Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Woodward Hills Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple complex conditions experienced a significant overnight change in condition, including markedly elevated and irregular pulse, increased respirations, and decreased responsiveness, after previously being documented as alert and cooperative earlier in the day. During the night, an LPN noted the resident responded only to painful stimuli and had abnormal vitals, but administered midodrine three hours earlier than ordered without a provider order or documented justification, and only left a voicemail for the NP. No further assessments, monitoring, or documented provider contacts occurred for several hours, despite ongoing abnormal vitals. Later that day, another LPN found the resident unresponsive to commands, with erratic heart rate and a fever, and arranged an emergent hospital transfer, though the transfer form did not reflect the earlier abnormal vital signs. The facility’s own change in condition and standards of practice policies requiring timely assessment, notification, documentation, and care consistent with professional standards were not followed, resulting in the cited deficiency.
Unlabeled medications were found in multiple medication carts, including loose pills and vials with no resident identifiers in the 600-, 100-, and 200-hallway carts. An RN, LPNs, and the DON observed unidentifiable medications and acknowledged the loose storage, while the facility policy required medications and treatments to be accurately labeled and dated for safe and secure storage.
Poor cleanliness and maintenance were observed in the laundry and pantry areas. Two soiled-linen carts had debris, soil, and a sticky brown substance under the false bottom, and both carts were cracked with worn metal attachments that were difficult to remove for cleaning. A cabinet under the sink had water damage and peeling surfaces, and an ice bin drain line lacked a proper air gap. Staff interviewed were not aware of the damaged surfaces or the drain issue.
Failure to assess residents for safe self-administration of medications. A resident with CHF and dysphagia was observed with antacid tablets left at the bedside, another resident was observed with seven pills left on the bedside table after staff documented the meds as given, and a third resident had multiple supplement bottles in the room. None of the three residents had an assessment, physician order, or care plan for self-administration, and the DON stated residents should be assessed and have orders and a care plan if self-administering.
Resident Mail Privacy Not Maintained: A resident reported receiving opened mail that was addressed to them and related to insurance or payment statements. The BOM acknowledged opening the resident’s Medicaid-related mail, stating they had authorization from the resident’s attorney, and later discussed the concern with the resident. The resident was their own responsible party, had moderate cognitive impairment, and the resident handbook stated mail and other deliveries would be brought to the resident’s room.
Failure to Provide Routine Bathing and Document Bathing Offers: Two residents who needed ADL assistance were not consistently offered bathing as scheduled. One resident with DM, neuropathy, and a LBKA was observed with poor hygiene, urine odor, soiled clothing, and dry flaking skin, while records showed limited shower documentation and a backdated note after staff confusion about where bathing was charted. Another resident with a prosthetic knee infection reported being offered bathing only once weekly instead of twice weekly, denied refusing, and the record contained only limited bathing documentation despite the DON stating bathing should be offered twice a week.
A resident with MS, anxiety, and depression required a sit-to-stand lift or 2-person assist for transfers, but the lift was reported as not working well and had previously caused an injury when the resident’s foot became caught under the platform and the toenail came off. Staff could not locate the lift during survey, and the DON and Maintenance Director acknowledged the only sit-to-stand lift in the building was unsafe and had not been removed from use until the concern was raised.
PICC line dressing care was not provided as ordered for a resident with a PICC in the R upper arm. The dressing remained dated with an older date, the tape was loosening and coming apart, and the TAR showed the dressing change as completed even though the Nurse Manager and DON verified it had not been done as documented.
A resident newly admitted with pneumonia and sepsis had physician-ordered CBC and CMP labs that were not completed because the admission nurse failed to place the request in the lab book. The EMR showed no results for the ordered tests, and the facility later had to reorder the labs to obtain baseline values; the reordered labs showed multiple abnormal results. The facility policy required ordered labs to be obtained and abnormal results to be promptly reported to the physician.
A resident with brain and lymph node cancer missed multiple doses of Namenda because the medication was not available and the orders were not clarified with the pharmacy and physician. The MAR and eMAR showed repeated missed administrations, with notes stating the drug was unavailable, needed clarification, or was not in the backup box, and the resident did not receive any Namenda after the titration period ended.
Failure to Monitor Suprapubic Catheter Care and Output: A resident admitted with neurogenic bladder and a suprapubic catheter had no specific MD orders, no documented nursing assessment or output monitoring, and repeated complaints of burning, pain, and hematuria were not promptly evaluated. Staff acknowledged the catheter was missed on admission, the EMR lacked catheter-specific orders, and the resident’s catheter care was not clearly identified or documented.
Hand hygiene was not performed during medication administration for three residents. An RN handled items on the med cart, prepared and administered meds while wearing the same gloves, and two separate observations of an LPN showed no hand hygiene before med prep, before med administration, or before donning PPE. The facility's hand hygiene policy required hand hygiene before and after PPE use and before preparing or handling medications.
A resident who required a two-person assist for ADLs was being changed by only one CNA, resulting in the resident rolling out of bed and sustaining a serious head injury. The CNA involved had a history of improper transfers with other residents, and required documentation for the incident was missing. The facility's fall protocol and transfer status policy were not followed.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
A resident admitted with hypokalemia and dependent on staff for all ADLs had concerns raised by their case manager, but the facility did not document, investigate, or resolve the grievance as required by policy. The social worker did not complete a grievance form, and the administrator could not provide any records of the grievance or its resolution.
Two residents with a history of conflict and behavioral issues were involved in a physical altercation after ongoing verbal threats and disagreements about room lighting. Despite staff awareness of escalating tensions and prior threats, no effective interventions or care plan updates were implemented, and there was a delay in reporting and documenting the incidents. The facility failed to protect residents from abuse and did not ensure proper communication or preventive measures.
A resident with moderate cognitive impairment was found by a family member to have an unexplained skin tear and bruising on the arm, with no documentation or investigation by facility staff. Required incident reporting, assessment, and notification procedures were not followed, and the injury was not addressed in the medical record or communicated to the responsible party.
Two residents experienced missed or delayed wound treatments, including omitted care for sacral, buttock, and heel wounds, and delays in identifying and treating a left heel pressure ulcer. Staff also failed to consistently complete and document required weekly skin assessments, with some assessments marked as done but lacking supporting documentation. Communication lapses and inconsistent adherence to wound care protocols contributed to these deficiencies.
A resident admitted with hypokalemia and dependent on staff for all ADLs did not receive an initial comprehensive visit from a physician as required. Instead, the first visit was completed by an NP, and there was no timely physician documentation or approval for the admission. The physician's order confirming agreement with care plans was signed after the resident had already left the facility.
A resident was not treated with dignity when staff failed to retrieve and deliver their personal hygiene wipes after a room transfer. Although a nurse documented the need and relayed the request, the DON confirmed that the nurse should have personally ensured the wipes were delivered, in accordance with the facility's resident rights policy.
