Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Northwest during CMS and state inspections, most recent first.
Kitchen sanitation and backflow deficiencies were observed during a survey. Drain lines from the ice machine and juice gun extended improperly into the floor drain, the ice machine had brown residue, stored pans contained water droplets and food particulates, a stand mixer had a pen and residue in the bowl, and a meat slicer had dried residue on the blade. The cook was unsure about the dishwasher’s sanitizing method and how to perform the chlorine test strip, and the mop sink setup was also observed in the dirty dish room.
Failure to submit PBJ staffing data: The facility did not electronically submit complete and accurate PBJ staffing information for the quarter. The PBJ report showed no submitted data and triggered a One Star Staffing Rating, excessively low weekend staffing, no RN hours, and no licensed nursing coverage 24 hours/day. The HRD said the PBJ was reviewed and sent to corporate for submission but was not submitted because it would have been late, and the NHA said HR submits the PBJ to CMS and was unaware it had not been submitted.
Facility staff failed to maintain an active water management program for legionella and other OPPP. Multiple hoppers, sinks, tubs, and water fountains were observed inoperable, turned off, not flushed, or producing discolored water, with residue and particulate matter noted in some fixtures. Interviews with ESM, MD, RMD, DON, and the Administrator showed limited knowledge of control measures, no established water management team, incomplete binder documentation, and no evidence of implemented water management activities.
Poor Premises Maintenance and Improper Storage of Clean Supplies: Surveyors observed multiple maintenance and housekeeping issues, including a faucet in the nutrition room with only a trickle of water, loose sink fixtures in several soiled utility and linen rooms, water damage on a linen storage ceiling, broken drywall exposing piping in a janitor closet, missing shower room floor tiles, and a loose wall handrail bracket. Clean linen areas also had disposable briefs, personal clothing, a bed pan, and a bottle stored on the floor near clean linen racks, along with residue, debris, and other contamination concerns in shower rooms and utility areas.
A resident with multiple psychiatric and medical diagnoses, including schizophrenia, bipolar disorder, substance use disorder, and COPD, was found repeatedly smoking or in possession of smoking materials despite being assessed as safe to smoke only with supervision. Staff documented cigarette smoke in the resident’s room, cigarette butts, marijuana odor and use, a weed pen, blunt wrappers, tobacco, and cigarettes on the bedside table, while interviews showed inconsistent control of smoking items and no family education on the smoking policy.
A resident with hand contractures, peripheral neuropathy, and generalized OA did not receive the ordered 2-handled cup with meals, despite the meal ticket specifying a divided plate and 2-handled cup. Staff observed the resident using a regular glass and having difficulty grasping it, while the DM, CNA, UM, and DON all acknowledged the resident should have the adaptive cup for every meal. The care plan and physician orders did not identify dining adaptive equipment.
Failure to provide ordered skin care for two residents. One resident with heart failure, kidney disease, depression, and HTN was observed with dry facial skin and scalp flakes, stated no moisturizer was being given, and the CNA and UM confirmed ordered creams were not applied and TAR entries were blank. Another resident with schizoaffective disorder and cognitive communication deficit was observed with extremely dry, peeling feet despite an order for ammonium lactate lotion; an LPN described the skin as extremely dry and scaly, and the DON stated staff are expected to provide skin care.
Failure to assess and address nutritional needs for a resident on dialysis with renal cancer. A resident with ESRD, atherosclerotic heart disease, and renal cell carcinoma was observed thin and had a care plan for nutritional risk that included a dialysis-specific supplement, but the supplement order had been discontinued and the RD was unaware of the cancer diagnosis. The RD’s nutrition assessments did not address the renal carcinoma, while nephrology documented a falling Hgb and concern about clearance for Epogen during dialysis; the DON stated the resident should have received more nutrition because of the cancer diagnosis.
Incomplete dialysis communication sheets were not consistently available for a resident with ESRD who received scheduled hemodialysis. Staff described a process where the forms were placed at the nurse’s station, reviewed by the RD, and then sent to medical records, but surveyors found multiple missing sheets across the review period. The resident’s care plan called for coordination of the nutrition plan with dialysis and monthly review of communication sheets and labs.
Failure to Post and Retain Daily Staffing Reports: The facility did not consistently display current daily staffing ratio information in a prominent, accessible area for residents, families, and vendors, and it did not retain prior postings. A staffing report was observed posted in the foyer, but review of prior reports showed multiple missing daily postings. The SC confirmed weekday responsibility for the report and the DON confirmed the postings were intended to show adequate staffing and were also the responsibility of weekend supervisors.
A medication cart on the Three-East hall was observed unlocked with the tubular lock key system extended outward while no staff were present in the hallway. Several unidentified residents were nearby, and the cart was not visible from the nursing desk. Nurse Q stated carts are expected to be locked when not in view, and the DON confirmed medication carts should be locked.
A dependent resident with right-side hemiplegia, dementia, and other comorbidities, whose MDS, care plan, and Kardex all required a two-person assist for showering and rolling, was transferred by two CNAs via Hoyer lift to a shower bed, after which only one CNA remained to provide the shower. In a shower room with a narrow stall opening and raised threshold, the CNA asked the resident to roll so the resident’s bottom could be washed and rolled the resident away from their own body, contrary to facility bed-mobility policies that direct staff to roll residents toward them. The resident continued rolling, fell from the shower bed to the floor, and sustained a facial laceration requiring sutures and reported knee pain, while an LPN was called only after the fall occurred.
A resident with right-side hemiplegia, vascular dementia, and total dependence for bathing was care planned and documented on the Kardex and MDS as requiring two-person assistance for showers and use of a shower bed. One CNA assisted only with the Hoyer lift transfer, then left after the primary CNA declined further help, and the primary CNA proceeded to shower the resident alone. While washing the resident’s bottom, the CNA rolled the resident away from themselves on the shower bed, and the resident continued rolling off the bed onto the floor, sustaining injuries. Interviews with the SDC and leadership and review of training logs showed there was no classroom training on shower-bed use, no documented training on bed mobility or positioning during showers, and no evidence that CNAs were trained to roll dependent residents toward them, despite facility policies describing that technique.
The facility's kitchen had multiple sanitation and maintenance deficiencies, including soiled surfaces, ineffective sanitizing solutions, and improperly cleaned and dried pans. Observations revealed issues such as a leaking garbage disposal, a non-functional sink faucet, and missing floor tiles, all of which failed to meet the 2013 FDA Food Code standards.
The facility failed to implement an effective QAPI program, as the NHA identified issues with customer service and resident smoking policy adherence but lacked objective data and analysis to address these concerns. The facility's QAPI policy requires data collection and analysis, which was not followed, and no additional documentation was provided during the exit conference.
