Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Interlochen Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed multiple gnats in various locations on one hall, including at both ends of the corridor, at the nurse’s station, and in a resident room where several gnats were seen around the resident and the sink despite the area being clean. The resident reported that gnats had long been a problem, had worsened, and were bothersome, and stated she had informed staff. Nursing staff acknowledged seeing gnats in rooms and on meal trays and described notifying housekeeping or the administrator, while the administrator admitted the gnat issue was known. When documentation was requested, the facility could only provide an insect and rodent control policy limited to the food service department and did not produce a facility-wide pest control policy or pest control log, supporting a deficiency for failure to maintain an effective pest control program.
A resident with dementia, anxiety, chronic pain, and metabolic encephalopathy was admitted with documented needs including poor memory, wheelchair use, two-person assist for transfers and ADLs, and multiple skin issues. Although admission notes and subsequent progress notes described falls, fall risk, skin tears, hospice involvement, agitation, and confusion, no baseline care plan or comprehensive care plan was documented in the EMR within 48 hours of admission. Staff interviews revealed that the admitting LVN did not know where baseline care plans were kept, the Regional RN confirmed there were no care plans in the system, and the ADON acknowledged only a verbal plan of care discussion with the family and admitted he failed to document the baseline care plan, despite facility policy requiring a written baseline care plan and summary within 48 hours.
A resident with severe cognitive impairment and multiple complex diagnoses, including prior cerebral infarction and acute kidney failure, was receiving Eliquis (apixaban) twice daily for clot prevention without a corresponding anticoagulant-focused care plan. Review of the care plan showed no measurable objectives or interventions related to anticoagulant use, despite an active medication order and a facility policy requiring comprehensive, person-centered care plans for all identified medical and nursing needs. Staff interviews confirmed that a care plan for anticoagulants should have included monitoring for bruising, bleeding, and other adverse reactions, but this was not documented or implemented for the resident.
A resident with dementia, metabolic encephalopathy, high fall risk, and extensive ADL assistance needs was found on the floor in front of a wheelchair. After an LVN assessed the resident and found no obvious injury, two CNAs manually lifted the resident from the floor to the wheelchair using a gait belt while placing their forearms under the resident’s arm pits, even though the resident did not assist and was effectively non–weight-bearing. Staff interviews showed that therapy and nursing leadership had instructed that residents should never be lifted under the arm pits and that a mechanical lift should be used when a resident cannot safely assist, but the CNAs proceeded with the manual lift based on their judgment and expectation that the resident would help. Facility policies addressed gait belt use and two-person transfers but did not specify procedures for non–weight-bearing residents during floor transfers, contributing to the failure to provide adequate supervision and appropriate assistance devices to prevent accidents.
A resident with chronic respiratory failure, hypoxia, and a tracheostomy was receiving oxygen therapy, but the facility did not post required oxygen use signage outside the room. Staff interviews confirmed there was no designated person responsible for ensuring the signage was in place, and facility policy requiring such signs was not followed.
A resident with severe cognitive impairment and a recent wrist injury did not receive timely pain management or appropriate monitoring, as staff failed to document pain assessments and the effectiveness of pain medications according to facility policy. Delays in diagnostic imaging and inadequate follow-up contributed to a delay in identifying a wrist fracture, resulting in unmanaged pain until the resident was sent to the hospital.
A resident with severe cognitive impairment and multiple health conditions experienced swelling and bruising of the wrist after a fall. Although a stat x-ray was ordered, it was not completed within the required timeframe, and the imaging was performed on the wrong body part. The correct diagnosis of a wrist fracture was delayed until the resident was sent to the hospital for further evaluation.
A resident with multiple medical conditions, who was cognitively intact and required assistance with daily living, experienced unauthorized withdrawals totaling over $11,000 from her bank account after her debit card was accessed by a caregiver. The facility did not inform the resident about available lock boxes or offer protection for valuables, and staff were unaware the card was kept in the resident's room until after the theft occurred. The resident suffered emotional distress and loss of trust as a result.
A facility failed to prevent a CNA, previously suspended due to an abuse allegation, from providing care to a resident with severe cognitive and physical impairments. Despite the suspension, the CNA continued to be assigned to the resident, highlighting a lack of effective policies and procedures to prohibit and prevent abuse and neglect.
