Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Samaritan during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction and malignant neoplasm reported missing funds from a debit card, and facility records and financial documentation showed that a CNA used the resident’s debit card without consent, resulting in $981 in unauthorized charges. The NHA confirmed that the internal investigation identified the CNA as the individual who misused the card, in violation of the facility’s abuse and neglect policy that prohibits misappropriation of resident property.
A resident with diagnoses including cerebral infarction and malignant neoplasm, and with intact cognition but needing max assistance for personal hygiene, developed unexplained facial bruising and right eye discoloration with swelling after being observed in bed with involuntary rapid movements and abrupt head movements. The admission skin assessment had shown no facial bruising. An LPN obtained orders for neuro checks, PRN Tylenol, and ice for the bruise, and another LPN/unit manager was informed that the facial bruising was unexplained and unwitnessed. However, neither LPN reported these suspicious, unexplained injuries to the administrator/abuse coordinator as required by facility policy, and the injury of unknown origin was not reported to the State Agency.
A resident with chronic systolic CHF, acute kidney failure, and a traumatic subarachnoid hemorrhage, and with intact cognition, had a physician order for a one-time Albuterol nebulizer treatment for SOB. The MAR showed the treatment was given as ordered, but a subsequent nursing note documented that an additional breathing treatment was administered when the resident was found short of breath, with the nurse explaining it as part of new prednisone therapy. There was no physician order for this repeat nebulizer treatment, and facility policy required medications to be given only on clear, complete, signed prescriber orders.
A resident with severe cognitive impairment and a history of right shoulder dislocation was physically abused by a CNA, who forcefully twisted the resident's arm during care, resulting in a dislocated shoulder and hospitalization. The incident was witnessed by another CNA, who delayed reporting due to fear of retaliation. The resident required two-person assistance, but this protocol was not followed at the time of the incident.
A resident with severe cognitive impairment and a recent shoulder injury was subjected to physical abuse by a CNA, who forcefully twisted the resident's arm during care. The incident was not immediately reported to the charge nurse due to fear of retaliation, and there was a delay in notifying the NHA and state authorities as required by facility policy. The resident sustained a dislocated shoulder and required hospital treatment, while the facility failed to report the involved CNA's license to the state agency.
A CNA engaged in a loud verbal altercation with two residents, one with cancer and intact cognition and another with severe dementia, using profane, derogatory, and racially charged language. The incident was witnessed and documented by staff, and the facility's policy prohibits such abuse. Leadership acknowledged the behavior was not in line with facility standards.
The facility did not maintain RN coverage for eight consecutive hours daily, as required, with a specific lapse on a day in October 2024. The staffing coordinator admitted challenges in weekend RN coverage, and the DON sometimes filled in, though this did not meet requirements when the census was over 60 residents. The facility lacked a specific RN coverage policy, relying instead on CMS guidelines.
The facility failed to employ sufficient dietary staff, leading to inadequate sanitation in the kitchen, potentially affecting 99 of 104 residents. Observations revealed understaffing, with the Food Service Supervisor performing multiple tasks due to a staff shortage. A cleaning schedule was not provided, and the dietary department was consistently understaffed, particularly on Mondays and Fridays. The Administrator acknowledged staffing was under review, but no explanation was given for the lack of monitoring and oversight.
The facility's kitchen was found to be unsanitary, with improper use of beard restraints by a cook, unsafe food temperatures, and unclean equipment. Potato salad was stored at 60°F without proper cooling, and the kitchen's exhaust hoods were heavily soiled. The Food Service Supervisor could not provide recent cleaning documentation, indicating a lack of oversight.
A facility failed to ensure proper cleaning and disposal of loose medications in a medication cart. An observation revealed 19 loose pills of various shapes, colors, and sizes scattered in the drawers of the 400 Hall medication cart, along with dried stains, lint, and dust. Nurse G acknowledged the cart should have been clean and stated that loose pills should be discarded. The DON confirmed that nurse managers were responsible for maintaining the cleanliness of medication carts. The facility's policy required medication storage areas to be clean and clutter-free.
