Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At West Branch during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Transfers and Discharges: The facility did not send required Ombudsman notices for transfers, discharges, or admissions for three years. Two residents reviewed had hospital transfers, and the social service designee had not been sending the required notifications. Corporate and facility leadership confirmed the omission, and the facility’s transfer/discharge guidelines stated that a copy of the discharge notice is sent to the State Office of LTC Ombudsman.
The facility failed to fully carry out its IC program, with staff observations showing missed hand hygiene during meal service, failure to use gown and gloves for EBP care on a resident with a PICC line, no cleaning of a shared glucometer between resident checks, and a resident’s urinary catheter tubing and drainage bag on the floor. Record review also showed incomplete and inconsistent infection surveillance data, with the IC staff unable to clearly identify trends, symptom onset, or TBP details for several infections.
Delayed call light response and loss of resident dignity: A resident who was alert and dependent on staff for ADLs reported waiting over an hour for help and soiling herself, while also stating that call lights on nights and weekends were often answered after about 30 minutes or shut off without care. In a Resident Council meeting, 6 of 7 residents reported the same issue, citing poor weekend staffing, call lights not being answered timely, and an unidentified CNA telling residents to just wet their pants.
Unsafe medication storage and labeling were observed when a bedside cream for a resident was found in an unlabeled specimen cup, loose tablets were left in a med cart, and multiple opened meds, inhalers, glucose strips, and wound care products were not dated. Expired and undated multi-dose treatments remained in treatment carts, and an LPN and DON acknowledged that several items were not being monitored or properly labeled.
Failure to assess and monitor self-administration of an inhaler: A resident with CHF, respiratory failure, and falls was observed self-administering an albuterol inhaler from the overbed table without staff present, despite the inhaler being labeled expired and still showing remaining doses. The resident was cognitively intact, but the EMR had no self-administration assessment, no related care plan interventions, and the DON confirmed the resident should not have had the inhaler available without an assessment.
Failure to provide ADL care and maintain clean bedding: one resident who needed assistance reported limited showers, no offered toothbrushing, and no care plan for bathing preferences despite preferring showers over bed baths; another resident was observed with sheets visibly soiled with dried blood after a documented nosebleed, and the DON confirmed the bedding should have been changed.
Failure to monitor weights for two residents with nutritional risk and significant weight loss. One resident with dysphagia, nutritional deficiency, and multiple chronic conditions was observed thin, eating poorly, and reporting weight loss, while records showed substantial unplanned loss and no added care plan interventions after early March. Another resident with stroke-related deficits, dysphagia, and cognitive impairment was supposed to have weekly weights, but only three weights were documented and the EMR did not identify the 5.9% loss; the RD and DON confirmed weekly weights were required.
The facility failed to follow respiratory care procedures for two residents. One resident with stroke-related deficits, dysphagia, and COPD had a nebulizer set with visible fluid in the chamber and NC tubing found on the floor despite an active order for continuous O2 at 2 L/min. Another resident with CHF and acute/chronic respiratory failure had an uncovered CPAP mask, a nebulizer mask stored in an open drawer, and a nebulizer set with fluid and condensation present. The DON confirmed the fluid should not remain in the chamber and stated tubing on the floor should have been discarded.
A facility failed to maintain an accurate controlled substance count for a medication cart. Staff and surveyors found the cart count was off by 1 narcotic for two consecutive shifts, and the discrepancy was traced to an empty cartridge sheet that had not been subtracted from the count. Review of the emergency drug kit record for a discharged resident also showed missing documentation, including no seal number, lock number, nurse signature, or date/time, and the Ativan vial was not in the backup kit.
A resident’s personal in-room refrigerator contained expired cheese sticks and sour cream, and none of the food items had been dated when brought in. The resident was cognitively intact, required max to total ADL assistance except set-up for eating, and said staff retrieved items from the fridge when asked. The DON and an RN stated staff should ensure no expired items are present, but they needed to review the procedure for monitoring and disposal.
Nurse staffing information was not posted in a prominent, visible location and the posted sheet did not include actual hours worked for RNs, LPNs, or CNAs. The form listed scheduled staff for three shifts, but review of prior staffing sheets showed the actual hours worked were never documented, and one day’s CNA count did not match timeclock punches because a CNA call-in was not removed from the posting.
Surveyors identified multiple deficiencies in medication storage and labeling, including medications and insulin pens lacking required expiration dates after opening, missing open dates, loose tablets in medication carts, and expired medical supplies in the medication room. Additionally, a medication cart was left unlocked and unattended with resident information visible, and some medication containers were missing lids or not stored in original packaging. These issues were confirmed by nursing staff and the DON.
Surveyors found that staff failed to follow food safety and sanitation procedures, including not wearing hairnets, not washing hands before food preparation, storing open staff beverages in the kitchen, and preparing food on visibly soiled surfaces. Expired and improperly stored food items were found in refrigerators and freezers, with inadequate temperature monitoring and significant ice build-up. Staff and leadership demonstrated inconsistent understanding and enforcement of facility food safety policies, affecting all residents receiving kitchen-prepared meals.
The facility did not maintain a comprehensive infection control program, with incomplete infection tracking, inconsistent antibiotic stewardship, and lack of process surveillance. Additionally, a resident's urinary catheter drainage bag and tubing were repeatedly observed on the floor, and staff failed to follow proper infection control procedures when handling the catheter.
Three medication errors were observed, resulting in an 8% error rate. Incidents included an IV antibiotic left hanging in a resident's room for several hours before administration by a different LPN, medications left at a resident's bedside without proper orders, and levothyroxine given with breakfast instead of on an empty stomach. These events were confirmed through staff interviews and record reviews, showing non-compliance with medication administration policies.
The facility did not ensure that arbitration agreements were explained in a way that residents or their representatives could understand. Several cognitively intact residents who signed the agreements could not recall or describe what they had signed, and none of the residents attending a council meeting understood the arbitration process. This resulted in residents being unsure of their rights regarding the arbitration agreement.
Surveyors found that several residents with urinary catheters were not treated in a dignified manner, as their urine collection bags were left uncovered or with tubing on the floor, despite the facility having privacy covers available. In some cases, staff were unaware of the catheter's status or did not use appropriate PPE when handling the equipment, and residents expressed confusion or dissatisfaction with their care.
A resident with severe cognitive impairment and a formal determination of incompetency was allowed to sign their own advance directive (MI-POST) form, rather than having it completed by the designated patient advocate. Staff interviews confirmed this was an error, as facility policy requires advance directives to be completed by a responsible party when a resident is deemed incompetent.
A resident with severe cognitive and physical impairments was not provided with shaving and personal hygiene care according to their preferences. Staff and documentation confirmed that shaving was only performed on shower days, despite the resident's stated desire to be clean-shaven more frequently. The care plan and facility procedures did not address the resident's individual needs or preferences for ADL care.