A nurse failed to properly review and interpret an abnormal X-ray result for a resident with a recent fall and ongoing pain, resulting in a two-day delay in recognizing and treating a hip fracture. The X-ray report, which showed a pelvic fracture, was misread as negative and this incorrect information was communicated to other staff and the NP. The resident continued to experience pain and impaired mobility until being sent to the hospital, where the fracture was confirmed and treatment was provided.
A nurse failed to fully review and accurately report an abnormal X-ray result showing a hip fracture for a resident with dementia and ongoing pain. The nurse only read part of the report and incorrectly informed the NP that the result was negative, leading to a two-day delay in appropriate medical evaluation and treatment until the resident was hospitalized.
A resident on Enhanced Barrier Precaution due to feeding tube status was not properly protected when an LVN administered medication without wearing a gown, contrary to facility policy. The LVN admitted to forgetting the gown, acknowledging the risk of infection spread. The DON emphasized the importance of adhering to infection control policies, which require gown and gloves during high-contact care activities.
A resident with COPD and pulmonary hypertension experienced shortness of breath and required oxygen therapy, but the facility failed to notify the physician of the condition change. Despite multiple episodes of respiratory distress, there was no documented attempt to contact the physician until the resident's condition worsened, leading to hospitalization and eventual death.
A resident with COPD and pulmonary hypertension experienced shortness of breath and required respiratory care, but the facility failed to conduct proper assessments or notify medical personnel of the resident's condition change. Despite low oxygen saturation levels and breathing treatments, staff did not document vital signs or communicate with the physician, leading to the resident's transfer to the ER and subsequent death.
Two residents with severe cognitive impairment were not provided a dignified dining experience when staff stood over them while assisting with meals, contrary to the facility's policy of promoting dignity by sitting at eye level. Interviews confirmed that staff should sit next to residents during meals to respect their dignity, highlighting a deficiency in maintaining residents' quality of life.
A resident with cerebral palsy and other conditions required total assistance for transfers, but the facility failed to include the use of a mechanical lift in the care plan. Staff used unsafe manual lifting methods, contrary to facility policy, posing a risk of injury. The deficiency was due to the care plan not being updated to reflect the resident's needs.
A resident with severe cognitive impairment and a history of fractures suffered a new fracture when his hand and wrist became stuck in his wheelchair wheel. The incident was not reported to the state agency within the required two-hour timeframe, as the facility's administrator admitted to possibly sending the report to the wrong number and forgetting to send it immediately. This delay in reporting violated the facility's abuse policy and placed residents at risk of ongoing neglect.
A facility failed to implement a comprehensive care plan for a resident with cognitive decline and fall risk, resulting in the resident falling from an elevated bed and sustaining a head injury. The care plan interventions were not followed, and the resident was left unattended during incontinence care, leading to the incident.
A resident with cognitive decline and a history of falls fell and sustained a head injury requiring sixteen staples after a CNA failed to follow the care plan for incontinence care, which required lowering the bed. The care plan was later revised to require two staff members for incontinence care.
Failure to Maintain Effective Pest Control for Gnats on One Hall
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Hall 200 free of gnats. On multiple observations on Hall 200, surveyors saw gnats in various locations, including one gnat at the south end of the hall, one gnat at the north end of the hall, and one gnat at the nurse’s station. In one resident room at the south end of Hall 200, a surveyor counted three gnats around the resident and five gnats around the sink, despite the sink being clean and without foul odors. The resident in that room reported that gnats had always been an issue, stated the gnats were worse than in the past, and said the gnats bothered her. She indicated she had informed staff about the gnats and that the room had been sprayed. During interviews, LVNs reported seeing gnats in resident rooms and on meal trays, and one LVN stated she was supposed to notify housekeeping when gnats were present. Staff described removing meal trays when gnats were seen and suggested that food in resident rooms might be contributing to the issue. The administrator acknowledged that gnats were a known issue on the hall. When surveyors requested documentation, the facility did not provide a pest control policy for the entire facility or a pest control log, but only produced a 2012 food service department policy on insect and rodent control that applied specifically to the food service area. This lack of a facility-wide pest control policy and documentation, combined with ongoing observations of gnats on Hall 200 and in a resident room, formed the basis of the deficiency.