The facility failed to maintain a comprehensive infection control program due to a lack of leadership and documentation from August to September 2024, increasing the risk of infection spread. Additionally, clean environmental services equipment was improperly stored in the soiled laundry area, as confirmed by staff, further compromising infection control efforts.
The facility failed to maintain a continuous Antibiotic Stewardship Program, leading to potential unnecessary medication use and antibiotic resistance. The Director of Nursing, who took over the infection control program in August 2024, confirmed the absence of documentation for the program from August to September 2024. Despite discussions in morning meetings, there was no documented evidence of antibiotic use, dosage, or monitoring, violating the facility's policy on Infection Prevention and Antibiotic Stewardship.
The facility failed to maintain continuity in the role of Infection Control Preventionist (ICP) and did not ensure the ICP completed necessary training, leading to potential knowledge deficits and delays in infection control data collection. The DON took over the role in August 2024 after the previous IP resigned, but did not complete the required training until November 2024, leaving a gap in infection control program documentation.
The facility did not screen residents for COVID-19 vaccine eligibility, provide education, or offer the vaccine, resulting in residents not receiving immunization. The DON revealed no documentation of a COVID-19 vaccine program and stated that an outside company previously handled vaccinations but was no longer available. The facility's policy for COVID-19 immunization was not provided.
The facility failed to provide adequate personal care for several residents, resulting in unmet needs. A resident was found with long, dirty fingernails and matted hair, while another had significant plaque buildup on their teeth and an unkempt appearance. Despite requiring assistance, there was no documentation of care refusal, and care plans lacked specific instructions. Additionally, a resident was found lying in urine multiple times, indicating a failure to provide timely incontinence care.
The facility failed to maintain RN coverage for eight consecutive hours daily, as required, due to staffing issues, particularly on weekends. This deficiency was confirmed by the staffing coordinator and DON, affecting all 120 residents.
The facility's second floor had several maintenance deficiencies, including a soiled elevator exhaust fan, scuffed and dingy paint, exposed nails on a handrail, and missing flooring in day rooms. These issues affected all residents on the floor and those using the elevator. The Director of Maintenance acknowledged the problems, and the Nursing Home Administrator agreed that maintenance is an ongoing process, but a maintenance checklist was not provided.
The facility failed to provide annual dementia management and abuse prevention training for three CNAs, as required. Records for CNAs H, I, and J showed no evidence of the necessary training within the specified time frames. Interviews with the Staff Educator and DON confirmed the absence of training records, despite the facility's policy requiring 12 hours of annual training for CNAs.
A resident was found with their arm wedged between the bed and the wall, unable to reach the call button clipped to their pillowcase, resulting in unattended pain. An LPN confirmed the situation and assisted the resident. The DON acknowledged the call light should have been within reach, but no additional information was provided during the exit conference.
A facility failed to complete an Advance Directive for a resident with impaired cognition and multiple diagnoses, including heart disease and dysphagia. Despite attempts by the social worker to obtain a signed document from the guardian agency, the Advance Directive was not returned. The DON noted that the document should have been reviewed during care conferences, which occurred twice since the resident's admission, but it remained unsigned.
A resident with a history of serious medical conditions was found with bloody urine, which was reported to the nursing staff but not followed up with physician notification or further assessment. The facility's policy on acute changes in condition was not adhered to, leading to a potential delay in care.
A facility failed to report an injury of unknown source for a resident in a timely manner, resulting in a delayed investigation. The resident, who had severe cognitive impairment, complained of pain in the lower extremities, and an LPN observed a bruise but did not report it to the DON or NHA. The facility's policy required immediate reporting of such findings, but the NHA was only informed of the fracture by the hospital days later.
A facility failed to develop a comprehensive care plan for a resident with a tracheostomy. The resident, who had acute respiratory failure, laryngeal cancer, esophageal cancer, and tracheostomy status, was observed with a tracheostomy tube. The DON confirmed the absence of a care plan for tracheostomy care, which should have included care instructions and monitoring guidelines. No additional information was provided during the exit conference.
A resident's room contained hazardous objects, including a sharp metal screw protruding from a detached closet door and a bed bumper with protruding screws. The resident, who had severe cognitive impairment and required assistance with daily activities, expressed concern about potential injury. Maintenance staff confirmed the safety hazard, but repairs were not documented in the TELS system. The facility's maintenance policy was not followed.
A resident with severe cognitive impairment and dependent on a feeding tube was not properly monitored for weight fluctuations, despite being at high risk for weight loss. The facility failed to record accurate readmission and weekly weights, as required by policy, leading to potential undetected nutritional compromise.
The facility failed to provide necessary emergency tracheostomy supplies for a resident and did not consistently follow physician orders for tracheostomy care for another resident. Emergency equipment was missing from a resident's room, and trach care was not performed as ordered, with multiple instances of missed care documented.
A resident with a stoma was found to have expired medical supplies in their room, including heat and moisture exchangers and stoma caps. The DON acknowledged that these expired supplies should not have been stored with unexpired ones and should have been removed to prevent use. The resident had a history of cancer and an artificial larynx, with intact cognition.
A resident's privacy was compromised due to broken window blinds that were not repaired, resulting in feelings of disrespect and potential exposure during care. The resident, who requires significant assistance with daily activities and has multiple health conditions, expressed dissatisfaction with the situation. Interviews revealed that the nursing staff was responsible for notifying maintenance about repairs, but the facility's policy was not followed, leading to the deficiency.
The facility failed to implement proper hand hygiene and glove use during wound care for a resident and did not provide the proper receptacle for the disposal of PPE for another resident. A wound nurse did not follow hand hygiene protocols, and a resident's isolation room lacked an appropriate trash receptacle for PPE disposal, both of which were acknowledged by the DON as against the facility's policies.
A resident with severe cognitive impairment was found restrained in bed with garbage bags, a gown, and a sheet, without any orders, consents, or care plans. The CNA responsible claimed it was to prevent choking, but the facility's policy prohibits such restraints without proper documentation and consent.
A resident with severe cognitive impairments was found restrained with a plastic bag, a gown, and a sheet by a CNA, who claimed it was to prevent choking. The incident was reported internally but not to the State Agency, as required by the facility's policy. The facility is a restraint-free building, and the restraints used were not approved.
A facility failed to provide an armrest on a resident's wheelchair, resulting in the resident falling and sustaining a large hematoma. The resident, with a history of falls and impaired cognition, was sent to dialysis with only one armrest. The CNA admitted to not attaching the second armrest, and the DON confirmed the expectation for both armrests to be intact during transport. No specific policy was provided to ensure proper equipment assembly before transportation.