Three residents received inappropriate respiratory care due to staff not following physician orders for oxygen administration, failing to update care plans, and not maintaining oxygen equipment in a sanitary manner. One resident used a nebulizer that was not cleaned after use, another received oxygen at a rate inconsistent with the physician's order and care plan, and a third had access to oxygen equipment without a physician's order or documentation, with therapy staff administering oxygen based on verbal direction.
A resident with multiple medical conditions was found using bed rails without a provider order, assessment, or informed consent, despite facility policy requiring these steps. Staff confirmed the absence of required documentation and assessments for bed rail use, and the care plan did not specifically address the use of bed rails.
The facility did not provide meals according to the posted menu and failed to inform residents of food substitutions. A resident received hot dogs instead of the scheduled bratwurst, leading to visible distress and complaints about frequent unannounced menu changes. Multiple residents confirmed that substitutions were common and not communicated in advance, resulting in frustration and dissatisfaction with meal service.
The facility failed to implement and operationalize policies for pressure ulcer prevention and management, resulting in the development and worsening of pressure ulcers for four residents. One resident developed a Stage 3 pressure ulcer that deteriorated to an unstageable wound, while another resident's pressure ulcer became infected, leading to hospitalization. The facility did not provide timely interventions, adequate documentation, or investigate contributing factors, causing significant harm to the residents.
A resident with a history of anemia, chronic kidney disease, diabetes, and heart disease experienced severe rectal injuries after an improperly administered enema at an LTC facility. Despite having multiple bowel movements prior, the facility failed to document a clinical rationale for the enema and did not follow established bowel protocols. The resident suffered multiple anal mucosa tears and a full-thickness rectal tear, requiring surgical repair. The facility delayed calling emergency services despite the resident's complaints of pain and requests for hospital transfer.
The facility failed to adhere to food safety standards, including improper labeling and dating of food items, inadequate temperature control of cold and hot foods, and potential cross-contamination during meal preparation. Additionally, moldy bread was found in the nourishment room, indicating lapses in infection control monitoring.
The facility failed to ensure accurate code status documentation for six residents, resulting in conflicting and incomplete DNR orders. The DNR forms lacked clearly delineated physician signatures, and one resident's records contained both DNR and Full Code orders, leading to confusion about the resident's actual code status.
The facility failed to ensure accurate dispensing, administration, and reconciliation of controlled substances, resulting in discrepancies in narcotic medication counts and improper storage of an unlabeled syringe containing morphine. The DON confirmed the inaccuracies and acknowledged the issues with medication management.
The facility failed to implement a comprehensive infection control program, resulting in inadequate infection tracking and monitoring, and lacked functioning hand hygiene equipment. Additionally, a nurse administered medications in an unsanitary manner, leading to cross-contamination.
The facility failed to ensure planned fall prevention interventions were in place for a resident with a history of stroke and Alzheimer's disease. Despite the care plan requiring fall mats on both sides of the bed, observations revealed that only one side had a fall mat, increasing the risk of injury.
The facility failed to change a urinary catheter as per physician's orders for a resident, leading to recurrent UTIs. The resident's medical records revealed multiple missed catheter changes, contributing to several infections and hospitalizations. Interviews and records confirmed the lapses in catheter management and the resulting health complications.
A resident with a stage IV pressure ulcer received Rocephin antibiotic therapy for 7 days before wound culture results showed no susceptibility to the antibiotic. Despite the culture revealing MRSA and Streptococcus Agalactiae, the resident continued to receive Rocephin without any adjustment to the antibiotic regimen.
The facility failed to justify the use of PRN antianxiety medication and document the rationale for indefinite use for two residents, resulting in the likelihood of unnecessary medications and adverse effects. Orders for Ativan and Xanax were found to be indefinite without a 14-day stop date, contrary to facility policy.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.4% error rate. A resident was left unattended during a nebulizer treatment, and another resident received incorrect insulin administration. Staff were unaware of the proper procedures.
The facility failed to submit PBJ data on time for the second quarter of 2023, leading to CMS triggering staffing concerns for low weekend staffing in the fourth quarter. Additionally, the posted nursing staffing information was not easily readable, which could hinder effective communication and staffing management.
A resident with a stage IV pressure ulcer received ceftriaxone sodium (Rocephin) for a wound infection without appropriate clinical rationale. The wound culture results did not recommend Rocephin, and the facility's policies on infection surveillance and antibiotic stewardship were not followed, leading to inappropriate antibiotic use.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of pending transfers and discharges for the last three years, including for two residents reviewed for hospitalization. Record review showed that Resident #6 was sent to the hospital in February 2026 and later readmitted, and Resident #10 was hospitalized on 2/27/26 for 24 hours, discharged to the hospital on 5/4/2026, and returned to the facility on 5/7/2026. During an interview, Resident #10 could not recall why he went to the hospital and stated it may have been for an infection. In interviews on 06/10/2026, the Corporate Operations Consultant and the Nursing Home Administrator stated that the facility had not sent Ombudsman notifications of transfers, discharges, or admissions for three years. The facility social worker was identified as the designee responsible for sending the notifications but had not been doing so. The corporate and regional staff stated that the corporation had yearly training and a spreadsheet form for social workers to use, and the facility’s Transfer and Discharge Guidelines stated that a copy of the discharge notice is sent to the State Office of Long-Term Care Ombudsman.
Infection Control Program Not Fully Implemented
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control program. Survey observations and record review showed that infection surveillance data were incomplete and inconsistent, with the infection control staff unable to clearly identify trends, causative organisms, symptom onset dates, or the type and timing of transmission-based precautions for several residents. The monthly infection control summary, line list, and mapping tool for December 2025 contained discrepancies in the number of infections documented, and the infection control staff stated that potential infections not treated with antimicrobials were not tracked. During dining observations, staff served residents in the main dining room and during hallway tray pass without performing hand hygiene between residents, and residents were not offered hand hygiene before or after meals. The facility’s dining guideline and hand hygiene policy stated that staff should perform hygienic practices and that residents should be offered hand sanitizer, including before and after assisting with meals. Staff were observed passing trays, removing lids, applying clothing protectors, and moving from one resident to the next without hand sanitation. For Resident #12, who had a PICC line and TPN, staff were observed providing IV medication administration while wearing gloves but not a gown, despite an EBP sign posted at the room entrance. The same resident was later observed receiving PICC care and assessment of a colostomy bag, abdominal wound dressing, and peri-area without a gown and without hand hygiene after removing gloves and before donning new gloves. The DON and infection control staff stated that gown and gloves should be worn for PICC lines, wounds, catheters, and ostomies, and that hand hygiene should occur after glove removal. Glucose meter cleaning was not performed between resident blood sugar checks. An RN used the same glucometer for multiple residents, placed it in a clear plastic cup with supplies, and returned to the medication cart to document results without cleaning or disinfecting the device. The facility policy required shared glucometers to be cleaned and disinfected after every use and between each resident. In addition, Resident #11’s urinary catheter tubing and drainage bag were observed on the floor while the resident was in bed, and staff and the DON observed the condition. Staff stated that a urinary catheter bag or tubing should not be on the floor, and the infection control preventionist acknowledged that staff had not been educated to use a barrier from the floor.