Failure to Develop and Implement Timely Baseline Care Plan on Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission, or to have a comprehensive care plan in place within that same timeframe, for one resident. The resident was an adult male admitted with dementia, anxiety disorder, chronic pain, and metabolic encephalopathy, conditions associated with confusion, memory issues, and personality changes. On admission, an LVN documented that the resident was admitted to a secured unit from another nursing facility, arrived on a stretcher, had poor memory, used a wheelchair, and required two-person assistance for transfers, hygiene, and bathing. A skin assessment at admission identified bruising and small scabs on his body. Record review on a later date showed that the resident’s electronic medical record contained no care plans on the care plan page, and the admission MDS was still being edited. Progress notes from admission through several days afterward documented multiple care concerns, including fall risk and actual falls, skin tears, hospice services, agitation, and confusion, but there was no corresponding baseline care plan in the EMR during that period. A Baseline Care Plan Acknowledgment form indicated that the resident and his representative were given a copy of a baseline care plan several days after admission, yet the EMR still showed no care plans until a later date, when multiple care plans (ADLs, medications, skin, cognition/dementia, communication, falls, and behaviors) were all initiated on the same day. Interviews with staff further clarified the lack of a documented baseline care plan. The admitting LVN stated she did not know where baseline care plans were kept, though she entered admission information in her note. The Regional RN explained that baseline care plans were created in the same section as regular care plans and acknowledged that there were no care plans visible for this resident at the time of review. The ADON reported that he had provided a baseline care plan acknowledgment to the resident’s responsible party after a verbal discussion of the plan of care but admitted there was no documented baseline care plan, stating he must have forgotten to enter it. The facility’s own baseline care plan policy required completion and implementation of a baseline care plan within 48 hours of admission, including initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations, and required documentation that a written summary was provided to the resident and representative, which was not met in this case.
Failure to Care Plan Anticoagulant Therapy for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and interventions for a resident receiving anticoagulant therapy. Record review showed that the resident, an elderly female admitted with a primary diagnosis of cerebral infarction and additional diagnoses including dementia, sepsis, obstructive and reflux uropathy, and acute kidney failure, had a BIMs score of 3 indicating severe cognitive impairment. Medication orders reflected an active prescription for Eliquis (apixaban) 2.5 mg twice daily for clot prevention, started several months prior. However, review of the resident’s care plan, last revised on 12/20/2025, did not show any care plan addressing anticoagulant use. Interviews with facility staff confirmed that a care plan for anticoagulant medication should have been in place. The Regional RN stated there should be a care plan for anticoagulants to help staff identify adverse reactions, with interventions such as daily monitoring and CNA observation of the resident’s skin. The ADON reported she was responsible for parts of the care plan related to acute care, antibiotics, and falls, and described that staff were expected to monitor for bruising and bleeding in residents on anticoagulants as part of their tasks and morning rounds. The Administrator acknowledged that not care planning for medications like anticoagulants posed a risk that residents could receive medications they should not be getting or experience medication interactions. The facility’s Comprehensive Care Planning Policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ identified medical, nursing, mental, and psychosocial needs, but this was not carried out for the resident’s anticoagulant therapy.
Improper Manual Floor-to-Wheelchair Transfer Without Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe transfer techniques for a newly admitted resident with significant cognitive and functional impairments. The resident was an elderly male with dementia, anxiety disorder, chronic pain, and metabolic encephalopathy, admitted via EMS on a stretcher and requiring extensive assistance with ADLs. Admission and nursing notes documented that he needed two-person assistance for bed mobility, transfers, dressing, bathing, and hygiene, used a wheelchair most of the time, was unable to use devices or comprehend instructions due to poor cognition, and had poor decision-making ability requiring reminders, cues, and supervision. A fall risk assessment identified him as high risk for falls due to recent fall history, intermittent confusion, chair-bound status, inability to stand, and multiple medications contributing to fall risk. His care plan included two-person assistance for transfers but did not specify assistive devices. On the day of the incident, the resident was observed sitting on the floor in the dining area in front of his wheelchair. An LVN ran to assist, assessed the resident on the floor, and found no evidence of injury. The LVN then directed two CNAs to transfer the resident back to his wheelchair. The CNAs placed a gait belt around the resident’s waist, positioned themselves on either side of him facing him, grasped the gait belt in the back, and simultaneously placed their forearms directly under his arm pits to lift him from the floor into the wheelchair. During this maneuver, the gait belt slid up the resident’s back, and the resident did not appear to assist in the transfer, resulting in the CNAs performing the full lift. The resident was then positioned near the nurses’ station, where he intermittently leaned forward as if attempting to stand, and staff verbally redirected him to remain seated. Interviews with staff revealed uncertainty and inconsistency regarding