Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Timbers Of Cass County during CMS and state inspections, most recent first.
Resident-to-resident sexual abuse occurred when a cognitively intact resident with a history of sexual boundary violations entered another resident’s room and engaged in unwanted sexual contact. The affected resident had PTSD, depression, reduced mobility, and moderately impaired cognition, and he later told staff he did not want the other resident in his room, felt unsafe, and wanted to leave. Records and staff interviews showed repeated prior attempts by the female resident to enter his room, prior inappropriate sexual behaviors, no sexual behavior care plan, and monitoring that staff said was not enough to keep track of her movements.
Surveyors found that the facility failed to provide required 30‑day written notice, appeal rights information, and adequate discharge planning for two residents whose discharges were initiated by the facility. One cognitively intact resident with diabetes, a Foley catheter, bowel incontinence, and malnutrition risk was pressured to leave due to an unpaid balance and discharged to a hotel without food resources, catheter‑care training, or a glucometer, despite APS having deemed his home uninhabitable. Another resident with severe cognitive impairment, a colostomy, and reduced mobility was told he had to leave on short notice, and his DPOA reported being warned he would be put outside if not picked up; he was discharged home alone without documented colostomy‑care training or a home safety evaluation for his walker. The NHA confirmed that no written discharge notices or appeal documents were provided and that required involuntary transfer/discharge forms were not submitted, contrary to facility policy requiring written notice at least 30 days before a facility‑initiated discharge.
Surveyors found multiple food items in the kitchen and pantry without proper date marking, including open hot dogs, thickened juice, and soup, along with nutritional supplements that were not handled in line with thawed-use guidance. They also observed heavy debris on a stand-up mixer and dried splatter inside a microwave. In addition, shredded pork loin from lunch was placed in a zip lock bag and cooled without a temperature check, and it was still 90F-95F when observed.
Water Management Plan Not Active or Fully Documented: The facility failed to maintain an active and ongoing WMP to reduce the risk of legionella and other OPPP. The Maintenance Supervisor reported weekly flushing and monthly water strip testing, but was unsure of control limits for water quality measures. Surveyors observed two uncapped water lines behind the water softener system, and monthly logs showed unclear acceptable ranges, missing entries, and two months with 0 ppm free chlorine residual without documented corrective action. The WMP also lacked documentation of an active Water Management Team or annual review.
A facility failed to maintain a clean, comfortable, and homelike environment when a resident’s loud oxygen concentrator disturbed two roommates and multiple residents were observed with blood-stained, stained, or hole-ridden bed linens. Residents reported the noise interfered with sleep and TV viewing, and one resident said her sheets and pillowcase were filthy and had not been changed for weeks. Staff observations confirmed the noisy concentrator and the unclean or damaged linens.
A resident with an order for regular showers reported not receiving a shower since admission, and two other residents also had repeated shower refusals or missing documentation without supporting progress notes. One resident with stroke, contractures, paralysis, and diabetes was observed with long, jagged fingernails and black debris under and in the nails, despite staff stating nail checks and cleaning should occur during routine skin assessments.
Failure to Provide Resident-Centered Activities: The facility did not provide individualized activity programming to meet the leisure needs of three residents with dementia, stroke, aphasia, and depression. Observations showed residents sitting with eyes closed or alone in rooms, with little meaningful participation in scheduled activities. One resident reported boredom and concern that the lack of activity could worsen depression, while staff acknowledged limited evaluation of leisure needs and inconsistent 1:1 activity support.
A resident with rheumatoid arthritis, chronic pain, weakness, heart failure, and prior cellulitis reported painful feet and blue discoloration under her toenails, but staff did not promptly evaluate or communicate the concern for provider review. An LPN suspected fungus and thick, curved toenails, yet the resident was not placed on the MD/NP list and was not seen when the provider rounded; the resident continued to report foot pain while waiting for relief.
Failure to implement ROM and contracture care for two residents. One resident with stroke-related weakness, contracture, and dependence for all cares did not consistently receive the ordered hand roll, arm elevation, or wedge positioning, and the care plan did not include the OT-directed interventions. Another resident with stroke, paralysis, and multiple contractures was observed without the ordered hand roll in the left hand despite room signage and OT guidance for daily hand roll use, PROM, and skin checks.
Failure to Address Ongoing Diarrhea and Bowel Incontinence: A resident who was admitted as continent of bowel developed frequent loose, liquid stools and bowel incontinence, but CNA concerns were not documented as being addressed for an extended period. The record showed bowel movement tracking, yet there were no provider contacts, assessments, or treatment orders in response to the ongoing diarrhea until later, despite staff reporting the resident had little sensation of stool incontinence and needed repeated toileting assistance.
A resident with COPD and moderate cognitive impairment had a half-length bedrail in place without a documented entrapment risk assessment, physician order, care plan, or informed consent. Staff reported the bedrail had been used for at least a month, and observations showed the resident asleep with her feet protruding through the rail and later sitting in a recliner while the rail remained raised and locked.
A resident with CHF, stroke, valve insufficiency, irregular heartbeat, and cardiomyopathy had an order for digoxin 125 mcg daily for AFIB, with instructions to hold if the apical pulse was <60 bpm. The MAR showed digoxin was administered multiple times when the recorded pulse was below the ordered parameter, and one dose was given with no pulse documented. The DON stated the pulse should be checked before giving digoxin and held if below 60, and the pharmacist noted digoxin levels should be monitored every 6 months.
The facility failed to employ a qualified Activity Director, as required by federal and state regulations, and did not ensure that activity assessments were conducted or that individualized activity information was shared with staff. As a result, a resident with a history of stroke and depression, who was cognitively intact, reported a significant decline in available activities, increased boredom, and loss of meaningful engagement, with similar concerns observed among other residents.
The facility did not provide individualized activities for several residents, including those with cognitive and physical impairments, resulting in a lack of engagement and unmet preferences for music, socialization, and meaningful activities. Staff and family interviews, as well as direct observations, revealed that residents were left unengaged, with limited or no access to preferred activities, and that activity programming was not tailored or consistently offered, especially for those unable to participate in group events.
A resident who was cognitively intact was documented as attending several activities that she did not actually participate in. Staff interviews revealed that activity attendance was sometimes recorded at the end of the day, leading to discrepancies and inaccurate records of resident participation.
A resident with dementia who developed symptoms and tested positive for influenza was not placed under appropriate transmission-based precautions. Staff, including housekeeping and the Activities Director, entered the resident's room wearing only KN95 masks, did not use additional PPE, and failed to perform hand hygiene upon exit. Isolation signage and a PPE cart were not present, and the resident was invited to participate in group activities despite the confirmed infection.
The facility failed to manage food storage and cleanliness, with unlabeled and undated food items found in coolers and nourishment rooms, and inadequate cleaning of kitchen equipment. Dietary staff did not consistently follow labeling and cleaning protocols, leading to potential health risks for residents. Additional issues included improper storage of wet pans, a soiled stock pot, and the use of a stained bowl for serving food.