Delayed Call Light Response and Loss of Resident Dignity
Penalty
Summary
The facility failed to ensure residents’ dignity by not answering call lights in a timely manner for 6 of 7 residents discussed in a confidential Resident Council meeting and for Resident #57. Resident #57 was alert with a BIMS score of 14, described as her own person, and dependent on staff for ADLs. Her diagnoses included depression, anxiety, bipolar disorder, fibromyalgia, obesity, difficulty walking, and chronic kidney disease. She stated she had waited over an hour for assistance and soiled herself, describing the situation as embarrassing and upsetting. She also reported that on weekends, especially at night, staff took about half an hour to answer her call light and sometimes shut it off without providing care, saying there was not enough staff. During the confidential Resident Council meeting, 6 of 7 residents reported that staff did not answer call lights in a timely manner on night shift and weekends. They stated it often took about 30 minutes for staff to respond, that staffing was not sufficient on weekends, and that if someone called in, the nurse did not replace them. Residents also reported that staff would come in, turn off the call light, and say an aide would come later, and that residents were sometimes left sitting by the nurse’s station with no TV or music. One unidentified CNA was reported to have told residents to just wet their pants. Prior Resident Council meeting notes also documented concerns about waiting for call lights to be answered, and facility policies stated call lights should be answered as soon as possible and residents have the right to be treated with respect and dignity.
Unsafe Medication Storage and Improper Labeling of Medications and Treatments
Penalty
Summary
The facility failed to ensure safe medication storage and proper labeling of drugs and biologicals. During observation, a urinalysis specimen cup containing a thick white cream was found sitting on a bedside stand for Resident #39 with no resident name, room number, or medication name on the container. The nurse manager could not identify the cream and stated it should not have been at the bedside or placed in a urine specimen cup, and that medications were not to be transferred into different containers than those in which they were received. Medication carts and treatment carts contained multiple unlabeled or improperly dated items. An opened medication cart contained loose peach-colored tablets identified as hydrochlorothiazide 12.5 mg. Another cart had opened Ultra trak glucose test strips that were not dated, and Resident #43’s Ventolin inhaler had a peeled-off label with no date on the bag or device when opened. In the treatment cart, several multi-dose wound care products were opened with no date when opened, including Coloplast hydrophilic wound dressing cream, pain-relieving gel, collagen dressing hydrogel, Solosite wound gel, SilvaKollagen gel, and Derma Syn/Ag silver antibacterial wound gel; one of the Solosite tubes had a manufacturer expiration date of 8/1/2025, and Derma Syn/Ag had an expiration date of 3/29/2025. Additional observations showed a multi-dose bottle of olanzapine for Resident #69 with no date when opened, and more treatment items on another unit, including Triad hydrophilic wound dressing, triamcinolone acetonide cream, and Iodosorb, all opened and not dated, with no resident name on the Iodosorb tube or box. The DON acknowledged that expired wound care treatments were available for use in the cart and that the treatment cart was not being monitored. The wound care nurse stated that treatment carts were reviewed and that multi-dose treatments should have an open date when first used, but the items observed remained in the carts without required dating or removal.
Failure to Assess and Monitor Self-Administration of an Inhaler
Penalty
Summary
The facility failed to implement procedures and monitoring to ensure the assessment and clinical appropriateness of medication self-administration for one resident. Resident #55, who had diagnoses including CHF, acute and chronic respiratory failure, and falls, was observed sitting in a wheelchair in the room with an albuterol inhaler on the overbed table. The resident self-administered two puffs back-to-back without staff present, and the inhaler had a written expiration date on the sticker while the built-in dose counter still showed 40 doses remaining. When asked about the expired date and remaining doses, the resident stated it was probably due to not taking every dose and could not explain how long the inhaler had been in the room or where it came from. Record review showed the resident was cognitively intact and required supervision/touching assistance for transfers and maximum assistance for bathing, but there was no assessment for medication self-administration in the EMR. The resident had an order for Ventolin HFA 2 puffs three times daily for shortness of breath, and the MAR documented all doses as administered by facility nursing staff. The DON stated the resident should not have had the medication on the overbed table or self-administered it without an assessment, and confirmed expired medication should be disposed of. Review of the EMR also showed no care plan or care plan interventions related to self-administration of medications, including inhalers, and no progress note documentation of such an assessment.
Failure to Provide ADL Care and Change Soiled Bedding
Penalty
Summary
The facility failed to ensure that ADL care, including bathing and oral hygiene, was provided to a resident who was unable to complete those tasks independently. Resident #12, who was admitted with diagnoses including infection, nutritional deficiencies, and an intestinal fistula, stated they needed assistance to get out of bed and complete ADL care and reported they had only had one shower because of a time limit. The resident said they preferred showers, had previously showered one to two times daily at home, and also stated they had to ask for toothbrushing because staff did not offer. Review of the EMR showed the resident was scheduled for bathing on Wednesdays and Saturdays, but over the prior 30 days received one shower and four bed baths. The resident did not have a care plan specifically related to bathing/showers and/or individual bathing preferences. The facility also failed to ensure that visibly soiled bedding was changed for another resident. Resident #55, who was cognitively intact and required maximum assistance for bathing, was observed in bed with sheets containing a significant, highly visible amount of dried dark red substance that appeared to be dried blood. The resident stated they had a bloody nose the prior night and that nursing staff had assisted to stop the bleeding. The EMR documented a nosebleed with estimated blood loss of 50 cc during the night, yet the blood remained on the bedding when observed later that day. The DON confirmed that bedding should be changed when visibly soiled and acknowledged that the resident's bedding should have been changed.
Failure to Monitor Weights for Residents with Nutritional Risk
Penalty
Summary
The facility failed to implement procedures to ensure weight monitoring for two residents with nutritional risk and significant weight loss. Resident #10 was observed in the dining room appearing thin with loose skin, seated with other residents and able to self-dine but needing encouragement to eat. He stated that he had lost weight and did not know why, and staff noted that he preferred to drink hot tea rather than eat. His record showed diagnoses including dysphagia, nutritional deficiency, diabetes, heart disease, kidney failure, anemia, depression, and memory deficit, along with a mechanically altered diet and prior dietary notes documenting poor intake and significant weight loss. Resident #10’s record showed progressive weight loss over time, including a loss of 6.9% in 30 days and 33.8 pounds, or 15.6%, over 90 days. The care plan identified nutritional risk and documented registered dietitian recommendations, but the intervention section had no added interventions after 3/5/26 to address the weight loss. The RD stated she had reviewed the record but had not seen the resident and had only increased supplements after reviewing the chart. Resident #50 had diagnoses including cerebral infarction with left-sided hemiplegia and hemiparalysis, dysphagia, aphasia, heart failure, and muscle wasting, and the MDS showed moderate cognitive impairment with extensive ADL assistance needs. The resident was supposed to be weighed weekly, but only three weights were documented, showing a decline from 143.5 pounds to 135 pounds, a 5.92% loss. The EMR did not identify the weight loss in progress notes, and the RD confirmed the resident should have been weighed weekly but did not know why the weights were not completed. The DON also confirmed the resident should have been weighed weekly due to being a new admission/readmission.