appropriate transfer methods for this resident, particularly when he was unable to bear weight or assist. The LVN who responded to the fall believed the CNAs were supposed to “cup their arms under his” to lift him. Therapy and nursing leadership, including the OT, DOR, ADONs, and Regional RN, stated that residents should not be lifted under the arm pits and that a mechanical lift should be used when a resident cannot safely assist or when staff cannot safely lift with a gait belt alone. The OT specifically stated she would never go under a resident’s arms to lift and described alternative methods that avoid stress on the shoulders. Both CNAs acknowledged that lifting under the arm pits could injure a resident’s shoulders and that a mechanical lift is normally used when a resident cannot stand or bear weight, but they proceeded with the manual lift because they expected the resident to help and he did not. Review of CNA proficiency audits showed both CNAs had previously been deemed satisfactory in various transfer techniques, and review of the facility’s transfer policy showed it addressed gait belt use and two-person transfers but did not address procedures when a resident is unable to assist or bear weight. Additional documentation and interviews indicated that the resident had a prior unwitnessed fall in the facility, was combative and agitated at times, did not call for assistance, and resisted redirection, leading to additional fall precautions such as a low bed, air mattress, and fall mat. The ADON reported that at admission he believed the resident was unable to bear weight and that the resident had not noticeably changed since admission. Multiple staff, including the DOR, ADON, and Regional RN, confirmed that staff were trained not to lift under the arm pits and that mechanical lifts should be used when manual lifting exceeded the capabilities of the resident or staff. Despite this, the CNAs manually lifted the resident from the floor using their forearms under his arm pits in combination with a gait belt, rather than using a mechanical lift, which constituted the failure to provide adequate supervision and appropriate assistance devices to prevent accidents. The facility’s fall policy stated that staff must be trained in safe transfer techniques and proper body mechanics, and the transfer procedure referenced the use of a gait belt and two-person assistance but did not specify what to do when a resident could not assist or bear weight. Staff interviews also referenced that an ice storm had interfered with therapy’s timely evaluation of new residents, including this resident, which contributed to the lack of a therapy assessment at the time of the incident. Nonetheless, the existing nursing assessments and fall risk evaluation already documented the resident’s high fall risk, cognitive impairment, and extensive assistance needs. In this context, the decision by CNAs to lift the resident from the floor by supporting him under the arm pits, combined with the absence of clear policy guidance for non–weight-bearing residents in floor transfers, led to the cited deficiency for failure to ensure the resident received adequate supervision and appropriate assistance devices to prevent accidents.
Failure to Post Oxygen Use Signage for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy and tracheostomy management. Specifically, the facility did not ensure that cautionary and safety signs indicating oxygen use were posted outside the resident's room, despite the resident receiving oxygen via nasal cannula connected to an oxygen concentrator at 2 LPM with a capped tracheostomy. Observations confirmed the absence of required signage, and interviews with staff revealed there was no designated individual responsible for ensuring oxygen signage was posted. The resident involved was admitted with a primary diagnosis of cerebral infarction and secondary diagnoses including chronic respiratory failure with hypoxia and tracheostomy status. Facility policy required "No Smoking" signs to be placed in areas where oxygen was administered or stored, but this was not followed. Both the ADON and DON acknowledged their responsibility for ensuring proper signage and recognized the risks associated with the lack of oxygen use indicators, such as the potential for staff to inadvertently use flammable substances or electrical appliances near the oxygen source.
Failure to Provide and Document Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and a history of type 2 diabetes and dementia. The resident developed swelling and bruising on her right wrist, which was reported to nursing staff and the nurse practitioner (NP). Orders were given for a stat x-ray and ice pack application, but the x-ray was not completed within the expected four-hour window, and the imaging performed was of the forearm rather than the wrist. Despite ongoing swelling and bruising, the resident remained in the facility without timely escalation or reassessment, and the stat x-ray order was not properly followed up as required by facility policy. Throughout the incident, pain management was inconsistent and not documented according to professional standards or the facility's own pain management policy. The resident was administered Tylenol routinely, but there was no documentation of pain assessments or follow-up on the effectiveness of pain medication in the treatment administration record (TAR). Staff interviews revealed that pain assessments were not consistently performed or recorded, especially for residents unable to verbalize pain, and that documentation of pain and medication effectiveness was lacking. The facility's policy required monitoring and recording of pain medication effectiveness, but this was not done for the resident in question. The deficiency was further compounded by communication issues among staff, delays in obtaining appropriate diagnostic imaging, and a lack of timely escalation to higher levels of care when the stat x-ray was not completed. The resident was eventually sent to the hospital at the request of her responsible party, where a wrist fracture was diagnosed. The failure to follow the facility's pain management policy and to document pain assessments and medication effectiveness placed the resident at risk of uncontrolled pain.
