Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At Silverbell Estates during CMS and state inspections, most recent first.
Food service areas had multiple equipment and sanitation issues, including frozen condensate in the walk-in freezer, a damaged walk-in cooler door with an exposed sharp edge, an overflowing ice machine drain tray, and a resident/personal food refrigerator holding at 47 F. The dish machine area also had dried debris on the machine and gauges, missing gauge covers, missing caulk and wall tiles, and black buildup on the wall, while about half of the domed plate covers were heavily worn and peeling.
Improper Waste Disposal and Dumpster Area Maintenance: Surveyors observed the outside garbage enclosure with multiple items stored within and adjacent to it, including wood pallets, a grill, a small refrigerator, and a cabinet unit. Loose litter, including food wrappers and used gloves, was also seen on the ground in the adjacent wooded area. The MD stated the items were intended for disposal and would be removed as soon as possible, including large items into the dumpster as space was available.
Unsafe Premises and Damaged Fixtures: A resident had an extension cord covered with plastic plugged into the wall and running across the bed to charge a cell phone, and another resident had a similar extension cord and phone setup across the bed. Surveyors also observed missing and damaged floor tiles, damaged concrete around a shower room drain, separated and missing wall base molding, and worn wooden handrails with exposed, splintered surfaces and missing corner endcaps in multiple hallways.
The facility failed to keep complete documentation of monthly pharmacist MRRs for several residents with complex medical histories, including diabetes, dementia, schizophrenia, and other chronic conditions. Multiple EMR entries only said “See report for comment,” but the actual pharmacy reports and physician responses were not available for review, and some monthly reviews were missing altogether. Staff stated the documents should have been scanned into the EMR, but they were not available when surveyed.
Medication and treatment cart storage was not maintained in a clean, safe, and sanitary manner. A treatment cart was observed unlocked with supplies stored inside, and a medication cart had a heavily soiled drawer with sticky debris. A liquid nutritional supplement and a package of heartburn relief medication were both observed with dark tan sticky substance on the containers, and the LPN could not explain the condition of the cart or items.
Call lights were not kept within reach for three residents. One resident in bed reported not having a call light when asking for a soda pop, and CNAs could not locate it; the Administrator later found it out of reach. Two other residents also had call lights placed out of reach, including one behind the bed and one on the floor across the room. The DON stated call lights should be within reach wherever the resident is in the room.
A resident with dementia, anxiety, epilepsy, hemiplegia, and repeated falls received frequent PRN lorazepam in both oral and powder forms while also taking scheduled buspirone. Many EMR entries did not identify the specific behaviors prompting use or document non-pharmacological interventions, and the DON and ADON acknowledged the lack of clinical rationale and supporting documentation for the duplicate anxiolytic use.
A resident with dementia, anxiety, mood disturbance, and other significant diagnoses had multiple scheduled and PRN psychotropic orders, and the MAR showed repeated PRN anti-anxiety use. The resident was observed in a wheelchair in the hallway and a staff member noted the resident was easily agitated, but the care plan did not address the resident’s psychotropic medication use, targeted behaviors, or non-pharmacological interventions; the DON and ADON confirmed no such care plan had been initiated.
Failure to use EBP during wound care dressing changes. A resident with an open vascular wound to the ankle, along with COPD, malnutrition, peripheral vascular disease, and mild cognitive impairment, had no EBP signage or documented EBP orders/care plan. During an observed dressing change, an LPN did not wear a gown and touched the soiled dressing with loose hair, while the DON and Infection Control RN acknowledged that wound care requiring dressing changes was to be on EBP.
A resident with documented osteomyelitis and recurrent major depressive disorder had a signed DNR order and advance directive clearly indicating no resuscitation if heart or breathing stopped. Despite this, when the resident was found unresponsive on a bathroom floor without respirations or pulse, staff initiated a Code Blue and performed five rounds of CPR without first verifying code status. A nurse supervisor and the resident’s nurse later acknowledged that the DNR status had not been checked before starting CPR, and the DON confirmed that nursing staff failed to review the advance directive, resulting in CPR and transfer to an acute care hospital against the resident’s expressed wishes.
A resident with multiple medical conditions, including a prior femur fracture, was injured during a transfer when staff used a Hoyer sling that was not properly inspected and was in poor condition. The sling snapped during the transfer, causing the resident to fall and sustain a right femur fracture that required surgery and hospitalization. Staff interviews confirmed the sling was old and damaged, and laundry staff had no established protocol for inspecting slings prior to use.
A resident with dementia and physical impairments was found with extensive bruising by several CNAs over a period of days, but the injury was not promptly reported to the Administrator or Abuse Coordinator as required by facility policy. The assigned nurse delayed both assessment and notification, and other staff failed to escalate the concern, resulting in a deficiency for not timely reporting suspected abuse or injury.
A resident with dementia and a hip contracture developed extensive bruising and a change in mentation, but staff failed to perform or document a thorough assessment, including skin and pain evaluation, after the initial report. Nursing staff did not directly assess the resident or monitor her condition for several hours before she was sent to the hospital, and no skin assessments were documented for an extended period. Leadership was unaware of the lack of assessment and monitoring, resulting in a deficiency related to inadequate care and documentation.
A resident with chronic pain did not receive scheduled Morphine due to the facility running out of the medication, and there was a discrepancy in documentation. The resident reported going without the medication for days, and the DON confirmed that medications should be ordered timely. An LPN failed to update the MAR after the resident initially refused but later accepted the medication. The facility's policy on reordering controlled substances was not followed.
A resident with multiple comorbidities, including respiratory distress, was found to have tracheostomy supplies improperly stored in their room. An open box of tracheostomy mask tubing was observed on the floor, with one open package resting on a trash can. Staff acknowledged the supplies should not have been on the floor and should have been sealed, as per CDC guidelines.
A portable oxygen tank was found unsecured and leaning against a wall in a nursing station near resident areas, posing a potential safety hazard. Nurse A and the DON acknowledged the tank should have been secured with a caddy, as per facility policy, to prevent accidents.
The facility failed to maintain sanitary conditions in food preparation, storage, and distribution, including issues with staff hygiene, unclean equipment, and improper food labeling and storage, potentially affecting all residents consuming food from the kitchen.