Respiratory Equipment Not Properly Stored and Oxygen Not Managed per Orders
Penalty
Summary
The facility failed to implement policies and procedures for respiratory equipment care and for administering oxygen according to HCP orders for two residents. For one resident, a nebulizer machine was observed in the room with the administration set connected and visible fluid present in the medication chamber, and the resident’s nasal cannula tubing was later found on the floor near the oxygen concentrator. The resident had diagnoses including stroke with left-sided hemiplegia and hemiparalysis, dysphagia, aphasia, heart failure, and muscle wasting, and the MDS showed moderate cognitive impairment and dependence for most ADLs. The resident also had an active order for continuous oxygen via NC at 2 L per minute and a care plan for oxygen therapy related to emphysema/COPD. For the second resident, an uncovered and uncontained CPAP mask was observed on top of the dresser next to the bed, and a nebulizer administration mask was observed in an open dresser drawer. The nebulizer administration set was connected with visible fluid and condensation in the medication chamber. The resident was receiving oxygen via NC at 5 L/minute with humidification and stated they used oxygen continuously as well as inhalers and nebulizer treatments. The resident’s diagnoses included CHF, acute and chronic respiratory failure, and falls, and the MDS showed the resident was cognitively intact and required assistance with transfers and bathing. During interview, the DON stated the nebulizer should be rinsed and left out to dry on a barrier after each use and confirmed fluid should not remain in the chamber. The DON also confirmed the first resident had an active order for continuous oxygen and stated the NC tubing that had been on the floor should have been disposed of. Facility policy for oxygen administration stated oxygen supplies not in use should be stored in a designated storage bag to keep free from dust and dirt, and a nebulizer storage policy was requested but not provided by the end of the survey.
Inaccurate controlled substance count and incomplete narcotic documentation
Penalty
Summary
The facility failed to ensure accurate narcotic counts and controlled substance documentation for 1 of 4 medication carts. During observation and interview, the A-B Unit medication cart’s controlled substance drawer was checked against the facility’s "Controlled Substance Shift Inventory" form, which listed 47 total narcotics. Physical count of the cart and refrigerator supply did not match the documented total: staff counted 44 punch cards in the drawer, 1 used medication card, and 1 controlled substance in the medication room refrigerator, for a total of 46, leaving the count off by 1. The discrepancy remained unresolved after repeated counting with the surveyor and facility staff. Record review and interview also showed problems with the emergency drug kit documentation for a discharged resident’s Lorazepam 1 mg/2 mg supply. The slip lacked a seal number, lock number, nurse signature, and date and time, and the Ativan 2 mg vial was not in the backup emergency kit. The acting DON and Clinical Regional Director stated that a narcotic sheet from an empty cartridge had been found in the DON’s office and had not been subtracted from the card count for two shifts, meaning the nurses did not catch that the card count was off during the prior shift counts. The facility policy required nurses to count controlled medications at the end of each shift and report discrepancies to the DON, who was to investigate and document the findings.
Expired Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to implement its policies and procedures for personal in-room refrigerator food storage, monitoring, and disposal for one resident. During observation, a small personal refrigerator was found in the resident’s room, and the resident stated staff retrieved items from it when asked and that it mainly contained pop. Inside the refrigerator were several cans of pop, a bottle of sauce, a package of cheese slices, cheese sticks, and a single-serving container of sour cream. Five cheese sticks and the sour cream were expired, and none of the food items had been dated when brought to the facility. The resident was observed in bed with eyes open and reported they rarely left their room and did not get out of bed to use the bathroom. Record review showed the resident was admitted with diagnoses including seizure disorder, anxiety, depression, and bipolar disorder, and the MDS indicated the resident was cognitively intact and required maximum to total assistance with ADLs except set-up for eating. The DON and a clinical RN stated staff should ensure there are no expired food items in resident refrigerators, but both said they needed to review the procedure when asked who was responsible for monitoring and disposal of expired items. The facility policy required food brought from outside sources to be labeled with a received date, use-by date, and staff initials.
Nurse Staffing Posting Was Not Visible or Accurate
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent and visible location and that the posting included the actual hours worked for licensed and unlicensed nursing staff. On 6/9/26, surveyors did not observe the nursing staffing data near the visitor/front entrance or in a visible area upon entering the resident care area from the main entrance. During interview, the DON stated they were interim at the facility and were unsure where the staffing information was posted until another staff member identified it as being across from the Side Two nurses' station, which was on the opposite side and end of the building from the visitor entrance. The staffing sheet posted on 6/9/26 listed census and the number of RNs, LPNs, and CNAs for three shifts, but it did not include the actual hours worked for any shift despite having a section labeled for actual hours worked. Review of the last 18 months of staffing sheets showed none included the total actual hours worked for RNs, LPNs, and CNAs. A comparison of the posted staffing sheet with 6/8/26 timeclock punches showed the CNA count did not match the punches provided because a CNA had called in and was not removed from the posted sheet. The Administrator stated they were unaware of the Federal regulation requirements for the posting and indicated that either they or a manager updated the posting when there were call-ins or staffing changes.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in medication storage and labeling practices across several medication carts and a medication room. Medications, including multi-dose vials, insulin pens, and eye drops, were found without required expiration dates after opening, despite facility policy mandating that opened medications be dated and assigned a new expiration date. Some medications were missing open dates entirely, and loose tablets were found in medication cart drawers. Additionally, a medication cart was left unlocked and unattended with a computer screen displaying resident medical information, contrary to facility policy requiring carts to be locked when not in direct supervision. Further observations revealed expired medical supplies, such as povidone iodine and bleach wipes, stored in the medication room. There were also instances of medication containers missing lids and multi-dose ampules not stored in their original packaging or properly dated. These findings were confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged the lapses in medication storage and administration procedures.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food safety and sanitation procedures. Upon entering the kitchen, staff were not wearing hairnets as required, and there was confusion about where hairnets should be located and when they should be worn. Staff were seen entering food preparation areas without washing their hands, and open, uncovered staff beverages were stored on a shelf in the dishwashing area. The food preparation table was visibly soiled with food debris and crumbs, and staff were preparing resident meals on this unclean surface. Additionally, the sanitizer bucket used for cleaning was found to have zero parts per million of sanitizer, far below the required level, and was not kept in the food preparation area for easy access. Further inspection of food storage revealed several expired food items in both the refrigerator and freezer, including ham, sour cream, diced chicken, and canola oil. Some food items, such as individual ice cream cups, were not frozen solid, and there was no thermometer inside the freezer to monitor temperature. Freezer and refrigerator organization was poor, with food stored directly on the floor, significant ice build-up, and icicles present. Thawing meat was placed on top of boxes of produce, and containers of whipped topping were found with greasy substances on their surfaces. Staff were unclear about proper storage procedures and expiration dates, and the maintenance schedule for defrosting the freezer was unknown. Interviews with the Administrator, DON, and Infection Control LPN revealed a lack of consistent understanding and enforcement of food safety policies, including the use of hairnets and the prohibition of personal beverages in food preparation areas. Facility policies required hairnets to be worn at all times in the kitchen and specified proper hand hygiene, food storage, and temperature monitoring, but these were not being followed. The observed deficiencies affected all residents who consumed food prepared in the kitchen, creating the potential for food contamination and foodborne illness.