Kitchen sanitation and backflow deficiencies
Penalty
Summary
The facility failed to maintain best practices in the kitchen food service area during a survey observation and interview review. Surveyors observed a plastic tube from the ice machine drain line extending into the floor drain below the flood level rim, and a black corrugated tube from the juice gun drain line also extending down into the floor drain, creating improper air gaps. The report cited 2022 FDA Food Code section 5-402.11 regarding backflow prevention for these direct connections between equipment drains and the sewage system. Surveyors also observed brown residue on the interior wall of the ice machine, and kitchen staff stated they did not clean the ice machine because another department was responsible. Two quarter pans stored on a dry rack had water droplets and food particulates inside them. A stand mixer that staff said was used a couple times a month had a pen in the bowl and white residue near the attachment area under its plastic cover, and a meat slicer covered with a plastic bag had dried residue on the backside of the blade. The cook was unsure whether the dishwasher was a chlorine-sanitizing unit or a high-temperature sanitizing unit, did not know why the temperature and PPM log was filled out for lunch, and did not know what to look for when performing the chlorine test strip. During the kitchen tour, the mop sink was identified in the dirty dish room within a one-compartment sink, and a clear container was observed sitting at the base of the sink.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate PBJ staffing information based on payroll and other verifiable and auditable data for Fiscal Year Quarter 4 2025 (July 1 - September 30). A review of the PBJ report showed that the facility did not submit data for the quarter and triggered a One Star Staffing Rating, Excessively Low Weekend Staffing, No RN Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day. During interviews, the Director of Human Resources stated that the PBJ had been analyzed, reviewed, and sent to the corporate office for submission, but it would have been late so it was not submitted. The NHA stated that HR submits the PBJ to CMS and was not aware that the PBJ had not been submitted, although the report had been reviewed and should have been submitted.
Lack of Active Water Management Program for Legionella Control
Penalty
Summary
The facility failed to have an active infection prevention and control program for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During observation, multiple water fixtures throughout the building were found inoperable, turned off, or not being flushed, including water fountains, hoppers, sinks, tubs, a mop sink, and a utility sink. Several fixtures produced discolored water when turned on, and some hoppers contained water, black particulate material, brown residue, or layered residue along the bowl and drain line. In several areas, staff identified that fixtures were not used, were not flushed, or had been out of service for extended periods. Environmental Services and maintenance staff interviews showed limited knowledge of water management practices. The Environmental Services Manager stated housekeeping flushed the hopper once a week when cleaned but did not turn on the hopper faucet or use the spray hose. The Maintenance Director stated the hot water tank was flushed once a month and was not certain of any other controls. The Regional Maintenance Director stated chlorine testing was not done, legionella testing was performed once a year using a test kit, and flushing the boiler was the only control measure used. The Regional Maintenance Director also stated the water management binder had not yet been completed and that there was no established water management team, with the process mostly falling on maintenance. Additional interviews and observations showed that several fixtures were not being monitored or maintained as part of a coordinated program. Staff were unaware whether some sinks, hoppers, tubs, and fountains were used, whether they were shut off at the main line or fixture valve, or how long some fixtures had been out of order. The Administrator stated maintenance discussed water management in QAPI once a month, but there had been no meeting regarding water management with the new Maintenance Director. The Director of Nursing stated there was no water management team in regard to legionella. A record review of the facility's Legionella binder showed the CDC toolkit Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, but there was no evidence of completed work or implemented activities.
Poor Premises Maintenance and Improper Storage of Clean Supplies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises and failed to properly store clean and sanitary supplies. During observations, surveyors found a sink faucet in the first-floor nutrition room releasing only a trickle of water, nails screwed into cabinet doors beneath the sink in the third-floor nutrition room with the nails protruding through the wood, and a container with a thick black substance along the bottom edges beneath the sink drain line. In the linen bulk storage room, surveyors observed evidence of water damage with black residue on the ceiling and a repaired section adjacent to the affected area, which staff identified as the result of a previous water leak. Surveyors also observed multiple storage and housekeeping concerns. In the first-floor clean linen room, disposable briefs and padding in plastic bags were on the floor next to the clean linen rack, with a bed pan on the floor beneath the rack. In the first-floor janitor closet and second-floor janitor closet, mop sinks with chemical pre-dispensing systems had faucets left on, creating undue back pressure on the faucets’ internal atmospheric vacuum breakers; in the first-floor closet, broken drywall above the mop sink exposed internal piping, a hole was visible in the pipe, and duct tape was peeling from the wall. In the second-floor clean linen room, disposable briefs in a plastic bag and personal clothing were on the floor, with a plastic bottle beneath the clean linen rack. Additional observations showed a shortened shower curtain in the third-floor east wing shower room, residue on the shower curtain and green substance on the floor in the third-floor west wing shower room, a brown smear on a shower chair seat and debris under a shower bed mat in the second-floor west wing shower room, and a tissue pressed to the floor in the second-floor east wing shower room. Surveyors also found loose sink fixtures in the first-floor soiled linen room, second-floor east wing soiled utility room, third-floor west wing soiled utility room, and third-floor east wing soiled utility room; accumulated debris in drains and a hopper with black particulates in the second-floor west wing soiled utility room; missing floor tiles in the second-floor west wing shower room; dust and debris behind a separating baseboard in the second-floor central supply room; and a gap at a wall-mounted handrail bracket in the third-floor west wing. The facility’s Environmental Safety Program Preventative Maintenance document stated that preventive maintenance schedules shall be developed and implemented to ensure the building and equipment are maintained in a safe and operable manner.
