Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At Green Lake Estates during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls suffered multiple injuries, including facial fractures and loss of consciousness, after falling on an unsecured staircase and from bed. The facility failed to implement required safety interventions such as a perimeter mattress and soft helmet, did not adequately document or report incidents, and did not communicate with the resident's POA regarding care decisions or falls.
A resident with multiple medical conditions did not receive physician-ordered lab tests, including UA, C&S, CBC, and BNP, due to the facility's failure to process and arrange for the tests as required by policy. The omission was discovered only after the resident was transferred to the hospital, and review confirmed that no lab results were present in the medical record for the ordered tests.
A resident with multiple pressure ulcers and significant care needs was not provided with individualized interventions for skin protection, as required by facility policy. Instead, only general monitoring and treatment measures were documented in the care plan, despite the presence of several stage three and four wounds. The DON confirmed that nurses were responsible for implementing skin management interventions but did not provide further explanation for the lack of individualized care.
A resident with severe cognitive impairment, developmental delay, and a history of falls was not provided with adequate supervision or individualized interventions to prevent falls, despite clear documentation of high risk and non-compliance. The care plan lacked specific strategies for increased monitoring, resulting in an unwitnessed fall with significant injuries that required hospital transfer.
Two residents developed or experienced worsening pressure ulcers due to the facility's failure to conduct timely and accurate skin assessments, document and report skin impairments, and implement effective interventions. One resident suffered a medical device-related wound from a Life Vest that was not properly monitored or addressed, while another developed multiple advanced-stage pressure ulcers that were not identified by staff until noted by a wound care consultant. The facility did not follow its own policies for skin inspection and documentation, leading to delayed recognition and treatment of pressure injuries.
An LPN was found with an opened, undated Humalog (insulin) pen and five loose, unidentifiable pills in a medication cart. The LPN could not explain the lack of dating or the presence of loose pills. Interviews with the unit manager and DON confirmed that facility policy requires opened insulin to be dated and medications to be properly stored, but these procedures were not followed.
A resident receiving hospice care, with diagnoses including dementia and Alzheimer's disease, experienced inconsistent and infrequent hospice nurse and aide visits. The facility provided unclear documentation of hospice staff schedules and lacked a facility-initiated care plan for hospice services. Staff interviews revealed uncertainty about who was responsible for monitoring hospice service provision, resulting in uncoordinated care.
Surveyors identified that 26 rooms did not meet the minimum 80 square feet per resident requirement for multiple occupancy rooms, with each room measuring approximately 148 to 149 square feet for two residents. Residents interviewed did not express dissatisfaction with room size, and the administrator reported no plans to expand or convert these rooms.
A resident reported multiple missing personal items and did not receive follow-up or resolution from facility staff or administration, as concerns were not documented unless a formal grievance was filed. Additionally, several residents expressed ongoing dissatisfaction with laundry services and a lack of effective response to their concerns. The facility's practice of only documenting formal grievances did not align with its policy requiring all grievances to be tracked and resolved.
A resident with severe cognitive impairment and wandering behaviors was found with unexplained bruises on two occasions. Staff documented the injuries but did not report them to the Administrator or conduct required investigations, despite facility policy mandating immediate reporting and investigation of injuries of unknown origin. The Administrator confirmed that these incidents were not brought to their attention, resulting in a failure to comply with reporting and investigation protocols.
A resident with multiple serious diagnoses, including acute respiratory failure and dementia, was admitted to hospice services, but the facility did not develop its own care plan for hospice or document coordination with the hospice provider. The DON confirmed that such a care plan should have been created, in accordance with facility policy requiring comprehensive, person-centered care planning.
A resident with multiple chronic conditions did not receive daily dressing changes for a skin tear as ordered, despite the TAR being marked as completed each day. Observation and interview revealed the dressing had not been changed for several days, and the DON confirmed the documentation did not match the actual care provided.
Two residents were not treated in a dignified manner when one was transported in a geri-chair facing backward while being pulled forward by a CNA, and another was described by a CNA as 'moody' and sleeping much of the day without appropriate context or sensitivity. The DON confirmed that such actions do not align with facility expectations for resident dignity.
Three residents experienced inadequate supervision and lack of effective interventions, resulting in one resident eloping from the facility, another repeatedly entering other residents' rooms and experiencing multiple falls, and a third resident having a fall that was not properly assessed or reported. Staff failed to document required checks and interventions, and care plans were not updated to reflect incidents, despite facility policies requiring these actions.
A resident was prescribed Ivermectin for possible scabies, but the order lacked a stop date, resulting in the medication being administered daily beyond the intended treatment period. The NP was unaware the medication continued, and the DON acknowledged a stop date should have been included, as required by the facility's antibiotic stewardship policy.
A resident's funds were misappropriated when a CNA accepted the resident's debit card and used it for unauthorized withdrawals and purchases, exceeding the amount authorized by the resident. The resident had not left the facility except for hospital visits and reported the issue after noticing suspicious transactions on her bank statement. The CNA's actions violated facility policy regarding the protection of resident property.
Two residents were affected by improper implementation and documentation of transmission-based precautions (TBP): one had an active order for contact isolation due to scabies but lacked required signage and PPE outside their room, while another had TBP signage and PPE present without any corresponding physician's order. Facility staff were either unaware of the need for TBP or unable to provide justification, and the facility's policy did not clarify the requirement for physician orders for TBP.
A resident in an LTC facility sustained a shoulder injury requiring stitches after falling out of bed when left unattended by a CNA during the night shift. The CNA, unfamiliar with the resident's needs and overwhelmed by being short-staffed, left the resident in an unsafe position. The resident, who was on a blood thinner, required maximal assistance for bed mobility, which was not provided, leading to the fall.
The facility failed to implement effective discharge planning for two residents, leading to psychosocial harm. One resident was transferred without family approval or notification to the receiving facility, while another resident's request to move was not followed up on, leaving them frustrated. The facility did not involve families in planning or communicate effectively with receiving facilities.
A facility failed to provide written transfer notification to a resident's representative and the Ombudsman, as required for facility-initiated transfers. The resident, with severe cognitive impairment and language barriers, was transferred without the representative's involvement in the discharge plan. The representative was only informed via phone the day before the transfer, unaware of the new facility's location. Interviews confirmed the facility did not follow its policies for discharge planning and notification.
The facility failed to properly document and administer controlled substances for two residents, leading to discrepancies between the Medication Administration Record (MAR) and the Medication Monitoring/Control Record. One resident's alprazolam administration was not consistently documented, and another resident found pills in their bed despite records indicating they had been administered. Interviews with the DON confirmed that medications should be signed out and observed as taken, but the facility could not reconcile the discrepancies.