Failure to Provide Timely and Correct Radiology Services
Penalty
Summary
A deficiency occurred when the facility failed to provide or obtain timely and appropriate radiology services for a resident with severe cognitive impairment and multiple comorbidities, including type 2 diabetes and dementia. The resident was observed with swelling, bruising, and discoloration on the right wrist, which was possibly related to a prior fall. A nurse practitioner assessed the resident and ordered a stat x-ray of the right hand and wrist, along with ice pack application. The stat x-ray order was not fulfilled within the expected four-hour window, and the x-ray provider was unresponsive to follow-up calls from nursing staff. The x-ray was eventually performed more than 24 hours after the initial order, but it was conducted on the resident's right leg (tibia/fibula) instead of the wrist as ordered. The radiology report for the leg was negative for fracture, and the resident continued to experience swelling and bruising of the right hand. Despite ongoing monitoring and communication with the resident's responsible party, the correct imaging of the wrist was not obtained in a timely manner, and the resident's pain was managed with ice packs and Tylenol. Subsequently, the resident was sent to the emergency room for further evaluation due to persistent swelling and bruising of the right hand. Hospital imaging revealed a nondisplaced fracture of the distal radius (wrist), which had not been identified by the initial, incorrect x-ray. Interviews with facility staff and administration confirmed that the stat x-ray order was not properly processed, follow-up was inadequate, and communication breakdowns occurred. The facility did not provide a policy on x-ray services during the survey.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
The facility failed to protect a resident's property from misappropriation, resulting in unauthorized use of the resident's debit card for 25 ATM withdrawals totaling $11,735. The resident, a cognitively intact female with multiple medical conditions including gram-negative sepsis, morbid obesity, hypokalemia, muscle atrophy, and kidney failure, was admitted to the facility and required assistance with activities of daily living. The resident kept her debit card in her room and had allowed one or two staff members to use it for vending machine purchases, but did not recall who they were. She reported that the card was never removed from her room by her, and the unauthorized withdrawals were only discovered after the bank and police became involved. The facility's admission policy did not offer protection for residents' property or valuables, and the availability of lock boxes for securing valuables was not communicated to residents in the admission packet. The resident was not informed by the facility that her bank card could be protected or stored securely. The social worker and administrator were made aware of the missing funds after the resident reported the issue, but the facility was unaware that the resident was keeping her debit card in her room until after the theft occurred. The administrator acknowledged that it was his responsibility to ensure the safety of residents' valuables, including bank and credit cards, but this was not effectively communicated or implemented prior to the incident. Interviews and record reviews confirmed that a caregiver employed at the facility was identified by the bank's fraud investigator as the individual making the unauthorized withdrawals, as evidenced by video footage. The resident expressed emotional distress and a loss of trust following the incident. The facility's abuse and neglect policy stated that residents have the right to be free from misappropriation of property, but the necessary measures to protect residents' belongings were not in place or communicated to the resident prior to the theft.
Failure to Prevent Suspended CNA from Providing Care After Abuse Allegation
Penalty
Summary
The facility failed to develop and implement written policies and procedures that effectively prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not ensure that a certified nursing assistant (CNA) who had been suspended following an allegation of verbal abuse by a resident was restricted from providing care to that resident upon returning to work. Documentation revealed that the CNA continued to provide care to the resident after the suspension, contrary to the intended protective measures. The resident involved was an older female with multiple complex medical and psychiatric diagnoses, including Multiple Sclerosis, incomplete paraplegia, and severe bipolar disorder with psychotic features. She had significant memory impairment, exhibited both physical and verbal behaviors, and required extensive assistance with activities of daily living. The resident was unable to complete cognitive interviews and was noted to have difficulty recalling the incident in question during subsequent interviews. The facility's investigation into the alleged abuse was inconclusive, but the lack of clear and enforced policies allowed the suspended CNA to resume care duties for the resident. Interviews with staff confirmed that the CNA had continued to provide care, and that room assignments were made by the charge nurse without adequate safeguards to prevent the CNA from being assigned to the resident. The facility's existing policy on abuse and neglect did not provide sufficient guidance or enforcement to prevent this lapse.