Smoking policy not followed for resident with repeated access to tobacco and marijuana
Penalty
Summary
The facility failed to ensure its smoking policy was implemented and practiced for one resident who smoked. The resident was observed in the bedroom while the odor of cigarette smoke was present outside the room, and was later observed smoking independently in the designated smoking area with other residents. The resident was admitted with diagnoses including HIV, personality disorder, lupus, schizophrenia, bipolar type disorder, substance use disorder, and chronic obstructive pulmonary disorder, and was documented as cognitively intact with a BIMS of 15 and independent with activities of daily living. The resident’s record showed a smoking assessment indicating the resident was safe to smoke with supervision, but the assessment was not completed after readmission or quarterly. The smoking care plan documented that the resident attempted to smoke in the room at times and included interventions such as education not to smoke in the room and giving smoking products to activity staff. The care plan also stated the resident was not allowed to leave the premises without supervision and that the charge nurse was to be notified if the policy was violated. Progress notes documented repeated smoking-related concerns, including cigarette smoke odor in the room, cigarette butts found in the room, marijuana odor, marijuana use with another resident, a weed pen found under the pillow, blunt wrappers and tobacco scattered in the room, cigarettes on the bedside table, and ashes and cigar or cigarette remnants on the floor. Interviews revealed staff were uncertain how the resident obtained smoking materials, the family had not been educated on the smoking policy, the front desk and nursing staff were inconsistently involved in controlling the resident’s smoking materials, and the resident was found to still have cigarettes in a coat pocket while stating staff had taken the lighter away.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide assistive dining equipment for one resident with limited ROM and hand contractures. R49 was observed in bed on 03/08/2026 with contractures of both hands, and on 03/09/2026 and 03/10/2026 was observed eating breakfast with a divided plate but a regular glass instead of the ordered 2-handled cup. R49 stated that staff did not bring the special cup and that it was easier to drink with it, and was observed having difficulty grasping and bringing the regular cup to the mouth. R49’s meal ticket was highlighted for a 2-handled cup and divided plate, and the Dietary Manager stated R49 should have those items for every meal but they were missed and the facility sometimes ran out of the cups. The CNA who set up the tray stated there was no 2-handled cup and said she should have notified the nurse. The Unit Manager stated the kitchen was responsible for providing the adaptive equipment, but nursing staff should obtain it if missing. The DON stated the expectation was for R49 to have a 2-handled cup for every meal due to hand contractures. Record review showed R49 had diagnoses of peripheral neuropathy and generalized osteoarthritis, severe cognitive impairment on the MDS, upper extremity impairment on both sides, and required setup or clean-up assistance for eating. The care plan did not include dining assistive equipment, and physician orders did not identify dining adaptive devices.
Failure to Provide Ordered Skin Care for Two Residents
Penalty
Summary
The facility failed to provide proper skin care for two dependent residents who had physician-ordered treatments for dry, flaky, or itchy skin. One resident was observed seated in a wheelchair with dry facial skin, visible scalp flakes, and large flaky skin particles on the front of the pants. The resident stated that no treatment was being provided for the dry, flaky skin and requested moisturizer. The assigned CNA stated the resident had some kind of cream treatment but acknowledged it was not applied. The unit manager confirmed the ordered cream should have been applied and noted the treatment was not completed on the TAR. The resident’s record documented diagnoses including heart failure, kidney calculus, major depressive disorder, and hypertension, and included a skin care plan for dry skin to the face and scalp with hydrocortisone cream and ketoconazole shampoo. Review of the March TAR showed multiple blank entries for the hydrocortisone cream, indicating the treatment was not completed at scheduled times. The unit manager also presented the ordered cream and shampoo and agreed the medications appeared not to have been used. A second resident, admitted with schizoaffective disorder and cognitive communication deficit, was observed awake in bed with feet outside the covers and very dry, peeling skin. On a return observation, the resident’s feet continued to appear very dry and peeling. The clinical record showed orders for ammonium lactate lotion to the upper and lower extremities for itchy dry skin and torso, and care plans identified the need for assistance with personal hygiene and skin treatment. An LPN described the feet as extremely dry and scaly and noted flakes on the floor, while the DON stated staff are expected to provide skin care and that the resident’s skin concerns and need for a change in intervention should have been addressed before the exit conference.
Failure to Assess and Address Nutritional Needs for Resident on Dialysis with Renal Cancer
Penalty
Summary
The facility failed to properly assess the nutritional status and implement nutrition interventions for a resident with ESRD on hemodialysis and a diagnosis of atherosclerotic heart disease. The resident was observed thin in appearance before transport to dialysis and reported eating okay. The record showed the resident was on a regular diet with pureed texture and thin liquids, and had been identified as nutritionally at risk related to chronic disease and dialysis. The care plan included a specialized nutrition shake for people on dialysis, but the supplement order had been discontinued on 9/24/25, and the unit manager confirmed there was no current order for it. The resident’s record also documented renal cell carcinoma, including a dialysis communication sheet noting the diagnosis and a nursing note describing nephrology concern about a consistent drop in hemoglobin and the need for urology clearance before Epogen could be administered during dialysis. An emergency care conference documented discussion of the renal carcinoma with the resident’s son. The RD stated she was unaware of the renal cancer diagnosis and said it would change the resident’s nutritional requirements and affect nutrient absorption, but the nutrition assessments completed on 1/7/26 and 2/28/26 did not address the renal carcinoma. The DON stated the resident should have received more nutrition because of the cancer diagnosis.
Incomplete Dialysis Communication Sheets
Penalty
Summary
The facility failed to ensure consistent coordination of care between the facility and the contracted dialysis center for a resident with ESRD who was ordered to receive hemodialysis on Monday, Wednesday, and Friday. During the review, dialysis communication sheets for the resident were found in multiple locations, including the nurse’s station, the RD’s records, and scanned documents in the EHR, but the documents were not consistently available or complete across the review period. Staff interviews showed that completed dialysis communication sheets were placed in a purple book at the nurse’s station, reviewed by the RD, and then sent to medical records, but the records available to surveyors did not include all expected forms. The resident’s record showed an original admission date of 5/24/25 and readmission on 10/21/25, with diagnoses including ESRD and atherosclerotic heart disease. The care plan directed staff to coordinate the nutrition plan with dialysis and to review communication sheets and labs monthly. Surveyors determined that multiple dialysis communication sheets from January and February 2026 were not available during the review, including forms dated 1/7/26, 1/9/26, 1/19/26, 1/23/26, 1/26/26, 2/4/26, 2/9/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/23/26, 2/25/26, and 2/27/26. The DON stated the purpose of the dialysis communication sheets was to collaborate with dialysis center staff and the physician to help create a positive health outcome for the resident.
Failure to Post and Retain Daily Staffing Reports
Penalty
Summary
The facility failed to display current daily staff ratio information in a prominent area that was readily accessible to all 117 residents, visitors, and vendors, and failed to retain prior staff ratio postings. On 3/8/26 at 8:30 AM, a Daily Staffing Report dated 3/6/26 was observed posted in the foyer. During interview, the Staffing Coordinator confirmed responsibility for the daily staffing report Monday through Friday and stated weekend supervisors were responsible on Saturday and Sunday, and that the postings were intended for families to check whether staffing was adequate. Review of January 2026 daily staffing reports with the Staffing Coordinator showed missing postings for multiple dates, including 1/1/26, 1/3/26, 1/4/26, 1/9/26, 1/10/26, 1/11/26, 1/15/26, 1/17/26, 1/18/26, 1/24/26, 1/25/26, and 1/31/26. The DON stated the purpose of the daily staff report was to show appropriate staffing to provide adequate care and confirmed that the posted information was for staff, family, and residents. The DON also confirmed the weekend supervisor was responsible for completing the posting on Saturday and Sunday.