The facility failed to ensure dignified treatment for seven residents, with CNAs entering rooms without permission, using undignified terms, and standing while feeding residents. Additionally, a resident with a colostomy was improperly cared for with a plastic bag and towels, which the DON confirmed was inappropriate.
The facility failed to provide sufficient nursing staff on weekends, affecting resident care. Residents reported long wait times for call light responses and slow meal tray delivery. The staffing coordinator confirmed the struggle with weekend staffing, particularly on Sundays, leading to missed showers and delayed responses. A resident and a CNA both expressed concerns about the impact of staff shortages on resident care.
The facility failed to ensure proper storage and security of medications, with multiple medication carts observed unlocked and unattended, and three unopened insulin pens improperly stored in a cart instead of the refrigerator. The DON confirmed the requirements for medication storage and security.
The facility failed to ensure palatable meals for six residents, resulting in complaints about insufficient portions, tough and cold food, and lack of meal choices. Observations revealed unappetizing food and improper food temperatures, with the dietary manager acknowledging the issues.
The facility failed to meet the food preferences of seven residents, resulting in complaints and dissatisfaction with meals. Issues included residents not receiving requested items, meal tickets not matching served meals, and ongoing problems acknowledged by the Dietary Manager.
The facility failed to implement enhanced barrier precautions (EBP) and required PPE for residents with urinary catheters, colostomies, wounds, or feeding tubes. The Director of Nursing acknowledged incomplete staff education and considered CDC guidelines as recommendations.
A resident with multiple health conditions requested to go to the emergency room due to not feeling well and suspecting pneumonia. The facility staff did not facilitate the transfer, and the resident had to call 911 themselves. The resident was later diagnosed with pneumonia and received IV antibiotics at the hospital.
The facility failed to provide proper documentation for the involuntary discharge of a resident who was found with alcohol. Interviews with the SSD and DON revealed inconsistencies and lack of documentation to support the discharge decision.
The facility failed to order X-rays in a timely manner after a resident's fall, despite the resident experiencing severe pain. The resident initially refused assessment and pain medication, and the facility's attempts to contact the physician were unsuccessful due to after-hours issues. X-rays were not ordered until the afternoon, highlighting a gap in the facility's procedures for timely diagnostic testing.
A resident with dementia and legal blindness did not receive appropriate vision care, including the application of warm compresses for blepharitis, as ordered by an optometrist. Despite multiple reports from the resident about their vision difficulties, the facility failed to document or follow through with the necessary care.
The facility failed to follow Physician's orders for oxygen therapy for two residents. One resident received 1.5 LPM instead of the prescribed 3 LPM, and another had an oxygen concentrator set at 5 LPM instead of 3 LPM, with improper placement of the humidification bottle.
The facility failed to provide adequate pain management for two residents, resulting in unrelieved pain. One resident with a fractured humerus did not receive any pain medication despite hospital discharge instructions, while another resident with cancer experienced significant delays in receiving prescribed morphine.
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12% error rate. During a medication pass, a nurse did not administer several medications and did not sign out an as-needed medication. The DON acknowledged that staff education on a new liberal medication schedule was still in progress.
The facility failed to document pertinent information for a resident with severe cognitive impairment and no legal representative. Despite efforts by a social service worker to obtain a legal guardian, there was no documentation of these efforts or the guardianship process in the resident's medical record.
The facility failed to ensure accurate wound assessments, timely treatment, and coordination of care for two residents with pressure wounds. One resident developed an infected unstageable wound requiring hospitalization, while another had untreated pressure sores on their penis and bottom. The facility did not follow its skin protection guidelines, leading to these deficiencies.
The facility failed to document the administration of Schedule II controlled substances according to professional standards for nine residents. Discrepancies were found between documented and actual amounts of medications, and nurses admitted to not documenting removals in a timely manner. The DON confirmed the protocol but could not explain the discrepancies found in closed clinical records.
The facility failed to accurately reconcile, administer, and document Schedule II controlled substances, leading to discrepancies in medication counts for multiple residents. LPNs admitted to not reporting discrepancies and failing to document medication administration properly. The DON confirmed that the facility's process for administering controlled substances was not followed, resulting in significant documentation and administration errors.
A resident with multiple diagnoses, including heart failure, had an x-ray showing pulmonary vascular congestion that was not promptly reviewed by the physician. Despite worsening symptoms, there was no documentation of a timely assessment or review of the x-ray results, leading to the resident being sent to the hospital for evaluation.
Food Service Equipment and Surfaces Not Maintained in Cleanable Condition
Penalty
Summary
Food service equipment and surfaces were found in poor condition and not maintained in good repair during a kitchen tour and dining room observations. In the walk-in freezer, frozen condensate had built up on the shelving and floor. The interior of the walk-in cooler door was damaged, with surface material pulling away and creating an exposed sharp edge, and the door surface was no longer smooth and cleanable. The Dietary Manager stated repair requests had already been entered in the electronic maintenance tracking system for both issues. Additional observations in the dining and dishwashing areas showed a Pinegrove dining room ice machine drain tray full of water and overflowing onto the floor, and a resident/personal food refrigerator in the Pinegrove dining room holding at 47 F as verified by the unit thermometer and a digital thermometer. In the dishwashing area, the top of the dish machine and the pressure and temperature gauges had dried red-brown debris, the gauge covers were missing, there was no caulk between the stainless drainboard and wall, several wall tiles were missing behind the dish machine, and a black substance had built up on the wall above the drainboard surround. Half of the domed plate covers used for lunch service were heavily worn with peeling interior surfaces and were no longer smooth and cleanable.
Improper Waste Disposal and Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests. On 05/04/2026 at 9:40 AM, surveyors observed the outside garbage enclosure with several items stored within and adjacent to it, including approximately 10 wood pallets, a grill, a small refrigerator, and a cabinet unit. Surveyors also observed many loose litter items, including food wrappers and used gloves, on the ground in the adjacent wooded area. Later that day, at 3:45 PM, the maintenance director stated that the items were intended for disposal and would be removed as soon as possible, including large items into the dumpster as space was available.