A resident reported feeling unsafe and alleged verbal and physical abuse by a CNA, prompting the involvement of the DON and local police. Although the CNA was removed from duty and an internal investigation was conducted, the facility did not report the abuse allegation to the State Agency as required by policy, citing lack of substantiation.
A resident with paraplegia and multiple diagnoses, who required a two-person assist for bed mobility, was turned by a CNA without assistance, leading to the resident rolling out of bed and sustaining a skin tear. The CNA was unaware of the two-person requirement, and the care plan was not followed, resulting in an avoidable fall.
A resident with significant pain management needs did not receive prescribed oxycodone as ordered due to the facility running out of the medication. Despite the availability of oxycodone in the emergency supply, staff did not utilize it, resulting in a delay of approximately 12 hours between doses and the resident experiencing severe pain.
A resident with dementia and diabetes developed an unstageable pressure ulcer on the left heel due to wearing tight-fitting shoes in bed, leading to a sepsis infection. The facility failed to document attempts to remove the shoes or the resident's refusal, and did not implement care plan interventions such as floating heels or providing heel boots. Interviews with staff confirmed the lack of prior intervention, contributing to the development of the ulcer.
A facility failed to provide adequate supervision and safe transfer assistance, resulting in multiple falls and injuries for residents with cognitive impairments and mobility issues. One resident suffered fractures due to a CNA not following the care plan for a two-person assist. Another resident, with a history of falls, was found without necessary Dycem on their wheelchair cushion, leading to a fall. A third resident, with severe cognitive impairment, was observed attempting to get out of bed without assistance, highlighting the facility's failure to implement effective interventions.
The facility failed to maintain sanitary conditions in the kitchen and pantry areas, with issues such as missing plastic edging on a cart, buildup on a coffee dispenser, and missing grout in the dish machine room. Additionally, microwaves were rusted, and fruit cups were uncovered during transport to resident rooms, violating FDA Food Code standards.
The facility failed to maintain comfortable room temperatures, with measurements in several rooms ranging from 60 to 69 degrees Fahrenheit, below the required 71-81 degrees. A resident in one room was observed cold, wrapped in a blanket and wearing a winter hat. The Maintenance Director acknowledged that temperatures are monitored but not recorded, violating the facility's policy.
A resident experienced frequent shortages of pain medication due to the facility's failure to accurately document and account for controlled substances. Discrepancies were found between the MAR and Proof of Use forms, with doses documented as administered without corresponding entries and unaccounted tablets. The facility's protocols for administering controlled substances were not followed, leading to inconsistencies in medication records.
A resident received duplicate doses of furosemide on three occasions due to active duplicate orders on the eMAR. The Consultant Pharmacist had recommended discontinuing one order, but both remained active, and the error was not communicated to a physician. The DON and AIT noted the error occurred after the resident's hospital readmission.
A resident on contact precautions for VRE was not properly isolated, as staff failed to display signage or provide PPE outside the room. The resident was observed interacting with others and moving around the facility, contrary to physician orders. The facility's infection control policy was not adhered to, as confirmed by interviews with the DON and AIT.
The facility failed to maintain resident dignity and respect, as evidenced by multiple incidents of inappropriate staff behavior and inadequate care. Residents reported rude interactions, lack of privacy, and insufficient assistance during personal care. The facility's policy on dignity was not adhered to, compromising resident well-being.
A resident with severe cognitive impairment and multiple mental health diagnoses did not receive a timely referral for a PASARR Level II evaluation. The facility's policy requires such evaluations to ensure appropriate placement and service determination, but there was no evidence of a completed evaluation or exemption request in the resident's record.
A facility failed to timely assess a facial bruise for a resident with impaired cognition, assuming it was from a previous fall without proper documentation. Additionally, two residents did not receive medications on time, with one experiencing pain due to the delay. The facility's policy required medications to be administered within a one-hour window, which was not adhered to. Furthermore, a resident had an undated dressing on their arm without a physician's order, contrary to facility policy.
The facility failed to ensure proper orders and monitoring for PICC line dressing changes for two residents. One resident, receiving antibiotics through a PICC line, was observed with a dressing that was not properly adhered. There was a gap in the orders for dressing changes, and existing orders lacked specific details. The AIT and DON acknowledged the oversight and the improper use of order templates.
A facility failed to follow up on the guardianship process for a resident deemed incompetent to make medical and financial decisions. Despite a competency evaluation and a plan for the resident's son to file for emergency guardianship, there was no evidence of follow-up by the Social Work Department. The former DON, now an AIT, confirmed the department's responsibility for this task.
The facility did not ensure that a resident's monthly drug regimen review by the consultant pharmacist was reviewed by the medication provider for recommendations. The resident, with chronic respiratory failure, chronic kidney disease, and type II diabetes, had irregularities noted by the pharmacist, but no documentation of these was found in the clinical record. The DON/AIT could not locate the necessary documentation in the electronic record during the survey.
A resident was not offered the 2024-2025 seasonal influenza vaccine at the start of the new flu season. The resident's immunization records showed no evidence of the vaccine being offered, and the Infection Control Preventionist confirmed this oversight. The facility's vaccination policy did not address offering the influenza vaccine at the beginning of the flu season.
A resident in a LTC facility did not receive timely follow-up dental services, despite expressing a desire for bottom dentures and having intact cognition. The resident's last documented dental evaluation was over a year ago, with no follow-up services recorded. Facility staff were unable to provide documentation of refusal or explain the lack of follow-up, contrary to the facility's dental services policy.
The facility failed to ensure skin assessments were documented, completed accurately, and timely for a resident with a history of Metabolic Encephalopathy, Cellulitis, and Sepsis. Despite physician orders and indications in the Treatment Administration Record, proper documentation in the Total Body Skin Evaluation was not completed, as confirmed by nursing staff and the DON.