A resident's room in the facility had a hole in the floor that was not repaired for a year, leading to frustration and a potential hazard. The Maintenance Supervisor acknowledged the issue but had not created a work order, and the facility lacked a formal work order system. The Nursing Home Administrator recognized the tripping hazard, especially given the resident's moderately impaired cognition and weak ambulation. The facility's policy on regular room maintenance was not adhered to, resulting in this deficiency.
A resident receiving oxygen therapy was found with an unsecured oxygen tank at their bedside, posing a potential safety hazard. The tank was fully pressurized and not stored in a medical rack or stand, contrary to the facility's policy. The resident had a complex medical history but intact cognitive function. The DON acknowledged the risk associated with the free-standing tank.
The facility failed to properly manage oxygen therapy for two residents. One resident's oxygen tubing was not labeled, and the concentrator was unclean, despite care plan instructions. Another resident wore oxygen without a physician's order, and the tubing was also unlabeled. Both residents had intact cognitive function and significant medical histories.
A facility failed to address MRR recommendations timely, resulting in unnecessary medications for a resident with intact cognition and multiple diagnoses. Duplicate orders for Famotidine were administered, and Lidoderm patch usage exceeded recommended duration. The DON acknowledged the physician's lack of response to the pharmacist's irregularity reports.
The facility failed to prevent unnecessary medications for two residents, leading to potential adverse effects. One resident received prolonged Guaifenesin without a stop date, while another had duplicate Famotidine orders. The DON acknowledged the issues, and the facility lacked an unnecessary medication policy.
Surveyors found that the facility did not maintain a clean and safe environment, with heavily soiled kitchen vents, broken and dirty equipment, missing or stained ceiling tiles, and unclean resident rooms. Observations included food residue, debris, and unsanitary conditions in both common areas and resident rooms, with staff interviews confirming lapses in cleaning procedures and maintenance responsibilities.
A resident with oral cancer experienced uncontrolled pain due to the facility's failure to administer Oxycodone as prescribed. The resident's pain medication was delayed or withheld without proper justification, leading to significant distress and eventual discharge against medical advice. Interviews and records revealed lapses in following medication administration policies.
A facility failed to report an allegation of employee-to-resident abuse to the State Agency, involving a cognitively intact resident who was allegedly slapped by a staff member. Despite complaints being reported to the state hotline, the facility did not submit a Facility Reported Incident (FRI). The Nursing Home Administrator concluded the incident did not occur and did not report it, contrary to the facility's policy requiring timely reporting of such allegations.
A resident with a history of multiple health conditions experienced critical anemia symptoms and lab results, but the facility failed to timely address these issues. Despite discontinued iron supplements and decreased iron levels, no changes were made to the care plan, leading to hospitalization for anemia, fluid overload, and acute kidney injury. The DON and physician could not explain the delay in intervention, and the facility's policy on acute change in condition was not followed.
A resident with multiple diagnoses, including chronic pain, was prescribed Oxycodone HCl. An LPN signed out two tablets from the Pyxis system, although only one was administered, citing preparation for the next shift. The DON confirmed this was against standard practice, as narcotics should be signed out only at the time of administration.
A resident with severe cognitive impairment exited the facility without staff knowledge, despite being last seen at a bingo event. The resident was found the next morning by police, having left through the main elevator. Staff interviews confirmed the resident was reported missing later in the evening, highlighting a lapse in supervision.
The facility failed to provide timely incontinence care for a resident, resulting in a strong urine smell and heavily saturated briefs on multiple occasions. Despite the care plan requiring checks and changes every two hours, staff interviews and observations confirmed that this protocol was not followed.
