Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Springs At Rochester Hills Rehab And Nursing C during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, delusional disorder, impaired cognition, and antipsychotic/antidepressant use did not have a PASARR Level II evaluation completed or documented in the record. A PASARR Level I screening before admission indicated mental illness and medication treatment, but no exemption form or Level II eval was found, and the ADM acknowledged the eval should have been obtained or requested.
Two residents with severe cognitive impairment and significant psychiatric and medical histories were involved in a resident‑to‑resident assault when a wheelchair user appeared to roll over an ambulatory resident’s foot, after which the ambulatory resident intentionally punched the wheelchair user in the nose with a closed fist. Witnesses, including a CNA and an LPN, reported the punch, the aggressor’s statement that he “meant to do it,” and immediate nasal bleeding and distress, and the aggressor later admitted to staff and law enforcement that he struck the other resident. The injured resident, who had dementia, bipolar disorder, prior brain bleed, and was on hospice, sustained bilateral nasal fractures, experienced 10/10 pain requiring PRN analgesics, showed anxiety and agitation, and later reported ongoing head and ear pain, bruising, and feeling unsafe. Records showed the aggressor had previously assaulted another female resident with a closed fist, and the facility’s abuse policy defined such willful hitting as abuse and required protection and care plan revision after abuse; however, the facility’s investigation did not verify abuse and the injured resident’s care plan was not updated to address protection or psychosocial needs following the incident.
The facility failed to maintain a comfortable, homelike environment by not ensuring consistent availability of towels, washcloths, and personal clothing for multiple residents. CNAs reported chronic linen shortages, starting some shifts with no linens and resorting to using cut bath blankets, pillowcases, wipes, and draw sheets for hygiene care. Several residents stated they were not provided towels or washcloths, had to wait to be cleaned while staff searched for linens, or had to "fight" for scheduled showers. Observations of clean utility rooms showed minimal or no towels and washcloths, and some residents’ rooms lacked any linens or personal clothing, as confirmed by family members and staff. At the same time, surveyors discovered large quantities of new towels and washcloths stored unopened on a closed construction unit inaccessible to floor staff. The housekeeping and laundry staff cited being short-handed and lacking a clear system, and the facility had no written linen or laundry policy addressing how linens and residents’ clothing should be laundered and distributed.
The facility failed to provide adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one case, a resident with severe cognitive impairment and a history of aggression was heard yelling at another resident and was then observed kicking that resident while they were on the floor in his room, causing minor injuries and pain. In another case, staff placed two residents together as roommates despite staff concerns about one resident’s known aggressive behavior and dislike of roommates; shortly after the move, the other resident reported being hit and expressed feeling unsafe in that room. Additional incidents involved a resident who did not like others entering his room physically engaging with a resident who frequently climbed into other residents’ beds, and a separate hallway altercation where two cognitively impaired residents struck each other after one accused the other of stealing. These events occurred despite a written staffing policy stating that adequate licensed nursing and CNA coverage would be maintained to meet residents’ needs and provide necessary supervision.
The facility failed to consistently provide and offer evening and HS snacks as required by its own policy. A bedbound, oriented resident reported never being offered facility snacks and relying on family-provided food, while another oriented resident in a wheelchair stated they often missed evening snacks because they had to be at the nurses’ station at the right time and some days received no snack despite wanting one daily. A nonverbal resident’s family member reported the resident appeared hungry at night, requested double portions that were often not received, and had not been offered a grievance form. The Dietary Manager stated that various snacks were prepared and sent to the unit but acknowledged that snacks disappeared quickly, possibly due to residents hoarding them or staff taking them, and snacks were also kept in the dietary office. These observations and interviews showed that snacks were not reliably offered or made accessible to all residents in line with facility policy.
Multiple residents reported prolonged waits, often an hour or more, for toileting, incontinence care, transfers, water, and medications, with one bedbound resident describing inadequate perineal care that left stool caked on until morning and another bedbound resident waiting 1–2 hours for brief changes after using the call light. Two alert, oriented residents using wheelchairs stated they frequently waited in bed for assistance with bathroom needs and medications, while a family member repeatedly found their relative soaked in urine during visits. CNAs reported that when only two aides were assigned per floor of about 40 residents, especially on the night shift, they could not complete two-hour check-and-change care or timely feeding, and staffing records confirmed multiple nights with only two aides despite many residents requiring lift assistance, contrary to the facility’s own policy to maintain adequate staffing to meet resident needs.
Surveyors found that the facility did not consistently provide meaningful, person-centered activities as posted on the activity calendar. Two residents reported that scheduled activities such as BINGO and brain games, especially on weekends, were frequently missed or started very late, that music did not match their preferences, that room visits were not occurring, and that they were often not included in community outings. Observations confirmed that a scheduled BINGO session did not begin at the posted time, leaving residents waiting without explanation, and that some weekend and Sunday activities were not occurring despite being listed. Activity logs showed gaps in documented activities, no refusals, and minimal Sunday programming, while the Activity Director acknowledged late and missed activities and difficulty covering simultaneous activities on multiple floors with limited staff.
Failure to assess and document change in condition and medication administration for two residents. One resident with severe cognitive impairment and diabetes had suspected UTI symptoms, refused urine collection, and had limited monitoring documented before later being sent to the hospital with hypotension, hyperglycemia, and septic shock due to a UTI. Another resident receiving IV meropenem for osteomyelitis missed multiple doses, was documented as self-administering IV antibiotics despite dependence, became unresponsive, and was transferred without documented VS, assessment, or notification to family or MD.
Homelike Dining Environment Not Maintained: During a lunch meal observation, several residents with severely impaired cognition were served meals on trays in the dining room, including one tray with a TV remote control on it. Two residents at the same table pulled another resident’s tray toward themselves before they were served. The RD stated meal trays should be removed from the table to provide a homelike dining experience.
A resident with severe cognitive impairment and an order for IV meropenem for a skin infection and osteomyelitis missed 18 doses of the antibiotic. The MAR showed the resident was documented as self-administering the IV medication, and a nurse later reported the missed doses were discovered during an investigation after the resident had a change in condition and was sent to the hospital.
Insufficient dietary support personnel were provided during a lunch meal in the second-floor dining room. One resident’s tray was shared and handled by nearby residents before staff intervened, another resident needed help opening items and later spilled a nutritional shake, and two other residents had meals in front of them for extended periods without timely encouragement or assistance. The affected residents had dementia or Alzheimer’s disease and required varying levels of meal assistance per their care plans.
A resident with impaired cognition and diagnoses including major depressive disorder, vision loss, and CKD had DNR paperwork in the record, but the EMR and physician order listed the resident as Full Code. Staff interviews showed the assigned nurse relied on the EMR/face sheet for code status, and the UM said she changed the status to Full Code by default while competency was being determined. The record also showed the resident was later deemed incompetent, yet no POA-signed advance directive was present.
Failure to complete required OBRA Level II evaluations for two residents with serious mental health diagnoses. Records showed each resident had a prior Level II determination stating specialized MH services could be met in the facility and that a follow-up evaluation was due later, but those evaluations were not completed. A SW reported that several residents had missed Level II reviews before their employment and that audits were being done.
Inaccurate nursing documentation and assessment: A resident with a PEG feeding order was observed without tube feeding hung or infusing, yet an LPN documented the feeding as administered before it had actually been given. The same resident’s sling size for a mechanical lift weight was inaccurately assessed and documented, leading to a transfer in which the resident slipped in the sling. Another resident with a left elbow skin tear had a dressing observed dated with one nurse’s initials, while the TAR showed a different nurse documented the treatment as completed even though it was not.
Missed Physician-Ordered Weight Monitoring: Two residents with documented weight loss, one with dysphagia and impaired cognition and another with dementia and severe cognitive impairment, did not have physician-ordered weekly weights completed as ordered. The chart showed repeated weight warnings, poor or variable intake, and limited documented weights during the ordered monitoring periods, while the RD acknowledged that completing weekly weights was an ongoing concern.
A resident with a PEG tube, severe cognitive impairment, dysphagia, dementia, and aphasia did not receive tube feeding according to the physician’s order. Staff observed no formula hung or infusing during multiple checks, yet an LPN documented tube feeding as given on the MAR, including amounts that did not match the ordered 1170 mL/day. The LPN stated there was nothing hanging on arrival and acknowledged signing off on an amount that had not yet been administered; the RD later confirmed the documentation showed the resident did not receive the required amount.
The facility failed to maintain ongoing communication and collaboration with the dialysis center for a resident with ESRD who was dependent on hemodialysis. The resident had an order for hemodialysis on Tuesdays, Thursdays, and Saturdays, but the submitted dialysis communication forms showed no communication for one month, and the DON stated that what was uploaded was all that was available.
A facility failed to maintain resident dignity during mobility and mealtime care. A resident with severely impaired cognition was pulled backwards in a geri chair by a UM instead of being moved facing forward, and during lunch a UM and a CNA were observed standing over two residents while providing feeding assistance. The RD stated feeding staff should sit next to residents at eye level, and facility policy called for residents to be treated with consideration, respect, and full recognition of dignity and individuality.
Failure to Provide Basic Care and Prevent Neglect: A resident with severe cognitive impairment, dysphagia, dementia, aphasia, and PEG tube dependence was repeatedly observed confined to bed in a hospital gown, without oral care, and not dressed in clothing. Staff interviews and record review showed the resident was not being gotten up in a geri chair or wheelchair because of the DPOA’s requests, despite prior documentation that the resident enjoyed being out of bed and an existing care plan for daily chair time. The record also showed directives to avoid oral hygiene and partial denture care, while the facility policy defined neglect as failure to provide necessary and adequate care.
Failure to Report Suspected Neglect: A resident with severe cognitive impairment, dysphagia, dementia, and aphasia was kept in bed in a gown, with oral care and denture care withheld and no routine out-of-bed activity, based on the DPOA’s requests. Staff documented the requests in progress notes and care plans, and the DON acknowledged the resident was not receiving these basic care services. The Administrator/Abuse Coordinator confirmed the concern was not reported to the State Agency or investigated as neglect.
Failure to provide feeding assistance and nail care. Two residents who required help with meals were observed struggling to eat without staff assistance, with one resident’s meal left untouched and the other unable to get food off the plate. A third resident was observed with dirty, overgrown fingernails and no documented nail care, despite records showing the resident had psychiatric diagnoses and had not had recent documented grooming support.