Failure to Timely Respond to Change in Condition and Improper Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to timely recognize and respond to a significant change in condition for one resident, and to provide care in accordance with physician orders and professional standards of practice. The resident had multiple serious diagnoses, including CAD, HTN, DVT, kidney disease, diabetes, dementia, seizure disorder, prior sepsis, and lung disease, and required extensive assistance with mobility and supervision with eating. Prior to the incident, the resident was documented on the afternoon of 5/16 as alert, oriented to name and place with cues, calm and cooperative, denying pain, shortness of breath, chest pain, or abdominal pain, and with a Foley catheter intact, initially with hematuria that later cleared. A subsequent note that evening documented a small amount of blood in the Foley, with the NP notified and no further catheter concerns noted. During the night shift, the resident’s condition changed significantly. Blood sugars were elevated the evening of 5/16 (356 mg/dL twice), higher than the resident’s usual range. In the early morning hours of 5/17, the resident’s pulse readings were markedly elevated and irregular (120–133 bpm) compared to their prior baseline of 51–85 bpm, and the resident’s respiratory rate increased to 28. At 2:34 a.m., a nursing progress note documented that the CNA called the nurse to the room because the resident was not at their normal baseline; vital signs showed BP 96/64, pulse 120, RR 20, and blood sugar 184. The resident responded only to painful stimuli and would not vocalize discomfort, and had a large bowel movement. The nurse administered midodrine at 3:00 a.m., three hours earlier than the scheduled 6:00 a.m. dose, without a corresponding physician order or documented clinical justification, and despite the MAR specifying scheduled dosing and a hold parameter for elevated systolic BP. Subsequent vitals showed BP 111/75 with pulse 128 and RR 28, and at 3:18 a.m. BP 111/81 with pulse 126. The nurse documented leaving a voicemail for the NP and on-call staffing number and awaiting a callback, but there was no documentation of further assessment, monitoring, or escalation. From 2:34 a.m. until early afternoon, there were no additional nursing progress notes documenting the resident’s clinical status, reassessment, or further attempts to contact a provider, despite the documented change in condition and abnormal vital signs. At 6:29 a.m., a note only recorded that the NP called back and ordered labs (CBC, CMP) and a chest x-ray, with no description of the resident’s condition at that time. The next detailed note was not entered until 1:23 p.m. by a day-shift LPN, who reported entering the room to check blood sugar and finding the resident lying in bed, unresponsive to commands, with eyes open and mouth breathing. Vital signs at that time showed BP 105/70, oxygen saturation 92% on room air, temperature 100.5°F, and an erratic pulse fluctuating between 42 and 125 bpm. The LPN contacted the physician and supervisor, and the resident was emergently transferred to the hospital for change in mental status. The transfer form listed change in mental status as the reason for transfer but did not include the earlier fluctuating vital signs, tachycardia, increased respirations, or unresponsiveness. The medical director, interim DON, and involved LPN later acknowledged, upon review of the record, that the resident should have been sent out sooner and that midodrine had been given early without an order, and the facility’s own change in condition and standards of practice policies required timely notification, assessment, documentation, and intervention for such significant changes, which did not occur. The facility’s policies on Change in Condition Notification and Standards of Practice required that significant changes in a resident’s physical or mental condition be promptly assessed, that the physician/practitioner and resident representative be notified, and that the change, assessments, notifications, interventions, and resident response be documented in the medical record. A significant change was defined as one that would not normally resolve without intervention and that affects more than one area of health status. The policy also required comprehensive assessment when a significant change occurs and specified that residents receive care consistent with professional standards of practice. In this case, despite the resident’s acute change in responsiveness, abnormal and worsening vital signs, and the need for early morning provider contact, there was a prolonged gap in documentation and monitoring, no documented comprehensive reassessment, no timely escalation or transfer, and administration of a scheduled medication (midodrine) outside ordered parameters without provider authorization, all of which led to the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, goals, and professional standards.
Unlabeled medications found in multiple medication carts
Penalty
Summary
The facility failed to ensure medications were labeled with the medication name and resident-specific identifiers in three of five medication carts reviewed for medication storage. During observation on the 600-hallway medication cart, nine loose medications were found on the bottom of drawer two, two loose medications were found on the bottom of drawer three, and five vials of albuterol were lying on the base of the drawer with no patient identifiers. The RN and DON acknowledged that loose medications were not proper storage in the medication cart. Similar findings were observed on the 100-hallway medication cart, where four unidentifiable medications were found in drawer two and four unidentifiable medications were found in drawer three, all without resident identifiers. On the 200-hallway medication cart, nine unidentifiable medications were found in the bottom of drawer two, and the last bottom drawer contained one vial of an unknown respiratory medication with no resident identifier. The DON was informed that the 600-hallway cart findings were similar to those on the 100 and 200 medication carts. The facility policy titled Medication and Treatment Storage, dated 2/3/2026, stated that medications and treatments must be accurately labeled and dated for safe administration and safe and secure storage.
Poor Cleanliness and Maintenance of Laundry and Pantry Areas
Penalty
Summary
The facility failed to maintain general cleanliness and repair of a cabinet surface, laundry equipment, and a plumbing fixture. In the laundry soiled linen room, two plastic carts used for transporting soiled linens were observed with debris and soil, including used gloves, food wrappers, and a sticky brown substance, covering the interior bottom beneath the false fabric bottom. The same two carts were cracked and not smooth or easily cleanable around the top perimeter, and the metal attachments near the four corners of each bin were worn, difficult to remove for cleaning, and had worn to sharp edges. In the 1st floor Cranbrook pantry room, the floor of the cabinet under the sink was water damaged, peeling, and no longer smooth and cleanable. In the 2nd floor pantry room, the drain tubing from the ice bin was submerged below the rim of the drain line and was not properly protected with an air gap. Staff interviewed during these observations stated they were not aware of the damaged cabinet surface or the required air gap and indicated the issues would be added to the task list or adjusted.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed for safe self-administration of medications for three residents reviewed for self-administration. R134 was observed with two antacid tablets in a medication cup on the bedside table after reporting that nursing staff had left medications for them to take after morning medications. The medical record showed diagnoses including congestive heart failure and dysphagia, and review of the record did not reveal any physician orders, care plan direction, or assessment for self-administration of medications. R27 was observed in bed with a medication cup containing seven pills on the bedside table, and the resident indicated staff had entered the room and left the pills there. The eMAR showed seven scheduled medications documented as given, but the nurse could not confirm observing the resident take them. R27's record had no assessment, physician's order, or care plan for self-administration. R138 was observed with four bottles of supplements on the sink countertop, including sleep supplement, multivitamin, protein supplement, and magnesium supplement, and the same items remained there on a later observation. R138's record also had no assessment, physician's order, or care plan for self-administration, and the facility's report of residents assessed and deemed appropriate for self-administration did not include R27 or R138.
Resident Mail Privacy Not Maintained
Penalty
Summary
The facility failed to ensure resident rights related to privacy in the use of communication methods for one resident. During a resident meeting on 3/03/26, the resident reported that about two weeks earlier they received mail that had already been opened by facility staff, which upset them. The resident clarified that the opened item was a statement from their insurance company, Medicaid, or Medicare, and said it was addressed to them and related to payments. The resident was interviewable, oriented to self, situation, place, and time, and their profile showed they were their own responsible party with bills marked. Record review showed the resident’s MDS dated 1/21/26 listed diagnoses including diabetes, heart failure, lung disease, depression, and malnutrition, and the BIMS score was 11/15, indicating moderate cognitive impairment. On 3/04/26, the Business Office Manager acknowledged opening the resident’s Medicaid application and stated they had been authorized by the resident’s attorney. The Business Office Manager also reported the resident later expressed that the opened mail bothered them, and both the Business Office Manager and DON stated they understood the concern related to residents’ rights to open their own mail. The resident handbook stated that mail and other deliveries would be brought to the resident’s room.