Failure to Review and Report Abnormal X-ray Result Led to Delay in Fracture Care
Penalty
Summary
A deficiency occurred when a nurse failed to properly review and interpret an abnormal X-ray result for a resident who had a recent fall and was experiencing pain. The resident, an elderly female with a history of muscle weakness, dementia, and hypertension, was assessed as having low cognitive function and a high risk for falls. After reporting pain following a fall, the resident was evaluated and an X-ray was ordered. The X-ray, which showed a stable acute nondisplaced fracture of the left pubic rami, was misread by the nurse as negative, and this incorrect information was verbally relayed to other staff and the nurse practitioner. The resident continued to experience pain and showed signs of impaired mobility, such as dragging her left leg. Despite ongoing complaints and ineffective pain management, the abnormal X-ray findings were not recognized or acted upon for two days. The nurse who received the X-ray result only reviewed the first page, which did not indicate a fracture, and failed to read the subsequent page that documented the fracture. This led to a delay in appropriate medical evaluation and treatment for the resident, who was eventually sent to the hospital where the fracture was confirmed and pain management was initiated. Interviews with staff revealed that the process for reviewing and reporting diagnostic results was not consistently followed, and that communication breakdowns contributed to the delay in care. The nurse practitioner did not receive the faxed X-ray result and relied on a verbal report from the nurse, which was inaccurate. The deficiency was identified as Immediate Jeopardy due to the risk of harm from delayed treatment, and the facility's investigation confirmed that the failure to review and report the X-ray findings in a timely manner constituted neglect.
Failure to Promptly Notify Practitioner of Abnormal X-ray Result
Penalty
Summary
A deficiency occurred when a nurse failed to properly review and communicate the results of an abnormal X-ray for a resident with muscle weakness, dementia, and hypertension. The resident, who had a low cognitive function as indicated by a BIMS score of 4 out of 15, experienced pain in her left hip and waist. After a stat X-ray was ordered due to ongoing pain, the result, which showed a stable acute nondisplaced fracture of the left pubic rami, was not correctly read by the nurse on duty. The nurse misinterpreted the report, only reviewing the first page and reporting a negative result to the nurse practitioner, which led to a delay in appropriate medical intervention. The resident continued to experience pain and was observed dragging her left leg, with routine pain management proving ineffective. Despite ongoing complaints and visible symptoms, the abnormal X-ray findings were not communicated to the practitioner or acted upon for two days. The error was discovered only after the resident was sent to the hospital, where a hip fracture was confirmed and pain management was initiated. Interviews with staff revealed that the nurse responsible for reviewing the X-ray result failed to read the entire report and provided incorrect information to both the nurse practitioner and the next shift nurse. The facility's policy required immediate notification of abnormal diagnostic results to the practitioner, but this protocol was not followed, resulting in a delay in care for the resident.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident on Enhanced Barrier Precaution (EBP) due to feeding tube status. The resident, an elderly female with multiple diagnoses including spondylosis, chronic obstructive pulmonary disorder, and muscle weakness, was observed to have an EBP sign on her door. Despite this, LVN A administered medication via the resident's feeding tube without donning the required gown, although gloves were worn after hand hygiene. Interviews revealed that LVN A acknowledged forgetting to put on a gown, understanding the risk of infection spread to staff and residents. The Director of Nursing (DON) confirmed that staff should be aware of which residents require EBP and adhere to the infection control policy. The facility's policy, dated April 2024, mandates the use of gown and gloves during high-contact care activities, such as feeding tube care, to prevent the transmission of infections.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform the resident's physician and notify the resident's representative when there was a significant change in the resident's condition. Specifically, a resident experienced shortness of breath and required breathing treatments and oxygen therapy over several days. Despite these changes, there was no documented evidence that the facility attempted to notify the physician during this period. The resident was eventually transferred to the emergency room, where he was intubated and subsequently passed away. The resident, an elderly male with a history of COPD and pulmonary hypertension, was admitted to the facility with a recent diagnosis of a displaced comminuted fracture of the right femur. His care plan included monitoring for signs of respiratory distress and administering oxygen therapy as needed. However, the facility's records showed inconsistencies in documenting vital signs and the administration of treatments. Nursing progress notes indicated that the resident experienced episodes of shortness of breath, but there were no attempts to contact the physician or nurse practitioner until the resident's condition significantly worsened. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's deteriorating condition. Several staff members, including LVNs and CNAs, noted the resident's difficulty breathing and elevated temperature but failed to ensure timely notification of the physician. The facility's policy required immediate notification of the physician for significant changes in a resident's condition, but this protocol was not followed, contributing to the resident's decline and eventual death.