The facility failed to properly store and label medications in two medication carts. On the third floor, an RN found undated insulin pens in the cart, while on the first floor, a nurse discovered insulin pens without dates or resident labels. Additionally, various medications and treatment supplies were improperly stored together. The DON acknowledged the issue, emphasizing that maintaining cleanliness was a shared responsibility among nurses.
The facility failed to promptly respond to call lights for three residents, leading them to contact the receptionist for assistance. Residents with conditions such as Multiple Sclerosis, bladder dysfunction, and stroke experienced delays, with one resident waiting up to an hour. The DON acknowledged the issue, noting the facility's outdated call light system and the policy requiring responses within 5 minutes.
The facility failed to ensure residents' rights to private and confidential mail delivery. Several residents reported concerns about not receiving their mail timely and unopened. Interviews with the Administrator and Admissions Director revealed inconsistencies and a lack of awareness in the facility's mail handling practices.
The facility failed to ensure residents and visitors had access to previous survey results, as guaranteed by federal and state laws. During a resident council interview, none of the 11 residents knew where to access the survey binder, and the receptionist was also unaware. The Administrator confirmed that the survey binder had been removed temporarily and was not put back, leading to residents and visitors being uninformed of deficiencies identified in the facility.
The facility failed to maintain sanitary conditions in the kitchen and ensure food items were labeled, dated, and discarded when expired. Personal items were stored on food bins, a scoop was improperly stored in rice, and the dish machine was non-functional without proper sanitization monitoring. Expired food items were found in storage, and equipment cleaning logs were outdated, posing health risks to residents.
The facility failed to document, investigate, track, and resolve grievances from the resident council. Interviews and record reviews revealed that concerns such as staff phone usage, delayed call light responses, and missing personal items were not followed up on, despite the facility's policy requiring immediate submission and resolution of grievances.
The facility failed to provide timely incontinence care for a resident and routine showers for another. One resident was left without incontinence care for nearly two hours despite reporting discomfort, and another reported receiving only two showers since admission. The facility's policies for incontinence care and shower frequency were not followed.
The facility failed to ensure an environment free from accident hazards regarding the storage of blood sugar testing lancets in a medication cart. Approximately 40 lancets were found in an uncovered container on top of the cart, with no nurse in view. The DON confirmed the improper storage and directed the nurse to place the container inside the cart. The facility's Medication Storage Checklist did not address the storage process for lancets before use.
The facility failed to ensure appropriate consent, assessment, and physician orders for the use of assist bars/rails for eight residents, posing a potential risk to all 76 residents. Interviews revealed a lack of clear responsibility and documentation, contrary to the facility's guidelines.
The facility failed to provide sufficient nursing staff on the first floor, resulting in delayed medication administration and unmet care needs. Multiple residents reported issues with call light response times, cold food, and infrequent showers. An agency nurse admitted to being overwhelmed, and the DON acknowledged the staffing concerns but had not added additional staff. Facility policies on staffing and medication administration were not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions requiring such measures, and also failed to maintain proper linen storage practices. Observations revealed a lack of EBP signs, PPE availability, and improper storage of personal care items with clean linens.
A resident reported being accused of drug-seeking behavior by an LPN in front of others, affecting their treatment by staff. The resident's care plan included pain management, but the LPN's progress notes contained subjective and inappropriate comments. The DON acknowledged the inappropriateness of the notes, and the LPN admitted to subjective charting but denied personal issues with the resident.
A resident with multiple diagnoses, including pneumonia and lung cancer, was found self-administering an albuterol inhaler without an assessment or care plan in place. Despite having intact cognition, the facility failed to document the resident's ability to self-administer medication, as confirmed by the DON and other staff.
A resident with a history of physical abuse was told by the Administrator they would have to change rooms to avoid a particular LPN, despite the resident's attachment to their current room as a safe place. The Administrator did not consider using other nurses to accommodate the resident's preference, contradicting the resident's care plan and facility policy on resident rights.
The facility failed to ensure timely medication administration and proper physician notification for a resident. Several residents reported receiving medications late, and one resident did not receive their 9:00 AM medications on time. The DON acknowledged the issue, but the facility's process for late medication administration was not followed, and staffing levels were inadequately managed.
The facility failed to implement necessary interventions for pressure ulcer prevention for a resident and did not complete required skin assessments for another resident. One resident was observed without the ordered low air loss mattress and heel offloading boots, while another resident was left without incontinence care for an extended period and lacked documented skin assessments for two months.
A facility failed to document intermittent catheterization for a resident with quadriplegia and bladder dysfunction. The resident experienced discomfort due to delayed catheterization, and significant amounts of urine obtained were not recorded. The Director of Nursing confirmed the necessity of such documentation.
A resident was prescribed Seroquel without adequate indication, appropriate consent, or clinical rationale. The social service assessment was overdue, and the care plan lacked specific details. Conflicting opinions on the resident's competency were noted, and the facility's policy on psychotropic medication management was not followed.
The facility failed to provide the required 80 square feet per resident in multiple resident rooms for 26 out of 42 rooms. Despite no resident complaints, the rooms did not meet the regulatory space requirements.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision to prevent accidents for a resident identified as high fall risk, a wanderer, and with severe cognitive impairment. The resident had a history of falls with injury and was completely dependent on staff for mobility and transfers. Despite these risks, the resident experienced multiple falls, including incidents on a staircase that resulted in multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain. The facility did not ensure the environment was free from accident hazards, as the stairwell was open and accessible to cognitively impaired residents without any deterrents in place at the time of the incidents. Interviews and record reviews revealed that the facility did not follow the resident's care plan, which included interventions such as a perimeter mattress and a soft helmet. The resident was observed without a perimeter mattress or helmet at the time of the falls, and staff were unable to explain why these interventions were not in place. Documentation of the incidents was incomplete or delayed, with missing progress notes, lack of vital sign documentation, and late entries in the medical record. The facility also failed to notify the State Agency of the incidents involving major injuries in a timely manner. Additionally, the facility did not involve the resident's Power of Attorney (POA) in care decisions or care planning, including the initiation of hospice services and notification of falls. The POA reported not being informed of significant events, including additional falls, and expressed concerns about the lack of communication and coordination with the facility. The combination of inadequate supervision, failure to implement care plan interventions, lack of environmental safeguards, and poor communication contributed to the resident's repeated injuries and decline.
Removal Plan
- Nurse management team completed new fall risk assessments for all like residents.
- The interdisciplinary team updated all current resident's plans of care based on new risk assessments.
- Stop sign barrier banners have been placed at the entrance way of the stair well on ascending and descending sides to impede resident usage.