Failure to Implement Comprehensive Infection Control Program and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control (IC) program, as evidenced by incomplete and inconsistent infection surveillance, inaccurate infection tracking, and lack of data monitoring and analysis. The IC LPN responsible for the program had less than a month of experience in infection control and was unfamiliar with key aspects of the role. Discrepancies were found between the infection mapping tool and the monthly infection control log, with infections missing or misclassified, and no system in place to track resident discharges, room changes, or carryover infections from previous months. Additionally, the facility did not track potential infections that were not treated with antimicrobials, and the IC LPN was unfamiliar with process surveillance and had not completed required audits. Further review revealed that antibiotic stewardship practices were not consistently followed. Several residents received antibiotics without appropriate culture and sensitivity (C&S) testing, and documentation was lacking regarding the rationale for antibiotic use when criteria were not met. In some cases, antibiotics were administered based solely on physician orders, without evidence of infection or proper risk versus benefit analysis. The facility's infection control policy required a system for monitoring antibiotic use, but this was not operationalized in practice. Direct observation of a resident with a urinary catheter revealed that the catheter drainage bag and tubing were repeatedly found lying on the floor, both inside and outside the privacy bag. The resident was unaware of the catheter's management, and staff who entered the room did not address the issue until prompted by a surveyor. When the LPN picked up the catheter from the floor, they did so without enhanced barrier personal protective equipment (PPE). These lapses in infection control practices created the potential for environmental contamination and the spread of infection among residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as three medication errors were observed out of 25 opportunities, resulting in an 8% error rate. One incident involved an intravenous (IV) antibiotic, Meropenem, which was mixed by an LPN during the night shift and left hanging in a resident's room from approximately 6:00 AM until after 11:00 AM, when it was administered by another LPN. The medication was signed out as given at 6:00 AM, despite not being administered until much later. Both LPNs involved acknowledged the delay and improper handling of the medication, with the IV bag left unattended in the resident's room for several hours. Another incident involved a resident who had three white tablets and a green Tums tablet left at the bedside by the night nurse, despite no physician order for Tums and no standing order for medications to be left at the bedside. The resident reported that the night nurse provided the tablets to moisturize her mouth. Additionally, levothyroxine was administered to the same resident with breakfast and other medications, contrary to guidelines that require it to be given on an empty stomach. These actions were observed and confirmed by staff interviews and record reviews, demonstrating non-compliance with the facility's medication administration policies.
Failure to Adequately Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were explained in a manner that could be understood by residents or their representatives. Interviews with the nursing home administrator and admissions director confirmed that while the arbitration agreement was presented and residents were told it was not required for admission, several cognitively intact residents who had signed the agreement were unable to explain or recall what the arbitration agreement was. Specifically, three residents with high BIMS scores, indicating cognitive intactness, could not describe or remember the arbitration agreement they signed, and one stated it was not explained to her. Additionally, during a resident council meeting, all six residents in attendance reported not understanding the arbitration process or what the agreement meant. One resident expressed that the volume of information provided during admission made it difficult to remember what was signed, and another cited a lack of trust. The findings indicate that the facility did not adequately ensure residents or their representatives were informed about the arbitration agreement or their right to refuse, resulting in a lack of understanding among those who signed.
Failure to Maintain Resident Dignity with Urinary Catheter Management
Penalty
Summary
Surveyors identified that the facility failed to ensure residents with urinary catheters were treated in a dignified manner, as evidenced by uncovered urine collection bags and lack of respect for residents' individuality. One resident with an indwelling urinary catheter was observed multiple times with an uncovered urine collection bag, both in their room and in the dining area, despite the facility having dignity bags and covered collection bags available. The DON confirmed that these covers should be used and are accessible to staff. Another resident was observed with a urinary catheter and tubing lying on the floor outside of the privacy bag, both at bedside and while awaiting a meal. The resident was unaware of the catheter's status, and an LPN, when notified, picked up the catheter from the floor without enhanced barrier PPE, stating uncertainty about why the catheter was out of the privacy bag. A third resident was initially observed with a visible urinary catheter and urometer from the doorway, with no privacy bag in place. The resident reported being new to the facility and expressed concerns about staff responsiveness. The following day, a privacy bag was in place, and the resident stated that staff had added the cover the previous afternoon, after the catheter had been visible to others. These observations demonstrate that the facility did not consistently maintain resident dignity regarding the management and privacy of urinary catheters.
Plan Of Correction
F550(D) Resident Rights/Exercise of Rights Residents 4, 108, and 208, all have catheter dignity bags or leaf covered catheter bags and have been verified that they are being used appropriately to maintain residents' rights and dignity. Any resident with a catheter could be affected by this. Residents with catheters have all been reviewed and verified to have dignity bags or leaf covered catheter bags. Any concerns identified were immediately corrected. The Residents Rights guideline was reviewed and deemed appropriate by the NHA and DON. The DON/Designee will educate all staff on the guideline and the need to treat residents with dignity and respect by keeping their catheters covered with a dignity bag or a leaf covered bag. The DON/Designee will audit all catheters 3x/weekly for 4 weeks and until substantial compliance is achieved to verify that all catheters are covered with appropriate dignity device. The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and continued improvement.
Advance Directive Signed by Incompetent Resident
Penalty
Summary
The facility failed to ensure that advance directive forms were properly completed by a designated responsible party for a resident who was deemed incompetent to make medical decisions. The resident, who had diagnoses including dementia and a history of falls, was assessed as severely cognitively impaired and required substantial to maximum assistance. Documentation in the medical record indicated that the resident was admitted to hospice services and had been formally evaluated as incompetent to make healthcare decisions by both a physician and a clinical psychologist. Despite this determination of incompetency, the most recent advance directive form specifying code status (MI-POST) was signed by the resident, rather than by the designated patient advocate or responsible party. Interviews with facility staff confirmed that the resident should not have signed the form due to their incompetency, and the error was attributed to a likely mistake by nursing staff. The facility's policy requires periodic evaluation of residents' decision-making capacity and proper completion of advance directives, which was not followed in this instance.