Failure to Provide Routine Bathing and Maintain Bathing Documentation
Penalty
Summary
The facility failed to ensure routine bathing was provided for two residents who required assistance with ADLs. One resident had diabetes with peripheral neuropathy and a left below-knee amputation, and the other resident had an infection and inflammatory reaction related to an internal right knee prosthesis. Both residents had care plans that included bathing or showering assistance, and both were assessed as needing help from facility staff with bathing. For the first resident, surveyors observed disheveled hair, long and dirty fingernails, a strong urine odor, heavily soiled clothing, food and crumbs on the wheelchair, and very dry skin with flaking on the right foot. The resident stated showers were an issue and could not recall the last one received, and later said no shower had been provided the night before and that they had not refused, but had simply not gotten one. Record review showed only limited shower documentation for the month, with eight opportunities for a shower but only three documented offers. Staff interviews revealed confusion about where shower documentation was recorded, and a nurse later stated a note had been backdated after the fact to reflect a refusal. For the second resident, the resident reported being offered bathing only once a week even though the schedule was supposed to be twice weekly, and stated staff gave a blank stare or dodged the question when asked about shower days. The resident denied refusing bathing. Record review showed only one shower documented in CNA task records, one shower sheet showing a shower, one skin assessment noting a shower, and one bathing refusal. The DON stated bathing should be offered twice a week, but no additional documentation was provided to show that routine bathing had been offered as scheduled.
Mechanical lift accidents and continued use of malfunctioning transfer equipment
Penalty
Summary
The facility failed to prevent two accidents involving a sit-to-stand mechanical lift and failed to remove the malfunctioning lift from use until after surveyor inquiry. One resident with multiple sclerosis, depression, and anxiety was assessed as cognitively intact, dependent for transfers, and requiring either a sit-to-stand lift or two-person assistance. The resident stated that the lift had not been operating well for several days, that staff sometimes kept them in bed because of the problem, and that transfers were delayed when the lift did not work. The resident also reported that the lift had injured them in a prior incident when staff did not operate it correctly. The resident described one prior accident in which a foot became caught under the sit-to-stand platform during a transfer, causing the toenail to come off and resulting in an open wound that took time to heal. The resident said the aide moved too quickly and did not position the foot correctly. The progress note for that incident documented that the resident’s foot was caught under the lift, the toenail was bleeding and coming off, and wound care and physician notification were required. A later progress note also documented another conflict involving the same resident and malfunctioning transfer equipment when staff were unable to transfer the resident because the lift was not working. During the survey, staff could not locate the sit-to-stand lift, and the DON and Maintenance Director acknowledged that the only sit-to-stand lift in the building was not functioning and had been removed from circulation only after the concern was brought to their attention. The DON stated staff and nursing management had not made them aware the lift was unsafe, and the Maintenance Director confirmed no concerns had been reported to maintenance. The resident’s care plan and room posting indicated the resident was to use the sit-to-stand lift for transfers and toileting, and the resident stated they felt safest with that device because of leg weakness related to MS.
PICC Line Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to provide appropriate PICC line care for a resident who had a PICC inserted in the right upper arm and was receiving treatment for infection and inflammatory reaction due to an internal right knee prosthesis. The resident’s care plan identified a potential for complications at the IV insertion site and directed dressing changes by physician order and as needed if soiled or wet. A physician order dated 1/31/26 directed the PICC line dressing on the right upper extremity to be changed every Sunday and as needed for safety monitoring. On 3/2/26 and again on 3/3/26, the resident was observed in bed with the PICC line dressing dated 2/25/26, and the tape securing the dressing was observed to be losing adhesiveness and coming apart. On 3/3/26, the Nurse Manager verified the dressing date was 2/25/26, while the March 2026 TAR documented the dressing change as completed on 3/1/26. The Nurse Manager and DON both indicated that the dressing should have been changed on Sunday and that the record reflected a documentation error for a treatment that had not been completed.
Failure to Complete and Report Ordered Labs
Penalty
Summary
The facility failed to ensure physician-ordered laboratory diagnostics were completed and reported in a timely manner for one resident who was newly admitted with diagnoses including pneumonia and sepsis. A physician order dated 2/20/26 required a CBC and CMP for the new admission, but a review of the electronic medical record did not reveal any results for those ordered labs. During interview, the Nurse Manager reported that the labs were never drawn because the nurse who completed the admission orders failed to place the request in the laboratory book for the lab technician. The Nurse Manager stated the facility had to reorder the labs to obtain baseline results. The reordered labs, completed on 3/2/25 per the report, showed multiple values outside normal reference ranges. The facility policy stated that labs ordered by a physician must be provided or obtained, that labs not drawn as ordered are reported to the attending physician, and that staff will process test requisitions and arrange for tests.
Missed Namenda Doses Due to Unavailable Medication and Unclarified Orders
Penalty
Summary
The facility failed to ensure medications were available for administration and failed to clarify physician orders with the physician and pharmacy for one resident, R204, resulting in missed doses of Namenda. R204 was admitted with diagnoses including malignant neoplasm of the brain and malignant neoplasm of lymph nodes of multiple regions. A progress note dated 8/21/25 stated that the resident was started on a Namenda titration pack by radiation/oncology, and a physician order dated 8/21/25 directed Namenda Titration Pak 5 mg by mouth daily for 7 days starting 8/22/25. A second physician order dated 8/30/25 directed Namenda Titration Pak 5 mg by mouth twice daily for 7 days starting 8/30/25. Review of the August and September 2025 MAR showed missed doses on 8/23, 8/24, 8/25, 8/30, 8/31, 9/1, and 9/2, and the eMAR notes documented that the medication was not available, needed clarification per pharmacy, or was not in the backup box. The record also showed that after 9/5/25, R204 did not receive any Namenda, and the DON stated the orders should have been clarified with the pharmacy and physician to ensure the medication would be delivered and available for administration.
Failure to Monitor and Provide Ordered Care for Suprapubic Catheter
Penalty
Summary
The facility failed to implement timely care and monitoring for a resident’s suprapubic urinary catheter, including physician orders and nursing assessment, for one resident reviewed for urinary catheters. The resident was admitted with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus with diabetic nephropathy, kidney transplant status, end stage renal disease, and neurogenic bladder. Hospital records showed the resident had a suprapubic catheter that had been exchanged shortly before admission, and the resident reported burning had resolved at the hospital before transfer. After admission, the clinical record contained no physician orders for the care, monitoring, or assessment of the suprapubic catheter, and there was no documentation in the medication or treatment records showing catheter monitoring or care. The admission nursing evaluation identified the resident as having an indwelling Foley catheter and also incorrectly documented an external catheter, but did not identify the suprapubic catheter. The care plan included generic catheter care interventions, but there were no specific details, no physician order for catheter changes, and no documentation that the urinary collection bag was changed or that urine output was monitored. Progress notes documented repeated complaints of pain, burning, hematuria, and discomfort related to the catheter, but there was no evidence of a provider evaluation of the catheter site until after the survey concern was identified. Nursing staff acknowledged they did not typically deal with suprapubic catheters, confirmed there were no orders in the EMR, and stated there should have been an order to monitor output. The nurse manager also acknowledged the catheter care had been missed, that ongoing nursing evaluation should have occurred, and that specific orders for suprapubic catheter care should have been in place at admission but were not.