Unlocked Medication Cart on Three-East Hall
Penalty
Summary
The facility failed to ensure a medication cart was secured in accordance with professional standards for one of six medication carts reviewed for medication storage and safety. During a tour of the third floor on the Three-East hall, a medication cart was observed with a tubular lock key system extended outward and unlocked. The cart drawers were opened and closed to confirm the finding. Three unidentified residents were sitting in wheelchairs near the cart, and one unidentified resident was walking up and down the hallway. No staff were observed in the Three-East hallway, and the medication cart was not visible from the nursing desk. When questioned, Nurse Q stated that nurses are expected to lock their medication carts when not in view of the cart. The DON later stated that the medication carts should be locked. The facility policy stated that medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.
Failure to Provide Two-Person Assist and Safe Positioning During Shower Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide the required two-person assistance during a shower and to safely reposition a dependent resident, resulting in a fall from a shower bed and injury. The resident had a history of right-side hemiplegia following a stroke, diabetes mellitus with diabetic retinopathy, dysarthria, aphasia, vascular dementia, and seizure disorder, and was unable to complete a BIMS interview. The resident’s MDS and care plan documented total dependence for showering/bathing and rolling in bed, with the need for assistance from two or more helpers, and the Kardex specified a two-person assist when showering and using the shower bed. Despite these documented needs, only one CNA provided the shower at the time of the incident. During the incident, two CNAs used a Hoyer lift to transfer the resident onto a shower bed, but only one CNA remained to perform the shower. The CNA who provided the shower reported that they were alone in the shower room and did not believe additional help was needed. While washing the resident, the CNA asked the resident to roll to the right side so the resident’s bottom could be washed and demonstrated rolling the resident away from their own body. The resident continued rolling and fell off the shower bed onto the shower floor. The LPN, who was not present during the shower, was called afterward and found the resident screaming and bleeding from the head, and emergency services were contacted. Post-incident observations and interviews further described the environment and staff practices that preceded the fall. The shower room had a narrow opening into the shower stall, with the shower bed only able to fit partway into the stall and a raised threshold at the entrance. The resident later reported having been on the shower bed, rolling over, and falling to the floor, and indicated ongoing pain in the right knee area. Staff interviews revealed that CNAs were expected to obtain care information from the Kardex and that there was no classroom training on the use of shower beds. The staff development coordinator stated that staff should roll residents toward themselves during care, and facility policies on bed mobility and turning a dependent resident directed staff to roll residents toward the staff member, but the CNA involved in the incident rolled the resident away from themselves while working alone, contrary to the resident’s documented need for two-person assistance.
Failure to Train CNAs on Safe Shower-Bed Positioning and Required Two-Person Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure CNAs had appropriate training and competencies in repositioning techniques and shower-bed care, which led to a resident rolling off a shower bed and sustaining injuries. The resident had a history of stroke with right-side hemiplegia, diabetes mellitus, diabetic retinopathy, dysarthria, aphasia, vascular dementia, and seizure disorder, and was totally dependent for bathing/showering per the MDS, requiring assistance of two or more staff. The resident’s care plan and Kardex both specified two-person assistance when showering and using the shower bed, and that the resident was totally dependent for transfers. Despite these documented needs, the resident reported being assisted by only one staff member during the shower when they rolled off the shower bed onto the floor. Surveyor interviews and record review showed that on the day of the incident, one CNA (CNA B) assisted another CNA (CNA C) only with the Hoyer lift transfer, then left, after CNA C declined further help with the shower. CNA C confirmed they were alone in the shower room while providing the shower. CNA C stated they rolled the resident onto their right side, away from themselves, to wash the resident’s bottom, and the resident “kept rolling,” ultimately falling from the shower bed to the floor. CNA C acknowledged that they obtain resident care information by reading the Kardex at the beginning of the shift and that they did not receive specific training on whether to roll residents toward or away from themselves during care, stating that their technique “depends on what I’m doing.” Further interviews with the Staff Development Coordinator and facility leadership revealed that staff did not receive classroom training on the use of shower beds, and the Staff Development Coordinator stated they did not provide training on bed mobility or positioning during showers/bed baths, believing it to be “common sense” and that CNAs should follow the Kardex. The ORMI/Annual Tracking Log for CNA in-services did not show training on bed mobility, Kardex training, or shower bed training. The DON acknowledged that, according to the MDS, care plan, and Kardex, two staff should have assisted with bathing and that the resident should have been rolled facing the CNA, consistent with facility policies on bed mobility and turning a dependent resident toward staff, which instruct staff to roll residents toward them. The facility did not have a specific policy for shower beds, and the DON and NHA were unable to provide evidence that the CNAs involved had been trained on shower bed use and proper positioning after the accident.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation standards in the kitchen, as observed during a survey. Several issues were noted, including visibly soiled surfaces such as a dust-covered disk above the handwashing sink and a dirty trash can lid. The floor in the dish tank machine area had chipped or missing tiles, making it difficult to clean. Additionally, food splatters were observed on the backsplash of the dishmachine, and these remained uncleaned during a follow-up visit. The garbage disposal was leaking, and the sanitizing solution used in the kitchen was found to be ineffective, testing below the required concentration. Further observations revealed that pans in the storage area were not properly cleaned and dried before being stacked, with some containing food debris. The stove's drip pan was also soiled with burnt food debris. The sink faucet in the cook's prep area did not shut off completely, and several floor tiles were missing in the dry food storage room, exposing surfaces that were not easily cleanable. These deficiencies were identified as not meeting the standards set by the 2013 FDA Food Code, which requires equipment and surfaces to be clean and sanitized, and floors to be smooth and easily cleanable.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of objective data collection and analysis regarding identified areas of concern. During an interview, the Nursing Home Administrator (NHA) acknowledged issues with customer service and adherence to the resident smoking policy, noting that staff were not consistently speaking to residents in a professional manner and that residents were keeping smoking paraphernalia on their persons and smoking unsupervised. Despite recognizing these issues, the NHA was unable to provide any objective data or analysis to support the identification of trends or the effectiveness of any performance improvement plans. The facility's policy on Quality Assurance Performance Improvement, dated January 2019, outlines the responsibilities of the QAPI committee, including the identification and response to quality deficiencies, development and implementation of corrective actions, and monitoring of performance goals. However, the facility did not adhere to these guidelines, as there was no evidence of data collection or analysis to measure the situation or track improvements over time. During the exit conference, neither the NHA nor the Director of Nursing provided additional documentation or information to address the deficiency.