Unsafe Premises and Damaged Fixtures
Penalty
Summary
The facility failed to maintain general repair and safe conditions of the premises. During observation, a resident was seen lying in bed with an extension cord covered with plastic plugged into the wall and running across the resident’s bed; the resident stated the cord was being used to charge a cell phone. On a later observation, the same extension cord was still plugged into the wall and lying on the resident’s bed. Another resident was observed lying in bed with an extension cord plugged into the wall and a cell phone attached to the cord running across the bed, and on a later observation the extension cord remained plugged into the wall with the resident’s phone attached. During a tour with the Maintenance Director and Regional Maintenance Director, surveyors observed missing and damaged floor tiles and damaged concrete around the floor drain in the Oakland Hall central shower room. They also observed plastic molding at the wall base separated from the wall and some molding missing. In four unit hallways, many wooden handrails were worn with eroded coating, exposed surfaces, and in some places damaged and splintered; several handrail corner endcaps were missing, leaving exposed sharp corners. The Maintenance Director and Regional Maintenance Director acknowledged the observed items, and it was indicated that needed repairs would be logged into the electronic tracking system and addressed.
Missing Documentation for Monthly Pharmacy Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacist drug regimen reviews were properly documented in the residents’ electronic medical records and that irregularities identified by the consultant pharmacist were addressed and noted in the chart for five residents reviewed. The deficiency involved residents with multiple chronic conditions, including diabetes, schizophrenia, dementia, vascular dementia, anxiety, depression, intellectual disabilities, chronic kidney disease, dysphagia, and osteoarthritis. For several residents, the pharmacy notes in the EMR stated only “See reports for comment,” but the actual reports and any physician response to the pharmacist’s recommendations were not available in the record. For one resident with diabetes, schizophrenia, and PTSD, multiple MRR notes were present, but the chart did not contain the referenced reports or any physician response. Another resident with senile degeneration of the brain, diabetes, and dementia had several MRR notes with the same “See reports for comment” notation, but the record lacked the underlying reports and physician follow-up, and two monthly reviews were not found at all. A resident with senile degeneration of the brain, diabetes, and depressive disorder had one MRR note that referenced a report, but the report content and physician response were not documented in the chart. Two additional residents also had MRR entries that referenced reports without the actual irregularity documentation or physician response being available in the EMR. One resident had monthly pharmacy reviews from June 2025 through May 2026 with two entries marked “See report for comment,” and another resident had five monthly reviews with that same notation. During interviews, staff reported that the documents should have been scanned into the EMR, but the records were not available for surveyor review, and the facility stated it was still gathering the information at the exit conference.
Medication and Treatment Cart Storage Not Maintained in Sanitary Condition
Penalty
Summary
Medications and biologicals were not maintained in a clean, safe, and sanitary manner in one medication cart and one treatment cart. On 5/3/26, the treatment cart in the hallway outside the small dining room was observed unlocked, with treatment and biological supplies stored inside the cart. On 5/4/26, the medication cart used by Nurse F was observed with a drawer containing several bottles of liquids that was heavily soiled with sticky debris on the bottom of the drawer. During the same observation, a bottle of liquid nutritional supplement labeled as opened on 4/15/26 had a dark tan sticky substance around the lid and on the side of the bottle. In another storage compartment of the same medication drawer, a package of generic heartburn relief medication labeled as opened on 3/25/26 was also covered with the same dark tan sticky substance. When asked about the condition of the cart and its contents, Nurse F stated they could not offer any further explanation and would have to follow up to clean it up. The DON later stated that each nurse is responsible for ensuring the carts are clean, and the facility policy required medication storage and preparation areas to be maintained in a clean, safe, and sanitary manner and to be locked when not in use.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure call lights were accessible to residents for three residents reviewed for accommodation of needs. R8 was observed lying in bed and told staff they were very thirsty and wanted a soda pop, but reported they did not have a call light to press. Two CNAs responded to the roommate’s call light, could not locate R8’s call light, and told the resident they could not provide a soda pop because R8 needed to give them money to purchase it. The Administrator later entered the room, located the call light, and stated it was out of the resident’s reach and should have been placed within reach. R8’s record showed diagnoses including senile degeneration of brain, type II diabetes, and dementia. R47 was observed lying in bed with the head of bed elevated, and the call light was behind the head of the bed on the mechanical portions of the bed and out of reach. R47 stated they could not find the call light and would not be able to ask for help right then. R93 was observed seated in a wheelchair beside the bed, with the call light on the floor on the other side of the bed and not within reach; R93 stated that when they were in bed they could usually reach it, but could not right then. A CNA assigned to the room stated the call lights should be placed where the residents could reach them. The DON stated the facility’s process was for call lights to be within reach wherever the resident was in the room, and the facility had not identified any issues with call light placement prior to the survey.
PRN anxiolytic use lacked behavioral documentation and non-pharmacological interventions
Penalty
Summary
The facility failed to consistently identify targeted symptoms and document non-pharmacological interventions before administering multiple PRN anti-anxiety medications to one resident. The resident had diagnoses including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, epilepsy with status epilepticus, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction, adjustment disorder with depressed mood, mild neurocognitive disorder, insomnia, repeated falls, and a right hand contracture. The MDS described moderately impaired cognition and multiple mood concerns, but no hallucinations, delusions, or behaviors were identified. The resident received repeated PRN lorazepam administrations in both oral and powder form, and many of the EMAR entries did not describe the specific behaviors that prompted use or what non-pharmacological interventions had been attempted. Several entries only noted general terms such as agitation, restlessness, or combativeness without details of how the behavior presented, when it occurred, or with whom. Some administrations were documented around times when the resident was attempting to stand, self-transfer, or walk, and there was no documentation supporting why both oral and powder lorazepam were given at or near the same time in some instances. The record showed 58 PRN doses of lorazepam from 4/2/26 through 5/4/26, in addition to scheduled buspirone 15 mg three times daily, which had been increased from 10 mg TID on 4/24/26. Nursing notes included examples such as the resident being restless, agitated, fidgeting, combative, or found on the floor or on his knees, but most administrations lacked supporting clinical rationale. During interview, the DON and ADON acknowledged that nurses should document why PRN psychotropic medication was given and should document non-pharmacological interventions, and the ADON stated that agitation/restlessness were symptoms rather than an indication. The DON also confirmed there was no mention of the resident’s lorazepam use or clinical rationale, including specific targeted behaviors and justification for duplicate anxiolytic medication, and acknowledged that some staff documentation contained minimal detail or no supporting documentation.