Failure to Protect Resident From Misappropriation of Debit Card by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by an employee. A complaint alleging misappropriation was received by the State Agency on 3/16/2026. Review of the facility’s incident and investigation reports showed that on 2/3/2026 the resident reported that $981 was missing from her debit card. The Nursing Home Administrator reviewed financial records from the debit card company with the resident’s family friend, which identified a Certified Nursing Assistant as having used the resident’s debit card without the resident’s consent. The facility’s Abuse and Neglect Prohibition Policy, last reviewed on 2/17/2020, states that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, and misappropriation of property. The resident’s EHR showed admission on 1/27/2026 and discharge on 2/9/2026, with diagnoses including cerebral infarction and malignant neoplasm. Attempts by the surveyor on 4/24/2026 to contact the CNA involved were unsuccessful, and attempts to contact the resident by phone were also unsuccessful due to a non-working number and no other contact numbers in the medical record. During interview, the Nursing Home Administrator confirmed that the internal investigation determined the CNA had used the resident’s debit card without consent and stated that the expectation is that residents be protected from misappropriation of property.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an injury of unknown origin to the State Agency for one resident. A resident was admitted with diagnoses including cerebral infarction and malignant neoplasm, with an admission MDS indicating intact cognition and a need for maximal assistance with personal hygiene. The admission skin assessment did not show any facial bruising. On a later date, a progress note documented a new physician order for neuro checks every six hours for three days, Tylenol 650 mg every six hours as needed, and application of ice due to a bruise on the left side of the resident’s forehead at the eyebrow. An unwitnessed incident report documented that the resident was observed in bed experiencing involuntary rapid movements, hitting the right eye and attempting to hold the right arm with the left hand, with uncontrollable movements at times, and right eye discoloration with swelling. The resident was described as having involuntary head movements, swinging the head abruptly especially when speaking, being bedridden, and unable to provide a consistent description of whether a fall had occurred. Despite these unexplained facial injuries and the facility’s policy requiring staff to report all allegations of abuse, neglect, misappropriation of property, and injuries of unknown origin to the administrator immediately, the required reporting did not occur. An LPN/unit manager stated that another LPN had notified her of unexplained facial bruising that was not witnessed, and acknowledged that she did not report this injury to the abuse coordinator, although she believed she should have. The nursing home administrator confirmed that neither of the involved LPNs reported the resident’s facial injuries to her, contrary to the facility’s Abuse and Neglect Prohibition Policy, which specifies that the administrator is responsible for overseeing investigations and reporting alleged violations, including injuries of unknown origin, to the State Agency. As a result, the injury of unknown origin was not reported to the State Agency as required.
Unauthorized Repeat Administration of Nebulizer Treatment Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for one resident. The resident had diagnoses including chronic systolic congestive heart failure, acute kidney failure, and traumatic subarachnoid hemorrhage, and had an intact cognition score of 15/15 on the Brief Interview for Mental Status. A physician’s order dated 2/17/26 directed that Albuterol Sulfate Inhalation Nebulization (2.5 mg/3 mL 0.083%) be given as one vial via nebulizer one time only for shortness of breath for one day. The February 2026 medication administration record showed that this nebulizer treatment was administered on 2/17/25 in accordance with the order. However, a nursing progress note dated 2/18/2026 at 20:03 documented that the resident was found sitting in a chair with pants off and experiencing some shortness of breath, and that the writer (nurse) administered a breathing treatment and explained to the resident that the doctor had started them on a new medication, prednisone, to help reduce shortness of breath and help their lungs. The note further documented that the resident tolerated the medications well, could make needs known, was continent of bowel and bladder, and had vital signs recorded. There was no physician order for an additional breathing treatment beyond the original one-time-only nebulizer order, and the DON confirmed that the order was for one time only and should not have been given again without a physician’s order. The facility’s Medication Orders Policy stated that medications are to be administered only upon the clear, complete, and signed order of an authorized prescriber.
Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including dementia and polyneuropathy, required total assistance with activities of daily living. On the night in question, a Certified Nursing Assistant (CNA) was observed by another CNA forcefully twisting the resident's right arm behind their back during care, after expressing frustration and making an inappropriate comment. The resident was noted to be squirming and attempting to free their arm, and the incident was not immediately reported to the charge nurse due to fear of retaliation. Following the incident, the resident was assessed by a registered nurse, who initially found no injuries and noted the resident could move both arms without apparent pain. However, a subsequent assessment revealed slight bruising and pain when the right arm was raised. Diagnostic imaging later confirmed a dislocated right shoulder, and the resident was transferred to the hospital for treatment. The incident was reported to law enforcement, and the CNA involved was suspended and later terminated. The facility's documentation and interviews revealed that the resident required two-person assistance for care, but the incident occurred with only one CNA present initially. The other CNA, who witnessed the abuse, did not immediately report the event due to concerns about retaliation, resulting in a delay in addressing the situation. The resident's medical record indicated a history of right shoulder dislocation, and the incident led to further injury and hospitalization.
Failure to Timely Report Suspected Physical Abuse and Injury
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of a reasonable suspicion of physical abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent right shoulder dislocation. On the night in question, a CNA observed another CNA forcefully twisting the resident's right arm behind their back during care, causing the resident to squirm and attempt to free themselves. The observing CNA did not immediately report the incident to the unit charge nurse due to fear of retaliation and instead reported it to the Nursing Home Administrator (NHA) approximately two hours later. The resident was later found to have a dislocated shoulder and was transferred to the hospital for treatment. The facility's policy required immediate reporting of abuse allegations to the Administrator and the State Agency, especially when serious bodily injury is involved. However, the incident was not reported to the appropriate authorities within the required timeframe, and the NHA did not report the involved CNA's license to the state agency as required. The delay in reporting and failure to follow established procedures resulted in the abuse going unreported in a timely manner, placing the resident at further risk.
Failure to Prevent Verbal Abuse by CNA Toward Two Residents
Penalty
Summary
The facility failed to prevent verbal abuse involving two residents, one with intact cognition and a diagnosis of ovarian cancer, and another with severe cognitive impairment and dementia. On the date of the incident, a Certified Nursing Assistant (CNA) was witnessed by another CNA and documented by a Registered Nurse (RN) to have engaged in a loud verbal altercation with the residents, using profane and derogatory language. The CNA directed explicit insults and threats toward both residents, including referencing one resident's terminal illness in a disparaging manner and using racial and gender-based slurs. The incident was reported by the affected resident to an LPN, and corroborated by staff witness statements and written documentation. The resident with intact cognition provided a detailed written account of the incident, while the resident with dementia was unable to recall the event during interview. Staff interviews and written statements confirmed the occurrence of the verbal abuse, with the RN noting the CNA's continued aggression until being removed from the unit. The facility's policy prohibits all forms of abuse, including verbal abuse defined as the use of disparaging or derogatory language toward residents. The actions of the CNA were acknowledged by facility leadership as inappropriate and not in accordance with established standards or policy.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. This deficiency was identified during a review of the nurses' schedule for October, November, and December 2024, which revealed a lack of RN coverage on October 20th, 2024. The staffing coordinator acknowledged difficulties in securing RN coverage for weekends and noted that the Director of Nursing (DON) sometimes covered shifts. However, the staffing coordinator was unaware that the DON's coverage does not count towards RN coverage when the facility census exceeds 60 residents. The DON confirmed that there were instances when an RN was unavailable and acknowledged the necessity of RN supervision for the resident population. Additionally, the facility lacked a specific RN coverage policy and instead referred to the Center for Medicare and Medicaid Services guidelines.