The facility failed to honor the mealtime preferences of residents, including one with vascular dementia and major depressive disorder, by not allowing them to eat in the communal dining room due to staffing concerns. Despite being fully staffed, the facility maintained dining restrictions, leading to resident frustration and discontent, contradicting their policy on self-determination.
A resident was not informed in a timely manner about the exhaustion of their Medicare Part A benefits, leading to unexpected financial liability. The resident, who was cognitively intact, was distressed upon learning of a $10,000 bill. The facility's admissions and billing teams failed to communicate the resident's limited coverage, resulting in a missed notification.
The facility failed to develop comprehensive care plans for two residents, one with a nephrostomy bag and another with diabetes and medication needs. The responsible MDS RN confirmed these oversights, leading to potential unmet needs.
A resident experienced dysuria for seven days due to a delay in obtaining a urinalysis (UA) at the facility. The resident reported symptoms to an RN, who documented the complaint, and an NP gave a verbal order for a UA, which was not placed until several days later. The NP confirmed the delay in care, acknowledging that the UA should have been completed the same day the resident reported pain.
A resident with vascular dementia and severe cognitive impairments did not receive individualized activities based on their preferences and needs. Observations showed the resident often sat alone in the day room without engagement in preferred activities like music or pet interactions. Staff interviews revealed limited room visits and a lack of sensory stimulation activities, highlighting a gap in implementing individualized activity plans.
A resident with severe cognitive impairment and difficulty swallowing experienced significant weight loss due to the facility's failure to ensure timely and consistent weight monitoring. Despite being on a Mechanical Soft diet, the resident's weight dropped significantly, and the necessary reweights were not obtained. The RD and DS did not follow up on the weight changes, and the DON was not informed in a timely manner, leading to a decline in the resident's nutritional status.
A facility failed to document education provided to a resident or their representative about the benefits and risks of prescribed psychotropic medications. The resident, who was severely cognitively impaired, had consent for an antipsychotic but lacked documentation for antidepressants. The Social Services Director was unsure if education on antidepressants was documented, and no evidence was provided before the survey exit.
The facility failed to honor the food preferences of two residents, leading to complaints and potential nutritional decline. A resident with diabetes and anxiety did not consistently receive her ordered meals, and another resident with severe cognitive impairment often lacked her preferred drink, chocolate milk, due to supply issues. These deficiencies were noted in Resident Council Minutes, indicating ongoing concerns.
A facility failed to maintain proper infection control standards for a resident's tube feeding equipment, resulting in potential pathogen harborage. The equipment, including the feeding pole and pump, had dried splatters of the feeding formula. An LPN confirmed the need for immediate cleaning to prevent infection but was unaware of who was responsible for this task, highlighting a lapse in infection control practices.
The facility failed to ensure that residents were screened for eligibility and received Pneumococcal vaccinations if eligible, affecting three residents. One resident had not been screened or offered an updated vaccine since their last vaccination in 2018, despite consent being given. Another resident had not received a vaccine according to records, and a third resident was due for an update since their last vaccination in 2015. The DON acknowledged the oversight in monitoring and administering vaccines, contrary to the facility's policy.
The facility failed to offer COVID-19 vaccinations to two residents, increasing the risk of infection. Both residents, admitted with weakness, had not been screened or offered vaccines since their last immunizations. The DON admitted to not screening or offering vaccines to eligible residents, contrary to the facility's policy.
The facility failed to maintain clean conditions for two residents, resulting in deficiencies. A resident with pulmonary hypertension and diabetes had a soiled privacy curtain and dusty blinds, while another with vascular dementia had a visibly soiled wheelchair. Observations confirmed these issues over multiple days, and interviews revealed that cleaning protocols were not followed.
A resident with a history of exit-seeking behavior eloped from the facility due to inadequate supervision and ineffective alarm systems. Despite being identified as an elopement risk, the resident's care plan lacked specific interventions, and the facility's alarm system was insufficient, as it could not be heard from the resident units. The resident was able to leave the premises unnoticed and was later found outside, highlighting significant gaps in the facility's elopement prevention measures.
A facility failed to report a resident-to-resident abuse incident involving two cognitively impaired residents in a timely manner. The incident, which resulted in a skin tear for one resident, was not reported to the State Agency within the required two-hour timeframe due to technical difficulties experienced by the NHA. Despite the facility's policy allowing multiple reporters, the NHA was solely responsible for the submission, leading to the delay.
A resident with visual impairments was transported in a wheelchair without footrests by staff, despite the requirement for footrests when being pushed. Staff acknowledged the need for footrests but continued to transport the resident without them, citing the resident's preference.
The facility failed to securely store medications in three treatment carts, leaving them accessible to anyone on the unit. Observations revealed that [NAME] Pain Gel and other topical treatments were left unsecured on carts behind nurse's stations. Interviews with LPNs confirmed that these medications require a physician's order and should be applied by licensed nurses. The DON acknowledged the oversight, and it was noted that the medication cart at the Evergreen nurse's station was unlocked.
The facility failed to ensure proper hand hygiene during medication administration for three residents, leading to potential infection risks. Observations showed that an LPN did not perform hand hygiene while administering medications, using Sani-Cloths instead of proper hand sanitizers. Another LPN also failed to sanitize hands after administering an insulin injection. Interviews confirmed that hand hygiene should be performed between residents and before and after glove use, as per facility policy.
Resident-to-Resident Sexual Abuse Not Prevented
Penalty
Summary
The facility failed to protect a resident from resident-to-resident sexual abuse when a cognitively intact resident with a documented pattern of sexual boundary violations entered another resident’s room and engaged in unwanted sexual contact. The affected resident had diagnoses including bipolar disorder, muscle weakness, reduced mobility, depression, and PTSD, and his BIMS score was 9 out of 15, indicating moderately impaired cognition. He had a trauma history noted in his care plan and later told staff he did not want the other resident in his room, did not feel safe, and wanted to leave the facility after the incident. The record shows that the other resident had a history of inappropriate sexual behaviors and repeatedly attempted to enter the male resident’s room despite staff and ombudsman discussions about respecting his wishes. Her chart contained behavior notes describing repeated attempts to go to male residents’ rooms, argumentative behavior when redirected, and prior incidents involving exposure and unwanted contact. However, her care plan did not include a behavioral plan for sexual behaviors or interventions for staff to use when the behavior was unwelcome. Staff interviews confirmed that she moved throughout the facility, was difficult to monitor, and had previously been on 1:1 observation before being changed to 15-minute checks. During the incident, staff observed the female resident touching the male resident while he was in bed, with one nurse reporting that the resident mouthed for help and that the female resident’s hands were underneath his pants. The male resident later described that she pulled back his covers, put her hand under his pants, and touched his genitals after giving him gummies, which he said made him feel unwell and lethargic the next day. He also reported that she had previously shown him her privates and tried to get him to touch her. Staff interviews reflected that the male resident became more secluded, avoided meals and activities to avoid seeing her, and repeatedly asked staff to keep her away from him. The facility’s records and interviews also showed that the resident’s concerns about unwanted sexual contact had been ongoing for months before the incident.