Failure to timely identify pressure ulcers: A resident with Alzheimer's disease, anxiety disorder, peripheral vascular disease, and severely impaired cognition developed a right heel wound that was first documented as a ruptured blister and later found to be unstageable, then stage 4. The resident also developed a left heel blister/DTI and a new right gluteal fold wound that was later identified as unstageable and then stage 4. The POA reported noticing dirty, wet socks and an open heel wound earlier, while the UM stated pressure ulcers should ideally be identified at stage 1 and had no explanation for why the wounds were not found sooner.
A resident with Parkinson’s disease, lack of coordination, and dependence for ADLs had repeated falls and floor incidents despite a fall-risk care plan that included non-skid socks and increased observation. Incident reports documented the resident falling while walking, trying to toilet independently, crawling or rolling out of bed, and being found on the floor in the dining room, with several events noting socks without grippers or no footwear. The UM acknowledged the resident continued to fall after the sock intervention was started and that staff were trying to monitor the resident.
A resident with paraplegia and a chronic Foley catheter did not receive timely catheter care as ordered, and the TAR was left blank for the scheduled catheter change. The guardian repeatedly reported UTI symptoms and requested hospital evaluation, but the facility initially told the guardian the resident did not need to be sent out. No vitals were obtained for several days, and the resident was later hospitalized with hypotension and a complicated UTI related to the catheter.
Medication administration errors exceeded the allowed rate when two errors were found during observation of 26 opportunities. An LPN gave a resident Oyster Shell Calcium instead of the ordered Oyster Shell Calcium/Vitamin D, and another LPN crushed a Docusate Sodium tablet while administering meds to a second resident; the resident’s order was for Senna Plus. The facility policy required meds to be given according to the prescriber’s orders and matched to the MAR and drug label.
Multiple incidents of resident-to-resident physical abuse occurred, including one resident punching another and breaking her jaw, and another incident where a resident was pushed to the floor, kicked, and struck with a wheelchair. Staff witness statements and medical records documented more severe injuries and aggression than what was reported to the State Agency. Some staff did not report observed abuse incidents, and there were discrepancies between internal documentation and official reports, indicating a failure to accurately document and respond to abuse as required by facility policy.
The facility did not ensure timely and accurate reporting of suspected abuse incidents involving multiple residents, with staff failing to promptly notify authorities and accurately document the extent of injuries. A nurse admitted to not reporting all observed altercations and lacked training on abuse protocols, while the Administrator delayed reporting based on incomplete information. The facility could not provide evidence that all staff had received required abuse reporting education.
Insufficient nursing staff resulted in residents not receiving water for two days, incorrect meal tray delivery, lack of supervision for residents with dementia who wandered into other rooms, and staff confusion about assignments. Multiple residents with cognitive impairments were affected, and staff interviews confirmed delays in basic care due to heavy workloads and unclear responsibilities.
Facility administration did not follow its grievance policy after a family raised concerns about a resident with epilepsy, dementia, and cognitive communication deficit who required staff assistance for all ADLs. The family was not provided with documented follow-up or updates regarding their concerns about care, despite policy requirements for timely and ongoing communication.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent documentation, and unclear reporting mechanisms, resulting in inadequate protection for residents.
A resident with cognitive impairment and a care plan requiring staff assistance for grooming was observed with significant facial hair, despite CNA documentation indicating that shaving had been completed. The resident's care plan included a family request for the individual to be kept clean shaven, but direct observation revealed this was not done as required.
Two residents with cognitive impairment and on hospice care were physically assaulted by another resident with severe cognitive and psychiatric conditions, resulting in pain and swelling. Despite documented injuries and staff witness accounts, the facility did not substantiate abuse, citing lack of intent due to the aggressor's cognitive status.
A resident with multiple complex diagnoses was administered Lorazepam for anxiety without a documented anxiety diagnosis, targeted behaviors, or evidence of nonpharmacological interventions being attempted first. The care plan lacked person-centered behavioral interventions, and a behavioral health consultation was ordered but not completed, in violation of facility policy requiring proper assessment and alternative measures before psychotropic drug use.
A resident at an LTC facility experienced two falls, resulting in multiple femur fractures that were not reported to the hospital upon admission. The facility failed to fully investigate the falls, did not complete recommended follow-up radiographs, and did not ensure correct interventions were in place. Documentation was incomplete, and staff interviews revealed a lack of awareness and communication regarding the resident's condition and necessary follow-up actions.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the worsening of their conditions. One resident developed a stage IV ulcer with osteomyelitis due to inadequate repositioning and delayed medical oversight, while another developed an unstageable ulcer due to prolonged wheelchair use against physician orders. Documentation inconsistencies and untimely treatments were noted.
A resident experienced an 11.67% weight loss over six months, which the facility failed to identify and address in a timely manner. Observations showed the resident with an uneaten breakfast tray and no staff present. The facility did not update nutritional interventions since 2023, and the resident was not weighed weekly as required by policy. The new RD acknowledged the delay in addressing the weight loss.
The facility failed to maintain sanitary conditions in the kitchen, with raw chicken improperly thawed in a sink and several undated food items in the walk-in cooler. Dietary Staff M confirmed the chicken was thawed incorrectly and that food items should have been dated, violating the 2017 FDA Food Code.
A facility licensed for 126 residents failed to employ a full-time qualified social worker, leading to deficiencies in social services such as improper documentation of advance directives, unsafe discharge planning, and incomplete PASRR assessments. The facility had not employed a full-time social worker since March, with various individuals assisting part-time since a change in ownership in August. A new social worker was scheduled to start in September.
The facility failed to implement consistent infection control practices, affecting all residents. The Infection Control Nurse, who had multiple roles, did not provide required monthly reports or maintain accurate infection mapping. An LPN did not follow proper hand hygiene during trach care for a resident, as confirmed by the DON. These issues highlight significant lapses in the facility's infection prevention and control program.
The facility failed to prevent falls for a resident with dementia, provide appropriate care assistance for a resident with severe cognitive impairment, and ensure supervision to prevent altercations involving a resident with aggressive behaviors. Inconsistent documentation and lack of effective interventions contributed to these deficiencies.
The facility failed to provide adequate social services to eight residents, including coordination of advance directives, discharge planning, and completion of PASARR assessments. Two residents lacked social service assessments despite having significant medical needs. A change in ownership led to a gap in full-time social worker employment, contributing to these deficiencies.
The facility failed to implement an effective antibiotic stewardship program, affecting multiple residents. A review of infection logs revealed a lack of documentation on whether infections met criteria, with antibiotics prescribed without confirming appropriateness. The Infection Control Nurse acknowledged the issue, noting a new program would address it, but concerns remained.
The facility failed to ensure effective communication regarding advanced directives for two residents. One resident's medical record indicated a DNR status, but a nurse believed they were a full code, leading to potential miscommunication. Another resident expressed a desire to be a DNR, but the facility's records listed them as a full code. These discrepancies highlight the facility's failure to maintain accurate records of residents' advanced directives.
A resident with psychotic disorder and dementia was involved in an incident where they poured coffee on another resident, causing injuries. Despite the incident being documented and reported internally, the facility failed to report the allegation to the State Agency as required by their policy.
The facility failed to investigate allegations of abuse and injuries for two residents. One resident was involved in multiple altercations, including pouring coffee on another resident, but these incidents were not reported or investigated. Another resident was found with a bruised and swollen eye, but no investigation or reporting was conducted. The facility's policy requires immediate investigation of such incidents, which was not followed.
A resident admitted with epilepsy and dementia did not receive a required Level II PASARR screening after staying beyond the 30-day exemption period. The facility's Administrator, acting as the Social Worker, acknowledged the oversight, attributing it to a focus on guardianship issues following a recent change in ownership.
A resident who only speaks Arabic was not provided with adequate communication interventions, as the facility failed to utilize available resources such as an interpreter hotline and an Arabic flip guide. The care plan relied on an activities aide or family for translation, but on the day of observation, the aide was off duty, leaving staff unable to communicate effectively with the resident.
A facility failed to ensure a safe discharge for a resident with a tracheostomy and PEG tube, who was released without home health care or adequate nutrition. The DON stated that discharge planning usually involves the IDT, but the facility lacked a social worker to coordinate with outside agencies. No discharge progress note or home health care agency was ordered in the resident's medical record. The identified home health care agency confirmed the resident was not on their caseload due to insurance issues, which was communicated to the facility.
The facility failed to coordinate follow-up appointments for two residents, one with breathing issues and another with a tracheostomy and PEG tube, as per hospital discharge instructions. Additionally, there were errors in transcribing medication orders for a resident, leading to discrepancies and unnecessary contact isolation. These deficiencies highlight issues in care coordination and medication management.
A resident with hearing difficulties did not receive timely follow-up on audiology recommendations, including medical clearance for hearing aids and wax removal. Despite multiple physician notes and an audiology consult indicating moderate to severe hearing loss, the facility failed to act on these recommendations, leaving the resident without necessary hearing aids.
PASARR Level II Evaluation Not Completed
Penalty
Summary
The facility failed to ensure that a PAS/ARR Level II evaluation was completed and that its recommendations were incorporated into the resident’s assessments and plan of care for one resident, R802. R802 was admitted with diagnoses including schizoaffective disorder and delusional disorder, had moderately impaired cognition on MDS assessment, and was prescribed antipsychotic and antidepressant medications. A PASARR Level I screening completed before admission indicated a mental illness, treatment for mental illness, and use of antipsychotic or antidepressant medications, which required referral to the local Community Mental Health Services Program unless an exemption applied. During interview, R802 stated a Level II evaluation had not been completed in the current facility and that the last one had been done at a different facility in January 2025. Review of the clinical record found no DCH-3878 showing an exemption and no Level II evaluation. The Administrator stated the facility’s process was to complete a Level I screening on admission and obtain a Level II evaluation within 14 days, and later acknowledged that the Level II evaluation should have been obtained from the referring facility or requested by the current facility.
