nursing and a Nurse Practitioner, confirmed that there was no record of the physician's response or any orders for the recommended lab test.
Failure to Attempt Gradual Dose Reduction for Antidepressant Medication
Penalty
Summary
The facility failed to attempt a required Gradual Dose Reduction (GDR) of an antidepressant medication, specifically Fluoxetine, for a resident diagnosed with anxiety disorder, major depressive disorder, and dementia. The resident was receiving two different dosages of Fluoxetine, 10 mg and 20 mg, daily for depression. Despite federal guidelines requiring an attempt at a GDR twice per year for the first year, there was no documented attempt or contraindication for a GDR in the resident's medical records. This oversight was confirmed during interviews with the Social Services Director and the Assistant Director of Nursing, who both acknowledged the absence of a GDR attempt for the resident. The Social Services Director indicated that the Interdisciplinary Team (IDT) typically reviewed medications for GDRs during Risk Meetings, and it was usually the responsibility of the contracted behavioral health service or the resident's physician to make GDR recommendations. However, the resident had not been seen by a contracted behavioral health service. The Assistant Director of Nursing also confirmed that the IDT was responsible for tracking GDRs, but she had not been involved in this process. The Nursing Home Administrator stated that nursing staff, including the Director of Nursing, were responsible for tracking GDRs, but the Director of Nursing was unavailable for comment during the survey. The lack of documentation for a GDR or a contraindication highlights a gap in the facility's medication management process for this resident.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation of education, offering, and timely receipt of the COVID-19 immunization as recommended by the CDC. This deficiency was identified for one resident, who was not offered the COVID-19 immunization upon admission to the facility, as per the facility's policy and CDC guidelines. The resident, who was severely cognitively impaired with a BIMS score of 00/15, had last received the COVID-19 vaccine in June 2022. During an interview, the Assistant Director of Nursing/Infection Prevention acknowledged that the resident should have been offered the COVID-19 vaccination upon admission and annually thereafter. The failure to offer the vaccine was attributed to a mistake during the resident's initial nursing assessment. The facility's policy, dated September 2023, states that residents should receive an additional dose of the updated COVID-19 vaccine at least four months after the previous dose unless medically contraindicated, already immunized, or if the resident refuses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 121 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Douglas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resthaven Care Center | 9.7 mi | ★★★★★ | 0 | 0 |
| The Inn At Freedom Village | 12.1 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Holland | 12.7 mi | ★★★★★ | 4 | 0 |
| Heritage Nursing And Rehabilitation Community | 15.6 mi | ★★★★★ | 19 | 0 |
| Medilodge Of Zeeland | 15.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.