Inadequate Infection Control Program and Improper Storage of Clean Equipment
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by the lack of documentation and operationalization of the program from August 10, 2024, through September 30, 2024. The Director of Nursing (DON), who assumed the role of infection control leader in August 2024, confirmed that the program was not executed due to the resignation of the previous Infection Preventionist (IP) and the unsuccessful hiring of a new IP in September. This resulted in a lack of accurate infection control tracking, surveillance, and data monitoring, increasing the potential for the spread of infections among residents. Additionally, the facility failed to properly store environmental services equipment, as observed on January 7, 2025. Clean items such as rags, mop heads, and towels were stored in the soiled laundry area, where items are placed into washing machines. The Laundry Aid (LA) and Head of Laundry (HL) acknowledged the improper storage and confirmed that clean items should not be stored in areas designated for soiled articles. This improper storage practice further compromised the facility's infection control efforts.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a continuous Antibiotic Stewardship Program, which resulted in the potential for unnecessary medications and antibiotic resistance. The deficiency was identified during a review of the facility's infection control program with the Director of Nursing (DON), who had been overseeing the program since August 2024. The review revealed that there was no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed that the previous Infection Preventionist (IP) resigned in early August 2024, and although another IP was hired in September, it did not work out. During this period, the facility lacked documented evidence of resident antibiotic use, including the indication of use, dosage, duration of treatment, or monitoring of symptoms. The facility's policy on Infection Prevention and Antibiotic Stewardship was not effectively implemented. The policy outlined the need for written antibiotic use protocols, periodic reviews of antibiotic use, and feedback reports on antibiotic use and resistance patterns. However, the facility did not have a system in place to monitor antibiotic use or provide feedback reports. The DON mentioned that discussions about residents on antibiotics occurred during morning meetings, but there was no documented evidence to support these discussions. This lack of documentation and oversight led to the deficiency in maintaining an effective Antibiotic Stewardship Program.
Inadequate Infection Control Leadership and Training
Penalty
Summary
The facility failed to ensure continuity of care for the role of an Infection Control Preventionist (ICP) and did not ensure that the ICP completed specialized training in infection prevention and control. This resulted in potential knowledge deficits regarding current infection prevention and control standards, undetected outbreaks due to inadequate infection control surveillance, and delays in infection control data collection and summary. The Director of Nursing (DON) has been performing as the facility's designated infection control leader since August 2024, following the resignation of the previous Infection Preventionist (IP) in early August 2024. A review of the facility's infection control program revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed that they did not complete the Nursing Home Infection Preventionist Training Course until November 18, 2024, and there was no one else in the facility who completed the required training from August 2024 to November 17, 2024.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to screen residents for eligibility to receive the COVID-19 vaccine and/or booster, provide education regarding the COVID-19 vaccine and/or booster, and offer the COVID-19 vaccine and/or booster. This resulted in residents not receiving the COVID-19 immunization, potentially decreasing their protection from the SARS-CoV-2 virus and increasing the risk of serious illness and complications. During a review of the facility's infection control program with the Director of Nursing (DON), it was revealed that there was no documentation of an infection control program related to COVID-19 vaccines and/or boosters. The DON stated that no one in the facility had received the vaccine and that an outside company previously provided education and administered vaccines, but was no longer available in Michigan. The DON mentioned the possibility of calling a pharmacy for vaccines but could not explain why residents had not been offered or administered COVID-19 vaccines prior to the recertification survey. The facility's policy for COVID-19 immunization for residents was requested but not provided.
Failure to Provide Adequate Personal Care and Hygiene
Penalty
Summary
The facility failed to provide adequate personal care and assistance with activities of daily living (ADLs) for several residents, resulting in unmet needs. Resident R2 was observed with long, dirty fingernails, matted hair, and crusty residue on the lips and eyes, indicating a lack of personal hygiene care. Despite being scheduled for showers twice a week, R2's condition suggested that these were not being consistently provided. The Director of Nursing (DON) confirmed that such care should be part of daily routines, yet was unaware of R2's condition. Resident R108 was noted to have significant plaque buildup on their teeth and an unkempt appearance, with an odor emanating from their mouth. Despite requiring assistance with personal hygiene, there was no documentation of care being refused, and the care plan did not include specific instructions for bathing or oral care. The DON acknowledged that all residents should receive morning care, but R108's condition indicated this was not happening. Resident R112 was observed with thick, scruffy facial hair and appeared disheveled, despite requiring substantial assistance with personal hygiene. There was no record of care refusal, and the DON stated that any refusal should be reported. Additionally, Resident R49 had long, discolored nails with dark matter underneath, and Resident R51 was found lying in urine on multiple occasions, indicating a failure to provide timely incontinence care. The facility's policies on ADLs and personal hygiene were not being followed, as evidenced by the observations and interviews conducted.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which is a requirement for adequate coordination of care. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage on multiple dates across October, November, and December 2024. The staffing coordinator acknowledged the lack of RN coverage, particularly on weekends. The Director of Nursing (DON) confirmed the inconsistency in RN weekend coverage, despite the expectation of having 8-hour RN coverage every day. The facility's policy on staff scheduling emphasizes the need for adequate staffing and RN coverage, which was not met, potentially affecting all 120 residents in the facility.
Deficiencies in Environmental Maintenance on Second Floor
Penalty
Summary
The facility failed to maintain a clean and safe environment on the second floor, affecting all residents residing there and those using the elevator. During an environmental tour, several deficiencies were noted, including a soiled exhaust fan in the elevator, scuffed paint on the pantry door, and dingy, scratched paint in the hallways. Exposed nails were found on a handrail between the soiled and clean linen rooms, and multiple resident room doors had scuffed paint. Additionally, missing flooring was observed in the east day room, and the west day room had missing and peeled paint at the baseboard. The entire second floor had scuffed and peeled paint on the handrails. The Director of Maintenance acknowledged these issues, and the Nursing Home Administrator agreed that cleaning and maintenance are ongoing processes, but a maintenance checklist was not provided by the survey exit.
Deficiency in Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nurse Assistants (CNAs), identified as H, I, and J, received their required annual training in dementia management and abuse prevention. This deficiency was discovered during a review of the in-service training records for five CNAs. The records for CNAs H, I, and J did not show any evidence of the required training within the specified time frames. CNA H, hired on 5/28/2004, had no record of such training from 5/28/24 to 6/28/24. Similarly, CNA I, hired on 5/17/2016, lacked documentation of the training from 5/17/23 to 5/17/24, and CNA J, hired on 6/21/2010, had no record of the training from 6/21/23 to 6/21/24. Interviews with the Staff Educator and the Director of Nursing (DON) confirmed the absence of training records for these CNAs. The Staff Educator, who assumed the position in September 2024, acknowledged the limited availability of staff education records. The DON confirmed that CNAs are expected to complete annual training in abuse and dementia management to ensure adequate resident care. The facility's policy mandates that CNAs receive at least 12 hours of training annually, and those who do not meet this requirement are to be removed from the schedule until the training is completed. However, the records did not reflect compliance with this policy for CNAs H, I, and J.