Failure to Provide 30‑Day Notice and Safe Discharge Planning for Two Facility‑Initiated Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide required 30‑day written notice of facility‑initiated discharge, failure to inform residents of their right to appeal, and failure to implement appropriate discharge planning and preparation for two residents. For the first resident, an older male with traumatic ischemia of muscle, diabetes mellitus, neuromuscular bladder dysfunction with an indwelling Foley catheter, bowel incontinence, malnutrition risk, and fluctuating ADL abilities, the MDS showed he was cognitively intact. His care plan included management of his Foley catheter, diabetes, incontinence, and a planned discharge with needed equipment and supplies. Despite this, he reported being told by the NHA that he had to leave because he had met all his goals, and he was discharged to a hotel one day after that meeting without being informed of his right to appeal the discharge and without a glucometer for blood sugar monitoring. Staff interviews indicated that the first resident sometimes needed help with bowel incontinence and catheter management, and that he expressed concern about having no food when leaving, wishing he had oatmeal and milk to take with him. The former social services staff reported that the resident’s home had been deemed unsafe and uninhabitable by APS, that the resident was hesitant to leave because he knew repairs would take months, and that the facility pushed for discharge due to his outstanding balance and failure to pay. The APS caseworker described the home as having severe clutter, tripping hazards, no running water, utility issues, and a kicked‑in front door, and stated the resident confirmed he could not return there until it was cleaned and repaired. The resident’s DPOA reported being told by the NHA that the resident could not afford to stay, was not informed of any option to remain or appeal, and later learned he had been discharged without her knowledge and without a glucometer. An emergency department note documented that the resident reported being moved from a SNF to a motel, felt unable to care for himself, had no way to check his glucose at home until prescribed a glucometer there, and that EMS had been called by home health because he was covered in feces. For the second resident, an older male with malignant neoplasm of the colon, alcohol dependence with delirium, and intestinal perforation, the MDS showed severe cognitive impairment (BIMS 5), a colostomy, and independence only for wiping the ostomy opening. His care plan identified impaired cognition with a goal of making safe decisions with staff supervision. Social services documentation showed he was notified one day prior that he would discharge home the next day. His DPOA reported telling the NHA there was no safe place for him to go and no one to care for him, and that the NHA focused on not wanting him to build up medical debt. She stated she ultimately picked him up because an unknown staff member told her that if he was not picked up by midnight, he would be escorted outside and the door locked behind him. She reported that he initially did not want to discharge but agreed after repeated staff inquiries about when his ride was coming, that he had never previously cared for his colostomy, had poor short‑term memory and reduced mobility, and that his walker did not fit through his bathroom door and he had fallen several times at home. Therapy and nursing leadership interviews confirmed that the second resident should have received colostomy care training and that no documentation of such training existed. The COTA stated that a home evaluation to determine safe use of the walker in the home was not completed and that, due to his cognition, he would have needed repetitive training and displayed impulsivity with unfamiliar tasks. The DON reported the facility could not provide documentation of colostomy training for this resident or catheter and blood glucose training and provision of a glucometer for the first resident. The NHA acknowledged that the DPOA for the second resident did not want him discharged on the identified date but ultimately took him home, asserted that all discharges were voluntary, and confirmed that the facility did not provide either resident with written notice of discharge or information on the right to appeal. The governing body confirmed that the required state involuntary transfer/discharge and appeal forms were not submitted for either resident, and the facility’s own policy required written notice in a language the resident or representative could understand, given at least 30 days before a proposed facility‑initiated discharge.
Food items lacked proper date marking and equipment was not kept clean
Penalty
Summary
The facility failed to maintain best practices in the food service area, with surveyors finding multiple food items in the kitchen and pantry that were not properly date marked or were being held beyond the required time limits. On 1/6/26, three boxes of nutritional supplements were observed in the walk-in cooler with facility dates that did not match the product guidance for thawed use, and an open package of hot dogs was also found with no discard date. In the Birch Pantry, three open containers of thickened juice were found in the refrigeration unit without discard dates, and an open container of soup was dated 12/27/25. Dietary staff stated that items were dated when brought down, while nursing should date them when opened. Surveyors also observed sanitation concerns in the kitchen equipment. The stand-up mixer was covered with a clear plastic bag, and when the bag was removed, heavy accumulation of stuck-on white debris was found on the back shield of the unit. The inside ceiling of the kitchen microwave also had an increased accumulation of dried splatter debris. These observations were made during the same survey visit and were documented as not meeting food-contact and nonfood-contact surface cleanliness standards. Later that day, surveyors found a sealed zip lock bag of shredded pork loin leftover from lunch service in the walk-in cooler. The kitchen supervisor stated the pork had been placed in the bag and put into the cooler about 30 minutes after lunch ended, but no temperature had been taken to determine where it was in the cooling process. At the time of observation, the pork measured 90F-95F. The report cited FDA Food Code requirements for cooling cooked time/temperature control for safety food within specified time and temperature limits.
Water Management Plan Not Active or Fully Documented
Penalty
Summary
The facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During an interview with the Maintenance Supervisor, the facility’s water fixtures were described as being flushed weekly to remove stagnant water, and the supervisor stated he had a monthly water strip test for free chlorine and other factors, but he was unsure of the control limits for maintaining those water quality measures. Observation of the water softener salt room found two uncapped water lines behind the large water softener system, and the supervisor stated he was not aware of those hidden fixtures and would add them to his flushing list. Record review of monthly logs from April through November showed seven water quality parameters listed on each monthly chart, but there was no clear distinction of acceptable ranges representing control limits. The logs also showed multiple missing entries, including two of eight months with 0 parts per million free chlorine residual, with no corrective action noted. Review of the facility’s Water Management Plan found that an interdisciplinary Water Management Team should meet at least quarterly and review the plan at least annually, but the plan contained meeting minute templates without completed forms or documentation of an active Water Management Team or annual review.
Noisy Oxygen Equipment and Soiled, Damaged Linens
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four residents. One cognitively intact resident reported that his roommate’s oxygen concentrator was very loud and could be heard in the hallway with the room door closed. The resident stated the noise interfered with watching television and sleeping, and he repeatedly asked why a quieter concentrator had not been obtained. The roommate, who was also cognitively intact and receiving continuous oxygen therapy for COPD and acute respiratory failure with hypoxia, confirmed the concentrator was noisy and bothered both residents. The same room also contained unclean bedding. The roommate’s bed linens had blood stains and holes in the fitted sheet, and blood was noted on the flat sheet and pillow in his wheelchair. He stated he had a bloody nose from blood thinner medication and that his linens had not been changed when his bed was made for shower day. An LPN observed the blood and holes and stated she would expect the linens to be changed when blood was first noted and when the holes were observed. Another resident, who was cognitively intact and dependent for all cares due to prior intracranial hemorrhage, contracture, weakness, and lack of coordination, was observed with multiple holes in her fitted bed sheet near her head on repeated observations. Staff interviews indicated worn or stained linens should not be left in resident use, and an RN and OT both stated linens with holes or blood should be removed and changed. A fourth resident, who had dementia and major depressive disorder but was assessed as cognitively intact, was observed with heavily stained bed linens and a stained pillowcase. The fitted sheet had large reddish discoloration across its surface, and the pillowcase had a large yellow and tan circular stain. The resident stated she was very displeased, felt the linens were filthy, and believed they had not been changed for weeks. On a later observation, the stains remained. The resident and CNA both stated linens should be changed on shower days and when soiled, but the resident reported her linens remained dirty and she should not have to ask staff to change them.