Failure to Care Plan Psychotropic Medication Use and Targeted Behaviors
Penalty
Summary
The facility failed to develop an individualized care plan for one resident’s use of psychotropic medications and specific targeted behaviors, and failed to identify non-pharmacological interventions. The resident was observed self-propelling in a wheelchair in the hallway and was attempted to be interviewed but did not respond and continued down the hallway. A staff member who observed the interaction stated caution was needed because the resident was easily agitated. The resident was admitted and readmitted with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, epilepsy with status epilepticus, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, adjustment disorder with depressed mood, mild neurocognitive disorder, insomnia, repeated falls, contracture of the right hand, and other specified disorders of the brain. The MDS showed moderately impaired cognition and multiple mood concerns, and the MAR documented multiple PRN anti-anxiety medication administrations. Current physician orders included scheduled anti-anxiety and anti-depressant medications and multiple PRN anti-anxiety medications, but the care plan contained no interventions for the psychotropic medication use, targeted behaviors, or non-pharmacological approaches. The DON and ADON reviewed the record and confirmed no such care plan had been initiated.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open vascular wound to the right outer ankle. The resident was admitted with a history of COPD, malnutrition, and peripheral vascular disease, and a BIMS score of 8/15 indicated mild cognitive impairment. On observation, the resident’s right foot was elevated and dressed with white gauze and tape, and no EBP signage was observed outside the room. Record review showed the wound was identified on 4/24/26, but EBP orders and care plan documentation were not present. Orders were later implemented for daily wound care to the right ankle, including cleansing with normal saline, applying Santyl, covering with moistened gauze with Dakins, and securing with gauze. During an observed dressing change, an LPN did not don a gown and was seen with hair draping loosely over and touching the removed soiled dressing. When asked about precautions, the LPN stated the resident did not have an active infection and did not require EBP, and said there was no sign or PPE cart in front of the room to indicate precautions. The DON and Infection Control RN later acknowledged that wound care requiring dressing changes was to be on EBP and confirmed the resident was not on precautions.
Failure to Honor Resident DNR Resulting in Unwanted CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s advance directive and DNR (Do Not Resuscitate) order when the resident was found unresponsive. The resident had been initially admitted with diagnoses including osteomyelitis of the left hand and recurrent major depressive disorder. The medical record contained a Code Status-Elective Form signed by the resident and the attending physician indicating a DNR status, explicitly stating that no one should attempt resuscitation if the resident’s heart and breathing stopped. A physician’s order and a social services evaluation also documented that the resident had an advance directive specifying DNR status, with copies of the directive present in the chart. On the date of the incident, an incident/accident note documented that the resident was found unresponsive on the bathroom floor with no respirations and no palpable pulse, and a pipe and cigarette lighter with an unknown substance were observed nearby. Staff initiated a Code Blue and began CPR at 23:03, completing five rounds of chest compressions. The note states that the resident regained spontaneous respirations and a palpable pulse prior to EMS arrival, remained unresponsive but breathing spontaneously, and was then transferred to an acute care hospital for a higher level of care. Interviews with staff confirmed that the resident’s DNR status was not checked before CPR was started. The nurse supervisor who performed CPR reported that they did not verify the resident’s code status, assuming the primary nurse had already done so, despite stating that the nursing standard was to quickly verify code status before initiating CPR. The resident’s nurse at the time of the event also acknowledged that they did not verify the code status before the team started CPR and later learned the resident was DNR and should not have received resuscitation. The DON confirmed that issues were identified with the CPR process for this resident and that nursing staff failed to check the advance directive before performing CPR, resulting in resuscitation being carried out contrary to the resident’s documented wishes and legal DNR order.
Failure to Ensure Safe Hoyer Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident using a Hoyer lift, resulting in the resident falling and sustaining a right femur fracture that required surgery and an extended hospital stay. The incident took place during a transfer from bed to wheelchair, when the Hoyer sling snapped, causing the resident to fall to the floor. The resident, who had diagnoses including a previous right femur fracture, morbid obesity, type II diabetes, and schizoaffective disorder, was alert and oriented at the time and reported ongoing pain following the incident. Staff interviews revealed that the CNA responsible for the transfer, along with an orientee, retrieved a Hoyer sling from the laundry area without thoroughly inspecting it before use. The CNA admitted to not noticing the sling's frayed edges prior to the transfer and only realized the sling was old and slightly ripped after the resident had fallen. The sling was not in good condition and should not have been used for the transfer. Laundry staff, who were contracted employees, reported that prior to the incident, slings were washed and stored in the laundry room without a specific protocol for inspecting their condition. The Director of Nursing and the Administrator confirmed that the sling used during the incident was not in acceptable condition for use. The failure to properly inspect and ensure the integrity of the Hoyer sling directly led to the resident's fall and injury.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the Administrator/Abuse Coordinator within the required timeframe for a resident who was reviewed for abuse. The incident involved a resident with dementia and physical impairments who was found to have significant bruising on her arm, breast, and back. Multiple certified nursing assistants (CNAs) observed the bruising at different times, with one CNA noticing the bruises as early as two days before the injury was reported to the Administrator. Despite the facility's policy requiring immediate reporting of such injuries, the bruising was not promptly communicated to the appropriate authorities. The resident was dependent on staff for most activities of daily living and had a history of chronic fractures. On the day of the incident, a CNA discovered extensive bruising while assisting the resident with care and reported it to the assigned nurse. The nurse did not immediately assess the resident in person and did not report the injury to the Administrator until several hours later. Other staff members also observed the resident's change in condition and the presence of bruising but did not escalate the concern as required by facility policy. Interviews with staff revealed a lack of clarity and adherence to the facility's protocol for reporting injuries of unknown origin. Some CNAs admitted to not reporting the bruising when first observed, assuming others were aware or that it was not necessary. The facility's policy clearly states that any unexplained injury, especially those of significant extent or in unusual locations, must be reported immediately to the Administrator. The delay in reporting and failure to follow established procedures resulted in a deficiency related to timely reporting of suspected abuse, neglect, or injury.