Failure to Provide ADL Care According to Resident Preference
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, paralysis, and a history of heart disease and strokes was not provided with personal hygiene care according to their preferences. The resident was observed on multiple occasions to have an unshaven face and an unkempt appearance, despite expressing a preference to be clean-shaven. Interviews with staff confirmed that shaving was only performed on shower days, which was the facility's usual procedure, rather than according to the resident's stated preference. The resident's care plan indicated a need for assistance with personal hygiene due to significant physical and cognitive limitations. Documentation reviewed did not specify shaving as a separate hygiene task, and the Director of Nursing stated that the resident could request to be shaved, without addressing the impact of the resident's cognitive impairment on their ability to make such requests. This failure to provide ADL care in accordance with the resident's preferences and needs led to the identified deficiency.
Failure to Follow Physician Orders and Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not following physician's orders for oxygen administration, not updating care plans to reflect current oxygen orders, and not maintaining oxygen supplies in a sanitary manner. One resident, with COPD and other comorbidities, was observed completing a nebulizer treatment independently, after which a nurse placed the used nebulizer mask and tubing with medication residue into a plastic bag without cleaning or drying the equipment. This was confirmed by both the nurse and the Director of Nursing. Another resident with COPD and chronic respiratory failure was observed receiving oxygen at a rate different from the physician's order. The electronic medical record indicated an order for continuous oxygen at 4LPM, but the concentrator was set to 3LPM. Additionally, after the order was updated to allow a range of 2LPM-4LPM, the care plan and Kardex still reflected the previous order of 4LPM continuous, resulting in inconsistent documentation and care instructions. A third resident, with a history of CHF and other conditions, was found with an oxygen concentrator and nasal cannula tubing in their room, despite having no physician's order or care plan for supplemental oxygen. The tubing was undated, uncontained, and showed signs of use. Therapy staff reported that the resident had been given oxygen during therapy sessions at the direction of nursing staff, but there was no documentation or order for this intervention in the resident's medical record.
Failure to Follow Bed Rail Assessment and Documentation Procedures
Penalty
Summary
The facility failed to implement and operationalize its policies and procedures regarding bed rail use for one resident. The resident was observed in bed with side rails present, but there was no evidence in the medical record of a health care provider order, assessment, or monitoring for the use of bed rails. The facility's own policy requires a physician order, initial and ongoing assessments, informed consent, and documentation of risks and benefits before bed rails are used, none of which were found in this case. The resident involved had a history of left lower limb monoplegia, schizophrenia, depression, and traumatic brain injury, and was cognitively intact but required assistance with activities of daily living. The care plan referenced a previous fall and included education on the use of half rails and call lights, but there was no separate or current care plan specifically addressing bed rail use. Documentation showed that after a fall, the resident was educated on using side rails for bed mobility, but no formal assessment, consent, or provider order was documented. Interviews with the DON and a clinical RN confirmed that the required documentation, including a physician order and assessment for bed rail use, was missing from the resident's record. The facility's policy outlines a comprehensive process for evaluating and documenting bed rail use, including alternatives, risk assessment, and informed consent, but these steps were not followed for this resident.
Failure to Follow Menus and Notify Residents of Meal Substitutions
Penalty
Summary
The facility failed to provide meal items as listed on the menu and did not notify residents of menu changes. During a kitchen tour, staff were observed preparing hot dogs for lunch, although the menu specified bratwurst on a bun. One resident received hot dogs instead of the expected bratwurst and expressed disappointment and frustration, stating that not receiving the planned menu items was a frequent occurrence. The resident became visibly upset upon receiving the incorrect meal and reported that this issue happened often. A review of the facility's menu confirmed that hot dogs were not listed as the lunch item for that day. Additionally, during a resident council meeting, all six residents present confirmed that food substitutions were often made without prior notification. This lack of communication and failure to follow the planned menu led to residents feeling frustrated and discontent with the meals provided.
Failure to Implement Pressure Ulcer Prevention and Management Policies
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for pressure ulcer prevention and management, resulting in the development and worsening of pressure ulcers for four residents. Resident #9, who had multiple diagnoses including Multiple Sclerosis and paraplegia, developed a Stage 3 pressure ulcer on their right posterior thigh while at the facility. Despite being at high risk for pressure ulcer development, the resident did not receive timely and appropriate interventions such as an alternating pressure mattress or regular repositioning. The resident's pressure ulcer deteriorated to an unstageable wound with necrotic tissue and tunneling, causing significant pain and discomfort. Staff failed to document and implement necessary care interventions, and the resident was often left in their electric wheelchair for extended periods without repositioning, contrary to care plan instructions. Additionally, the facility did not investigate the suitability of the resident's wheelchair cushion for pressure reduction, despite concerns that it may have contributed to the pressure ulcer development. Resident #59, who was admitted with a right femur fracture and other conditions, developed a pressure ulcer that became infected while at the facility. The resident's family members, including a nurse, discovered the pressure ulcer and informed the facility staff, who were unaware of its existence. The resident's condition worsened, with an elevated white blood cell count indicating infection, and the resident was eventually transferred to the hospital. Documentation revealed inconsistencies and a lack of timely interventions for the pressure ulcer, including the absence of a specialty mattress and regular repositioning. The facility's records did not include necessary wound care orders or treatments for the pressure ulcer, and staff failed to document and address the resident's pain and skin integrity concerns adequately. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention and management resulted in significant harm to the residents. The lack of timely and appropriate interventions, inadequate documentation, and failure to investigate and address potential contributing factors led to the development and worsening of pressure ulcers, causing unnecessary pain and suffering for the residents involved.