Inconsistent bathing and nail care documentation and provision
Penalty
Summary
The facility failed to ensure residents were consistently provided showers/bathing and, for one resident, nail care. For Resident #31, the record showed an order for showers on Mondays and Wednesdays, but the chart contained only a few shower review documents, including refusals and one entry signed by staff without a nurse signature. There were no additional shower sheets, no progress notes supporting refusals, and no care plan addressing refusal of showers. In an interview, the resident stated she had not had a shower since admission. For Resident #36, the record showed diagnoses including rheumatoid arthritis, cellulitis of both lower limbs, chronic pain, weakness, and need for assistance with personal care. The care plan addressed altered ADLs and directed staff to allow the resident time to complete ADLs and provide assistance as needed. The resident stated she wanted showers as expected and reported she was not receiving them as she should, saying she got one shower a week but needed two. Although the order called for showers every Tuesday and Friday, the record contained only several shower review documents marked refused or lacking nurse signatures, with no other documented showers or refusals and no progress notes supporting the refusals. For Resident #41, who had diagnoses including stroke, multiple contractures, paralysis affecting the left side, diabetes, bed confinement, abnormal posture, and need for assistance with personal care, observations showed long, jagged fingernails with black debris under and in the nails. The record contained multiple shower review documents marked refused or lacking nurse signatures, but no other shower sheets and no progress notes supporting the refusals. Staff interviews indicated that refusals should be reoffered, documented on the shower sheet, signed by the nurse, and entered in the behavior log and progress notes, yet the record did not contain those supporting entries. RN staff also stated nails for residents with diabetes should be checked during weekly skin assessments and cleaned if dirty, but the resident was observed with untrimmed, dirty nails.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities designed to support the leisure needs of three residents who were reviewed for activities. The deficiency was identified through observation, interview, and record review and involved residents with significant cognitive, communication, and mood-related diagnoses, including dementia, aphasia, stroke, and major depressive disorder. The report states that the lack of appropriate activity support resulted in feelings of boredom and the potential for worsening symptoms of depression, as well as a decline in physical and cognitive well-being. Resident #70 had diagnoses including dementia, cognitive communication deficit, aphasia, and depression. Her care plan identified preferences for music, television, magazines, animals, and going outside, and her MDS indicated severe cognitive impairment with a BIMS score of 2. Although records noted she liked independent activities and attended activities of choice, multiple observations showed her seated at or near the nurse’s station with her eyes closed, head down, or not interacting with others. She was also observed in her room talking to stuffed animals while lying in bed. During the survey, she was not observed participating in any scheduled activities. Resident #60 had diagnoses including stroke, speech disturbance, and dementia, and his records showed severe cognitive impairment with a BIMS score of 0. His care plan identified preferences for country music, television, being outdoors, and people watching, with interventions including calendars, reminders, escort, encouragement, and social or outdoor activities. However, observations repeatedly showed him seated in his wheelchair with his eyes closed, head down, or leaning forward, including while positioned at the nurse’s station and in his room. The activity director also reported concerns about residents being placed at the nurse’s station listening to music and stated the music was not age appropriate for residents in their 70s, 80s, and 90s. Resident #75 had diagnoses including multiple strokes and major depressive disorder, and his MDS showed a BIMS score of 15 with little interest or pleasure in doing things and feeling down, depressed, or hopeless nearly every day during the assessment period. His care plan addressed lack of initiative and isolation, but during interview he stated he was not interested in the activities offered, frequently felt bored, and worried that the lack of activity could worsen his depression. He also reported needing support to occupy his free time. Activity staff reported he did not attend group activities and spent most of his time alone in his room, and the activity director stated the facility had not been able to evaluate his leisure needs and had no additional documentation of his participation beyond one recorded activity.
Delayed Foot Care and Evaluation for Toenail and Foot Pain
Penalty
Summary
Provide appropriate foot care was not ensured for a female resident with rheumatoid arthritis, chronic pain, weakness, heart failure, and a history of cellulitis of both lower limbs. The resident reported that her feet hurt and that she had something blue under her toenails, and she wanted to soak her feet. She also stated that a podiatrist had previously cut her toenails because they were crooked, but he did not address the blue discoloration concern. The resident later reported that her feet still hurt and that she was waiting for relief after telling the nurse about the pain. Staff interviews showed the concern was not promptly evaluated or communicated for provider review. An LPN stated she thought the resident may have fungus under her toenails because the toenails were severely thickened and curved, and she planned to contact the doctor, but the resident was not on the doctor book when the MD/NP rounded and was not seen. The LPN also reported the doctor had not examined the resident at the time she was referenced as having been seen, and nothing had been prescribed. The resident’s ordered Voltaren for her fingers and toes was documented as given, but the resident was still waiting for the cream to be applied when the MDS nurse later observed it being administered.
Failure to Implement ROM and Contracture Care
Penalty
Summary
The facility failed to implement positioning and contracture-related interventions for two residents who had limited range of motion and mobility needs. One resident had diagnoses including nontraumatic intracranial hemorrhage affecting the left non-dominant side, lack of coordination, contracture of muscle, and weakness, and was documented as dependent for all cares. The other resident had diagnoses including stroke, muscle weakness, contracture of multiple sites including the left elbow and left hand, bed confinement, paralysis affecting the left dominant side, diabetes, and abnormal posture. For the first resident, handwritten instructions posted in the room directed staff to place a rolled washcloth in the left hand for contracture management and a pillow under the left forearm and hand for edema management, but observations showed these devices were not in place. The resident stated the washcloth would fall out, staff had said they would get a brace or something that would stay in the hand, and no wedges or pillows were under the left arm, hand, or side. A nurse observed the resident without the washcloth or pillow/wedge and stated refusals should be documented and the unit manager updates the care plan when residents do not want something done or refuse. Occupational therapy stated the washcloth and pillow/wedge were to be done by caregivers, and if a resident refuses, it should be documented in nursing notes or behavior logs. Record review for the first resident showed occupational therapy notes identifying poor CNA follow-up with hand rolls and daily positioning, but there was no resident-specific care plan for the rolled washcloth, left arm elevation, or wedge use. The behavioral log also lacked consistent documentation of refusals or behaviors, with no entries for two months and only one later entry that did not specify what care was refused. The unit manager stated there was no order in the chart for the washcloth or wedge and acknowledged there was not a care plan for the occupational therapy recommendations. For the second resident, a sign in the room indicated a washcloth should be placed in the left hand every morning, but observations found the left hand in a loose fist with no washcloth in place. The resident confirmed the washcloth was not in his hand during observations and could not remember if it was placed there daily. Occupational therapy staff stated the hand roll was used to keep the hand dry and prevent nails from digging into the palm, and nursing staff were to complete passive range of motion with daily care, complete hand hygiene, and perform skin checks before and after placing the cloth roll. The discharge summary also stated the left hand roll was to be placed during first shift and caregivers were to complete left upper extremity passive range of motion with daily care and skin checks.