Inadequate Dietary Staffing and Sanitation in Kitchen
Penalty
Summary
The facility failed to employ sufficient dietary staff and ensure operational consultation was provided to supervisory staff, resulting in inadequate sanitation in the kitchen. This deficiency had the potential to affect 99 of the 104 residents who consumed meals from the kitchen. On the morning of 3/24/25, the Food Service Supervisor (FSS) D was observed performing multiple tasks, including collecting trays, transporting food carts, and organizing the walk-in refrigerator and freezer, due to a staff shortage. FSS D reported that one employee had called in sick that morning, and a dietary aide position had been vacant since the previous month. During an observation, FSS D was unable to provide a cleaning schedule, indicating a lack of structured sanitation monitoring. Further investigation revealed that the dietary department was consistently understaffed, particularly on Mondays and Fridays, with only three dietary aides and one cook available for breakfast and lunch. The Area Manager (A.M.) F confirmed the staffing shortage and acknowledged that the facility had scheduled 55 hours instead of the initially reported 51 hours. However, no explanation was provided for why the additional hours did not address the sanitation issues. The Administrator mentioned that staffing was under review but did not explain the lack of monitoring and oversight in the kitchen. Upon exiting the facility, the audit form for the department was found to be blank, and no cleaning schedule was provided as requested.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment for food storage, preparation, and service, which could potentially lead to foodborne illnesses affecting 99 of the 104 residents. Observations revealed that a cook was improperly using a beard restraint, covering his beard but not his mustache, which was later corrected. Additionally, during a lunch meal observation, potato salad was found at an unsafe temperature of 60 degrees Fahrenheit, without any cooling device to maintain the required temperature of 41 degrees Fahrenheit or below, as per the 2023 Food Code. Further inspection of the facility's main kitchen revealed cracked and detached caulking along the dish machine's scrape table, with standing water, food debris, and a black mold-like substance present. The kitchen's exhaust hoods were heavily soiled with grease, lint, and food ash, and the last professional cleaning was recorded on January 7, 2025, with the next scheduled for July 15, 2025. The Food Service Supervisor was unable to provide documentation of recent cleaning schedules or tasks, indicating a lack of oversight and adherence to sanitation protocols. These deficiencies were acknowledged by the Area Manager during a walkthrough but remained unaddressed by the time of the survey exit.
Improper Cleaning and Disposal of Medications in Medication Cart
Penalty
Summary
The facility failed to ensure proper cleaning and disposal of loose medications for one of the four medication carts observed. During an observation and interview with Nurse G, it was found that the 400 Hall medication cart contained 19 loose pills scattered across the bottom of the first and second drawers. These pills varied in shapes, colors, and sizes. Additionally, the drawers had dried tan stains, lint, and dust. Nurse G acknowledged that the cart should have been clean and stated that their policy required loose pills to be discarded. The Director of Nursing confirmed that nurse managers were responsible for checking and cleaning the medication carts on their units. A review of the facility's policy on medication storage indicated that medication storage areas should be kept clean and free of clutter.
Failure to Repair Resident's Room Floor Creates Hazard
Penalty
Summary
The facility failed to maintain a safe and homelike environment for a resident, identified as R95, by not repairing a hole in the floor of their room. The resident expressed frustration over the issue, which had persisted for a year without being addressed. The hole, approximately six by four inches in size, was located near the foot of the resident's bed and was observed during an interview with the resident. The Maintenance Supervisor acknowledged the issue but admitted that no work order had been created, and the facility lacked a formal work order system. This oversight resulted in the repair not being completed in a timely manner. The Nursing Home Administrator also acknowledged the hole in the floor, agreeing that it posed a tripping hazard and could not be cleaned properly. The resident, who was admitted to the facility with diagnoses including chronic heart failure and age-related physical debility, had a moderately impaired cognition as indicated by a BIMS score of 12/15. Additionally, the resident was assessed as a weak ambulator, which further emphasized the potential risk posed by the unrepaired floor. The facility's policy on resident room maintenance, which requires regular inspections and maintenance, was not followed, contributing to the deficiency.
Improper Storage of Oxygen Tank Poses Safety Hazard
Penalty
Summary
The facility failed to properly store an oxygen tank for one resident receiving oxygen therapy, which resulted in a potential safety hazard. During an observation, the resident was found in bed using oxygen via a nasal cannula, with the oxygen set at 2 liters through a concentrator. Next to the resident's bed was a green cylinder oxygen tank, which was fully pressurized but not secured in a medical rack or stand. This improper storage posed a risk of the tank tipping over, potentially causing damage or leaks. The oxygen tubing also lacked a date label, which is necessary for tracking and safety purposes. The resident involved had a complex medical history, including conditions such as stroke, seizures, atrial fibrillation, asthma, chronic obstructive pulmonary disease, diabetes type II, heart disease, and chronic pain. Despite these conditions, the resident had an intact cognitive function, as indicated by a Brief Interview for Mental Status score of 15/15. The Director of Nursing acknowledged the issue, noting that a free-standing oxygen tank could be dangerous. The facility's policy on oxygen use safety, revised in December 2009, clearly states that oxygen cylinders must be stored in racks, sturdy portable carts, or approved stands and should not be left free-standing or stored in resident rooms or living areas.