Failure to Assess and Monitor Resident with Change in Condition and Bruising
Penalty
Summary
The facility failed to adequately assess and monitor a resident who exhibited significant skin discoloration and a potential change in condition. The resident, who had a history of dementia and a left hip contracture, was observed by staff to have extensive bruising on her arm, breast, and back, with colors ranging from yellow to dark purple. Multiple staff members noted that the resident was not responding as usual and appeared to have a change in mentation, but there was a lack of thorough assessment and documentation by nursing staff. The nurse on duty did not enter the resident's room for a direct assessment when first notified of the bruising and relied on the CNA to check for warmth under the arm, rather than performing a comprehensive evaluation. There was no documentation of a full skin assessment or monitoring of the resident's condition between the time the bruising was first reported and when the resident was eventually sent to the hospital several hours later. The only progress note written by the nurse reflected what the CNA reported, without any detailed description of the bruising's size, color, or the resident's pain level. Additionally, there was no documentation of vital signs or other monitoring during this period, and the last recorded vital signs were taken approximately nine hours before the hospital transfer. Further review revealed that no skin observation assessments were documented for the resident for a period of 25 days, despite staff having observed bruising prior to the incident and not reporting it. Interviews with the DON and ADON indicated a lack of awareness regarding the absence of assessments and monitoring, and there was inconsistency in staff understanding of the protocol for assessing and documenting changes in condition. The deficiency centers on the facility's failure to provide appropriate assessment, documentation, and monitoring in response to a resident's change in condition and visible injuries.
Failure to Provide Scheduled Pain Medication and Maintain Accurate Documentation
Penalty
Summary
The facility failed to ensure that scheduled pain medication was available per physician orders and maintain accurate documentation of controlled substances for a resident with chronic pain. The resident, who had moderately impaired cognition and was diagnosed with primary generalized osteoarthritis, rheumatoid arthritis, and chronic pain syndrome, reported that the facility frequently ran out of their prescribed Morphine, causing them to go without it for days. The Medication Administration Record (MAR) indicated that doses were missed due to the medication not being on hand, and the Director of Nursing (DON) confirmed that medications should be ordered timely to prevent missed doses. A discrepancy was found between the Medication Monitoring/Control Record log and the MAR, where a dose was documented as removed but also marked as refused. The LPN involved explained that the resident initially refused the medication but later decided to take it, and she forgot to update the MAR. The DON acknowledged that the medication should have been reordered before only one dose remained and that the facility's narcotic audit failed to catch this oversight. The facility's policy stated that controlled substances should be reordered when a 5-7 day supply remains, but this was not followed in this case.
Improper Storage of Tracheostomy Supplies
Penalty
Summary
The facility failed to maintain tracheostomy supplies in a clean and sanitary condition for a resident with multiple comorbidities, including intracranial hemorrhage, seizures, and respiratory distress. The resident, who was breathing through a tracheostomy and receiving nutrition via a PEG tube, was under enhanced barrier precautions. During an observation, a surveyor noted an open cardboard box containing tracheostomy mask tubing on the floor, with one open package of tubing resting on an open trash can. This situation was not addressed by the staff until it was pointed out by the surveyor. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) involved acknowledged that the supplies should not have been on the floor and that clean supplies should be sealed. The Director of Nursing (DON) confirmed that the supplies were delivered the previous day and should not have been left in such a condition. The facility's failure to properly store and handle medical supplies was contrary to the Centers for Disease Control and Prevention's guidelines, which state that medical supplies should not be stored in areas where they can become wet or contaminated.
Unsecured Oxygen Tank Poses Safety Hazard
Penalty
Summary
The facility failed to ensure the proper securing of a portable oxygen tank, which was left unattended and leaning against a wall in the front nursing station. This area was located next to the dining room and a resident area hallway, where multiple residents were present. The unsecured tank posed a potential hazard as it could be knocked over, leading to the risk of the cylinder rocketing and causing injury to residents in the vicinity. During the survey, Nurse A acknowledged that the oxygen tank should not have been left in such a manner and indicated that it should be secured with a caddy to prevent it from falling. The Director of Nursing (DON) also confirmed that the tank should be secured for safety. The facility's policy on the storage of compressed gas for oxygen use was reviewed, highlighting the importance of securing oxygen cylinders to prevent accidents and the potential dangers associated with oxygen-enriched environments.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared, served, and stored in a sanitary manner, which had the potential to affect all residents consuming food from the kitchen. During an initial tour of the kitchen, several deficiencies were observed, including a dietary staff member with a long beard not wearing a beard restraint, dusty and peeling ceiling vent covers, a large puddle of brown liquid on a table, a soiled ice scoop holder, cracked and moldy tiles behind the dish machine, and spilled powder in the dry storage room. Additionally, the resident refrigerator in the dining room was found to have an interior temperature of 49 degrees Fahrenheit and contained expired and undated food items, contrary to the facility's policy on food safety requirements. Further observations revealed that a resident's bedside table contained undated peanut butter and jelly sandwiches, which attracted fruit flies. Meal trays delivered to the unit had uncovered bowls of cobbler, exposing the food to air. Another resident refrigerator contained a wrapped burrito, a bowl of tomato bisque, and a package of pepperoni slices, all without proper labeling or dates. These findings indicate a failure to adhere to professional standards for food storage, preparation, and distribution, as outlined in the FDA Food Code and the facility's own policies.
Failure to Ensure Dignified Treatment and Proper Colostomy Care
Penalty
Summary
The facility failed to ensure treatment in a dignified manner for seven residents. Certified Nurse Aide (CNA) 'B' repeatedly entered residents' rooms without knocking or asking for permission, disrupting interviews and personal time. This behavior was observed multiple times, including when CNA 'B' entered rooms to collect breakfast trays and during interviews with residents. Additionally, an overhead page announced the delivery of a lunch cart, and CNA 'E' referred to it as the 'Feeder Cart,' which is a term that could be considered undignified. CNA 'D' was observed standing while feeding two residents, which is not a respectful or dignified manner of providing care. Furthermore, Nurse 'C' was seen using a cell phone while a resident ate their lunch, which is against the facility's policy on device usage during working hours and does not demonstrate respectful engagement with the resident. Another significant issue involved a resident with a colostomy. The resident was observed with a plastic bag and towels wrapped around their colostomy to prevent leakage, which is not an appropriate or dignified method of care. The resident reported that the nurse provided these materials. The Director of Nursing (DON) confirmed that this method was not appropriate and had not personally assessed the resident's colostomy. The resident had a diagnosis of colostomy status, type 2 diabetes, and adjustment disorder with mixed anxiety and depressed mood, with a moderately impaired cognition score. This improper care method was observed on two separate occasions, indicating a lack of proper colostomy care and monitoring.