Failure to Protect Resident From Physical Abuse and Address Psychosocial Impact After Resident‑to‑Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to address the abused resident’s subsequent psychosocial needs. On the evening of 1/10/26, one resident who ambulated without a device was walking in the hallway when another resident, who used a wheelchair, appeared to roll over the ambulatory resident’s foot. Witness statements from a CNA and an LPN indicated that the ambulatory resident then came around behind the wheelchair user near the elevator and punched the wheelchair user in the nose with a closed fist, causing immediate nasal bleeding, crying, and visible distress. The assaulted resident verbally stated that the other resident had hit her, and the aggressor resident was heard saying, “No, I meant to do it. These people are always touching me and rubbing on me. I'm tired of it.” The aggressor resident later told the NHA, DON, and surveyor that he had “knocked her in the face” or “punched her in the nose” after she ran over his foot or grabbed his pants, and acknowledged feeling angry and not liking to be touched. The assaulted resident had multiple diagnoses, including vascular dementia, generalized anxiety disorder, bipolar disorder, prior subarachnoid hemorrhage, muscle wasting, and malnutrition, and was severely cognitively impaired per a BIMS score of 6/15. Following the punch, she was emergently transferred to the hospital, where imaging confirmed bilateral nasal bone fractures. Progress notes and pain logs documented pain rated 10/10 requiring additional PRN acetaminophen, as well as visible anxiety and refusal of vital signs at the time of transfer. A subsequent physician note confirmed recent nasal fractures from being struck by another resident, described a small bruise on the bridge of the nose, and noted ongoing pain management with acetaminophen and morphine. The physician also documented that the resident was experiencing an acute psychotic episode with delusions and agitation in the context of recent trauma and hospitalization. The aggressor resident also had significant cognitive and psychiatric diagnoses, including dementia, schizophrenia, diabetic neuropathy, and an adjustment disorder with anxiety, and had a BIMS score of 6/15. Facility records showed a prior resident‑to‑resident assault by this same resident on another female resident months earlier, in which he struck her with a closed fist and police were contacted, with 15‑minute checks implemented for 48 hours. Despite this history and the facility’s abuse policy defining physical abuse as willful infliction of injury by non‑accidental means (including hitting and punching) and requiring immediate protection of residents and care plan revision when needs change as a result of abuse, the investigation documents indicated the facility did not verify that abuse occurred in the 1/10/26 incident. Additionally, review of the assaulted resident’s care plan showed no updates to address protection or psychosocial concerns after the event, even though the resident later reported feeling terrible about the incident, described ongoing head and ear pain, recounted bruising and attempts to cover it with makeup, and stated she did not feel safe in the facility and wanted to go home. A police report classified the event as a simple assault/battery, documented the aggressor’s admission that he punched the victim once in the face, and verified that a facility nurse witnessed the punch. The facility’s own abuse and neglect policy, updated 6/18/25, stated that abuse includes willful infliction of injury such as hitting and punching, and that any person, including other residents, may be a potential aggressor. The policy required immediate steps to assure resident protection and revision of the resident’s care plan if medical, nursing, physical, mental, or psychosocial needs changed as a result of an incident of abuse. In this case, the documented willful punch to the face by one resident against another, resulting in nasal fractures, severe pain, anxiety, and later expressed fear and lack of safety by the victim, along with the absence of care plan revisions to address the victim’s psychosocial needs, formed the basis of the deficiency for failure to protect the resident from abuse and to respond appropriately to the consequences of that abuse.
Failure to Ensure Consistent Availability of Linens and Laundry for Resident Hygiene and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring consistent availability of bath linens and adequate laundry services for multiple residents. An anonymous complaint alleged there were not enough linens to meet residents’ care needs. During interviews, several CNAs reported that linens, especially towels and washcloths, were short almost all the time, with some shifts starting with no linen available. CNAs described cutting bath blankets and using pillowcases to clean residents, and stated that shortages delayed resident care and showers. One CNA stated they did not understand the linen system and noted that laundry was typically done only in the morning, with no one staying to wash at night. Residents also reported not receiving necessary linens and hygiene items. One resident stated they did not get towels or washcloths and that staff had never offered them, relying instead on hygiene wipes brought by family and expressing a desire to use water for cleaning. Another resident reported that towels were short, they could not take showers as needed, and they had to “fight for a shower.” A resident described aides coming in and stating they were completely out of washcloths and towels and could not change the resident until they found some, resulting in the aides going on a “scavenger hunt” for linens. A family member reported that a resident had no laundry or clothes in the room, that a blanket brought from home had gone missing, and that most of the time the resident had no clothing available despite the family frequently refilling drawers. Observations of the clean utility linen supply closets on multiple units showed no washcloths and only a few towels, and no towels or washcloths were seen in residents’ rooms during interviews. The Housekeeping Supervisor reported that one laundry staff member had left and another had a broken arm, acknowledged that the laundry department was responsible for stocking clean utility rooms, and speculated that staff or residents might be keeping extra supplies in rooms. When the laundry room was toured, washers were running mainly with sheets, and there were no clean towels or washcloths in the clean laundry bins. A separate, closed construction unit—unavailable to floor staff—contained numerous unopened boxes of new towels and washcloths that were not in circulation; the Housekeeping Supervisor had no explanation for why these were not being used. The NHA later stated that this was considered emergency stock and that they believed staff had been delivering needed linens, although this was not supported by staff or resident reports or surveyor observations. Additional issues with residents’ personal clothing were identified. One resident, who was fully alert and oriented, reported frequently missing dresses and pants, and a room inspection with the NHA and Housekeeping Supervisor found only a few dresses and no pants. Another resident’s family member reported that the resident’s clothes and blanket repeatedly disappeared in laundry, that drawers were often empty of clothing, and that on the day of observation there were no clothes in the room except for a damp, urine-smelling shirt and pants that did not belong to the resident. The assigned CNA confirmed there were no clothes in the room and acknowledged ongoing shortages of washcloths, towels, and linens since starting work three months earlier, stating they had resorted to using wipes and draw sheets for care. The laundry aide reported linen shortages on the units, attributed mainly to being down two laundry staff, and stated that while supply was not the main problem, there was insufficient staff to get clothes and linens up to the floors. The facility had no written linen or laundry policy, and the only provided environmental services policy did not address laundering linens or residents’ clothing. Following the surveyor’s identification of concerns, later observations showed the clean utility rooms stocked with ample washcloths and towels, and no further shortages were reported during the remaining survey period. However, the deficiency centers on the period when residents and staff experienced ongoing shortages of towels, washcloths, and clothing, the lack of a defined linen/laundry policy, and the existence of substantial unused linen stock stored in an inaccessible construction area while residents lacked basic linens and adequate laundry support for personal hygiene and comfort.
Failure to Provide Adequate Supervision to Prevent Multiple Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one incident, a nurse heard a resident with severe cognitive impairment and a history of aggression yell at another resident to get out of his room, followed by observation of the second resident on the floor in the first resident’s room. The nurse then witnessed the first resident kick the second resident twice in the back/shoulder area while staff were attempting to assist the resident from the floor. Both residents had documented histories of aggression toward others, and both had psychiatric and cognitive diagnoses, including traumatic brain injury, dementia, schizoaffective disorder, bipolar disorder, schizophrenia, PTSD, and anxiety. The facility’s own investigation acknowledged that physical contact occurred between the two residents, resulting in a scratch on one resident’s neck, a cut on the other resident’s arm, and reported back pain. In a separate incident, two roommates were involved in a physical altercation after one resident was moved into the other’s room despite staff concerns. One resident, who was described by staff as aggressive and known not to like having roommates, was placed with another resident who was described as nice and who preferred the door open, in contrast to the aggressive resident’s preference for a closed door. Shortly after the room change, the second resident exited the room distressed and reported being hit by the roommate, initially stating they were hit in the face with a hand and also reporting being struck with a bathrobe related to a misunderstanding over clothing. The resident reported feeling unsafe in that room and only feeling safe after being moved, and staff confirmed that they had previously expressed concerns to administration that this roommate pairing would not be a good fit due to the aggressive behaviors of the first resident. Two additional incidents involved a resident with marked cognitive impairment who did not like others entering his room and another cognitively impaired resident who had a behavior of climbing into other residents’ beds, as well as a separate altercation between the same resident and another cognitively impaired resident in a hallway. In the first of these, staff responded to yelling and found one resident partially on the bed and the other resident in a wheelchair holding the first resident’s wrist and making physical contact. In the second, the resident who believed another resident had stolen his items confronted that resident in the hallway, and both residents struck each other in the face after the confrontation escalated. In all of these events, the residents involved had documented cognitive impairments and behavioral histories, and physical contact between residents was observed or confirmed by staff, demonstrating that supervision and monitoring were insufficient to prevent repeated resident-to-resident altercations. The facility’s staffing policy stated that adequate staffing would be maintained on each shift to ensure residents’ needs and services were met, including supervision and monitoring by licensed nurses and CNAs. Despite this, multiple resident-to-resident physical interactions occurred across different dates and units, involving residents with known behavioral issues and cognitive impairments. Staff interviews indicated that some concerns about roommate compatibility and aggressive behaviors were known prior to at least one of the incidents, yet the room assignment proceeded and an altercation followed. The pattern of events described in the report shows that the facility did not provide adequate supervision or environmental management to prevent these resident-to-resident altercations, resulting in physical contact, minor injuries, and distress for the residents involved.
Failure to Consistently Provide and Offer Required Evening Snacks
Penalty
Summary
The facility failed to ensure the consistent provision and availability of evening and bedtime snacks in accordance with residents’ needs and preferences. One resident, who was alert and oriented and restricted to bed, reported that they had never been provided or offered a snack by the facility and relied on family to bring snacks, expressing a desire to at least be offered something to see if there was an item they liked. Another alert and oriented resident in a wheelchair stated they were missing snacks at times, especially in the evenings, and explained that if they were not at the nurses’ station when snacks were passed out, they did not receive one. This resident described that snacks such as peanut butter and jelly sandwiches, pudding, and chips were available but that residents had to “run to that desk” to get them, and there were days they did not receive a snack despite wanting one daily. A family member of a nonverbal resident reported they were not aware of the resident receiving snacks and stated the resident seemed hungry during visits, leading the family member to request double food portions, which were often not received. During the interview, the nonverbal resident, who used a manual wheelchair, indicated through nonverbal cues (pointing to the surveyor’s and their own stomach and grimacing) that they were hungry at night, which the family member said occurred often. The family member had not been offered a grievance or concern form regarding snacks until prompted during the survey. The Dietary Manager reported that snacks such as chips, cookies, Jello, pudding, sandwiches, and rice crispy treats were prepared and sent to the unit on a tray, but acknowledged awareness of residents stealing and hoarding snacks and stated it was possible staff were taking snacks as they disappeared quickly. Although dry snacks were observed in the Dietary Manager’s office, residents’ reports and staff statements demonstrated that snacks were not reliably offered or made accessible to all residents as required by the facility’s policy, which states that all residents on regular diets are to be offered a bedtime snack each evening and that such snacks must be documented as offered.