Deficiencies in Oxygen Therapy Management for Residents
Penalty
Summary
The facility failed to properly manage and document the use of oxygen therapy for two residents, R9 and R33. For R9, the oxygen tubing was not labeled with a date, and the resident was unsure of how frequently the tubing was changed. Additionally, the oxygen concentrator was observed to be unclean, with a thick white substance and dust debris present. R9's care plan and physician orders indicated that the oxygen tubing should be changed weekly and dated, but this was not adhered to. R9 has a history of morbid obesity, seizure disorder, COPD, diabetes mellitus type 2, anxiety, and heart failure, with an intact cognitive function as indicated by a BIMS score of 15/15. For R33, the oxygen tubing was also not labeled with a date, and there was no physician's order for supplemental oxygen therapy in the resident's electronic medical record. Despite wearing oxygen via nasal cannula, R33's care plan did not include an order for oxygen therapy. R33 has a medical history of stroke, seizures, atrial fibrillation, asthma, COPD, diabetes type II, heart disease, smoking, and chronic pain, with a BIMS score of 15/15 indicating intact cognitive function. The Director of Nursing acknowledged the deficiencies and stated that the issues would be addressed.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address Medication Regimen Review (MRR) recommendations in a timely manner for a resident, resulting in the continuation of unnecessary medications and a lack of communication between the pharmacist and physician. The resident, who had intact cognition, was admitted with diagnoses including cerebral infarction, major depressive disorder, and anxiety disorder. The review of the resident's Electronic Health Record (EHR) revealed duplicate orders for Famotidine (Pepcid) 20mg, with one order written on 12/12/24 and another on 1/8/25. Both medications were administered until 2/24/25, despite being the same medication, indicating a failure to address the pharmacist's irregularity report. Additionally, the facility did not adhere to the pharmacist's recommendation regarding the use of Lidoderm patches, which should only be worn for 12 hours to avoid local adverse events. The Director of Nursing (DON) acknowledged that the physician did not respond to the irregularity reports and confirmed the oversight in the medication orders. The lack of timely response and communication regarding the pharmacist's recommendations contributed to the deficiency in the resident's medication management.
Failure to Prevent Unnecessary Medications for Residents
Penalty
Summary
The facility failed to ensure that two residents, R4 and R5, did not receive unnecessary medications, which could potentially increase the risk of adverse drug effects. Resident R5, who had severe cognitive impairment and required extensive assistance with activities of daily living, was administered Guaifenesin Oral Syrup for an extended period without a documented stop date or documented need for continued use. The Director of Nursing (DON) could not provide an explanation for the prolonged use of the cough syrup, which was initially prescribed for a cough related to COPD and congestion. The nurse practitioner did not respond to inquiries regarding the necessity of the medication. Resident R4, who had intact cognition and was diagnosed with cerebral infarction, major depressive disorder, and anxiety disorder, was found to have duplicate orders for Famotidine (Pepcid) 20mg. The duplicate medication was not discontinued until over a month after the irregularity was identified in a pharmacist's report. The DON acknowledged that the physician did not provide a timely response to the irregularity report, and the Nursing Home Administrator confirmed that the facility lacked an unnecessary medication policy.