Hand Hygiene Not Performed During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when proper hand hygiene was not performed during medication administration for three residents. During an observation with RN C for R128, the nurse donned clear gloves at the medication cart without cleaning hands, touched items on top of the cart including plastic cups, poured a brown liquid supplement into a cup, retrieved a pen, opened the top drawer while wearing the same gloves, removed the medication cup of opened medications and liquid supplement, and administered the medications at bedside. During an observation with LPN B for R53, the nurse did not perform hand hygiene before medication preparation or before medication administration. During an observation with LPN B for R215, the nurse did not perform hand hygiene before donning PPE, then returned to the cart, touched the prepared medications, opened the room door, moved the bedside table, and administered the medications to the resident. The facility's Hand Hygiene policy dated 4/14/2023 stated hand hygiene should be performed before applying and after removing PPE, including gloves, and before preparing or handling medications.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan and facility fall protocol, resulting in a serious injury. One resident, who was care planned as a two-person assist for activities of daily living (ADLs), was being changed by only one certified nursing assistant (CNA). During this process, the resident rolled out of bed, sustained a head injury, and required a higher level of care. The resident was later re-admitted with a diagnosis of traumatic subarachnoid hemorrhage, contusion of the left eye, and a history of falls. The incident report confirmed that the transfer was not performed according to the resident's required assistance level. Further review revealed that the CNA involved had previously dropped three different residents during improper transfers. The administrator acknowledged that the CNA had been educated on proper transfer procedures but failed to follow them. Additionally, required documentation related to the incident and accident reports was missing. The facility's policy mandates adherence to transfer status and completion of all necessary documentation, which was not followed in this case.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Address and Resolve Resident Grievance
Penalty
Summary
The facility failed to address and resolve concerns reported on behalf of a resident who was admitted with hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). The resident's case manager raised concerns to the facility's social worker, who documented that appropriate parties were asked to follow up. However, there was no evidence that a formal grievance was filed or that the concerns were investigated and reported back to the complainant as required by the facility's grievance policy. The facility's grievance policy states that all grievances, whether oral or written, must be investigated and reported back to the grievant within fifteen days. Despite this, the administrator was unable to provide any documentation of grievances or concerns filed for the resident, and the social worker could not recall the specific concerns or provide additional documentation. No further explanation or documentation was provided by the end of the survey, indicating a failure to follow the established grievance process.
Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during two resident-to-resident incidents involving two cognitively intact residents with multiple medical diagnoses. One resident, who required maximal assistance with activities of daily living, was transferred into a shared room, which led to escalating tensions with their roommate. The roommate, who had a history of behavioral episodes and vision concerns, became increasingly agitated over disagreements about room lighting and personal space. Despite prior verbal threats and staff awareness of ongoing conflicts, no effective interventions were implemented to prevent further escalation. On the day of the incident, the agitated resident used a metal reacher to strike their roommate in the leg following a verbal altercation about the room lights. Staff responded immediately to the incident, separated the residents, and contacted law enforcement. The assaulted resident reported pain and minor bruising but was not found to have sustained injuries upon subsequent assessment. The aggressor admitted to the physical act and showed no remorse, expressing ongoing dissatisfaction with having a roommate. Prior to the physical altercation, staff and social work documentation indicated awareness of repeated verbal threats and behavioral issues, including the resident's calls to 911 and explicit statements about not wanting a roommate. Despite these warning signs, the facility did not update care plans or implement interventions to mitigate the risk of abuse. Additionally, there was a delay in reporting the verbal abuse to facility leadership, and the incident was not documented in the assaulted resident's medical record as expected. The facility's failure to act on known risks and to document and communicate incidents contributed to the deficiency.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and follow up on an injury of unknown origin for one resident who was admitted for short-term skilled rehabilitation and nursing care. The resident, who had a history of atrial fibrillation, stroke, urinary tract infection, hearing loss, and dementia with moderate cognitive impairment, was found by a family member to have a bandage on their arm, which upon removal revealed bruises and a gash. The family member reported not being notified by the facility about how the injury occurred, and there was no documentation in the resident's medical record regarding the incident, treatment, or notification to the physician or responsible party. Review of the resident's electronic medical record and skin assessments showed no documentation of a skin tear or related injury on the arm prior to the family member's discovery. Subsequent skin assessments did note a healing skin tear, but there were no corresponding incident or accident reports, progress notes, or treatment orders. The facility administrator confirmed that there were no incident or accident reports or investigations related to the injury, and the unit manager, upon review, was unable to find any documentation or explanation for the injury in the medical record. Interviews with facility staff, including the unit manager and administrator, revealed that the expected process for investigating such injuries—completing a nursing assessment, incident report, notifying the physician and responsible party, and implementing treatment orders—was not followed in this case. The facility's abuse policy requires thorough investigation and documentation of all injuries of unknown source, but this was not completed for the resident's skin tear, resulting in a failure to respond appropriately to an alleged violation.
Failure to Consistently Complete Wound Treatments and Timely Identify Pressure Ulcers
Penalty
Summary
The facility failed to consistently complete wound treatments and timely identify and treat pressure ulcers for two residents reviewed for wounds. For one resident, the medical record showed that wound care orders for the sacrum, right buttock, and left heel were not followed as prescribed, with treatments omitted on specific dates. Additionally, staff applied a prescribed ointment more frequently than ordered. The resident required assistance with all activities of daily living and had multiple wounds documented upon admission. For another resident, there was a delay in the identification and treatment of a left heel wound. Although a clinician noted a possible pressure ulcer and recommended close monitoring and a wound care consult, nursing staff did not acknowledge the wound until two days later, and treatment orders were not implemented until six days after the initial identification. The resident also required staff assistance for most activities of daily living and had no pressure wounds documented at admission. The facility also failed to consistently complete and document weekly skin assessments as required by policy. In one instance, a weekly skin assessment was marked as completed in the medical record, but no supporting documentation was found. Interviews with facility staff confirmed that wound treatments were sometimes missed when the wound nurse was off duty and that communication lapses contributed to delays in wound identification and treatment.