Failure to Address Ongoing Diarrhea and Bowel Incontinence
Penalty
Summary
The facility failed to provide appropriate care to prevent bowel incontinence for a resident who was admitted as continent of bowel and used the toilet. The resident had pertinent diagnoses including disorders of bone density and structure, a fall on the same level, and osteoarthritis. On admission, the resident was documented as continent of bowel, but subsequent CNA documentation showed multiple episodes of loose, liquid stool and incontinence after admission. A CNA reported that the resident had not been normal since admission and that the resident had diarrhea with no control of her bowels. The CNA stated she had informed the nurse a few days after admission about the diarrhea, but she was not aware that anything had been done. The CNA also reported that the resident would often need to return to the toilet after being assisted and that stool was coming out almost as soon as the resident finished eating. A progress note later documented that the resident was continent of bladder but had little sensation and did not know when she had been incontinent of stool. The medical record showed orders to document bowel movements every shift, but there were no orders, assessments, provider contacts, or progress notes addressing the ongoing diarrhea after the concern was reported. Review of the record showed no medications prescribed to address diarrhea during the period reviewed. Staff interviews indicated that loose stools should have prompted nurse assessment, provider notification, possible stool softener review, and documentation, but none of that was found in the record until later when the resident was finally spoken with about bowel habits and an order for Imodium and lab work was obtained.
Bedrail Used Without Required Assessment or Consent
Penalty
Summary
The facility failed to ensure a resident was assessed for risk of entrapment and informed consent was obtained before a half-length bedrail was installed and left in use for Resident #78. The resident had diagnoses including COPD and hallucinations, and an MDS assessment dated 12/6/25 showed a BIMS score of 8/15, indicating moderate cognitive impairment. During an observation on 1/6/26, the resident was asleep with her head at the foot of the bed and her feet protruding through the bars of the raised and locked bedrail. The care plan contained no bedrail care plan, the medical record contained no interdisciplinary physical restraint assessment related to the bedrail, and there were no physician orders for its use. The bedrail remained raised and locked during a later observation on 1/7/26 while the resident sat in a recliner in her room. A CNA reported the resident had used the half-length bedrail for a long time and said it had been in use for at least a month, based on having it before the resident moved to the current room on 12/15/25. In an interview on 1/8/26, the resident stated she did not like the bedrail because she regularly bumped her feet on it. The facility policy required assessment for entrapment risk, review of risks and benefits with the resident or representative, informed consent prior to installation, an IDT physical restraint assessment, a physician order, and completion of a consent form.
Digoxin Given Despite Low or Missing Pulse Checks
Penalty
Summary
Ensure that residents were free from significant medication errors was not met when the facility failed to administer digoxin according to the physician’s order for one resident. Resident #60 had diagnoses including congestive heart failure, stroke, mitral valve insufficiency, irregular heartbeat, tricuspid valve insufficiency, and cardiomyopathy. The physician’s order dated 5/24/23 directed digoxin 125 mcg once daily for AFIB and to hold the medication if the apical pulse was less than 60 beats per minute. Review of the MAR showed digoxin was administered on multiple occasions when the recorded pulse was below the ordered parameter, including pulse rates of 53, 58, 58, 52, 54, and 56. One administration also had no pulse rate documented. During interview, the DON stated the nurse should check the pulse before giving digoxin and hold it if the pulse was below 60. The pharmacist stated the digoxin level should be checked every 6 months, and the resident’s last level was done on 6/20/25.
Unqualified Activity Director and Lack of Individualized Activities
Penalty
Summary
The facility failed to employ an Activity Director who met the required federal and state qualifications for the position. The Activities Director, who assumed the role approximately nine months prior, did not possess certification as an Activity Director, nor could the facility provide verification that she had two years of full-time experience in a therapeutic activities program as required. The Nursing Home Administrator confirmed that the Activities Director was hired with the expectation to obtain certification but was not held accountable for achieving this requirement. Interviews and record reviews revealed that the Activities Director was not conducting activity assessments as required, and was unaware of the facility's initial or annual activity assessment forms. Instead, she relied solely on section "F" of the Minimum Data Set (MDS) to gather information about residents' leisure preferences and needs. The Activity Assistant reported not receiving any information about individual resident preferences or needs, making it difficult to provide individualized activities. The Activities Director also acknowledged that some residents were dependent on structured leisure activities and that isolation could occur if activities were not provided based on each resident's needs and preferences. A resident with a history of stroke, major depressive disorder, and hemiplegia, who was cognitively intact, reported a significant decline in the number and variety of activities over the past nine months, especially on weekends and evenings. The resident expressed feelings of boredom and frustration due to the lack of activities and the discontinuation of her volunteer role in the activity store, which had become nearly empty. The resident also observed that more residents were unengaged and sitting in their rooms, and several had expressed similar feelings of boredom.
Failure to Provide Individualized Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide individualized activities based on the preferences, needs, and abilities of four residents, as required by regulation. Multiple observations and interviews revealed that residents with varying degrees of cognitive and physical impairment were left without meaningful engagement or access to activities tailored to their interests. For example, one resident with legal blindness and moderate cognitive impairment was unable to use his smart device to listen to music, despite this being a documented preference, and reported feeling bored and anxious in his room. Another resident with severe cognitive impairment and a history of depression was observed sitting passively in a lounge with no staff engagement, and her family member reported that the only activity provided was popcorn, with no regular access to music or religious services as preferred. A third resident, moderately cognitively impaired, was observed repeatedly in her room without music or television, despite her care plan indicating these as important interests. Her family member reported that the facility had not contacted her about the resident's leisure interests and noted a lack of mental stimulation, with the resident appearing increasingly disconnected. The fourth resident, who was cognitively intact and previously active as a volunteer, reported a significant decline in available activities, especially on weekends and evenings, and expressed frustration over the lack of purpose and engagement due to the reduction in activity programming and the near-empty resident store. Staff interviews corroborated these findings, with activity assistants and CNAs reporting a lack of structured one-on-one visits, insufficient information about resident preferences, and a reduction in group and individualized activities, particularly for those with cognitive impairments. The Activities Director acknowledged that assessments were not being completed as required and that evening programming was not provided according to facility policy. The Nursing Home Administrator confirmed these deficiencies, noting that the current activity program did not meet policy standards and that individualized activities were not being offered.