Inadequate Bowel Assessment and Enema Administration Leads to Resident Injury
Penalty
Summary
The facility failed to adequately assess and monitor a resident's bowel condition, leading to inappropriate medical intervention. The resident, who was cognitively intact and had a history of anemia, chronic kidney disease, diabetes, and heart disease, experienced constipation and rectal bleeding. Despite having multiple bowel movements prior to the incident, the facility did not document a clinical rationale for administering an enema, nor did they follow the established bowel protocol. The resident requested an enema, which was administered by a nurse who expressed discomfort with the procedure. The nurse encountered resistance during the enema administration and repeatedly inserted the enema tip, causing significant injury to the resident's rectal area. The resident experienced severe pain during the procedure and subsequently suffered from multiple anal mucosa tears and a full-thickness rectal tear, requiring surgical repair. Despite the resident's complaints of pain and requests to be sent to the emergency room, the facility delayed calling emergency services for several hours. The resident's condition deteriorated, necessitating a transfer to a hospital where he received blood transfusions and underwent surgery for rectal injuries. Interviews with the nursing staff revealed a lack of proper assessment and documentation regarding the resident's condition and the enema procedure. The nurses involved were deemed competent in enema administration and change of condition assessments, yet failed to adhere to facility protocols and policies. The Director of Nursing acknowledged discrepancies in the accounts of the incident and the failure to perform necessary assessments prior to the resident's transfer to the emergency room.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to food safety standards, resulting in multiple deficiencies observed by surveyors. Food items in the kitchen were not properly dated or labeled, including beverages, sandwiches, and other prepared foods. Additionally, pasteurized eggs in the walk-in cooler were not marked with an expiration date, and the Dietary Director was unsure of their shelf life. During meal preparation, the cook did not clean the thermometer between checking different food items, and the thermometer was not sanitized after falling into a gravy mixture. Furthermore, the cook did not change gloves after handling different food items, leading to potential cross-contamination. The surveyors also observed that cold beverages were not kept at safe temperatures, with milk being served at 51.6 degrees Fahrenheit, well above the recommended maximum of 41 degrees Fahrenheit. Hot food items were also found to be at unsafe temperatures, with biscuits and gravy served at 97.5 degrees Fahrenheit. The facility's 'Food Safety Requirements Guideline' policy clearly states the danger zone for food temperatures, which was not adhered to during these observations. In the nourishment room, a loaf of wheat bread was found to be moldy, despite being marked with a date indicating it was recently received. The Licensed Practical Nurse/Unit Manager/Infection Control Preventionist acknowledged that infection control rounds were conducted monthly, but the moldy bread indicated a lapse in monitoring. The Dietary Director confirmed that the bread was used to make sandwiches, further highlighting the risk of contamination. The facility's failure to maintain proper food safety protocols and temperature controls poses a significant risk to the health and safety of its residents.
Inaccurate Code Status Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of code status documentation for six residents, resulting in conflicting and incomplete Do Not Resuscitate (DNR) orders. Resident #4's DNR form lacked a clearly delineated physician signature, despite being signed by the resident and two witnesses. Similarly, Resident #8's DNR form was signed by the responsible party and only one witness, with no physician signature. Resident #36, Resident #29, and Resident #40 also had DNR forms that were signed by the residents and two witnesses but lacked a clear physician signature, with the physician signing as a witness instead. This inconsistency voided the residents' wishes for their DNR status as per the Michigan Do-Not-Resuscitate Procedure Act requirements. Additionally, Resident #22's records contained conflicting code status documentation, with both DNR and Full Code orders active, leading to confusion about the resident's actual code status. During the initial tour, Resident #4 was observed to be self-propelling in a wheelchair and in good spirits, while Resident #8 was resting in bed. Resident #36, Resident #29, and Resident #40 were also reviewed, revealing similar issues with their DNR forms. The facility's DNR forms did not have a specific signature line for the physician, leading to the physician signing as a witness instead. This issue was confirmed during interviews with the Social Work Director, Director of Nursing (DON), and Regional Clinical Nurse, who acknowledged the lack of a separate physician signature line on the DNR forms. Resident #22's case highlighted the confusion caused by conflicting code status documentation. The resident's electronic medical record showed both DNR and Full Code orders, with no care plan addressing the advanced directive. The Unit Manager confirmed the discrepancy and clarified the code status with the resident, who elected to continue as a Full Code. A new advanced directive form was signed, but the initial conflicting documentation indicated a failure to ensure accurate code status records for the resident.
Failure to Ensure Accurate Controlled Substance Management
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure accurate dispensing, administration, and reconciliation of controlled substances. During a tour of the C Hall Number Two Medication cart, an unlabeled oral syringe containing 0.25 mL of a light blue substance, identified as morphine, was found improperly stored. The Registered Nurse (RN) on duty was unaware of the syringe's presence and could not explain the discrepancies in the narcotic medication counts. The morphine bottle for a resident was found to contain 15 mL instead of the documented 16 mL. Additionally, discrepancies were found in the counts of Ativan, Xanax, and Gabapentin for other residents, with the RN admitting to not signing out three of the four pills administered and being unable to explain the fourth discrepancy. The Director of Nursing (DON) was informed of the findings and confirmed the inaccuracies in the medication counts. The DON acknowledged that the presence of the unlabeled syringe and the discrepancies in the controlled substance counts were not acceptable. The facility's policy and procedure documents related to medication administration and controlled medication storage and reconciliation were requested but not provided by the conclusion of the survey. The failure to maintain accurate records and proper storage of controlled substances poses a risk of medication errors and potential diversion of narcotics.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection control program, which included outcome and process surveillance, accurate data collection, and analysis. This resulted in a lack of accurate and comprehensive infection control tracking, surveillance, and data monitoring/analysis. Additionally, there was a lack of accessibility to hand hygiene supplies and functioning equipment, increasing the likelihood of microorganism spread and illness among all 56 facility residents. Specific observations included a non-functioning hand sanitizer dispenser in a resident's room and a broken soap dispenser in a communal bathroom, which were not promptly addressed by the maintenance and environmental services staff. Interviews with the Infection Control (IC) Licensed Practical Nurse (LPN) revealed significant gaps in the infection control program, including the absence of process surveillance for hand hygiene and environmental surveillance in resident rooms. The IC LPN was unaware of the issues with hand hygiene equipment and did not have a comprehensive system for tracking and monitoring infections. The data provided for infection surveillance was inconsistent and incomplete, with discrepancies in the line listings, summaries, and mapping tools. The IC LPN also lacked knowledge about the criteria for treating infections and the proper documentation of infection symptoms and treatments. Additionally, the facility failed to administer medications in a sanitary manner. During a medication pass task, a nurse placed two narcotics directly on top of the medication cart, which led to cross-contamination of oral medications. The nurse attempted to rectify the situation by placing the pills in a medication cup and administering them to a resident, but this action did not adhere to proper sanitary protocols. This incident further highlights the facility's deficiencies in maintaining a sanitary environment and preventing the spread of infections.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that planned interventions for fall prevention were in place for Resident #14. On multiple observations, it was noted that the resident's bed had a fall mat only on the left side, despite the care plan indicating that fall mats should be on both sides of the bed. This discrepancy was observed on 5/06/24 and 5/08/24, and confirmed during an observation with the Unit Manager on 5/09/24. The Unit Manager acknowledged that the resident had bilateral fall mats before moving rooms but did not respond when alerted that the second fall mat was missing during the survey period. Resident #14, who was admitted on 4/20/2020, has a medical history that includes stroke, difficulty in walking, and Alzheimer's disease. The resident is at high risk for falls due to gait and balance problems, hemiparesis on the right side, and Alzheimer's disease. The care plan, initiated on 4/28/23, specified the use of fall mats on both sides of the bed to prevent injury. However, this intervention was not consistently implemented, as evidenced by the observations made during the survey.