- Measurements for the stairwell have been taken by the Maintenance Director to research and implement a more permanent solution.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered by a physician for one resident during their stay. The resident, who had diagnoses including intellectual disabilities, pneumonia, and anxiety disorder, was admitted following hospitalization for a left ankle fracture. A physician order was placed for urinalysis (UA) with culture and sensitivity (C&S), complete blood count (CBC), and B-type natriuretic peptide (BNP) testing to rule out infection and monitor health status. However, review of the electronic medical record showed no lab results for these tests, and an interdisciplinary team note indicated no new labs had been completed. The facility's protocol required staff to process test requisitions and arrange for tests, but this was not followed. The deficiency was confirmed through interviews and record review, including an interview with the DON, who acknowledged that the lab draw was missed and the facility was not compliant with its own lab policy during the resident's stay. The issue was identified only after the resident was transferred to the hospital following a fall. The facility's own review confirmed that the required laboratory services were not provided as ordered between the dates in question.
Failure to Implement Individualized Skin Protection Interventions
Penalty
Summary
Facility staff failed to follow their own policy regarding the implementation of individualized interventions for skin protection for a resident with multiple pressure wounds. The resident, who was admitted with diagnoses including paraplegia, pressure ulcers, and contractures, required staff assistance for all activities of daily living. Upon review, the resident was found to have numerous wounds, including stage three and four pressure ulcers on various parts of the body. Despite these findings, the care plans only included general interventions such as monitoring skin during care and notifying nurses of changes, as well as evaluating and treating per physician orders. No additional individualized interventions or care plans were implemented to address the resident's specific skin management needs, as required by facility policy. The facility's Skin Protection Guideline policy mandates the identification of at-risk residents and the prompt implementation of individualized interventions to prevent and treat skin breakdown. However, the care plans for this resident did not reflect individualized strategies or a turning and repositioning schedule, despite the presence of multiple wounds. When questioned, the DON acknowledged that nurses were responsible for implementing wound and skin management interventions but did not provide further explanation or documentation regarding the lack of individualized care plans and interventions for the resident.
Failure to Provide Adequate Supervision and Resident-Specific Fall Prevention
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and implement resident-specific interventions to prevent falls for a resident with a known history of falls, severe intellectual disabilities, developmental delay, and non-compliance with care. The resident was admitted with multiple risk factors, including a recent joint replacement, non-weight bearing status, impulsiveness, combativeness, and inability to follow commands. Documentation from the transferring hospital and facility records consistently noted the resident's high fall risk, cognitive impairment, and need for 24/7 supervision and assistance. Despite these documented risks, the facility's care plans and interventions did not reflect the level of supervision or specific interventions required for the resident's safety. The care plans included general fall prevention strategies such as keeping the bed in a low position, encouraging hydration, and providing non-skid footwear, but did not address the resident's inability to comply with instructions or the need for increased monitoring. Staff and the DON acknowledged the resident's non-compliance and impulsiveness, but interventions such as increased monitoring were only communicated verbally and not documented or clearly defined in the care plan. The facility's policy required individualized assessment and implementation of adequate supervision, but this was not effectively carried out for this resident. The deficiency resulted in an unwitnessed fall, during which the resident sustained significant injuries, including a head laceration, facial bruising, and bleeding, necessitating transfer to the hospital for a higher level of care. The fall occurred despite earlier staff assistance and placement of the call light within reach. The facility's investigation confirmed that interventions for increased observation and supervision were not documented in the care plan, and the root cause analysis did not provide a clear explanation for the failure to prevent the fall.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. One resident, who wore a Life Vest (a wearable cardioverter defibrillator), reported that the vest was too tight and caused a painful wound on his torso. Despite the resident's complaints and visible skin impairment, there was no documentation of a skin assessment or treatment for the wound upon admission, and the care plan did not address the medical device-related wound or include interventions for monitoring skin under the vest. Weekly skin checks were ordered, but the vest was only removed for showers, limiting the ability to assess and protect the skin. The wound was eventually identified as a full-thickness pressure injury with slough and black, scab-like areas, but documentation and intervention were delayed, and there was no evidence of timely communication with the vest provider for a better fit. Another resident, who was quadriplegic and required total assistance for care, developed multiple pressure ulcers, some of which were acquired in the facility. The clinical record showed a lack of timely and accurate documentation of skin impairments, with wounds first identified at advanced stages (Unstageable or Stage 3) by a wound care consultant. There were significant gaps in weekly skin observations, and new wounds were not documented by facility staff prior to consultant identification. The care plan included general monitoring instructions, but there was no evidence that staff consistently monitored, documented, or reported changes in skin condition as required. Interviews with the DON and ADON revealed a lack of clear oversight and accountability for wound care, with inconsistent skin checks and delayed identification of wounds. The facility's own policy required daily skin inspections and immediate reporting of any signs of breakdown, but these procedures were not followed. The deficiencies resulted in the development and worsening of pressure ulcers for both residents, with inadequate documentation, assessment, and intervention throughout their stays.
Failure to Properly Date and Store Medications in Medication Cart
Penalty
Summary
Surveyors observed that an opened Humalog (insulin) pen was found undated in the top drawer of a medication cart during a medication pass with an LPN. The LPN confirmed the insulin pen was open and should have been dated but was unsure why it was not. Additionally, five loose, unidentifiable pills were found in the same medication cart drawer. The LPN, who identified as a new nurse, could not explain how the loose pills ended up in the drawer and stated that management was checking medication carts weekly. Interviews with the unit manager and the Director of Nursing confirmed that insulin should be dated upon opening and that staff are expected to follow facility procedures for medication storage and handling. Facility policy requires that all medications be stored in properly labeled containers, with opened medications such as insulin dated and assigned a new expiration date. The presence of undated insulin and loose pills in the medication cart indicated a failure to adhere to these established protocols.
Failure to Coordinate and Monitor Hospice Services
Penalty
Summary
The facility failed to ensure coordinated hospice service visits for a resident who was admitted with multiple diagnoses, including dementia, acute respiratory failure, high blood pressure, and Alzheimer's disease, and who was enrolled in hospice services. Record review showed significant gaps in hospice nurse and aide visits, with only three nurse visits documented over a one-month period and inconsistent aide visits, including a complete absence of aide visits for one month. The hospice visit schedule provided by the facility was unclear, lacking information on the discipline of staff making the visits, and was difficult to read. Interviews with facility staff revealed a lack of clarity regarding who was responsible for monitoring hospice staff visits. The social worker was unable to identify who ensured hospice services were provided as scheduled and did not follow up with this information. The DON acknowledged that a facility-initiated care plan for hospice services should have been in place but was not. Review of the facility's hospice policy confirmed the responsibility to coordinate care and maintain updated care plans, which was not met in this case.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for 26 out of 42 resident rooms, as determined through observation, interviews, and review of facility records. Measurements of the affected rooms showed that each had approximately 148 to 149 square feet for two residents, which is less than the required 160 square feet total (80 per resident). Interviews with residents revealed no complaints regarding room size, and there was no indication that resident health or safety was affected by the room dimensions. The facility administrator confirmed there were no current plans to expand or convert the rooms to singles, only plans for aesthetic changes.