Inaccurate Documentation of Resident Activity Participation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was reviewed for activity participation documentation. The resident, who was cognitively intact as evidenced by a perfect score on the Brief Interview for Mental Status (BIMS), reported that she did not attend several activities that were documented in her records, including a movie, a social hour, and a resident council meeting. The resident was able to recall with certainty that she did not participate in these events, and her recollection was supported by a Certified Nursing Assistant who confirmed the resident's cognitive abilities and reliability in recalling daily events. Interviews with the Activities Director and Activity Assistants revealed inconsistencies in the documentation process. The Activities Director stated that daily records of resident participation were maintained and reviewed, while one Activity Assistant admitted to noticing discrepancies in the records. Another Activity Assistant reported that she often waited until the end of the day to document attendance, which sometimes made it difficult to accurately remember which residents attended each activity. These practices led to inaccurate documentation of the resident's participation in activities, resulting in incomplete and unreliable medical records.
Failure to Implement Transmission-Based Precautions for Resident with Influenza
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident who was symptomatic and later confirmed to have influenza. The resident, who had a diagnosis of unspecified dementia and was alert and oriented, reported a severe sore throat and cough, with wheezing noted on auscultation. The physician assistant was notified, and testing for Influenza A and B was ordered. Despite these symptoms and the subsequent positive flu test, no isolation signage was present on or near the resident's room, and isolation precautions were not visibly in place at the time of observation. During the period when the resident was symptomatic and should have been under droplet precautions, two housekeeping staff entered the room to clean the carpet. They wore KN95 masks but did not use any other personal protective equipment (PPE) and failed to perform hand hygiene upon leaving the room. The staff also continued to wear the same masks as they moved through the hallway, potentially increasing the risk of cross-contamination. Additionally, the Activities Director entered the resident's room wearing only a KN95 mask, did not use additional PPE, and invited the resident to a group activity, further disregarding isolation protocols. The Activities Director also did not perform hand hygiene upon leaving the room and continued to wear the same mask in the hallway. Interviews with staff confirmed that the resident had tested positive for influenza and that requests for isolation signage and a PPE cart had been made but were not yet in place. The Director of Nursing/Infection Preventionist stated that isolation precautions should be implemented at the onset of symptoms for suspected contagious illnesses. Facility policy and CDC guidelines both require droplet precautions for influenza, including the use of appropriate PPE, hand hygiene, and isolation signage, none of which were properly implemented for this resident.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to properly manage food storage and cleanliness, leading to potential health risks for residents. During an initial kitchen and food service tour, several issues were observed, including opened food containers in the walk-in cooler and reach-in cooler that were not labeled with opened or discard dates. Additionally, the plate warmer used for resident meal trays contained plates with dried food debris, indicating inadequate cleaning practices. In the nourishment rooms, various food items were found unlabeled, undated, and in some cases, spoiled or moldy, further highlighting the lack of proper food management. The facility's dietary staff were responsible for cleaning the nourishment room refrigerators and freezers, but the cleaning schedule was not effectively maintained. The Dietary Supervisor reported that staff attempted to clean when they noticed dirt, with a deep scrub scheduled once a week. However, the expectation for food labeling and dating was not consistently met, as evidenced by numerous unlabeled and undated food items. The failure to discard opened drinks after five days and prepared foods after three days from preparation was also noted, increasing the risk of foodborne illness. During a follow-up tour, additional deficiencies were identified, such as wet pans being improperly stored, a stock pot with dried residue, and a knife storage rack with dust and debris. Furthermore, a stained bowl was used to serve gravy to a resident, despite the availability of new bowls. These observations indicate a systemic issue with maintaining cleanliness and proper food handling procedures, which could compromise the safety and well-being of residents consuming food from the facility.
Failure to Honor Resident Mealtime Preferences
Penalty
Summary
The facility failed to honor the mealtime preferences of several residents, including a resident with vascular dementia and major depressive disorder, who expressed a desire to eat in the communal dining room. Despite the resident's care plan indicating the importance of socialization and the dining room setting for initiating self-feeding, the facility did not accommodate this preference due to staffing concerns. The resident's family member, who visited daily to provide socialization and support, reported that the facility had been informed of the resident's preference but did not make the necessary arrangements. Interviews with staff and residents revealed that the facility had not allowed residents to eat their evening or weekend meals in the dining room for nearly two years, citing staffing issues as the reason. The Director of Nursing acknowledged the importance of communal dining for residents' socialization and independence but noted that the dining restrictions remained despite the facility being fully staffed. The facility's policy on self-determination emphasized respecting residents' autonomy, yet the dining restrictions contradicted this policy, leading to resident frustration and discontent.
Failure to Notify Resident of Medicare Part A Exhaustion
Penalty
Summary
The facility failed to provide timely notification to a resident regarding the exhaustion of Medicare Part A benefits, resulting in the resident being unaware of changes in financial liability. The resident, who was cognitively intact, was informed late about the lack of Medicare coverage and the impending financial burden of approximately $10,000. The resident expressed distress and uncertainty about how to manage the unexpected financial responsibility. The deficiency occurred due to a lack of communication and oversight within the facility's admissions and billing processes. The Business Office Manager and Admission Director were unaware of the resident's limited Medicare coverage at the time of admission, and the MDS RN, responsible for notifying residents of benefit exhaustion, was not informed in time. This oversight led to the resident not receiving the required notice three days before the benefits ended, as per protocol.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in the potential for unmet medical, physical, mental, and psychosocial needs. Resident #53 was admitted with a need for assistance with personal care and had an order to empty a left nephrostomy bag every shift. However, a review of the care plan revealed that there was no care plan developed for the nephrostomy bag. During an interview, MDS RN M, who was responsible for ensuring care plan orders were in place, confirmed that this was an oversight. Similarly, Resident #90 was admitted with a diagnosis of type 2 diabetes mellitus and had orders for medications including Duloxetine, Eliquis, and Olanzapine. The care plan review showed that there was no care plan developed for the resident's diabetes diagnosis or the use of anticoagulant and psychotropic medications. MDS RN M acknowledged that a care plan should have been in place for these conditions and medications, but it was missed.
Delay in Urinalysis Order Leads to Prolonged Resident Discomfort
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident who experienced dysuria for approximately seven days. The resident, who required assistance with personal care, initially reported frequent urination and suspected a urinary tract infection (UTI) to a registered nurse (RN) on 10/24/24. The RN documented the complaint in the provider notification book. The following day, a nurse practitioner (NP) saw the resident and noted an increase in urinary frequency and burning, indicating consent for work for a UTI. However, the urinalysis (UA) was not ordered until 10/29/24, despite the resident's ongoing complaints of pain with urination. Interviews revealed that the NP had given a verbal order for a UA to a licensed practical nurse (LPN) on 10/24/24, but the order was not placed. The NP followed up on 10/25/24 and discovered the UA had not been ordered, prompting another request to staff. The delay in obtaining the UA resulted in the resident experiencing prolonged discomfort. The NP confirmed that the UA should have been completed the same day the resident reported pain, acknowledging the delay in care due to the facility's failure to promptly place the order.