Insufficient Nursing Staff on Weekends
Penalty
Summary
The facility failed to ensure sufficient nursing staff were provided to meet resident needs, affecting three identified residents and potentially all 87 residents in the facility. The payroll-based journal report revealed excessively low weekend staffing hours during the first fiscal quarter of 2023. During an anonymous group meeting, two residents reported long wait times for call light responses and slow meal tray delivery on weekends due to insufficient nursing aides. One resident mentioned that sometimes only one nursing aide was available to pass trays, resulting in cold food being served. The staffing coordinator confirmed the facility's struggle with staffing on weekends, particularly Sundays, and acknowledged the impact on resident care, including missed showers and delayed call light responses. The facility's staffing levels on several weekends were below the minimum required, as reported by the staffing coordinator, who also noted the use of staffing agencies for nurses but not for nursing aides, leading to unfilled assignments and staff shortages. A resident expressed concerns about the amount of staff working in the facility, specifically mentioning issues with getting their hair washed and wanting more frequent bathing than the facility's twice-weekly schedule. A certified nursing assistant corroborated the resident's concerns, stating that weekends were worse than weekdays in terms of staffing levels. The assistant indicated that when the facility was short-staffed on weekends, they had to prioritize keeping residents safe and dry, which sometimes resulted in missed showers and longer call light response times. A facility document claimed that adequate staffing was maintained on each shift to meet resident needs, but the findings contradicted this assertion.
Improper Storage and Security of Medications
Penalty
Summary
The facility failed to ensure proper storage and security of medications, specifically insulin pens and medication carts. On multiple occasions, medication carts on the Oakland and [NAME] units were observed unlocked and unattended. Additionally, three unopened insulin pens were found in the top drawer of a medication cart instead of being stored in the refrigerator as required. Nurse O confirmed the improper storage of the insulin pens, and the Director of Nursing acknowledged that all medication carts should be locked and unopened insulin should be refrigerated. These observations were made during a survey conducted on 5/6/24 and 5/7/24, and the findings were confirmed through interviews with nursing staff and the Director of Nursing.
Failure to Ensure Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure palatable meals for six residents, resulting in verbalized complaints and frustration with meals. Observations and interviews revealed that residents received insufficient food portions, with some reporting hunger due to the long interval between meals and inadequate snacks. The food was described as tough, unpleasant in aroma, and often cold. Specific instances included a resident receiving a burnt toast without coffee or milk, and another resident receiving the same vegetable two days in a row without being offered soup. Additionally, residents were not provided with menus to choose their meals, leading to dissatisfaction and confusion about meal options. The facility's dietary manager acknowledged the concerns and admitted that no menus were posted or provided to residents. Observations of the lunch meal showed unappetizing food, such as a dry baked potato without sour cream, slimy spinach, and mushy meat with watery condensation. Furthermore, the internal temperature of the soup served in the dining room was measured at 117 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit as per the 2017 FDA Food Code. This failure to maintain proper food temperature and quality resulted in multiple resident complaints and highlighted significant deficiencies in the facility's food service practices.
Failure to Meet Resident Food Preferences
Penalty
Summary
The facility failed to ensure that food preferences for seven residents were met, resulting in verbalized complaints and dissatisfaction with meals. Specific instances included a resident who was never served coffee despite it being listed as a liked item on their meal ticket, and another resident who frequently requested items from the always available menu but rarely received what they asked for. Additionally, several residents received meals that did not match their meal tickets, such as being served oatmeal instead of cold cereal, or receiving a grilled cheese sandwich without the accompanying tomato soup. One resident also complained about receiving a fudge brownie for dessert despite their meal ticket indicating they did not like chocolate. The facility's Dietary Manager acknowledged ongoing issues with ensuring that meal tickets matched the meals served and that residents' choices were honored. The facility's policy on food preferences and portions, dated September 2021, stated that individual tray assembly tickets should identify all food items appropriate for the resident based on diet orders, allergies, intolerances, and preferences. However, the observations and interviews conducted during the survey revealed that this policy was not being consistently followed, leading to dissatisfaction among the residents regarding their meals.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to appropriately implement enhanced barrier precautions (EBP) and wear the required personal protective equipment (PPE) for residents on EBP. Specifically, four residents with urinary catheters, colostomies, wounds, or feeding tubes did not have signage indicating they were treated with EBP. This lack of signage was observed during a survey, and the residents were at increased risk of multidrug-resistant organism (MDRO) transmission due to their medical conditions. The absence of proper EBP signage was noted for residents with urinary catheters, a colostomy, wounds on the buttocks, and a feeding tube. During an interview, the Director of Nursing (DON) acknowledged that the facility had started educating staff and residents about EBP and had begun cohorting like residents. However, the DON admitted that not all precautions were fully implemented because the staff education was incomplete. The DON also mentioned that they considered the EBP guidelines from the Center for Disease Control (CDC) as recommendations rather than mandatory requirements. A review of the CDC document confirmed that EBP involves targeted gown and glove use during high-contact resident care activities to reduce MDRO transmission.
Failure to Honor Resident's Request for Hospital Transfer
Penalty
Summary
The facility failed to coordinate a transfer to the hospital per the resident's choice, resulting in the resident feeling that their health condition was not taken seriously. The resident, who had a history of multiple sclerosis, paraplegia, chronic obstructive pulmonary disease, and pneumonia, requested to go to the emergency room due to not feeling well and suspecting they had pneumonia. Despite the resident's request, the staff did not facilitate the transfer, and the resident had to call 911 themselves. The resident was subsequently diagnosed with pneumonia and received intravenous antibiotics at the hospital. The clinical record showed that the resident had intact cognition and required assistance for most activities of daily living. The last documented vital signs were taken approximately nine hours before the resident's request to go to the emergency room. Interviews with the nurse and the Director of Nursing revealed that the staff did not consider the resident's condition emergent and did not facilitate the transfer, despite the resident's complaints of cough, shortness of breath, and chills. The facility's policy on resident rights was reviewed, which stated the right to reasonable accommodation of needs as long as it does not endanger health or safety.