Failure to Maintain Effective Grievance Resolution Process
Penalty
Summary
The facility failed to maintain an effective grievance resolution process, as evidenced by the lack of prompt and documented responses to resident concerns. One resident, who was cognitively intact, reported multiple instances of missing personal items, including clothing, a purse, a wallet, a significant amount of money, and a blanket. The resident stated that she had reported these issues to both a staff member and the Administrator, but did not receive any follow-up or information regarding what actions, if any, were taken to address her concerns. The Administrator confirmed that unless a formal grievance form was completed, concerns were not documented or formally investigated, and no records existed of any investigation or follow-up for this resident's reported missing items. Additionally, during a group interview with eight residents who attended resident council meetings, seven expressed ongoing dissatisfaction with the facility's handling of laundry, specifically regarding the return of their clothing. Residents reported that labeled clothing often did not return from laundry, and issues persisted for a long time without resolution or explanation from the facility. Residents also indicated a lack of clarity and confidence in the grievance process, with some stating that expressing concerns did not lead to resolution and that there was confusion about how to file grievances. A review of the facility's grievance policy revealed that all grievances, whether expressed orally or in writing, should be tracked, investigated, and resolved, with the resident kept informed of progress. The policy also required the Grievance Officer to maintain a log of all grievances. However, the facility's practice, as described by the Administrator, was to only document and investigate concerns if a formal grievance was filed, resulting in a lack of documentation, tracking, and resolution for concerns that were not formally submitted. This practice did not align with the facility's written policy and led to unresolved resident grievances.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin to the Administrator/Abuse Coordinator for a resident with severe cognitive impairment and wandering behaviors. The resident, who had diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, and Alzheimer's disease, was observed wandering into other residents' rooms, attempting to get into their beds, and was unable to provide clear explanations for her actions or injuries. On two separate occasions, the resident was found with unexplained bruises: one on the back of her right leg and another on her left eyebrow. In both cases, the source of the injuries was not witnessed, and the resident could not describe what had happened. A review of the clinical record and incident reports revealed that while the injuries were documented by staff, there was no associated investigation conducted or provided for either incident. The facility's policy required that injuries of unknown origin be immediately investigated and reported to the Administrator and, if necessary, to the State Agency. However, the Administrator confirmed that these incidents were not reported to him, and no further investigation was initiated as required by facility policy. Interviews with the Administrator/Abuse Coordinator confirmed that the protocol was not followed, as injuries of unknown origin should have been reported to initiate an investigation and determine if further reporting to the State Agency was necessary. The lack of reporting and investigation for these injuries constituted a failure to comply with the facility's own policy and regulatory requirements regarding the timely reporting and investigation of suspected abuse, neglect, or injuries of unknown origin.
Failure to Develop Integrated Hospice Care Plan
Penalty
Summary
The facility failed to develop and implement an integrated hospice care plan for a resident who was admitted with acute respiratory failure, high blood pressure, Alzheimer's disease, and dementia, and who was receiving hospice services. Although the hospice company had developed a care plan, the facility's own care plans did not include a plan for hospice services or outline coordination between the facility and the hospice provider. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that a facility care plan indicating hospice status and coordination should have been in place. Review of facility policy also indicated the requirement for a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the resident's identified needs.
Failure to Complete and Accurately Document Dressing Changes
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes, Parkinson's disease, and heart disease, who was cognitively intact, did not receive dressing changes for a skin tear as ordered. The resident was observed with a gauze dressing on his left wrist dated five days prior, and he reported that it had been a couple of days since the dressing was last changed. The treatment order specified that the wound should be cleansed, antibiotic ointment applied, and a dry dressing placed every day shift. Record review showed that the Treatment Administration Record (TAR) was marked as completed daily, indicating the dressing change was performed, even though the date on the dressing and the resident's statement suggested otherwise. The Director of Nursing confirmed the discrepancy between the TAR documentation and the actual date on the dressing, acknowledging that the TAR should only be marked as completed after the treatment is performed. This failure resulted in the resident not receiving care as ordered and documented.
Failure to Ensure Dignified Treatment During Resident Transport and Communication
Penalty
Summary
The facility failed to ensure that two residents were treated in a dignified manner, as required by policy. One resident was observed being transported in a geri-chair by a CNA who pulled the chair forward while the resident was facing backward, which is not an appropriate or respectful method of transport. Another resident was discussed by a CNA, who described the resident as sometimes being 'moody' and sleeping throughout the morning and into the afternoon, without further context or sensitivity. The DON confirmed that wheelchairs should not be pulled in a forward motion with the resident facing backward and that staff are expected to treat residents with dignity. The facility's policy emphasizes care that promotes dignity, respect, and individuality for each resident.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent accidents for three residents, resulting in incidents of elopement, repeated entry into other residents' rooms, and a fall without proper assessment or follow-up. One resident with a history of adjustment disorder, dementia, and severely impaired cognition was identified as an elopement risk and had demonstrated exit-seeking behaviors, including attempting to leave the floor and pushing on doors. Despite this, the only intervention in place prior to the resident's elopement was staff awareness of the wander risk. The resident was able to exit the building, traverse stairwells, and reach the parking lot before being intercepted by staff, indicating a lack of effective supervision and failure to implement additional interventions despite known risks. Another resident with severe cognitive impairment and a history of wandering was observed repeatedly entering other residents' rooms, sometimes attempting to get into their beds. The care plan for this resident included 30-minute checks after wandering incidents, but there was no documentation of these checks or of the resident's behaviors in the clinical record. Staff interviews revealed a lack of awareness and inconsistent documentation regarding the resident's wandering and the required interventions, and the resident experienced multiple falls, including one resulting in a head injury and hospital transfer. A third resident, with intact cognition but significant mobility assistance needs, experienced a fall in their room. The incident was documented as a behavior note rather than a fall, and there was no evidence of a post-incident assessment, incident report, or notification to the resident's physician or legal guardian. The care plan was not updated to reflect the incident, and staff interviews confirmed that the facility's process for fall events was not followed. Facility policies required identification, evaluation, implementation, and monitoring of interventions to reduce accident risks, but these processes were not consistently applied for the residents involved.
Failure to Include Stop Date for Antibiotic Therapy
Penalty
Summary
A nurse practitioner prescribed Ivermectin for a resident to treat possible scabies, with specific administration days outlined in the order. However, the order did not include a stop date, and as a result, the medication continued to be administered daily beyond the intended treatment period, except for a few days when the resident refused the medication. The medication was only discontinued after a review of the records revealed the ongoing administration. During interviews, the nurse practitioner stated they were unaware the medication had not been stopped after the intended treatment days and confirmed it should not have been given beyond that period. The Director of Nursing acknowledged that a stop date should have been included in the order. The facility's infection prevention and control manual specifies that antibiotic stewardship includes documenting the duration of therapy and ensuring discontinuation when antibiotics are no longer needed.