Failure to Provide Timely ADL and Incontinence Care Due to Inadequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision of activities of daily living (ADL) care, including toileting and incontinence care, for multiple dependent residents. An anonymous complaint alleged short staffing, residents remaining in wet or soiled briefs for extended periods, and staff sleeping on the night shift, resulting in neglect of basic care needs. CNAs reported that when only two aides were scheduled instead of three on a floor of about 40 residents, they were unable to provide needed care, including timely feeding and two-hour check-and-change incontinence care, particularly on the midnight shift. Facility schedules showed multiple midnight shifts with only two aides assigned per floor despite a census in the 80s and 22 residents requiring lift assistance. Several residents described prolonged waits for assistance with toileting, incontinence care, and other basic needs. One bedbound, fully dependent resident reported that call lights often took up to two hours to be answered, that staff sometimes turned off the call light and said they would return but did not, and that some aides told them they went to the bathroom too often or were not “wet enough” to be changed despite the resident being on Lasix. This resident recounted an incident where a midnight aide performed inadequate perineal care, leaving stool that became hard and caked on by morning, which made the resident feel awful. Another bedbound, fully dependent resident reported waiting 1–2 hours after activating the call light to be changed, which caused frustration. Two alert, oriented residents who used manual wheelchairs reported frequently waiting about an hour or longer in bed for help with transfers, toileting, water, and medication, including an instance of waiting about an hour and a half for tray pickup and ice, and over an hour for an anxiolytic medication. Another resident’s family member reported repeatedly finding the resident “soaked” in urine during visits, including on the morning of the survey, and the resident nonverbally confirmed distress about being wet. These accounts, combined with staff interviews and staffing records, demonstrated that residents’ ADL and incontinence care needs were not being met in a timely manner, contrary to the facility’s written staffing policy stating that adequate staff would be maintained on each shift to meet residents’ needs and services.
Failure to Provide Consistent, Person-Centered Activities as Scheduled
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent, meaningful, person-centered activities as scheduled and in accordance with residents’ preferences. One resident reported that the Activity Director posted monthly activity calendars but did not follow them, resulting in missed activities, particularly on weekends, such as BINGO and brain games. This resident stated that activity staff never conducted room visits, that music activities did not reflect their preferences, and that they were usually not taken on community outings when other residents went into the community. The resident described being bored on weekends and said they would attend activities if they were consistently offered. They also reported not being notified when activities were cancelled or times were changed, which caused frustration and upset. Surveyor observations corroborated these concerns. The activity calendar in the resident’s room showed a scheduled Brain Games activity on a Saturday, but the resident reported that when they went to attend, no one came to the activity room. The first-floor activity calendar posted in the dining room showed BINGO scheduled at a specific time, but when the surveyor observed the room during that period, there was no BINGO activity and no activity staff present. Another resident was observed waiting in their wheelchair in the dining room for BINGO to start and reported that activity staff were always late, that activities did not start on time, and that there were no activities on Sundays and some Saturdays. This resident stated that BINGO, previously held three times a week, was now only on Mondays and expressed frustration with the delays and missed activities. Further observations showed that the resident who had been waiting for BINGO left after waiting approximately 40 minutes, along with at least three other residents, and no activity staff or BINGO activity were present during that time. BINGO was later observed to have just started nearly an hour after the scheduled time. The Activity Director acknowledged that BINGO started late and attributed delays and missed activities to staffing shortages, a no call/no show by an activity aide, and the need to cover activities on both floors with limited staff. The Activity Director also acknowledged that activities were getting missed more often on the first floor, where residents were more independent, and that there were simultaneous activities scheduled on both floors that could not be covered by the available staff. Review of activity logs for the two residents showed participation on only a portion of days in the look-back period, similar dates with no activities documented, no refusals recorded, and minimal Sunday activities, despite a posted calendar indicating a full schedule. The facility’s policy stated that residents would be informed of activities through posted calendars, announcements, and individual communication, and that assistance would be provided to residents who wished to participate but could not get to activities on their own, but the documented and observed practices did not align with these procedures.
Failure to Monitor Change in Condition and Missed IV Antibiotic Doses
Penalty
Summary
The facility failed to assess, monitor, and document changes in condition in a timely manner for two residents reviewed for change in condition. For one resident with severe cognitive impairment and type 2 diabetes, staff suspected a UTI and obtained physician orders for a urinalysis and culture, but the resident was combative, refused care, and urine could not be collected. The record showed limited documentation of ongoing monitoring for UTI signs and symptoms after the specimen could not be obtained, and there was no evidence the resident was evaluated by a medical provider for the change in condition between the initial UA order and the later transfer to the hospital after a fall, hypotension, and markedly elevated blood glucose. For that resident, progress notes documented refusal of food and medications, inability to obtain urine, low blood pressure, and later a fall in the dining room with blood sugar of 516 and blood pressure of 80/56. The resident was sent to the hospital, where records showed lethargy, hypotension, elevated WBC, a positive urinalysis, and treatment in the ED with IV fluids, IV antibiotics, insulin drip, and ICU admission. The hospital discharge summary identified septic shock likely due to acute complicated UTI, along with high anion gap metabolic acidosis and DKA likely due to UTI. For the second resident, who had severe cognitive impairment and was receiving IV meropenem for osteomyelitis, the record showed missed doses of antibiotic therapy. A nurse reported the resident missed 18 doses of meropenem and later became unresponsive, prompting transfer to the hospital. The record also showed the resident was documented as self-administering IV antibiotics despite being dependent, and the transfer note lacked vital signs, assessments, and notification to family or physician about the transfer.
Homelike Dining Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment during dining for four residents. During the lunch meal observation in the second floor dining room, one resident’s meal was served on a tray instead of having the plate placed on the table, and a television remote control was observed on the tray. Another resident’s meal was also served on a tray, while two other residents seated at the same table had not yet been served and each pulled that tray toward themselves before receiving their own meals. One of the residents was then moved to another table and served her meal on a tray, and the other resident was later served his meal on a tray. The residents involved were R7, R47, R64, and R72. Record review showed R7, R47, R64, and R72 each had severely impaired cognition on MDS assessments. During interview, the Regional Registered Dietician stated that meal trays should be removed from the table to provide a homelike dining experience.
Missed IV Antibiotic Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication error when 18 doses of prescribed IV meropenem were missed and not given as ordered. The resident was admitted with local infection of the skin and acute hematogenous osteomyelitis and had a BIMS score of 00, indicating severe cognitive impairment. The record showed a prescription for meropenem 500 mg IV every eight hours for 11 days, for a total of 33 doses. The MAR showed that beginning at 4:00 PM on 7/16/25, the resident was documented as self-administering the IV antibiotic, and from 7/16/25 through 7/22/25, 18 doses of IV meropenem were recorded as self-administered. During interview, a nurse reported the resident missed several doses of IV antibiotics and that the missed doses were discovered during an investigation after the resident had a change in condition and was sent to the hospital. The nurse also reported the physician was notified that the resident had missed several doses of antibiotic therapy.
Insufficient Dietary Support During Meals
Penalty
Summary
The facility failed to maintain sufficient dietary support personnel to meet the needs of residents in the second-floor dining room for five residents reviewed for the dining task. During the lunch meal observation, the resident meals cart arrived at 12:39 PM and food service began, but one resident’s tray was served while nearby residents were not yet served. Two residents at the same table touched the tray and food, and one resident drank juice mixed with food from the tray while no staff were seated at the table with them. The tray was later removed after the DON was alerted that other residents had made contact with the food. Additional dining observations showed that one resident was served a meal with no set-up assistance, another resident had a nutritional shake unopened and asked the surveyor for help opening it, and an LPN later assisted that resident before switching to assist the first resident. During that time, the resident spilled the shake and ate with a knife instead of a fork. Two other residents were observed with meals in front of them for extended periods without staff encouragement or assistance; one remained asleep until a CNA later removed the tray and fed a few bites, and another picked at rice with her hands without successfully eating. The residents involved had diagnoses including dementia or Alzheimer’s disease, and their care plans called for meal assistance ranging from set-up and supervision to partial or moderate assistance and touching assistance.
Inaccurate Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for one resident who was admitted with diagnoses including major depressive disorder, vision loss, and chronic kidney disease and who had severely impaired cognition on the MDS. The clinical record showed the resident had a DNR advance directive signed by the resident and witnesses, with physician signatures on the advance directive paperwork, and the care plan also identified that the resident had an established DNR and a POA assisting with decisions. A separate document to determine competency later marked the resident as incompetent and was signed by a second physician. Despite the DNR paperwork, the resident’s electronic medical record listed the resident as Full Code, and a physician order for Full Code had been created by the UM. Staff interviews showed the assigned nurse relied on the EMR and face sheet for code status and stated the resident was Full Code. The UM stated she had been instructed by the former DON to make the resident Full Code by default while competency was being determined, and she had no explanation for why there was no advance directive signed by the POA after the resident was deemed incompetent. The DON stated the facility used separate forms depending on whether the resident, POA, or guardian signed, and that all forms had to be signed by the doctor and witnesses.
Failure to Complete Required OBRA Level II Evaluations
Penalty
Summary
The facility failed to ensure PASSAR/OBRA Level II documentation and exemption criteria were completed appropriately for two residents reviewed for PASSAR/OBRA assessments. One resident was admitted with diagnoses including bipolar disease, paranoid schizophrenia, PTSD, and chronic pain, and the clinical record contained an OBRA Level II evaluation dated November 6, 2024 stating that specialized mental health services could be met in the nursing facility and that a Level II evaluation would be needed again by November 5, 2025. The record review found that the Level II evaluation due by that date was not completed. A second resident was admitted with diagnoses including undifferentiated schizophrenia, bipolar disorder, and adjustment disorder, and the clinical record contained an OBRA Level II evaluation dated September 11, 2024 stating that specialized mental health services could be met in the nursing facility and that a Level II evaluation would be needed again by September 10, 2025. The record review found that the Level II evaluation due by that date was not completed. During an interview on December 3, 2025, the Social Worker reported being fairly new to the facility and stated that, before their employment, several residents including these two had not received Level II evaluations as needed.
Inaccurate nursing documentation and assessment
Penalty
Summary
The facility failed to ensure professional nursing standards were followed for a resident with a PEG tube feeding order. The resident was observed in bed on multiple occasions with no tube feeding formula hung or infusing, yet the MAR showed an LPN documented that 325 mL of tube feeding had been administered. When questioned, the LPN stated there was nothing hanging when he arrived on day shift and said the night nurse must not have hung the second bottle, but he also documented the feeding as given before it had actually been administered. The resident had an active order for Jevity 1.5 via pump through the PEG at 65 mL/hr for 18 hours or until 1170 mL daily was reached. The facility also failed to accurately assess and document the correct sling size for the same resident during a mechanical lift weight procedure. During the transfer, the resident began slipping out of an XL sling, and the sling then slipped over the resident’s head when the resident was lifted again. The DON later stated she did not physically assess the resident and relied on what an LPN said, while the LPN stated the sling was held over the resident rather than being properly assessed. The resident’s lift assessment changed from Large to XL and then back to Large, and the resident had diagnoses including Pick Disease Type C, dysphagia, dementia, and aphasia, with severely impaired cognition and dependence on staff for transfers. The facility also failed to maintain an accurate treatment record for another resident with a left elbow skin tear. The resident had an order to cleanse the wound, apply triple antibiotic ointment, and cover it with a border foam dressing. The resident was observed with a foam dressing on the left forearm that was dated 11/30/25 with one nurse’s initials, yet the December TAR showed another nurse documented the dressing change as completed on 12/1/25. The unit manager stated that nurses should only document in the TAR if they actually performed the treatment. The resident had dementia, hypokalemia, a BIMS score of zero, and needed assistance from staff with most ADLs.