Resident Unable to Reach Call Button, Resulting in Unattended Pain
Penalty
Summary
The facility failed to ensure that a call button was within reach for a resident, resulting in the resident not having a method to request assistance when needed. On January 6th, a resident was observed awake and lying in bed with their right arm wedged between the bed and the wall, indicating they were in pain and unable to free their arm. The resident's call light was clipped to their pillowcase, and they were unable to reach it with their left arm. A Licensed Practical Nurse confirmed the situation and assisted in freeing the resident's arm. The Director of Nursing later acknowledged that the call light should have been placed within the resident's reach. During the exit conference, the Nursing Home Administrator and Director of Nursing did not provide additional documentation or information regarding this concern.
Failure to Complete Advance Directive for Resident
Penalty
Summary
The facility failed to ensure an Advance Directive was completed for a resident, identified as R14, which resulted in the potential for inaccurate life-sustaining measures or withholding medical treatment. R14 was admitted with diagnoses including Candidiasis, Atherosclerotic Heart Disease, Benign Prostatic Hyperplasia, Dysphagia, and Myocardial Infarction. The resident had impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4/15 and required extensive assistance with activities of daily living. Despite the social worker's attempt to obtain a signed Advance Directive from the guardian agency at the time of admission, the document was not returned. The Director of Nursing noted that the Advance Directive should have been reviewed during care conferences, which occurred twice since the resident's admission, but the document remained unsigned.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, identified as R65, who was observed with approximately 550 milliliters of red-colored urine in a urinal. R65, who had been admitted with diagnoses including candidal sepsis, enterocolitis due to C-Diff, chronic kidney disease stage 5, and hypertension, reported the presence of blood in the urine to the nursing staff the previous night. Despite the resident's intact cognition and the facility's care plan interventions to observe and report signs of infection, there was no documentation of assessment, monitoring, or physician notification in the electronic health record. Interviews with the resident and staff revealed that the midnight nurse was aware of the bloody urine, but no follow-up actions were taken, and the physician was not notified. The resident expressed fear due to the lack of response, and the urine cleared up on its own without medical intervention. The Unit Manager and Director of Nursing were unaware of the situation until informed later, and the facility's policy on acute changes in condition, which requires communication of symptoms to the physician, was not followed.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source for a resident, leading to a delayed investigation. On 10/4/24, a resident, identified as R125, complained of bilateral lower extremity pain, prompting an order for a stat x-ray. The x-ray results showed no recent fracture or dislocation, but the resident continued to experience pain and swelling, leading to further tests and eventual transfer to a local hospital. On 10/7/24, the hospital informed the Nursing Home Administrator (NHA) that the resident had a fracture. The investigation concluded that the origin of the injury could not be identified, and staff interviews did not yield any viable results. The deficiency was further highlighted by the failure of a Licensed Practical Nurse (LPN) to report the observation of a bruise on the resident's leg, which was a potential indicator of a fracture. The LPN noted the resident's pain and administered acetaminophen but did not notify the Director of Nursing (DON) or the NHA about the bruise. The facility's policy required staff to report all allegations of abuse, neglect, and misappropriation of property immediately to the Administrator. The NHA and DON confirmed that they were not notified of the bruise or pain, which was against the facility's policy for reporting changes in a resident's condition.
Failure to Develop Comprehensive Tracheostomy Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a tracheostomy. The resident, identified as R175, was observed awake and lying in bed with a tracheostomy tube secured around his neck. The clinical record for R175 indicated an admission date and diagnoses including acute respiratory failure with hypoxia, laryngeal cancer, esophageal cancer, and tracheostomy status. On review, the Director of Nursing confirmed that a comprehensive care plan addressing tracheostomy care had not been developed for R175. This care plan should have included instructions on how to care for the tracheostomy and what to monitor. During the exit conference, no additional documentation or information was provided by the Nursing Home Administrator or Director of Nursing.
Failure to Remove Hazardous Objects from Resident's Room
Penalty
Summary
The facility failed to remove broken and hazardous objects from a resident's room, resulting in a potential safety risk. During an observation, a long sharp metal screw was found protruding from a detached closet door leaning toward the resident's bed. Additionally, a detached bed bumper with multiple protruding screws was observed against the wall behind the resident's bed. The resident, who was alert and able to be interviewed, expressed concern about the door potentially falling and causing injury. The resident had been admitted with several medical conditions, including anoxic brain damage, epilepsy, and a history of repeated falls, and required assistance with activities of daily living due to generalized weakness. The maintenance staff confirmed that the broken closet door was a safety hazard and removed it from the room. However, it was noted that the necessary repairs for the resident's room had not been documented in the TELS system, which is used to track maintenance needs. The Director of Nursing acknowledged that the broken door should not have been in the resident's room due to safety concerns. The facility's Resident Room Maintenance policy outlines the need for regular inspections and maintenance of resident rooms to ensure safety, but these procedures were not followed in this instance.
Failure in Weight Monitoring for High-Risk Resident
Penalty
Summary
The facility failed to ensure proper weight monitoring for a resident at nutrition risk, identified as R20, who was observed in bed with severe cognitive impairment and dependent on a feeding tube. The resident's electronic health record indicated a history of fecal impaction, cerebral palsy, acute and chronic respiratory failure, and anoxic brain damage. Despite being classified as comatose and totally dependent on staff for all activities of daily living, R20 did not have an accurate readmission weight recorded, nor were weekly weights documented as required. The resident's recorded weights showed significant fluctuations, with a noted error in weight documentation by the registered dietitian. Interviews with the registered dietitian and the Director of Nursing confirmed that R20 was at high risk for weight loss and should have been reweighed weekly until the weight stabilized. The facility's policy on unintended weight loss required new residents to be weighed upon admission and weekly for four weeks, with re-weights initiated for specific variances. However, R20's weight was not accurately monitored, and the necessary re-weights were not conducted, leading to a potential compromise in the resident's nutritional status going undetected.