Failure to Prevent Misappropriation of Resident Funds by CNA
Penalty
Summary
A facility failed to protect a resident from misappropriation of funds when a Certified Nurse Aide (CNA) accepted and used the resident's debit card for unauthorized transactions. The resident, who had not left the facility except for hospital visits since admission, noticed suspicious transactions on her bank statement and reported that she had only given her debit card to one CNA to withdraw a specific amount of money. The CNA withdrew more money than authorized and made additional point-of-sale purchases unrelated to the resident's requests, including transactions near the CNA's home and not near the facility. The facility's investigation included interviews with the resident, the involved CNA, and another staff member, as well as a review of bank statements and facility policies. The resident consistently denied giving her card to anyone other than the implicated CNA. The CNA's actions were found to be in violation of the facility's code of conduct and policy regarding the misappropriation of resident property, which defines such misappropriation as the wrongful use of a resident's belongings or money without consent.
Failure to Ensure Proper Implementation and Documentation of Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices regarding transmission-based precautions (TBP) for two residents. One resident with an active physician's order for contact isolation due to scabies was observed multiple times without any TBP signage or an isolation caddy with personal protective equipment (PPE) on the door to their room. This lack of visible precautions was noted on several occasions, despite the ongoing order for contact isolation. Another resident was observed with both contact and droplet precaution signage and an isolation caddy on their door, but a review of their physician's orders revealed no active or discontinued orders for TBP. When questioned, the assigned nurse was unaware of the reason for the precautions and did not follow up. The facility's Director of Nursing later confirmed that the first resident should no longer have been on TBP and the order should have been discontinued, while the second resident should have had an order and indication for TBP. The facility's policy referenced CDC guidelines but did not specify whether a physician's order was required for TBP.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a fall with injury for a resident, resulting in actual harm when the resident required stitches to their shoulder after falling out of bed. The incident occurred when the resident, who was cognitively intact and had a history of stroke, heart failure, arthritis, anxiety, and depression, was left unattended by a Certified Nurse Aide (CNA) during the night shift. The resident was positioned on their side unsupported and rolled out of bed, sustaining a laceration that required 11 stitches. The resident was on a blood thinner at the time, increasing the risk of bleeding. The CNA, who was recently hired and unfamiliar with the resident, reported being overwhelmed due to being short-staffed and having to care for more residents than usual. The CNA left the resident unattended to gather supplies, believing the resident could hold their weight. The bed was positioned at mid-height and not lowered to the ground, which contributed to the fall. The CNA did not review the resident's care plan or any care designation guide, which indicated the resident required maximal assistance for bed mobility and was dependent on a full mechanical lift for transfers. The facility's policy on fall evaluation and safety guidelines was not adequately followed, as the resident was left in an unsafe position, leading to the fall. The incident report and investigation revealed that the CNA had only one day of training on the hall and was not familiar with the resident's specific needs. The resident's care plan required assistance by staff to turn and reposition in bed, which was not adhered to, resulting in the fall and subsequent injury.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to implement an effective discharge planning process for two residents, resulting in psychosocial harm. Resident R901, who had aphasia, a language barrier, and severe cognitive impairment, was discharged to a facility farther away from their family without the approval of their representative and without notifying the receiving facility. The discharge was initiated due to R901's wandering behavior and the facility's inability to provide adequate supervision. However, the facility did not involve R901's representative in the discharge planning process, nor did they provide an opportunity for discussion about the discharge plan, location, or appropriateness of the new facility for R901's care needs. The facility's social worker and interdisciplinary team did not engage with R901's family to develop a resident-specific discharge plan. The family was only informed of the transfer on the day it occurred, and the receiving facility was not notified in advance. R901 arrived at the new facility without personal belongings or medications, and the staff there were unaware of the transfer. The facility's discharge process lacked communication and coordination, leading to distress for R901's family, who were regular visitors and had not consented to the transfer. Resident R902 expressed dissatisfaction with their living situation and had requested assistance from the facility to transfer to another location. Despite the resident's intact cognition and clear communication of their desire to move, the facility did not follow up on the referrals sent to other facilities. The social worker did not provide updates to R902, and there was no evidence of further action taken to facilitate the transfer. This lack of follow-up and communication left R902 feeling frustrated and dissatisfied with their current living arrangements.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written transfer notification to a resident's representative and the Ombudsman, which is a requirement for facility-initiated transfers or discharges. The resident in question, identified as R901, was admitted to the facility after a hospital stay with diagnoses including aphasia, dementia, anxiety disorder, nutritional deficiency, and COPD. R901 had severe cognitive impairment and a language barrier, with their spouse appointed as the Durable Power of Attorney (DPOA). Despite these conditions, the facility did not provide the necessary written notice of transfer to the resident's representative or the Ombudsman. The facility's records showed that R901 was transferred to another facility due to the need for a more appropriate environment, as noted in a progress note. However, there was no evidence that the facility provided any written notices to R901's representative, nor did they involve the representative in developing a discharge plan. The representative was only informed via phone the day before the transfer, and they were not aware of the new facility's location, which was an hour away from their residence. This lack of communication and documentation was confirmed during interviews with the resident's spouse and daughter, who expressed their dissatisfaction with the process. Interviews with facility staff, including the social worker and the administrator, revealed that the facility did not follow its own policies regarding discharge planning and notification. The social worker admitted to not providing written notification, and the administrator acknowledged the concerns raised about the discharge process. The facility's policy requires a 30-day advance written notice for transfers or discharges, including specific information about the transfer, appeal rights, and contact information for relevant agencies, none of which were provided in this case.