Failure to Maintain Sanitary and Safe Environment in Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary physical environment, particularly in the kitchen and several resident rooms. Observations revealed that multiple ceiling vents and covers in the kitchen, storeroom, emergency supply storage, and paper supply room were heavily soiled with soot, ash, and grease. Walls and storage areas for food carts were marked with black rubber scarring and had broken, chipped areas with exposed cement blocks. The dish room had soiled ceiling tiles and corroded metal strips, while several ceiling tiles in storage areas were stained or missing. Kitchen equipment, including a convection oven, stove, and deep fryer, was found to be cracked, missing parts, and covered in burnt food residue and grease. Floor tiles were broken or missing, allowing debris to collect, and floor drains and dish machine areas were dirty with food residue. The cleaning schedule and sanitation audits were not provided, and maintenance staff were unaware of their responsibilities regarding vent cleaning and tile replacement. In addition to the kitchen deficiencies, the facility failed to maintain cleanliness in specific resident rooms. One room had a ripped floor mat, dried substances on the floor, a tube feeding pole with dried yellowish residue, and a wall with broken plaster covered by tape. Housekeeping staff reported that mats should be sanitized daily and removed if damaged, and that tube feeding poles should be cleaned, especially if soiled. Another room was observed to have a dirty floor with debris, soiled tissues, food, garbage, piles of clothes and linen, and a sticky substance on the floor. The bathroom in this room had paper on the floor, a toilet with thick black debris, a shower floor covered with scum, and a sink with brown stains. The resident in this room expressed dissatisfaction with the frequency and quality of cleaning. Interviews with housekeeping and nursing staff confirmed that cleaning procedures were not consistently followed, with staff acknowledging the need for better cleaning of corners, removal of damaged mats, and immediate cleaning of spills. The facility's cleaning policy outlined specific steps for disinfecting and cleaning resident rooms and restrooms, but observations indicated these procedures were not being adhered to, resulting in unsanitary conditions in both common and resident-specific areas.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer scheduled and as-needed pain medications per the physician's orders for a resident, resulting in uncontrolled pain and emotional distress. The resident, who had a history of oral cancer and related pain, was admitted to the facility with a prescription for Oxycodone to manage his pain. However, upon review, it was found that the resident did not receive his pain medication for 17 hours after his last dose, leading to significant discomfort and distress. The resident's clinical records and nurse progress notes revealed multiple instances where pain medication was either not administered on time or withheld without proper justification. On one occasion, the resident's pain medication was not available due to a pharmacy issue, and on another, it was withheld due to undocumented behaviors. The resident expressed feelings of helplessness and frustration due to the lack of timely pain management, which was corroborated by complaints made to the state agency complaint hotline. Interviews with the Director of Nursing and the resident highlighted the facility's failure to adhere to its own policies on medication administration and pain management. The Director of Nursing acknowledged that behaviors should not justify withholding pain medication and that non-pharmacological interventions should have been attempted. The resident ultimately left the facility against medical advice due to inadequate pain management, further emphasizing the severity of the deficiency.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the State Agency for one resident, resulting in a deficiency. The incident involved a resident who was allegedly attacked by a female staff member, with the complainants reporting that the resident was slapped on the arm several times. Despite the complaints being reported to the state complaint hotline, the facility did not submit a Facility Reported Incident (FRI) for the allegation. The Nursing Home Administrator (NHA) was notified of the allegation but concluded that the incident did not occur and, therefore, did not report it to the state agency. The resident involved was admitted to the facility with multiple diagnoses, including malignant neoplasm of the mouth, dysarthria, and generalized anxiety disorder, among others. The resident was cognitively intact and required limited assistance with activities of daily living. The facility's policy required the Administrator or designee to report all alleged violations involving abuse to the State Agency within specified timeframes, depending on the severity of the allegation. However, the NHA stated that they were instructed not to report the incident, leading to a failure in compliance with the facility's policy and state regulations.