Failure to Provide Proper Documentation for Involuntary Discharge
Penalty
Summary
The facility failed to ensure correct and completed involuntary discharge transfer documents for a resident who was being discharged due to possession of alcohol. The resident, who had a diagnosis of chronic obstructive pulmonary disease, chronic respiratory failure, and acquired absence of toes, was found with an unopened bottle of whiskey in their nightstand. This was the second time the resident was caught with alcohol. The resident stated that they were given a month to find new living arrangements. However, there was no documentation provided to support the claim that the resident had been educated or warned about the behavior leading to the discharge. Interviews with the Admissions and Social Services Director (SSD) and the Director of Nursing (DON) revealed inconsistencies and lack of proper documentation. The SSD stated that the discharge was due to aggressive behaviors and safety issues, but could not provide documentation to support this. The DON mentioned that the resident's drinking during leave of absences made it unsafe to care for them medically, but again, no supporting documentation was found in the progress notes. The survey concluded with no additional information provided by the facility to support the involuntary discharge decision.
Failure to Order Timely X-rays After Resident Fall
Penalty
Summary
The facility failed to ensure X-rays were ordered in a timely manner after a fall for one resident. On 5/6/24 at 1:16 PM, the resident was observed in their wheelchair and reported having fallen the previous night, resulting in pain in their left arm and leg. Nurse 'H' documented the fall at 6:35 AM, noting the resident's severe pain levels (10/10 for the left upper extremity and 9/10 for the left lower extremity). Despite this, X-rays were not ordered until the afternoon of 5/6/24, after the resident finally agreed to a post-fall assessment and skin evaluation at 3:55 PM. The Director of Nursing (DON) stated that the resident initially refused assessment, pain medication, and X-rays, but could not explain how a resident could refuse just the order for an X-ray. The progress notes indicate that attempts to contact the physician's office were unsuccessful due to after-hours issues, and a log was placed in the physician's book for evaluation during daily rounds. However, the delay in ordering the X-rays was not addressed in the facility's policies regarding falls and diagnostic testing. This deficiency highlights a gap in the facility's procedures for timely diagnostic testing following a fall, especially when a resident is in significant pain.
Failure to Provide Appropriate Vision Care
Penalty
Summary
The facility failed to ensure appropriate vision care for a resident (R21) who reported difficulty with their vision. Despite being diagnosed with dementia and legal blindness, and having a documented need for cataract surgery and daily warm compresses for blepharitis, the facility did not follow through with the necessary care. The resident expressed concerns about their vision on multiple occasions, but there was no documentation of the warm compresses being applied as ordered by the optometrist. Additionally, there was no evidence that the attending physician reviewed the order for the warm compresses. The resident's medical record indicated a referral for cataract surgery and a plan for daily warm compresses, but the facility failed to document any follow-up actions. Conversations with the social service worker and nurse manager revealed that while the cataract surgery appointment was addressed, there was no documentation or evidence of the warm compresses being administered. The facility's guidelines for vision services were reviewed, but they did not ensure the resident received the necessary treatment to maintain their vision.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure Physician's orders were followed for oxygen therapy administration for two residents. Resident R63, who has diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and pulmonary collapse, was observed receiving oxygen at 1.5 liters per minute (LPM) instead of the prescribed 3 LPM. Despite the resident's moderately impaired cognition, they were aware of the correct oxygen setting. The discrepancy was confirmed by the Unit Manager, who subsequently adjusted the oxygen flow to the correct setting after verifying the Physician's order. This failure to follow the prescribed oxygen therapy was observed multiple times over two days. Resident R58, diagnosed with COPD and chronic respiratory failure, was observed with an oxygen concentrator set at 5 LPM, while the electronic health record indicated an order for 3 LPM. Additionally, the resident's oxygen humidification bottle was improperly placed on the ground and inside the resident's shoe, leading to water entering the oxygen line and causing the resident to remove their oxygen for short periods. The facility staff, including a CNA and the Unit Manager, were unaware of the correct placement and maintenance of the humidification bottle, leading to further complications in the resident's oxygen therapy.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management services for two residents, resulting in unrelieved pain. Resident 290, who was admitted with a displaced fracture of the left humerus, chronic obstructive pulmonary disease, and muscle weakness, reported severe pain and stated that they had not received any pain medication since their admission. Despite the hospital discharge summary indicating the need for oxycodone, morphine, and Tylenol, the facility did not provide these medications. The Director of Nursing (DON) explained that no narcotic prescription was provided and that the initial assessment did not indicate pain, leading to a lack of pain management over the weekend following admission. Resident 84, diagnosed with malignant neoplasms of the lung and bone, and anemia, reported living in excruciating pain due to cancer. Despite having an as-needed order for morphine every three hours, the resident's records showed significant gaps between doses, with the last dose administered four days prior to the survey. The DON claimed that the resident often refused medications, but the resident clarified that they only refused non-pain-related medications. This discrepancy resulted in inadequate pain management for Resident 84, who continued to experience severe pain without timely relief.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a medication error rate of 12%. During a medication administration pass, Nurse O did not administer Fenofibrate 54mg, Loratadine, and Sertraline 25mg to a resident, and did not sign out the as-needed Tylenol that was administered. Nurse O initially stated that all medications were given, but upon review of the electronic health record, it was found that these medications were not administered. Nurse O admitted to not knowing that these medications were to be given. The Director of Nursing (DON) explained that the facility was transitioning to a more liberal medication administration schedule, allowing a range from 7am-11am for morning medications. However, the DON acknowledged that the staff education on this new schedule was still in progress. The DON was informed of the medication administration pass issue and stated that she would investigate the situation further. No additional information was provided by the exit of the survey.
Failure to Document Pertinent Resident Information
Penalty
Summary
The facility failed to ensure pertinent resident information was documented in the medical record for one resident (R24). R24, who was observed to be confused and unable to answer any questions, had diagnoses including Adult failure to thrive, Dementia, and Cerebral Infarction (stroke). The medical record revealed that R24 had a BIMS score of one, indicating severely impaired cognition, and did not have a legal representative to assist with informed decision-making. A document titled Determination of Capacity, effective 2/9/24 and signed by two physicians, confirmed that R24 did not have the cognitive capacity to participate in their own medical and financial decisions due to Dementia. However, there were no recent notes on obtaining a legal representative for R24 in the medical record. During an interview, the social service worker (SS F) reported having conversations with multiple public guardianship agencies, R24's national embassy, and the Ombudsman's office regarding obtaining a legal guardian for R24 but had no results due to R24 not being a citizen. SS F admitted that there was no documentation of these conversations or the current status of the guardianship process in R24's medical record. SS F acknowledged the need to improve documentation regarding the social service needs and processes for R24.