Controlled Substance Documentation and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and administration of controlled substances for two residents, leading to discrepancies in medication records. For one resident, there were inconsistencies between the Medication Administration Record (MAR) and the Medication Monitoring/Control Record regarding the administration of alprazolam. The MAR indicated that the medication was given at specific times, but the Control Record did not document the removal of the medication from the supply, suggesting a lack of accountability for the controlled substance. Additionally, the facility was unable to provide the Control Records for certain dates, further highlighting the documentation issues. Another resident experienced a similar issue with the administration of controlled substances. A registered nurse expressed concerns about the administration and recording of medications, particularly controlled substances. The resident reported not receiving their pain medication, despite the controlled substance sheet indicating it had been signed out and administered. The resident later found two pills in their bed, which they believed were not their pain medication. A review of the resident's records revealed discrepancies between the doses signed out on the Control Record and those documented as given on the MAR. Interviews with the Director of Nursing (DON) confirmed that the facility's protocol requires medications to be signed out on the Control Record and marked as given on the MAR after being observed as taken. The DON acknowledged that medications should not be left for residents to take on their own and that any refusal should be documented. Despite these protocols, the facility was unable to provide additional documentation to reconcile the discrepancies between the Control Records and the MARs for the residents involved.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatment supplies in two of five medication carts, as observed during a survey. On the third floor, a Registered Nurse (RN) identified three insulin pens in the medication cart that lacked dates indicating when they were removed from refrigeration. The RN expressed uncertainty about how to proceed with these undated insulin pens, acknowledging that they should have been dated upon removal from the refrigerator. On the first floor, a review of the medication cart with a nurse revealed two insulin pens sealed with tamper-resistant tape, but without dates indicating when they were placed in the cart. Additionally, one of the pens lacked a label with a resident's name. The nurse was unable to identify when the pens were placed in the cart or the owner of the unlabeled pen. Further inspection of the cart revealed improper storage of various medications and treatment supplies, including rectal suppositories, topical lotions, creams, and shampoos stored alongside oral medications. The facility's Director of Nursing acknowledged awareness of the medication cart conditions and stated that maintaining cleanliness was the responsibility of all nurses.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to provide reasonable accommodation for resident needs by not promptly responding to call lights, affecting three residents. A complaint was received by the State Agency alleging that a resident had to wait for assistance for 45 minutes to an hour, leading to the involvement of the facility receptionist. Interviews and record reviews revealed that residents R800, R801, and R802 experienced delays in call light responses, prompting them to use personal cell phones to contact the receptionist for assistance. R800, diagnosed with Multiple Sclerosis and requiring extensive assistance with ADLs, expressed frustration over the delayed response times. R801, with a diagnosis of bladder dysfunction, diabetes, hypothyroidism, and chronic blood clots, reported that call lights could take up to 30 minutes to be answered, affecting their ability to receive timely meal deliveries. R802, who had a stroke resulting in left-sided paralysis, also resorted to calling the receptionist for basic needs like razors and water. The Director of Nursing (DON) acknowledged that nursing staff are educated to respond to call lights within 2-5 minutes, but the facility's outdated call light system does not allow for electronic tracking of response times. The DON was unaware that residents were contacting the receptionist due to unresponsive call lights and admitted that this was inappropriate. The facility's policy states that calls for assistance should be answered as soon as possible, but no later than 5 minutes, with urgent requests addressed immediately. The failure to adhere to this policy resulted in residents seeking alternative means to get assistance, highlighting a deficiency in the facility's response system.
Failure to Ensure Private and Confidential Mail Delivery
Penalty
Summary
The facility failed to ensure that residents' rights to private and confidential mail delivery were maintained. During a resident council interview, several residents expressed concerns about not receiving their mail timely and unopened. One resident showed an admission packet that included an authorization form allowing the facility to open certain types of mail, which raised concerns among other residents about the legality of this practice. The facility's policy on resident rights guarantees access to mail with privacy, and state law prohibits taking, holding, or destroying another person's mail. Interviews with the Administrator and the Admissions Director revealed a lack of awareness and inconsistency in the facility's mail handling practices. The Administrator admitted that mail should not be opened by staff and that residents should ask for help if needed. The Admissions Director acknowledged the admission agreement's verbiage but claimed it was a typo and was not responsible for the contract's contents. This inconsistency and lack of awareness led to the deficiency in maintaining residents' rights to private and confidential mail delivery.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents and visitors had access to previous survey results, which is a right guaranteed by federal and state laws. During a resident council interview with 11 residents, none were aware of where they could access the facility's survey binder or that anyone had discussed this with them previously. Additionally, the receptionist was unaware of the survey binders' location and the process for accessing them, despite signage indicating that such information was available upon request from the Administrator. The Administrator confirmed that the survey binder had been removed temporarily and was not put back, and the receptionist, who had been in their role for about three years, should have known about it. The facility's policy titled 'Resident Rights' guarantees residents the right to examine survey results. However, the facility did not adhere to this policy, as evidenced by the lack of awareness among residents and staff about the location and accessibility of the survey binders. The Administrator admitted that the survey binder had been removed temporarily and was not returned, leading to a situation where residents and visitors were uninformed of deficiencies identified in the facility. This failure had the potential to affect all residents residing in the facility.
Sanitary Conditions and Food Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure food items were labeled, dated, and discarded when expired. During an initial tour of the kitchen, personal items were found stored on top of food storage bins, and a scoop was improperly stored inside a bin of rice. The high-temperature dish machine had been non-functional for about two weeks, and staff were using a hose in a bottle of bleach for sanitizing without proper monitoring or testing strips to ensure effective sanitization. Additionally, the ice machine cleaning log was outdated, and the machine had visible debris, while the juice machine had accumulated thick dust despite weekly servicing claims. The walk-in freezer and refrigerator temperature logs were not up-to-date, and expired food items, such as cottage cheese and pre-scooped ice cream, were found in storage. The facility's Certified Food Manager (CFM) confirmed these observations and acknowledged the lapses in monitoring and discarding expired food. The dish machine, which had been temporarily fixed, still failed to reach the required sanitizing temperature during a test run, indicating ongoing issues with the equipment. These deficiencies were observed and confirmed through interviews and record reviews, highlighting the facility's failure to adhere to the 2017 FDA Food Code standards. The lack of proper food storage, labeling, and equipment maintenance had the potential to affect all residents consuming food from the kitchen, posing significant health risks due to possible contamination and inadequate sanitization practices.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents participating in the resident council were promptly documented, investigated, tracked, and resolved. During an interview with the Activity Director, it was revealed that some resident council minutes were damaged, and there was no documentation of follow-up on grievances. The Activity Director mentioned that concerns were being put on grievance forms since the last annual survey, but these forms were not provided for review by the end of the survey. Previous resident council minutes highlighted various concerns, including staff being on their phones, delayed call light responses, missing clothing, and inadequate housekeeping. However, there was no evidence of follow-up or resolution for these grievances. An interview with 11 residents confirmed that there was no follow-up on concerns discussed in previous resident council meetings. Residents reported ongoing issues with staffing, long response times to call lights, and missing personal items. The Administrator acknowledged the concern but could not provide further explanation. The facility's policy on grievances states that all grievances identified during the Resident Council meeting should be submitted immediately to the Grievance Official for investigation and resolution, with outcomes reported back to the Resident Council, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care and Routine Showers
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R9) and routine showers for another resident (R56). Continuous observations on 5/6/24 revealed that R9 was left without incontinence care from 10:42 AM to 12:39 PM, despite reporting discomfort due to being wet. Certified Nursing Assistant (CNA 'V') did not check or provide incontinence care when interacting with R9. The Director of Nursing (DON) confirmed that incontinence care should be provided every two hours, which was not done for R9. R9's clinical record indicated a diagnosis of dementia and Alzheimer's disease, with a care plan requiring assistance with toileting and incontinence care after each episode, which was not followed. Additionally, resident council interviews revealed that multiple residents had concerns about not receiving showers or having to wait prolonged periods for toileting/incontinence care. R56 reported receiving only two showers since admission on 4/11/2024. The DON confirmed that showers should be documented in the electronic health record and on paper, but records showed R56 received only one shower and refused another, with no rationale for missed showers. The facility's policy encourages a minimum of two showers per week, which was not adhered to for R56.