Missed Physician-Ordered Weight Monitoring
Penalty
Summary
The facility failed to ensure physician-ordered weekly weight monitoring was obtained and completed for two residents, R64 and R70, who were both being followed for weight loss. R70 was observed in bed with an untouched breakfast tray and reported not knowing whether they had lost weight or had any issues with the facility food. R70 had diagnoses including dysphagia and muscle weakness, required staff assistance with most ADLs, and had a BIMS score of 9 indicating moderately impaired cognition. The record showed repeated dietary concerns, including significant weight loss, variable appetite, pureed diet texture after a mandible fracture, and orders for weekly weights during multiple monitoring periods. For R70, the chart documented weights during the ordered monitoring periods, including 117.9 lbs on 6/10/25, 107.2 lbs on 7/9/25, 108.0 lbs on 8/4/25, 107.2 lbs on 9/8/25, and 103.0 lbs on 10/7/25. However, further review did not reveal any additional weights for the physician-ordered weekly monitoring periods. Dietary notes stated that weekly weights were monitored, but the documented record did not show completion of the ordered ongoing weekly weights after the listed dates. R64 had diagnoses including dementia and vitamin deficiency, required staff assistance with most ADLs, and had a BIMS score of 0 indicating severely impaired cognition. Progress notes documented repeated weight warnings, including significant weight loss and a BMI as low as 13.7, with weekly weights ordered for additional monitoring. The documented weights included 110.6 lbs on 8/5/25, 110.8 lbs on 9/3/25, 98.1 lbs on 10/2/25, and 97.8 lbs on 11/5/25, but no further weights were found for the physician-ordered weekly monitoring. On interview, the RD acknowledged that getting weekly weights completed was an ongoing concern at the facility and that the facility had developed an action plan, but the issue remained ongoing.
Tube Feeding Not Administered per Order
Penalty
Summary
The facility failed to administer tube feeding according to a resident’s assessed needs and physician’s orders for one resident who received all nutrition through a PEG tube and did not eat or drink by mouth. The resident had diagnoses including Pick Disease Type C, dysphagia, dementia, and aphasia, and was described on the MDS as having severely impaired cognition and being dependent on staff for bed mobility, transfers, and all ADLs. The active order was for Jevity 1.5 via pump at 65 mL/hr for 18 hours or until a total of 1170 mL was reached daily. During observations, the resident was found in bed with no tube feeding formula hung or infusing in the room on multiple occasions. Despite this, the MAR showed that an LPN documented 325 mL of tube feeding as administered on day shift, and the MAR also reflected that 325 mL was signed off on each shift for several days, totaling 975 mL per day, which did not match the ordered amount. When questioned, the LPN stated there was nothing hanging when he arrived and said the night nurse must not have hung the second bottle, then acknowledged signing off on an amount that had not yet been administered. The RD stated he monitored tube feeding by reviewing weights, nursing documentation, observation, and staff communication, and later confirmed that based on the documentation the resident did not receive the required amount of tube feeding.
Lack of Dialysis Communication
Penalty
Summary
The facility failed to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one resident who was admitted with End Stage Renal Disease and was dependent on hemodialysis. The resident had a physician order for hemodialysis on Tuesdays, Thursdays, and Saturdays, and a care plan was initiated. During survey review, the Director of Nursing was asked to provide dialysis communication forms for four months between the facility and the dialysis center. The forms submitted showed no communication between the facility and the dialysis center for the month of October, and the resident’s medical record showed no leave of absence or hospital visits during that month. When asked about the missing communication forms, the DON stated that what was uploaded was what they had.
Failure to Preserve Resident Dignity During Mobility and Feeding Assistance
Penalty
Summary
The facility failed to provide an environment that promoted and enhanced residents’ dignity for three residents reviewed for dignity. One resident with diagnoses including Alzheimer’s disease, anxiety disorder, and peripheral vascular disease, and with severely impaired cognition per the MDS, was observed sleeping in a geri chair holding a baby doll. A Unit Manager then turned the chair around and pulled the resident backwards out of the room and down the hall to the dining room, continuing to pull the resident backwards to a table. When interviewed, the Unit Manager stated she always pulled the chairs because it was easier than pushing them. The DON later stated residents should always be pushed in the chair facing forwards, not backwards. During the lunch meal in the second-floor dining room, one Unit Manager was observed standing over one resident for an extended period while attempting to feed them, and a CNA was observed standing over another resident while providing feeding assistance. The RD stated that staff providing feeding assistance should be seated next to residents and engaging them to provide an optimal dining experience and treat them in a dignified manner. Facility documents titled Feeding the Dependent Resident and Resident Rights stated that residents should be treated with consideration, respect, and full recognition of dignity and individuality, and that staff should sit at eye level of the resident during feeding assistance.
Failure to Provide Basic Care and Prevent Neglect
Penalty
Summary
The facility failed to protect one resident from neglect by allowing the resident to remain confined to bed and the room, not receiving oral hygiene, and not being changed out of a hospital gown. The resident was observed multiple times lying in bed in a hospital gown, including while asleep and while awake but not responding when addressed. A sign in the room, signed by the resident’s responsible party, directed that the resident always wear a bra and hospital gown, have no wheelchair or geri chair, and receive no oral care. The resident had diagnoses including Pick disease type C, dysphagia, dementia, and aphasia, and was dependent on staff for bed mobility, transfers, and all ADLs, including oral hygiene and dressing. The resident received all nutrition through a PEG tube and did not eat or drink by mouth. The clinical record showed that after a fall from bed, the interdisciplinary team had implemented an intervention to offer the resident a geri chair daily, and progress notes documented that the resident had previously enjoyed being up in a chair and appeared comfortable when taken to the dining room. Despite this, facility documentation showed repeated directions from the DPOA not to provide oral care, not to remove or care for partial dentures, not to dress the resident in clothing, and not to get the resident up in a chair or wheelchair. Staff interviews confirmed that the resident was not being gotten out of bed because of the family’s request, and that the mechanical lift was used only to weigh the resident. The DON and Administrator acknowledged the resident’s basic care needs and discussed the family’s requests, while the facility policy stated that neglect includes failure to provide necessary and adequate care and failure to care for a person in a manner that would avoid harm and pain.
Failure to Report Suspected Neglect
Penalty
Summary
The facility failed to report suspected neglect to the Abuse Coordinator and the State Agency for one resident. The resident was admitted with diagnoses including Pick disease type C, dysphagia, dementia, and aphasia, had severely impaired cognition, and was dependent on staff for bed mobility, transfers, and all ADLs, including oral hygiene and dressing. The resident received all nutrition through a PEG tube and did not eat or drink by mouth. During observations, the resident was repeatedly found in bed wearing a hospital gown, and signage in the room directed that the resident remain in a bra and gown, not be placed in a wheelchair or geri-chair, and receive no oral care. The signage was signed by the resident’s responsible party. Staff observed that the resident was not being gotten out of bed, and when the resident was weighed with a mechanical lift, the sling was too large and the resident began to slip out, requiring a smaller size. Staff also reported that the resident had previously enjoyed being out of bed in a chair, but the resident was not being taken out of bed because the family member did not want it. Record review showed multiple progress notes documenting the responsible party’s requests to withhold care, including not getting the resident up to a chair, not dressing the resident in clothing, not performing oral care, and not removing partial dentures. The facility’s care plans reflected these requests. The DON acknowledged that the resident’s DPOA did not want oral care, denture care, or the resident dressed or out of bed, and stated the DPOA became angry if staff provided those services. The Administrator/Abuse Coordinator stated he was not aware of the issue as a neglect concern and confirmed he did not report the neglect to the State Agency or conduct an investigation because it was not brought to his attention in that way. The facility policy defined neglect as failure to provide necessary and adequate care and required allegations or suspicions of abuse to be reported immediately.
Failure to Provide Feeding Assistance and Nail Care
Penalty
Summary
The facility failed to provide assistance with activities of daily living for dependent residents who required help with eating and nail care. During the lunch meal observation on 12/2/25, R26 was seen trying to eat independently despite a meal ticket indicating staff assistance was required, and R23 was observed sitting silently with untouched food and no staff assisting with the meal. R26 continued to struggle with the meal over an extended period, and neither resident had consumed their food before staff later removed the meals. When queried, CNA P stated that R23 normally did not need assistance and that R26 sometimes required help with eating. The RD later stated that staff should be providing assistance to residents who were having difficulty eating on their own. R23’s comprehensive plan of care identified nutritional problems related to dementia, dysphagia, anxiety disorder, diabetes, major depressive disorder, and hospice status, and included an intervention to offer meal setup and feeding assistance as the resident allowed. R26’s comprehensive plan of care identified an ADL self-care performance deficit related to Alzheimer’s disease, adjustment disorder with mixed anxiety and depressed mood, psychotic disorder with hallucinations, muscle weakness, difficulty walking, generalized muscle weakness, and psychoactive drug use, with an intervention for eating requiring 1 person partial/moderate assist. The facility’s policy stated it was the facility’s policy to ensure adequate nutrition for residents unable to feed themselves and to sit at eye level of the resident. The facility also failed to provide nail care for R3. On 12/2/25, R3 was observed with disheveled hair and dirty long fingernails on both hands and stated the nails had not been cut in a while and that they could not remember the last shower. R3, who had diagnoses including bipolar disease, paranoid schizophrenia, PTSD, and chronic pain, also reported being bitten by a roommate and alleged unwanted kissing. The record showed no ADL Kardex documentation for nail care, and the last shower documented was 11/27/25. A later progress note described the nails as over the base of the fingers with redness under the nails and dry brown grit present, and noted the resident refused nail care. The DON reviewed paper skin observations titled Nails Filed and Needs Clipping, but the November entries provided did not indicate that R3’s nails were either filed or needed clipping.