Failure to Provide Individualized Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide individualized activities based on resident preferences, needs, and abilities for Resident #55, who was reviewed for activities. Resident #55 was admitted with diagnoses including vascular dementia and cognitive communication deficit. The Minimum Data Set (MDS) assessment indicated that Resident #55 had severe cognitive impairments, including short- and long-term memory deficits, disorganized thoughts, and was rarely understood. Despite these challenges, the resident's care plan noted preferences for activities such as listening to music, being around pets, and spending time in groups. Observations revealed that Resident #55 was often left alone in the day room without engagement in preferred activities. The resident was seen sitting in a wheelchair, flexed at the hips, with eyes cast downward, and not interacting with the environment or other residents. The television was on, but Resident #55 did not appear aware of it, and no music was available. Interviews with staff indicated that room visits were limited to brief interactions, and there was a lack of sensory stimulation activities provided to Resident #55 over a five-month period. The Activities Director reported that residents who did not attend group activities should receive room visits 2-3 times a week, and sensory stimulation activities were supposed to be provided regularly. However, the Activity Assistant and a Certified Nursing Assistant noted limitations in the activities offered, particularly for residents with severe cognitive deficits. The facility had some activity supplies available, but there was uncertainty among staff about which residents used them, indicating a gap in the implementation of individualized activity plans for residents like Resident #55.
Failure in Timely Weight Monitoring Leads to Undetected Weight Loss
Penalty
Summary
The facility failed to ensure timely and consistent weight monitoring for a resident, leading to undetected weight loss and a decline in nutritional status. The resident, who had severe cognitive impairment and difficulty swallowing, was observed to have significant weight loss over a short period. Despite being on a Mechanical Soft diet and receiving nutritional supplements, the resident's weight dropped from 144.6 lbs to 126.0 lbs within a few weeks, indicating a 12.8% weight loss. The facility's dietary and nursing staff did not adequately monitor the resident's weight changes. The Registered Dietitian (RD) and Dietary Supervisor (DS) failed to follow up on the significant weight loss recorded on 9/13/2024. Although the resident was placed on a weekly weight monitoring list, the necessary reweights were not obtained, and the staff did not communicate effectively about the resident's nutritional needs. The RD was only present at the facility once a month and did not attend weekly Standards of Care (SOC) meetings, where such issues should have been discussed. The Director of Nursing (DON) and other staff members were not informed of the resident's weight loss in a timely manner. The DON was unaware of the weight loss until the day before the survey, and the weight monitoring policy was not followed. The policy required reweights to be conducted within 48 hours of a significant weight change, but this was not done. The lack of communication and follow-up among the interdisciplinary team contributed to the deficiency in addressing the resident's nutritional needs.
Lack of Documentation for Psychotropic Medication Education
Penalty
Summary
The facility failed to provide documentation of education to a resident or their representative regarding the intended or actual benefits versus potential risks or adverse consequences associated with psychotropic medications. This deficiency was identified for a resident who was prescribed multiple psychotropic medications, including mirtazapine, Zoloft, and Seroquel. The resident, who was severely cognitively impaired with a BIMS score of 6, had a signed consent form for the antipsychotic medication Seroquel but lacked documentation of education for the antidepressants mirtazapine and Zoloft. During an interview, the Social Services Director (SSD) indicated that they were trained to obtain consent only for antipsychotic medications and were unsure if education on antidepressants was documented. Despite reviewing the resident's medical record, the SSD could not locate any documentation of education on the risks versus benefits of the antidepressant medications. The surveyor encouraged the SSD to provide additional documentation before the survey exit, but no such documentation was provided.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to consistently honor the food preferences of two residents, leading to complaints and potential negative impacts on their meal enjoyment and nutritional intake. Resident #27, who is cognitively intact and has a history of anxiety, depression, and diabetes, reported not consistently receiving the meals she ordered. This issue was corroborated by a Certified Nurse Aide who observed that Resident #27 and other residents did not receive the items they requested on their meal trays. During a meal trayline observation, a Dietary Assistant was seen placing a tray into the delivery cart without the requested pudding due to a shortage, which was later rectified by the Dietary Supervisor. Resident #78, who is severely cognitively impaired and requires assistance with eating, also experienced issues with meal preferences. Her family member reported that Resident #78 did not consistently receive her preferred drink, chocolate milk, due to delivery issues. This was significant as it was sometimes the only nourishment she would accept. A Certified Nursing Assistant confirmed that Resident #78's tray often lacked chocolate milk, and the kitchen staff frequently cited supply issues. These deficiencies were noted in the Resident Council Minutes, highlighting ongoing concerns about incorrect food and unmet dietary preferences.
Infection Control Deficiency in Tube Feeding Equipment
Penalty
Summary
The facility failed to adhere to professional standards of infection control concerning a resident's tube feeding equipment, leading to a potential risk of pathogen harborage and cross-contamination. The facility's policy on cleaning and disinfecting resident-care items, reviewed in January 2024, mandates that equipment be cleaned according to CDC recommendations and OSHA standards. Additionally, the policy on tube feeding specifies that the nursing department is responsible for all feeding equipment. However, during an observation, it was noted that the tube feeding equipment for a resident, who required total assistance with activities of daily living and had a diagnosis of stroke, was not properly maintained. The equipment, including the tube feeding pole, base, pump, and surrounding items, had splatters of a dried substance resembling the tube feeding formula. During an interview and observation with an LPN, it was confirmed that the splatters should have been cleaned immediately to prevent infection control issues, as they become sticky and attract dirt. The LPN was unaware of who was responsible for cleaning the equipment, indicating a lapse in the facility's infection control practices. This oversight in maintaining cleanliness of the tube feeding equipment presents a potential risk for infection in a vulnerable population.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were screened for eligibility and received Pneumococcal vaccinations if eligible, affecting three out of five residents reviewed. Resident #18 was admitted with a diagnosis of weakness and had last received a Pneumococcal vaccine in 2018. Despite the legal guardian's consent for vaccination dated 10/2/23, there was no verification that Resident #18 had been screened for eligibility or offered an updated vaccine since admission. The Director of Nursing (DON) confirmed that Resident #18 was due for an updated vaccine. Resident #35, admitted with difficulty walking, had not received a Pneumococcal vaccine according to the Michigan Care Improvement Registry. Although consent was given on 8/24/23, there was no verification of screening or offering of the vaccine. Similarly, Resident #48, admitted with weakness, had last received a Pneumococcal vaccine in 2015 and was due for an update. The DON acknowledged the oversight in monitoring and administering vaccines. The facility's policy required assessment and offering of vaccines upon admission, but this was not adhered to, leading to the deficiency.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to two residents, resulting in a higher likelihood of infection and complications from COVID-19. Resident #18 was admitted with a diagnosis of weakness and had not been screened or offered a COVID-19 vaccine since their last immunization on 10/25/22. The Director of Nursing (DON) admitted that the facility was not screening and offering COVID-19 immunizations to eligible residents at admission or annually, and was unable to provide verification that Resident #18 had been offered the vaccine since admission. Similarly, Resident #48, also admitted with a diagnosis of weakness, had not been screened or offered a COVID-19 vaccine since their last immunization on 9/20/2022. The DON confirmed that this was missed as well. The facility's COVID-19 Vaccine Program Policy, last revised in 9/2024, mandates that COVID-19 vaccinations be offered to residents when supplies are available, in accordance with CDC and FDA guidelines, unless medically contraindicated or refused. However, the facility did not adhere to this policy, as evidenced by the lack of screening and offering of vaccines to these residents.