Removal Plan
- All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses. No additional issues were found.
- DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse practitioner. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting.
- All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained by the DON/ADON. No additional issues were found.
- LVN A and LVN B were immediately suspended pending investigation.
- LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse.
- Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect.
- Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress.
- Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified.
- The medical director was notified by the administrator of this plan.
- An Ad Hoc QAPI meeting to include the Director and IDT team was held.
- All charge nurses will be in-serviced by the DON/ ADON regarding the following and all nurses not in-serviced will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1:1 by Compliance Nurse.
- Abuse and Neglect- failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect.
- Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident non pharmacological or pharmacological. Notification of the MD and RP.
- Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified.
- The medical director was notified by the administrator of this plan.
- An Ad Hoc QAPI meeting to include the Director and IDT team was held.
- The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began and will continue x 4 weeks.
Failure to Provide Adequate Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required such care, leading to a significant deficiency. The resident, an elderly male with a history of COPD and pulmonary hypertension, experienced shortness of breath and required breathing treatments and oxygen therapy. Despite these needs, the facility did not conduct a proper respiratory assessment or notify the necessary medical personnel when the resident's condition changed. This lack of action resulted in the resident being transferred to the emergency room, where he was intubated and subsequently passed away. The report highlights several instances where the facility's staff did not perform necessary assessments or document vital signs and respiratory conditions. On multiple occasions, the resident's oxygen saturation levels were low, and breathing treatments were administered, but there was no follow-up or communication with the resident's physician or nurse practitioner. The staff failed to document full sets of vital signs and did not consistently monitor the resident's condition, despite clear signs of respiratory distress and a significant change in the resident's health status. Interviews with facility staff revealed a lack of communication and understanding of the procedures required for handling a resident's change in condition. Staff members, including LVNs and CNAs, did not adequately assess the resident's respiratory status or notify medical personnel of the resident's deteriorating condition. The facility's policy on responding to significant changes in a resident's condition was not followed, contributing to the resident's decline and eventual death.
Removal Plan
- All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses. No additional issues were found.
- DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse practitioner. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting.
- All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained by the DON/ADON. No additional issues were found.
- LVN A and LVN B were immediately suspended pending investigation.
- LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse.
- Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect.
- Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident nonpharmacological or pharmacological. Notification of the MD and RP.
- Notifications of changes of conditions test, to include components of a focused respiratory assessment.
- Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified.
- The medical director was notified by the administrator of this plan.
- An Ad Hoc QAPI meeting to include the Director and IDT team was held.
- All charge nurses will be in-serviced by the DON/ ADON regarding the following and all nurses not in-serviced will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1:1 by Compliance Nurse.
- The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began and will continue x 4 weeks.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, leading to a deficiency in maintaining their dignity and quality of life. Resident #2, a female with severe cognitive impairment and dependent on staff for eating, was assisted by a staff member who stood over her while feeding, rather than sitting at eye level. Similarly, Resident #3, also with severe cognitive impairment and requiring supervision while eating, was assisted by a CNA who stood over her during the meal. Both residents were observed in their geri chairs with food trays in front of them, and the staff's actions did not align with the facility's policy of promoting dignity during dining. Interviews with the CNA, personnel staff, and the Director of Nursing (DON) confirmed that staff should sit next to residents when assisting them with meals to respect their dignity. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, promoting a respectful environment, and ensuring a dignified dining experience. Despite in-service training on resident rights and dignity, the staff's actions during the dining service did not adhere to these standards, resulting in a deficiency report.
Failure to Implement Comprehensive Care Plan for Resident Transfer
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, a male with cerebral palsy, scoliosis, muscle weakness, and other conditions, required total assistance for transfers and bed mobility. However, the care plan did not specify the use of a mechanical lift for transfers, leading to staff using unsafe manual lifting methods. Observations and interviews revealed that the resident was transferred by staff using a method where one person held his shoulders and another held his legs, without the use of a mechanical lift. This practice was observed by a CNA who had been employed for one month and was following what she had seen other staff do. The resident expressed that he was accustomed to being lifted manually, as his brothers used to do, but this method was not safe according to facility policy and posed a risk of injury. The facility's policy required the use of a mechanical lift for residents who were totally dependent on staff for mobility. Interviews with the DON and other staff confirmed that the use of manual lifting was against policy and unsafe. The deficiency was identified as a failure to update the care plan to include the use of a mechanical lift, which could lead to inadequate interventions and potential injuries for the resident.