Failure to Timely Identify Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely identification of pressure ulcers for one resident with Alzheimer's disease, anxiety disorder, peripheral vascular disease, and severely impaired cognition. The resident was admitted on 3/3/25 and later developed a right heel wound that was first documented on 5/6/25 as a new in-house acquired ruptured blister on the right heel, measuring 4.5 cm by 3.2 cm with moderate serosanguineous drainage and a faint odor after cleansing, with heel protection added. By 5/13/25, wound care rounds documented the right heel as an unstageable wound measuring 6.5 cm by 6.5 cm with 90% eschar and 10% slough eschar, moderate malodorous serosanguineous drainage, and noted decline. The wound was later described as a right heel DTI due to trauma and then as a stage 4 pressure injury. The resident also developed a left heel blister and DTI, and later a new open area to the right gluteal fold that was first documented on 9/9/25 as measuring 2.3 cm by 1.2 cm by 1.3 cm with granulation tissue and slough. The contracted wound care NP later identified the right gluteal wound as an unstageable pressure-induced tissue damage on 9/11/25 and reclassified it as a stage 4 pressure wound on 9/18/25. The resident's POA reported noticing dirty, wet socks in early April 2025 and finding an open wound on the right heel, then later a pressure ulcer on the left heel and another on the bottom in September 2025. The facility's UM stated pressure ulcers should ideally be identified at stage 1 and should not be discovered when unstageable or stage 3, but had no explanation for why the right heel and right gluteal fold were not discovered earlier. The facility policy required licensed nurse assessment of wounds identified after admission and documentation of all areas of breakdown, excoriation, discoloration, or other unusual findings.
Repeated Falls Despite Fall Prevention Measures
Penalty
Summary
The facility failed to ensure effective interventions were implemented to prevent multiple re-occurring falls for one resident with Parkinson’s disease and lack of coordination. The resident required assistance with activities of daily living and had a care plan identifying fall risk related to bladder incontinence, hypotension, psychoactive medication use, muscle weakness, difficulty walking, and abnormal posture. The care plan included interventions such as non-skid socks when shoes were not worn and assisting the resident to a wheelchair when awake for frequent observation. The resident experienced multiple falls and related incidents over the course of the month. The incident reports described the resident falling while walking with a walker, attempting to toilet independently, crawling out of bed, rolling out of bed, and being found on the floor in the dining room. Several events documented the resident wearing socks without grippers or no footwear at all, and one report noted the call light was on the floor and not active. One progress note also documented the resident sitting on the floor in front of the wheelchair and later being transferred to the hospital for further evaluation. During interview, the Unit Manager acknowledged that interventions such as grippy socks had been used, but the resident continued to have repeated falls after that intervention was initiated. The Unit Manager also stated staff were trying to keep the resident in the common room during the day and were trying to monitor the resident. The facility’s Fall Prevention policy stated that each resident would be evaluated for fall risk and that individualized preventive measures would be implemented to reduce falls.
Failure to Provide Timely Catheter Care and Respond to UTI Concerns
Penalty
Summary
The facility failed to ensure timely catheter care and timely response to the guardian’s concerns for a resident with paraplegia, a chronic Foley catheter, and diagnoses that included urinary tract infection and bipolar disorder. The resident had a BIMS score of 15/15. An order was in place to change the 16 Fr catheter with a 10 cc balloon on the 9th of each month, but the Treatment Administration Record for that date was left blank, and the resident’s catheter change was not documented as completed as ordered. The resident’s guardian repeatedly contacted the facility reporting signs of a UTI and requesting hospital evaluation. A progress note documented that the guardian reported fatigue, increased sleep, and confusion, and the resident was ultimately sent to the hospital after physician contact. The record showed no vitals, including temperature, oxygen saturation, or pulse oximetry, were obtained between 8/7/25 and 8/13/25. Hospital records documented the resident was admitted for hypotension and a complicated UTI related to the catheter, and the final report noted the resident had a chronic Foley catheter that had been in place for years and could not recall when it was last changed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent when two medication errors were identified during observation of 26 medication administration opportunities, resulting in a 7.69% error rate. During the medication pass, an LPN prepared five medications for one resident and administered them, including Oyster Shell Calcium 500 mg. Later review of the physician order showed the resident had an order for Oyster Shell Calcium/Vitamin D 500-200 mg/Unit, and the LPN stated that the combination stock bottle was not in the medication cart used for the pass. During another observed medication pass, an LPN prepared four medications for a second resident and crushed all four medications, including Docusate Sodium 100 mg. Review of the physician orders showed the resident had an order for Senna Plus 8.6-50 mg, and it was noted that Docusate Sodium tablets should not be crushed. The facility policy stated that medications must be administered in accordance with the prescriber’s written orders and that the nurse should compare the MAR with the drug label before administration.
Failure to Protect Residents from Physical Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations that caused significant harm. One incident involved a resident with moderate cognitive impairment and a history of behavioral disturbances punching another resident in the face twice, breaking the victim's jaw. Witness statements and medical records confirmed that the altercation was witnessed by staff, and the injured resident reported severe facial pain and was subsequently transferred to the hospital for evaluation and treatment. The facility's documentation submitted to the State Agency did not accurately reflect the severity of the incident, as more detailed accounts in witness statements and the electronic medical record described greater injury and aggression than initially reported. Another incident involved the same resident who sustained the jaw fracture later pushing a third resident to the floor, then kicking and attempting to run over the resident with a wheelchair. Witness statements from nursing staff described observing the aggressor kicking the fallen resident and running into her with the wheelchair. The clinical record for the aggressor documented a history of combative and aggressive behaviors toward both residents and staff, including entering other residents' rooms, rummaging through belongings, and being verbally and physically aggressive. Despite this documented pattern, the facility's reporting to the State Agency again did not fully capture the extent of the altercation as described in internal records and staff statements. Interviews with staff revealed that some incidents of resident-to-resident aggression were not reported to facility leadership or the State Agency, and that staff had not received additional training on abuse reporting expectations. Staff also reported overhearing inappropriate comments from other staff members regarding the incidents, and there was acknowledgment of discrepancies between witness statements and the facility's official investigation documentation. The facility's abuse and neglect policy defined physical abuse and willful actions but did not appear to be consistently followed in practice, as evidenced by the incomplete and inaccurate reporting of serious resident-to-resident abuse events.
Failure to Timely Report and Accurately Document Suspected Abuse Incidents
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. In multiple incidents involving three residents, staff did not accurately or promptly report resident-to-resident physical altercations to the appropriate authorities. Documentation submitted to the State Agency did not fully represent the extent of the events as recorded in witness statements and the electronic medical record (EMR). For example, an incident where one resident struck another in the face was not reported to the Administrator until approximately seven hours after it occurred, and the initial report did not reflect the severity of the injury, which was later determined to be a fractured jaw. Further review revealed that staff, including a nurse who witnessed the incidents, did not consistently report all observed altercations. The nurse described witnessing additional aggressive interactions between residents, including physical assaults, but admitted to not reporting some of these events. The nurse also indicated a lack of training regarding the facility's abuse reporting protocols and expectations. There was no evidence that this nurse had received any abuse prevention or reporting education from the facility, despite the facility's claim of recent staff education efforts. Interviews with the Administrator and DON confirmed gaps in understanding and execution of reporting requirements. The Administrator delayed reporting an incident based on an initial assessment that there was no injury, only reporting after learning of a serious injury. The facility's own policy required immediate reporting of all allegations or suspicions of abuse to the Administrator and state agencies, but this was not followed. Additionally, the facility could not provide evidence that all staff, including agency nurses, had received the required training on abuse reporting procedures.
Insufficient Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents on the second floor, as evidenced by multiple observations and interviews. On the day in question, only two CNAs were present for the first part of the shift due to a third CNA arriving late, and staff were unclear about their assignments. As a result, residents did not receive fresh water for two days, meal trays were delivered incorrectly or left in rooms for extended periods, and staff were unaware of which residents they were responsible for. Several residents, many with dementia or Alzheimer's disease, were observed without water within reach, with empty or outdated cups, or with no water available at all. Additionally, residents with a history of wandering were not redirected by staff, despite being observed entering and exiting multiple rooms that were not their own. Staff present in the hallway did not intervene or provide supervision. Interviews with CNAs and the RN assigned to the unit revealed that the workload was heavy, and tasks such as passing water and meal trays were delayed or not completed. The RN reported that medications were sometimes not given timely due to the workload, and agency CNAs were unfamiliar with their assignments and had not provided basic care such as water or meals to residents by mid-morning. The staffing coordinator and unit manager both confirmed that staffing was based solely on census rather than resident acuity, and that agency staff were used to fill gaps due to retention challenges. The facility's own policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved. The administrator and unit manager acknowledged that the lack of fresh water and delayed care should have been identified and addressed, but it was not recognized until brought to their attention during the survey.
Failure to Follow Grievance Policy and Provide Family Follow-Up
Penalty
Summary
Facility administration failed to adhere to its grievance policy regarding a resident with epilepsy, dementia, and cognitive communication deficit, who required staff assistance for all activities of daily living. The resident's family, who are also the legal guardians, submitted concerns about the frequency of changing and catheter monitoring. The facility's grievance documentation indicated that the family was not satisfied with the resolution and requested continued updates. However, there was no documented follow-up with the family after their concerns were verbalized. The facility's grievance policy requires the administrator or designee to contact the concerned party within 24 hours of receiving a grievance, provide written and oral explanations of findings within three to seven days, and maintain frequent contact until resolution. In this case, the administrator acknowledged that the follow-up was not completed, attributing the lapse to being off duty and leaving the responsibility to the DON, who was also unavailable. No further explanation or documentation of follow-up was provided by the end of the survey.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training, inconsistent documentation, and a lack of clear reporting mechanisms for suspected incidents. As a result, the facility was unable to demonstrate that it had taken adequate steps to protect residents from potential harm related to abuse, neglect, or theft.
Failure to Provide Grooming Assistance as Required by Care Plan
Penalty
Summary
A deficiency was identified when staff failed to provide necessary assistance with grooming for a resident who required help with activities of daily living (ADLs). The resident, who had diagnoses including epilepsy, dementia, and cognitive communication deficit, was assessed as having moderately impaired cognition and required staff assistance for all ADLs. The care plan specifically included an intervention, at the family's request, for the resident to be kept clean shaven. Despite this, the resident was observed with significant facial hair and in need of a shave during a surveyor's visit. Review of the medical record and CNA documentation showed that personal hygiene tasks, including shaving, were marked as completed multiple times on the days in question. However, direct observation contradicted these records, as the resident's facial grooming had not been performed according to the care plan. The unit manager confirmed that staff were expected to shave the resident during morning care, but no further explanation or documentation was provided regarding the discrepancy between the documentation and the resident's observed condition.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents where one resident physically assaulted two other residents. In the first incident, a resident with severe cognitive impairment and multiple psychiatric diagnoses punched another resident in the face with a closed fist, resulting in swelling and pain near the lower jaw. The assaulted resident, who was receiving hospice care and had severe cognitive impairment, reported pain and swelling but was unable to provide a pain scale rating. In the second incident, the same resident exited his room while agitated and yelling, and punched another resident in the right cheek with a closed fist. This second victim was also on hospice care and had moderate cognitive impairment. Progress notes documented the physical assault and subsequent pain experienced by the resident. The aggressor was later placed on 1:1 supervision and transferred to a hospital following continued aggressive behavior. Despite clear documentation of physical contact and resulting pain and swelling, the facility concluded that abuse could not be substantiated, citing lack of intent due to the aggressor's poor cognition and the victims' inability to recall the incidents. The facility's policy defines abuse as causing physical harm, pain, or mental anguish, regardless of the perpetrator's mental or physical condition, and specifies that 'willful' refers to deliberate action, not necessarily intent to harm.