Failure to Change Urinary Catheter Leading to Recurrent UTIs
Penalty
Summary
The facility failed to change a urinary catheter as per physician's orders for a resident, leading to recurrent urinary tract infections (UTIs). The resident's medical records revealed multiple instances where the catheter was not changed on the scheduled dates, as indicated by the physician's orders. For example, the catheter change scheduled for September 2023 was not performed, and there were no records of catheter changes in November 2023, December 2023, February 2024, March 2024, and April 2024. This non-compliance with the catheter change schedule contributed to the resident experiencing multiple UTIs over several months, requiring various antibiotic treatments, including Rocephin, Bactrim, and Keflex. The resident's condition was further complicated by hospitalizations due to sepsis and infections with multiple organisms, including Proteus Mirabilis, Citrobacter Freundii, Pseudomonas Aeruginosa, and Enterococcus Faecalis. The facility's failure to adhere to its own 'Urinary Indwelling Catheter Management Guideline' and 'Urinary Tract Infections/Bacteriuria-Clinical Protocol' policies was evident in the lack of consistent catheter care and timely changes. Interviews with the Licensed Practical Nurse/Infection Control Preventionist/Unit Manager (LPN/ICP/UM) confirmed the recurrent UTIs and the lapses in catheter management. The facility's infection control logs and treatment administration records further corroborated the deficiencies in catheter care and the resulting health complications for the resident.
Improper Antibiotic Therapy for Wound Infection
Penalty
Summary
The facility failed to provide proper antibiotic therapy for a resident with a wound infection. The resident, who had bilateral lower limb amputations and a stage IV pressure ulcer, received Rocephin antibiotic therapy for 7 days prior to the wound culture results. The wound culture, collected on the same day the antibiotic therapy started, revealed the presence of Methicillin Resistant Staphylococcus Aureus (MRSA) and Streptococcus Agalactiae, with no susceptibility to Rocephin. Despite this, the resident continued to receive Rocephin for the entire 7-day course without any adjustment to the antibiotic regimen based on the culture results. The facility's Medication Therapy policy emphasizes that medication use should be consistent with an individual's condition and diagnostic test results. However, the review of the resident's Medication Administration Record (MAR) and wound culture report indicated that the prescribed antibiotic was not appropriate for the identified organisms. The Licensed Practical Nurse (LPN) and Infection Control Preventionist confirmed that no other antibiotic was ordered post wound culture results, leading to the resident receiving an ineffective treatment for the wound infection.
Failure to Justify and Document PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to justify the use of PRN antianxiety medication and document the rationale for indefinite use for two residents, resulting in the likelihood of unnecessary medications and adverse effects. For Resident #46, the physician's order for Ativan 1mg every 4 hours as needed was found to be indefinite without a 14-day stop date. Additionally, the order was changed to every 2 hours as needed indefinitely without proper documentation. The Corporate Clinical Consultant acknowledged the oversight and indicated that the order would be corrected to include a 14-day stop date. For Resident #48, the physician's order for Xanax 0.5mg every 4 hours as needed for anxiety was also found to be indefinite without a 14-day stop date. The medication was administered 32 times in April and 12 times in May, exceeding the 14-day limit. The Social Services Director confirmed the oversight during an interview. The facility's policy mandates that PRN psychotropic medication orders be discontinued after 14 days unless re-evaluated by the attending physician, which was not adhered to in these cases.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure a medication error rate less than 5%, resulting in a medication error rate of 7.4%. This was observed in two residents out of 27 observations. Resident #7 was left unattended while receiving a nebulizer treatment, which is against the facility's policy. The resident was heard coughing and was found with minimal mist in the nebulizer mask, indicating improper administration. The nurse responsible, RN X, admitted to starting the treatment but did not stay with the resident, and was unaware of the facility's policy regarding nebulizer treatments. Another nurse, RN O, confirmed that staff should remain with residents during such treatments but was initially unaware of the policy as well. Resident #18 experienced a medication error during insulin administration. Nurse A administered Fiasp insulin but did not follow the proper procedure as outlined in the Fiasp Flex Touch instructions. The nurse injected the insulin and held the needle in the skin for only 4 seconds instead of the required 10 seconds. This improper administration could lead to incorrect dosing. The facility's policy/procedure related to inhalation medication, including nebulizer administration, was requested but not provided by the conclusion of the survey.
Failure to Timely Submit PBJ Data and Inadequate Staffing Information Display
Penalty
Summary
The facility failed to ensure timely submission of Payroll-Based Journal (PBJ) data for the second quarter of 2023, leading to staffing concerns being triggered by CMS. The facility's policy mandates that direct care staffing information be reported electronically to CMS no less frequently than quarterly, with specific deadlines for each fiscal quarter. However, the third-party payroll service used by the facility did not submit the required data on time, resulting in excessively low weekend staffing being flagged for the fourth quarter of 2023. This issue was compounded by a change in the third-party payroll service system in January 2023, which may have contributed to the delay. Additionally, observations and interviews revealed that the facility's posted nursing staffing information was not easily readable, which could hinder effective communication and staffing management. The Nursing Home Administrator acknowledged that the placement of the staffing report needed to be reviewed and improved. The Corporate Clinical Director of Operations confirmed that the PBJ policy and procedure were in place and that the corporate payroll department was responsible for submissions. Despite having analysts to review staffing submissions, the facility still received a citation for low weekend staffing.
Failure to Monitor and Justify Antibiotic Use
Penalty
Summary
The facility failed to monitor and justify the administration of an antibiotic for a resident, resulting in the resident receiving an antibiotic without appropriate clinical rationale. The resident, who had bilateral lower limb amputations and a stage IV pressure ulcer, was administered ceftriaxone sodium (Rocephin) intramuscularly for a wound infection over a period of seven days. However, the wound culture results, which were available six days after the antibiotic administration began, did not recommend Rocephin for treatment. The culture identified organisms such as gram-positive cocci, Streptococcus agalactiae, and Methicillin-resistant Staphylococcus aureus (MRSA), and listed eight different antibiotics that could have been used, but Rocephin was not among the recommended options. The facility's policies on 'Surveillance of Infections' and 'Antibiotic Stewardship' were not followed, as the antibiotic therapy was not appropriately justified or modified based on the culture and sensitivity results. The Licensed Practical Nurse (LPN) and Infection Control Preventionist reviewed the resident's medication administration record and wound culture report, confirming that the antibiotic administered was not suitable according to the culture results. This failure to adhere to the facility's policies and the inappropriate use of antibiotics could contribute to antibiotic resistance and compromised resident care.
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 52 citations issued within 25 miles in the last 12 months — 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 West Branch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Rose City | 11.7 mi | ★★★★★ | 20 | 0 |
| Medilodge Of Sterling | 15.6 mi | ★★★★★ | 0 | 0 |
| Gladwin Nursing And Rehabilitation Community | 22.3 mi | ★★★★★ | 14 | 0 |
| Mymichigan Skilled Nursing Facility | 23.7 mi | ★★★★★ | 9 | 0 |
| Intersect Healthcare Of Roscommon | 23.9 mi | ★★★★★ | 9 | 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 October 2026) and official state health department websites.