Improper Storage of Sharps on Medication Cart
Penalty
Summary
The facility failed to ensure an environment free from accident hazards regarding the storage of sharps, specifically blood sugar testing lancets, in one of four medication carts reviewed. On 5/7/24 at 8:15 AM, an observation revealed that the first-floor medication cart had a small, white plastic container with a handle, containing approximately 40 individual blood sugar testing lancets, stored on top without a covering or lid. There was no nurse in view of the cart or the surrounding area. When questioned, Nurse 'W' and Nurse 'C' were unable to explain why the lancets were stored in the container on top of the cart. The Director of Nursing (DON) confirmed that the lancets should not have been stored on top of the cart and directed Nurse 'W' to place the container inside the medication cart. The facility's Medication Storage Checklist Tool dated 6/2023 did not address the process for storing lancets before use.
Failure to Document and Assess Bed Rail Use
Penalty
Summary
The facility failed to have a system in place prior to installing assist bars/rails to ensure appropriate consent, assessment, and physician orders were completed with ongoing monitoring and assessment for eight residents. This resulted in the potential for inappropriate use and/or injury from the device. The deficiency was identified through observation, interview, and record review, revealing that the facility did not follow its own guidelines for bed rail device evaluation and documentation. For instance, Resident 32, who had moderate cognitive impairment, had assist rails/bars on their bed without any initial or follow-up assessments, clinical rationale, consent, or physician orders documented in their Electronic Medical Record (EMR). Similarly, Resident 42, who had intact cognition and required substantial staff assistance for mobility, also had assist rails without the necessary documentation and assessments. This pattern was consistent across other residents, including those with intact cognition and those with moderate cognitive impairment, indicating a systemic issue. Interviews with the Director of Rehab, physical therapist, and Director of Nursing revealed that there was a lack of clear responsibility and documentation regarding the assessment and need for assist bars/rails. The facility's own guidelines stipulated the need for regular bed maintenance, individual bed rail evaluations, informed consent, and physician orders, none of which were consistently followed. This lack of adherence to established protocols posed a potential risk to all 76 residents of the facility.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff was provided for the residents on the first floor, resulting in delayed medication administration and increased potential for unmet care needs. Multiple residents, including R72, reported concerns about not receiving timely care and assistance. The resident council minutes highlighted ongoing issues with call lights not being answered promptly and insufficient nursing staff, particularly when agency staff were present. Specific complaints included cold food, infrequent showers, and agency staff being inattentive and unprofessional. R72 specifically reported not receiving their scheduled medications on time, which was confirmed by a review of their Medication Administration Records (MARs) showing blank entries for the 9:00 AM medications. Nurse 'C', an agency nurse, admitted to being overwhelmed with the number of residents and tasks, leading to delays in medication administration. The Director of Nursing (DON) acknowledged the concerns but indicated that no additional nursing staff had been added despite discussions. The facility's policies on staffing and medication administration were not adhered to, as medications were not administered within the prescribed time frame, and there was no documentation of physician notification for late administration. Interviews with other nursing staff confirmed that only one nurse was typically assigned to the first floor, making it challenging to administer medications on time. The DON later confirmed that 11 out of 30 residents on the first floor required two-person assistance, further highlighting the inadequacy of the staffing levels.
Infection Control and Linen Storage Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control practices with regards to Enhanced Barrier Precautions (EBP) and linen storage for eight residents. Observations revealed that residents with conditions requiring EBP, such as surgical wounds, colostomies, tube feedings, and indwelling catheters, did not have signs posted indicating the type of precautions and PPE required. Additionally, no PPE was readily available for staff use, and no staff were observed wearing PPE during direct care activities for these residents. The Director of Nursing (DON) and Unit Manager acknowledged the oversight but had not implemented the necessary precautions. For instance, one resident with a large dressing on their right lower leg had no EBP signs or PPE available, despite having a surgical wound. Another resident with a colostomy bag also lacked EBP signs and PPE. Similar deficiencies were noted for residents with tube feeding pumps, catheters, and other indwelling devices. The DON confirmed awareness of the EBP changes but admitted that no residents had been properly identified or labeled for EBP. Additionally, the facility failed to maintain proper linen storage practices. Observations of linen carts revealed the presence of personal care items, briefs, wipes, and even a used Styrofoam cup stored directly with clean linens. The DON confirmed that these items should not be stored with linens and began removing them. However, the facility's policy did not address the storage of non-linen items with linens, indicating a gap in their infection control procedures.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the actions of an LPN towards a resident (R73). The resident, who was cognitively intact and had a history of traumatic subdural hemorrhage, a displaced trimalleolar fracture, and confirmed adult physical abuse, reported that the LPN accused them of drug-seeking behavior in front of other residents and staff. This accusation affected how other staff treated the resident. The resident's care plan included interventions for pain management, but the LPN's progress notes contained subjective and inappropriate comments about the resident's behavior and attitude, which were not aligned with the facility's policy on resident rights to be treated with respect and dignity. The Director of Nursing (DON) acknowledged that subjective information should not be included in progress notes and admitted that the LPN's notes were inappropriate. Despite the resident's complaints and the subjective nature of the LPN's documentation, the DON was unaware of any personality conflict between the resident and the LPN. The LPN admitted to having a weakness in subjective charting but denied any personal issues with the resident. The facility's policy on resident rights emphasized the importance of treating residents with respect, kindness, and dignity, which was not upheld in this case.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident (R12) was assessed for safe self-administration of medication. R12, a long-term resident with diagnoses including pneumonia, lung cancer, and depression, was observed with an albuterol inhaler on their bedside table, which they reported using as needed. Despite having a BIMS score of 15/15, indicating intact cognition, there was no documentation in R12's Electronic Medical Record (EMR) or care plan regarding their ability to self-administer medication. Interviews with the unit manager and LPN confirmed that R12 was self-administering the inhaler without an assessment or care plan in place. The Director of Nursing (DON) acknowledged the lack of an assessment and care plan for R12's self-administration of medication. The facility's policy on self-administration of medication was requested but not provided before the survey exit. This oversight indicates a failure in the facility's process to ensure residents are safely administering their medications as per physician orders.