Deficiencies in Tracheostomy Care and Emergency Equipment Availability
Penalty
Summary
The facility failed to have emergency tracheostomy supplies readily available for a resident, identified as R175. During an observation, it was noted that R175, who had a tracheostomy tube, did not have an emergency trach bag or box visible in their room. Licensed Practical Nurses (LPNs) W and X were unable to locate the necessary emergency equipment, which was supposed to be tacked on a bulletin board that was found empty. The Director of Nursing (DON) confirmed that the emergency trach equipment should have been present in the room to replace the trach tube immediately if it became dislodged. Additionally, the facility did not consistently follow the physician's medical orders for tracheostomy care for another resident, identified as R74. R74, who had a tracheostomy tube, reported that trach care was provided only once a week, despite physician orders requiring daily changes of the inner cannula, trach tie, and collar every shift and as needed. A review of R74's treatment record revealed multiple instances where these changes were not documented as completed. The DON acknowledged that the nurses should have adhered to the physician's orders for trach care.
Expired Medical Supplies Found in Resident's Room
Penalty
Summary
The facility failed to ensure that medical supplies for a resident, identified as R10, were not expired. During an observation, it was noted that R10, who was in bed eating lunch, had expired tracheostomy care supplies in their room. Although R10 did not have a tracheostomy, they had a stoma, and the supplies were intended for stoma care. The Licensed Practical Nurse (LPN) initially stated that R10 did not have a tracheostomy but had a stoma. Upon further inspection by the Director of Nursing (DON) and the State Surveyor, it was found that the supplies included a box of heat and moisture exchangers (HME) and three full boxes of stoma caps, all of which were expired. R10's clinical record indicated a history of cancer of the larynx and supraglottis, and the presence of an artificial larynx, with intact cognition as per a Minimum Data Set assessment. The DON acknowledged that the expired supplies should not have been stored with unexpired supplies and should have been removed to prevent their use. During the exit conference, neither the Nursing Home Administrator nor the DON provided additional documentation or information regarding the expired supplies.
Failure to Maintain Resident Privacy Due to Broken Window Blinds
Penalty
Summary
The facility failed to maintain visual privacy for a resident by not repairing broken window blinds, which resulted in feelings of disrespect and the potential for exposure during care. The resident, who was observed in bed covered with a sheet and not wearing a gown, expressed dissatisfaction with the broken blinds that had been covered with a soiled sheet for some time. The resident was concerned about being visible from the outside, especially at night, and was frustrated that the staff had not addressed the issue. The blinds had several broken slats, preventing them from closing properly, which compromised the resident's privacy. The resident, who requires substantial to maximal assistance with activities of daily living, was admitted to the facility with multiple diagnoses, including cerebrovascular disease, epilepsy, hypertension, osteoporosis, and chronic kidney disease. Interviews with the Director of Maintenance and the Director of Nursing revealed that the nursing staff was responsible for notifying maintenance about repairs needed in residents' rooms. However, the facility's policy on resident room maintenance was not followed, as the broken blinds were not repaired, leading to the deficiency in maintaining the resident's privacy.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper hand hygiene and glove use during wound care for one resident and did not provide the proper receptacle for the disposal of PPE for another resident. Specifically, a wound nurse did not perform hand hygiene before applying gloves, did not change gloves or perform hand hygiene between removing an old dressing and applying a new one, and did not place wound supplies on a barrier. Additionally, the nurse exited the room without performing hand hygiene after removing gloves. The Director of Nursing confirmed that these actions were against the facility's standard precautions policy, which mandates hand hygiene and proper glove use to prevent cross-contamination. Another deficiency was observed in the room of a resident in isolation for Candida Auris. The room lacked an appropriate receptacle for the disposal of PPE, having only a small garbage can with a thin, clear plastic liner. The Director of Nursing acknowledged the need for an appropriate trash receptacle to ensure proper disposal of PPE. The facility's infection prevention and control policy requires measures to reduce the risk of acquiring and transmitting infections, which were not followed in this instance.
Failure to Prevent Use of Physical Restraints
Penalty
Summary
The facility failed to prevent the use of physical restraints on a resident, resulting in potential physical and psychosocial harm. The resident, who had diagnoses including diffuse traumatic brain injury, anoxic brain damage, and dementia, was found restrained in bed with garbage bags, a gown, and a sheet. The resident's medical records showed no orders, consents, assessments, or care plans for the use of restraints. The incident was reported by a nurse who discovered the resident tied up and immediately took steps to free the resident and notify the appropriate authorities. Interviews with staff revealed that the CNA responsible for restraining the resident claimed she did so to prevent the resident from choking on pieces of a brief. However, the facility's policy clearly states that physical restraints are not to be used for discipline or convenience and must be accompanied by proper documentation and consent. The Director of Nursing confirmed that the facility is a restraint-free building and acknowledged that the restraints used were not approved types.
Failure to Report Allegations of Abuse and Improper Use of Restraints
Penalty
Summary
The facility failed to report allegations of abuse for one resident, resulting in the allegations not being reported to the State Agency in a timely manner. The resident, who had severe cognitive impairments and required dependent assistance for mobility, was found restrained with a plastic bag, a gown, and a sheet. The CNA responsible for the restraint claimed it was to prevent the resident from choking on pieces of a brief. The incident was reported internally but not to the State Agency as required by the facility's policy. The Nursing Home Administrator did not consider the incident as abuse and therefore did not report it, despite the facility's policy mandating immediate reporting of such incidents. The resident's clinical chart revealed no orders, consents, assessments, or care plans for the use of restraints. Interviews with the LPN and DON confirmed that the facility is a restraint-free building and that the restraints used were not approved. The facility's policy clearly states that residents have the right to be free from abuse and restraints imposed for discipline or convenience. The failure to report the incident to the State Agency and the improper use of restraints led to the deficiency cited in the report.
Failure to Provide Proper Wheelchair Armrest Leads to Resident Fall
Penalty
Summary
The facility failed to provide an armrest on a resident's wheelchair, resulting in the resident falling from the wheelchair and sustaining a large hematoma. The resident, who had a history of falls and impaired cognition, was sent to dialysis with only one armrest on the wheelchair. During the dialysis appointment, the resident fell and had to be taken to the hospital for treatment of a head injury and hyperkalemia. The resident's care plan included the need for a safe environment and functioning wheelchair, but this was not adhered to during the incident. The CNA responsible for preparing the resident for transport admitted to not attaching the second armrest, believing it was safe without it. The DON confirmed that it was the facility's expectation that wheelchairs have both armrests intact during transport to prevent falls. However, there was no specific policy provided that outlined the need to ensure proper equipment assembly before transportation. The incident highlights a lapse in following the resident's care plan and ensuring the safety of the equipment used for transport.
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 1,211 citations issued within 25 miles in the last 12 months — including the 6 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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Nursing Center | 0.5 mi | ★★★★★ | 21 | 0 |
| Sheffield Manor Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 15 | 0 |
| Hartford Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 23 | 0 |
| Oakpointe Senior Care And Rehab Center | 1.6 mi | ★★★★★ | 0 | 0 |
| The Villa At Great Lakes Crossing | 2.4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.