Failure to Implement Nonpharmacological Interventions and Behavioral Health Services Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions were implemented and utilized before administering pharmacological interventions for a resident with a history of traumatic brain injury, acute respiratory failure, acute embolism and thrombosis, and major depressive disorder. The care plan for fall risk included offering PRN anxiolytic medication for increased anxiety, despite the absence of an anxiety diagnosis for the resident. Documentation showed that Lorazepam was administered without evidence of targeted behaviors or moods warranting its use, and there was no record of consent for starting the medication. Additionally, there was no documentation of non-pharmacological interventions attempted prior to medication administration, nor was there a care plan for anxiety in place. A behavioral consultation was ordered but not completed, and the resident was not seen by behavioral health services as required. Facility policies require that psychoactive drugs only be used with a diagnosed specific condition and after alternative measures or consultation with appropriate health professionals. The facility did not follow these protocols, as evidenced by the lack of behavioral health service provision, absence of a person-centered behavioral care plan, and failure to document or attempt non-pharmacological interventions before administering a psychotropic medication.
Failure to Investigate Falls and Ensure Correct Interventions
Penalty
Summary
The facility failed to fully investigate two falls involving a resident, R804, and did not ensure that correct interventions were in place. R804 was transferred to the hospital emergency room due to low blood pressure, where it was discovered that the resident had multiple fractures in both femurs. The facility did not report these injuries to the hospital upon admission, and the incident was later addressed as an injury of unknown origin. R804's clinical record indicated a high risk of falls, with a Fall Risk Assessment score of 20. Despite this, the facility did not complete recommended follow-up radiographs after initial x-rays showed abnormal findings. The resident experienced two falls, one on 12/6/24 and another on 12/10/24, during transfers. The facility's documentation was incomplete, lacking interviews with involved CNAs and failing to identify all staff present during the incidents. Additionally, the care plan intervention to use a two-person assist for ambulation was not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition and the necessary follow-up actions. Nurse F was unaware of the need for additional x-rays, and the Director of Nursing did not believe the falls caused the fractures, despite the lack of thorough investigation. The facility's fall prevention policy was not effectively implemented, as evidenced by the inadequate tracking and intervention for R804's falls.
Plan Of Correction
1. Resident 804 no longer resides in the facility. 2. All residents that are categorized as “High Risk for Falls” based on their most recent fall assessment, or residents that have sustained a fall in the last 30 days, have the potential to be affected by the alleged deficient practice. By 3/7/2025, these identified residents will have their fall Care Plan reviewed by the Clinical IDT team to ensure appropriate fall interventions were in place and updated as needed. Any resident that has sustained a fall in the last 30 days will have their chart reviewed to ensure an IDT RCA along with a complete physical assessment of the resident has been completed and documented. 3. By 3/7/2025, the DON/designee will provide the following to all Clinical IDT members and licensed nurses: a. Fall Investigation Education with specific attention on determining and documenting the root cause of fall. b. Fall Prevention Education with specific attention on implementation of appropriate interventions. 4. The DON/designee will review 5 residents with sustained falls to ensure that a root cause analysis has been completed and documented, with immediate implementation of post-fall intervention along with a complete physical assessment of the resident. This review will occur 5 days per week for 4 weeks, then monthly thereafter for 3 months, or until substantial compliance has been maintained. Results will be presented monthly at the QAPI meeting for committee review. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 3/7/2025 and for sustained compliance thereafter.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, R58 and R22, and did not implement treatments in a timely manner or according to physician orders. Resident R58 developed a stage II pressure ulcer that progressed to a stage IV with acute osteomyelitis, while R22 developed an unstageable pressure ulcer. Observations revealed that R58 was consistently positioned on his back without appropriate off-loading devices, and there was a lack of timely medical provider oversight after the development of the pressure ulcer. R58 was admitted with severe cognitive impairment and was dependent on staff for mobility. Despite being at high risk for pressure ulcers, as indicated by a Braden Scale score, the facility did not adequately assess or document the progression of R58's wounds. There were inconsistencies in the documentation regarding the location and treatment of the pressure ulcers, and treatments were not administered as ordered. R58 was not evaluated by a medical provider after the development of the pressure ulcer until much later, contributing to the worsening of the condition. For R22, the facility failed to follow physician orders to keep the resident out of a wheelchair to prevent pressure ulcers. R22 was observed seated for extended periods, contrary to orders. The facility's documentation was inconsistent, with a pressure ulcer being identified as unstageable without prior documentation of its development. The facility's policy required weekly skin assessments and timely treatment, which were not adhered to, resulting in the development of an unstageable pressure ulcer.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to timely identify and address significant weight loss in a resident, referred to as R25, who experienced an 11.67% weight loss over six months. Observations revealed that R25 was found in bed with an uneaten breakfast tray and was not responsive to questions, although they continued to sip milk. The facility did not have staff present in the room at the time of observation. A review of R25's records showed a gradual weight loss from April to August 2024, which was not promptly identified or addressed by the facility staff. The care plans lacked updated nutritional interventions since 2023, and the facility's policy on nutrition monitoring was not followed, as R25 was not weighed weekly despite meeting the criteria for significant weight loss. The Registered Dietician (RD) C, who began working at the facility in August 2024, acknowledged the delay in identifying R25's weight loss and implementing interventions. RD C stated that they could not account for the actions of the previous dietician but took steps to address the issue once they became aware of it. The facility's policy required that any resident experiencing significant weight loss be evaluated by the Interdisciplinary Team and weighed weekly, but these measures were not in place for R25 at the time of the survey. No further explanation or documentation was provided by the facility by the end of the survey.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Raw chicken was found under running water directly inside the sink basin of a two-compartment sink, with an internal temperature of 67 degrees Fahrenheit. Dietary Staff M indicated that the chicken was initially in the walk-in cooler but was still frozen, leading to its placement in the sink for thawing. However, no explanation was provided for why the chicken remained in the sink at such a high temperature, which is inconsistent with the 2017 FDA Food Code requirements for thawing potentially hazardous food. Additionally, in the walk-in cooler, several food items were found undated, including pans of leftover enchiladas, white sauce, gravy, an opened package of bologna, and containers of Italian, ranch, and creamy Caesar dressings. Dietary Staff M confirmed that these items should have been dated upon opening. According to the 2017 FDA Food Code, ready-to-eat, potentially hazardous food held for more than 24 hours must be clearly marked with the date by which it should be consumed or discarded, which was not adhered to in this instance.
Failure to Employ Full-Time Social Worker Leads to Deficiencies
Penalty
Summary
The facility, licensed to care for 126 residents, failed to employ a full-time qualified social worker, resulting in multiple deficiencies in social services. These deficiencies included inadequate coordination of advance directives, leading to improper documentation of residents' desired code status in their clinical records. Additionally, there was a failure in discharge planning, which resulted in an unsafe discharge without necessary home health care services. The facility also did not complete Preadmission Screening and Resident Review (PASRR) assessments and failed to facilitate ancillary services such as dental and audiology, as well as assess residents for their social service needs. During an onsite annual recertification survey, it was revealed that the facility had a change in ownership on August 1, 2024, and had not employed a qualified social worker since the previous social worker's last day on March 28, 2024. The Human Resources Director and Corporate HR confirmed that various individuals were assisting with social services since the change in ownership, but none were onsite full-time. A new social worker was scheduled to start on September 4, 2024, but until then, the facility was without a full-time social worker, affecting the care of all 62 residents residing in the facility.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to consistently implement infection control standards and practices, affecting all 62 residents during the survey period. The Infection Control Nurse (ICN), who also served as the facility's Infection Preventionist, was responsible for the infection control program but was unable to provide monthly Infection Control Analysis reports for May, June, or July 2024, and there was no surveillance log for July 2024. The ICN, who had multiple roles including staff development coordinator and unit manager, devoted only four hours per shift to the infection control program and was unaware of the requirements for the analysis report. Additionally, the facility's infection mapping was inaccurate, as evidenced by discrepancies in the July 2024 antibiotic audit. A specific incident involving a resident with a tracheostomy tube and PEG tube highlighted further infection control deficiencies. During trach care, an LPN failed to perform hand hygiene between glove changes, moving from a dirty to a clean procedure, which was against the facility's infection control policy. The Director of Nursing confirmed that the LPN should have changed gloves and performed hand hygiene between cleaning secretions and applying clean gauze. This incident, along with the overall lack of effective infection control practices, demonstrates significant lapses in the facility's infection prevention and control program.
Deficiencies in Fall Prevention, Care Assistance, and Resident Supervision
Penalty
Summary
The facility failed to identify the root cause of multiple falls and implement effective interventions to prevent falls for a resident, resulting in multiple falls with injuries. The resident, who had dementia and severely impaired cognition, was observed in various positions and settings without consistent interventions to prevent falls. Despite being identified as a fall risk, the facility did not conduct thorough investigations or implement new interventions after each fall. The facility's documentation was inconsistent, with missing incident reports and follow-up assessments for several falls. Another deficiency involved the facility's failure to provide care according to a resident's assessed level of assistance. A resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and PEG tube, required assistance from two staff members for bed mobility. However, a CNA was observed providing care alone, contrary to the resident's care plan. The CNA reported not having access to care plans and deciding on the level of assistance independently, which was not in line with the facility's procedures. The facility also failed to ensure appropriate supervision to prevent resident-to-resident altercations. A resident with a history of aggressive behaviors and dementia was involved in multiple incidents of aggression towards other residents. Despite being identified as needing supervision, there were instances where the resident was left unsupervised, leading to altercations. The facility's lack of supervision and failure to implement effective interventions contributed to these incidents.