Resident's Right to Refuse Room Change Not Upheld
Penalty
Summary
The facility failed to ensure a resident with a confirmed history of physical abuse was not threatened to change rooms for staff convenience. The resident, who was cognitively intact and had a history of traumatic subdural hemorrhage and a trimalleolar fracture, expressed issues with a particular LPN and requested not to have this nurse assigned to them. The resident was told by the Administrator that they would have to change rooms to avoid the LPN, despite the resident's attachment to their current room as a safe place. The Administrator did not consider utilizing other nurses in the facility to accommodate the resident's preference. The resident's comprehensive care plan included a focus on providing a safe environment due to their history of physical abuse. However, the facility's actions contradicted this care plan by suggesting a room change instead of addressing the resident's concerns about the LPN. The facility's policy on resident rights, which supports residents in exercising their rights, was not upheld in this instance. The Administrator's response indicated a lack of consideration for the resident's preferences and safety needs, leading to the deficiency noted in the report.
Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for one resident reviewed for medication administration. During a confidential resident council meeting, several residents voiced concerns about frequently receiving their medications late. One resident, who was their own responsible party, reported not receiving their scheduled 9:00 AM medications and questioned if it was their responsibility to ask for them. A review of the resident's Medication Administration Records (MARs) revealed that none of the 9:00 AM medications had been documented as administered, and there was no documentation that the physician had been notified or approved the late administration. An interview with Nurse 'C', who was from a staffing agency, revealed that they were unsure how many residents they had left to administer medications to and expressed concern about the workload. The Director of Nursing (DON) acknowledged the concerns raised by residents and reported that other staff should be available to help when needed. Despite being informed of the issues, the DON confirmed that the medications were later documented as administered without proper notification to the physician, and the documentation falsely reflected that the medications were given at the scheduled time. Further review of the clinical record and interviews with the DON revealed that the facility's process for late medication administration was not followed. The facility's policy required medications to be administered within one hour of the prescribed time, and if not, the physician should be notified. However, there was no documentation of physician notification for the late administrations, and the facility's policy did not address this requirement. The DON also reported that the staffing levels and assistance required for residents were not adequately managed, contributing to the delay in medication administration.
Failure to Implement Pressure Ulcer Prevention and Conduct Skin Assessments
Penalty
Summary
The facility failed to consistently implement interventions to prevent the development of a new pressure ulcer and/or worsening of an existing pressure ulcer for one resident and failed to ensure skin assessments were completed for another resident. Resident R42, who had multiple serious health conditions and was dependent on staff for mobility, was observed multiple times without the necessary pressure-relieving interventions in place. Despite having a low air loss mattress and heel offloading boots ordered, these were not utilized, and R42 was left lying on a regular mattress with heels unsupported. The staff failed to implement the ordered interventions, and there was a lack of communication and follow-through among the staff and maintenance department regarding the necessary equipment and care for R42. Resident R9, who had moderate cognitive impairment and was always incontinent of bowel and bladder, was observed sitting in a wheelchair and later in the dining room without being offered or assisted with toileting or incontinence care for an extended period. The CNA assigned to R9 was unaware of the resident's incontinence needs and did not check or assist the resident as required. Additionally, R9's clinical record revealed a lack of documented skin assessments from March to May, despite having an order for weekly skin checks. The DON acknowledged the lapse in monitoring and the concern it raised. The facility's failure to implement and follow through with the necessary interventions and assessments for pressure ulcer prevention and management for both residents highlights significant deficiencies in care and communication among the staff. The lack of adherence to the care plans and orders resulted in inadequate care for residents at risk of skin breakdown and pressure ulcers.
Failure to Document Intermittent Catheterization
Penalty
Summary
The facility failed to ensure complete and accurate documentation of intermittent catheterization for a resident with quadriplegia and neuromuscular dysfunction of the bladder. The resident reported experiencing significant discomfort due to difficulty urinating and requested catheterization. The midnight nurse deferred the procedure to the day nurse due to an impending shift change. When the day nurse performed the catheterization, a substantial amount of urine (1200 ml) was obtained, but this amount was not documented in the resident's records. Additionally, the midnight nurse had previously obtained 900 ml of urine at 9:00 PM the night before, but this was also not documented properly. Review of the resident's Treatment Administration Record revealed that the catheterization procedure was not documented for two scheduled times on the previous day. The Director of Nursing confirmed that the amount of urine obtained from catheterization should be documented to inform the physician about the resident's urine retention levels. The lack of documentation was acknowledged, but no further documentation was provided before the end of the survey.
Failure to Ensure Adequate Indication and Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident prescribed psychotropic medication had adequate indication for use, appropriate consent, and clinical rationale to support continued use in the absence of mood or behavior symptoms. The resident, who was admitted with multiple diagnoses including vascular dementia and anxiety, was observed to be moderately cognitively impaired but had no documented behavior concerns or hallucinations. Despite this, the resident was prescribed Seroquel for depression without any attempt at gradual dose reduction or physician documentation that a reduction was clinically contraindicated. Additionally, the care plan lacked specific details on the clinical rationale for the medication or target behaviors for staff to monitor. The social service assessment for the resident was incomplete and flagged as overdue, and there was no documentation indicating the resident had been deemed incompetent. The Social Service Director confirmed that the resident's spouse had signed a generic consent form without identifying clinical rationale or targeted behaviors, despite the resident being listed as their own responsible party. The Medical Director and a contracted psychologist had conflicting opinions on the resident's competency, but the Medical Director's assessment did not provide specific clinical rationale for the use of the antipsychotic medication. Further review of the clinical record revealed no additional documentation or completed assessments to support the use of the antipsychotic medication. The facility's policy on psychotropic medication management was not followed, as there was no informed consent from the resident, no appropriate monitoring for mood or behavior, and no individualized care plan reflecting pharmacological and non-pharmacological interventions. The lack of supporting documentation resulted in the unnecessary use of psychotropic medication and the inability to monitor its effectiveness.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in multiple resident rooms for 26 out of 42 rooms. This deficiency was identified through observation, interview, and record review. Specific rooms, including rooms 101 through 113 and 201 through 213, were found to have less than the required space, with room sizes ranging from 145 to 156 square feet for two residents. Despite individual interviews with residents revealing no complaints regarding the room size, the facility did not meet the regulatory requirements for room space per resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,127 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orchard Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marvin & Betty Danto Health Care Center | 3.5 mi | ★★★★★ | 6 | 0 |
| West Bloomfield Health And Rehabilitation Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Notting Hill Of West Bloomfield | 3.6 mi | ★★★★★ | 23 | 0 |
| Medilodge Of West Bloomfield | 4.2 mi | ★★★★★ | 21 | 0 |
| Westlake Health Campus | 4.5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Villa At Green Lake Estates.
100% money-back within 48 hours.
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.