Failure to Ensure Physician Completed Initial Comprehensive Visit
Penalty
Summary
A deficiency occurred when the facility failed to ensure that an initial comprehensive consultation was completed by a physician for one resident who was admitted with hypokalemia and required assistance with all activities of daily living. The resident was admitted and later transferred to the hospital, but the medical record review showed that the initial comprehensive visit was performed by a nurse practitioner, not the assigned physician, as required. There was no documentation of a written approval or recommendation by the physician for the resident's admission. Further review of the physician orders revealed that the physician signed an order agreeing with the care plans and diagnosis list only after the resident was no longer under the care of the facility. The facility's policy stated that a physician is responsible for the resident's first initial comprehensive visit. During interviews, facility leadership could not provide a timely or adequate explanation for the absence of the required physician documentation, and the only physician consult provided was completed after the nurse practitioner's initial visit.
Failure to Ensure Dignified Treatment During Room Transfer
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner when staff did not retrieve and deliver the resident's personal hygiene wipes after the resident was moved from one unit to another. Documentation in the resident's progress notes indicated that a nurse recorded the resident's need for wipes from their previous room and requested that the message be relayed to the day shift supervisor or maintenance. However, the Director of Nursing confirmed that the nurse should have personally retrieved and delivered the wipes to the resident's new room. The facility's policy on resident rights, which includes the right to a dignified existence and to be treated with respect, was not followed in this instance.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the State Agency as required. On December 28, 2024, a resident reported feeling unsafe after a CNA made a verbal statement, "I could strangle somebody today," in response to the resident's request for assistance. The resident subsequently alleged that the CNA became aggressive and assaulted him, leading to the resident contacting a staff manager and the police. Documentation shows that the CNA was sent home and removed from the schedule pending investigation, and the police responded to the incident and took the resident's statement. Despite the resident's allegations and the involvement of law enforcement, there was no evidence that the facility reported the incident to the State Agency. The DON confirmed that the incident was not reported because the facility could not substantiate the allegation. Facility policy requires that all allegations of abuse be reported to the State Agency immediately, but this protocol was not followed in this case. The failure to report was identified through interviews, record reviews, and examination of facility documentation.
Failure to Follow Two-Person Assist for Bed Mobility Resulting in Resident Fall
Penalty
Summary
A resident with paraplegia, spinal cord injuries, bipolar disorder, pain, foot drop, and post-traumatic stress disorder was admitted to the facility and was assessed as non-ambulatory, with intact cognition, and dependent on staff for bed mobility. The resident's care plan specified a two-person assist for bed mobility. Despite this, a Certified Nurse Aide (CNA) provided incontinence care and attempted to turn the resident alone, during which the resident rolled out of bed and sustained a skin tear to the right knee. The CNA was not aware that two staff members were required for bed mobility and was not assisted by another staff member at the time of the incident. Facility documentation confirmed that the CNA was responsible for the resident's care at the time of the fall and that the care plan's requirement for a two-person assist was not followed. The facility's Fall Management Guidelines emphasized the need for individualized interventions to address fall risk factors, but these were not implemented as specified in the resident's care plan, resulting in an avoidable fall.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
A resident with a history of paraplegia, spinal cord injury, wounds, bipolar disorder, adjustment disorder, and post-traumatic stress disorder was admitted to the facility and had a physician's order for oxycodone 20 mg every four hours as needed for pain. On one occasion, the resident requested pain medication but was informed by the nurse that the medication was completely out. The nurse attempted to contact the on-call physician without success and then reached out to the pharmacy, which indicated the medication would arrive later that evening. As a result, the resident experienced a delay of approximately 12 hours between doses, with a pain rating of 10 reported at the time the medication was finally administered. Review of the resident's Medication Administration Records for several months showed frequent requests and administration of pain medication every four hours as ordered. The Director of Nursing confirmed that the medication should have been reordered before running out and that alternative options, such as using the facility's back-up medication supply, were available. Documentation showed that oxycodone was stocked in the facility's emergency supply in various dosages, but these were not utilized during the incident. Facility policy also directed staff to refer to emergency pharmacy delivery and emergency supply kit procedures if a medication was not available.
Failure to Prevent Pressure Ulcer Due to Inadequate Intervention
Penalty
Summary
The facility failed to prevent a facility-acquired pressure ulcer for one resident, resulting in the development of an unstageable pressure ulcer on the left heel and a subsequent sepsis infection. The resident, who was admitted with diagnoses including dementia, type II diabetes, and atrial fibrillation, was observed with a severely impaired cognitive status. The care plan indicated a risk for pressure ulcer formation due to decreased mobility, and interventions included encouraging the resident to float heels and wear heel boots. However, documentation revealed that the resident developed an unstageable pressure ulcer on the left heel, attributed to wearing tight-fitting shoes while in bed. The facility's records showed that the resident had a history of refusing to remove shoes, which were identified as the cause of the wound. Despite this, there was no documentation of attempts to remove the shoes or any refusal by the resident prior to the discovery of the wound. The wound was first noted on 8/19/24, and the resident was subsequently seen by wound care services. The wound care team confirmed the presence of a swollen ankle and bleeding heel, and the resident was treated for cellulitis. The facility's documentation lacked evidence of interventions such as floating the resident's heels or providing heel boots, as outlined in the care plan. Interviews with facility staff, including the Wound Nurse Coordinator, Director of Nursing, and Medical Director, revealed that the wound was attributed to the resident's refusal to remove tight shoes. However, there was no prior documentation of such refusals or interventions to address the issue. The facility was unable to provide evidence of any attempts to remove the resident's shoes or documentation of the resident's refusal before the wound was discovered. This lack of documentation and intervention contributed to the development of the pressure ulcer and subsequent infection.
Inadequate Supervision and Transfer Assistance Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure safe transfer and adequate supervision for a resident, resulting in multiple falls and injuries. One resident, who had a history of hemiplegia and osteoarthritis, reported falling multiple times due to inadequate assistance from staff. On one occasion, a CNA failed to assist the resident back into bed after using the bathroom, leading to a fall that resulted in a right oblique humerus fracture and a fracture of the right fifth digit. The resident's care plan required a two-person assist for transfers, but this was not followed, contributing to the fall and subsequent injuries. Another resident, with severe cognitive impairment and a history of repeated falls, was observed without the necessary Dycem on their wheelchair cushion, which was intended to prevent sliding. Despite a care plan intervention to apply Dycem after a previous fall, it was not consistently implemented, leading to another incident where the resident slid out of the wheelchair. The facility failed to investigate the root cause of the falls adequately and did not ensure that the care plan interventions were effectively implemented. A third resident, also with severe cognitive impairment, experienced multiple falls due to inadequate supervision and assistance. The resident was observed attempting to get out of bed without assistance, with their call light out of reach. Despite a history of falls and a care plan that included frequent rounding and assistance, the facility did not provide the necessary supervision to prevent further incidents. The lack of effective interventions and failure to adhere to care plans contributed to the resident's continued risk of falls.