Failure to Timely Report Alleged Neglect Incident
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident to the State Agency within the required timeframes. The incident involved a male resident with severe cognitive impairment, who required modified to total assistance for daily care. The resident, who had a history of acute hairline fractures and peripheral vascular disease, suffered a fracture when his left hand and wrist became stuck in the wheel of his wheelchair. The incident occurred on April 17, 2024, but was not reported to the state agency until April 30, 2024, which was beyond the two-hour reporting requirement for incidents resulting in serious bodily injury. The facility's administrator admitted to possibly sending the Provider Investigation Report to the wrong number and acknowledged forgetting to send it to the correct CII provider immediately after the incident. The facility's abuse policy, revised in March 2028, mandates immediate reporting of all alleged violations to the appropriate authorities. However, the administrator failed to adhere to these guidelines, resulting in a delay in reporting the incident. This oversight placed residents at risk of ongoing neglect, as the facility did not comply with the required reporting timeframes outlined in Provider Letter PL 19-17.
Failure to Implement Comprehensive Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs. The resident, an elderly female with a history of cognitive decline, falls, and lack of coordination, was dependent on staff for all activities. Despite these needs, the care plan did not adequately address the necessary interventions to prevent falls and ensure proper supervision and incontinence care. This deficiency was highlighted by an incident where the resident fell from her bed and sustained a head injury requiring sixteen staples. The care plan had listed interventions such as keeping the bed in the lowest position and ensuring the call light was within reach, but these were not effectively implemented or followed by the staff, leading to the resident's fall and injury. The incident occurred when a CNA left the resident unattended on an elevated bed while retrieving an item, resulting in the resident sliding off the bed and hitting her head on the floor. The CNA admitted to not lowering the bed and turning her back on the resident, which directly contributed to the fall. The facility's failure to ensure that staff followed the care plan interventions for proper supervision and incontinence care placed the resident at risk for injuries. The report also noted that the facility's policy on fall prevention strategies was not adequately followed, as individualized nursing care plans were not effectively implemented to prevent falls. The resident's care plan was not updated to reflect the need for two staff members to be present during incontinence care until after the incident occurred.
Failure to Follow Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that Resident #1's environment remained as free of accident hazards as possible and that the resident received adequate supervision and assistance devices to prevent accidents. Resident #1, an elderly female with age-related cognitive decline, a history of falling, and other coordination issues, was dependent on staff for all activities. Despite these needs, the care plan interventions for proper supervision and incontinence care were not followed by CNA-J, leading to a fall incident where the resident sustained a head injury requiring sixteen staples. On the day of the incident, CNA-J was providing incontinence care to Resident #1 but did not lower the bed as required by the care plan. When CNA-J turned her back to retrieve a brief from the nightstand, Resident #1 slid out of the bed and hit her head on the floor, resulting in a 10 cm laceration. Immediate first aid was administered, and the resident was sent to the hospital for further evaluation. The hospital performed a CT scan, which was negative for fractures, and treated the laceration with sixteen staples. The resident was also diagnosed with a urinary tract infection and prescribed antibiotics. Interviews with facility staff revealed that the initial care plan required only one person for incontinence care based on a fall assessment score indicating low risk. However, following the incident, the care plan was revised to require two staff members for incontinence care to prevent future falls. The facility's policy on fall prevention and care planning was not adequately followed, leading to the incident and subsequent injury to Resident #1.
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 1,237 citations issued within 25 miles in the last 12 months — including the 54 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 Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Purehealth Transitional Care At Thr Arlington | 0.6 mi | ★★★★★ | 0 | 0 |
| Viridian Wellness & Rehabilitation | 2 mi | — | 41 | 0 |
| Avir At Arlington | 2.2 mi | ★★★★★ | 13 | 3 |
| Town Hall Estates Arlington, Inc. | 4.7 mi | ★★★★★ | 1 | 1 |
| Green Oaks Nursing & Rehabilitation | 4.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Interlochen 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.