Failure to Provide Timely and Appropriate Wound Care
Penalty
Summary
The facility failed to ensure accurate wound assessments, timely implementation of treatment for identified wounds, coordination of care and wound services, and a collaborative approach for wound healing with the dietician for two residents reviewed for pressure wounds. One resident developed an infected unstageable buttocks/sacral wound that required hospitalization due to sepsis. The medical record revealed that the resident had a Braden Scale score indicating they were at risk, but there was no documentation of the physician being notified of identified skin impairments or new treatments being implemented in a timely manner. The resident's wounds were not treated for over a week after being identified, and the dietician was not notified to optimize nutrition for wound healing. The second resident was noted to have two pressure sores, one on their penis and one on their bottom, which were not documented or treated appropriately. The resident's clinical record showed that they had intact cognition and required assistance for most activities of daily living. Despite the identification of open areas on the resident's sacrum and penis, there were no notes indicating that the resident was seen by the wound care nurse practitioner, and no interventions were noted for skin impairment following the discovery of the wounds. Upon the resident's return from the hospital, assessments were not fully completed, and no treatments were put in place for the multiple open areas on the scrotum and penis. The facility's policy on skin protection guidelines was not followed, as residents were not evaluated and provided with individualized interventions to prevent, reduce, and treat skin breakdown. The facility failed to implement, monitor, and modify interventions to stabilize, reduce, or remove underlying risk factors for pressure ulcers. The lack of timely and appropriate wound care, coordination with the dietician, and adherence to the facility's skin protection guidelines led to the deficiencies identified in the report.
Failure to Document Administration of Controlled Substances
Penalty
Summary
The facility failed to document the administration of Schedule II controlled substances according to professional standards of practice for nine residents. During an observation of the Oak Unit medication cart, discrepancies were found between the documented amounts of medications and the actual amounts present. For instance, R509's Morphine Sulfate Solution had a 5.25 ml discrepancy, and LPN 'B' admitted to not reporting the discrepancy. Similar issues were found with R516's Acetaminophen with Codeine tablets, R511's Norco tablets, and R512's Percocet tablets, where the nurses did not document the removal of medications from the supply in a timely manner or at all. Further observations on the [NAME] Unit medication cart revealed additional discrepancies. R513's Norco tablets had a discrepancy of two tablets, and LPN 'C' continued to document incorrect numbers despite being aware of the discrepancy. R514's Hydrocodone-acetaminophen tablets and R515's Norco tablets also had discrepancies, with LPN 'C' admitting to not documenting the removal of medications from the supply. The Director of Nursing (DON) confirmed that the protocol required nurses to document the exact time and amount of controlled substances pulled from the supply and to sign it out on the Medication Administration Record (MAR) after administration. Review of closed clinical records for R502 and R504 revealed multiple instances of missing documentation for scheduled and PRN Percocet administrations. R502's controlled substance record showed 13 discrepancies where Percocet was documented as removed but not administered. R504's MAR documented medications as administered even after the resident was discharged from the facility. The DON was unable to provide an explanation for these discrepancies and reported that further investigation was needed. No additional documentation was provided by the end of the survey.
Controlled Substance Management and Documentation Failures
Penalty
Summary
The facility failed to ensure that Schedule II controlled substances were accurately reconciled, administered, and documented, leading to discrepancies in medication counts for eight residents. During an observation, it was found that the amounts of controlled substances in the medication bottles did not match the amounts documented on the Medication Monitoring/Control Records. Licensed Practical Nurse (LPN) 'B' admitted to not reporting discrepancies and failing to document the administration of medications in a timely manner. Similar issues were observed with LPN 'C', who also failed to document medication administration accurately and did not address discrepancies in medication counts properly. Further review of the clinical records revealed multiple instances where controlled substances were documented as removed but not administered according to the Medication Administration Records (MARs). For example, R502 had 13 discrepancies in the administration of Percocet, and R504 experienced delays in receiving medications upon admission, leading to missed doses. The Director of Nursing (DON) confirmed that the facility's process for administering controlled substances was not followed, and discrepancies were not reported as required. The facility's policies on controlled substances and medication administration were not adhered to, resulting in significant documentation and administration errors. The DON acknowledged the issues and reported that the facility had been conducting audits on controlled medications due to a history of concerns. However, the deficiencies observed during the survey indicate a systemic failure to manage controlled substances and ensure timely medication administration for residents.
Failure to Promptly Report Abnormal X-ray Results
Penalty
Summary
The facility failed to promptly report abnormal x-ray results to the physician for a resident with a change in condition. The resident, who had diagnoses including diabetes, chronic kidney disease, obesity, and heart failure, was observed with a swollen arm and difficulty breathing. An x-ray taken on 10/11/23 showed pulmonary vascular congestion and congestive heart failure, but the results were not reviewed by the Director of Nursing until 10/29/23. Despite the resident's worsening condition, there was no documentation that the nurse practitioner assessed the resident or reviewed the x-ray results on 10/12/23. On 10/13/23, the resident's condition further deteriorated, leading to a request for hospital evaluation due to respiratory distress and swelling of the right arm. The resident was sent to the emergency department on 10/14/23. The Director of Nursing could not provide evidence that the physician or nurse practitioner reviewed the x-ray results promptly. The nurse practitioner involved no longer worked at the facility and could not be reached for comment. The facility's policy required prompt reporting of diagnostic results to the ordering provider, which was not followed in this case.
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What surveyors actually found near you
We read the 931 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Orion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa At Pine Place | 4.1 mi | ★★★★★ | 14 | 0 |
| Lake Orion Nursing Center | 4.7 mi | ★★★★★ | 5 | 0 |
| Regency At Waterford | 5.1 mi | ★★★★★ | 3 | 0 |
| Oakland Manor Nursing And Rehabilitation Center Ll | 5.3 mi | ★★★★★ | 14 | 0 |
| Wellbridge Of Clarkston | 5.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.