Deficiencies in Sanitary Conditions for Residents
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for two residents, resulting in deficiencies in their living environment. Resident #27, who is cognitively intact and has diagnoses including secondary pulmonary arterial hypertension and type 2 diabetes mellitus, was found in a room with a stained and soiled privacy curtain and dusty blinds. Despite the resident's report that these items were never cleaned, observations confirmed the lack of cleanliness over a 24-hour period. Interviews with housekeeping staff revealed that the privacy curtains should be disinfected daily and replaced if dirty, and blinds should be dusted as needed, but these procedures were not followed. Resident #55, who has vascular dementia and a cognitive communication deficit, was observed in a visibly soiled wheelchair with dried brown and white liquids and food crumbs on various parts of the chair. Despite the resident's inability to express preferences, the condition of the wheelchair was noted to be uncomfortable for a reasonable person. Observations over two days confirmed the lack of cleaning, indicating a failure in maintaining sanitary conditions for the resident's equipment.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Systems
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R82, who was at risk for elopement due to cognitive impairment and a history of exit-seeking behavior. Despite being identified as an elopement risk, the resident's care plan did not include specific interventions to prevent elopement until after the incident occurred. The resident was able to leave the facility unnoticed and was later found outside, highlighting a lack of adequate supervision and ineffective alarm systems. R82 had a history of wandering and exit-seeking behavior, as documented in progress notes and elopement risk assessments. The resident was moderately cognitively impaired and required substantial assistance with daily activities. Despite these risk factors, the facility did not implement sufficient monitoring or interventions to prevent the resident from leaving the premises. The resident's care plan lacked specific elopement precautions, and there were no orders for increased supervision or frequent checks prior to the incident. The facility's alarm system was inadequate, as the front door alarm could not be heard from the resident units, and the French doors separating the lobby from the resident areas were closed after hours, further limiting staff's ability to respond to alarms. Staff interviews revealed that the resident had been exit-seeking throughout the night and was able to leave the facility while staff were occupied with other duties. The incident exposed significant gaps in the facility's elopement prevention measures, including insufficient staff presence and ineffective alarm systems.
Delayed Reporting of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report a resident-to-resident abuse incident in a timely and accurate manner to the State Agency, involving two residents with severe cognitive impairments. Resident #104, diagnosed with Alzheimer's disease and vascular dementia with behavioral disturbances, and Resident #105, diagnosed with unspecified dementia and anxiety, were involved in an altercation at the nurse's station. The incident resulted in Resident #105 sustaining a skin tear on the left hand. The facility's policy requires that all alleged violations involving abuse be reported immediately, but not later than two hours after the allegation is made. The Nursing Home Administrator (NHA) was responsible for reporting the incident but failed to do so within the required timeframe. The incident occurred at 6:50 PM on 2/28/24, but the report was not submitted to the State Agency until 8:57 AM the following day. The NHA cited technical difficulties with a new laptop as the reason for the delay. Despite the facility's policy allowing for multiple reporters, the NHA was the sole individual responsible for the submission, which contributed to the delay in reporting the incident.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair by not using footrests, which is a necessary safety measure. The resident involved, identified as Resident #106, has significant visual impairments, including legal blindness, and is moderately cognitively impaired. Observations on multiple occasions revealed that the resident was being pushed in a wheelchair without footrests by staff members, including an Activities Aide and the Activities Director. Despite acknowledging the need for footrests, the staff continued to transport the resident without them, citing the resident's preference as a reason. Interviews with various staff members, including a Certified Nurse Assistant and a Registered Nurse, confirmed that footrests are required for residents being pushed in wheelchairs, especially for those who cannot self-propel due to visual impairments. The care plan for the resident indicated the use of a wheelchair for mobility and assistance with transfers, but there was no mention of footrests. The Director of Nursing was in the process of re-educating staff on the use of footrests, but this was not part of the deficiency findings.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications securely in three treatment carts, as observed during a survey. Medications, including a pain gel labeled as [NAME] Pain Gel, were found on top of treatment carts behind various nurse's stations, including Birch, Dogwood, and Evergreen. These carts were accessible to anyone on the unit, as there were no barriers to prevent access, and the medications were not locked as required by the facility's policy. Interviews with staff, including LPN Q and LPN P, confirmed that the [NAME] Pain Gel is a medication that requires a physician's order and should only be applied by licensed nurses. Despite this, the pain gel and other topical treatment creams and ointments with resident-specific information were left unsecured on the treatment carts, contrary to the facility's policy that mandates all medications be stored in locked compartments. The Director of Nursing (DON) B acknowledged during an interview and observation that all medications should be locked in the carts. Upon inspection, it was found that the medication cart at the Evergreen nurse's station was unlocked, and the medications were not secured inside the cart. This oversight was confirmed by LPN P, who was present at the time and began removing the medication items from the top of the treatment cart to secure them.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration for three residents, leading to potential risks of infection and cross-contamination. Observations revealed that an LPN did not perform hand hygiene while administering medications to two residents. The LPN was seen preparing and administering oral and injectable medications without washing hands or using hand sanitizer between tasks and residents. The LPN incorrectly used Sani-Cloths, intended for disinfecting surfaces, as a substitute for hand hygiene, which is against the facility's policy. Another LPN also failed to perform hand hygiene while administering medications to a third resident. This LPN did not sanitize hands after administering an insulin injection and before handling oral medications. Interviews with the LPNs and the Assistant Director of Nursing confirmed that hand hygiene should be performed between residents and before and after glove use. The facility's policy mandates hand washing after contamination with blood, after resident care, and before and after nursing procedures, which was not adhered to in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dowagiac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cass County Medical Care Facility | 8.5 mi | ★★★★★ | 2 | 0 |
| The Orchards At Niles | 14.2 mi | ★★★★★ | 20 | 0 |
| Niles Care Center, Llc | 14.8 mi | ★★★★★ | 33 | 2 |
| West Woods Of Niles | 18.2 mi | ★★★★★ | 24 | 1 |
| Coventry House Inn | 18.5 mi | ★★★★★ | 14 | 0 |
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