Deficiencies in Social Services Provision
Penalty
Summary
The facility failed to provide medically related social services to eight residents, as identified during an onsite annual recertification survey. The deficiencies included a lack of effective coordination of advance directives, resulting in improper documentation of residents' desired code status in their clinical records. Additionally, there was inadequate discharge planning, leading to an unsafe discharge without necessary home health care services. The facility also failed to complete PASARR assessments and did not facilitate necessary ancillary services such as dental and audiology, nor did they assess residents for their social service needs. For Resident #59, the medical record review revealed that despite being admitted with diagnoses of Bipolar disorder and Dementia, there were no completed social service assessments to identify any medical or psychosocial needs. The Director of Nursing confirmed the absence of such assessments. Similarly, Resident #60, who had diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction, expressed a desire to speak with a social worker for assistance with discharge planning and applying for Social Security. However, no social service assessments were completed for this resident either. The facility experienced a change in ownership, and since the previous social worker's resignation, there was no qualified social worker employed full-time. Various individuals were assisting with social services, but not on a full-time or onsite basis. This lack of consistent social service support contributed to the deficiencies observed during the survey, as the facility failed to meet the social service needs of its residents, impacting their overall quality of life.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain and implement an effective antibiotic stewardship program, affecting multiple residents who were prescribed and administered antibiotics. The deficiency was identified through a review of infection surveillance logs from April, May, and June 2024, which revealed a lack of documentation on whether infections met the criteria for an infection. For instance, a resident was prescribed Cephalexin for swelling and pain from an IV site, but the antibiotic was discontinued after a hospital admission revealed no infection. Another resident was readmitted from the hospital with pneumonia and started on Doxycycline, yet there was no documentation reviewing the appropriateness of the antibiotic. Further deficiencies were noted in June and July 2024. A resident was administered Levaquin for an unspecified infection without documentation of the infection type or criteria. Another resident was prescribed Amoxicillin-Pot Clavulanate for a UTI, but there was no documentation of symptoms meeting UTI criteria or the appropriateness of the antibiotic. In July, an audit revealed a resident on Macrobid for a UTI without a completed surveillance log or documentation of infection criteria. The Infection Control Nurse acknowledged the lack of documentation and stated that a new program would address these issues, but concerns about infection criteria and antibiotic appropriateness remained.
Failure to Honor Advanced Directives for Two Residents
Penalty
Summary
The facility failed to ensure effective communication regarding advanced directives for two residents, R48 and R315. For R48, there was a discrepancy between the documented Do Not Resuscitate (DNR) order and the information available to the nursing staff. R48's medical record indicated a DNR status, signed by the resident's power of attorney and physician, yet Nurse D was under the impression that R48 was a full code, meaning they would perform full resuscitation if necessary. This inconsistency was noted during a conversation with the Administrator, who acknowledged the importance of aligning the profile page with the documented wishes to honor the resident's directives. For R315, there was a similar issue with the communication of code status. Although R315 expressed a desire to be a DNR and believed they had signed the necessary documents, the facility's records still listed them as a full code. The hospice nurse confirmed R315's DNR status, but the Director of Nursing (DON) was unaware of this and stated that the resident was a full code according to the hospice company. Upon further investigation, a signed DNR document for R315 was found in the hospice communication binder, indicating a lack of proper communication and documentation within the facility. These deficiencies highlight the facility's failure to maintain accurate and consistent records of residents' advanced directives, leading to potential miscommunication among staff and the risk of not honoring residents' end-of-life wishes. The discrepancies in the documentation and communication processes for both residents underscore the need for improved coordination and verification of advanced directives within the facility.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R11, to the State Agency. R11, who had diagnoses including psychotic disorder with delusions, anxiety, and dementia, was involved in an incident where they poured coffee on another resident, R37, and grabbed them, resulting in an abrasion to R37's cheek and discoloration to their lower right arm. Despite the incident being documented in the nurses' notes and reported to the family, unit nurse, administrator, and medical doctor, the facility did not report the allegation to the State Agency as required by their policy. The facility's policy mandates that all allegations of abuse be reported to the Administrator immediately and subsequently to the appropriate State Agencies. However, during a review of the facility's reported incidents in the State Agency's electronic system, it was found that the incident involving R11 and R37 was not reported. The Administrator confirmed the lack of reporting and documentation to the State Agency, acknowledging that the incident should have been reported and investigated according to the facility's abuse and neglect policy.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and injuries of unknown origin for two residents, R11 and R25. For R11, the medical record revealed multiple incidents where the resident was involved in altercations with other residents, including an incident where R11 poured coffee on another resident and grabbed them, resulting in injuries. Despite these incidents being documented in the progress notes, the facility did not report them to the State Agency or conduct any investigations. The new Administrator, who started in August 2024, confirmed that these incidents were not reported or investigated. For R25, the resident was found with a bruised and swollen left eye and a cut on the side of the left eye, which required medical attention. The incident was documented in the facility's incident report, but there was no evidence of an investigation or reporting to the State Agency. The current Administrator, who was not in the position at the time of the incident, was unable to provide hospital records or evidence of an investigation. The previous Administrator also did not recall being informed of the incident and stated that they would have initiated an investigation if they had known. The facility's policy on abuse and neglect requires immediate investigation of all allegations and incidents, but this was not followed in the cases of R11 and R25. The lack of investigation and reporting for these incidents represents a failure to comply with the facility's own policies and regulatory requirements, resulting in deficiencies in handling allegations of abuse and injuries of unknown origin.
Failure to Complete Level II PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a Level II PASARR screening was completed for a resident who remained in the facility beyond the 30-day exemption period. The resident, who was admitted with diagnoses including epilepsy and dementia, was initially given a hospital exemption discharge with a Level I screening indicating mental illness and recent use of antipsychotic or antidepressant medications. Despite the resident's extended stay, the facility did not submit a subsequent Level II screening as required. During an interview, the facility's Administrator, who was temporarily fulfilling the role of the Social Worker, acknowledged the oversight. The Administrator, recently hired following a change in facility ownership, admitted that their focus had been on addressing guardianship issues, which led to the neglect of the PASARR screening requirement. The Administrator confirmed that the resident should have undergone another screening after the initial 30-day period.
Failure to Implement Language Barrier Interventions
Penalty
Summary
The facility failed to implement adequate care plan interventions for a resident with a language barrier, specifically for a resident who only speaks Arabic. During an observation, the resident was seen in a wheelchair, and an attempt to interview them was unsuccessful due to the language barrier. A Certified Nursing Assistant (CNA) confirmed that the resident only speaks Arabic and stated that communication was typically facilitated through an activities aide who speaks Arabic or the resident's family. However, on the day of the observation, the activities aide was off duty, leaving the CNA without a means to communicate effectively with the resident. The resident's care plan, created on 8/30/23, included interventions such as providing a translator as needed, with the translator being the family or activities aide. However, the care plan did not include the use of an interpreter hotline, which the facility had available. The Administrator acknowledged the existence of the interpreter hotline but noted that it was not included in the care plan and that the CNA was unaware of it. Additionally, the facility had a flip guide in Arabic, which was also not utilized. This oversight led to a deficiency in the care provided to the resident, as the staff was not equipped with the necessary resources to communicate effectively with the resident.
Improper Discharge of Resident with Tracheostomy and PEG Tube
Penalty
Summary
The facility failed to facilitate a safe and coordinated discharge for a resident with a tracheostomy and PEG tube. The complaint alleged that the resident was improperly discharged into the community without home health care or adequate nutrition. During an interview, the Director of Nursing (DON) explained that discharge planning typically involves the interdisciplinary team (IDT) to discuss the resident's needs and necessary community resources. However, the facility lacked a social worker to effectively coordinate with outside agencies. It was noted that there was no discharge progress note or home health care agency ordered in the resident's medical record. The home health care agency identified by the DON confirmed that the resident was not on their caseload due to insurance coverage issues, which had been communicated to the facility.
Deficiencies in Follow-Up Care and Medication Transcription
Penalty
Summary
The facility failed to coordinate follow-up appointments for two residents, leading to a deficiency in providing appropriate treatment and care according to orders and residents' preferences and goals. One resident, who had been hospitalized for breathing issues, was supposed to have follow-up appointments with cardiology and pulmonology as per discharge instructions. However, the facility did not assist in making these appointments, and there was no documentation of a medical justification for not following through with the cardiologist and pulmonologist. The resident continued to experience shortness of breath and discomfort, indicating a lack of proper follow-up care. Another resident, who had a tracheostomy tube and PEG tube, was discharged from the hospital with instructions to follow up with a gastrointestinal specialist within 1 to 2 weeks. The facility failed to make this appointment, as confirmed by the Director of Nursing. This oversight in coordinating necessary follow-up care for residents with complex medical needs highlights a significant deficiency in the facility's care coordination processes. Additionally, the facility failed to properly transcribe hospital discharge orders for a resident, leading to medication discrepancies. The resident was placed in contact isolation based on hospital diagnoses, but upon review, it was found that the resident had completed their antibiotics and no longer required isolation. Furthermore, there were errors in transcribing medication orders from the hospital discharge paperwork, including incorrect indications for use and missing orders for prescribed medications. This lack of accurate transcription and verification of medication orders upon admission contributed to the deficiency in care provided to the resident.
Failure to Follow Up on Audiology Recommendations
Penalty
Summary
The facility failed to follow up on audiology recommendations and services for a resident who was hard of hearing. The resident, who was admitted in 2016 with diagnoses including major depressive disorder and Parkinson's disease, had a documented intact cognition with a BIMS score of 14. Despite multiple physician notes indicating the resident's hearing difficulties, there was no record of an audiology assessment or examination in the medical record. An audiology consult from February 2024 noted moderate to severe sensorineural hearing loss in both ears and recommended medical clearance for hearing aids and wax removal, but these recommendations were not followed up. The resident expressed difficulty in obtaining hearing aids and was not directed to the appropriate resources by the facility staff. The Administrator, who was also assisting with social work duties, was unaware of any audiology appointments for the resident until prompted by the surveyor. The Director of Nursing, recently hired, acknowledged the lack of follow-up and added the resident to the audiology list. However, no further documentation or explanation was provided before the end of the survey, indicating a deficiency in the facility's process for ensuring timely follow-up on audiology services.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 949 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rochester Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bellbrook | 1.2 mi | ★★★★★ | 6 | 0 |
| Wellbridge Of Rochester Hills | 1.9 mi | ★★★★★ | 13 | 0 |
| Optalis Health And Rehabilitation Of Troy | 4.1 mi | ★★★★★ | 16 | 0 |
| Pomeroy Living Rochester Skilled Rehabilitation | 4.7 mi | ★★★★★ | 13 | 0 |
| The Villa At Silverbell Estates | 6.2 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.