Sanitation and Food Safety Deficiencies in Kitchen and Pantry Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and pantry areas, as well as during the transportation of food items. During an observation, a rolling cart in the kitchen was found with large portions of missing plastic edging, exposing porous particle board that was no longer smooth and easily cleanable. The Dietary Director confirmed the issue but did not provide an explanation for its continued use. Additionally, the Grind master coffee and hot water dispenser had a heavy buildup of coffee grounds and debris, and the dish machine room had missing grout between floor tiles with standing water and fruit flies present. The Maintenance Director was unaware of the missing grout issue. In the Cranbrook and [NAME] pantry, microwaves were observed with heavily rusted finishes on the inside top surface, which were confirmed by the Dietary Director as needing replacement. During the lunch trayline service, fruit cups were observed uncovered while being placed on trays and transported through hallways to resident rooms. The Dietary Director could not explain how the fruit cups would be protected from contamination during transport. These observations indicate a failure to adhere to the 2017 FDA Food Code standards for maintaining sanitary conditions and protecting food from contamination.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable ambient air temperatures in multiple resident rooms, as observed during a survey. On December 2, 2024, between 12:34 PM and 1:05 PM, the air temperatures in several resident rooms were measured and found to be below the required range of 71-81 degrees Fahrenheit. Specifically, temperatures ranged from 60 to 69 degrees Fahrenheit in rooms 100, 101, 103, 105, 107, 111, 201, 203, 205, and 207. In room 101, a resident was observed sitting in a wheelchair, wrapped in a blanket, wearing a winter hat, and stated she was cold. Additionally, a pillow was observed over the window in room 100 to block a draft. The Maintenance Director confirmed that room temperatures are monitored but not recorded, which is contrary to the facility's policy that requires maintaining comfortable and safe temperature levels as per Section 483.15 (4)(6) of the Quality of Life requirements.
Controlled Substance Documentation Deficiency
Penalty
Summary
The facility failed to ensure that all controlled substances were accounted for and accurately documented for a resident reviewed for pain management. The resident, who had a history of hemiplegia, hemiparesis, Charcot joint of the ankle, and Parkinson's Disease, reported frequent shortages of his pain medication, including oxycontin and oxycodone, leading to delays in receiving doses and experiencing pain. The resident's clinical records showed active orders for oxycodone and oxycontin, but discrepancies were found between the Medication Administration Record (MAR) and the Proof of Use forms, indicating issues with medication administration and documentation. The review of the resident's records revealed multiple instances where doses of oxycodone were documented as administered on the MAR without corresponding entries on the Proof of Use forms, and vice versa. There were also instances where tablets were pulled from the supply but not documented as administered or wasted, leading to inconsistencies in the medication count. Interviews with the resident's assigned nurse and the facility's Administrator in Training (AIT) confirmed the discrepancies and acknowledged the concerns regarding the facility's protocols for administering controlled substances. The facility's policy on controlled medications required licensed nurses to validate and document the receipt and administration of controlled substances accurately. However, the report highlighted several failures in adhering to these guidelines, resulting in unaccounted doses and discrepancies in medication records. The facility's Director of Nursing (DON) and AIT acknowledged the issues and confirmed that all medications pulled from the controlled substance supply needed to be accounted for on the MAR or through the process for wasting medications.
Duplicate Medication Error for a Resident
Penalty
Summary
The facility failed to prevent a significant medication error for one resident, resulting in the resident receiving duplicate doses of a diuretic medication, furosemide, on three separate days. The Consultant Pharmacist had identified duplicate orders for furosemide on the resident's eMAR and recommended that one of the orders be discontinued. Despite the nurse signing off on the pharmacist's recommendation, both orders remained active, and the resident received duplicate doses on three occasions. The error was not communicated to a physician, as there were no progress notes indicating that a physician was contacted when the error was identified. The Director of Nursing and the Administrator in Training acknowledged that the error occurred because some orders were not discontinued when the resident was readmitted from the hospital.
Failure to Implement Transmission-Based Precautions for Resident
Penalty
Summary
The facility failed to implement physician-ordered transmission-based precautions (TBP) for a resident identified as R20, who was placed on contact precautions for Vancomycin-resistant Enterococci (VRE). On the morning of December 2, a Certified Nursing Assistant (CNA) was observed entering R20's room to provide incontinence care without any signage indicating contact precautions or personal protective equipment (PPE) available outside the room. Later, R20 was seen interacting with another resident near the nurse's station and was taken to the dining room, despite the physician's orders for contact precautions starting on November 29. The Infection Control Preventionist, RN 'BB', later placed the necessary signage and PPE outside R20's room. Interviews with the Director of Nursing (DON) and the Administrator in Training (AIT) revealed that R20 was supposed to be on contact precautions as per the physician's order. However, R20 was kept in the room due to incontinence issues and refusal to wear a brief, with the condition that if the family and resident agreed to wear a brief, R20 could leave the room during the isolation period. The facility's policy on infection control and transmission-based precautions was not followed, as it required hand hygiene, PPE use, and limiting resident movement outside the room to medically necessary purposes.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of several residents, as evidenced by multiple incidents involving inappropriate staff behavior and inadequate care. One resident reported that a CNA rudely instructed them to shampoo their own hair during a shower. Another resident was left exposed on a bedpan with the door open, compromising their privacy, and the CNA responsible admitted to not ensuring the door was closed. A third resident experienced a lack of preparedness during a shower, with the CNA leaving multiple times to retrieve supplies and engaging with their cell phone instead of assisting the resident. Additionally, a family member was inappropriately asked to clean a resident, which they found to be the CNA's responsibility. Further incidents included a resident who was not offered assistance when they requested it, and another instance where a CNA caused pain by improperly handling a resident's bandaged foot. A resident also reported being discouraged from using their call light during meal times. These incidents were reported to the facility's administration, who acknowledged the complaints and expressed an expectation for residents to be treated with respect and dignity. The facility's policy on dignity emphasizes the importance of treating residents with respect and maintaining their privacy, which was not adhered to in these cases.
Failure to Ensure Timely PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a timely referral for a Level II evaluation for a resident with mental disorders and intellectual disabilities. The resident, who was admitted and readmitted with diagnoses including paranoid schizophrenia, vascular dementia, schizoaffective disorder bipolar type, and major depressive disorder, had severely impaired cognition. A review of the resident's PASARR Level I Screening form indicated the presence of mental illness and dementia, necessitating a referral to the local Community Mental Health Services Program for a Level II evaluation. However, there was no evidence of a Level II evaluation or an exemption request form in the resident's clinical record. The Director of Social Work was unable to locate the Level II evaluation initially and later reported that the exemption form was not completed until a day after the inquiry. The facility's policy on PASARR, revised in 2020, outlines the requirement for a two-level screening process to ensure appropriate placement and service determination for individuals with mental illness or intellectual disabilities. The policy mandates that the PASARR process be completed prior to admission, after significant changes in the resident's condition, and at least annually. The deficiency arose from the failure to adhere to these requirements, as evidenced by the lack of timely documentation and referral for the resident in question.
Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to timely identify and assess a facial bruise for a resident with severely impaired cognition. The resident was observed with a brownish bruise below their left eye, and there was no documentation of the bruise in the resident's clinical record until eight days after an unwitnessed fall. The facility did not provide additional investigation reports, and a skin assessment conducted two days after the fall did not note any bruising. The nurse who documented the bruise reported notifying the supervisor, but no further investigation was conducted as it was assumed the bruise was from the fall. The facility also failed to ensure medications were administered on time and according to physician's orders for two residents. One resident was heard yelling in pain and had not received their morning medications, which were scheduled for 9:00 AM but were administered two and a half hours late. The assigned nurse confirmed the delay and cited reasons such as looking for supplies and talking to family. Another resident reported chest pain and requested pain medication, which was administered an hour and a half after the request. The facility policy required medications to be administered within a one-hour window of the scheduled time, and any delays should have been communicated to a physician. Additionally, the facility failed to ensure a physician's order for wound care for a resident. The resident was observed with an undated bulky dressing on their right elbow and forearm, but there was no order for the dressing in the resident's records. The assigned nurse was unaware of the order and did not apply the dressing, indicating it was done on a previous shift. The facility policy required treatments to be ordered by a medical practitioner and dressings to be dated and initialed by the licensed nurse when applied.
Failure to Ensure Proper PICC Line Dressing Orders and Monitoring
Penalty
Summary
The facility failed to ensure appropriate orders for PICC line dressing changes and monitoring for two residents. One resident, who was receiving antibiotics through a PICC line in their right arm, was observed with a dressing that was mostly hanging loose and not properly adhered. This resident had been admitted with diagnoses including a cutaneous abscess and cellulitis, and had moderately impaired cognition. Despite the need for regular dressing changes, there was a gap in the orders for the PICC line dressing change from 11/26/24 to 12/2/24, and the existing order lacked specific details about the dressing. The Administrator in Training (AIT) and the current Director of Nursing (DON) were interviewed and acknowledged that an order should have been in place upon the resident's admission with a PICC line. The AIT explained that a template was used for entering orders, but it was not properly utilized in this case, leading to the absence of a specific order for the PICC line dressing change. The observation of the dressing being barely attached and hanging loosely indicated a failure to adhere to the facility's policy for PICC line care.
Failure to Follow Up on Guardianship Process
Penalty
Summary
The facility failed to follow up on the guardianship process for a resident who was deemed incompetent to make complex medical and financial decisions. A competency evaluation dated 10/18/24, signed by two physicians, indicated that the resident was not competent to make such decisions. A progress note from 10/17/24 by the Social Work Director documented that the resident's son was informed of the need for a guardian and that he planned to file for emergency guardianship. However, there was no evidence of any follow-up by the Social Work Department after this date, as confirmed during an interview with the Social Work Director on 12/4/24. The former Director of Nursing, now an Administrator in Training, confirmed that the Social Work Department was responsible for this follow-up.
Failure to Document Pharmacist's Recommendations in Resident's Record
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medication provider for recommendations to act on. This deficiency was identified for one resident out of five reviewed for unnecessary medications. The resident in question was admitted with diagnoses including chronic respiratory failure, chronic kidney disease, and type II diabetes. The consultant pharmacist reviewed the resident's medication and noted irregularities and/or recommendations on a specific date. However, there was no documentation in the resident's clinical record indicating what these irregularities or recommendations were. During an interview and record review, the Director of Nursing/Administrator in Training acknowledged that all responses to the consulting pharmacist should be documented in the resident's clinical record but was unable to locate the necessary documentation in the electronic record before the end of the survey.
Failure to Offer Seasonal Influenza Vaccine
Penalty
Summary
The facility failed to offer the 2024-2025 seasonal influenza vaccine to a resident, identified as R49, who was reviewed for influenza vaccines. During a review of R49's immunization records, it was found that the last documented entry for the influenza vaccine was on September 10, 2024, indicating that the 2023-2024 seasonal vaccine was not offered because the resident was admitted after the influenza season. There was no evidence that the 2024-2025 vaccine had been offered at the beginning of the new flu season. An interview with the Infection Control Preventionist confirmed that the vaccine had not been offered or administered to the resident. Additionally, the facility's policy on vaccination, dated October 2023, did not address the offering of the influenza vaccine at the start of the new flu season, which is between October 1st and March 31st each year.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely follow-up dental services to a resident, identified as R25, who was observed to be missing teeth on the lower jaw and wearing dentures on the upper jaw. The resident expressed a desire to see a dentist and obtain bottom dentures. Despite being alert and having intact cognition, as indicated by a BIMS score of 15/15, there was no documentation in the resident's clinical record of having received dental services since a comprehensive oral evaluation on 8/21/23. During this evaluation, it was noted that two lower teeth were to be extracted as needed in preparation for a lower denture, but no follow-up services were documented. Interviews with facility staff, including the Social Worker Director and the Director of Nursing/Administrator in Training, revealed a lack of clarity and documentation regarding the resident's dental care. The Social Worker Director mentioned that residents were seen annually or as needed, but could not provide documentation of R25 refusing follow-up dental services. The Director of Nursing/Administrator in Training was unable to explain why there had been no follow-up within the year following the last dental appointment. The facility's policy on dental services requires documentation of oral/dental status according to assessment findings, which was not adhered to in this case.
Failure to Document and Complete Accurate Skin Assessments
Penalty
Summary
The facility failed to ensure skin assessments were documented, completed accurately, and timely for a resident with a history of Metabolic Encephalopathy, Cellulitis of the right lower limb, and Sepsis. The resident was readmitted from the hospital and had a physician's order for weekly skin evaluations. However, a review of the medical records revealed that no accurate documentation of the resident's skin presentation was completed from mid-March to mid-April, despite the Treatment Administration Record indicating that weekly skin evaluations were performed during this period. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the assessments were documented as completed in the Treatment Administration Record but were not properly recorded in the Total Body Skin Evaluation under the medical records assessment tab. The DON acknowledged the issue and indicated that a past non-compliance action plan had been initiated to address the lack of proper documentation, but the problem persisted for the resident in question. The facility's Skin and Wound Guidelines also emphasized the importance of documenting body audits in the residents' electronic medical records, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,104 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bloomfield Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation Of Bloomfield Hill | 1.7 mi | ★★★★★ | 29 | 0 |
| Pomeroy Living Rochester Skilled Rehabilitation | 3.5 mi | ★★★★★ | 13 | 0 |
| Regency At Troy | 3.7 mi | ★★★★★ | 18 | 0 |
| Harmony Village Of Beverly Hills | 4.3 mi | — | 15 | 1 |
| Greenfield Rehab And Nursing Center | 4.9 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodward Hills Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.