Failure to Address Critical Lab Findings and Delay in Treatment
Penalty
Summary
The facility failed to address changes in laboratory findings in a timely manner for a resident, resulting in significant critical laboratory values, delay in treatment, and hospitalization. The resident, who had a history of atrial fibrillation, breast cancer, diabetes, heart attack, hypertension, Covid-19, and anemia, was observed with mild edema in both lower legs and reported feeling weak, dizzy, and short of breath. Despite these symptoms and critical lab results indicating severe anemia, there was no change in the resident's plan of care or implementation of interventions to address the decreased iron levels. The resident's electronic medical record showed that their iron supplement was discontinued in July, and subsequent lab results in July indicated a decrease in hemoglobin and iron levels. However, there was no evidence of a change in the plan of care or involvement of a dietitian to address the low iron levels. The resident experienced symptoms of anemia, such as shortness of breath and dizziness, but the facility did not take timely action to address these issues. The Director of Nursing and Physician D were unable to provide a satisfactory explanation for the lack of timely intervention. The resident was eventually sent to the hospital after experiencing critical symptoms and lab results, where they were diagnosed with anemia, fluid overload, and acute kidney injury, and received a blood transfusion. The facility's policy on acute change in condition was not followed, contributing to the delay in treatment and hospitalization.
Improper Storage of Narcotic Medication
Penalty
Summary
The facility failed to ensure the proper storage of a narcotic medication for a resident, identified as R103, which potentially resulted in a missed dose, medication waste, and misappropriation. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mouth, chronic kidney disease, and generalized anxiety disorder, and was cognitively intact, requiring limited assistance with daily activities. The resident was on a scheduled and PRN pain regimen, which included Oxycodone HCl, a controlled drug. On a specific date, the resident's medication was not delivered, and the pharmacy was contacted. Subsequently, a physician's order was sent, and the resident was administered one 5mg tablet of Oxycodone at 9:30 am. However, the Pyxis record showed that two 5mg Oxycodone tablets were signed out by an LPN, although only one tablet was administered. During an interview, the LPN stated that the extra tablet was pulled from the backup supply for the next dose or shift. The Director of Nursing (DON) confirmed that it was not standard practice to pull and store extra narcotics for future use, and narcotics should be signed out at the time of administration. The facility's policy on medication storage emphasized that medications should be stored safely and securely, accessible only to authorized personnel.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in the resident exiting the facility without staff knowledge. The resident, who had diagnoses of Dementia and Alcohol Dependence with Alcohol-Induced Persisting Dementia, was last observed at a bingo event on the brown unit at 8:45 p.m. Staff noticed the resident was missing during rounds while passing medications. Despite a thorough search of the entire building, the resident could not be located, and the administrator, DON, and physician were notified. The resident returned to the facility the next morning, accompanied by a police officer, with empty alcohol bottles and unopened beer cans. The resident was confused but demonstrated how they exited the building. Interviews with staff revealed that the resident was last seen on the brown unit and was reported missing at 9:40 p.m. The Nursing Home Administrator confirmed that the resident exited through the main elevator near the receptionist desk. The facility's policy on elopement was reviewed, which stated that residents with cognitive loss who leave without authorization are considered an elopement risk.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R53), resulting in the potential for skin breakdown and infection. On two separate occasions, surveyors observed that R53's room had a strong urine smell, and the resident's brief was heavily saturated with urine. The first observation occurred on 2/27/24 at 11:52 a.m., and the second observation was on 2/29/24 at 8:13 a.m. In both instances, the resident's bed pad was also soiled. Interviews with CNAs and the LPN confirmed that R53 was not being checked and changed every two hours as required by the care plan and facility policy. R53 was admitted to the facility with diagnoses including Dementia and Atopic Dermatitis. The care plan for R53 specified that the resident should be checked and changed at least every two hours during the day. However, observations and staff interviews revealed that this protocol was not being followed. CNA D reported that R53 was last checked and changed at 7 a.m. and 12 p.m. on 2/27/24, while CNA E reported that R53 was changed for the first time that morning on 2/29/24. The Director of Nursing confirmed that incontinent residents should be checked and changed every two hours and as needed, which was not adhered to in R53's case.
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Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Omni Continuing Care | 0.8 mi | ★★★★★ | 0 | 0 |
| Qualicare Nursing Home | 2.3 mi | ★★★★★ | 8 | 0 |
| Hamilton Nursing Home | 2.5 mi | ★★★★★ | 10 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 2.5 mi | ★★★★★ | 26 | 0 |
| St. Joseph's, A Villa Center | 2.8 mi | ★★★★★ | 6 | 0 |
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